MENTAL HEALTH BILL

THE LORD CHANCELLOR (VISCOUNT KILMUIR)

My Lords, I rise to move the Second Reading of what your Lordships will have observed to be a long and important Bill. It is, in fact, the first fundamental revision of the English mental health laws since 1845, when the two Bills introduced by George Ashley, later the seventh and famous Earl of Shaftesbury, created the system on which all the later additions of the last hundred years have been based. The Bill completely repeals the existing Lunacy and Mental Treatment Acts and the Mental Deficiency Acts. There is, I think, general agreement that a root and branch measure of reform is needed. The existing Acts had many virtues in their day and incorporated several humane and important advances, such as the Mental Treatment Act, 1930. They have however become unduly complex, unnecessarily rigid and it many respects out of phase with contemporary thinking and the medical and social advances of recent years.

The Bill has received the support of all political Parties and the general 667 approbation of the professional and other organisations who are particularly concerned with it. This is due in large measure to the labours of the Royal Commission on Mental Health. Their recommendations derived from a thorough and comprehensive review of the present law and existing services, and provide with only slight modification the foundation for this Bill. I should like to repeat the tributes paid to the Commission when your Lordships debated their Report last year on the motion of my noble friend Lord Feversham. Our only regret—and it is indeed a deep regret—is that Lord Percy of Newcastle has not lived to see his work translated into legislation.

Advances in medical treatment, coupled with the introduction of the National Health Service and other social services, have begun to break down the isolation of mental health from other health and welfare services. It is no longer necessary or appropriate to segregate mental patients in hospitals remote from the community. Increasing numbers of psychiatric beds are already being provided in general hospitals. More treatment is being given in out-patient departments or in day hospitals which patients attend during the day while continuing to live at home. More domiciliary visits are being paid by hospital doctors to patients in their own homes. And the policy of discharging patients back to their homes as early as possible, even though there may be a recurrence of the illness, benefits patients by not separating them from their homes more than is necessary. At the same time it increases the importance of good arrangements for after-care.

These trends in treatment have been accompanied by a much greater readiness on the part of patients to accept treatment voluntarily. Since 1930, when voluntary admissions to mental hospitals began, the proportion of voluntary to certified patients has steadily increased. Between 1949 and 1957 the number of voluntary admissions more than doubled, and it now accounts for more than four-fifths of all admissions. It has also been possible in recent years to de-certify a considerable number of certified patients. In 1958, for example, about 12,500 were regraded to voluntary status.

The Mental Health Bill carries these developments an important stage further. 668 It completes the process of administrative integration of the mental health services into the National Health Service. In particular it abolishes the separate designation of mental hospitals and mental deficiency hospitals, and removes the formalities at present attached to voluntary admissions to mental hospitals.

Under the Acts which the Bill repeals "persons of unsound mind" can be received only into designated mental hospitals, and those hospitals cannot admit patients except through the procedures of the Lunacy and Mental Treatment Acts. Patients dealt with under the Mental Deficiency Acts may be admitted only to other specially designated hospitals. The system of designation thus creates a rigid barrier between hospitals for treatment of mental illness and hospitals for treating mental deficiency. It also limits the types of psychiatric patients who can be received into general hospitals. This system has no counterpart in the Bill. Both psychiatric hospitals and general hospitals will therefore be able to receive any class of mentally disordered patient for whom they can provide appropriate treatment. Specialised psychiatric hospitals will of course still be needed, but psychiatric wards or wings in or attached to general hospitals are likely to became more common, especially for patients who need to stay in hospital only a short time.

The Bill also abolishes the present requirement that voluntary patients entering mental hospitals must sign an application form. This legal formality has meant that some patients have had to be certified because they could not give a valid signature, although their relatives wanted them to be admitted and they themselves did not object. These formalities disappear with the repeal of the existing Acts. The declaratory Clause 5 of the Bill makes clear that patients can be admitted in future quite informally on the same footing as patients suffering from any other forms of illness. We expect that this will further increase the proportion of patients whom it will be unnecessary to subject to the power of compulsory detention and to all the formalities which are necessary when such a power is invoked.

