§ 3.5 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Elton)My Lords, I beg to move that this Bill be now read a second time. The Mental Health Act 1959 was a landmark in the development of care for the mentally disordered. It established many important principles. Among them are those which require that where care and treatment in hospital are needed, they are given upon a voluntary basis wherever that is possible and that, in those few cases where compulsion does prove necessary, it must be subject to strict controls. I doubt whether anyone would challenge those principles today; this Bill seeks to amend the 1959 Act but it does not challenge those principles. On the contrary, it seeks to ensure that they are more perfectly implemented. The Government still see the 1959 Act as the foundation of modern practice in providing for 934 those few mentally disordered people for whom compulsory powers are needed. Some of those patients are offenders, detained as a result of court proceedings; others have been convicted of no offence but are admitted to hospital and there detained under applications made by those empowered to do so under the Act. These people comprise only a fraction of the mentally disordered in hospital. As for the number under guardianship at any one time, it is likely to be only about 130.
The numbers may seem small, but the importance of this Bill should not be judged solely upon the number of people it affects. It touches upon principles of profound importance affecting the liberties and rights of those of our fellow citizens who are, perhaps, least able of all to look out for themselves. The workings of this part of the 1959 Act have been under scrutiny in one way and another for a considerable time. If I go back no further than 1975, your Lordships will immediately recall the report of the Committee on Mentally Abnormal Offenders. This committee was chaired by my noble friend Lord Butler and I deeply regret, as I know will all Members of this House, that he is unable to be with us today. I hope it will not be long before we see him in full health in this House again. However, my noble friend was kind enough to write to me last week and in part of his letter he said:
I would be perfectly happy if you would tell noble Lords that I support the Bill in its various aspects, including those referring to my own Report".In the same letter he expressed in general terms a wish that we could go further in implementing the changes suggested in his report or in the Blue Book on the Mental Health Act 1959. I know that other noble Lords share that wish. Let me say at this stage that the Government's mind is not closed to any reasonable proposals. We are not bound to party lines on this legislation. There are none. This is a non-political Bill. There are, however, two considerations that will bind the Government. They are the interests of the people affected by the legislation and the question of practicability. Much of this ground will, I think, be suitably tested at Committee stage, but may I draw to your Lordships' attention one important consideration. The instrument that lies to our hand and for which parliamentary time is available is a Bill to amend the Mental Health Act 1959. Much of what some noble Lords wish to achieve can only properly be accomplished by the amendment of other statutes. Thirty-four of the recommendations made in the Butler Report relate, for instance, to the Criminal Procedure (Insanity) Act 1964. This Bill is not an appropriate instrument for that purpose and a separate Bill would be needed to accomplish it.On the other hand, I am glad to draw your Lordships' attention to our provisions, for instance, for remands to hospitals and for interim hospital orders. These arise directly from the Butler Report and are already in the Bill. There are others, such as the proposals on the treatment of patients without their consent, which have come into the Bill from Butler via the 1978 White Paper. By one route or another 17 of my noble friend's recommendations which require legislation have reached this Bill. It is also the Government's intention to implement a further 10 recommendations 935 relating to admission to and discharge from hospital of offenders; but legislation is not necessary for these. It will be done by the issue of official guidance.
If I were asked to list briefly the most important and beneficial provisions in this Bill, they would be: the requirement that, except in particular circumstances, people should not be admitted to detention for treatment in hospital if their condition is not treatable; the provision of much more frequent access to mental health review tribunals; the more stringent regulation of the use of treatment without the consent of the patient; the institution of a special health authority, with particular responsibility to oversee the powers to detain and treat patients under the Act; the institution of interim hospital orders; the power to remand to hospital for assessment; and, I think, the limitation of the powers of a guardian to apply only to people over 16 years of age and their curtailment to what is strictly necesssry.
Legislation by amendment is never a simple matter, and the 51 clauses of this Bill provide no exception. For that reason, we published together with the Bill a White Paper which I hope your Lordships will have found, or will find, a useful aid to interpreting its provisions. That White Paper does not follow the sequence of clauses in the Bill. For the sake of clarity, it picks up a series of central concepts and draws to each the relevant provisions wherever they appear in it. In Committee, of course, we have to follow a different convention. We have to follow the sequence of clauses, and I will now try to summarise them briefly for your Lordships in preparation for the next stage. As there are 51 of them, however, and as the White Paper is available, I hope I may be forgiven if I by-pass a few and lump some of the others together.
