§ 3.32 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. J. K. Vaughan-Morgan)
I beg to move,That this House takes note of the Report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency.My only regret in standing at this Box today is that I take the place of my right hon. Friend. I can assure the House that he is making good progress. That it will be a matter of signal regret to him not to be here today I know, because this is an occasion to which he had been looking forward a very long time.
I think that we can offer our warmest congratulations to Lord Percy and the members of the Royal Commission not 36 only on the Report they have produced, but on its being unanimous, which gives added weight to the opinions expressed therein. I feel that it must also be a matter of great pride to us that Members of this House served on that Royal Commission. I should like, also, to echo the praise which is expressed in the Report by the Royal Commission for the work of the secretary, Miss Hedley, of the Ministry of Health.
The Report was published five weeks ago and has been well received both in the general and medical Press. For my part, I am glad that we are having a debate now. This is an important Report involving, as it does, the health and well-being of so many of our fellow citizens, and touching, as it does, so many different aspects of public and private life.
I cannot as yet make any statement of the Government's views on the Commission's recommendations, almost all of which require detailed discussion with local authorities and hospital authorities. This applies to recommendations which might not require new legislation just as much as to those which would.
I have asked all those authorities, the professional associations and the other bodies interested, to let us have their views by the end of September, which, I understand, is the minimum period they may need to look into the implications of the Report.
Nevertheless, while these discussions and conferences are going on, it is desirable that we should at this stage collect the opinions of the House on the Report and on the issues, some of which may be contentious, which it raises. I can assure the House that the Government will consider very carefully everything which is said by hon. Members today.
I do not, therefore, propose to detain the House for very long. This should be a back benchers' debate. I propose, first, to deal only very briefly with the content of the Report and, secondly, to give the House a general account of some of the developments in recent years, not all of which are known.
The general principles underlying the Commission's Report are in accord with recent trends in the mental health services. It is held that mental and mental deficiency services should be brought into line wherever possible with general health 37 services and compulsion used only when positively necessary for the protection of society or in the interests of the patient.
No doubt we are all in agreement with these general principles. Major recommendations may be summarised as follows. First, to review the duties of hospitals and local authorities in regard to mental health so as to bring them into line with their other duties and to encourage the use wherever suitable of other general social services by mental patients.
Secondly, to expand the community services, including residential services, for all groups of mental patients.
Thirdly, the recognition in the future of three main groups of patients—mentally ill, psychopathic, severely sub-normal—instead of two as now.
Fourthly, by abolishing the designation of hospitals. Every hospital suitable for the purpose will be free to accept patients either informally or under compulsion if necessary.
Fifthly, a revision of the procedures of admission and discharge and of the methods of review where compulsion has been used and the lessening of the present distinctions in this respect between the mentally ill and the mental defective.
These are formidable proposals, and the House will, therefore, fully understand why consultation is necessary even as regards those recommendations which can be implemented without legislation. These are the proposals on which we are seeking the views of the House today.
Let me turn now to certain aspects of the current picture. A word, first, about the attitude of the public to mental health. The enlightenment of public opinion, which began perhaps a generation ago, has improved remarkably in recent years, particularly since mental and mental deficiency hospitals became an accepted part of the hospital services. The public thinks less in terms of inmates, asylums and institutions, and more of hospitals, patients and nurses. It is not the words which are used which matter; it is the attitude which they express with which we are most concerned, and the public is now more sympathetic and more enlightened.
This process has been helped by many things. The most important is the 38 increasing number of patients who are admitted and who, having been successfully treated, speak of their experiences openly to their friends and relations. The open days at the hospitals, the work of the Leagues of Friends and other voluntary bodies—these are factors which are helping to make mental and mental deficiency hospitals what they should always have been, a part of the community which they serve.
I must mention, too, the work of specialist bodies such as the National Association for Mental Health and the Central Council for Health Education. All the work that the B.B.C. has done, particularly in the last year, is immensely appreciated. Above all, the attitude of the Press has improved with growing knowledge, although, alas, there are still a few pockets of irresponsibility whose attitude is hopelessly old-fashioned, and who pander to an appetite for sensationalism.
All of these activities and the work of the various professional bodies, too numerous to mention today, are beginning to make themselves felt in the greater sympathy and understanding which the public show towards the mentally ill.
Now, since it figures so largely in the Report, let me say a word about the services for the mentally ill and the mentally defective provided already in the community. Since the end of the war there has been a remarkable expansion in local health authority services for care and after-care along the lines now endorsed by the Royal Commission. The most dramatic developments have been, quite rightly, among the services which take care of children. The Child Guidance Service and welfare centres and the work of health visitors have a contribution to make to fostering mental health and preventing maladjustment, and subsequent serious disturbances later in life.
But the most striking development of these services has been in the provision of training centres for the mentally defective. Most of these are primarily for children, where they are taught good personal habits and, within the limits of their disability, trained to be as independent and useful as possible.
In 1948, there were 100 centres. Today, there are 312. In 1948, the number 39 receiving training was 4,000. Today, the number under training is 15,500. But there is more to be done, for there are still over 8,000 reported suitable for training, but not yet receiving it. Another new and promising development is the arrangements which are made to take a mental defective into hospital temporarily to help the family over a crisis, or just to have a holiday. But there is more to be done on these lines.
When it comes to the local authority services for the mentally ill, it is not so easy to point to any obvious developments. An increasing amount is being done along lines with which we are already familiar. But we must remember that until 1948 the work which was done was centred by the local authorities on their own mental hospitals, and since the break which took place then they have had to develop their own services with a shortage of trained staff, and in fields which, at least in their preventive aspects, are still largely unexplored.
Home visiting by welfare workers, either as part of after care or to deal with early signs of mental disturbance is the main instrument. But much more remains still to do in this field of domiciliary work.
The main new scope for local authorities would, under the Royal Commission recommendation, lie in the provision of residential care on a considerable scale for suitable mental patients, either under the National Assistance Act or under the National Health Service Act. The implications of these are far-reaching, and will need very careful consideration and discussion, but the House should appreciate how much has, in fact, already been done in different ways in different areas.
Of course, the kind of services of which I have been talking depend far more on people than on buildings. Apart from medical staff, the local authorities employ a small number of psychiatric social workers, and over 1,000 mental welfare officers. Their job rarely attracts public attention, and when it does it is usually the part that they themselves like least—the removal of patients to hospital. But there could not be more humane work than the visiting of the mentally ill, work which is painstaking, slow, but very rewarding. Theirs is, however, a calling 40 which has not received either the praise or the credit which is its rightful due.
I want to turn now to the hospital services. The demands on our mental hospitals have increased greatly during the last few years, and the admission rate has increased from 59,000 in 1949–37,000 of them being voluntary patients—to 88,000 in 1956, including 69,000 voluntary patients.
Much of this increased hospital work has to be done in buildings which, as we all know, are unsuitable because they are too old, too big, designed for the ideas of another age, and usually in the wrong places—not that any blame attaches to our forbears for that fact. They were acting in a contemporary spirit of enlightenment.
We are now thinking again very seriously as to what type of hospital for the mentally ill or mentally defective we shall need when we are planning for the future, and the Royal Commission's Report will give fresh impetus to our study of this question. Meanwhile, we are doing what we can, by additions and conversions, to bring the old and unsuitable buildings up to date.
Since I was appointed I have been to a good many hospitals, and I think it is marvellous how an energetic hospital management committee can, with a few pots of paint, make some of these rather grim barracks a bit brighter. At least, we are making some progress in overcoming overcrowding, which has been, and still is, such a headache.
Since the peak period about 1953, there has been a decline in the degree of overcrowding in both mental and mental deficiency hospitals.
So much for the buildings—now for the patients. I want to give the House an idea of the changing picture there. I do not want to overwhelm the House, as I have said, with statistics that are particularly complicated and, as the Royal Commission pointed out, not entirely in a satisfactory form, but I can give a general picture of the trend.
Much treatment, and this will apply increasingly in the future, takes place outside the conventional designated hospital. I refer to day hospitals, to the long-stay annexes, hospitals other than designated hospitals where psychiatric treatment is given, and so on.
41 The number of mentally ill out-patients dealt with in ordinary hospitals has gone up by nearly 50 per cent. since 1949, and the number of domiciliary visits by hospital specialists to such patients has more than trebled in the last seven years, all of which indicates the pattern of development for the future.
The number of voluntary admissions has, as the House knows, been rising steadily over a generation. The number of voluntary patients in residence has also been rising, but not, of course, so fast.
The effect of the increasing rate of voluntary treatment may be beginning to be reflected in the figures concerning certified admissions. Until recently, the number of certified admissions remained fairly constant with a tendency to rise since the war, but during 1955 and 1956 there has been a significant decrease both in the number of certified admissions and in the number of certified patients resident in hospital. Certified admission, which was about 20,000 per annum in 1954, had dropped to 17,500 in 1956, while the number of certified patients resident had dropped from 114,000 at the end of 1954 to 104,000 at the end of 1956.
I am chary of building too much on these figures, but hon. Members may care to look on this significant drop as being a hopeful pointer to the future.
Now I turn to what has been a black spot, and that is the waiting list for admission to mental deficiency hospitals. The waiting list, which was over 7,000 in 1954, is now down to just over 6,000. The Royal Commission's proposal that local authorities rather than hospitals should be responsible in future for providing homes for those who no longer need continual nursing and psychiatric care will, if acted on, have far-reaching effects on the organisation of the hospitals. Indeed, the implications of this recommendation must be one of the chief subjects for discussion in the future.
Now a word about those who have been working under very difficult conditions for so many years in mental and mental deficiency hospitals. I know that the whole House will want to join with me in paying a tribute to all of them for what they have done. Old buildings, overcrowding, the surge of voluntary admissions—all of these have made difficulties for them. Nevertheless, against 42 this background, it is a miracle to be able to record that the amount of treatment—and successful treatment—which is being carried out has increased out of all measure.
But we still have much to do to fill the gaps in the ranks both of medical and of nursing staff. There is still a serious shortage in psychiatric consultant staff; we are paying the price of the isolation and separation in the past of this branch of medicine. There is, nevertheless, an improvement, I am glad to say. Our general policy is to try to strengthen the medical staff in the senior grades first, and to provide for an increasing number of consultants in the future by increasing and improving the intake to the senior registrar grade. This policy is bearing fruit in that there are now nearly half as many psychiatric consultants again as in 1949, while the number of consultants in all specialities in the hospital service has increased by a little over a quarter.
As to nursing, there is also heartening evidence here of an improvement in the staffing position, particularly shown by the substantial increase last year in the numbers of student mental nurses, which has risen by nearly 20 per cent. This branch of the nursing service has had a long and uphill struggle to overcome the traditional view of their duties, which dates from the days when they were custodians or attendants. All that is gone. Today, the mental nurse is highly regarded as a worthy member of a great profession.
Finally, let me pay a tribute to one group who do not figure in any statistics —the voluntary workers, the Leagues of Friends and the other bodies who do so much to bring life in a hospital as near as possible to ordinary life, and whose work perhaps does more than any single factor to break down prejudice on this subject.
I have tried to give the House some idea of what is happening in the mental health services. I can assure the House that I have shown a self-denying ordinance in the length of my speech. I am only too conscious not of what I have said, but of what I would like to have said, but I wanted to give the House an assurance that there is no question in my Department, or in any sphere of the mental health services, of there being any 43 stagnation or complacency about present conditions; nor is there any lack of hope for the future.
My generation has seen a revolution in our approach to mental illness; never was a revolution more needed. We, as I see it, are just beginning to reap the benefits of all the new developments there have been in the last generation. It takes time to achieve worthwhile results; and now this very great Report comes to point lines of advance for the future in this difficult sphere of mental health. Difficult it may be, yet there is no field of medical activity in which there is more reason to have hope—hope for the lightening of at least one of the scourges which afflict the human race.
§ 3.54 p.m.
§ Dr. Edith Summerskill (Warrington)
I hope that the Parliamentary Secretary will not regard it as a reflection upon himself when I say that we regret that the Minister of Health himself is not here today. Knowing the interest which the Minister has in this subject, and how he was looking forward to the Report, I should like a message to go from this side of the House, and, indeed, I am sure from the whole House, to the Minister expressing the hope that he will make a rapid recovery.
I should like also to congratulate the whole of the Royal Commission on producing a Report which bears the mark of a painstaking inquiry which has resulted in recommendations which, I believe, when implemented will make history in the field of mental health. I am sorry that my hon. Friend the Member for Liverpool, Exchange (Mrs. Braddock) is not here today, because she played a part on the Commission. My hon. Friend was anxious that she should be acquitted of any discourtesy to the House, but she had a previous longstanding engagement, of which I think the Parliamentary Secretary is aware.
Personally, I am very glad that this was a unanimous Report and that there was not a minority Report. A unanimous Report on a subject of this kind helps to promote constructive criticism, and I am quite sure that all of us in the House this afternoon are anxious to be constructive in whatever criticism we wish to make.
44 The importance of the matter under discussion can be measured by the fact that about 200,000 of our hospital beds —that is, nearly half the available accommodation in the country—are occupied by patients suffering from some form of nervous disorder, and about one-third of the drugs prescribed in this country by doctors—and often in this House the drug bill is discussed—are for some form of nervous complaint. The sickness and the misery of both the patients and their families is, of course, immeasurable. Therefore, this Report, as the Parliamentary Secretary has said, is of profound significance.
Everyone must welcome the new approach to mental disorder which is contained here, because it emphasises the importance of care rather than custody, and the removal of all formalities of admission. Of course, as the Parliamentary Secretary has implied, while, administratively, this feature of the Report, the removal of all formalities of admission, may be regarded as very important, nevertheless the figures which we have heard this afternoon show that certification has already become outmoded, and we are doing what we always do in our legislation and in our recommendations; we have approached this problem in an empirical manner. We have proved that voluntary admission without certification is highly successful.