Informal admissions to mental deficiency hospitals (as distinct from mental hospitals for the mentally ill) started in 669 1958, following a recommendation of the Royal Commission which we were able to implement under the existing law. Over 27,000 of the 60,000 patients in hospital have already been decertified so as to remain in hospital on the same footing as any other hospital patients, and the review and process of decertification is still continuing. About 70 per cent. of the new patients admitted in 1958 entered informally. Under the Bill statutory procedures for admission will be used only for the minority of patients whom it is necessary to compel to enter hospital or guardianship against their own or their relatives' wishes. This will be permitted only when it is necessary in the interests of the patient's health or safety, or for the protection of other people, and also for patients who have come within the ambit of the criminal law.

It is with these matters that the Bill is largely concerned, but before dealing with the compulsory powers, which are contained in Parts IV and V of the Bill, I should say a word about the earlier clauses. Part I contains the clauses repealing the existing law and the declaratory clause about informal admissions to which I have referred. The repeal of the present law also dissolves the Board of Control, whose members are transferred to the staff of the Minister of Health by Clause 2 of the Bill.

The Board has deservedly earned respect for its work over the years in improving the mental health services. It has performed with dedication a number of important functions. These functions will remain as important as ever, but changed circumstances require them to be redistributed to other hands. Some will be performed by the Ministry of Health to which the members of the Board will be transferred; others will be performed by the Mental Health Review Tribunals which are set up under Clause 3 of the Bill and to which I shall refer later.

Clause 4 is an important clause, introducing the terminology used in the Bill for various forms of mental disorder. I am the first to realise, my Lords, that changes of name do not of themselves achieve anything if the underlying attitudes and the situations which have given rise to these attitudes remain unchanged, but the replacement of terms which have acquired misleading or offensive conno- 670 tations can at least contribute to the necessary change of attitude. We have, as the Royal Commission recommended, provided new categories of patients, with new titles to replace the terms used in the Mental Deficiency Acts, and the term which I quoted a moment ago, "person of unsound mind".

The Bill diverges from the Royal Commission here only in two respects. It sub-divides the category to which the Commission applied the term "psychopathic" into two categories, "subnormal" and "psychopathic". This has been necessary because it was clear from the views expressed on the Report, including views expressed in your Lordships' House, that the Commission's wide use of the term "psychopathic" involved so great a departure from the sense in which it is normally used by the medical profession and the public as to be liable to lead to confusion. This is one of the points on which we have been able to meet criticisms of detail made in your Lordships' House and elsewhere. The Bill also departs from the Royal Commission in that it contains definitions of the terms "severe subnormality", "subnormality" and "psychopathic disorder." These conditions, together with mental illness, are the four forms of mental disorder in respect of which compulsory powers may be used under Parts IV and V of the Bill. Unlike "mental illness" these terms are not in general use at present, and we have therefore thought it desirable to define them for the guidance of those applying the compulsory powers.

Parts II and III of the Bill are based on the principle to which I have already referred—namely, that of the integration of the mental health service into the general health and welfare services. The wide powers contained in the National Assistance Act and the Children Act make it no longer necessary to have special statutory authority for the provision of hospital or community services for mental patients. As the Royal Commission pointed out, the necessary provision can and should be made as part of the general health and welfare services. Most mental health services are, in fact, already provided under the National Health Service Acts, but local authorities still derive some of their powers to provide community care from the Mental Deficiency Acts. Clause 6 671 makes it clear that the local health authorities' general powers under Section 28 of the National Health Service Act are wide enough to cover the services now provided under the Mental Deficiency Acts, and also the provision of residential hostels.

Clauses 8 to 10 follow the same principle. By amendments to the National Assistance Act and the Children Act they allow local authorities greater flexibility in organising services for the mentally disordered within the framework of their general health, welfare or child care services. Clauses 11 to 13 revise the procedures used in relation to children who are unsuitable, because of mental disability, for education at school; provide greater opportunities for the review of such cases, and empower local health authorities to require their attendance at a training centre on the same lines as compulsory school attendance.