Part I of the Bill contains two clauses and deals with definitions. Your Lordships will note that the term "mental handicap" is to replace the more familiar and the more pejorative term of "subnormality". I think I should, at this point, mention to your Lordships that I am aware of a body of opinion forcefully held by distinguished people that mentally handicapped people ought not ever to have been included in the principal Act and that one purpose of this Bill should be not to change the nomenclature but to take them out of the Act altogether. I certainly appreciate the strength of the conviction with which this view is held.
I know that it is held by my noble friend Lord Renton and that he has the very weighty support of MENCAP, of which he is the distinguished chairman. His views carry for us an extra interest and an extra weight, because he was himself Parliamentary Under-Secretary of State at the Home Office when the 1959 Act was passing into law. Indeed, I believe that he was actually responsible for the whole of Part V. I think that this concern springs from a desire, which I share, to make clear in the minds of all—particularly of those who administer justice and who keep the peace—that mental handicap is an unalterable condition, usually acquired before birth, whereas mental illness is a treatable condition acquired at any age. The conditions are not the same and to have them lumped together in one Act of Parliament obscures the difference.
Being aware of this view and of the strength with which it is held, I have tried to see what can be done, 936 and it is not as much as my noble friend would wish. At present, to separate the two conditions within one Act of Parliament is practicable; to separate them into two different Acts of Parliament is not. We can make the distinction that many people want by consolidation. The rest of the 1959 Act has been much amended, and consolidation will, in any case, follow close on the heels of this Bill. Consolidation takes very little parliamentary time, but legislation takes a great deal; and time for two Bills on such closely related subjects is not in any sort of prospect. I earnestly hope that we can keep some such end in view, but we should not delay the passing of this Bill, which embraces so many objects which all of us want to see accomplished, by trying to use it for a purpose to which it is not suited.
It may, of course, be argued—though I hope it will not—that the provisions in the Act that we are now amending for the mentally handicapped and the severely mentally handicapped are unnecessary; that they can simply be deleted, rather than being transferred into a separate statute. I wish that were so, but it is not. Nor do I think that it would be in the interests of the people concerned if it were. Mental handicap leaves some people with the biological drives of adults and the minds of children which cannot dependably control them.
It simply is not the case that they can always be cared for in the community. Mentally handicapped people differ from one another very much. Some make very agreeable friends and delightful members of the family. Others are best cared for away from home and some are very much in need of detention and can, in fact, be very violent. I have a catalogue of cases which I may have to deploy in Committee, but which I shall not draw upon now. Suffice it to say that every case shows a person with no classifiable mental disorder other than mental handicap who should never go to prison. There are cases among them of such people eventually emerging from the stabilising influence of hospital to return and live in the community.
It may be argued by some that, when a mentally handicapped person becomes violent, he is suffering not only from mental handicap but also from some form of mental illness. I am not a doctor, but I can only say that the people who have made the diagnosis in the catalogue of cases that I have read were doctors, and they were convinced that the patients' condition amounted to mental handicap only and that they were not mentally ill.
There are, again, some who would say that it is axiomatic that no person suffering only from mental handicap can need to be detained in hospital, either for his own safety or for anyone else's, and that, therefore, the diagnoses must ipso facto be wrong. To test this axiom, I have to turn to a more expert authority than my own. The weightiest opinion that I can find is that of the Royal College of Psychiatrists. That is the professional body for trained psychiatrists and comprises a vast body of clinical experience. It is their expressed opinion that there is a very small minority of mentally handicapped people without any other mental disorder, who need to be detained in hospital. That opinion may be regretted; it may be questioned. My noble friend Lord Renton has questioned it in another place and I expect him to question it again here today. But the fact remains 937 that it is the most authoritative opinion we have available to us and I have to accept it.
If we were to take mental handicap out of the Act, a few—a very few—people suffering from it would be denied the stabilising care which they need. What is more, on the appointed day a considerable number of other patients—some hundreds—would cease to be detainable anywhere and some of them would, I fear, without doubt constitute a considerable threat to the public. That is not an acceptable result.
