MENTAL HEALTH: ATTITUDES AND POLICY

HL Deb 12 November 1969 vol 305 cc668-739

4.29 p.m.

Debate resumed.

THE COUNTESS OF LOUDOUN

My Lords, this is my maiden speech and I crave the indulgence of the House for any faults, an indulgence which I know your Lordships always readily give. First of all, I, too, should like to thank my noble friend Lord O'Hagan for initiating this debate. Much has been done in the last few years to bring to the notice of us all the problems and stresses of mental health. The contemporary attitudes to mental health are somewhat contradictory at the present time, but could be looked at from three points of view. In the first case, there is the critical searchlight which is directed particularly to subnormality hospitals, triggered off, one must admit, by events that have taken place in the hospitals. Although the policy of the authorities is constantly to improve the service, it is possible that recent events have been inclined to overshadow the great amount of good and to emphasise the bad. I am glad to say that in the most recent programmes on the radio steps have been taken to correct this difficulty. We know that in many cases the buildings are old and that the work is made more difficult because of this. But the majority of hospitals are not deterred by this, and the work is going forward in a very progressive manner, with ever-increasing imaginative enthusiasm.

Of recent years, big efforts have been made to make the public more aware of the hospitals and what goes on; and the recent spate of programmes on both radio and television indicates that some success has been achieved in this respect. I should like to emphasise the need for it to be understood by the wider public that the patients are people, just as much as any other section of the community, and should not be regarded as a kind of lower order of life just because their difficulty lies in the intellectual sphere. In recent programmes and articles one has been inclined to detect a slight amount of surprise on the part of the writers when they found the patients doing "ordinary things". I feel that it would help people generally if they could think of people with subnormality as a glass half-full, rather than as one half-empty.

The second point is the attitude of the staff who are intimately concerned with the day-to-day care of the patients. They have no power to provide buildings and facilities, and yet they feel that they bear the brunt of the criticism. Although many are able to weather the storm, there are some who are discouraged by it. There has been a noticeable reduction in recruiting in the last few months, which, of course, makes the work more difficult for those who have to carry on.

In the third matter, there has been a considerable increase in the interest of voluntary workers, who seem to be motivated by the feeling that things are so bad that they feel compelled to come and lend a hand to put them right. In one hospital I know that they have over 100 volunteers on the books. The contradictions I mentioned earlier are between the critical attitude, on the one hand, and the increase in the desire to help by members of the public on the other. I have the greatest admiration for all those connected with nursing of all types, but I should like to pay my tribute especially to those of the mental health service.

4.33 p.m.

THE LORD BISHOP OF LICHFIELD

My Lords, I am very happy that it should be my privilege to be the first to congratulate the noble Countess on her maiden speech. I am sure that we all much appreciated her most thoughtful speech, and that the House will look forward to further speeches from the noble Countess in due course.

I am grateful to the mover of this Motion, the noble Lord, Lord O'Hagan, for drawing our attention to this subject this afternoon, because it is a vast problem which needs regular consideration. I am informed on good authority that it is the case that the number of hours lost in work to the nation through mental illness probably amounts to about four or five times the amount that is lost by strike action. Those figures, which, as I say, I have obtained from the most creditable source, show the vast scope of the problem with which we are dealing. The noble Lord, Lord O'Hagan, has drawn attention to contemporary attitudes to mental health, and I would say that in this respect the public attitude has greatly improved. As has already been remarked, there is no longer a stigma attached to it, and people are more open about the subject. This is wholly desirable. It is one of the reasons why the rate of admissions to mental hospitals has increased, because many who in former years would not have asked for admission are now doing so.

There is, however, one respect in which the attitude of the public falls short. It does not sufficiently realise that new money will have to be obtained if the problems are to be overcome. Recently there has been a great deal of holding up of hands in horror about the statements that have been made in regard to overcrowding in these hospitals. I shall refer to that again in a moment, but undoubtedly those statements were justified. It is no good just holding up hands in horror; the nation must realise that improvements will cost money. If I may speak as a member of a Regional Hospital Board, I should like to say how, sometimes, it is frustrating for a Board to know of these problems but to be unable to cope with them to the extent they would like. Time and again,, the anxious choice has to be made as to the way in which the money available to the Board should be spent. There are other ways in which contemporary attitudes to mental health can be improved. First, there is a need to convince people that psychiatry is nothing of which they need be afraid. I think it is true to say that in the past people have shrunk from admitting that they themselves might have need of psychiatric treatment. It is therefore necessary that we should overcome this very natural reluctance. So let it be understood that there are periods of particular risk in people's lives; and let it also be understood, as again has been remarked, that none of us can say that at any time in our lives we may not be subject to this kind of difficulty.

I hope, too, that further consideration will be given to the use of mass media in order to dispel fear of psychiatric treatment. This has been used to a certain extent, but in regard to one programme I was not quite sure whether, rather than being dispelled, fear was increased; but that might have been a personal opinion. This is a matter which has to be carefully approached by producers. When we come to physical illness, an operation can be portrayed on television in such programmes as "Your Life in Their Hands", and we all look at it goggle-eyed, but it is not so easy with this kind of ailment. The line between physical health and physical illness may be clearly defined, but it is not so clearly defined in mental health. The line there is much more indistinct, and in order to prevent the trouble we have to help people to understand that in their lives they may be near this line.

I therefore hope that we shall refrain from making moral judgments on such people. It is only too easy to do so, and is perhaps rather natural. On the other hand, I hope that none of us will ever regard psychiatry as being a kind of panacea for all such types of mental illness. Some people do so, and apply to a psychiatrist in order to try to dodge the realities of life, when in reality they should be taking a grip on themselves. But here a difficulty arises for those who are in a position to try to help. How, for instance, are people who desire to help to know whether others are in need of psychiatric treatment? When, for instance, ought people to go to their doctor, and when ought they, frankly, to try to snap out of it? Here I think the clergy, in particular, need real guidance. They often have to deal with this type of case, and efforts are now being made to give them some knowledge in order to equip them for their task. I do not want to imply for one moment that what we want to do is to try to turn the clergy into a group of amateur psychiatrists—that would be highly dangerous—but I feel that it will help them to recognise certain psychiatric cases as a rather different matter. Here we are particularly grateful to a number of consultants in this speciality of medicine who have given up their time freely to lecture to ordinands and clergy, and courses have been arranged in clinical theology. If I may say so, turning from my own profession to another, the general practitioner is probably recognising psychiatric cases to a greater extent than in the past. This is also leading to a greater caseload in mental hospitals.

The increase in the caseload leads me on to stress once again that surely overcrowding is still one of the greatest problems. Looking back over the years, how often have I heard it said that as a result of the new techniques, and so on, the number of patients was going to come down; and yet here we are, still the same in 1969 with this terrible problem pressing upon us. I suppose the consultant might say, "All right, do not admit any more patients. This is the number of beds we have, and that is that." When I was discussing this subject the other day with a medical superintendent of one of these large hospitals he said, "In all the years I have been here I have not turned away a case that a general practitioner has sent to me. If I did, what would happen to that person, and what would happen to the family?".

It is not so easy to say, "Clamp down on it". The Hospital Service cannot be expected to cope with the whole of this problem. It is a fact that there are many people in hospitals to-day who, by their presence, reflect a lack of community care, because many of them, we know, ought not to be there at all. There is this tremendous problem of the overlapping between the psychiatric and the geriatric patients. We must do all we can to keep psychiatric beds simply for psychiatric patients, and not for others. So the Hospital Service must look to the other authorities to play their part. Most of the local authorities are making some provision for community services for the mentally ill. This, however, is still far from enough. I hope the possibility of boarding patients out will he still further developed. I understand that one of the authorities in Northern Wales by this expedient has greatly reduced the crowding in the mental hospitals, and of course if it can be pursued it is far less costly than keeping patients in hospital.

In this matter of the mentally subnormal, to which many references have already been made in this debate, as was natural, may I come again to the need for more money if the problem is to be overcome? Given the proper facilities, many of these people could lead useful and productive lives in the community, and we need greater provision of day centres for their training in simple occupations. But a consultant psychiatrist of great experience impressed upon me the other day that if the subnormal is to be cared for at home rather than in hospital, he must not be given any precedence in care over the rest of the family, but must be treated along with the rest; otherwise great jealousies and tensions can undoubtedly arise.

Efforts are now being made to avoid segregation of psychiatric cases, and the Bonham Carter Committee recommended that these cases should be dealt with in the district general hospital. I am quite sure that that suggestion must at any rate be tried. Also, we need more hostels to adjust patients to everyday life when they come out of the hospitals. But is it not true, my Lords, that these hostels are tending rather to price themselves out of the market? Could they cost less than they cost at the present time? It would be quite hopeless if these hostels were blocked by cases who stayed there a long time, for they are not there for that purpose. They must be short-stay institutions, or the whole object of the hostel is defeated.

Then there is a need for the follow-up on the part of the psychiatric social worker and the mental welfare officer. Again, as we have heard, there are still not enough of them to cover the work. Moreover, still more day hospitals arc needed where these patients can go and receive a certain amount of supervision. I am informed by people who have great experience in this matter that very many readmissions of patients are due to the failure on the part of those patients to carry out the instructions of their doctor when they have left the hospital.

In recent months there has been a lot of bad publicity for a number of these hospitals. There were the allegations that were made in a book which, if I remember aright, was entitled Sans Everything; there was the story of the Ely Hospital, and others. I agree that in a sense this publicity is desirable, because if there are instances of cruelty they should be very definitely stopped. On the other hand, we must always remember, before we criticise too sharply, the kind of tasks that the staff have to undertake. I have recently been around several of these hospitals. My Lords, honestly I wonder, as I look at the work that has to be done, that we get anyone to do the job at all. As has been remarked this afternoon by the noble Baroness, Lady Brooke of Ystradfellte, one hears about the cases of bad behaviour, and so on, and they get highlighted. In a sense that is right, because they must not be allowed to go on. But when one speaks to some of these ladies and gentlemen who act as the staffs of these hospitals, one feels most moved that they should go on year in and year out in the way that they do.

I said to the matron of one hospital. "Matron, looking at the jobs that have to be done, how do you get staff at all?". She replied, "Well, you know, after you have been at it for some time, you come to love them very much". It is that kind of attitude to the work which animates so many of the men and women who are serving on the staffs of these hospitals, and we should be indeed most grateful to them. If we get continuing adverse publicity, it is going to affect recruitment very badly. What the noble Countess said just now in her maiden speech is perfectly true: that in the past few months recruitment has been flagging very badly indeed. It is getting very worrying. If we keep on having this kind of publicity, what can be expected as a result of it? So I would add my voice to those speakers who have said that we must call on all kinds of voluntary workers to help as much as possible. And it is remarkable what a number of organisations do—for instance, an organisation like the Round Table, which comes and takes the patients out for the day, or organises their summer holidays. That kind of thing is going on to a much greater extent than people realise. Let it always be said, as is true, that in this day of the National Health Service there are more people engaged in voluntary work in our hospitals than ever before; and let us be most grateful for what is done.

May I, in my concluding remarks, say one or two things about chaplains and the part that the Church must play? It is very gratifying for us to know that in hospital after hospital the chaplain is now being regarded much more as a member of the healing team. We are trying as best we can to fit him for this work, and the Hospital Chaplains' Council organises regular training courses for chaplains. We are pleased to know that we have passed through these courses more than a thousand chaplains. I should like to express gratitude to the Department of Health and Social Security for the way in which they support these courses. They do so not only by paying for the men to attend the courses. We have had a senior representative of the Department to give the opening lecture; and this kind of seal, set on it by the Department, is something that helps the Church very much. A really good chaplain in a hospital is undoubtedly going to be a great source of strength to the patients, just as the good parish priest will be a source of strength in his work. Let it also be said that the chaplain should be a man who does much to help the staffs in their difficult tasks.

So, as we think of the role of the Church in this matter, surely the link between the Church and the sphere of psychiatry should be a close one; and here the Churches' Council of Healing and the Institute of Religion and Medicine have been very active in trying to bring the two together so that we may work in the closest harmony. The pastoral work of the good psychiatrist and of the good parson are closely akin. But it is important to remember one outstanding fact: what we must aim at, first and foremost, is not so much the treatment of mental illness, but its prevention. Prevention is so much better than cure; it relieves so much anxiety, and from the economic point of view it is far less costly. We must strive to help people to become, and to remain, whole. I hope, therefore, that the public will have a fair and open approach to this problem. And if this debate this afternoon helps us in our attitudes to this great problem, then I think that the noble Lord, Lord O'Hagan, will feel that he has been rewarded.

4.52 p.m.

LORD GRENFELL

My Lords, I know that we should all like to thank my noble friend Lord O'Hagan not only for initiating this debate but also for bringing the word "contemporary" before us: for never before, perhaps, has the situation of the mentally handicapped been more urgent than it is to-day. The right reverend Prelate has spoken most movingly on the subject of staff in hospitals, and I do not apologise in any way for speaking on that subject as well We all know that there have been incidents which have been highlighted in the Press and in books, with such unattractive names as Sans Everything and Put Away. I am told that this flurry of literature is necessary to inform the public on the conditions in our mental hospitals, and it is right that the public should know. But the fact is, of course, that many of the public do not read these books; they read only the extracts printed in our daily newspapers. And these, I fear, have on the whole been very one-sided and have deeply disturbed the staffs of mental hospitals, who in many cases are working under extreme pressure in near to impossible circumstances. My Lords, they are the salt of the earth; and if in some isolated cases the salt has lost its savour can we in Parliament, the local authorities, and indeed the public, put our hands on our hearts and say that we ourselves are blameless?

I doubt whether the record of spending in the last forty years on our mental hospitals would, if carefully analysed, make us very proud. In many hospitals our mentally handicapped live in conditions which we do not allow to our worst criminals. There is public indignation if we allow our prisoners to sleep three in a cell; but the fact that many of our mentally handicapped citizens are sleeping in overcrowed wards, with beds touching, and the nurses, both male and female, battling to keep them clean and happy—and, if I may say so, to remain sane themselves—has been largely overlooked. No, my Lords; we have little to be proud of in the way we care for these unfortunate people and those who look after them.

I shall be speaking a little later on the contemporary thought for the future. But before we look into the crystal ball let us face the hard facts of the present. For some years I have raised my voice in this House on the requirement for hostels for the mentally handicapped, and I have in the past given a résumé of what local authorities have done under the permissive rights given to them in the Mental Health Act 1959. I do not intend to go into these details to-day, but I will firmly state to both Front Benches, and to all your Lordships, that the provision of hostels is totally inadequate for the urgent need at the present.