Part III of the Bill deals with private homes for mental patients. The effect is to bring the arrangements for inspection and registration within the statutory arrangements for nursing homes and disabled persons homes generally. Instead of the special registration systems of the existing mental health legislation, the general provisions of the Public Health Acts and the National Assistance Act will apply, with suitable modifications.

I come now to Parts IV and V, which deal with compulsory powers and are, in a sense, the core of the Bill. Part IV deals with the compulsory admission to hospital or guardianship of patients other than those who come through the courts or are transferred from penal institutions. Our aim here has been to limit compulsory powers to cases in which it is positively necessary to override the wishes of the patient, either in the interests of his own health or safety or for the protection of others.

There are two basic forms of admission to hospital. The first, under Clause 25, is for observation, with or without other forms of medical treatment, and compulsory detention is normally limited to a period of not more than twenty-eight days. The second, under Clause 26, is not so limited. We attach great importance to the observation procedure. We expect that in many cases it will be 672 possible to give all the treatment which the patient needs during this period. In those cases where a longer period of treatment is necessary many patients will be willing at the end of the observation period to remain in hospital informally. Those who need to be under compulsory detention for a longer period will, we hope, be a diminishing minority. Where, however, compulsion is necessary, for long or short periods, the Bill provides a new system of powers and procedures incorporating safeguards for the liberty of the individual against any misuse of these powers.

There are three main elements in this system of safeguards. First, there are the safeguards provided in the admission procedures themselves and the circumstances in which the Bill allows them to be used. Secondly there are the time limits on the validity of the powers of detention, and the powers of discharge. Thirdly there are the new Mental Health Review Tribunals which the Bill sets up, with powers of discharge, to which patients and their relatives have access on various occasions.

This Part of the Bill is closely modelled on the carefully balanced recommendations of the Royal Commission. It provides better safeguards than the present system, in that it is less complex, more appropriate for use as part of a therapeutic service, and at the same time strong in its safeguards against unjustified encroachments on liberty. The new procedures and the new Tribunals make it possible to dispense with the magistrate's order, which has contributed to the stigma surrounding the present certification procedure without, in practice, providing really effective safeguard.

The Mental Health Review Tribunals, whose constitution is set out in the First Schedule of the Bill, are to consist of members appointed by myself. There will be one Tribunal for each hospital region, and the members in each region will consist of three panels: one of legal members, one of medical members, and one of other members with other relevant experience or qualifications. At least one person from each panel will sit together when applications from individual patients are considered. The regional chairman and the chairman of each group of members considering individual cases must be drawn from the 673 legal panel. The Tribunals will have power to discharge patients or to reclassify them, as provided in Clause 123. Rules to govern their procedure are to be made by me under Clause 124. In making these rules it will be necessary to establish a procedure suitable to the private and personal nature of the matters before the Tribunals, but which at the same time gives proper opportunities for formal, and even, where appropriate, public, hearings where this is desired by the applicant.

The essential feature of these Tribunals is that their decision will be based as much on their own observations and their own assessment of the patient's mental condition and of the need for compulsory detention, as upon the opinions put to them by the patient and the doctors and by other persons and authorities concerned.

My Lords, that brings us to Part V of the Bill, which deals with patients whose conduct has brought them within the ambit of the criminal law. Clause 60 enables the courts of criminal jurisdiction to make a hospital order or guardianship order when a person is convicted of an offence punishable with imprisonment for which the penalty is not fixed by law and is found to be suffering from mental disorder of a nature or degree which warrants detention in hospital or reception into guardianship. Such orders, however, are to be made only when the court is satisfied that this is the most suitable method of disposing of the case, having regard to the nature of the offence and the character and antecedents of the offender and to the other available means of dealing with him.