I return now to the text of the Bill and to Part II, which deals with compulsory admissions to hospital and to guardianship. The power of compulsory admission in an emergency has become the most widely used of all the compulsory powers. In 1979, nearly 8,400 patients were admitted under this power. This frequent use was never intended, and the Bill suggests changes in prodecure to help ensure that the power is used only when there really is an emergency. Clause 3 (3) also restricts the right to make an emergency application to the nearest relative—rather than any relative—and the mental welfare officer. On the subject of mental welfare officers—if I may be forgiven for stepping, for once, out of sequence—the Bill provides in Clause 43 for their replacement by specially designated and specially trained social workers, who will be known as approved social workers.
The power of compulsory admission for 28 days for obversation is a power which has proved useful. However, we want to introduce an important new safeguard for patients subject to it, and Clause 3 provides that, in future, they will be able to make an application within the first 14 days of their detention to a mental health review tribunal.
Clause 4 provides for changes in the grounds for admission to longer-term detention under Section 26 of the Act. These are designed to make sure that this power is used only for the purposes of treatment. The clause makes a new special provision for those suffering from psychopathic disorder or mental handicap. It provides that no such patient may be admitted under this power, unless medical treatment is likely to alleviate or prevent a deterioration of his condition. We have taken to referring to this as the "treatability" test and we shall doubtless use this term in debate. It replaces the existing provision, that patients, other than offenders, suffering from psychopathic disorder or mental handicap may not be detained after they reach the age of 21. We now know that some people over that age and suffering from those conditions can benefit from treatment, while others under that age may not.
Under Clause 12(5), the conditions for renewal of detention are also strengthened. First, the treat-ability test, to which I have just referred, will be applied to all patients. Secondly, the same conditions will be applied as are applied to cases for admission. However, the Bill provides an alternative test for the severely mentally handicapped and the mentally ill, if the treatability test is not met. Such a patient may be detained if he is unlikely to be able to care for himself, to obtain the care he needs or to be able to protect himself from serious exploitation if he is discharged. This recognises the need that some of these severely handicapped people have for the care and support that can be given to them in hospital, 938 even though little can be done for them in terms of improving their condition and even though they are not willing to stay there.
The changes we are making in Clause 12 should help to ensure that no one is detained for longer than necessary and that no one can simply be forgotten. For those detained under the longer term powers, the periods of detention are halved. Application for renewal of detention will have to be made at the end of each period and the patient will then be able to apply to the mental health review tribunal. This means that opportunities for access to a tribunal will be doubled. In addition, there will be automatic hearings for patients detained under Section 26. If patients do not themselves apply, hospital managers will have a duty to refer them to a tribunal after the first six months of their detention and, again, three years after any renewal of detention. This will afford protection to anyone who is too disturbed to apply and has no relative or friend to take the initiative for him.
The need to detain patients who are already voluntarily in hospital can cause difficulties. The patient may be in a distressed state and be quite unable to recognise the wisdom of staying in hospital, at least until the crisis passes. The Act already provides that in such cases the doctor responsible for the patient can authorise his detention for up to three days under Section 30. But the doctor may not always be there in an emergency. Clause 6 therefore provides safeguards for staff by stating that another doctor may exercise this power of detention if nominated by the patient's doctor to act in his absence. In addition, certain nurses are given a carefully controlled holding power for up to a maximum of six hours until the doctor can be brought.
The Act increases, in most cases to double, the frequency with which patients have access to mental health review tribunals. The main concern of mental health review tribunals must therefore be with their function of deciding whether or not a particular patient is properly detained within the terms of the Act. But the interests of detained patients go much wider than this, and they need to be carefully protected, too. There is therefore a need for a body entirely independent of those involved in the procedures of admission, detention and renewal to look after these wider interests. Such a body was suggested in the Boynton Report.
The Bill therefore proposes that a new special health authority be set up. It will be called the Mental Health Act Commission. The commission's duties will be delegated to it by the Secretary of State. It will therefore be directly accountable to him and will have his considerable authority. It will be concerned only with mentally disordered patients who are compulsorily detained in hospital under the powers of the Act. It will visit hospitals, examine records and its members will be available both to patients and to staff. It will bring to the attention of hospital managers and, if necessary, of the Secretary of State any case where the proper procedures for detention have not been followed. It will also take up on request any complaint about a patient's treatment which, in the view of the patient, has not been properly dealt with by the hospital managers. The commission will operate as a 939 multi-disciplinary body from various centres across the country. It will be composed of about 70 people, including lawyers, doctors, nurses, social workers, psychologists and lay people. It will have important functions relating to the giving of treatment without a patient's consent.