There are some local authorities who have a high record in their care of the mentally handicapped; and there are some who have not. And never at any time in our history should our consciences be more moved than at the present time. I would appeal to the public not to raise objections to the establishment of hostels for mentally handicapped in their neighbourhood. It is so easy to say, "Of course we must have hostels—but not next door to me". Those who can live in hostels will be harmless people, badly in need of help and friendship, and all the kindness that the public, whether they be children or adults, can give them. I can only trust that both Press and television will be of help in this cause. In some local authorities excuses may be made that, even if they had hostels, they would be unable to staff them. My answer to this is: acquire or build your hostels, and then get your staff. Experience shows that where there are hostels staff have been forthcoming; and I am certain that if they are shown the hostel there will be men and women of good will who will accept the challenge.

In disasters in war and peace we in this country immediately rally round—and in saying what I am about to say I am picking my words carefully. In many hospitals, including those in my own group, we have a great number of wonderful nurses, both male and female, from our Commonwealth. In my opinion, it is only right, should they so desire, that after we have trained them they should return to their country to take up posts in order to train their own people in the art and the care of healing. I have spoken to many of them, and the majority are undecided as to their future. But have we thought of the consequences should a great number of them, together with the doctors, decide to return to their native lands? Have we considered the consequences if a number of our nurses of the mentally handicapped came to the conclusion that conditions were so bad that they could not carry on? Have we considered the consequences of all this adverse publicity to recruitment of nurses, both here and overseas? My Lords, we indeed face a crisis, and I am firmly convinced that this crisis can be met only by the provision of increased accommodation in beds for the mentally handicapped in either hostels or hospitals.

Recruitment of nurses is naturally tied up with pay, about which I shall be speaking in a moment. But there is also the undoubted question of environment. There can be no doubt that it is far easier to work in bright, attractive wards rather than dark prison-like hospitals which savour of the old institutions. "Morale" is a difficult word to define. We all know that with fine leadership morale may be tremendously high in impossible situations; but this is characteristic of the British race. It is quite a different thing when nurses are working in terribly difficult circumstances, in which they can see no future improvement and at the same time are accused of cruelty and lack of care for their patients. On their behalf I would quote a line from Rudyard Kipling's famous poem: If you can keep your head while all about you Are losing theirs and blaming it on you". It is a well known fact in the world of hospitals for the subnormal that patients who are highly disturbed are prone to self-infliction of wounds, and in fact to wound each other. We do our best to help those who are prone to self-infliction of wounds by providing protective headgear, and in some cases gloves. Our nurses do all they can to prevent patients wounding one another, but it must be understood that, in the case of the severely disturbed, these things happen so suddenly that they may be impossible to avoid. In my opinion the complete answer to charges of cruelty is open visiting. We have nothing to hide. Any form of cruelty is immediately looked into. In return, we would ask visitors to trust us to give our all to the welfare of the patients, and not immediately to jump to a conclusion if a patient has an abrasion on his or her face.

As I am closely connected with mental hospitals, I feel a deep responsibility in speaking out for the nurses. Of course as in all professions, there are black sheep; but when I come back from a round of my hospitals I feel humble and grateful that there are so many people, both young and old, who are prepared, with loving care, to look after our fellow citizens. It infuriates me that, because of a few, as yet unproved, cases, they should be given a reputation which is wholly unjustified.

The present situation is frankly this. I say this in the full understanding that I have a group of hospitals with lovely 20-bedded wards in villas, and although for children we have a waiting list of over 100 we are better off than many. But as a Member of your Lordships' House I speak for all hospitals. There have been a number of conferences at which the future of the Hospital Service has been discussed. In one report to the Ministry it is stated that our mental hospitals are to be run down and abolished and that the mentally handicapped will be looked after in district hospitals, local authority hospitals and in the home. In my opinion it will be impossible to abolish the mental hospitals for at least twenty years. In fact, there can be only one solution to our present situation; namely, that to relieve overcrowding and the waiting list beds must be provided for adults and children. Time is not on our side. For this reason, in asking the noble Baroness to inform us of the plans of the Government for the immediate future I put forward suggestions which will go some way to deal with what is a very difficult problem.

I fully realise that it will take time to educate the public into having hostels next door to them. For this reason, as the noble Lord, Lord Amulree, has stated, where applicable hospital land should be released for prefabricated hostels to be occupied by patients released from hospital, and paid for by the local authority. This scheme would save an enormous amount of money in regard to the purchase of further land and would be the first stage in returning the mentally handicapped into community care.

My second suggestion is that in any New Towns or new housing developments it should be mandatory, commensurate with the proposed population, to include a number of hostels, thus making the hostel situation a fait accompli and furthering our hopes that, in the eyes of the public, more of our mentally handicapped can be brought into the community. My third suggestion, on which I have spoken before, is that if the cottage hospitals are to be closed in favour of district hospitals—a decision on which I cannot comment, except to say that it seems to be unpopular—I would hope that these hospitals would be used as hostels or, maybe even more important, as centres under the local authority for day help and for counselling the families of handicapped children and adults. If contemporary thought is that more children should be kept in the home these centres will be invaluable. It is to this subject that shortly I turn now.

I have spoken on many occasions of the strain placed on the family of the mentally handicapped child and I do not intend to weary your Lordships with repetition, but I would say this. If encouragement is to be given to such families to keep their children in the home, massive support must be given to them both in counselling and in money. Counselling centres must be set up where the family can obtain kind and understanding advice, especially on how to get assistance. Forms can be very cruel, especially in the early years when the whole family is desperately keyed up. Home help and laundry must be considered, for in the first place the parents are never able to go out together unless there is some responsible person to look after the child; and in the second place, and maybe reaching into adult years, incontinence can put an unbearable burden on the parents.

Above all, in order to encourage families to keep their children in the home an assurance must be given that the children will be happily looked after in case of their parents death. I am wonderfully blessed in the fact that my daughter can stay at St. Mary's Convent, Roehampton, for her life, but I get a number of letters from people who know that I am interested in this subject, begging me to find a place for their child. It matters not whether they are able to pay. There do not appear to be vacant beds, in hospitals or homes that I know of, to accommodate them. It would be of great assistance if there could be set up a central bureau of information—something on the lines of the emergency bed service —which would have knowledge of accommodation for the mentally handicapped available in hospitals, local authority and charity homes, and which would be able to advise families who have got to the end of their tether and require temporary relief, and those who have reached an age when they wish to have an assurance of their children's future in case of their death.

Let it be fully understood that parents just cannot leave the case of the mentally handicapped child to other members of the family. Other children will be growing up and will have children of their own, and it would be unfair to leave with them any care of mentally handicapped child or adult. We must take this heavy burden off the family, and ensure that anyone can die in peace and know that their child will be looked after in a way of which they would approve.

I know that I am speaking for quite a long time—more than I usually do—but I would add one final observation. In the last few months we have seen how strikes have been settled by the main demands being met. It is not necessary to go into that matter in your Lordships' House, but I cannot help feeling that those who are unable to strike through humane considerations are at a considerable disadvantage. Is it not time that, out of our consideration for fair play, we show our gratitude for the work that they do, and also, because of the urgent requirement of recruiting, decide to give a substantial increase in pay to our nurses? Those of us who work closely with them know their worth and realise fully their difficulties in making both ends meet at the end of the month. Apart from this, it is monstrous that a job which has responsibility for making decisions of life and death should be so badly paid in all ranks of the nursing service. The Daily Telegraph has announced that a great increase, amounting to £15 million, has been given to ancillary staff. I am delighted to read it. But does not this award make the case of the nurses even more urgent? My Lords, it is indeed urgent. It is a subject which is deeply worrying many of us. Something must be done immediately if real trouble is to be avoided.

I have spoken enough, but I trust that everyone in the House will realise how deeply we must feel with the situation as it is. We are in a crisis. As we go on we shall go deeper into that crisis, unless something is done to relieve the overcrowding of hospitals and to see that those who give such valuable service, our nurses, are properly paid.

5.12 p.m.

BARONESS BIRK

My Lords, may I first add my congratulations to the noble Countess, Lady Loudoun, on her maiden speech, and say how both informative and human I found it, as I think we all did. I am extremely grateful to the noble Lord, Lord O'Hagan, for couching his Motion in such wide terms so that it is possible for me, as Chairman of the Health Education Council, to say something about health education in this field. The Health Education Council, as your Lordships know, was set up as a result of a recommendation of the Cohen Committee. It had rather a prolonged gestation and also an uncertain post-natal progress, as I am sure my noble friend Lady Serota will agree. She was its first Chairman, and I had the privilege of following her as Chairman; but there was a year's gap in between. Though the Council itself was working during this time, there was no organisation, very little personnel, and it is really only in the last six months that we have been, so to speak, in business.

We are in an extraordinary position. We receive a main grant from the Ministry of Health—and I would point out to the noble Lord, Lord O'Hagan, who compared the sum of £223,000 that we get with the £10,000 which the Exchequer gives the National Association for Mental Health, that what we get is meant to cover the whole field of health education. I think that, measured in those terms, one can almost say that what we receive is proportionately even less! While cooperating and working out our programmes in conjunction with the Secretary of State and the Ministry of Health we do have a considerable degree of independence. We are the Health Education Council, Limited. This helps us to act both as a stimulus and, sometimes, as a goad to the established authorities, both central and local.

It is true that in our present and future estimates we have no special allocation for mental health. This does not mean for one moment that I, or the members of my Council, think that this is something that we should not be concerned with—far from it. This is something with which we are greatly concerned. But one of the reasons we have nothing under that head is lack of resources. In the context of mental health (I am talking of mental health, rather than mental illness or mental disease, about which so many other speakers have spoken, with great experience) the recent brochure which we pubished makes it clear that at least six of the subjects which we pick out as being among the most important of the current health problems have a mental as well as a physical content: alcoholism, drug addiction, venereal disease, sex education, health problems of new immigrants, preparation for retirement and helping old people to stay healthy and independent. I think this is a very important aspect of our work and our approach, that we should be able to try to integrate physical health with mental health, rather than have it divided, as unfortunately it is divided to such an extent because of the necessity to concentrate on mental disease and mental illness.

Where the major mental illnesses have their origins in biochemical causes and do not seem to be precipitated by behavioural or environmental causes, our rôle can be very important in helping to change the attitude of the community. My noble friend Lady Llewelyn-Davies referred to social attitudes, and there is no doubt that there has been a great deal of change. But I take issue with the right reverend Prelate when he says that the stigma of psychiatry has gone. This just is not so. It may be true so far as a great many fairly sophisticated people are concerned, but to many people to-day the word "mental" still means mad; and this is something we have to accept; it is no good pretending that it is not so. Indeed, this is to such an extent that the editor of the periodical, Mental Health, the publication of the National Association for Mental Health, was telling me that they were considering trying to find an alternative title simply in order to get away from the word "mental".

So far as the mentally handicapped are concerned, I think that we in the education field can perhaps be of some help. Again, my noble friend Lady Llewelyn-Davies spoke about a caring community, and I believe that a great deal of education of the community still needs to be done here. I am talking now of the cases of subnormal people. The principal way one can deal with the problem is through education of the patient, so far as that is possible, but much can be done also by education of the teachers and of the family, and also of employers. The attitude of employers is extremely important because a great many mentally handicapped people could be employed on certain jobs if only employers were prepared to take them on. But they have all sorts of fears about this, and often are not prepared to give them a chance. In addition there is, as my noble friend pointed out, the need for genetic counselling and emotional counselling, because the breakdown (to which several speakers have referred) in families can be a very serious thing. Very often a decision has to be made as to whether a child can be kept at home or should be sent to an institution; and this decision may leave the family, and particularly the mother, with a tremendous feeling of guilt. I am not suggesting that we should encourage people to put their children into institutions, but there are circumstances where it really is far worse for the child and for the family for the child to be kept at home. I feel that in these cases we should be doing what we can to mitigate the guilt, and to understand and support (my noble friend used that word) the family and the relatives, as well as the patient.

Where I think that we in the health education field can be of real assistance is in the preventable stresses, because here when we talk about prevention the main way we can bring it about is by means of education. As the right reverend Prelate pointed out—and it is perfectly true —figures show that in 1966–67 29 million working days were lost through mental disorders, depression and nervousness. This evidently equals £25 million in sickness benefit; but that figure gives no indication of what it means in terms of personal tragedy, unhappiness or, again, the effect on the family and workpeople and other people around.

In the prevention field one of the problems with which we are particularly concerned at the moment, and which I believe is responsible for a great deal of the bad mental health which is preventable, is the problem of the unwanted pregnancy. The effect of the unwanted pregnancy, not only on the mother but, if there is an illegitimate child, on the child itself, and on the child who is unwanted even though born in wedlock, and on the whole family can be extremely serious and traumatic and often long-term. What we want to see is a comprehensive contraception service which is part of the National Health Service. The Family Planning Association, whose slogan this year, "Every child a wanted child", is one that I warmly support, has done, as we all know, a magnificent job in this field. Nevertheless, the time has now come, in my opinion, when this work should be part of the State Health Service with, of course, the Family Planning Association and other bodies participating.

The question of education here is extremely important. One of the things that we have been pressing the Ministry to do is to try to see that whenever possible, when any woman leaves a hospital after an abortion, miscarriage or the birth of a child she is offered contraceptive facilities and is directed to them. At this point—and this is often the point where again some form of education could start—the ideal would be to have contraception clinics attached to the hospitals, all the hospitals, as well as having the contraceptive facilities provided by the local authorities. I have set up a Sex Education and Contraception Advisory Panel in order that we can work out the best way to set about so many of these problems, because there are a great many problems which come very much into the area of mental health. It is not just a question of the physical facilities and the geography. We also need to know why so many women who know about and have access to contraception do not in fact use them, and either have an abortion or give birth to an unwanted child.

We are also extremely concerned with sex education. Criticising parents for dereliction of duty is a very popular pastime, but I think it is both counter-productive and quite unfair, as many parents find it absolutely impossible to communicate in this way. Some of the reactions that I saw in letters to The Times, and other papers, to the announcement of the B.B.C. programmes, seem to me, with great respect to the Archbishop of Cardiff and some of the other people who wrote, a misunderstanding of the present problem. What we must hope for is that we are going to make it possible for future generations of parents to have this sexual dialogue with their children. This means that we must have a far better and more coherent form and more consistent system of sex education in schools which is part of an ongoing course in living. This seems to me to be part of the basis of a stable and good mental health structure for this country. Though there are some courageous exceptions, on the whole I am afraid that sex education in schools is inadequate, uneven, and often nonexistent.