Clause 61 gives a similar power to juvenile courts in respect of children or young persons found to be in need of care and protection or beyond control. In addition, Clause 65 enables courts of assize or quarter sessions to make an order restricting discharge, in addition to a hospital order, when they consider this necessary for the protection of the public, having regard, again, to the nature of the offence, the antecedents of the offender and, in this case, to the risk of the commission of further offences if he is set at large. Patients subject to restriction orders may not be discharged without the consent of the Home Secretary, and are subject to various other special provisions.

674 Clauses 71 to 79 deal with the powers of the Secretary of State to direct the transfer of persons suffering from mental disorder from prisons and other penal institutions and approved schools to hospital, and from approved schools to guardianship. These provisions are based on the recommendations of the Royal Commission. To some extent they are a re-enactment, within the framework of the new legislation, of the provisions of the existing law which relate to the mentally disordered who appear before the courts or are found to be mentally disordered while detained in penal institutions or approved schools. They are to that extent changes in form, rather than substance; but whether they relate to persons now subject to the Mental Deficiency Acts or to those now called "Broadmoor patients", they implement the recommendation of the Royal Commission in applying as nearly as maybe the spirit of the Commission's proposals to these classes and by equating them, where possible, with patients detained under Part IV.

The power which the Bill gives to the superior courts to make hospital orders and orders restricting discharge is, however, a change of some substance. The superior courts have power at present to send mental defectives to suitable institutions, but there is no comparable provision in existing legislation by which these courts are enabled to send to hospital a mentally ill offender or a psychopath who does not come within the existing definition of mental defective. It is true that at present if a person makes a successful plea of insanity it is possible to secure his admission to a suitable institution or hospital for treatment; but as your Lordships know, except in murder cases, such a plea is rarely made, and these new provisions fill a gap in the existing powers of the superior courts to deal suitably with mentally disordered persons who have offended against the criminal law.

Part V of the Bill is therefore designed to ensure that mentally disordered persons who have come within the ambit of the criminal law can be dealt with by medical, rather than penal, treatment where the court thinks such a course more suitable. At the same time, it enables the courts to ensure that the public is given a reasonable degree of protection against mentally disordered persons whose 675 criminal propensities are such that they are a danger to the community.

The remaining Parts of the Bill call for only a brief mention at this stage. Part VI deals with the transfer of detained patients from one part of the United Kingdom to another. Part VII transfers from the Board of Control to the Minister of Health the responsibility for managing the State institutions and renames them "special hospitals". These hospitals will be for patients requiring treatment under conditions of special security on account of their dangerous, violent or criminal propensities. Because of the questions of security involved it has been thought appropriate to keep them under the direct control and management of the Central Government, rather than to assimilate them into the Regional Hospital Board system.

Part VIII of the Bill deals with the important problem of the management of the property and affairs of patients. The Royal Commission did not have occasion to deal with this subject, save incidentally, but your Lordships will appreciate that it is of peculiar interest to me, since it deals with matters for which the Lord Chancellor is responsible as a Minister. Although, however, this part of the Bill makes a number of small changes in this branch of the law, and, I am glad to say, recasts it in modern language and in a convenient form, the substantial changes are of such minor importance that I ought not to take up your Lordships' time with them now. Part IX deals with a number of miscellaneous matters, including offences against patients and the powers and procedure of the Mental Health Review Tribunals. It also, together with the Sixth Schedule, contains transitional provisions governing the applications of the new procedure to existing patients.

I should, in conclusion, say a word about the development and improvement of the mental health services as a whole. This depends, in the main, on the action taken by the Minister of Health and the other authorities responsible for treatment, research and community care, rather than on anything in the Bill. It is the Government's intention to press on with developments in all these fields with vigour and determination. As noble Lords will be aware, the Medical 676 Research Council has recently decided to set up two new committees, one on clinical psychiatry and one on the epidemiology of mental disorders. It is also arranging to set up two new research units, one working on epidemiology, and the other on psychiatric genetics.