The Bill provides in this matter that some sorts of treatment shall never be given without the patient's consent and that that consent must be supported by a second medical opinion. These drastic treatments, such as psycho-surgery, will be listed in regulations or in a code of practice. Other items of treatment which do not give rise to such special concern but which do involve physical intervention, such as medication or electro-convulsive therapy, may be given without the patient's consent but not without the support of a second opinion given to the decision of the responsible medical officer. The remaining forms of treatment, such as general medical and nursing care, may be given without the patient's consent, if that is possible, but only by or under the direction of his responsible medical officer. And often, of course, they cannot be given without the co-operation of the patient.
The second opinion to which I have referred in each case can only be given by a doctor appointed by the commission. Very often he will himself be a member of the commission. I have already emphasised the multi-disciplinary character of the commission. It is our intention to secure that there is a constant exchange of views between these doctors and the rest of the commission about the cases with which they deal. This will ensure that non-medical opinion is fully involved in establishing the principles and the criteria to be observed in the sanctioning or, let me emphasise, in the refusal to sanction treatment without the patient's consent. This is another area in which I expect penetrating debate at the Committee stage.
The commission will itself consider what treatments should be listed in the regulations as giving rise to special concern, and will advise Ministers accordingly. For other items, it will draw up a code of practice and keep it up to date. The commission will also monitor the procedures applied where patients do give their consent to treatment. This will be part of its protective function towards detained patients when its members visit hospitals and interview patients and staff.
The commission will be a separate body, independent of management, and I believe it will build up a body of knowledge and experience which can be applied effectively to help detained patients, and those who care for them, and to throw light on the whole field of mental health.
I turn now to the provisions in the Bill which deal specifically with patients who, before their admission to hospital, have been the subject of proceedings in the criminal courts. Part III of the Bill amends sections of the 1959 Act which give powers to the courts to order the detention in hospital of persons convicted of criminal offences and which give to the Home Secretary powers to transfer mentally disordered persons to hospital.
Clause 18(4) provides that the treatability test must be applied by the court before it can make a hospital order on any person who is suffering from a psychopathic disorder or who is mentally handicapped. The 940 Home Secretary will have to apply the same test before he can transfer a prisoner who falls into either of these categories from prison to hospital. Both sorts of patient will benefit from the increased access to tribunals.
Clause 26 amends the criteria for the making of a restriction order so as to make it clear that such an order should be made only when it is necessary to protect the public from "serious harm". This is one of the changes recommended, again, by the Butler Committee. The most important provisions in the Bill as it affects offender patients are contained in Clauses 27 to 29. They provide that, if a person is suspected by the court of suffering from a mental disorder, he may be remanded to hospital for a report upon his mental condition. The court may also remand him to hospital rather than to prison if his condition warrants detention in hospital for treatment. A court may be in doubt as to whether a convicted offender's mental disorder is in fact such as to warrant detention in hospital for treatment. In that case, it can make an interim hospital order—again a new provision—and await the results of a period under hospital detention before deciding whether hospital or prison is the place for him to go.
The availability of a new power to make an interim hospital order will cause some small increase in the demand for hospital places. The creation of a new power for a court to make a remand to hospital will have a much more substantial effect on the demand for National Health Service resources. The service cannot be expected to meet this demand instantly. Additional facilities and more staff could well be required. The Government's intention is therefore that the operation of these two new provisions should be phased in gradually over a two- or three-year period after the main provisions of the Bill are brought into effect.
I must now refer very briefly to something which does not yet appear in the Bill. There is under the present legislation a small class of patients who cannot be discharged by any authority save that of the Home Secretary alone. In all other cases, the patient can have his case considered by the mental health review tribunal and the tribunal is free to order a discharge, if it thinks fit. Offender patients restricted under Section 65 of the Act may also have their cases considered by the tribunal, but the tribunal in this case cannot order discharge. It can only recommend discharge to the Home Secretary, who may or may not accept its advice.
Your Lordships may know that in a recent judgment in the European Court of Human Rights it was noted that restricted patients also should have access to a body of a judicial character with power to order discharge. I hope, therefore, to bring amendments before your Lordships to achieve this reform at Committee stage. Their terms are not yet finally decided, but I expect them to seek to give to mental health review tribunals a power to discharge in the case of restricted patients as well as others. As many of them will have committed very serious crimes, it is our intention to ensure that each tribunal panel shall include an experienced lawyer with experience at recorder level. There will be full opportunity for the House to consider the details of the new arrangements when the 941 necessary amendments to the Bill are put before your Lordships.