Recently—and I am not talking about years ago but in the last few months—I was talking to a number of youngsters from different schools; secondary modern, grammar and comprehensive. They were about the age of 15, and I asked them what sex education they had had. The majority had had one lecture at the age of 11, and some had seemed to manage to miss out altogether. Many knew all about the sex life of the salmon, but, as one boy pointed out, as he was not a salmon it was really very difficult for this to be of much use. One girl said, "Yes, I know all about V.D.". I asked, "What were you told? How old were you?". She said, "I was 11, and the games mistress told us never to go out with boys with spots around their mouths." If that is the extent of our sex education., then we ought to question the basis of whether we are going to have a positive mental health policy in this country.

But if the educators are not educated, how can they be expected to educate their pupils? This again is another of the things with which we are concerned. A report prepared by the Young Teachers Advisory Committee of the National Union of Teachers shows that of teachers entering the profession between 1964 and 1967, over one-third received no instruction in sex education during their three year training course. Of those who did receive it, 13 per cent. pronounced it inadequate, and only 12 per cent. found it was good. Therefore, in the Health Education Council we are calling a conference on sex education next spring in order to try to hammer out a coherent and consistent policy, and face up to many of the implications frankly and without hypocrisy, and to face the problems which are swept under the carpet. There is a point at which people shy off them. People will give instruction up to a point, but when it comes to imparting knowledge on contraception and giving advice they shy off it. I think we have to accept that the morals and values must be included, one hopes, in parental teaching, teaching in school, the churches, and any other agency with which the young person comes into contact. But it really must be at some point divorced from clinical advice, otherwise the results will be shown not only in bad physical health but also in bad mental health as well.

The Health Education Council has a field division which gives in-service training to health visitors and health education officers on human relations. One of the most important of our tasks, as I see it, is communication, because although a great many people are trained in their subject and have the knowledge, I think it is a skill in itself to be able to put it over to the people concerned, and even more so to many of the groups who are most at risk in the mental field. We need very many more trained health education officers. The majority of health authorities have someone responsible for health education, but only a minority of these people are professionally trained. This is no longer a job for the amateur, and, like many of us here, I am waiting anxiously to see what the Government's legislation on the Seebohm proposals is going to be. I earnestly hope that the conflict between the various vested interests will not weaken the sort of family service that so many of us want to see.

I believe that a health education officer must be an essential part of every local structure, because he or she forms one of the bridges between the medical and social agencies which are so important in the field of mental health work. For instance, in Croydon, which has a very good health education set-up, there is a mental health education committee which meets in the health education office, and which brings together G.Ps. and local and voluntary organisations, as well as so many other people who are involved in that field.

Also, because it is now recognised that education and behaviour patterns, which are going to affect the mental health of our lives in the future, start right back in childhood they hold ante-natal classes explaining the emotional effects on the mother and father before the arrival of the baby. I think it is very important to bring the father into many of these activities, because this creates a much better and healthier atmosphere in the family.

There are also what they call "toddlers' clinics", where mothers have group discussions every fortnight about the whole family. This is very important, because J. W. B. Douglas, in his book All our Future, reports that the mothers of a number of delinquents on whom he was researching and to whom he was talking had not used the facilities available for child welfare in their children's early years.

The health education officer should cover the school health service; and it is interesting that even in a place like Croydon, where the health education set-up is a good one, half the schools co-operate but the other half do not. We are concentrating on two campaigns which have a very direct relationship to mental health. One of them is anti-smoking, and, although that may sound a physical matter, I think there is a very strong mental content because although people who smoke are very well aware of the dangers there is still this compulsiveness to smoke which has something very much to do both with personality and, presumably, also with the stress of the life we are living. The ether is V.D. in young people. To tackle these matters adequately, we are doing an evaluation so that we know where we can make the most impact.

We also hold a number of colloquia—I was not sure what that is, but I understand that it is "a getting together"; it is not my word—on different subjects. Although we cannot run specific campaigns on them ourselves, it enables us to bring together the people concerned. We have had one on cancer, and yesterday we had a very successful one on nutrition. Here, again, you cannot completely segregate the physical from the mental, and one of the distinguished doctors present told us that there was now evidence to show that in the later months of pregnancy, or in the first few weeks of infancy, malnutrition can affect the growth of the brain. Similarly, another doctor concerned with geriatrics pointed out that his research had shown that malnutrition can lead to degenerative senile psychosis. So all these matters are very much interlocked.

There is another tie-up, my Lords, between mental health and nutrition. Domestic science training is very important, and such training, including budgeting, should be part of the curriculum of girls' schools, because so many of the family breakdowns, and so many of the difficulties that people get into, result from the mother's not being able to cope and not knowing where to go for help. Our next colloquia will be on mental health. Health education cannot be done just from the centre. We can lay down the guide lines, and we can produce material as we will; but it needs the close co-operation of doctors, nurses, teachers, social workers, and all those people who are in direct contact with the person concerned. One of the most important aspects is the training of doctors and nurses, and it seems incredible that sex education and human psychology form part of the basic curriculum for medical students and student nurses in so few medical schools. Then I think that medical students and student nurses need far more education in communicating with the patient, because the G.P., who has the closest contact, is often too embarrassed to discuss many of the problems with his patients, although the spoken word is often very much better than a prescription for another pill or another drug.

I also attach a great deal of importance to counselling. I am a member of the Youth Service Development Council, and in our recent publication, Youth and Community Work in the '70s, we stress the tremendous need for counselling for young people. I understand that at Cambridge University a group of about 12 G.Ps. and social workers, has been set up as an experiment in counselling for students. Many people either receive no help at all or are sent to a psychiatrist, when their G.P. or a counsellor could help them if those people were only available.

Finally—and I must apologise for taking up so much of your Lordships' time—we must look ahead to the human result of the technology and automation about which we hear so much, and which we also feel, since it is all around us. The Minister of Posts and Telecommunications, Mr. John Stonehouse, referring yesterday to some of the wonderful computers that there are going to be in the '70s, when people will not even have to leave their own homes and can do all their office work at home—a situation which, it seems to me, is going to create a tremendous problem of loneliness and isolation—said that Britain in the 1970s would get a new and infinitely more refined and sensitive "nervous system" What I want to know is, what is going to happen to the nervous system of the individual? These are matters about which we must be taking a very much longer-term view than we have taken up till now. In America, these are subjects with which "think tanks" are concerned, but that takes the sort of money that we do not have to spare. But I do not think we can afford to leave the subject alone, as otherwise we are going to have a great deal of human disaster.

In conclusion, I really believe that health education needs to be taken much more seriously if it is to become a natural part of people's lives and upbringing. But this can be done only if there is a far bigger allocation of resources. The subject must be high on the order of social and medical priorities, and a bit could be pinched here and there from other places. The noble Lord. Lord Bernstein, who was introduced in your Lordships' House this afternoon, said in a speech yesterday that he thought that colour T.V. would cost the nation £600 million over the next five years, and that we could not afford it at this time. He compared this unfavourably with money spent on housing subsidies, roads and education. I should like to add to that list health education, because if there was ever a good investment it is spending more money on health education. This will produce high dividends in economic, social and human terms; and this, in my opinion, is one of the most important ways of enormously improving our mental health.

5.40 p.m.

BARONESS SWANBOROUGH

My Lords, like other noble Lords I should like not only to thank the noble Lord, Lord O'Hagan, for making to-day's debate possible, but also to tell him what he has been able to do for me, the impetus which he has given to my thinking and the tremendous impression and inspiration which he has been able to create. It has been said before to-day that this strength coming from youth is doubly valuable, and perhaps he will never realise what he has started by putting the Motion down to-day. If only I had his ability to sychronise my thoughts with my words, I should be a much happier woman.

But, having spoken of Lord O'Hagan, I should like my first tribute to be to the nurses in the mental and subnormal hospitals. I think it is a mistake to keep on talking about the bad things which have been said. I should like to hear people refer to the things they have realised as they have visited hospitals and seen what these women and men do. This is one case where the greater embraces the less, and that is why I put the women before the men! I have a feeling that anyone who travels the country and visits mental hospitals can only come back, as I do, humbled at seeing what these nurses are prepared to do and the way in which they do it. I think I have the right to say this because I represent a body which works in 105 out of the 190 mental hospitals and in 49 out of the 181 subnormal hospitals. Here, I am ashamed that the percentage should be so low, but I hope that we shall soon he able to make it much higher. One of the things I regret about this afternoon's debate is that more tributes have not been paid to the tremendous work that has been done up to date by mental health associations of a variety of different natures. I suppose it is because of my age that I can look back to the times when such things did not exist, and to the great efforts of the late Lord Feversham and others, and can look at to-day's situation, which owes a very great deal to these societies.

My contribution to-day, I fear, is only a very small one. I want to make one point, and one point only. It is to emphasise that the slightest contribution from the volunteer who makes even the lowliest gesture is of value, for it is the start of the involvement of the individual within the community and is of paramount importance. I think the realisation by that individual of his own particular responsibility within the community is the start of the effort we are anxious that individuals should make in participating in helping both with mental health patients and also with subnormal patients. I think this can be achieved only by contacts and the understanding that is bred of such contacts. To do this, a great deal of individual hard work must be undertaken.

The reasons why people are sent to mental hospitals are many, but it is mostly because of their disregard of the rules of society or because in some way or other they have become too difficult within their own environment and are either an embarrassment or a real nuisance to handle within the community. One of the really serious problems which has not been mentioned today is that life in hospital often results in an illness of isolation, and institutional neurosis. This often results in the patient's lacking confidence and being fearful of going back to live in the great world from which he has come.

It is often thought that it is difficult to find volunteers to work in mental hospitals, but this is not so. It is true that there used to be a shrinking away, and the start of work in such a hospital was something which had to be undertaken rather carefully, but once volunteers have found how easy and how tremendously worth while the work is, the catchment area can produce the volunteers required. The demand, as it should be set out, is for regular workers, both in the mental and in the subnormal hospitals; and, whether it be for a day a week, half-a-day a week or whatever it may be, the work quickly becomes interesting to the individual. The patient gets to know and trust the volunteer, and the volunteer begins to appreciate the reason for his contribution and to understand why he is needed. I do not have to tell your Lordships that mental illness touches all sorts and kinds of persons, but I would remind your Lorships that equally help in voluntary service can be given by all sorts and kinds of human beings. It is the person that matters, not the clothing or the cut of the hair. The very quiet, simple, unassuming housewife is a much more welcome helper, because of her understanding smile and gentle patience, than her counterpart with a rich car and a hasty manner. The help from youth which comes forward to-day is of tremendous value and welcome in every single way. It may not, perhaps, be uninteresting to report that due to a Motion in this House, set down by the noble Lord, Lord Willis, youth, together with a background of older people, undertook to build an indoor, heated swimming pool in one particular mental hospital—a hospital which has 1,200 patients. The matron tells me they have never had any shortage of nurses because recruitment is facilitated by the fact that there is a swimming bath.

There are many ways in which those who live in the area can help. Very often people do not realise how much they can do. They can help in a mental hospital with music or drama, with art or craft, with needle or paint-brush, with visiting or canteen work. The work in the mental subnormal hospitals is rather different and has its own problems. The social behaviour of the patients is unacceptable to the community, and their personal care needs constant supervision. They have not learned to live within the community, and so they are sent to an institution. Their surroundings are not what any of us would like, but we all hope that they are going to be very much better—and, here again, keeping in touch with the outside world, with the community to which they belong, is supremely necessary.

My experience is in the simple, humble things done by the volunteer—things done on a large and continuous basis. The provision of bright and gay canteens where the patients can feel that they are on their own and away from their usual hospital environment; the running of a shop; the provision of a club—these things are the beginning of a small movement towards the restoration of dignity and independence. As patients order and pay for a cup of tea and a cake for themselves they begin to realise that they can do the same thing for other people. They recognise that they can entertain a friend, and they immediately take the opportunity to talk to someone sitting next to them at the table— a table at which the electrician, the telephone operator or someone else has just popped in for "elevenses".

All these little things start the patient moving forward towards self-dependence. They come slowly; and these people need a tremendous amount of patience to help them, whether it be in the selection of sweets or of cigarettes. I have watched a woman take 15 minutes to decide whether she would have pink or blue suckers! One realises then what is necessary in the way of tolerance and understanding on the part of the people who are helping. The time taken when a man is trying to decide what sort of tie he should buy or a woman is deciding on the colour of the stockings she is going to get is something that is unbelievable unless one watches oneself. With all these things, volunteers can help. They can help with the reading of plays in the clubroom, and they can help with all types of things—things that are a start to the return to normal life, aided by the quiet, patient help that can be provided. I would ask your Lordships to believe me when I tell you how deeply moved I have been, again and again, watching a man sitting in a canteen with a cup of coffee and a large jug of hot water, eking out his coffee, with the aid of a great deal of sugar, to last as long as two hours, so as to be sitting at a place busy with the va et vient of the people who, to him, are the world, and being given a feeling of being among other people, a feeling of friendliness, a feeling of happiness. Shops and canteens teach the patients to make choices and to spend their money. Beauty parlours which have been started in some hospitals help the women to re-establish their own self-respect, and individual kitchens where cooking is reintroduced to the housewife are of tremendous help. Friendly visiting is of great value. This is a field in which a great deal more could be done by a great many people.

As the volunteer works in the hospital —and this is the theme I really want to impress on your Lordships—so does much understanding come to him, under- standing that as an individual within the community he can really do something and be responsible. As he returns to the community this understanding in turn is shared with others by talking to them and by suggesting to them that their help also is needed. So little, when it is provided by those who are thoughtful of the loneliness of the patients away from home and personal surroundings, means so much when one is in hospital. Those with whom I have talked and who have invited patients to their homes for tea (and use good china and good linen) are made humble by the appreciation shown by their guests. A garden tea party with posies of flowers by each individual's plate results in so much pleasure that the hostess is appalled to realise how much she could do if she only applied herself to it.

Voluntary service in its manifold shapes can teach individual members of the community something of the degree of tolerance which can be such a strong factor in influencing admissions to and discharges from mental hospitals. This is where the community is suffering from a lack of knowledge, lack of impetus and lack of energy. One is apt to think of the community as a whole instead of as a collection of individuals. I am sure that if those who make up the community were to realise even a small part of their capacity to help, the lot of those in mental hospitals and subnormal hospitals could be greatly helped. The reentry, such a difficult thing at any phase of life, could be made easier for the ex-patients as they return to their own background within their own community.