In the hospital service considerable progress has been made in the uphill task of improving hospital accommodation, reducing overcrowding, developing Outpatient facilities, and increasing the number of medical and nursing staff. We are confident that this progress will continue. By 1961, for example, some 22.000 additional beds in psychiatric hospitals will have been provided since 1948. It is not, however, solely a matter of providing more beds, important as that is it is a question also of making better use of existing buildings by improved methods of treatment and by co-operation with the community services provided by local health authorities.

Local health authority services, especially for defectives, have been considerably increased in recent years, and we contemplate a further large expansion for all categories of mental patients. My right honourable friend the Minister of Health has recently asked local health authorities to review their existing services, and has suggested directions in which development is needed. These include, first, extension of junior training centres, with the provision of residential accommodation where necessary; more adult training centres, and the various types of hostel and residential accommodation recommended by the Royal Commission for patients ready for discharge from hospital but not yet fit enough to live unsupported in the community. A substantial sum towards the development of these services has been included in the general grant from the Exchequer for 1959–61.

These developments do not depend on the Bill, but my right honourable friend the Minister of Health has announced that when the Bill becomes law he will issue a direction under Section 28 of the National Health Service Act converting into duties all local health authorities' mental health functions under that section as clarified by Clause 6 of the Bill. The local authorities will be required to submit revised proposals for carrying out these duties. This will provide a phased programme of development, which will 677 take account both of the practical difficulties involved and of the importance of the social problem with which we are dealing.

There is, in fact, my Lords, a general forward movement all along the line in this important matter of mental health. The Bill is stimulating action and interest well beyond the particular matters actually dealt with in the Bill itself; but the Bill itself makes vital changes without which progress in treatment would be hampered and retarded. It is in this spirit that I commend the Bill to your Lordships and I now beg to move that it be read a second time.

LORD SILKIN

My Lords, the House will be grateful to the noble and learned Viscount the Lord Chancellor for the clear way in which he has explained the main purposes and the chief provisions of this Bill. I would at the outset join with him in expressing our gratitude to the Royal Commission for the fine and comprehensive work it has done, and our regret that the Chairman of that Commission has not survived to see the outcome of the Report. May I also take the unusual course of congratulating Her Majesty's Government on the speed with which they have implemented this Report? The other day, during a debate on charities, the noble Viscount, Lord Samuel, said that the average time taken to implement the Report of a Royal Commission by any Government was (I think he said) fifteen years. I thought that was a bit high as an average; but certainly the period of about a year and a half from the date of the presentation of this Report to Parliament to the date when this Bill was introduced in another place will greatly reduce the average.

May I say at once that we—and, I am sure, noble Lords in all parts of the House—welcome this Bill as an important, far-reaching and progressive measure. In another place it was received with great cordiality from all parts of the House. It was never regarded as a Party measure. All Parties claimed credit for it, and all Parties participated indiscriminately in such criticism of the Bill as was made during its progress. During the Committee and other stages it was very greatly improved; and on the Third 678 Reading the Minister of Health received unanimous praise for the way in which he had conducted himself during the progress of the Bill, and for the improvements that had been made. I want to say at once, however, that while we in this House are glad of such improvements, many of us feel that when the Bill received its Third Reading in another place not all the improvements possible had been made and we very much hope that, during its passage through this House, we shall be able to make still further improvements.

May I just say this also? While I yield to nobody in my praise of the Government and of the Minister in charge for introducing this Bill, and for the many improvements that have been made in the course of its progress, I still think that there are quite a number of matters which require the most careful consideration of this House, and I propose to make a number of critical observations, which I hope will be without prejudice to my general appreciation of the Bill.