I have dealt so far with patients detained in hospital. I turn finally to the small number of mentally disordered people who are received into guardianship in the community because they need a degree of supervision or control. Until now a guardian has had the same powers as a father has over a child of less than 14 years. The Bill proposes that the powers should be reduced to what is essential. They will consist of the power to require a patient to live at a certain place, to attend for training, treatment or occupation and to give access to doctors, social workers or otherwise specified persons. It will no longer be possible for patients under 16 to be received into guardianship. We feel that the children's legislation is much more appropriate for them. As with powers to detain in hospital, the duration of guardianship powers will be halved, and therefore applications to the tribunal will be more frequent.
Finally, there is implementation. The Bill specifies that all but three of its provisions should be implemented on 30th September 1983. We hope for Royal Assent by the summer of next year; thereafter we need to consolidate these and other amendments to turn the Act into a form in which it can easily be used. That opportunity may also be used, if your Lordships so wish, to separate the provisions which affect the mentally handicapped from those which affect the mentally ill.
The time before implementation will be needed also to draw up the regulations, to set up the Mental Health Act Commission, to strengthen the mental health review tribunals, to publish guidance and to make other administrative arrangements. Those will include arrangements to phase in gradually the provisions for automatic reviews by mental health tribunals of patients who have not recently been before the tribunal. We shall begin with those patients who have had the longest wait, and we want to do that as quickly as possible so that there will not be a monstrous backlog to be dealt with when the Bill comes into force.
This is a good Bill. I regret that because of the Second Reading procedure I have had to speak to it in such an analytical and dry manner, because it is a Bill in which I think we can all put our hearts. It is a good Bill, but it is a Bill which almost everyone here will have their own ideas about how they can make it better. I hope your Lordships will agree with me that it is a good Bill and that you will accept that the Government intend to make it better if that is practicable and in the people's interests. To that end I and my noble friend Lord Cullen of Ashbourne, who is to reply to this debate, will listen with the closest interest to noble Lords who have listened with such patience and such courtesy to me. I beg to move.
§ Moved, That the Bill be now read 2a.—(Lord Elton.)
§ 3.34 p.m.
Lord Wallace of CoslanyMy Lords, may I first extend a welcome to the noble Lord, Lord Elton, who is dealing, I believe, with his first Bill on his appointment to ministerial responsibility. The noble Lord has indeed taken on a tough task in following the noble Baroness, Lady Young, who set such a high standard and was a formidable opponent, but nevertheless was 942 approachable, seeking a degree of co-operation. The noble Lord, Lord Elton, has already extended courtesy and co-operation towards me, and although tough exchanges lie ahead, particularly in the field of social security, I am sure that the atmosphere of reasonable co-operation will continue.
The noble Lord has outlined with clear detail the provisions of this very important Bill. It is a Bill of general appeal which is completely devoid of party political divisions, following in many respects the conclusions of the 1978 White Paper initiated by my right honourable friend David Ennals and debated in another place on 22nd February 1979, with unfortunately the probability of legislation being thwarted by the general election a couple of months later. I refrain from making political capital on that point, my Lords.
The Bill now before us differs to a major extent in the proposal to set up a Mental Health Act Commission and I will refer to this later. In addition, the Bill before us does not include the 1978 White Paper proposals to give patients information of their rights on entering a hospital, or to inform patients within 24 hours if their status is changed from formal to informal or vice versa. As patients' rights is almost the theme of this Bill it seems to me to be a regrettable oversight, but I am sure it will be capable of adjustment during the Committee and Report stages. The Government and the noble Lord, Lord Elton, have indicated the possibility of accepting or bringing forward amendments during the various stages before Royal Assent. This is a welcome change, may I say in passing, from our experiences of other legislation brought forward by the Government, who introduce their own amendments but steadfastly refuse to accept others.