I had not previously heard the figures which the Parliamentary Secretary quoted for the last two years. These are, indeed, spectacular. What we have done before we are doing today. We are saying, "We made an experiment a little while ago and we have found it successful. Now we recommend that it should be embodied in future legislation"
The Parliamentary Secretary did not mention the Mapperley Hospital. I think it is mentioned in the Report. The figures relating to that hospital are quite outstanding. On 6th March, out of a total of 1,054 in patients, only one was certified. This is a remarkable advance in the field of mental health. I think that the proposed appeal tribunals and the patient's right to independent examination should present sufficient safeguard for the small minority who harbour a grievance, and I hope that my hon. Friend the Member for Erith and Crayford (Mr. Dodds), who has taken such an interest 45 in the matter, will be satisfied with these figures.
The new terminology and the abolition of the terms "certification" and "mental deficiency" is welcomed as a contribution to removing the stigma which has become attached to these words. Nevertheless, we must not be content simply with changing terminology and with the degree of formality. I am glad there is a psychiatrist on the opposite benches. I am sure that he will agree with me that the right approach is to ensure that psychiatry is integrated more closely into medicine and surgery. I am sure that that is what we should endeavour to do.
I feel that the public is not aware of the modern methods of treatment such as electro-convulsive therapy, insulin treatment, and improvements in psychotherapy which have not only revolutionised our attitude to mental treatment but have, indeed, provided cures for people who, in the past, would have been regarded as hopelessly insane.
While we may have read the Report and while we may, during our debate, support many of the recommendations of the Royal Commission, the general public will be very slow to change its attitude while mental patients are herded in buildings similar, in some respects, to our old prisons, and are served by men and women whose efforts to improve the lives of their patients are hampered by shortage of staff and overcrowded conditions.
The Parliamentary Secretary mentioned this, and I am quite sure that an effort is being made to change these conditions. I am very glad to hear of the recruitment of mental nurses. I always regard the nurse as overworked and under-paid. The nurse is an exploited individual, and we are all guilty of that exploitation of a woman, or man, in this case, who works in a selfless manner in a job which very few of us here would be prepared to undertake.
I agree with the Parliamentary Secretary about sensational publicity. I deplore it. I deplore the fact that, in the twentieth century, the Press has to use sick and helpless people to attract readers. It has highlighted the problems connected with individual patients, but the Press always fails to focus attention on the magnificent service given by the staffs of our mental hospitals. I am, therefore, very glad that, on 4th July, the 46 Manchester Guardian, in an excellent article on Rampton, went some way to remedy this.
Of course, there is a tendency to get the whole subject out of perspective. The mental patient is a tragic case. If any of us here had the choice to make between being physically afflicted or mentally afflicted, I believe that each one of us would choose physical rather than mental affliction. While every effort must be made, and will be made, to keep these tragic patients in the community, we must, nevertheless, face the fact that the best atmosphere for many thousands of mentally ill and sub-normal persons is that of a hospital, where their condition is understood and where they are cared for by people trained in mental illness who can be relied upon to deal with them sympathetically and wisely.
My experience of mental hospitals was not acquired only as a medical student. I actually did my courting in a mental hospital, where my future husband was a medical officer. For years after my marriage, we revisited the hospital and saw the staff and patients, who regarded us as their friends. I was a very impressionable young woman, and I should like to say that, from those many years during which I was attached to that hospital, I have not a single memory of anyone being detained against his or her will or coming to me and complaining about it. There were the paranoids with a sense of persecution, but my most lasting impression during those years was of the extreme patience and understanding exercised by the staff.
Those who are not closely familiar with these places do not fully understand how dedicated these men and women become. Of course, there is the occasional exception; there always is. But in these hospitals, where the patients rarely have visitors over the years, a community is formed and gradually, the staff become integrated with their helpless family. Often, a nurse is attracted to nursing because of her maternal instinct, and in the mental hospital she can, indeed, express that maternal instinct in a very fine and noble way, because the patients there are, in fact, her helpless charges.
My most recent visit, like that of other hon. Members, was a few months ago, to a mental hospital having over 1,500 patients, which was grossly overcrowded 47 and under-staffed. The nurses were doing their best in this old, ugly and inadequate building. The shortage of staff meant that hundreds of patients sat apathetically round the walls of the rooms, deprived of individual attention, with an inevitable deterioration in their minds. It was not the fault of the staff; they were doing their very best, but there were not enough of them to give the individual attention necessary.
I come now to the position of the local authorities. I hope that every member of a local authority will read paragraph 87, in page 28 of the Report, where the Commission says:… mental health in its widest sense embraces the whole field of human relationships and human behaviour, and many forms of mental disorder are evidenced by, and often arise from, disturbance in a person's relationship with other individual human beings or with the society in which he livesThis is, indeed, a new approach to mental health. I hope that the public will learn all about this Report, for, at long last, it is learning that much in mental health is related to the patient's relationship with the community and with individuals. It is in social relationships that a very great deal of preventive work can be successfully done.
I should like to pay my tribute to the excellent work of the psychiatric social workers. I wish that, when the school's career mistress is advising girls what to do, she might have her attention directed to the important work done by the psychiatric social worker, who goes into the homes of people and discovers just where the stress or tension is, whether in the family or outside, and who can obtain the patient's confidence, the patient being relieved, perhaps for the first time, of much pent-up emotion. I believe that the psychiatric social worker is performing a most important function in our social services.
In bringing in the local authorities, we should, at last, be departing from the old conception of institutional treatment of mental illness. While benefiting the patient, of course, such an arrangement would give the local authorities much welfare work to do, work which they were deprived of in 1948. I should like the Parliamentary Secretary to tell us, not now, but later perhaps, more about the practical side of this matter. Will the ratepayers be prepared to play their part 48 in this important social development? We all know that the clinics, whatever we like to call them, the workshops, and so forth, which will be needed for this particular category of patient, will be expensive. I should like to have some assurance about the financing of this part of the service.
I come now to what I regard as the most important medical aspect of the Report. I assure the House that I have no desire to be destructive in my criticism, but any real criticism which I have relates to this part of the Report. It is suggested that three categories of mental disorder are to be recognised—mental illness, severe subnormality, and the psychopath. The psychopath is to be offered treatment or, in certain circumstances, compulsorily admitted to hospital. The Report devotes a considerable amount of space to this matter, because it is an entirely different approach to a very difficult problem. No one can quarrel with the principle—I am not quarrelling with it—but how is it to be put into practice?
In paragraph 357, the Royal Commission says:We have considered whether the law should attempt to define or describe psychopathic personality more precisely as a guide to the doctors who are called on to make the diagnosis. In our opinion it would do much more harm than good to try to include in the law a definition of psychopathic personality on the analogy of the present legal definition of mental defectivenessI find it difficult to agree with that. In fact, I regard it as the weakness m the Report. It is said with some humour that a psychopath is anyone that a psychiatrist does not like. Perhaps only one with a psychiatric mind can appreciate the humour in that. The fact is that the judgment of who is a psychopath is subjective and not objective. It is determined in part by certain conventions recognised in the society of the doctor and the patient.
Perhaps I may give an example of what comes to my mind as I look at the windows, although I know that in this House one is not expected to draw attention to anything which is not in the Chamber. The windows above once had a grill in front of them. Let us imagine what might have happened in those days had this recommendation been implemented and it was necessary to decide what should be the future destiny of an individual who might have been arrested. Imagine that a woman who had been 49 brought up in a comfortable home had decided, because she felt strongly about the suffrage movement, to go out of her home, to fight with policemen and to undergo forcible feeding again and again. In the light of all this, it might have been possible for a psychiatrist, who himself, perhaps, had certain emotions and certain views on feminism, to say, "For a woman with that background to do this, there may be a streak of subnormality" That is an example of what might happen in the past.
I might say that many of those women who underwent that fearful fight in the suffrage world are now very normal elderly ladies whom I occasionally see and who show no sign of mental disorder. Nevertheless, to illustrate my point, it might be possible that a psychiatrist would say that there might be a streak of abnormality in one of these women. If the psychiatrist is uncertain whether an individual has a psychopathic personality, how will a prison medical officer and a general practitioner always be certain of making accurate diagnosis?
I have said that I am always averse to destructive criticism and, therefore, I have tried to inform myself on this subject. It was an English physician, Dr. J. C. Pritchard, of Bristol, who in 1835 described what we have now come to recognise as a psychopathic personality, but it was in a lecture by Dr. D. K. Henderson, a professor of psychiatry at the University of Edinburgh, twenty years ago, that I came across what I consider to be the best description. I should have liked to see something like this included in the Report.
Dr. Henderson describes psychopaths asthose individuals who conform to a certain intellectual standard, sometimes high, sometimes approaching the realm of defect but not yet amounting to it, who, throughout their lives or from a comparatively early age, have exhibited disorders of conduct of an anti-social or asocial nature, usually of a recurrent or episodic type, which, in many instances, have proved difficult to influence by methods of social, penal and medical care …It is difficult to believe that a wide definition of that nature could create controversy in the psychiatric world. The Commission recognised the importance of this matter and the dangers involved in a wrong diagnosis and the Commission itself spoke of the need of safeguards. Of course, it is important to introduce 50 safeguards, for an error of judgment might infringe the liberty of the subject. It is of primary importance in this House to protect the liberty of the subject.
Again, if I may indulge in a little fancy, suppose that in this country there were a calamity and we had a near-Fascist Government, legislation of this kind was on the Statute Book and it was possible for it to operate in such a way that an individual could be compulsorily detained. It is for this reason that I speak so strongly. My feeling that civil liberties should be maintained is such that I would prefer many psychopaths to escape rather than that one individual should be deprived of his civil liberty.
Again, who can be certain of recognising the dividing line between extreme eccentricity and some pathological deviation? The example which I have given of the dedicated suffragette might be considered apt. Some might regard her as being extremely eccentric. Others might say that she had a pathological streak. Who is to say exactly who is right?
The very fact that we now propose officially to recognise a category of mental disorders which, hitherto, has tended to baffle authority is a reason for a wide definition which is comprehensible by an intelligent person. There are still many who are reluctant to recognise the special needs of the psychopath. I refer not only to the man in the street, but to judges and to doctors, for example. Many of them may be highly sceptical regarding the reality of such a state. Indeed, some learned judges, I believe, are a little suspicious of psychiatrists whenever they give evidence. They have a feeling that a psychiatrist is endeavouring to divert the course of justice.
It was the great English psychiatrist Maudsley who said that many people regarded moral insanity as an "unfounded medical invention", as a most dangerous medical doctrine, but that he himself was convinced that such a condition really existed. Now, I am glad to say, many prison officials and many judges are beginning to appreciate that those who are so afflicted are distinctive types, emotionally and instinctively unstable, who have no more power to control their conduct than the epileptic can control his fit. It seems to me that the whole problem of psychopathy is not tackled 51 with the necessary conviction and firmness, considering the huge numbers of people involved not only in this country but in countries like the United States of America, who are also faced with this problem.
One thing that I find it difficult to understand is why educationists do not teach their children, just as a beginging, the importance of habit to happy living. It is the new approach to the psychopath—indeed, the official recognition of his condition—to which I attach the greatest importance in the Report and which will come to be regarded as another step forward in the evolution of our civilisation.
§ 4.20 p.m.
§ Mr. Walter Elliot (Glasgow, Kelvingrove)
The House has only a short time to discuss this most important subject, and we are greatly indebted to the Parliamentary Secretary for the miracle of compression which he achieved in his review of this tremendous document. It may be that our debate may be interrupted halfway through by a Bill of great merit no doubt but of negligible importance compared to the subject we are now discussing. It behoves all of us, therefore, to do our best to emulate my hon. Friend's example of compression, and I shall confine myself to one aspect only of this problem.
The figures which the Parliamentary Secretary gave, and, indeed, with which we are familiar, and to which the right hon. Lady the Member for Warrington (Dr. Summerskill) referred, are not, I think, sufficiently appreciated by the public; that is to say, the size of this problem is not sufficiently appreciated. Half of our hospital population is of people suffering mental and not physical illness. Consider the amount of time and thought given to the other half of the sick population compared with the time and thought which are devoted to this 50 per cent. of the whole hospital population.
I think that in this debate we can well go a little wider than the Report of the Royal Commission was able to go, because the Royal Commission, by its terms of reference, was limited to the existing law and administrative machinery. But this is the only opportunity we 52 have of discussing the wider subject, and I think we should take advantage of it.
Even the attempt at definition to which the right hon. Lady referred still remains far from satisfactory. The right hon. Lady said such definitions might be subject to bias against a person disapproved of by the psychiatrist.
I was glad to hear the tribute which the right hon. Lady paid to the great Medical School in Edinburgh, but I do not feel that even Professor Henderson's definition is one to which I should like to entrust my own liberties suppose I found myself brought before either an extreme Fascist or extreme Communist tribunal. I might be held by either of them to have indulged in "anti-social or asocial" activities, which they might say have not been possible to get rid of by social or even penal pressures.
The lack of integration of this subject into the general sphere of medicine has produced this effect, namely, that research into this subject is of a minimal nature compared with the amount devoted to the physical make up of the individual. The normal work of the great medical schools in physiology and bacteriology naturally and inevitably considers the physical make-up of the human being. The mental make-up of the human being is very seldom considered at all.
I do not mean only of the abnormal human being. I should like a little more work to be done upon the mental makeup of the normal human being, upon the normal activities, the normal working, of this extraordinary machinery which entitles us to the proud but sometimes, I think, inaccurate description of homo sapiens. I think that homo robustus would be a good name for the human race. Whether we are entitled to the description sapiens, I am not quite certain. We have all these remedies, all these powerful treatments now being applied to abnormal persons. Yet we have practically all of their effect as applied to normal persons.