This is a very important subject. At the present time no fewer than a quarter of a million of our citizens are occupying hospital beds as mental patients, and that is out of a total of something like 550,000—a very high proportion. As the noble and learned Viscount the Lord Chancellor has said, about 80 per cent. of these mental patients are voluntary patients. The stress and the strain and the hustle and the bustle of modern civilisation. the noise and the speed of life, television and aeroplanes and all the rest of it—all the paraphernalia of progress and civilisation—have indeed made great inroads into the nerves of our people; and to-day there are more people, and an increasing number of people, suffering from mental trouble than there have ever been. Side by side with that, I would say that the improvement in scientific knowledge has not kept pace with the increase in the strain on our people. I see, for instance, that something like 40 per cent. of the people who have been discharged as cured of mental trouble have to be re-admitted to hospital. As I hope to make clear in the course of my speech, we have still a great deal to learn in the treatment of mental disorders.

The major alteration this Bill brings about is a new approach to mental disease. There is a complete revision 679 of the law, as the noble and learned Viscount has informed us. There are to be no more mental hospitals, so designated, although the hospitals themselves will remain. Later on, I should like to ask what is to happen to them. So many of them are very old and, in my view, quite unsuited for the reception and treatment of mental patients. I want to say at this stage that my knowledge of this subject is extremely limited and I speak with no authority whatever, and therefore with some diffidence. In the past, I have visited a number of mental hospitals and even before the war I regarded these hospitals as being quite unsuitable for their purpose. They are still there and still receiving patients in large numbers. One extraordinary thing about mental hospitals is that they are all very large. I wonder whether it is intended that these hospitals should remain in their present form, even though not designated, and still used for the treatment of patients.

There is to be no certification, but there will still be compulsory detention. I wonder whether that is very different. I wonder whether the effect on the patient is going to be similar to the old certification. The care and after-care of mental patients, and mental welfare, are being brought within the scope of the National Health Service Act, and, of course, that is a great improvement; but a great number of local authorities have already been carrying out these duties, even without complete authority, and it certainly is not a new thing.

I do not propose to go right through the Bill, but there are one or two aspects which caused me and a number of my noble friends some apprehension. We are all still concerned with the liberty of the subject. This Bill imposes certain restrictions and limitations on that liberty. Of course, they are not new, but in certain respects the safeguards have been removed. I refer first to compulsory detention. Under the Bill, except in the case of emergency, as the noble and learned Viscount said, two doctors have to certify that the patient is a proper subject for removal for his own health, for his own safety and for the safety of other persons. I am not so convinced that it is right compulsorily to detain a person simply on the ground of his own health; yet it is possible under 680 the Bill that that should happen. To do so for his own safety and for the safety of others, I understand, but merely for his own health, I am not sure. The Bill removes the requirement of authorisation by a justice of the peace—that is, by the civilian element—the lay element—and a patient can be compulsorily detained on the certification of two doctors alone.

I recognise that the Bill has gone some way to provide safeguards, on the assumption that there are to be two doctors responsible. I think that most of us would feel that in a case of the restriction of freedom, the civilian element should come into the picture. I know it has been said that a justice of the peace is no real safeguard. I do not accept that. He is a safeguard, even if he is only a psychological safeguard. The public feel that here is a layman who has some experience in these matters and who is there to look after the liberty of the subject, and if the doctors, in their enthusiasm, think it desirable that a patient should be detained, the justice of the peace is there to ensure that they do not overstep the mark. Although I freely admit that in many cases justices of the peace act as rubber stamps, and do not feel that they can reject the advice of the doctors, nevertheless, even if only in the minds of the patients and their relatives, he is a safeguard. And I do not accept that in the majority of cases the justice of the peace is a rubber stamp. I know a considerable number of justices who take their duties very seriously and who make it their business to see the patient themselves and form a judgment, and examine carefully the evidence upon which it is proposed to detain a patient. And if only a limited number of patients have been saved from detention, I should have thought that the retention of the civilian element was worth while.

I want to go a stage further. In this Bill certain requirements are laid down—what should be contained in the certificate, the periods in which people should be seen, the evidence upon which detention is being carried out—and I should have thought that it is essential that there should be somebody who should say that he is satisfied that the legal requirements have been carried out, or that on the evidence submitted he does not think that the case has been made for detention. I hope the removal 681 of a civilian check has not been accepted as final and that it will be possible to look at this point again.