The change indicated in Clause 1, to amend the 1959 Act by the replacement of "subnormality" by "mental handicap", is very confusing indeed. There is a considerable difference between mental handicap and mental illness. The all-embracing phrase "mental handicap" is completely misleading. The definition of "mental disorder" remains as in Section 4 of the 1959 Act, which includes the phrase:
and any other disorder or disability of mind".This remains an unsatisfactory and vague definition, which could bring into eligibility for detention on a compulsory basis many classes of people who could not be classified as "mentally ill" but who need care and treatment outside mental hospitals. A clearer definition of mental disorder is needed, but this is a complex and difficult matter. Perhaps it would be more direct and simple to delete the phrase:any other disorder or disability of mind".I should like to repeat what I mentioned some years ago in another place, concerning an incident in which I was involved before the 1959 Act became law. During the 1945–50 Parliament a constituent who was a Justice of the peace had been called in to certify a young woman for admission to a mental hospital. The justice of the peace was not happy about the case but was persuaded to give consent and then went home and told his wife. She was a determined but motherly lady and was not at all satisfied and said: "That girl is crossed in love. Go and get her and bring her to 943 me and I will look after her". The justice of the peace did as his wife told him; and then of course he was in serious trouble and came to me for help. Eventually I was able to persuade the authorities to let things stand and the young woman remained in the J.P.'s home in the care of his wife, where I am glad to say she fully recovered.Because of that, my Lords, and other experiences, I have often felt, and still feel, that there are many people detained in mental hospitals who need not be there if adequate facilities for residential and day care were available. It is true that there have been welcome improvements over the years, but such facilities are still far from adequate and in some cases have been reduced because of financial restraints.
I accept, of course, that the situation goes outside the comparatively narrow scope of this Bill, but, on the other hand, if the Mental Health Act Commission does its job (and indeed I wish it well) then the demand for greater facilities such as those I have mentioned will increase. And there is of course the problem of discharge after care. Many patients who may be discharged, particularly when the commission gets to work, will in fact face discharge after some periods of detention in a mental hospital, and as such will face great problems in acclimatising themselves to the great world outside which has changed considerably since they went in. It is a problem we have to face as a result of this Act.
I can only quote an experience I had when I was the Member for Norwich, North—and the right reverend Prelate the Bishop of Norwich may know this particular facility. A street of old houses had been taken over by a trust and converted to modern standards, and two of them were devoted to the use of people discharged from the nearest local mental hospitals in order to acclimatise them to the great world outside. They were supervised by an ex-nurse from the hospital. I had tea with them and they were very happy people. This is a problem which is bound to arise as soon as the commission gets to work; there will be people discharged who will have to face rehabilitation in the world outside, and rehabilitation of course would not be able to be achieved within the mental hospital.
There is a very big difference between mental handicap and mental illness. This is a field where I am sure the noble Lord, Lord Renton, will later speak with the authority and experience that he undoubtedly possesses, as indeed he did in another place during the debate on the 1978 White Paper. For those noble Lords who would like to read that speech, it is in columns 680 to 685 of the Official Report for 22nd February 1979. I will not draw any commission for that advertisement!
The position of the mentally handicapped is not dealt with within this Bill, but the Government have given a clear and definite undertaking to deal with this when they bring in a consolidation of mental health legislation very soon. Even on this point no one will accept that in this field the provision and services are at all satisfactory. Financial restraint has restricted or reduced facilities at a time when there is a need for expansion. Before I go any further I would draw attention to the fact that a number of 944 complex legal points arise from the Bill, particularly dealing with appeals in mental health tribunals, access to the courts, and some others. I do not presume to attempt to deal with these, but my noble friend Lord Elystan-Morgan will be winding up the debate from these Benches and he undoubtedly will extend to the House his experience and professional expertise in dealing with them.
On compulsory admission procedures, Section 29 of the 1959 Act is retained, but Clause 6 of the new Bill defines the emergency period as 72 hours for detention and determination. This, I feel, is too long. It is reasonable to expect that a hospital could obtain a second medical opinion within 24 hours, even at weekends when medical staffs—let us face it—are on a standby rota. In addition, there is a divergence from the 1978 White Paper, which proposes removal to a place of assessment in the community should emergency detention he necessary. As things stand under this Bill patients can only be detained in hospital, with, I may say, the prospect of probably a long stay. There is a view, shared by the British Association for Welfare Workers and MIND, that the provision on a wide scale of crisis intervention centres would reduce the need for emergency admission to hospital. I accept that it is perhaps too much to expect an acceptance of this view at this stage, but I must emphasise that this is a reform which must be given more detailed consideration in the future—and, may I add, the not too distant future at that.