The brain runs, it may be surprising to the layman to hear, on sugar. Sugar is what our minds work upon. Sugar is the food of thought. It is given a more technical name, carbohydrate; but sugar is the name more easily understood by the ordinary man or woman. The sugar metabolism of the brain is a thing about which we know very little. 53 No ambitious student starts research which may lead him into an investigation of mental processes, because there is no future in that. The great Chairs, the great research scholarships, are held by people investigating the physical makeup and the results of physical impacts on the body, and not by those who are investigating the results of physical changes on the mind. There is not enough; there is not 2 per cent, of research expenditure in this country which is applied to these mental questions.
We must cut at the root of the number of admissions to hospitals. All these administrative proposals we are discussing for painting, improving or brightening the hospitals will not get at the original causes, and it is getting at those which alone will enable us to reduce the impact of mental illness; which will bring about, and could bring about, reductions in mental illnesses, possibly comparable with the reductions in the zymotic diseases which have been carried out—reductions in such things as typhoid fever; or the wonderful reduction which we have seen in recent times in tuberculosis.
Great advances have been made. Now we even find tuberculosis beds vacant, whereas only a little whole ago there were more sufferers from these diseases than there were beds for them, so that there were long waiting lists. That in turn has had an effect upon the attitude of the public and the patients. It is the possibility of cure which leads patients to flock to treatment and flock towards hospitals. It is the possibility of cure which impels their relatives to induce them to go for treatment rather than fear it. The treatment of a disease, fortunately almost unknown in this country, but a scourge of the human race outside it, leprosy, up to a little while ago was a matter almost of penal settlements—of guards, of convict conditions. Now, owing to the existence of curative treatment, it is a case of the patient seeking the doctor rather than of the warder seeking the patient.
That attitude is what we must attempt to secure in this other great branch of medicine. Therefore, I would say that we must press very strongly for considerably more attention to be given to research into the problems of the normal working of the mind. Then, it may be, 54 we shall find that we throw light on the abnormal working of the mind. Eminent people, the Huxleys and others, write hooks about the extraordinary effect of slight doses of recognised drugs such as mescalin. I read that description of Huxley's looking at a pair of flannel trousers and of how he felt that for the first time he really understood the inner meaning of a pair of flannel trousers—the result of a slight change, effected by a dose of mescalin, in the circulation of his blood, some slight change in the fluids which were circulating through and nourishing his nerve centres—those nerve centres of ours on which we rely for our judgments.
I am sure that the difficulty of the beginning of confident and successful treatment of mental abnormality is that we do not know about the normal. Where is the result of a thousand volunteers having accepted the administration of a tiny dose of insulin to see what the effect of doses of insulin are on the normal man? We must know that before we use successfully these massive doses which in some cases produce magical results but, in some, do not.
There is another phenomenon which might be investigated which is very familiar to all of us, and particularly to Mr. Speaker and to Mr. Deputy-Speaker. That is the sudden onset of sleep. What is this extraordinary phenomenon from which we have all suffered? We have all found ourselves nodding even in conditions of danger, as, for instance, when driving a car. We have seen the tragic result of that recently in London. It is described as a "blackout," a metaphor, a term taken from the theatre. We know nothing about this extraordinary fact that a person suddenly finds himself nodding, passing into a coma, in which he may do some very dangerous things, such as neglecting to attend to the steering of a motor car. Those who have experienced that extremely unpleasant feeling know how suddenly and apparently inexplicably it can come on.
This is another example of the extraordinary lack of knowledge of the working of the normal brain. Therefore I would say that we have, first of all, to do our best on a wide basis to try to establish some norms, some criteria of normality, some purely physical criteria of normality which even a court, unless it 55 definitely went against the recorded investigations of science and medicine, would not be able to neglect.
Naturally, all of us would wish to discourse further on this extremely interesting and important subject; all the more for Scottish Members in that the Percy Report mentioned that it had under its review the Scottish Command Paper No. 9623, which was brought out as long ago as 1955, but upon which it has not yet been found possible to take action. The Percy Report goes much further in bringing out the wide and far-reaching administrative problems which, in view of the time, I shall not broach at all, except to say that on the administrative side I think there is a great danger of handing too much over to the local authorities before they have been, so to speak, graded up to a point where they can take these matters over.
Certainly I am sure of this, that the research that is necessary can be done only from the centre. Research on the scale which I envisage should be undertaken is really the responsibility of the Lord President of the Council; it is not the responsibility even of either of the Departments of Health. I am sure that both the Scottish and English Health Departments will not be able to go wide enough in their researches, and certainly the local authorities, as such, will be totally incapable of dealing with the problems, the mere physical questions and the ancillary conditions brought out by the Report.
Therefore, I say, like the Parliamentary Secretary, not at all because of my lack of interest in the subject, but merely because of my desire that the House of Commons should have the opportunity of discussing this in the widest field, I welcome this Report, with the highest congratulations for its authors and particularly its distinguished Chairman, Lord Percy of Newcastle, a colleague of mine long ago as a Parliamentary Secretary in the Department of Health. It may be an encouragement to the Parliamentary Secretary to recollect that this Report comes from the pen of one who formerly occupied the position which he at present adorns.
There is, undoubtedly, a great deal to be done in administrative work, and even 56 more in the legislative field. But the root of the whole thing lies in a further and better understanding of the problems that we are tackling, the problems of the abnormal mind and further knowledge of the working of the normal mind itself.
§ 4.35 p.m.
§ Mr. Christopher Mayhew (Woolwich, East)
I think that many of the remarks of the right hon. Member for Kelvingrove (Mr. Walter Elliot) will have won the support of both sides of the House. His speech, if I may say so, seems to be the product of a well-sugared mind. One of the remarks which he made and which, I think, attracted many of us, was when he regretted that this debate would shortly be interrupted by other business.
This is, I believe, the second general mental health debate that there has been in this House in the last twenty-seven years and it seems a pity that on this occasion—this big occasion, so far as this subject is concerned—we should be restricted to three or four hours, for increasingly this problem has emerged as our greatest social problem.
One of the weaknesses of the Royal Commission's Report—and the Parliamentary Secretary mentioned it, in passing—is the statistical weakness. That is not the fault of the authors' of the Report, but it is a fact that on this subject it is difficult to get a full view of the scope of the problem because of the statistical deficiencies, which, I suppose, are the Minister's responsibility.
I should like to know very much more precisely the scale of this problem and the trends—to what extent certain illnesses are increasing and others decreasing. I should like international comparisons. I should like to know the state of mental illnesses in this country compared with other countries and their approach compared with ours.
Nevertheless, I have tried, with the limited figures and facts available, to work out precisely how many mentally disordered people there are in this country in touch with the mental health service at some point or other.
We have already had quoted the figure of 200,000 in-patients in our mental and mental deficiency hospitals. To these we must add something for out-patients, and I suppose that the nearest approach that 57 we can get to this is the figure for 1955, quoted in the Royal Commission's Report, for the first approaches made to outpatients' clinics in that year. That number was 122,000.
Then we must add those who are mentally deficient, and under supervision or guardianship or on licence from mental deficiency hospitals. That figure would come to about 100,000. All told, it seems probable that there are about 450,000 mentally disordered people in this country at present in touch with our mental health service at some point or other.
An that is not the end of the story, unfortunately, because there are scores, perhaps hundreds and thousands, of mentally disordered people who are not in touch with our mental health service today. Some of them may have been discharged from hospital "improved" but not recovered. Others may have applied for out-patient treatment and have given it up. A large number, judging from the correspondence I get, will have been fobbed off by their local G.P. either because he is so desperately busy that he cannot cope with them, or because he simply does not understand the problems of mentally disordered people.
I would say how surprised I am to find how many people have written to me, and probably to other hon. Members, complaining that they have approached their G.P. with their mental problems and had been dismissed with instructions about "pulling themselves together", which have not been helpful and constructive. I am not blaming G.P.s altogether, because this is such a vast problem, and they are often desperately busy.
Finally, there is a category of mentally ill people who do not approach the National Health Service because they are ashamed to do so, or because they do not realise that there is treatment which they can have and which would be helpful to them.
Moreover, quite apart from the number of people involved, which is tremendous, the repercussions of this great problem on all spheres of social life are tremendous. Each one of these mentally ill people is a source of tragedy to a family, to a husband or a child. The other, less human, consequences are also appalling. One has only to look at the matter from the very much lower point of view of the cost to the national 58 economy. The cost of our hospitals and of sickness benefit and loss of wages come to about £200 million a year.
When all the factors that I have mentioned are added together, the question of mental disorder—a useful phrase which the Royal Commission has recommended—mental illness and mental deficiency is rapidly emerging as the greatest social problem in the country at the present time.
It is disappointing to see the strange disproportion of effort which the House of Commons applies to this question. One has only to look at the index of HANSARD to see an extraordinary disproportion of time taken on other no doubt worthwhile but far less important questions compared with this question of mental health. Last week, for instance, we discussed Purchase Tax on musical instruments again. It comes up year after year. It is in the Finance Bill and we have to vote on it. We cannot even pair when that gigantic subject comes up, but mental illness has been discussed only twice in the last twenty-seven years.
This is a case where we Members have a duty, because advance in this subject comes through informed public opinion. Speaking from my personal experience, I would say that our constituents are rather shy of coming to us on questions of mental illness and mental deficiency. Many electors are happy to stand up at Election meetings and complain of rising rents, or something of that kind, but they are ashamed to stand up and complain of conditions in local mental hospitals, most of all if they or a member of their family have been patients there. Therefore, we Members may unconsciously tend to under-rate the amount of suffering caused to our constituents by this problem. It has been only since I have become known as being interested in the subject that large numbers of my constituents have come to me on questions of mental health.
We hope that the Royal Commission's Report will change the position, as it is changing already. Whatever criticism will be made, I do not think that anyone has said or will say that the Report is not the work of humane and enlightened people battling with a difficult and complicated problem. Most of the recommendations are warmly and generally welcomed. There is the removal of emphasis on detention and the increased 59 emphasis on treatment and on the review tribunals, which are very much needed, not necessarily because injustice is being done on review but because it is not plainly seen by patients or relatives that it is done.
One of the great advantages of the review tribunals will be that not only will fairness be done but everyone will agree that it is being done. That is important in these delicate and difficult matters in which people's feelings are so vitally involved. Equally, the wide increase of activity on the part of local authorities is generally accepted and the idea that their duty should be a positive duty and not merely permissive. The change in terminology is also welcomed.
The controversial point which my right hon. Friend the Member for Warrington (Dr. Summerskill) mentioned is the one about the treatment of psychopaths. I find this whole question extremely complicated and, even when one has sorted it out, extremely difficult to judge. I can understand those who object to the Commission's recommendation on compulsory detention of psychopaths. What it comes down to is, plainly, that if we carry out the recommendations we shall create a new legal right to detain people—sometimes of high intelligence—who have committed no crime. That is the essential point. It is true that we can detain those over 21 for only one month, but those under 21 can be detained for a long period and we can detain them even though they would not be certifiable under existing legislation.
As my right hon. Friend pointed out, this raises the difficult question of definition, but I am inclined to agree with the right hon. Member for Kelvingrove against my right hon. Friend on this. I feel that the definition which my right hon. Friend read did not really solve the problem. I would not even say that there were absolutely no suffragettes who would not fall within that definition. One has the same problem of justice and equity in applying that definition as in leaving "psychopath" to mean what it means to psychiatrists and doctors in this country, bearing in mind that all these people who are compulsorily detained have review tribunal rights.
It should be borne in mind, particullarly, that if we carried out the recommendations we would be changing the 60 form and the law but not really changing the practice as much as many hon. Members might think. Already, the law is being stretched and strained to such an extent that many of these psychopaths who would fall under certifiability under these new recommendations are already certified by stretching the present legal position.
This is a matter which needs looking into and changing, but we should be wrong to think that if we accepted the recommendations of the Royal Commission we should necessarily, in practice, be giving greater powers to the Government, to doctors or to health authorities than they have already. It is very welcome that the Commission should have drawn attention to the position, which is unsatisfactory, and I think that, on balance, its recommendation may prove to be right. It really applies only to people aged from 17 to 21, because over 21 it is only a matter of one month's detention for treatment.
Under 17, a young person is already under the Children and Young Persons Acts. Therefore, it is only in the category of people between 17 and 21 that the civil liberties issue arises, and these are the ages in which treatment is most effective. Frankly, I feel less inhibition on restricting the civil liberty of young persons under 21 for their own good, for their training and health, than I should ever feel about an adult. We need to look at this matter from the point of view of the real future welfare of the psychopath of under 21. Though I am open to persuasion on this difficult question, I think that there is a lot to be said for the Commission's point of view.
I was glad that the right hon. Member for Kelvingrove drew attention to another very important fact. It would be a great pity if, as a result of this Report, undue emphasis was laid on the merely legal aspect of this vast problem of mental health. There is a danger that in its efforts to get rid of the stigma and put the treatment of mental illness in a proper perspective as part of the general Health Service of the country, the Commission's Report, by leading to constant debate on this narrow legal question of compulsion and certifiability, may distract public attention from other problems which, I agree entirely with the right hon. Gentleman, are even more important.
61 There are four major fields in which advance is needed. There is the field of legal reform, which is fully covered by the Report of the Royal Commission, and we hope that the Government will make rapid progress in the next Session in dealing with that. Then there is the great need of community care, touched on in the Report, which is of vast importance. Then there are the conditions in the mental hospitals, where great advances are necessary. Finally, there is the question of research.
I hope that we shall not get bogged down in the first field of activity and let others go. Particularly let us avoid, by small disagreements on the question of the psychopath, any suggestion that there is not a vast body of general agreement in the House on the recommendations of the Royal Commission.