5.55 p.m.

LORD AUCKLAND

My Lords, first I should like to apologise to the noble Baroness, Lady Serota, and to the House because I may not be able to stay until the end of the debate. To-day is Prize Day at our local district hospital in Epsom. I had promised a long time ago to attend and I feel I ought to do so, if only out of loyalty to the staff of that hospital. I hope that I have the indulgence of the noble Baroness and of the noble Lord, Lord O'Hagan, whom I should like to congratulate on a most courageous and thought-provoking speech with which to introduce this debate. I should like to add my congratulations to the noble Countess, Lady Loudoun, on a particularly charming maiden speech. I am sure that we all hope to hear much more from her in the future.

My Lords, Governments of all political Parties come and go; but the mentally handicapped and the mentally sick are with us, however good or bad the Government may be. I should like to follow the noble Baroness, Lady Swanborough, in her typically wise speech when she said that we are a nation of individuals and not just a mere collection of people. Those who are mentally handicapped are, each one of them, single, individual people. I think it is a fair estimate to say that on average one person in eight or nine at some time in their lives has treatment for some form of mental illness. This happened recently to a very close member of my own family. It need not necessarily be something particularly serious; it may just be a nervous breakdown—which is a small thing compared to the illness of somebody who is severely handicapped for life. It is when we think of mental health along those lines that our attitude, whether contemporary or in the past, must really take a jolt.

The first experience I had of visiting a mental hospital, or an asylum as it was called at the time, was at a large hospital in Bedfordshire. It was still known as "the loony bin", but, thanks to a very enlightened medical superintendent, the lot of the patients and the staff—this was just after the last war and shortly before the National Health Service came into being—was a relatively happy one. I myself used to play billiards with some of the patients as well as with the medical superintendent and his son, whom I happened to know particularly well. Contemporary attitudes have changed. There are more open days in our mental hospitals. The hospitals on whose house committee I have the honour to serve has as its outstanding chairman of the hospital management commiteee a Member of your Lordships' House. We have heard his first-class speech to-day. Here we have an outstandingly good staff, a dedicated staff with whom those of us who are on the house committee work in close liaison. We visit the wards; we talk to the nurses; we talk to the patients. Some of the patients are very severely handicapped; many will never walk; many will never talk; but I repeat that they are all human beings and should be treated as such.

Much has been said about our nursing staffs. Perhaps we tend to think of a radius of 30 to 40 miles of London as containing the whole of our mental hospitals. Some forget that there are places like the Black Country, that there are places on Tyneside and places near Glasgow which are perhaps not as salubrious as those areas nearer London. But, my Lords, mental health in those areas is just as important, if not more so, and one should be particularly grateful for the work of the staffs of hospitals in areas where it is perhaps not so easy to gather together a "League of Friends"; or where the local Rotary Clubs or Round Tables are perhaps not quite so prolific in membership. However, I think it may fairly be said that what might be lacking in quantity would certainly be made up for in quality, because the people of those places are people with extremely warm hearts.

There is a large mental hospital in Hertfordshire—I read about it in the Sunday Times supplement the other day —which has something like 24 different nationalities represented on the nursing staff. There are a large number of hospitals, and certain other noble Lords and I attend the prize-giving ceremony of one of them. There almost all the student nurses come either from Commonwealth countries or countries other than Britain. We should be extremely grateful to these people. It hardly needs me to reinforce the view already stated that if these people who came from Spain, India, Hong Kong, Sweden and other countries went back to their own countries tomorrow, it would be no exaggeration to say that the National Health Service would break down.

I live in a town in which there are seven mental hospitals, dating back to the Victorian days when these places were situated in concentrated areas. Recently one of the evening papers carried out a picture probe among some of the local people. This probe was not very favourable to the hospitals in the area. The impression given was that the local people lived in a reign of fear. My Lords, that is just the attitude that I hope we are trying to dispel this afternoon. Of course, if you have a young family and if you have patients from mental hospitals in the area, there is some risk. There have been incidents on our local common in which young girls and indeed children of both sexes have been attacked, and every now and again it may well be that a patient from a mental hospital was responsible. But that is not by any means true in every case, and I think that our Press and television, who on the whole do a very good job in this connection, have a bounden duty to make this absolutely clear; because if the staffs of these hospitals are not loyally backed up by our communication media, no campaign by any Government or from any other source, to recruit nursing stalls will succeed.

My Lords, I conclude by saying this: the more people who can visit mental hospitals on open days the better. The more schoolchildren from private and State schools who are enabled to meet their less fortunate colleagues the better. We all have to realise that we in your Lordships' House to-day, who have our sanity, are no more or less human beings than those unfortunate fellow creatures who cannot walk or talk, many of whom are in our mental hospitals. As I see it, that is what this debate is all about.

6.5 p.m.

LORD PLATT

My Lords, as one of the medical Members of your Lordships' House, I should like to add my thanks to those of other noble Lords who have thanked the noble Lord, Lord O'Hagan, for his excellent opening speech and for initiating this debate. The noble Lord deliberately opened the subject very widely for us in his title. Naturally, he referred to the fact that he could not cover every aspect of it himself. Nor, of course, shall I try to do so. I shall confine myself—not I hope at too great length—to two questions, some points about community services, and something about the education, or I might almost say the non-education of doctors and medical students in psychological medicine. As I have never specialised in the field of psychological medicine myself I have consulted a number of eminent colleagues who are my friends, and I shall call on their material and quote from it when necessary.

There has been great progress in mental health in the last 25 years and developments of which I think we may reasonably feel proud. The opening of the locked doors in mental hospitals and the opening of the mental hospitals into the community have transformed the relationships between patients and staffs, both within the hospitals and within the community, and the attitude towards the needs of psychiatric patients. The establishment of psychiatric units in general hospitals, the more active therapeutic programmes of mental hospitals, have brought the image of the psychiatric patient closer to that of a physically ill person who requires medical care; and at the same time an increasing emphasis has come to be laid on the psychological, social and family facets of psychiatric disorders. This has had its effect on medical practice as a whole.

Yet, my Lords, the amounts of money invested in community care are quite inadequate to do anything like a satisfactory job. There are far too few social workers, and the role of these and other community workers, and the optimal form of organisation, requires more precise definition. There is urgent need for objective investigation into the quality of care of such individuals who are discharged from mental hospitals into the community. There is some evidence that areas in which the community services are exceptionally poor get more than their share of patients discharged from the local hospitals. Some of these patients tend to drift into inferior lodging houses, or into vagabondage. As one of my friends said, it has become accepted as a principle that the community should care for its disabled persons, be they physically or mentally handicapped, but nobody has really defined community care; least of all have they asked whether the community really does care. Moreover, the effects of these current trends on the family also require investigation. Families are expected to care for psychotics, dementias in old people and the mentally subnormal. What are the social consequences of this? There is some danger of a backlash of intolerance. It tends to be forgotten that there are not numbers of pairs of spare female hands available at home. The emphasis on community care has come to stay, but programmes will need to be developed and applied with realism, flexibility and humanity, if we are not to run into serious difficulties.

Turning now to medical education, and starting at the beginning, I must say that there is still a quite inexcusable lack of any proper training in psychological medicine, and in the psychological background which should precede it, in most of our medical schools— though many of them are beginning to wake up to the facts. The Royal Commission on Medical Education called attention to this in strong terms and also to the almost equal lack— can you believe it?—of sex education, even to medical students, in universities. I was glad that the noble Baroness, Lady Birk, referred to this point in her speech. This lack of adequate attention to psychological medicine leads to a vicious circle. Because of it good men are only comparatively rarely attracted into psychiatry. Thus there is a shortage of teachers and, of course, the inadequate instruction in psychological medicine goes on. Fortunately, there are now a few very important exceptions and some very good growing departments of psychiatry, psychological medicine, mental health—call it what you like—but they are usually inadequately staffed and provided for. There is a real need here for something to be done to encourage these departments with better facilities and more money to spend, more teaching time and more opportunities created for the personnel they train, so that in time—and it will take some years —we can build up a core of good research departments in psychological medicine and good teachers to go with them. Only in this way, by a new realisation of the importance of psychological medicine in medical education, will the vicious circle to which I have referred be broken.

Even those who do become teachers are mostly concerned with adult psychiatry and not with child, or (as it is better called) family psychiatry. The emotional development of the child is neglected in teaching and research. Yet only here can the beginnings of psychological illness be studied; and only through this study can the violence and instability of certain young persons be eventually prevented or at least mitigated. The proper education of future general practitioners in psychological medicine is equally important and should also have a preventive function. At present, far too few of them are equipped to deal with the everyday neuroses and anxiety states, and with the early symptoms of mental breakdown which form so large a part of their practices—though here, as everywhere, I know of honourable exceptions to the general state of ignorance, an ignorance for which, I repeat, the medical schools are largely to blame.

Recruitment to the field of psychiatry suffers in another way. Quite naturally, young men and women with inquiring minds have been caught up in the technological advances of our age and are attracted to the departments in which phenomena of organic and physical disease can be accurately measured and assessed; and are little attracted to the vaguer and more difficult disorders of behaviour, which often they find frightening and bizarre. This re-erects the barrier between disorders of the body and disorders of the mind which it is important to try to remove; and, as a result, psychiatry gets less than its share of the kind of individuals it most needs. Yet there are plenty of questions to be answered in the psychological field, plenty of opportunities for rewarding research. One way to attempt to break the vicious circle would be to do what I believe has been done in Sweden, for the Government to take action to endow in various universities and medical schools research departments in psychological medicine. It is believed by friends whom I have consulted that there would now be enough good men to make a start with departments such as these.

My Lords, I have spoken mostly from the doctor's point of view, though I am very well aware that in this field the doctor is but one member of a team. But other noble Lords have spoken of other aspects of the mental health services, and I am convinced that doctors have an essential role in creating the new attitudes towards mental health which the noble Lord, Lord O'Hagan, so rightly feels are necessary. But until medical education is drastically revised, the doctors will far too often remain reluctant, unconvincing and insecure in a field in which their good influence and guidance are so much required.

6.17 p.m.

BARONESS STOCKS

My Lords, I had intended to discuss two matters which seem relevant to this debate. One was the question of priorities in connection with public spending, but my noble friend Lady Birk has dealt very pertinently with that and given us some exceedingly vivid examples of the relevant expenditure on various services. The only thing I would add to what she said is to suggest that the money spent on the Concorde would go a long way if spent on mental health services.

The other matter that I wish to raise was referred to by the right reverend Prelate the Lord Bishop of Lichfield, when he spoke of fear of psychological treatment. With several other speakers, he pointed out that recent publicity given to deficiencies, and even abuses, in mental hospitals might have occasioned such fear. It is possible that there have been abuses, and we shall all agree that they should not be swept under the carpet: if they are not known, they cannot be remedied. There is no doubt that those sections of the Press and others who have given them publicity were not actuated by a desire to denigrate or frustrate the mental health services as such.

The same cannot be said of a sect which seems to have taken the field under the name "Scientology". For some months—indeed, I think, for a year—I have received, unasked, a great deal of literature from that sect. Much of it appeared to me to contain what can only be described as the ravings of lunacy. My first impulse was to consign it to the wastepaper basket, and that I did for some time. Then I began to think again and I consigned it instead to my neighbour, Lady Norman, who is a devoted and hard worker for the National Association for Mental Health, of which I believe she is Vice-President, because it seemed to me that this was getting beyond a joke. Such literature, if widely disseminated and likely to fall into the hands of ignorant or disturbed people, might indeed create a general fear of psychiatry, of psychology or of the mental health services, as such: because the literature that I received contained accounts of sadistic torture in mental homes and psychiatric units, of horrifying pictures of skeletons labelled "psychiatry", and of trampling on unhappy human beings. So it went on from week to week, and is, I believe, still going on. No doubt other noble Lords have been similarly visited. The existence of this attempt, as I regard it, to denigrate the mental health services raises for the citizens of a free country a rather awkward problem. We pride ourselves on our freedoms: on the freedom of the Press; on the freedom that we allow individuals to express opinions, even unpopular opinions, to persuade others to share their opinions; to conduct propaganda, and to issue literature on behalf of their opinions. That is part of the freedom which we, as a free country with a free Press, cherish, and, I hope, shall always cherish. But there comes a point, in face of the kind of propaganda which is being carried on by the scientologists, when one may have to compromise with that conception of freedom.

I understand from the evening papers that I saw a little while ago in the Library, which contain a report of this afternoon's annual meeting of the National Association for Mental Health, that members of that sect, who have apparently infiltrated the membership of the Association, succeeded in disrupting the meeting, which I gather from the Press has been adjourned. What the result will be, I do not know. But this raises a legal problem. What I really want to know is whether Her Majesty's Government are aware of this risk; whether they have made any inquiries into the teaching and practice of this particular sect and its possible effect on the mental health services; and, if so, whether there is anything they can do about it.

6.22 p.m.

LORD CRAWSHAW

My Lords, I should like to start by thanking the noble Lord, Lord O'Hagan, for introducing this debate to-day, because I feel that if ever a subject wanted a good airing, this is it. The problem of mental health is often swept under the carpet. In spite of progress in this field, I feel that there is still a great deal of misunderstanding, fear and mistrust. There is an element of "Don't know" and "Don't want to know". The composition of our planet has been explored, and outer space and the oceans are continually being probed. A tremendous effort has gone into the finding out about the rest of the human body and its ills, but the mind and the brain has been left severely alone. To my mind, mental illness still carries a social stigma. People continually express revulsion about discrimination in other spheres, and I hope that some of this might be channelled into expressing disgust at treating mental patients as something apart. The illness itself makes no distinctions: it is everyone's problem, and can strike quickly and cruelly. I believe that one in four families in this country is in some way affected.

Is the attitude which I have described reflected in the fact that although some 40 per cent. of hospital beds are filled by mental patients of some kind, mental hospitals are in comparison understaffed and under-financed? I believe that a psychiatrist may well have to look after 200 beds in a mental hospital, whereas his counterpart in other spheres may not have to look after more than 50. The situation at the Ely Hospital seems a natural result of understaffing and under-financing. But I, like other noble Lords, should hesitate greatly before trying to criticise staff, who have a very difficult job in any mental hospital, because I feel that they and the patients alike are victims of certain public attitudes. While on the subject of staff, I should mention that over 40 per cent. of junior hospital staff come from abroad, and though we are grateful to them this is not a satisfactory situation in regard to psychiatry, where we need the maximum communication between doctor and patient. Three hundred doctors a year leave this country, and, as I say, this is an unsatisfactory state of affairs.