Social workers have, particularly in recent months, been placed in some difficulty and sometimes subjected to criticism of the part they play in the mental health sphere of their work. The proposal is that the role now undertaken by mental welfare officers, which in effect is all social workers, should after two years after the coming into operation of this Bill be taken over by "approved social workers" specially trained in mental health matters. Such approved workers will have to interview any patient prior to admission to hospital in order to ensure that hospital is an appropriate form of disposal. This is indeed a welcome reform, but it raises a number of very criticial questions.
First, such social workers before reaching the status of "approved" will have to undergo a fairly lengthy period of training into all aspects of mental health legislation and all that follows from it. With all the high degree of responsibility that the new post entails, it follows that the test of approval of the candidates must be rigorous and searching indeed. Secondly, in consequence of the nature of the post, there will have to be an attractive salary scale if staffing levels are to be adequate. Thirdly—and this is a vitally important point—it is assumed that the training and provision of such workers will continue to be the responsibility of local authorities. This will be an added financial burden to local authorities at a time when they are enduring demands for severe financial restraint, and in some cases are reducing the number of social workers employed already. Detachment of selected social workers under such circumstances will not only add to the problem but will in fact reduce staff available for other social work.
Will the Government face up to this problem and grant additional finance to local authorities for the purpose? I can only say that failure to do this will 945 reduce this desired reform to the status of pie in the sky. Certainly the two Secretaries of State and the departments involved must get together. Social workers apart, local authorities are involved in other important spheres in the field of mental health. It is no good introducing reforms on paper which are obstructed by financial considerations elsewhere.
There will be, I am sure, a mild welcome for the fact that the Bill clarifies the question of consent to treatment. This involves in the majority of cases the patient's consent and agreement of an independent doctor, or—and not all patients are capable of understanding this—giving consent on the advice of a doctor, backed by a second opinion of another doctor selected from a panel provided by the Mental Health Act Commission. This is a difficult and complex area where strong differences of opinion exist and where there is much public concern over some of the methods of treatment carried out. As the Bill stands the second opinion is medical, but there is a wide measure of feeling that a second opinion should not be medical alone, but what is required is a lay, social and commonsense judgment, for, after all, it is a question of imposing treatment on an adult against his will, or because of his lack of ability to give consent. The 1978 White Paper accepted that a second opinion should be multidisciplinary and not medical. This is a vital and complex matter probably best decided by the Mental Health Act Commission.
I come to the Mental Health Act Commission. The broad based membership of the proposed commission is welcome. The appointment of its 70 members is the responsibility of the Minister, who, I assume, will seek advice before making a final decision.
The responsibilities and powers of the commission, although not clearly defined in detail in the Bill, are on the surface an immense job for 70 part-timers. Apart from one or two visits a year to 300 or so local hospitals they have also the duty to visit four special hospitals at least every month, interview patients—and that can be a time-consuming process—study records and deal with complaints. But apart from that they have important duties regarding consent to treatment and drawing up a code of practice on treatment with regular revision and also to keep a watch on other regulations. My mind boggles. Even with a support staff of 14 this is a colossal job for part-timers to undertake, and indeed one wonders whether the professionals, the doctors and nurses et cetera, will find time even to carry out their normal professional duties.
I ask—because it is only implied in the Bill—whether there is a salary involved or an expense allowance because some of these professionals will be losing valuable time from their professional work and the right sort of people will not be obtained if they are to be financially penalised. We need the best and we must have the best and to get the best we must pay for the best. There is no argument about that whatever.
There are many other aspects of the Bill that I could deal with, but with so many experienced noble Baronesses and noble Lords to speak—and I am very much aware of that—I am sure that the points which I have mentioned and others will be well taken care of. This is an important debate with far-reaching consequences. The Bill, although welcome, only just touches the fringe of the problem of prevention, cure 946 and treatment of mental illness. Mental handicap in the accepted sense is put to one side for the time being.
Let us look at the background. Despite valiant efforts mainly by voluntary bodies to brighten interiors and surroundings, many mental hospitals are old, institutional and decaying monuments, but staffed, let me add, by dedicated people whether they be doctors, nurses, ancillary workers or visiting, caring volunteers all of whom deserve and earn the highest praise.
An immense amount of effort must be made by the Government and people to eradicate those social evils which so frequently give rise to mental strain—unemployment, bad housing, loneliness among the aged and the young, the unremitting battle by the mother against poverty. All this and much else can upset the balance of the mind leading to mental illness. The Bill is a step forward and welcome, but much more needs to be done.