I have said that there are four fields because the Report tends to suggest that the stigma of mental illness arises out of the legal position and out of the terminology. That is not so. It is wrong to think that if we change the law and the terminology we shall have done anything substantial to remove what stigma remains in mental illness. To my mind, it is putting the cart before the horse. The Parliamentary Secretary mentioned the word "asylum". I think he agrees with me that it is not the word "asylum" which puts the stigma into mental illness, but that it is our attitude to mental illness which puts the stigma on the word "asylum".
We can call mental defectives subnormal personalities, but it makes no difference whatever if there then attaches to the phrase "subnormal personality" the same stigma that tended to attach to the old terminology. I think, therefore, we should realise that if we want to destroy the stigma of mental illness, we must advance in all the four fields mentioned and not deal solely with the narrow question covered by the Report.
In the field of community care we have a great opportunity to lessen the stigma by destroying the isolation of mental illness from the rest of the community, by bridging and narrowing the gulf separating the mentally ill, in their remote, vast hospitals, from the rest of the community. By the various forms of halfway house outlined in the Report we can become familiar with the problem 62 of mentally ill people. On the whole, that would be a good thing. Some months ago, for the purpose of some broadcasts, I spent a few days in one of the wards of a mental hospital. As I went in I felt a certain apprehension, but after a few hours—hon. Members will not misunderstand me—I felt completely at home.
I feel, therefore, that the solution to the problem of the stigma is to come closer to it rather than to go farther from it. This enables one to see the mentally ill and the healthy disordered not as a vast and rather forbidding army, but as individual people; as somebody's wife, as a railwayman, as a clerk, as a professional man. In this way one gets insight into their problems, and with that insight comes the wish to try to help them and to do something about the problem. So, if we advance in the field of community care, that will be one more attack upon the stigma.
As my right hon. Friend said, perhaps the greatest support of the stigma is the spectacle of some of our vast and ugly and over-crowded hospital wards. We must get rid of that. I am referring not only to the actual size of the wards and the conditions in them, but to the amount of medical treatment given to the patient. There is one mental hospital in Warwickshire where the weekly cost of the mental treatment per patient is 2s. 2d. This means that those patients are not getting treatment of any effectiveness. That again, is an important problem which must be tackled.
Finally, we come to the point about research, mentioned by the right hon. Gentleman. As he rightly said, it is no use painting up what exists, we must cut at the root of the problem of mental illness. Nothing would do more to remove the stigma than a steady stream of people coming out of our mental hospitals, people once seriously mentally ill, now normal. Such people talking about it is the finest possible way to remove the stigma.
If we became mentally ill we would worry about the conditions in the mental hospital; we would worry on the issue of civil liberty, but the one thing we would pray for, above all, would be to have the best possible treatment and to be cured. That is where all the emphasis should be placed. We are not putting the necessary 63 emphasis on research in this country. It is true that advance has been made not only here, but in other countries. Some great mental illnesses have been suppressed altogether, for instance, general paralysis of the insane. Research and treatment have removed it from the list of the worst mental illnesses. New techniques are developing but the position is not yet satisfactory.
A few weeks ago, in a Question to the Minister, I asked how much money is spent on research into mental health in this country. The right hon. Gentleman replied:Expenditure by the Medical Research Council on research into mental illness during the year 1957–58 is estimated at approximately £55.000."—[OFFICIAL REPORT, 25th March, 1957, Vol. 567, c. 800.]It is true that there are some other small sources of funds, but £55,000 spent on research on a problem which, on my reckoning, is costing the country £200 million a year is inadequate.
§ Mr. R. W. Sorensen (Leyton)
Does that figure include the research which is going on in some small mental hospitals?
§ Mr. Mayhew
No, as I said, there are certain other sources of funds and I will come to that later. There is also the Mental Health Research Fund which, with small resources, is doing the best it can in this respect.
On the specific illness of schizophrenia, I asked the Minister how many hospital beds are now occupied by patients suffering from it. His Answer was, 54,179 patients. That figure makes it the worst mental illness in the country, both in its spread, and by reason of the terrible nature of the disease. When I asked what research is being done into it, the Minister replied that the average over the last five years had been £7,500, and that last year it was £11,000.
That is a disgrace. In my view it is scandalous that we are not putting more drive behind this research. The defence put up is that there are not enough ideas, that there is not enough talent. That is not good enough. New ideas and new talent do not grow in a vacuum. We need to create a climate in which young men will choose mental health research as their career. We need to provide fellowships and scholarships at the universities, and 64 these are not being provided now. We need to insist that our medical students, before becoming G.P.s, should study psychiatry. Today, they do not even have to pass an examination in psychiatry, yet they are examined in skin diseases. So, unless we create the climate, we will not get the talent and the ideas, and at present there is neither the necessary drive nor the essential money for tackling the problem of mental health by research.
The Parliamentary Secretary himself advanced one or two ideas as to the direction of research. So did the right hon. Gentleman, who mentioned mescolin, which I myself have taken for experimental purposes in this connection. I have made a study of it and I am certain that it is a promising line of research. I am sorry to have to tell the right hon. Gentleman that the two men who were the pioneers in this vital new means of research into schizophrenia have met discouragement in their research projects in this country. One has gone to America and the other is in the process of leaving for that country.
One cannot help feeling, therefore, that there is not the necessary drive here, and that if schizophrenia were only infectious, like polio, we would have had behind the research into it, the same money, the same drive, the same talent, the same ideas as we get behind research into polio. Maybe we would have had some of the same magnificent results that we have had in treating polio, though mental illness is a particularly difficult field for research.
I am not really blaming the Government for these matters. Frankly, I believe that all political parties are to blame for not giving enough priority to the subject of mental illness in past years. I think that the Press is much to blame. There is seldom a sensible, constructive article in the Press. When mental illness and mental deficiency are mentioned, it is always in a sensational context, connected with sex or violence, in some way or another. I also think that the medical profession is a little to blame for isolating mental illness and mental deficiency and allowing them to be so isolated from the general body of medical practice, and to that extent losing priority.
The Royal Commission's Report should be a great landmark, a great turning point. It has come at just the right 65 time. It has wide support in the country. I hope very much that it will be regarded by the Government not necessarily just as a signal for carrying out the recommendations in the narrow field covered by the terms of reference. I hope that the Government will regard it as a signal for attacking this giant social problem over the whole field.
§ 5.2 p.m.
§ Mr. R. H. Turton (Thirsk and Malton)
The hon. Member for Woolwich, East (Mr. Mayhew) is a very attractive speaker to follow because he opens up so many vistas for argument. I am determined to resist that attraction. I am certain that the debate should be conducted by as many speakers as possible and that we should confine ourselves to very short speeches.
Having for some while watched for the Report of the Royal Commission with eagerness and at times a little impatience, I felt that I should like to express my personal gratitude to Lord Percy not only for the contents of the Report but for the method of presentation. The Report is presented admirably. There may be parts of it with which we do not agree, but one can find in three different sections of the Report exactly what the Royal Commission has to say, in the early summary, in the body of the Report and in the summaries to each chapter, which is a very great advantage.
The main impression which I have received from the Report—it confirms one that I formed earlier—is that the law relating to mental health and mental deficiency is as out-of-date as the buildings which house the patients. There is urgent need for the House to modernise both the law and the buildings.
In this modernisation, we must do all we can to break down the division between mental and other hospitals. Some of the stigma to which the hon. Member for Woolwich, East referred was not derived from a legal definition but came from the separation of mental treatment from other treatment. When I was spending a certain amount of time visiting mental hospitals and mental deficiency hospitals, I formed the conviction that there were very many patients in those hospitals who, with advantage to themselves and the community, could be accommodated elsewhere.
66 I have read with care the parts of the Report which deal with that subject. The Report expresses a slightly different view from mine on certain matters—the Royal Commission may be right, or I may be right—but in the end we are agreed that what is wanted is not treatment in a hospital alone but more and more community care. By "community care" is meant that people who now have to be accommodated in hospitals will be accommodated outside.
All this is especially true in respect of old people. Recently, I was able to compare an old people's home in Berlin with old people's homes in this country. I noticed that in the old people's home in Berlin people who had their mental faculties as well as their physical faculties impaired could be accommodated. I feel that we should do a great deal to get the old people who are in mental hospitals into much smaller communities. I do not believe the large institutions are good for them.
I am in general agreement with the recommendations in the Report. In particular, I am sure that the time has come to do away with the Board of Control. It has done good work in the past, but with the changes in the law which are required and with the different conception of the method of treating mental disorder, it being looked upon as something which is medical and requires curative rather than custodial treatment, I feel that the time has come for the Board of Control to go.
My main disagreement with the Report arises on the question of discharge, which is dealt with in paragraph 421, in which the Royal Commission recommends that the power to discharge the patient from hospital should be in the hands of the patient's nearest relative, the medical superintendent of the hospital, any three members of the hospital management committee or board of governors and the Minister of Health.
I take the view that it is wrong to make the Minister of Health the final arbiter in a matter which affects the liberty of the subject. Let us see exactly what might be the case. If the Minister were asked to discharge a patient, it would mean that the medical superintendent had advised against it. Thus, the Minister could recommend a discharge only in a case where the medical superintendent, an 67 officer appointed by the regional hospital board, which had been appointed by the Minister, had advised against it. It would also be in a case where the patient's nearest relative had thought that the patient should not be discharged. The same argument would apply in respect of the members of the hospital management committee.
I do not believe that it would be in the interests of the patient to have the power to discharge in the hands of the Minister. I do not think that such a power would be exercised very frequently, but I think it is wrong for it to lie there. I feel that the final arbiter should be a judicial authority, and I would recommend either the commissioners mentioned in Chapter 11 of the Report or a county court judge or a judge in chambers. At all events, it is vital that the liberty of the subject should, in the end, depend upon a judicial authority and not upon a Minister looking after the administration of health.
The mental health review tribunals are an excellent idea, but I hope that the Government will not follow the suggestion made in paragraph 447 that the clerk to the tribunal should be a regional officer of a central department or an officer of a regional hospital board. We know quite well that the average citizen looks upon a tribunal of any kind very much in the light of where its office is. Here we are dealing with an appeal against a decision of a medical superintendent in a hospital appointed by a regional hospital board. Consequently, the officers of the tribunal should not come from the office of the regional hospital board. The office and the officer should be judicial in character and not administrative. In other words, if there has to be an office, it should be that of the local clerk to the magistrates or the county court judge. That does not mean that I do not agree that there should be on the tribunal medical representatives and representatives of the hosiptal management committees as well as legal representatives. It is the office which ought clearly to be judicial, because we are here dealing with an appeal.
I promised to be brief and I will therefore cut the rest of what I wanted to say. I trust that the Parliamentary Secretary, the Leader of the House and the Minister. whose absence today we regret 68 so much, will note that this is a matter for urgent decision. I know that it is complicated, but the great difficulty is that a Royal Commission has made very far-reaching recommendations for reform, and unless the Government take early action, there will be lack of confidence in the administration.
It is very difficult for the Board of Control to continue in operation for long when the Royal Commission has recommended that it should be superseded. That also goes for many other of the Commission's recommendations. I hope that the Government will bear in mind that in the Commission's view many of its recommendations can be carried out without amending legislation. I hope that they also realise that those which require amending legislation should be incorporated in a Bill to deal with this subject introduced at an early date, subject to the need for time for preparation. Matters affecting the health of the nation and the liberty of the subject brook no delay.
§ 5.11 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
The temptation to range over the whole of this subject, which to me is a very fascinating one, is almost irresistible, but I propose to try to emulate the example of the right hon. Gentleman the Member for Thirsk and Malton (Mr. Turton) and to direct my remarks to the Report itself and to speak briefly. On the whole, it is a most admirable and enlightened Report and I join in the congratulations to the members of the Royal Commission on the attention which they have given to the subject.
I want to take up the right hon. Gentleman on one point, the only one on which I disagreed with him. That was his objection to the Minister of Health being a final discharging authority in this matter. The right hon. Gentleman said that where the liberty of the subject was concerned it was inappropriate that the Minister should be responsible. It is appropriate for that very reason that a Minister should have responsibility, because a Minister is responsible to the House. I agree with the right hon. Gentleman that the Board of Control is a somewhat maligned body and one which has done a good job; but one of its great weaknesses is that it is not directly answerable to the House on matters of 69 civil liberty. I join issue with the right hon. Gentleman on that matter.
It is necessary to skate very briefly over those aspects of the Report, which constitute the great bulk of it, with which I am in agreement. Of course, we are all glad that compulsory powers are to be reduced to an absolute minimum and that safeguards against — I will not say improper detention because that is an unhappy phrase— unnecessary detention are to be increased to the maximum. I am also glad that the responsibility for the exercise of compulsory powers is to lie on the shoulders of the medical profession, and that one of the two doctors concerned is to be a psychiatrist.
I imagine— perhaps the Leader of the House can confirm this—that normally it will be the patient's own general practitioner and the medical superintendent of the hospital to which he is taken who will be the people to recommend treatment against his will, if he is not a voluntary patient. I have never set a great deal of store on the value of a magistrate's signature as a safeguard against wrong certification. It has had the effect in the past of making certification something of a judicial process and has added to the stigma which attaches to certification in the mind of the public.
I have one or two doubts about the Commission's recommendations on compulsory admission. The Commission recommended as a corollary to admission to hospitals being as informal as possible that mental hospitals should no longer be ordered to receive a patient. I can well see the motives which led the Royal Commission to make that recommendation, which is obviously intended in the patient's own interests. But the Commission says in paragraph 383 of the Report:We do not wish to encourage psychiatric hospitals to refuse to admit patients because they may be difficult and awkward to treat, nor to turn away any patient who urgently needs treatment which they can provide.However, enactment of that recommendation might lead to just that. When the Parliamentary Secretary and the Minister come to consider legislation I hope they will think about whether it is quite safe to give hospitals the right to turn away patients who urgently need treatment. We know that in general hospitals there have been unfortunate consequences of hospital after hospital 70 turning away patients needing treatment. I should not like to see that extended to mental hospitals.