I want to say a word about rehabilitation, re-employment and recirculation of mental patients. I feel that more should be done to bridge the gap between hospital life and the outside world. Here I support strongly my noble friend Lord Grenfell in his request for more hostels. I understand that in 1967 there were only 2,846 hostel beds available, and there is not much provision for sheltered employment and reserved jobs. This compares unfavourably with what is provided in other spheres of injury, disease, disablement and so on. In other spheres we have great work done by the Remploy Factory; and we have the 1944 Disabled Persons Act, which makes special provision for disabled people. I feel that this sort of attitude should be adopted with regard to the re-employment of mental patients. There is a crying need here, particularly when we consider that 32 million working days a year are lost to the country due to mental illness.

In all this, no progress can be made without research; and here I feel that as a country we are falling down badly. The Ministry of Health figures for 1967 show that the Health Service cost £1,500 million, out of which £610,000 was allocated for all research, and only £50,000 for mental research. The Americans, as I understand it, spend 4,000 times as much as we do on mental research. I realise that the National Health Service is under great strain, but I think we should appreciate that perhaps £1 spent on research could easily save £100 being spent on bricks and mortar in the form of hospitals.

To augment money available for mental research, the Menial Health Research Fund was set up in 1954, and has so far raised £400,000 to finance 230 different research projects. A sum of £50,000 has been distributed in the present year. I help to raise money in the East Midlands Division of this fund, and I have been greatly heartened by public reaction and support. A wide variety of people are involved. Those of your Lordships who read the sporting Press will have seen that the Wolverhampton Wanderers and Irish centre forward, Mr. Dougan, recently received eight weeks' suspension for saying something to a referee, or not saying something to the referee, whichever the case might be. But it is an ill wind which blows no good, and he has promised to use this time to raise more money for this fund, in addition to the several thousands of pounds that he has already been responsible for raising in the Wolverhampton area. I should like to take this opportunity of thanking him for the example he has given to all sportsmen and others by the great work he has done, and is doing. I believe that it is in no small part due to the efforts of people such as this that a revolution has taken place in recent years in the treatment of mental illness by modern techniques and drugs. I can personally vouch for the success of much of this. I hope that the Government will do all they can to encourage these spontaneous efforts, and that they might perhaps, for example, allow exemption from tax for money bequeathed to such funds.

I realise that much of what I have said is impersonal and unreal in terms of the suffering and hardship experienced by many people. I want to conclude my speech by mentioning just one specific case of a slightly eccentric friend of mine with whom I and several Members of your Lordships' House were at school. For the past 12 years he has been detained under Section 26 of the Mental Health Act. Apart from the odd week-end staying in my house and one or two others, he has had almost no contact with the outside world, his family or friends. In my opinion (confirmed yesterday by my noble friend Lord Elton, who is unfortunately not able to be here to-day) he remains remarkably cheerful and sane. Some six months ago a part-time occupational therapist at the hospital, with the consent of the hospital authorities, found him an outside job with an understanding employer. The day before he should have started someone at the hospital changed his mind, and he was refused permission to start work. He is now back in his old empty and frustrating routine with hopes dashed. In my view, unless something is done he will become institutionalised and without hope and liable to stay in the mental hospital for the rest of his days.

I mention this case to-day because it so happens that this man is, or is entitled to be, a Member of your Lordships' House. I thought it might illustrate that this problem is not far away from these four walls. I also mention it because it seems to me to illustrate a classic case of "don't know" and "don't want to know" attitude, a certain lack of communication between a mental hospital, the outside world and employment; and perhaps, above all, the chronic need for great research so that such cases of needlessly frustrated and wasted lives may be a thing of the past.

LORD PLATT

My Lords, may I intervene just for one second, before Lord Soper speaks, on the question of funds for research? Of course I agree with the noble Lord who has just spoken abort the need for more money. But we must not forget that the research funds in medicine, including psychological medicine, in this country largely come not from the National Health Service, but through the Medical Research Council, and through the University Grants Committee. I did not want that fact to be forgotten.

LORD CRAWSHAW

My Lords, I accept what the noble Lord said.

6.34 p.m.

LORD SOPER

My Lords, by this stage in this comparatively long debate I feel satisfied that the noble Lord, Lord O'Hagan, will have a quiet sense of satisfaction at the way in which the arguments have been deployed; and he has put us all in his debt for the initiation of this debate and for the quality with which he introduced it. Perhaps even more gratifying is the large amount of common ground that has been trodden by the various speakers and the large element of congruity in the kind of general results that have followed from the setting out of arguments and the describing of conditions. I should like to re-emphasise some of these common points. Let me begin by establishing unanimity with my noble friend Lady Stocks in her animadversions on Scientology. I think it is sufficient for your Lordships' House to read the "stuff", and that will have a converting influence immediately, and prevent any further contamination. The trouble is that there are so many suggestible people who are right for any kind of totalitarian offer, and I would cordially invite the Government to accede, if they can, to the general requirement that Lady Stocks was putting forward.

However, on the general theme of the debate, this is no comparative matter in the field of ethics or human behaviour. Your Lordships will have sensed the sense of almost the absolute in what has been described and called for in this debate to-day. I am reminded of the occasion when I listened to Dr. Inge comforting a number of undergraduates who were quite sure that there was no such thing as absolute morals. He said that there was, and he was challenged to give an illustration of anything that was absolutely wrong. He said that it was absolutely wrong to ill-treat a child; he said that it was absolutely wrong to mock the insane. I have never forgotten that second absolute. I was reminded of it a few days ago when I visited one of the great, large hospitals for mentally afflicted people, what has been cynically described as forming the "lunatic fringe" of London, stretching from Epsom, in the South, to St. Albans, in the North.

It happened to be the last day of this year's Indian summer: the countryside was resplendent, and the outward and visible signs of this large conurbation were equally attractive. It was my business to go to a closed ward. As I entered it, about 80 pairs of eyes were fixed upon me, and it was my job to try to talk to a number of people inside that closed, locked ward. I do not know whether I was more affected by the person whose eyes were fixed on me, and who said she could tell me of the room—which was very close—where they had the straitjackets, and where people were confined in chairs, or by the person with a blank look who told me that she was quite sane and was going to be released within a few days. The word "mockery" came back to my mind.

As I think of these things, I am well aware it would be foolish and churlish to fail to recognise that great changes for good have taken place; and that perhaps experiences in these large and, in my judgment, wrongly sited and wrongly formed hospitals are the residual legacies of the past, and no longer represent the intentions of Her Majesty's Government. The second unanimity to which I believe we have come is that the general direction to which Her Majesty's Government look, and the plans in the pipeline, are right. There may be modified rapture as to the pace at which they are going, but there is little contradiction as to the correct nature of this trend away from the whole area of stigma, and towards the area of community care.

I think your Lordships will also agree, however, that even if there is a marked movement towards better things there is still, if not stigma, at any rate indifference. One of the phrases colloquially to describe insanity is "round the bend". I believe that the vocabulary for those who are insane, as well as for those who are drunk, is probably more voluminous than almost any other human affair. When I think of "round the bend", I think of out of sight, for that is precisely, geographically, what "round the bend" means. As in our prison background, so with care for those who are mentally afflicted, there are far too many people who would prefer that the mentally afflicted are round the bend, so that they can no longer be seen; and in so many cases what the eye does not see, the heart does not grieve over. if we have been pricked in our consciences to-day and can communicate the sense of conscientious realisation to a wider community, we have done, I think, the first thing to break into this wall of indifference.

How will it be done? There has appeared in speech after speech the recognition of the block system, the large hospital catering, or pretending to cater, for a thousand mentally afflicted people, and of the intolerable strain on those who do the caring. Let me add my word of commendation and my word of humble recognition for the splendid work which is done, the self-sacrificial work which is done, and to echo what my right reverend friend said. He said he was surprised, as I think we all are, at the number of people who vocationally accept this unrewarding work and pursue it with such diligence. It nevertheless remains true that the proper care of those who are mentally afflicted must entail reducing the total numbers of those who are congregated together under conditions which militate against their own personal therapy. Therefore, how right, in my judgment, speech after speech has been in claiming that smaller units attached to local hospitals must be preferred to those vast conglomerations of 19th century huge residential premises, which were never really suitable and are now in so many respects a mockery.

I want to draw attention to one particular group: the rootless, unattached adolescents, of which there are far too many in London—and indeed it would be far too many if there were very few. I have it on the highest authority from those who, as in the Tavistock Clinic, have expert knowledge of this matter—and I have a little myself—that what is needed is far more experimentation, not only in day care but in residential care; and that residential care must be tuned to and geared to a variety of rootlessness and a varying degree of mental stress and difficulty. I am sure there is need for more approved hostels of the kind I know something about in the Catherine Price youth hostel. I am sure there is profound need for more hostels in which to care for boys. The tragedy is now that so often those who work in the Tavistock Clinic find in the end that the rootless adolescent ends up in borstal, where of course he cannot be refused. This is one of the experimental elements in your Lordships' debate which I am quite sure Her Majesty's Government have already intended to take seriously, and I hope they will be spurred by the unanimity with which this need has been expressed.

I will detain your Lordships to talk about only one other matter. I believe that mental health, as my noble friend Lady Birk exemplified in what she had to say, has more to do with social environment than have many other ailments from which we suffer. To put it simply, if I have a tooth that aches or if I contract gout—perhaps as a teetotal Methodist minister that is a more academic supposition, but suppose I were afflicted in either the tooth or the toe—therapy very largely would be directed towards that afflicted part; or at least such therapy would be directed to the individual who was suffering the affliction. But let me tell your Lordships a true story. Since the ingestion of the pill and the operation of the Abortion Act there has come a subtle and difficult change in the two hostels to which I have already given mention.

Once upon a time we calculated that if there were one disturbed girl among (shall we say?) 13 or 14 more or less stable girls, the effect of the stability would be reflected in an improvement in the condition of the unstable girl. But nowadays it is highly likely that those who come to a hostel—for instance, pregnant girls who are unmarried—will be those who are unstable, because of the opportunities that are now offered to more stable girls to avoid the troubles in which their less fortunate sisters find themselves. So it comes about that in these hostels today—I have checked it up within the last 24 hours—instead of having, say, 10 or 12 more or less stable girls (not ideal and not saintly, but stable) and one or two disturbed, the proportion is the other way round. This produces instability, or tends to produce instability, even among those who previously were stable.

The reflection which I would offer to your Lordships is that this question of mental health has far more to do with society, far more to do with the background and the environment in which people live. I reflect that, sometimes with kindness and not always with contempt, a place was found for the village idiot in the community of yesterday. It is possible that he would not find anything like that same place in the conurbations of today. As the noble Baroness, Lady Swanborough, said so eloquently, and as I should like to repeat out of an experience which for me grows almost daily, unless we are prepared to recognise that community care means care by the community, expressed by the totality of the community, alike in its corporate relationships and its family relationships, we shall be left with a residuum of mental ill-health which will become increasingly intolerable.

Therefore I would add my word of thanks to those who have initiated this debate, and invite those who would become volunteers to cheer themselves up with one reflection. It is my experience, and no doubt my right reverend friend also shares it, that ordinary decent people, if they are prepared with love and care to take into their own heart and mind and sometimes into their own house, certainly into their own environment, those who are at present mentally disabled, do not require to think that they are inadequate for the task. They require, obviously, the trained and occasional help from the psychiatrist—better still, I think, the parson, but that is another matter—but what is essentially demanded is the recognition that it is possible for decent, ordinary people to rise to heights of social and personal care, which I believe will have a greater therapeutic effect on the sum total of those who are now mentally afflicted than almost anything else I can think of.

6.47 p.m.

LORD VIVIAN

My Lords, it is always difficult to follow the noble Lord, Lord Soper, for he is a very experienced speaker. However, I shall not inflict myself upon your Lordships for more than ten minutes. Like other noble Lords who have spoken this afternoon in the important debate of the noble Lord, Lord O'Hagan, calling attention to contemporary attitudes to mental health, I wish to congratulate him most sincerely for initiating such a debate in your Lordships' House. The noble Lord, Lord O'Hagan, is one of the youngest Members of this Chamber a young man who has already proved himself in a thoughtful and brilliant maiden speech a few months ago. Like all noble Lords, no matter where they sit in your Lordships' House, I look forward to a great future for him in this Chamber.

Before going on to make my modest contribution to the debate, I should also like sincerely to congratulate the noble Countess, Lady Loudoun, on her maiden speech. My thoughts have been with her very much this afternoon, for every noble Lord or noble Baroness in your Lordships' House will recall the anxiety which he or she had to face up to when the day arrived on which they had decided to "take the plunge".

The stress and strain of everyday life in our present age is in a great way responsible, I feel, for much of our mental illness. In consequence, it is of vital necessity for any Government in power to keep a constant watch on the ways and means in which we may be able to improve our National Health services where mental health and the necessary treatments and hospitalisation are concerned.

In this connection I am firmly of the opinion that Her Majesty's Government are doing a good job, and, in common with other noble Lords, I greatly welcome the presence of the noble Baroness, Lady Scrota, on the Government Front Bench. I can think of no one in the Labour Party who is more fitted to undertake such high responsibility, nor can I think of anyone who would have devoted so much effort in the Ministry of Health and Social Security to the running of our mental hospitals. Your Lordships may have noticed that from time to time during the past year the noble Baroness has been absent from the Chamber. The reason was that she was visiting mental hospitals throughout England and Wales, trying to find ways and means of improving their administration, from the points of view of both the patients and the nursing staff. I felt very sincerely for the noble Baroness because of the many problems facing her. When she replies to the debate I wonder whether she can tell us how she has fared in connection with the existing problem of the understaffing of mental hospitals, for I feel that this is one of the major problems in the administration of our mental hospitals.

On May 15 last I spoke on the question of nurses' pay and conditions and pleaded for justice for the nurses in teaching and all other hospitals. What I said is recorded in Hansard of that day's date, and I need not go further into it this evening other than to say that I fear that justice has not as yet been done, although I feel sure that the noble Baroness and the Secretary of State for Social Services, Mr. Richard Crossman, have this firmly in mind and fully realise that justice in pay and conditions must be a priority in the National Health and Social Security Service. The speech made by the noble Lord, Lord Grenfell, this afternoon movingly underlined this.