I am well aware that the Royal Commission recommended that the function of the justice of the peace should be done away with, and to that extent the Government have acted within their rights. But they have not accepted all the recommendations of the Royal Commission; and I would say that this is one at which they might look again. If there is any doubt about whether a justice of the peace is the best person to carry out these duties, I would suggest that we might think of some alternative. One might be that there should be a panel drawn up of legal persons with, say, ten years' experience, who might act in the capacity of a civilian check. I imagine there would be no difficulty in getting a panel of that kind, and I put that forward in all seriousness in the hope that it will receive proper consideration.

My next point is on the psychopath. He enters into the field of legislation for the first time and he has had to be defined. I observe that in this respect the Government have not entirely accepted the recommendation of the Royal Commission. I would invite noble Lords to look at the definition of a psychopath which is contained in Clause 4 of the Bill, where it says: In this Act 'pschopathic disorder' means a disorder of personality (whether or not accompanied by subnormality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatment. If one looks at that definition carefully, one sees that the governing factor is the behaviour of the patient. He is a person of "aggressive or seriously irresponsible conduct". Under the Bill it is possible to take such a person, provided he is under the age of twenty-one, and compulsorily detain him until the age of twenty-five, subject, of course, to his right to make applications for release. The test, I repeat, is that he is of abnormally agressive or seriously irresponsible conduct, whether or not that is accompanied by subnormality of intelligence. In fact, large numbers of people of the highest intelligence are abnormally aggressive—which only means argumentative and difficult—and capable of irresponsible conduct. I do not want to say anything invidious, but we can all 682 think of people in either House of Parliament who might fit into that definition.

I would suggest that this definition is far too wide, particularly in view of the fact that the civilian element has disappeared. It leaves too much to the medical profession to say that, in their opinion, this person is of this character and requires or is susceptible to medical treatment. We have all at some time said about an inconvenient relative that he could do with treatment, but I hope that we never intended that that should be taken literally.

What will happen to this young person under twenty-one is that he will be faced with a psychiatrist, who as a rule knows nothing about him, and he will presumably be asked questions; but lie will know the purpose for which he is being interviewed. The young person will react in the way that young people do, and will become even more aggressive and argumentative, and this will confirm the opinion of the psychiatrist who will regard him as abnormally aggressive. In the normal course of events people put up with their young folk and take them for better or for worse; but let us not disguise the fact that there will be cases where the young person is a nuisance in the home. One or other of the parents may have remarried, and he may have a stepfather or stepmother who will not show him the same generosity and charity that a real parent might. He might even be a disturbing element in the home. So away he goes until lie is twenty-five. I beg those who are responsible for this Bill to look at that definition again and to see that this kind of thing is impossible; and I think one of the ways in which it would be made impossible would be if there had to be the additional safeguard of civilian control.

Now I want to say a word or two about observation and treatment. Those two terms are used in the Bill and it seems to me that they are, to a great extent, interchangeable: sometimes the expression "observation" is used alone sometimes it is "observation or treatment" and sometimes "observation and treatment". I should like to have a clear statement as to what is meant by "observation". What do you do when you observe a patient who has been forcibly detained? He is obviously not going to behave normally, even if he is a normal 683 person. The very fact of compulsory detention will make him behave in an unusual way, especially if he is a psychopath. I should be grateful if we could be informed as to what is meant by "observation of the patient" where observation is the only thing that is to happen to the patient. He is going to be observed in some cases for twenty-eight days.