We all approve the arrangements for the voluntary care of what used to be known as mental defectives. I approve of that as strongly as I disapprove of the title "severely sub-normal personality." I do not think that that title will become accepted and I believe that something will take its place. I hope that that matter is given thought before the Bill is drafted. The Royal Commission was surely a little glib in its assumption that it was possible for mental defectives under existing law to be taken in voluntarily for care and treatment. I question that. It is something which has never been decided in the courts and legal opinions differ on whether it is possible. It might be considered all right if the Ministry were now to issue a circular to all hospital authorities recommending that in fuure they should admit defectives to mental deficiency hospitals without certification.
I agree very largely with what my right hon. Friend the Member for Warrington (Dr. Summerskill) said about psychopaths. It is a pity that the Royal Commission was unable to agree on a definition. Having been unable to agree on a definition of a psychopath, it was an even greater pity that they made a virtue of their failure and said that no definition should be included in the law. That leaves the matter far too wide open, because it is not only psychiatrists who have to decide who are psychopaths and who are not, but also in some cases the courts, and without any guidance from legislation, that may lead to undesirably wide variations in practice in different parts of the country.
My right hon. Friend quoted Professor Henderson's definition, but I think that we can do better than that.
§ Mr. Robinson
I will have a talk with my right hon. Friend afterwards, because I am trying to be brief. It is not an easy task, but some definition must in my view be found.
I welcome very much the fact that the Commission had the courage to tackle the whole topic of psychopaths and I hope 71 that these incidental difficulties of translating the recommendations into legislative form will not discourage the Minister from going ahead. I hope that he will not use these difficulties as an excuse for saying, "We are not ready to do this yet; let us drop it; it is too hot to handle for the moment." It is most important that we should now take legal powers to deal with the psychopath as such.
On the question of community services, and this is perhaps the most important aspect of the Royal Commission's Report, all that it does, in effect, is to say that what local health authorities are now permitted to do they shall do in future as a duty. That means a very great change indeed for the majority of local health authority areas. I think that on the whole the local health authorities are the people to do this community work, but it will mean an enormous expansion of trained personnel, it will mean a considerable additional expenditure of money and it will also need a lot of building.
It is a most unhappy coincidence that the idea of putting these new responsibilities on the local authorities should come at a time when the Government are deciding to cut down the central grants to local authorities, because I feel that there is no hope whatever that the local authorities will carry out these recommendations in the spirit in which the Royal Commission made them unless they are given considerable encouragement, including financial encouragement, by the central Government.
In conclusion, I should like to repeat what was said by my hon. Friend the Member for Woolwich, East (Mr. Mayhew)—that legislation, although long overdue, will not itself give us the new deal for mental health which we urgently need. We need to do very much more. The question of research has been touched upon several times, and for three or four years one or two of us have been trying by Question and Answer to expose what I consider to be the serious failure of the Medical Research Council in research into mental illness. Nothing like enough is being done, and if the new interest in this subject which has been stimulated by the publication of this Report, by a number of broadcasts and television programmes and by serious articles in the Press, is to bear fruit, we 72 need research above all. The Royal Commission can congratulate itself on having done a first-rate job.
§ 5.22 p.m.
§ Dr. Reginald Bennett (Gosport and Fareham)
Before I began to take an interest in my fellow men in this House I spent a number of years taking an interest in them in considerably less august institutions. Therefore, I have been profoundly affected by the new accession of knowledge which has come to us through this Royal Commission's Report. It affects almost every facet of the outlook of one who has been working in mental medicine in any capacity whatever, and I for one welcome that most warmly, because clearly medicine had appeared to outstrip administration in this field for many years past.
I have always had the greatest sympathy with the attitudes of the hon. Member for St. Pancras, North (Mr. K. Robinson) in matters affecting mental health. He is a great lay expert on the subject. I have taken his point about the turning away of patients to which he referred earlier in his speech. When I was practising in mental hospitals, it was a matter of some pride that mental hospitals never turned away patients except under the stress of a complete lack of accommodation; and that did not happen until perhaps twice the designed number of patients was in the wards, whereas the disasters which occurred through the turning away of patients brought in in emergency were nearly always associated with the hospitals concerned with physical disabilities. If that distinction is to be lost administratively, I doubt whether it will be lost in spirit, and I do not fear that mental hospitals will now start turning away the patients sent to them.
I see in the Report that a letter of acceptance has to be provided before the patient is admitted under compulsory powers, but I fancy that that will not give rise to what one might call a stiff-necked attitude in the administration of mental hospitals. If that is possible, perhaps the views of the Government on this subject may be expressed in some way.
I agree with the hon. Member for St. Pancras, North that the phrase "severely sub-normal" is one which 73 comes a little clumsily to mind in dealing with what we have always known as mental deficiency. In fact, I think I am right in saying that the hon. Gentleman was the first speaker this afternoon to use that phrase, and then only in a critical sense.
The subject with which I have been concerning myself for the many years during which I have been in psychiatric practice has been that of the psychopath. I have tried to draw up papers on the subject and publish them and so on in the past ten years, and it has been one of the most unsatisfactory fields in which to work because of this very difficulty about definition. If one tries to compile any work on psychopaths one comes up against the very same snag which the Royal Commission duly met. That was the first thing I looked for on reading the Report.
Two distinguished authors of a standard text book on psychiatry prefaced their book with this statement:I cannot define an elephant, but I know one when I see one.That I think is very apposite to trying to define a psychopath. Almost any psychiatrist—not just those who are very self-opinionated, but those working in all humility—will probably think that he will be prepared to diagnose a psychopathic personality when he meets it, but I doubt if he could define the condition to anybody else.
The Royal Commission has not succeeded either in finding a definition. Perhaps we must come to the conclusion in this connection that the attitude of the Royal Commission to the psychopathic personality is somewhat ahead of its time, in that it leaves the diagnosis to the medical profession, which has got very far in ten years towards reaching some sort of definition; and perhaps by the time we see the new legislation implementing these things it may be possible to pin down this kind of elusive definition with some fair degree of accuracy.
Perhaps I should mention, without being thought to be advertising in any way, that we shall have some of the greatest experts in research in this field coming to this House on the 23rd of this month to address the Parliamentary and Scientific Committee, so that we may hear notably what Dr. Dennis Hill has 74 been doing with his electroencephalograph. He and his school have been making enormous progress, such that I personally would not have claimed to know more than the barest premisses from which their whole structure has been erected since I left the Maudsley Hospital and the practice in psychiatry in those extremely academic surroundings.
The action to be taken about psychopathic personality is another matter which causes me a little doubt. I am far from sure that the Royal Commission was itself sure of what it wants to do about psychopaths. It mentions that they should be dealt with under certain compulsory powers, but in paragraph 34 of the Report the Commission makes what is to me a rather astonishing suggestion—thatdoctors and others should not be too hesitant to use compulsory powers,andin particular the responsible authorities should not be reluctant to bring criminal charges … because they consider them mentally abnormal.I feel that in this age when we are trying to make progress with preventive medicine we should not try to push the authorities into bringing criminal charges in order to make it easier for the administration to deal with these people. Surely, we are putting the cart before the horse? We ought to try to get them before they are criminals, and before they have been labelled with a far worse stigma than that of mental illness. I think they have slipped up there, and that that is a symptom of the Royal Commission's inability to be quite sure of what it wanted to do for the detention of psychopaths who are not grossly, or certifiably, psychopathic. I think they are tending to slip up, and I can only hope, if I read the Report right, that this loophole is meant to be filled by a much more extensive and novel use of guardianship under compulsory powers than of the committal to institutions under compulsory powers, which is really tantamount to certification.
The hon. Member for Woolwich, East (Mr. Mayhew) mentioned the difference in the powers to be used for psychopaths under and over the age of 21, respectively. That is a very right decision. A psychopath over 21 has probably long since been a nuisance to everybody around him and is well known as one who, if not 75 actually involved in criminal proceedings, has been a pest and a public menace for years. But I think it is right to say that the younger psychopaths, who declare themselves quite clearly before the age of 21, are amenable to a certain amount of institutional correction, and the powers in respect of them should therefore be greater.
It is a fact, which the researchers have been working upon, that the psychopath improves spontaneously with the years. Probably every hon. Member knows that. It has been found by those wizards with the electro-encephalograph that the brain waves of a psychopath of any age correspond to the normal brain tracings of somebody many years younger. In fact, it is now seen to be a physical as well as a mental immaturity in every way. Therefore, I might perhaps myself be regarded as being now beyond the danger zone. In fact, by the time anybody enters this House he is probably almost free from any serious threat of the stigma of being called a psychopath. By the age of 30 the brain tracings of most psychopaths have settled down and are not so wildly zigzag. They are then well on the way to becoming more reasonable citizens, although there might have been great room for improvement when they started.
Another question is that of the abrogation of magistrates' committal of patients under compulsory powers. I do not know whether I can say that this is a good thing. I realise, as many hon. Members before me have said, that a magistrate's signature upon a certificate is no more than a formality. The magistrate might not have the faintest clue as to what his patient is up to, except for what is stated on the certificate, and he merely rubber-stamps the document. Do we want the onus of these compulsory powers to rest upon the medical profession? I very much doubt whether the medical profession will want that. It will disturb what has perhaps been made excessive political play of recently, namely, the doctor-patient relationship. It will certainly mean that patients will be leery of going near their doctors if there is any question of mental illness. I doubt whether this power will be welcomed by the medical profession. It will require a good deal of looking into before we can agree to make a decision in accordance with the 76 recommendation of the Royal Commission.
At this point I should like to consider the position of the doctors who get most of the odium of the use of compulsory powers—the superintendents and the staffs of mental hospitals. I deplore the buildup in the Press which has led to their being regarded almost as ogres, who keep their innocent patients captive. Nearly all of them would prefer an empty bed. They would then be able to admit somebody else. These much maligned doctors, who live in somewhat isolated places, have been greatly overworked on administrative as well as mental work, and they deserve a break from the British public. They have had a rotten time, and some attention might be given to brightening the lives of these rather remotely and "over-integrated" doctors, who very readily tend to join their patients if they are kept inside too long. Their lot might be alleviated considerably in many ways.
I find myself in almost complete agreement with everything which the right hon. Member for Warrington (Dr. Summer-skill) said, which is very pleasant. I much appreciated her point—which has perhaps not been well set out before—about the dreary deterioration of patients who stay in mental hospitals for a long period because of a shortage of staff to give them any form of medical treatment. Before I left the rather rarefied company of researchers they made out that they thought they had discovered that the deterioration of epileptics, for instance, over a period of time is not an integral part of the disease but is all part of that frightful word "institutionalisation". Their hopelessness, and the limbo in which they find themselves, are what cause the symptoms; it is not any part of the epileptic disease.
One other point that the right hon. Lady made which deserves to be underlined—or I would not presume to mention it again—is the question of the new treatments which have made such miraculous cures of diseases where, only a few years ago, the outlook appeared to be utterly hopeless. In that respect I go further than the right hon. Lady went. I say that it is now a wonderful thing—and a fact that we all ought to bear in mind—that the degree of disturbance, violence, disorderliness and irrationality of a patient 77 is in no sense an indication of the possibilities of a cure; in fact, it could almost be suggested—perhaps by somewhat gross exaggeration—that it is the more violent ones who have the better outlook. We should therefore certainly look to our new cures to bring hope to those whose antics were dismaying their families and neighbours the most.
I feel that this Report has now thrown some great light upon this very dark subject. The dark tunnel-like wards of the old mental hospitals, some of which I know so well, have now come into a blaze of the light of public notice, and I hope that Parliament and the Government will keep them there until all the darkness has cleared away.
§ 5.36 p.m.
§ Dr. A. D. D. Broughton (Batley and Morley)
I am aware that many hon. Members wish to take part in this short but very important debate, and I shall therefore follow the example set by previous speakers and address the House for only a few minutes.
I listened with great interest and approval to the speech made by the hon. Member for Gosport and Fareham (Dr. Bennett). He and I have very much in common, in that we are the only two hon. Members of this House who have had a long experience in psychiatry. I know of the useful and important work that he has done in connection with psychopaths, and his contribution to our discussions today was a particularly valuable one.
I think that I am right in saying that I am the only practising psychiatrist in this House, and I feel it incumbent upon me, as such, to give a brief expression of opinion on the Royal Commission's Report. The trouble is that the subject under discussion is such a vast one that in the time available one can do no more than touch lightly upon one or two aspects of it.
First, I wish to make it clear that psychiatrists welcome the Report. There are differences of opinion on certain details, but, generally speaking, the Report is warmly welcomed. Although it proposes many radical changes, these come as no surprise at all to psychiatrists, for those of us who work with mental patients have known for a long time that much of the law, as it relates to our patients, is antiquated and in urgent need of being brought up to date. I was 78 pleased to hear the Parliamentary Secretary tell us that he and the Minister are to have discussions with hospitals and local authorities in the near future. I hope that after the discussions steps will be taken speedily to implement the recommendations of the Royal Commission.
Mention has been made by several hon. Members of the overcrowding of mental hospitals and the shortage of staff. Medical officers do not overburden themselves with work deliberately by retaining patients in hospital unnecessarily. Taking the country as a whole, I think that medical superintendents would gladly discharge at least 25 per cent. of their patients if they could be sent out of hospital to satisfactory living and working conditions. But medical superintendents cannot send out of hospital those poor souls who have no other home, no work, possibly no relations and no friends and no social contacts in the outside world. Such a patient in the search for a home and work and friendship would suffer inevitably another breakdown.