Again in this connection, I am glad to see that the noble Lord, Lord Amulree, is to initiate a debate in your Lordships' House on a Motion for Papers asking Her Majesty's Government …whether they will consider the appointment of a review body to replace the present Whitley machinery dealing with the remuneration of nurses employed in the National Health Service in order to ensure that their pay is commensurate with their responsibilities. Then, perhaps the noble Baroness, Lady Serota, when she comes to reply, will also tell us what progress is being made in the social and welfare department within the National Health Service, for I have found from past experience that where mental hospitals are concerned there is some need for improvement, purely from the lack of teacher training.

To continue, those of your Lordships who have not experienced the great work which is done within our mental hospitals may not fully appreciate the difficulties that patients face when they are discharged. A patient is never discharged until such time as a psychiatrist is convinced that the patient is competent and willing and able to resume his or her normal responsibilities in the somewhat abnormal stresses of this day and age. it can and does happen that the patient may slip back. This is where a certain danger sets in, and that is why it is so necessary to have a broad and constant social and welfare follow-up. I am happy to say that, due to modern drugs and the skill of psychiatrists, so wonderfully backed up by a hard-working staff of nurses in our mental hospitals, there has been no reason for 90 per cent. of the voluntary patients treated to return for further treatment. Of the 10 per cent, who do return for treatment, I believe the main cause is due to lack of understanding by the general public of illnesses of the mind.

For this reason, I recommend that we should all do our best to try to understand the problems of such illnesses. It is my firm conviction that if this were done, the greater part of the other 10 per cent. who return for treatment would not have to do so. I do not exaggerate when I say that a chance remark, such as "Oh, did you know that so-and-so has just come out of a 'bin'?" can trigger off a subsequent mental breakdown in a person who has already received treatment. Do let us try to educate the public a little more with regard to illness of the mind. No stigma should attach to one's having had treatment for mental illness. As yet, I fear, this is not quite so. That is why I urge Her Majesty's Government to seek ways of educating the public a little further with regard to these illnesses.

There is one other point that 1 wish to make. I would implore any former patients who are in need of subsequent help, following discharge, not to delay in seeking their doctor's help, and readily to accept his advice if they should be urged to undergo further treatment as voluntary patients. I mention this point because from experience I have found that even one day's delay can result in at least one week's further hospitalisation. In saying this, I do not wish to add to the problems of the noble Baroness, Lady Serota. I do so simply with the idea of trying to suggest one way in which a quicker turn-round could be made.

In his excellent opening to this debate the noble Lord, Lord O'Hagan, said that the stigma is on the way out. I agree with him; but it has not completely disappeared, and I repeat that in my opinion it could be a thing of the past, provided that we continue to educate the public where illness of the mind is concerned. My Lords, I have spoken to-day as someone who in the past has accepted voluntary psychiatric treatment under the National Health and Social Security Service—treatment for which I am most grateful. In view of this, I considered that I should have been lacking in my duty and responsibility to your Lordships' House if I had not spoken.

6.59 p.m.

LORD SANDFORD

My Lords, I should like to start by congratulating the noble Countess, Lady Loudoun, on her maiden speech, and also on the subject which she chose as her main theme, that is to say, an appreciation of all that is being done in our mental services with so few resources. I should also like to thank the noble Lord, Lord O'Hagan, for having introduced this debate. It has indeed been wide-ranging. The noble Baroness, Lady Birk, took us into the fields of contraception and sex education. I do not want to say anything about that, except that I shall be glad if my two youngest children get through school before she gets any further with her plans.

BARONESS BROOKE OF YSTRAD-FELLTE

Hear, hear!

LORD SANDFORD

Then, my Lords, the noble Baroness, Lady Stocks, led us off on to scientology. I think it was a good thing that she raised this difficult subject, because it is a difficult one to deal with in a society that believes in free speech. Only the other day I heard from my honourable friend the Member for St. Albans and my friend the right reverend Bishop of St. Albans, who have had a similar problem with a self-styled college near that town which has already been the cause of a nervous breakdown by one of the people rash enough to attend it. If the noble Baroness, Lady Serota, is going to deal with this and would like more information, I can give it to her.

I should like now to turn to the question to which several noble Lords have referred; namely, the inadequacy of the resources committed to the treatment of mental disorders, and to follow the noble Lord, Lord Grenfell, and to some extent perhaps answer the point raised by the noble Lord, Lord Crawshaw. I think we can see how serious this problem is if we look at one or two figures. The cost of maintaining an inmate in an acute general hospital for one week is £45 11s. 1d; the cost of maintaining a convicted criminal in prison is £15 10s.; the cost of maintaining a patient in a mental hospital is £14 7s. 5d.; the cost of maintaining a subnormal patient in a mental hospital is £12 5s. 7d. Those are 1968 figures in respect of the hospitals and 1967 figures in respect of the prison. Surely something is wrong here.

On the question of staff, in the case of the care of the physically ill one nurse looks after one patient; in the care of the mentally ill one nurse looks after four patients; in the case of the mentally subnormal one nurse looks after five patients. Surely there is something wrong here, too. Take the case of consultants. In the case of physical illness we have one consultant to 19 patients; in the case of mental illness we have one consultant to 128 patients; in the case of the subnormal we have one consultant to 570 patients. Surely there is something wrong here as well.

Looking at hospital buildings, Her Majesty's Government, as the noble Baroness, Lady Llewelyn-Davies, pointed out, are following the 1962 hospital plan. This envisaged the development of psychiatric wings in general hospitals, and that was good. It envisaged the running down of the large, old mental hospitals, and that was good. But by that plan we shall still need beds for 92,000 mentally ill patients, leaving out the subnormal altogether, and in 1975 we may well need more. It is really quite unrealistic to think that enough money will be available, unless there is a very radical change, for 92,000 beds in those old hospitals to be converted to 92.000 beds in nice new psychiatric wings by anything like 1975. And if it were, would it be right to spend it on buildings and none of it on staff? The noble Baroness, Lady Llewelyn-Davies, did not indicate that we were going even to attempt to do this, but I think it raises false hopes to give any impression that we shall be able in the near future to sweep away all these old hospitals.

BARONESS LLEWELYN-DAVIES

My Lords, if I may interrupt the noble Lord, I did not give the impression that we were going to sweep them away in the near future. It was very specifically explained that I did not think we could.

LORD SANDFORD

My Lords, the noble Baroness will not mind my emphasising what she said, because I think it is important in order not to raise false hopes in the staffs who are going to have to work in these old hospitals for a very long time ahead. Still on the question of the inadequate resources for this field, I should like to turn, as other noble Lords have, to the question of research. The noble Lord, Lord Platt, was right to remind your Lordships that this is channelled through the Medical Research Council. The amount spent by that Council on mental disorder, which reached over £1 million for the first time last year, one might think was substantial and satisfactory. But this very large figure, or so it would seem, is only just over 8 per cent. of the Medical Research Council's total expenditure, the point at which it has been stuck for the last five years. If one considers—and several noble Lords have said this—that 40 to 50 per cent. of hospital beds are occupied by mental patients, 8 per cent. of the money spent on research seems to me very inadequate.

There is another factor which prompts me as a layman to think that this central effort on fundamental research is so inadequate, and it is this. If the noble Baroness will allow me to suggest a correction, I think it was in the 1930s that Sakel in Hungary introduced the insulin treatment; later on E.C.T. was discovered in Italy, leuchotomy in Portugal, and then, as she said, the French hit on the tranquillisers in 1950. All that constitutes advance and it is certainly very recent, though perhaps not as recent as was indicated. But it is an advance which has been made, I believe, by people stumbling on things when they were really looking for something else; and at least two of those forward steps have been based on theories about mental illness which have since been falsified. So far as I can understand, though treatment now proceeds, and indeed advances, there would still be very few experts able to give a comprehensive account of the fundamental causes of the main mental illnesses without any fear of contradiction from their colleagues. I believe that is the position.

I should have thought, in these circumstances, that the need for far more than the numerical share of any research was required on the mental health side. The applied research efforts of the pharmaceutical industry, which is about 16 per cent. of the total effort, is better than the M.R.C. is doing, but I would judge that neither is a match for the work to be done, and that here is really a case for grasping the nettle, as one noble Lord mentioned earlier.

I turn from this question of resources and the right balance to the centrality of community care in this field, which everybody has recognised and applauded. I believe that the Mental Health Act 1959, although, as the noble Lord, Lord O'Hagan, said, it was perhaps weak on the preventive side, will rate as a great turning point and one of the more far-reaching pieces of social legislation in the last decade. Last year, eight years after its coming into force, its main central concept of community care for the mentally disordered came true for the first time, when the number of patients in care in the community, 194,000, exceeded the number in care in hospital, 184,000—that is, mentally ill and subnormal taken together; the total case load of G.Ps. numerically exceeding both together. I submit that this marks the point after which we need to regard the facilities, such as they are—they have been immensely improved but they are far from adequate—in the community, and the care, such as it is, in the community, as the focus of treatment for the mental patient, and the mental hospital as the place to which from time to time and for fairly short periods of a week or so he goes for assessment and more intensive treatment.

However, the pattern of progress from community to hospital and back again varies enormously from area to area according to innumerable local factors, making it abundantly clear that it is virtually impossible to arrive at the optimum policy, from the patient's point of view, unless the hospital catchment areas and the local authority areas are made coterminous, so that the local policy for mental treatment can be formulated and executed by an authority that can decide the priority of expenditure and staffing for hospital and community and general practice within the same geographical area. It is abundantly clear, from what has been said in this debate, that this applies particularly to the psycho-geriatric problem. If something like this is not brought about, I see these poor, feeble minded elderly patients becoming a shuttlecock between these three services. Whatever balance of pros and cons there may be for the integration of the three parts of the National Health Service in other fields, in the mental health field the case for integration in coterminous areas is quite imperative and conclusive. Just as imperative and conclusive is the case for the integration of the social services for the mentally disordered, again within the same geographical area. Not only does it seem to me that the case for inclusion of the mental social services in area terms is well made in the Seebohm Committee Report, but so also is the case made for the psychiatric social workers to be concentrated in the local authority social service departments, once the integration of the three parts is achieved within the Health Service. I hope I make myself clear to the noble Baroness. Once that is done, it surely would be best for the psychiatric social workers to be employed in the social service department and seconded from there to the psychiatric hospital rather than vice versa, and rather than having their valuable and scarce manpower divided between two treatment agencies. It will be interesting to see how the Scots work this out because they will have to face it first. From the social service department and the local social service teams it should, I think, be possible in an increasing degree to second social workers on a part-time basis to general practice.

I should like to turn, and here follow the noble Baroness, Lady Swanborough, to the development of voluntary service in the mental health field. It is fashionable—though of course the noble Baroness knows too much about it to say so—to say that the main role of the voluntary organisations in social service is to plug gaps in the Welfare State; and, as the noble Lord, Lord Platt, said, there are certainly plenty of them, and big ones, in this field. That is not at all the main aim of the voluntary service. The main role of all voluntary service and voluntary organisations is to give the lay citizen larger and larger opportunities for bringing into being, and keeping in being, the kind of compassionate society which we all want to live in. The main role of voluntary organisations is to prevent our society from being shaped and moulded by the professionals and the bureaucrats because we are too indifferent or lazy to fashion it ourselves.

I do not mean any disrespect in this to the professional servants of the Welfare State. The British Welfare State, and particularly the mental health and welfare services, are as good as any in the world, and I join my tribute to those that have already been paid to the professionals working in them. But the professionals in the mental health and welfare services, as elsewhere, are paid not to do our work of caring for us, but to help us, as lay folk, to look after our families, friends, and fellow citizens more effectively, and to bring into the community more enlightened attitudes and higher caring skills. It is not the case that citizens are there to be gathered in to make good staff shortages in the statutory services. If my view on this is accepted, and I hope it is, it follows that the aim of any institutions, any part of the Welfare State, is to maximise voluntary service and to spread professional expertise as far and as wide as it can be got to go, not only to doctors, patients and social workers' clients bat to the families, friends and neighbours with whom the patients and tile clients live and work. That this is capable of being realised is shown by the report that the King's Fund have produced on the organisation of voluntary work in hospitals.

This movement, building on what had already been done by the Red Cross, W.R.V.S., the Leagues of Friends, and so on, and starting originally at St. Thomas's among the general hospitals, and Fulbourn at Cambridge among the mental hospitals, with the appointment of a full-time organiser in 1963, has led by now to the involvement of up to 400 volunteers in a single hospital. This produces 25,000 to 40,000 hours of voluntary help per annum, so in fact it does plug a manpower gap in a big way. However, that, I think, is not the main point. A voluntary organiser who can do this brings among patients and nursing staff a great mix of antique dealers, actresses, train drivers, computer programmers and all sorts of people, in their spare time; it brings into an otherwise detached and isolated community all this varied contact with the outside world. This is good for the hospital community and good for the community outside, and it is this great two-way process of knitting together which it is the main aim of the voluntary movement to promote. I very much hope that the publication of a document setting all this forward will encourage it to develop beyond the thirty or forty hospitals in which it now exists.

Finally—and I apologise for going on so long, but I think this is an extremely important subject—I should like to turn to the suggestion, which the Conservatives have had in their manifesto since the last election, of an inspectorate for the whole National Health and Social Security Service. It is very strange that the Government are taking so long to see the virtue of this proposition. They have accepted the idea that health and social security should be combined in one Ministry, and this is part of the same packet. One would have thought that when the Ombudsman was established—but, to the dismay of all, without powers to look into the Hospital Service—the alternative of an inspectorate for the Hospital Service would have been adopted. One would have thought that when Sans Everything and the Ely Report were causing so much concern, the advantages of having an inspectorate would have been even plainer. Exactly how it would be constituted, to whom it would report, to whom it would be responsible, are things that could have been discussed. There are plenty of models to refer to: the Police have their inspectors; the children have their inspectors; the Probation Service have also; but most apt of all is the greatly respected H.M. inspectors of Schools, to whom the whole education service, both statutory and independent, owes so much.

Speaking for myself, I am sure that the inspectorate, in contrast to the Hospital Advisory Service, which is not at all the right thing, should be independent of Whitehall, independent of local authorities. Its report should be published and available to the Press, and its aims should be to enlighten and form public attitudes by getting the firm facts to help the public to judge for themselves how the whole thing is going on and whether they are getting value for money, to appreciate what is being done in the service, to judge its efficiency and to judge the efficiency of the statutory and voluntary services and their partnership. Such an inspectorate would not be in any way responsible for policy, or for dealing with complaints, or for conducting research; but its activities over a span of time would be of immense assistance, I believe, for those who were responsible for policy, who had to deal with complaints and who had to put research in hand.