Because of that, I welcome the proposal that local authorities should be responsible for all types of community care for patients ready to return to the general community. Such arrangements when made could benefit thousands of patients, relieve the pressure on beds in mental hospitals, and ease the strain on the overworked medical officers and nurses. Of course, it will mean added responsibility and additional expense to the local authorities, but I think they must shoulder that burden if this great problem is to be tackled properly.
When considering the problem of the care of patients, I would draw the attention of the House to the value of day hospitals. I do so because I am at present privileged to serve on the staff of one of them, and I have reached the conclusion that day hospitals can be extremely useful to many types of patients. Like other hospitals, day hospitals have an out-patient department and provide most forms of modern therapy. But they have no beds for night-time. The patients live at home or in lodgings or hostels and come daily to the hospital for their treatment. Such a hospital cannot accept all types of cases. For example those who are a real danger to themselves or others cannot be accepted. But these hospitals 79 can take a surprisingly large variety of cases of psychosis and neurosis.
Because the hospital has no beds certain forms of treatment cannot be undertaken. For example, it is not possible to admit patients for surgical brain operations or deep insulin therapy or prolonged narcosis. But they can give psychotherapy with or without drugs, occupational and group therapy, electric convulsive therapy, modified insulin and other forms of treatment which do not necessitate the patient staying in bed overnight. Malborough Day Hospital was the first of its kind in this country and has been operating for nearly ten years. From my own experience there and from the study of the hospital records, I am convinced that it has served a useful purpose.
I understand from the Minister who replied to a Question which I put a few months ago that there are now fifteen day hospitals in the country. I suggest the time has come for the Minister to examine this policy when he will find that it is one of great value. It is much cheaper to take over a house and convert it into a day hospital at little cost than to build a new hospital or to extend an existing one. When the hospital has been acquired, the running costs are much lower than those of a residential hospital.
The patients attending day hospitals are not certified. They have no forms to sign. They attend of their own free will. The mention of certification brings me to that subject about which I have strong views. As the House knows, patients entering our mental hospitals do so as certified, temporary or voluntary patients. The procedure for temporary patients is somewhat complicated. It can be troublesome and may lead to difficulties. Consequently many medical superintendents do not welcome temporary patients. Most of our patients in mental hospitals are either voluntary or certified. A patient can be a voluntary patient only if he is well enough to sign an application form expressing a positive wish to receive treatment. If the patient is incapable of doing that, he cannot enter the hospital as a voluntary patient. I suggest that the result is that many patients are certified who never should be.
May I quote a couple of examples from my own experience in mental hos- 80 pitals fairly recently. One is the case of a man aged 82. He was a fine, sturdy, independent type of fellow. He had led a good and useful life, worked hard and brought up a family. It is not surprising that at his age his arteries were hardened and that one day he had a cerebral thrombosis. The effect upon him was that he became severely mentally confused. He was restless and resisted all attention. He could not be managed at home and was unacceptable for admission to a general hospital. A mental hospital was the only place for him and, therefore, he was certified. That man died within a week, and death was due to old age. I think it quite wrong that it should have been necessary for that man to have been certified as being of unsound mind in the last week of his long life.
Another case which I wish to quote is that of a woman of thirty who had had a great deal of domestic worry and trouble causing her to be depressed. She had neglected herself, eating little, drinking too much and losing a great deal of weight. She became stuporose and resisted all attention. She was certified and brought into a mental hospital. On examination she was found to be suffering from pneumonia. She died within two days and the post-mortem examination showed a massive low-grade pneumonia. Her mental condition had been due to her general debility and toxaemia from the pneumonia.
In both these cases there was a physical explanation for the condition and the mental derangement was a terminal phase of the fatal illness. Everyone who has worked in mental hospitals could quote similar cases by the score. I suggest that the only way to abolish this injustice, this stigma, is to abolish certification. There will have to be some powers for the compulsory detention of a few dangerous patients, but for the majority I should like to see mental and nervous cases able to enter mental hospitals just as patients can enter other hospitals.
The Report states:Great progress has been made during the present century in developing methods of treatment in many forms of mental disorder.That is true. I am very proud to say that Britain has been to the forefront in these advances. This year I was granted the privilege of visiting mental hospitals 81 in France, Western Germany and Czechoslovakia. Whilst there I met many distinguished psychiatrists and saw much of interest, but I can say with confidence that, broadly speaking, they are not ahead of us. Nevertheless, although we can be proud of our achievements in the field of psychiatry, much remains to be done.
Hon. and right hon. Members speaking today have put their fingers on the various bad spots, drawing the attention of the Minister—if indeed it needed to be drawn, as I think he is already aware of it—to the need for improvements in this field of medicine, but I think it is a fact that psychiatry is the Cinderella of the Health Service. It is quite ridiculous that it should be so, because half our hospital beds are occupied by patients with mental illness and it is probably true to say that as many as 75 per cent. of patients who go to visit their general practitioners are suffering from some form or other of psychosomatic illness.
Our hospitals are overcrowded, the establishment for medical officers in them is only 80 per cent. filled, there is a great shortage of nurses and, consequently, the treatment of patients really is not yet good enough. There is far too little research being done. As hon. Members have already mentioned, there is need for much more research.
I welcome the attention that this House is giving to the Report of the Royal Commission. I hope that the, Minister, assisted by the Parliamentary Secretary, will push ahead with the discussions that they are to have with local authorities, hospital authorities and others and waste no time in drawing up the necessary legislation to implement the recommendations of this Report, for it is necessary that great efforts should now be made to help those people who have the great misfortune to be suffering from nervous and mental illnesses.
§ 5.54 p.m.
§ Dr. Donald Johnson (Carlisle)
I rise to welcome this Report as much as any hon. Member who has so far spoken in the debate. I must say that my admiration for it is equalled only by my admiration for the Parliamentary Secretary, who told me the other day that he had read it through twice. It has been my constant companion, but I regret to say that I have got only as far as paragraph 458 in my own thorough reading 82 and have to content myself with just a smattering of knowledge picked up here and there of subsequent recommendations.
When one tries to look at the Report from a detached point of view, I think that what inevitably strikes anyone is the revolutionary nature of its recommendations as compared with the general mildness of its criticisms of the existing system. Indeed, I think any newcomer to this House listening to the opening speeches of this debate, would really wonder whether there was any necessity to make any changes at all. It was to some extent, therefore, in anticipation of this situation that the hon. Member for Erith and Crayford (Mr. Dodds) and I, over the past year, have worked together, sinking our party differences, to fill what we felt might be a gap. We, perhaps, have formed one of the pockets of disaffection to which my hon. Friend the Parliamentary Secretary referred in his opening remarks.
§ Mr. Vaughan-Morgan
May I correct my hon. Friend? I did not refer to "disaffection"; I just said "irresponsibility".
§ Dr. Johnson
I stand corrected, but I think that hon. Members who, apparently, will not find sufficient reasons in the Report as such for this or that recommendation, may well find them in the speeches and Questions which have been asked in this House and possibly in publications outside.
Rightly or wrongly, it is the custom for any criticism of our health and welfare services at present to be expressed in somewhat muted tones. Therefore, it is natural and proper that when we come to the recommendations of the Commission for the abolition of the Board of Control the Commission should distribute bouquets such as we find in paragraphs 788 and 791 of the Report in regard to work well done and such as have been repeated in this House. I, on the other hand, will be sending no orchids to the obsequies of the Board of Control. It has outlived its usefulness in the manner which has already been stated by my right hon. Friend the Member for Thirsk and Malton (Mr. Turton).
It is proper, also, that we should pay every tribute to those who work in these services and also to the undoubted advances that have been made in treatment and the general improvement of 83 conditions but, if we are going to reform, I submit that it is essential to know not only what we are going to reform, but why we are going to reform.
What one finds in taking a view of the mental health services of the country is an extreme variability between one district and another and one hospital and another. It is insufficient that here and there we should have the best—as, indeed, we have, as I am the first to admit. We must also think of the worst. To get a satisfactory service we must bring up the worst to the level of the best.
At the risk of continuing in heresy, I maintain that no one can give us better criticisms of what is wrong than the patient, even when the patient, as occasionally he does, complains. After all, there is nothing like being at the receiving end and, where compulsory powers exist, it is very easy for those who exercise them to live in a world of self-delusion, unless they take careful note of and listen to those unfortunate enough to be at the receiving end.
We are united in this House this afternoon in our anxiety to take the stigma out of mental illness. In this process we can start now, because if there is one thing more than anything else on which the mental patient and the ex-mental patient feel they are stigmatised it is that they are discredited people, that no one will believe them, no one will listen to them and give them facilities for putting their case. We have already heard it somewhat jestingly stated that anyone who differs from the psychiatrist is dubbed a psychopath. That is, perhaps, an exaggeration, but some of them are certainly dubbed paranoiacs if they complain of any form of psychiatric or other hospital treatment.
In particular, I welcome the fact that the Royal Commission examined a number of witnesses who were former mental patients, and published their evidence as a supplementary Report. At the beginning of what I hope will be a series of debates on this subject, I ask hon. Members to believe not that everything mental patients say should be implicitly believed, but that no evidence should be disregarded, just because it comes from mental patients, without carefully weighing it.
84 In this short debate there is little time to discuss in detail all the recommendations of the Report, so I propose to try to look at the matter in perspective and in the broadest outline. The effect of the Commission's Report on any further legislation would be to reform and bring up to date the Act of 1890, so I think it appropriate that, as a basic consideration, we look at that Act.
It is a reasonable Act in its way and in the context of the times in which it was enacted. Let us see what was the context of those times. If a man was mentally ill in those days, he did not go to any early consultation to see what was the matter with him. He hung on and on, until he was really mad in the proper sense of the word; his personality became disintegrated, he became impossible for others to deal with; and was then put away out of society, perhaps indefinitely, by the operation of this Act. That was the atmosphere that overhung the whole situation—an atmosphere of indefiniteness, of incurability, of general hopelessness and, perhaps, of degeneracy.
In those days the asylums were places far more isolated even than is the case today, in the age of the motor car. Consequently, they became populated with these people and infected with this atmosphere of hopelessness. In most cases, the people in them were those who, it was thought, would never recover; although there were occasionally included those who were not so ill but who had, nevertheless, slipped into the net. To prevent a man slipping into the net too easily, various defences of individual liberty were written into the Act.
Fortunately, times have changed. But they have not changed as much as all that, nor have they changed everywhere alike. For instance, the continuity of tradition, associated with the continuity of the law, has remained very strong inside many of these institutions. I hope that it will not be thought that I am just cracking at medical superintendents when I say this, because the more enlightened medical superintendents will themselves say that it is this tradition which is their most formidable obstacle to effecting improvements in their own institutions.
This tradition is the basis of the patients' main burden of complaint. Their complaint is, first, the attitude with which 85 they are regarded by those they meet in the institution when they enter it. Coming from the outside world as they do, and being not always dull people, but frequently especially sensitive people, they feel that very strongly. This attitude varies, naturally. In many hospitals the patients do not sense it at all. In others, where the tradition has remained stronger, the patients are very conscious of it indeed.
Their complaint, secondly, is their isolation—the fact that they are frequently cut off from friends and relatives and, above all, occasionally from legal advisers. Then, thirdly, the fact that, if they are removed to an institution compulsorily under certificate, they are deprived of their civic rights and—and this is immensely stressed by them—they are unable to deal with their financial affairs, which are taken right out of their hands immediately by the operation of law.
The primary cause of all this is these legal formalities which still surround the fact of admission to mental hospitals, particularly in the case of certified patients. A certified patient today immediately becomes a second-class or third-class citizen. That is why one welcomes so much the de-designation of the hospitals which is recommended by the Royal Commission. I particularly welcome paragraph 849 of the Report, in which the Commission actually recommends that even compulsory admission to hospital should not necessarily involve the patient being deprived of the control of his financial affairs. I welcome the remarks in that paragraph about the Commission's realisation of the distress, the immense distress that people feel over this, and I sincerely hope that that realisation will be noted when it comes to effecting new legislation.
We can look forward to vast changes in the whole atmosphere of our mental services through the de-designation of mental hospitals. It is fair to predict that the area in which compulsion has to be exercised will be greatly reduced, and will become very much more manageable than it is at present. Compulsory powers are, of course, occasionally necessary, just as it is necessary to have protection against their wrongful use.
86 There is no time to go into details in this respect, but, in particular, I welcome the recommendation that where compulsory powers are exercised two doctors should be called in so that there is at least some chance of establishing a proper diagnosis. I welcome, too, the independent tribunals which are so desperately a missing feature of the present System I should like to echo what the hon. Member for Gosport and Fareham (Dr. Bennett) has said about the dislike doctors have of being completely responsible for the exercise of these compulsory powers. In any case, where there is compulsory detention there should not be too long a period before legal procedure is taken, and the suggested period of six months is. I think, rather lengthy.
Whatever protections we put into future legislation I suggest that they should be tied up completely. We must not allow them to degenerate into the mere paper protections, of which there is no better object lesson than the 1890 Act. That Act is full of protection for individual liberties, which one after the other have gone by the board and have in many cases become completely valueless because of the loophole in the Act and because of the easy process of certification which in recent years has been found convenient to use.
I should like to say a great deal more on this subject, but time is getting short. Therefore, I should like, in conclusion, to express my pleasure at two recommendations in this Report which cover the mental deficiency, or psychopath, field as we shall probably be calling it. The first of these recommendations is that relatives shall have the right of discharge of all patients who come under the psychopath and mental deficiency laws, as well as the mental illness laws, except where there is court procedure; and, secondly, that psychopaths will not be detained over the age of 25.
I think it is agreed that we can do very little by way of treatment for psychopaths over the age of 25. If they get on the wrong side of the law and it is necessary to detain them for that reason, that is quite another matter, but I think it is generally agreed that treatment as such is of very little use.
Mental illness is a large and unwieldy problem, but I suggest that problems are apt to create themselves, and if they are 87 tackled competently, thoroughly and on right principles they reduce in size. I suggest that the Royal Commission's Report shows such a way to meet this problem of mental illness. We should appreciate that it cannot perhaps be implemented all at once. In fact, it may well be advisable to contemplate its introduction in two stages. The first stage, and perhaps the immediately urgent, is the de-designation of hospitals and the revision of the admission procedure. The second stage, which is admitted to be the more difficult, is to get the local authorities services functioning, to deal with the question of expense, to get them to work new duties and so on.
I am confident that, given good will, the Commission's Report, looked at from a practical point of view and carried forward with enthusiasm, will introduce a new era in the general treatment and administration of mental illness in the country.
§ 6.13 p.m.
§ Mr. R. W. Sorensen (Leyton)
This has been a bipartisan debate, a fact which some people may deplore but I do not because there is a wide field in which all parties and all persons can join together for the common good. Moreover, I think that this at least has been established in our discussion today, that all parties agree to what some of us would call the Socialist principle and what others, no doubt, would call the ethical principle—the principle that we are responsible for the well-being of a considerable and important section of our community. Some of us, of course, wish to expand that principle elsewhere.
I understand that even the hon. Member for Carlisle (Dr. Johnson) does not disagree with the proposals that have emanated from the consideration of this problem by the Royal Commission. As does everybody else, I, too, bear testimony to the thorough analysis which has been made of this problem by the medical and lay members of the Commission. It is significant, however, that there are both medical and lay members. It is significant because perhaps we should not overlook the necessity for the laity also to be consulted on the treatment of mental illness at other stages than the preliminary stages, and to be consulted along with the medical experts. 88 It has been said today by some hon. Members that the Report embodies revolutionary or far-reaching proposals. I venture humbly to disagree. I submit that the proposals, although admirable, are no greater advance relatively speaking than the advance registered in what is called the Greenwood Act, the Mental Treatment Act, 1930. I was present when it was passed and I remember the debates very well.
I was, as a mere layman, associated with mental illness for many years until 1945. In fact, in 1923, when I was first elected to the Essex County Council, I was asked on what committees I would like to serve. Having indicated that I would like to serve on the education committee and the public health committee, I was informed almost by return of post that it was considered more advisable to put me on what was then called the lunatic asylums committee. On that body I served for twenty-one years, and as a layman, therefore, I have had limited experience, I admit, but some experience which certainly was in my mind when, in 1930, the Greenwood Bill was introduced and ultimately became an Act.
What I see in this Report, which, I hope, will be applied administratively or even legislatively in course of time, is an expansion of the enlightenment that was embodied in the Greenwood Act. Expansion is highly desirable. The twenty-seven years which have elapsed since the discussion and passing of that Measure have brought many things to light. It is highly desirable, therefore, that by empirical means we should discover how we can still further improve and expand principles which were well recognised in 1930. We should, therefore, consider specific means by which those proposals of expansion can be carried into effect.
I hope most earnestly that we and the general public will recognise that there is a very great danger in exaggerating the weaknesses and limitations which we know exist in the treatment of mentally ill patients today. Some few weeks ago I read in one of the newspapers a well-known and respected publicist declare that 10,000 or 20,000 people were in mental hospitals who should not be there. It depends what is meant by that. If it is meant that there should be other and better kinds of treatment available 89 for them, we would all agree because, certainly, there are many patients in mental hopitals today for whom there should be other kinds of hospitalisation. In the absence of that, they should certainly not be transferred.
If, on the other hand, the statement that 10,000 or 20,000 people are in mental hospitals who should not be there means that they are sane people who are being treated as insane, I would submit that that is not only a gross perversion of the truth but leaves the most lamentable impression in people's minds if they assume that there is a great army of hapless, hopeless, sane people who, for a malicious and malignant reason, are being detained behind bars and treated abominably in some of our hospitals.
§ Mr. Sorensen
I admit that there is a possibility of error, but as a result of twenty-one years' close association with one and some contact with three mental hospitals and of membership of a mental hospital committee, every fortnight visiting the wards and the patients, talking to doctors and relatives, and after a great deal of discussion with mental patients today and having met those who have been in hospital and are now discharged, all I can say is that any idea that there is gross ill-treatment or unnecessary detention of vast numbers of patients is quite untrue. The sooner we make that clear, the better for the sake of the patients themselves and their relatives.
We all know that there are numbers of simple people—I have met them myself and have interviewed them—who have no really sound idea about mental illness. To give them the impression that their loved ones or friends are being treated in sinister segregation is to do a great disservice to them and the nation. I have to say that because there has been this unfortunate exaggeration in certain quarters, and that is why, while I warmly welcome what is proposed in the Report, I submit that we must not assume that these proposals are themselves an implicit admission of all the grossly exaggerated charges which have been made in the last few months in the Press and elsewhere.
The subject of our debate deserves detailed discussion, and we are grateful to those who have, with expert knowledge, 90 spoken so far. Though I do not intend to detain the House for long, I feel that I should refer to the proposal that there should be abolition of certification. That is, no doubt, highly desirable, but, here again, we should not assume, or allow the public to assume, that this will mean that compulsion will be abolished. In my humble estimation, we shall find a very small reduction in the number of patients compulsorily detained as compared with the number of those certified.
I do not believe that the great majority of patients now certified—they are now in the minority—are certified for malicious reasons. There must be some genuine and valid reason why patients are certified. They are certified because they need treatment, because either their relatives are not prepared to recommend that treatment or, because, unfortunately, they cannot decide what it is they need. They will not get the necessary treatment and help unless they are certified. Therefore, the mere elimination of the word "certification" will not mean the absence of compulsion, nor will it remove the problem. There is a number of human beings who, for one reason or another, are so mentally ill that they need, for their own sakes, to be compelled to receive treatment even as we insist on certification for infectious disease. Whether we call it "certification" or give it some other name makes no real difference.
The same applies to our terminology. The word "psychopath" seems less offensive than the word "idiot" or the word "imbecile". If I were to refer to any hon. Member in either of the latter terms, I am sure that Mr. Speaker would soon call me to order. If I were to refer to an hon. Gentleman as a "psychopath", that would, I suppose, sound less objectionable. But, in fact, whether we use the word "psychopath," "idiot," "madman," or anything else, in course of time the term can acquire an association which is offensive. This is why I am glad that so many hon. Members have referred to the stigma associated by many people with mental disorder and have condemned it, whatever the terminology associated with it.
It is good that from time to time there should be a review not only of administrations and treatment, but also of the terminology used; but, though there is no reason why we should not use new terms, 91 the mere exchange of terms by itself will not remove the stigma. What we must do is what, indeed, so many have pleaded for. We must recognise that mental disorder or illness carries no more stigma than a broken leg, blindness, pneumonia, or any other physical illness or disability.
We must get rid of the idea that there is a chasm between physical disorder, on the one hand, and mental disorder on the other; we know that they act and interact. The sooner the public mind appreciates that, whether we are ill physically or ill mentally, we are just ill, and need healing, the better for all, and the sooner will the absurd idea that there is some stigma attached to mental disorder be abolished. All of us are liable to both physical and mental illness.
Let us welcome the Report and let us pay tribute to the men and women, lay and medical, who have devoted great attention to it, but let us not cast a reflection on the admirable work which has been done in the past by assuming that what is now proposed is as revolutionary as some seem to suggest. It represents an expansion in the light of experience and new knowledge, a welcome expansion which we all wish to see, an expansion which springs from a deeper and sympathetic appreciation of how we can treat these disordered fellow human beings. The more we go along those lines, with the exercise of our own sanity and balance, the more will the foolish idea of a stigma being attached to mental illness be removed until it is finally abolished altogether.
§ 6.25 p.m.
§ Miss Mervyn Pike (Melton)
We have heard a great deal about the treatment of mental illness and the law relating to it, but very little has been said about prevention, and I should like to remind hon. Members of the great importance of prevention in mental health.
The right hon. Lady the Member for Warrington (Dr. Summerskill) referred to paragraph 87 of the Royal Commission's Report where the Commission draws attention to the importance of environment and a person's adaptation to society and human relationships, and she stressed the value of the psychiatric social worker's function. The right hon. Lady referred to the cost of these services and 92 asked how they were to be paid for by the local authorities.
It is important, in this debate, to draw attention to the need for preventive work in mental health. Mental disorder is one of the most tragic illnesses. When it strikes one human being, it affects the whole family. Also, it is a very expensive illness, and any money which can be spent in prevention performs a two-fold service, cutting down the toll of human suffering and, in fact, saving the material resources of the nation. In my view, therefore, we should pay close attention to the co-ordination and integration of these most important public services operated by the local authorities, such as community centres, youth centres, and marriage guidance clinics.
I regard child guidance clinics as very important in this respect. I have taken a great interest in the work of child guidance clinics, because I did for some time work in one. There is no doubt that the child guidance clinics play a very important part in prevention, early diagnosis and treatment of mental illness. Here again, early diagnosis is something upon which part of our legislation should be focussed, because, in mental illness more than in any other illness, time is very important.
I ask hon. Members to give their attention to the problem of prevention and the valuable part which can be played by such services as the child guidance clinics. It is tragic that there should today be long waiting lists in these clinics. The Report recommends that the child guidance clinic could be a nucleus for a general, comprehensive health service, and I commend to all hon. Members that suggestion. Prevention can do an enormous amount in reducing suffering, and, if we emphasise the importance of the problem and of the good work which can be done as I have suggested, we may go a long way towards solving the question of how the money will be found.
§ 6.28 p.m.
§ Mr. Charles Royle (Salford, West)
It is with very great humility, Mr. Deputy-Speaker, that I attempted to catch your eye, because this has been entirely a debate of specialists.
The hon. Lady the Member for Melton (Miss Pike), if I may say so, herself showed considerable knowledge of the 93 problem, and followed what had already been said. It is significant that there have been sitting on the benches opposite three right hon. Gentlemen who have, at one time or another, held the office of Minister of Health.
We remember that the right hon. Gentleman who is now the Minister of Labour and National Service was the Minister of Health at the time when the Royal Commission was appointed. We are greatly indebted to him for having done so, although, if I may say so, he was under very great pressure from, in particular, my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson). But, for all that, the right hon. Gentleman appointed the Royal Commission, and the House owes him a debt.
Conscious of my temerity in rising to speak at all, I wish to devote my attention to a specific aspect of the Report only, and it may well be that the House will very quickly realise to what part of the Report I wish to devote attention. My text is contained in paragraph 40 of the Report:It is essential that the working of the new procedures should be in the hands of the people who have the sort of knowledge and experience needed to form a sound judgment on the questions at issue … No one who is not medically qualified should be required to state an opinion on the patient's state of mind or need for care on his own responsibility, even after considering medical certificates, nor to take action without medical advice.The few words I want to say are front the viewpoint of the magistrate. Whatever happens, in spite of our desire to reach the stage of voluntary admission, some amount of compulsory admission will remain. I agree entirely, therefore, with the terms of the Report when the Commission repeats in paragraph 390 the opinion that present methods arenot satisfactory from the layman's point of view nor from the doctor's and in our view is of little value as a safeguard to the patient.I am in complete agreement, and I disagree with the hon. Member for Gosport and Fareham (Dr. Bennett), who touched upon the subject, concerning magistrates.
I would not dare to suggest that I should be speaking for magistrates in general in agreeing with what the hon. Member said concerning the Report, but I know very well that I am speaking for a responsible sub-committee of the Magistrates' Association in expressing the belief that undoubtedly the stigma is 94 increased because the magistrate is brought in at the time of certification. I am perfectly sure of that and I think that the time has come to get rid of this system.
Let us consider briefly what happens. A doctor is brought to see a patient. He regards it as desirable that the patient should be certified. The patient may be taken to the local hospital as a temporary measure. Perhaps in the middle of the night, a justice of peace is called out of his bed to assist in the certification. The justice of peace is not in the right frame of mind to begin with, and it is totally unfair to lay upon the magistrate, as a lay person, the grave responsibility for this great task. I know that this argument leads to the abolition of the judicial authority and I consider that abolition is desirable.
Paragraph 265 of the Report gives the history of the magisterial jurisdiction and it tells how, many years ago, county justices were the forerunners of the county councils with the administrative powers under the Poor Law. Until 1889, they were responsible for the building and management of what were then called lunatic asylums. Every Member of the House will agree that that system is long out of date. In my view, the present recommendation is the logical conclusion.
I have a great deal of faith in my fellow justices, but in these days this duty is not in keeping with their appointment in any way. There is too much likelihood that it is a mere formality to bring in the justice of the peace. The doctor involved in the early stages may be right or may be wrong in asking for compulsory detention, but the magistrate is in no position either to confirm or to contradict. He is completely lacking in knowledge of these matters, unless he has had a medical training, and I do not believe that he ought to be in on it at all. I do not oppose the abolition of the judicial authority, because I consider that the safeguards are sufficient at present without the magistrate.
What I want is a more sure and authoritative safeguard. This is dealt with in paragraphs 42 and 396 to 407. In those paragraphs, the Report recommends second medical opinions. My view is that one doctor might do it with certain limitations, that he should have the power to detain, say, for one week on his own 95 responsibility, perhaps as the general practitioner of the family concerned, and that following that we might appoint in every area a panel of three mental specialists—doctors—who would be called upon to certify in compulsory cases for the more unlimited period of time.