It is a constant surprise to me that there is so much defensiveness about this proposal, because, after all, people who are doing their best—as the great majority are—have nothing to fear from being inspected. Those who are doing their best will have their service publicly recognised. The people who want to do better and to get ideas from other areas, will have everything to gain from the reports published by the inspectorate. The people who are not doing their best ought not to be allowed to continue without being spurred on. No one to-day questions the appropriateness of exposing the activities of management and company directors to the scrutiny of the shareholders; in fact, the idea is now to have them open to the scrutiny of their work force as well. So I should have thought, as shareholders of the National Health Service—which is what we all are—that we had every bit as much right to help keep an eye on the whole show and see how it is going, and no more so than in this field of mental health where so much is changing, where so much experiment and evolution is in hand, and where through community care there are so many opportunities for personal services to some patients, and so much danger of neglect and isolation to others.

I make no apology for labouring this point, and I do not press any particular detail. But, like Professor Townsend, who is well-known to Members on the Benches opposite and to others who have seen their hopes for the British Health Service eroded, if not dissolving, I see no hope for any further advance in the services, no hope for due recognition of what is being done, and no hope of more enlightened attitudes to mental health, without a very radical change in the style of leadership that we are getting now; a much more ruthless facing of the hard and very serious facts of financial stringency and staff shortage which confront us; and an end of the unnecessarily defensive attitude in Ministries and statutory authorities. To set up a strong, experienced, independent, wide-ranging inspectorate is the first step to put this position right. I readily acknowledge that it will be a bold step to take, but I am sure it is overdue. This is a nettle still waiting to be grasped, but it is an agency which could do a tremendous lot to help us and to give this service the honour which is its due.

7.23 p.m.

THE MINISTER OF STATE, DEPARTMENT OF HEALTH AND SOCIAL SECURITY (BARONESS SEROTA)

My Lords, I think that all of us who have been in the Chamber through the long hours of this debate will recognise that our discussions here today are welcome, certainly to Her Majesty's Government; and I would say that in some senses the debate is even overdue. All our thanks, and mine in particular, are due to the noble Lord, Lord O'Hagan, for the most thoughtful and moving way in which he introduced his Motion. It has also given us an opportunity to hear from the noble Countess, Lady Loudoun, for the first time, and I join with other noble Lords in congratulating her on what I think we all agree was a most effective, informed and compassionate speech. This House, as I have learned in the last three years prides itself on the specialist knowledge of its Members and on the contribution they can make to particular topics in debate. In Lady Loudoun we clearly have a most valuable new addition to our counsels and I hope that, having overcome what to all of us is a considerable hurdle, she will now feel able to contribute freely and easily to our deliberations.

It is right that the services for the mentally ill and the mentally handicapped should be the subject of public interest and concern, and it would be surprising if this were not so. It would also be surprising if these services were not at times the subject of public criticism. I am sure that all those people who are responsible for these services, in whatever way and at whatever level, and who are anxious to develop them, welcome informed and constructive criticism, for it is in this way that we can measure our achievements, that we can make improvements and can extend further as the frontiers of knowledge, in this relatively new field of the care, the treatment and the rehabilitation of the mentally ill, advance.

I agree with the noble Lord, Lord Soper, who is always so wise in his thought that it would be fair to conclude from the debate that public attitudes have changed much more in the last ten years towards the acceptance and treatment of mental illness than they have to the needs of the mentally handicapped, who require support, help and care, of various kinds and in different degrees, from their earliest years right up to and into adult life. The noble Baroness, Lady Brooke, in what I think we all recognised as a typically practical, forthright and constructive speech setting the whole tone of our debate today, confirmed the view that I think all of us now hold, that the worst of the stigma of mental ill health is disappearing from our society, although clearly we still have some way to go until we see throughout the country the kind of constructive and positive attitudes which all of us would wish to see, including social acceptance of mentally ill members within the community itself.

As I have listened to the debate three main themes seem to have emerged from the many speeches that have been made. First, there has been the general discussion flowing from the terms of the Motion of the noble Lord, Lord O'Hagan, on changes in attitudes and the need for further change. Then several of your Lordships have dealt with the effect and consequences of those changes, including certain criticisms of services for long-stay patients and especially for the mentally handicapped. both children and adults. Finally, many of those who have taken part in the debate have spoken from knowledge, and very frequently from their own personal experience of the services, of the kind of action they think we should provide in order to develop more effective services in the future.

My Lords, in a debate of this kind it is clearly impossible for me to deal in detail with every topic that has been raised. My noble friend Lady Llewelyn-Davies of Hastoe dealt generally at the outset of our debate with the therapeutic revolution that we have seen beginning in this field of mental illness, and with general aspects of the development of services within the community for the mentally handicapped. I will of course study with very great care the Record of the debate and will consider the suggestions which noble Lords have put to me. But in replying to-night I shall in the main confine my remarks to those aspects of the services for the mentally handicapped which are causing us such concern and I shall try to indicate to your Lordships how the Government are trying to tackle them. I do this on the basis that most of us seem to have agreed during our discussion that the greatest changes, both in attitudes and in services, are now required in this field of our national and community health and social services. I think we should consider the developments that are needed for the future in the context of past achievements, which to my mind are more significant than the black spots which have claimed so much interest in the last six months. The noble Lord, Lord Sandford, talked about resources. I do not want to labour the point with figures, especially at this late hour, but in financial terms the rate of progress is this. In the last five years the Government have raised the annual rate of spending on local health authority and hospital provision for the mentally ill and the mentally subnormal by, on average, about 8 per cent.

My Lords, in trying to form a balanced view of the achievements in these services I shall do as I always do and try to begin at the beginning, and start with the children. In this field we are coil cerned with children whose care, treatment and training must surely be at the heart of our pattern of services for mentally handicapped persons of all ages. Several noble Lords have spoken about the changes that have already taken place, and my noble friend Lady Llewelyn-Davies gave the House at the outset of the debate certain facts and figures. But I am not sure, my Lords, when we think of the changes that have taken place, particularly in the last ten years since the passing of the Mental Health Act, and when we talk about the inadequacy of our services for community care, that everyone realises that it is the local authorities who to-day already care for the majority of mentally subnormal people—just under 100,000, compared with some 64,500 in hospital. In the child population, local authorities are, now making day and residential provision for about 28,000 children, compared with the 7,000 in our hospitals; and there are 20,000 children in junior training centres, including 3,000 of some of the most severely handicapped children for whom our society needs to provide in special care units.

Great advances have been made, too, since the setting up of the training council for the Teachers of the Mentally Handicapped, in training staff to work in the training centres; and it is these junior training centres, with which many noble Lords will I am sure be familiar, that have shown that these children are not ineducable. It is on this basis of achievement that the Government have decided that the training and education of these children should become the responsibility of the education service. This decision is one which I believe will be welcomed, and has been welcomed everywhere, especially by parents. Those noble Lords who have had the unenviable task from time to time, as I myself have had, of telling parents that their child must be excluded from school, will know what it will mean to parents of handicapped children to feel that their children will in future be able to benefit from the whole range of educational services and not be cut off from them under this ugly term "ineducable". I entirely agree with the moving speech of the noble Lord, Lord Grenfell, when he told us what a tragedy it would be if this new generation of youngsters, many of whom are better trained and socially much more competent than their predecessors, were to end up in large, long-stay hospitals because there was nowhere for them to live when their parents grew old—and this is a point I should like to develop a little later when I come to talk about changes needed in services in the future.

There have, of course, been vast improvements, too, in our hospital services, although I am only too conscious of the amount of public interest and concern that has recently been focused on our long-stay hospitals for the mentally handicapped. Over the past ten years, six virtually new sub-normality hospitals have been built, and there have been improvements and additions, as several of your Lordships know, to a great number of the existing ones. Unfortunately, the new provision has not always been reflected in an increase in the number of available beds, because some of these new buildings have admittedly had to be used to replace unsatisfactory accommodation and to relieve overcrowding. But all noble Lords have pointed out in their speeches that the day-to-day care of patients in our hospitals depends almost entirely on nurses. Nurse staffing and nurse training are clearly the critical factors in providing better services and conditions of work. Between 1949 and 1967 there was a large increase—some 47 per cent.—in the nursing staff of sub-normality hospitals; but their numbers are still quite insufficient in view of the heavier work-load imposed on them by the increasing severity of handicap with which they now have to deal. I hear this story from nursing staff wherever I go, and it is clearly a factor that we shall have to take into consideration as we plan our services for the future.

The expansion of the local authority services has enabled many more of the less seriously handicapped to remain in the community, while previously they would have required community care. As a result, the proportion of those in hospitals who are severely disabled has risen. I do not think there is a single Member of the House who is familiar with cur hospitals who would not confirm this particular trend in terms of level of disability, particularly in the field of the multiple handicapped in some of our long-stay hospitals. Furthermore, this is a problem which several noble Lords have mentioned as one that will be with us in the future, in that higher survival rates among those born with serious handicaps have increased the number of patients who will continue to live into old age. It is also quite true to recall at this point that whereas the number of staff in some hospitals in some parts of the country is sufficient to enable nurses to provide no more than the basic care for patients, it is absolutely essential that this scarcity should not be allowed to inhibit new ideas in training which nurses are now receiving for this difficult and taxing work.

To-day, nurse training in this field is oriented towards the development of the patient's full potential—his self-confidence, his self-help and his self-reliance—and the aim of nurses, in association with all the other professions concerned, must surely be to develop in each patient the maximum social independence of which he is capable, to prepare him to return to the community wherever possible, or to enable him to live as full a life as he can within the supported community of the hospital. But it is quite clear, from the changes we have already seen in the services, that further changes in nurse training will be required if we are to develop, and indeed to reflect, the concept that the care of the mentally handicapped in the future will extend beyond the conventional hospital. In a few moments I shall be saying something about the immediate steps we hope to take to improve conditions in our hospitals—a point on which I have been questioned by several noble Lords—and I have made this reference to nurse training at this stage because I am quite convinced that this is one of the areas where we need to see that there is rapid development in the immediate future.

Turning now to the question which has been the subject of so much discussion during the debate—namely, what are we doing now?—I think I can best answer in the context of what action my right honourable friend the Secretary of State and I intend to take. I would also say that we see these measures as an earnest of the Government's intent to improve the existing services and to develop new ones. My Lords, immediately following the publication of the Ely Report, which has been spoken of at some length to-day, my right honourable friend the Secretary of State set up a small, expert working party to advise and assist us in tackling problems which had been revealed in the existing services and to help us plan for the future. I am very conscious that the noble Baroness, Lady Brooke of Ystradfellte, asked me what had happened since the Report, and I am equally conscious of the time at which I am speaking. I would therefore, if she is agreeable, only tell her at this stage that some 38 of the 45 recommendations have been carried out. I am more than happy to give details of what is happening on the remaining seven.

Ely was, whether we like it or not, a watershed both in policy and in thinking in this field. In addition to setting up the working party we have reviewed and are reviewing the whole question of dealing with complaints, with the object of ensuring that anyone—patients, relatives or staff—who wishes to make a suggestion or a complaint should know how to make it and feel free to do so in the confidence that it will be properly and fairly considered on its merits and without fear of victimisation. If you were to ask me what I found the most disturbing feature of the Ely Report, it was that the nursing staff who complained about conditions had to go. The noble Lord, Lord Sandford, in a speech which I felt was somewhat at odds with the general tenor of this debate, was very critical of the Government's decision to establish the new hospital advisory service for the regular visiting and scrutiny of all hospitals, starting with our long-stay hospitals.

LORD SANDFORD

My Lords, may I interrupt at this point? I was not critical. I said that it did not, in my view, constitute any sort of substitute for a full-blown inspectorate.

BARONESS SEROTA

Well, my Lords, I am not quite sure what the noble Lord, Lord Sandford, means by a "full-blown inspectorate", but I hope we can come to that in a moment. We decided to establish this new service, which clearly is not the kind which the noble Lord, Lord Sandford, would like to see. I must confess that I found some of his remarks difficult to follow. if there was an urgent need for an inspectorate in the National Health Service I am surprised that this is the first occasion that he has brought the matter to our notice. But, in addition to appointing the Advisory Service—and I will say a word about that in a moment—at the same time, because of the urgent nature of the situation which the Report on Ely revealed, we immediately called all Regional Hospital Boards into consultation and asked them to undertake an urgent, comprehensive review of the conditions in our long-stay hospitals. The Director of the Advisory Service was appointed on November 1. Although I know that all Governments are slow. I would submit to the House that, in view of the major policy implications of the setting up of such a new service in relation to the National Health Service, this was very quick work.

The Director will arrange for teams to visit the hospitals not only to disseminate information on new, improved methods of care and treatment and training and provide advice to those working there, but also to convey from the staff concerned—and we regard this as equally important—particularly from those working at ward level, their views direct to the Secretary of State. The teams will be concerned not only with physical conditions in hospitals but also with their organisation and management. The Department of Health, the Regional Hospital Boards and individual hospital management committees will also be concerned with organisation in the hospital itself, and we hope that this promotional service, if I may put it that way, will enable those working in the Service to make the best possible use of the resources available.

I disagree with the noble Lord, Lord Sandford, in his belief that what he called a "full-blown inspectorate" should be the organisation that we should set up at this moment of time and in this situation. I, too, am very familiar indeed with the working of the children's inspectorate at the Home Office and the educational inspectorate at the Department of Education and Science. I think that if you were to ask either of those two bodies to-day what kind of role they see themselves as playing, they would say, "Promotional, advisory, consultative". And not the noble Lord's "full-blown inspectorate", which I regard as a rather "old hat" way of raising professional standards.

Initially this new service, as I have already indicated, will concentrate on the long-stay hospitals and will be concerned both with work inside the hospitals and with its relationship to the general practitioners, the local authorities, the general public and the community it serves—in fact, with all aspects of the health and social needs of the patient. We have at the same time given a great deal of thought to the development of a proper and clearly understood complaints procedure. The House will be aware from my recent Written Answers to the noble Lord, Lord O'Hagan, that my right honourable friend the Secretary of State is now preparing new guidance to hospitals on the handling of complaints and will also be consulting the professional staff and others interested in this matter as well as in the idea of a Health Commissioner, on which we feel it is essential to have the views of the staff before final decisions are taken about the kind of structure that we should set up. I can assure the noble Lord, Lord O'Hagan, that these questions of complaints procedures and all that is involved, be it through complaints procedures at hospital level or the introduction of a system of health commissioners, are matters very much in the forefront of our minds.