Surely it would be possible to find such panels and for every county to find sufficient experts to man them. The large cities certainly could. The smaller county boroughs could bring in the assistance of the counties for the creation of such panels. They, rather than the present setup, would be responsible for the ultimate certification. After that, I would go on to the review tribunal in an appeal sense if the patient or his relatives felt that the certification was not justified. That is my view concerning certification. I feel very strongly that the magistrates should no longer be brought into it.
Coinciding with that is the question of discharge. My hon. Friend the Member for Erith and Crayford (Mr. Dodds) and the hon. Member for Carlisle (Dr. D. Johnson) have been very active in recent months on the question of discharge and it is certainly an important question. I feel that the suggestions contained in paragraphs 421 to 427 of the Report are wholly good and, if adopted in the form of legislation, would provide sufficient safeguard for the patient, for the relatives, for the medical staff and for the community at large.
Paragraphs 511 onwards deal with court procedure when children and young persons are felt to be mentally ill, severely sub-normal, or psychopathic. I hope it will be agreed that great care is necessary and that if legislation follows the Report we shall have full opportunity to discuss it. All such cases in which children and young persons are concerned as mental defectives must be heard under the juvenile or domestic court procedure. Under no circumstances must they drift into the open court.
My last word concerns the application of Section 28 of the National Health Service Act. I shall not take up time by quoting the relevant parts of the Report, but the Parliamentary Secretary will find what I mean in paragraphs 714 and 715 with a further reference in paragraph 14 of Part V, in page 247. This applies only to mental defectives. At the 96 moment that Section 28 of the National Health Service Act makes provision permissible: the local authorities are not compelled to make it. The Report recommends that it shall be compulsory. I hope that when legislation comes it will be compulsory on local authorities that that provision shall be made.
I say again as a magistrate that one of our great problems in dealing with this type of patient—because although these people come before us as defendants, in many cases they are, in effect, patients—is the lack of places to which they can be sent. We must do something about that and do it very quickly.
So, in general, with every other hon. Member who has spoken in the debate, I welcome the Report, and I express sincere thanks to Lord Percy and his colleagues for the great job of work they have done. I hope that legislation will be before us soon. I hope that we shall hear in the next Speech from the Throne a statement that we shall have the legislation quickly.
§ 6.41 p.m.
§ The Secretary of State for the Home Department and Lord Privy Seal (Mr. R. A. Butler)
I am rising solely because the Government thought this a matter of sufficient importance for a member of the Cabinet to intervene just for a few minutes in reply to the speech of the right hon. Lady the Member for Warrington (Dr. Summerskill) and to the many constructive speeches which have been made in the debate. I, also, shall not detain the House very long.
I should like to join the hon. Member for Salford, West (Mr. Royle) in paying tribute to the present Minister of Labour on setting up this Commission. I think that both the Parliamentary Secretary, who has acquitted himself so nobly in his chief's absence, and the Minister, who, I hope, is gradually becoming restored to his normal health, will join with me in that tribute to one of their predecessors.
I think that the hon. Member for Woolwich, East (Mr. Mayhew) is quite right in saying that we should debate this subject more often. We are apt to go round on the same record with the needle sticking year after year. Indeed, I have had plenty of experience of this. Those debates we have had, like the debate we 97 had the other day on penal reform, find the soul and conscience of the House, and they really make very much more repercussion in the country than some of our more reiterative debates followed by the perpetual perambulation through the Lobbies afterwards. I hope that we shall have a debate like this again.
It so happens that I am, and have been for some years, the President of the National Association for Mental Health. It is, therefore, not altogether unsuitable that I should take part in the debate, though I would make clear that I am not in any way speaking for that Associaiton today. I would be unfair to it if I were thought to do so. Indeed, that is precisely the sort of body which the Government have to consult at some length on the findings of the Commission. I am certain that it welcomes the Report, though I am not here to say so. I am equally certain that the Government welcome the Commission's remarkable Report, and I would pay my tribute to Lord Percy and his fellow members of the Commission.
The object of this debate was to give the first opportunity for consultation with the House of Commons. I say the "first" because I think that perhaps the only error into which some hon. Members may have fallen has been to think that consultation will be able to be carried out absolutely immediately. We have already started consultations, but it will take time. This debate has already indicated to me various points upon which we shall want further clarification. As my right hon. Friend and my hon. Friend, who will be in charge of any Bill we may produce, will want to work with the House, I hope that this will not be the only occasion for consultation. I know I am not letting them down in asking hon. Members to keep in touch with them and with the Ministry of Health in this formative period.
The right hon. Lady asked whether the findings of the Commission would be embodied in legislation. I thought, therefore, it was also appropriate for me to speak as Leader of the House. I want to deal with this by reference to three of the most clipped paragraphs in the Commission's Report under the simple heading:Need for new legislation98 because they really sum it up in a few words. The Commission says this, in paragraph 60:Many of our recommendations for the development of community health and welfare services can be undertaken under local authorities' existing powers without new legislation, but there are some points on which amendment or clarification of the present law would be needed.That enables me to answer the point raised also by my right hon. Friend the Member for Kelvingrove (Mr. Elliot), himself a considerable expert on this as on many other subjects. He asked whether it was wise to delegate so much to the local authorities, and other hon. Members have asked whether, apart from legislation, the Government can give an assurance that progress will be made administratively. I am trying to clip everything together, and that enables me to answer these two points.
I would say that we want further consultation with the local authorities and with hon. Members and all concerned before we decide whether the immense area of delegation recommended by the Commission is advisable. But we think that we are behind the Commission in this. It depends partly, of course, on finance, about which I shall say a word in a moment, but it is also a matter which we should follow my right hon. Friend the Member for Kelvingrove in examining with great care. The local authorities, I am sure, are ready for the job, but we must continue to examine the question.
The Commission says there are other points on whichamendment or clarification of the present law would be needed.I shall come to those in a moment, but I want to refer to what my right hon. Friend said about research. I have been provided by the Ministry of Health and my colleagues with information on the whole matter of research which is now taking place. It is quite considerable, but I think I should acknowledge, on their behalf as well as my own, that an indefinite amount of research could do nothing but good. It is almost exactly the same kind of problem as that with which I am faced in penal reform, in that without the guide of statistics one cannot do proper navigation.
Without going into detail about the institutions in which research is carried out at present—and I find that it is on a 99 considerable scale in the hospitals and elsewhere—I would only add that research in industry and outside is, of course, equally important in mental health. Indeed, in appealing for help on behalf of the National Association for Mental Health some time ago to industrialists I hope that I was able to convince them of the need for their voluntary support of this work, because without further research in industry as well as in hospitals it is impossible to make progress along the whole front.
Do not let us regard research as coming purely under the Government. Let us encourage it elsewhere. I am simply giving a general undertaking, on behalf of the Government, in answer to the points made, for example, by my right hon. Friend the Member for Kelvingrove, that we regard research as of vital importance in this problem.
The right hon. Member for Thirsk and Maldon (Mr. Turton), also a former Minister of Health, pressed the importance of doing what we can by administrative means. I have answered that by saying that we will do so in so far as our consultations permit it and it is considered to be wise.
I now come to the major point raised by the right hon. Lady the Member for Warrington, about legislation itself. That is referred to in the next two paragraphs of the Report, paragraphs 61 and 62. The first refers toThe transfer to local authorities of responsibility for the registration or approval of hospitals and homes outside the national health service and for the general oversight of patients in private care …That is one lesser aspect of new legislation which we accept. The other is the major aspect of new legislation, which is summed up as follows, in paragraph 62:Our recommendations for new procedures"—to which the right hon. Lady referred—to apply to individual patients and for the abolition of the Board of Control would entail the complete repeal of the Lunacy and Mental Treatment Acts and Mental Deficiency Acts and their replacement by a new Act laying down the circumstances in which compulsion might be used in future and the procedures to be followed.Then it draws attention to some statutes which would need alteration.
100 We are quite prepared to face the major and minor tasks of the transfer to local authorities of theresponsibility for the registration or approval of hospitals …I cannot give a guarantee, here and now, in which Session legislation will fall, not because we want to go backwards or because I want, by saying that, to indicate that we are jettisoning the Commission's findings, but because I must insist, on behalf of my right hon. Friend the Minister and the Parliamentary Secretary, and the Government as a whole, that consultation with the bodies concerned, whether local authority, hospital, or this House, or another place, is absolutely vital if we are to mobilise the best opinion.
I am not at all convinced that it would be possible to do this in time for the coming Session. If we can leave the matter like that, we will see how we get on. But I unreservedly accept the recommendation of the Commission for a revision of the law, and that it should be broadly on the lines indicated in the Report.
My right hon. Friend the Member for Thirsk and Malton said that not only the law wanted radically altering, but that buildings wanted radically altering. While I am no longer Chancellor of the Exchequer and, therefore, must be somewhat cautious in what I say. I am still able to quote statistics comparatively accurately.
§ Mr. Butler
I am able to point out to the House that the total capital expenditure on mental and mental deficiency hospitals has already, under the administration of my right hon. Friend and his predecessors, increased from an average of 22 per cent. of the total of national investment in hospital building for the years 1948 to 1955 to no less than 34 per cent, in 1955–56. That is an earnest of the efforts of those immediate predecessors of my right hon. Friend the Minister to improve the proportion of the national investment in hospitals which is devoted to mental and mental deficiency hospitals.
As one of those who has had, as Chancellor of the Exchequer, to review parsimony with which the national 101 finances are conducted, I can assure hon. Members that I realise that this field of mental hospitals is one in which we simply must make a forward move. If possible, it should be on the line of preparing new designs and not simply of repairing the old buildings. Just as with my own problem of the prisons, we need not just refurbishing but the redesigning of smaller units. The two problems are remarkably similar, and that gives me an additional opportunity of speaking about them with absolute sincerity today.
I want to say one word about the Commission's Report from the point of view of the Home Office. I have personally studied the proposal for giving the Courts of Record new powers for dealing with mentally disordered persons convicted of criminal offences and also those relating to the treatment of persons in prisons, Borstal or approved schools found to be mentally disordered. The Commission, for example, suggests that consideration should be given to the extent to which the principles underlying its proposals can be applied to Broadmoor.
May I take up a phrase of the right hon. Lady the Member for Warrington about personal liberty in relation to the position in Broadmoor and the Commission's Report? In view of the proposals which come before me, it is the difficulty of reconciling the individual's right to liberty and society's right to protection which presses heavily upon one's mind. I simply undertake, from the point of view of administration at the Home Office, to do what I can to carry out the spirit of the Commission's Report.
I now come to the points raised in relation to what might be described as the new procedures and the new definition. Members will not expect me, in a debate, the design of which was to listen for advice, to decide absolutely what the policy should be, for example, on the problem of the psychopath, to which the right hon. Lady referred, and on the subject of which the hon. Gentleman the Member for Leyton (Mr. Sorensen) made so remarkable a contribution.
The philosopher Coleridge never tired of asserting that the human mind is composed of a great deal more than intelligence. He described the shaping spirit of imagination. The question before us involves the whole rich and complex 102 range of the emotions. Therefore, it is not surprising if, in one afternoon, it is not possible for Her Majesty's Ministers to accept a definition put forward by the right hon. Lady, even though she did do her courting in a mental home.
We shall study her definition and also the other definitions given to us. We realise that the Commission found it unfortunate that the same general term "mental defective" should be applied both to patients who are seriously subnormal in all aspects of their personality and to those who are normal or near normal in their intelligence. That is a very great achievement of the Commission. I think that it can be fairly said that the minds of this latter group have developed unevenly, so that although they may be capable of normal or near normal performance in intelligence their powers of reasoning or of emotional control may sometimes be dangerously immature.
The Commission emphasised that we have to decide how to deal with the difficult problems relating to the feeble minded who are at present covered by the Mental Deficiency Acts, and to the mental defectives of higher intelligence. That is a very great contribution. We cannot expect all to be in absolute agreement. In answer to the hon. Member for Woolwich, East, I do not believe that, looking back, the law as at present codified has been unduly stretched. We can argue about that at another time. I do not think that the Commission felt so, but it certainly felt that the law wants altering and I agree with my hon. Friend the Member for Gosport and Fareham (Dr. Bennett) who has spent so much of his time in this sphere.
I should like to conclude by saying that not only on the technical definition will the Government study the arguments put forward in the course of the debate this afternoon; but they will also take up the challenge of my right hon. Friend the Member for Kelvingrove. My right hon. Friend said that this was a great adventure. I have always thought it so.
I remember the first time I met, in Canada, the surgeon who has done so much in exploring the recesses of the mind and has received the O.M. in recognition of it. We simply do not know what occurs in a great part of the human mind and we should accept what was 103 said by the hon. Member for Leyton, that there should not be in future the stigma of differentiation between physical and mental disorder. We should realise that we must bring in the community to help in the cure of this disease.
That is why the community care recommended by my hon. Friend the Member for Thirsk is so important. We want a little time because we must bring in the community, the authorities and Parliament, and must have opinion with us—otherwise, we cannot make a success on the broad, majestic scale that the Commission's Report demands. If we are given a little time, I can only say to the House that the time will be most thoroughly used.
§ 6.57 p.m.
§ Sir Keith Joseph (Leeds, North-East)
I am sure that the whole House will welcome the humane and constructive speech which the Home Secretary has just delivered, and the acceptance by the Government, expressed by him, of the need of legislation when consultations have occurred on what he has called the broad front covered by the Royal Commission's recommendations.
Like other hon. Members who have spoken, I shall concentrate on one small part of this subject, and I am choosing that of local authorities. The House ought to recognise that it is not only the Percy Report, but also the Piercy Report, which, in the near future—
§ It being Seven o'clock, and there being Private Business set down by direction of The DEPUTY-CHAIRMAN OF WAYS AND MEANS, under Standing Order No. 7 (Time for taking Private Business), further Proceeding stood postponed.