Clearly, a debate such as this is not complete without reference to nurses' pay and conditions. Several noble Lords have raised this question; and quite rightly. Since 1965 there have been two salary increases to nurses: one in 1965, up to 11 per cent.; and one last April, a salary increase of between 9 per cent. and 14 per cent. The last pay improvements cost the country £37 millions, and this comprehensive settlement should run until April of next year. I think I should remind your Lordships that in this last comprehensive review of the salaries of nurses, the "mental lead" of £50 was increased to £100 and extended to all grades of nursing staff in psychiatric hospitals, whereas previously it had gone only as far as ward sister level. The review body also recommended that paid overtime, which had previously applied only to students, pupils and nursing assistants in psychiatric hospitals, should be extended to all other grades in these hospitals up to and including ward sister and charge nurse. Both of those recommendations were implemented.

But in saying that, I am equally conscious that a new settlement is due to be negotiated by the Nurses' and Midwives' Whitley Council for application as from next April. We are expecting the staff side claim very shortly and then negotiations will begin. In this context, those of your Lordships who are regular readers of the Morning Star will recently have seen a long article by the general secretary of the Royal College of Nursing stating that they do not intend to by-pass the official machinery and to go round the Whitley Council in their activities. I say this because one is only too conscious of the level of public interest in this question of nurses' pay. We know the great affection in which the public hold nurses. I put the timing of the pay negotiations on record in this debate because I think it is a matter constantly in people's minds.

I should like to thank the right reverend Prelate the Bishop of Lichfield, as a member of his Regional Board, and also those noble Lords who serve as members of hospital management committees, for the efforts they have made since April 1 this year to re-allocate expenditure to give greater weight to the needs of our long-stay hospitals. It is not easy, my Lords, as those of us who have served on these bodies know, to change your allocations in the middle of a financial year, and this is what we had to ask Regional Boards to do in view of the very urgent and pressing problems which the report on the conditions at Ely Hospital revealed. As a result of their efforts—and I am only too conscious of some of the agonising decisions in which this must have involved them—the Regional Boards this year managed to devote some £2 million, which otherwise they would have used in other ways to improve conditions in our long-stay hospitals of all kinds. They have used it to recruit extra staff to develop schemes of staff training; to provide patients with personal clothing—a matter about which we are all concerned—and to provide lockers and better standards of decoration. As I have gone round the hospitals it has been possible to get some little idea of what this has meant to staff in some of our long-stay hospitals.

My Lords, this of course is only the beginning, and my right honourable friend has decided that a further £3 million, which represents an increase of 7.3 per cent. of the revenue estimates of the subnormality hospitals, will be made available to Regional Boards in the coming year to be used solely for improvements in subnormality hospitals. We are at present considering targets, immediate for the coming year, and continuous in terms of a five-year plan, so that we may guide and help hospitals where they need our help and show them the most effective ways in which these additional funds may be spent. I know that the noble Baroness, Lady Brooke of Ystradfellte, is concerned about the whole range of immediate short-term measures. The noble Lord, Lord Sandford accused us of raising false hopes. I think I can do no more than give some kind of indication of the way our minds are going.

The Secretary of State and I have on many occasions spoken publicly and said that one of the things we can no longer tolerate is that less should be provided for food for the mentally handicapped than for other long-stay patients; and we are determined to close the gap that exists between the standards of cost of provisions. This, my Lords, must be one of our top priorities. It will cost £1 million, but we shall be having discussions with Boards about making this money available. I see that the noble Lord, Lord Grenfell, is shaking his head, but those of us who talk to the staffs in our long-stay hospitals must be only too conscious of the fact that eating is one of the few pleasures in the lives of the mentally handicapped patients. I simply cannot understand why it is possible to make adequate provision for a mentally handicapped person for 26s. 5d. a week whereas it costs 33s. 10d. to provide an adequate standard of diet for a psychiatric patient. Mentally handicapped people are not ill, and we find this difference quite indefensible.

The other matters which we shall be discussing with Regional Boards who work out allocations of this additional money relate to staff and the use of volunteers. We must devise ways of lightening the burden on nursing staff. The noble Baroness, Lady Brooke, mentioned that they had inadequate domestic help. I think it also fair to say, as the noble Lord, Lord Platt, pointed out to us, that they have inadequate medical help; the noble Lord, Lord Sandford, gave us the figures. We need more medical help in our long-stay hospitals; we need the help of a whole range of professional skills; occupational therapy; chiropody for the elderly; more help with the education and training and play facilities for our children in long-stay hospitals. We also need to initiate the new training schemes that I mentioned earlier, if necessary by the appointment of training officers, and we also need to do something about staff accommodation.

I have mentioned food as the first priority. The problems of personal clothing, which so many people have mentioned to-day, will present certain difficulties, as we all know; and we think that this kind of situation may perhaps be tackled over a slightly longer period—shall we say a two-year programme? I will mention our suggestions in relation to volunteers in a few moments when I turn to the need to encourage community involvement and participation in the work of our services in the field of mental health.

The other short-term measures include the building of two experimental demountable ward units, one in the North-East metropolitan region area and one in the Midlands, to see whether these buildings, which are comparatively cheap and quick to erect, can assist us in easing the overcrowding situation. So often, my Lords, it is not possible to relieve overcrowding because, let us face it, there is nowhere to care for the patients while improving and upgrading, and providing what all of us would regard as absolutely basic minimum standards of care. We have also commissioned a team of outside experts to undertake as speedy an evaluation as possible of various types of hospital buildings which have been used for the mentally handicapped and which have been completed in the last few years. We expect their first interim report in January.

I was delighted when the noble Baroness, Lady Brooke, pointed out to us that we should not make the mistake of thinking that all improvements we wish to see simply require extra money. As she said, a great deal may be done without money. A great deal can be done to improve the quality of life of our patients. There is the whole question of the better day-to-day organisation of services within hospitals, and also the point which several noble Lords have stressed; namely, better communications between staff of different grades and disciplines. All noble Lords have agreed that there is a need to encourage even further development of closer links between the community and the hospitals. We need to encourage more help from voluntary bodies and relatives so that the patients may have outings and feel less isolated, and so that arrangements may be made for patients to go shopping and to go to their local stores. I must not give Lord Sieff's firm another "plug", but I think we all know where they want to go. There is another matter to which I attach very great importance; namely, that hospital management committees should look at the times of their meetings to see whether they cannot bring active younger members of the community into the work of hospital management and hospital visiting. These are some of the immediate steps that we have taken, and are taking, to remedy what we accept as defects in our present situation. We are also very much involved in planning the services for the future. This clearly is a very complex operation and, as several noble Lords have said, it involves the reorganisation of our National Health Service and our personal social services—and indeed the restructuring of local government. The position of Her Majesty's Government on this question was, I think, made very clear in the Gracious Speech. After Christmas we shall be introducing legislation, following the report of the Seebohm Committee, and we shall also be producing a Green Paper on the reorganisation of the National Health Service and proposals on Maud. We accept—and I must confess that this was the only point in the speech of the noble Lord, Lord Sandford, with which I wholeheartedly agreed—that the personal health services, the personal social services and the reorganisation of local government are inextricably interlinked. It is in this context that the Government are looking at the future structure of these services. But whatever form the structure takes, it is clear from all that has been said today that effective services for the mentally handicapped will continue to require close co-operation among a whole range of services, however they are organised. I think that our aim and our thinking is to build on the fairly solid structure we have achieved in helping people to live outside hospitals, and especially to emphasise the need to develop preventive services for children.

My noble friend Lord Soper, from his great knowledge and experience in this field, reminded us that there will be a need for a considerable expansion in the provision of homes and hostels for children and adults. Local authorities have in prospect in their future planning some 2,300 residential places, but we think that this will need to be at least doubled. For adults they have over 4,000 residential places and plans to build by 1972 another 86 hostels, with an additional 1,860 places, but again a great many more places than this are going to be needed if we are to do what so many noble Lords have asked us to do—that is, to prevent unnecessary hospital admissions and enable more patients to be discharged.

My noble friend Lord Soper made a plea for experimentation in this field, particularly with some younger groups, but I agree with him that hostels could well become a gimmick, if I may put it in that way. We need to provide a whole range of services and the more varied the range the more likely it is to meet the needs of individual patients. There are so many kinds of hostels, and if my noble friend and other noble Lords interested in this field can persuade people to try all kinds of experiments, I know that my right honourable friend and I will be deeply grateful.

I have mentioned the advisory group that we set up at the beginning of April to help us with planning both the short-term and the long-term strategies which we need to tackle the problem. One aspect of our consideration which has broken new ground is that we have had a two-day residential consultation (if I may call it that), with a whole range of people working in the services. It was very good, and I found the noble Lord, Lord Grenfell, there, whether in his capacity of chairman of a hospital management committee or of treasurer of the National Association for Mentally Handicapped Children, I do not mind. A whole range of people gave freely of their experience and knowledge, generally participating with Ministers in planning new services for the future. In a few weeks' time we are going to have a day with the nurses to do just the same thing. And when I say "nurses" I do not mean only matrons and chief nursing officers; I mean nurses from the ward level. Only in this way will we develop a realistic and practical policy. We cannot think out policy in the isolation of Alexander Fleming House. We are trying hard to get the views of as many people as possible on the kind of ways in which we should develop.

At the same time, we can develop on the solid findings of a number of feasibility studies which the Department has been undertaking. One is on the development of psychiatric services in a joint co-operative scheme with the Regional Hospital Boards, general practitioners and others concerned. A second is concerned with model services for the mentally handicapped and a third, perhaps even more ambitious, has just been started in the North Eastern Metropolitan area, where the object is to bring together the services for the mentally handicapped and those for the mentally ill.

All these discussions covering the points I have mentioned, and many more, form part of the Government's major reappraisal of all aspects of the services for the mentally handicapped. We hope to complete this wide-ranging study by early next year, and we shall be publishing a policy statement for public discussion soon after the publication of the Green Paper. I can assure the House that we are determined to tackle these problems and not to neglect them or, as I believe the noble Lord, Lord Vivian, said, sweep them under the carpet. I hope that the account that I have given to the House of the measures we have taken and intend to take and the special injection of funds which we are making available in the coming year, will testify to our determination in this field.

Many tributes have been paid to-night to the work of the staffs of our services to the mentally ill and mentally handicapped. I am most grateful for all that has been said by noble Lords, and I am particularly grateful to the noble Lord, Lord Vivian, for his kind comments about the work my right honourable friend the Secretary of State and I are trying to do. We have been visiting hospitals and local authority services extensively up and down the country during the last few months, and wherever we have gone we have been deeply impressed by the concern for the patients, by the personal kindness and by the stamina, which seems to us to be the special characteristic of the staff of mental hospitals. As our knowledge of the difficulties has increased by seeing them actually on the spot, although admittedly from what I call the "V.I.P. catwalk", so has our regard for their work increased and so, too, has our determination increased to create a situation which will enable them to do their jobs better. If this debate has done nothing else, we see it as yet another step forward in arousing the public conscience to the stresses to which those who work in our mental hospitals have been subjected.

I should also like to take this opportunity to thank the workers in all the voluntary organisations, such as that of the noble Baroness, Lady Swan-borough. the Women's Royal Voluntary Service, the National Association of Mental Health, the National Association for Mentally Handicapped Children and the Spastics Society, to mention just a few. These organisations have laboured in this field for a very long time and as the noble Baroness reminded us, in the past the voluntary organisations have pioneered many of our social services. We believe that they will need to continue to play an active role not only, as the noble Lord, Lord Sandford, said, to fill the gaps in the statutory services and to mobilise enough resources to provide this additional and, I think, necessary impetus for continued development, including experimentation in the forms of care, but also, above all, I would say, to enrich the quality of the services offered. I think all of us believe that there is in the public a vast amount of good will, which can be of immense practical assistance in the struggle with these problems.

I was in a large long-stay hospital on Monday morning, a hospital which has great difficulties and a considerable degree of overcrowding and concentration of patients with multiple handicaps. It was perhaps the most cheering thing that morning for me to hear that a group of boys was coming from a local school to help in the wards. The staff told me that at the beginning, when they heard that the boys were going to come, they wondered what on earth they were going to do; but they found that when they came they were prepared to do anything, and to do it with pleasure. That, I think, is a fair illustration of the kind of reservoirs of help that exist, and, I would say, particularly among the young. That is why, again, we feel that one of the first short-term measures, one of the ways in which this new injection of money can be used, is to extend the scheme to which the noble Lord, Lord Sandford, referred, and have paid voluntary organisers.

My Lords, various other questions have been raised, including scientology and a whole host of others. I hope that, in view of the time, noble Lords will allow me to answer them individually. In the last resort, and in conclusion, one conies back to the point of Lord O'Hagan's Motion namely, "public attitudes". I see this debate as part of a much needed wider campaign to help the handicapped, a campaign in which Government, both central and local, hospitals, voluntary associations, individual volunteers, staffs, relatives and parents must work together to improve the service. The community as a whole, as so many noble Lords have said, must accept its responsibilities for the mentally ill and mentally handicapped, and neither deny them nor hide them away in isolated institutions.

I am beginning to feel that, when the day comes when there is not a single local protest about the setting up of a hostel in a residential area, and when there is not a single child or adult in our long-stay hospitals who never receives a visitor, then we really will have changed public attitudes. I thank the noble Lord, Lord O'Hagan, and all who have taken part in this debate. I hope that it will serve a useful purpose.

LORD GRENFELL

My Lords, before the noble Baroness sits down, could she kindly inform me whether the Government have considered, or will consider, what I asked for; namely, a certain amount of monetary help to those who have their children at home?

BARONESS SEROTA

My Lords, I think the noble Lord, Lord Grenfell, is aware that this is a matter that we have under consideration, and one to which I may say without giving away any secrets, the Government are very sympathetic. I must ask him to await the publication of the Government's new Social Insurance Bill, and to look there at some of the provisions suggested in it.

LORD O'HAGAN

My Lords, I do not really know what to say. I, at least, after all these hours cannot take in any more. So may I just thank all speakers most sincerely, and beg leave to withdraw my Motion?

Motion for Papers, by leave, withdrawn.