I now come to Part II of the Bill, which is that part dealing with conferring upon local authorities certain duties, such as the provision of aftercare, welfare and so on. In another place there was considerable discussion as to whether, as is the case in this Bill, these functions should be optional or mandatory. I have no doubt that they ought to be mandatory. I think the Minister went a long way in making it mandatory without actually saying so in the Bill. I wonder why he is not prepared to say so in the Bill. If, in fact, the device—and it is a device —of issuing a direction, and so on, to the local authorities is effective, why need you have a device at all? Why cannot it be said straight out that this is the duty of the local authorities. I hesitate to use the word "wangle", but to issue a direction and then to require local authorities to do it under a direction when it could equally well be done under the Bill itself seems to me to be a rather circumlocutory way of doing it. Furthermore—no doubt the noble and learned Viscount can give me the answer—I wonder whether it is valid to issue a direction under this Bill requiring a local authority to do something it is not required to do. Suppose the local authority refuses, and says, "You say that I may do this under this Bill. Now you are compelling me to do it." What is the remedy? Whether that be so or not, I suggest that a much more effective way would be to make the Bill mandatory in its terms.

Next, I want to say a word about the admission of patients. There is no doubt that under the old law once a patient requires to be given accommodation in a hospital he gets it. There is no argument about whether they have room or not—they take him. But under this Bill it will be open to any hospital to refuse permission for the patient to be entered. It would be a fatal thing if, a detention order having been made, patients were 684 hawked around from one hospital to another. I do not imagine that this will be very common, but 1 should think the more difficult a patient—the more of a psychopath; the more crockery he has broken—the less likely a hospital would be to take him if they had a choice. The Bill itself puts no responsibility upon anybody to ensure that the patient is received into a hospital. I should like to see some responsibility put upon somebody—for instance, the Regional Board or some other body—to see that once a patient is genuinely and truly in need of admission to a hospital he can gain admission.

The Bill does away with certification and the stigma of certification, and I should like to ask—and I am genuinely seeking information on this point—whether there will not be an equal stigma after a time if a compulsory detention order has been made against a patient. Will it not be recorded against the patient? It may be inevitable, but I am very much against humbug and pretence, and so I say, if we are doing away with certification in the interests of the patient, let us do away with it; but let us not re-create the thing under the name of compulsory detention. I wonder whether that is what we are doing? I should be grateful to have a reply on that point.

There are two other points I wish to raise, and one is the censorship of correspondence. Under Clause 36 of the Bill, incoming and outgoing correspondence of patients is liable to be censored. Under Clause 133 this power is extended even to voluntary patients. A person goes in as a voluntary patient, and somebody will examine all letters he writes or receives. That seems an unwarrantable interference with the liberty of the subject. I know that some patients can write awkward letters, and I realise that in the Bill provision is made to enable them to write awkward letters to Members of Parliament and people whose duty it is to receive them. But why cannot the patient be free to write to anybody he likes? I know that this may make a bit of trouble here and there, but I regard the evil of censorship as even greater than the possible danger of a patient occasionally breaking out and writing offensive letters. Moreover, this censorship is not likely to be really effective, because most patients can get out at times, or find other ways of sending off letters—though I admit that it is 685 a little more difficult in the case of incoming letters. But those are not the things that are important. The danger that is sought to be guarded against in the Bill is of outgoing letters and, as I say, the power will not be really effective, because if a patient really wants to send a letter out he will find ways and means of doing so. In the meantime, it is infringing the liberty of the subject, and it is involving the hospital in a great deal of administration when it could use its time to better advantage.

The final point I wish to raise is the rather delicate question of Members of the other House who become insane. Provision is made so that in due course they are not allowed to function. I wonder why this House is privileged. Is it because we are not likely to get insane people? Perhaps we are not overworked like the other place. But I feel that some provision, if only for parity of treatment, should be introduced into the Bill so that if a Member of this House should become incapable of carrying out his duties he could be prevented from doing so. Perhaps the noble and learned Viscount will look at that.

LORD WINSTER

Will the noble Lord allow me to intervene? I believe that there was a case of a Peer who was declared incapable of managing his own affairs but there was nothing to stop him from coming to your Lordships' House to sit and vote.

LORD STONHAM

My Lords, my noble friend is, of course, aware that we also have parity with the patients in mental hospitals, because we share with them the disability of not being able to vote.

LORD SILKIN

The fact is that this Peer was declared to be incapable of managing his own affairs, and yet was quite free to manage the affairs of the nation.

I have made a number of criticisms of the Bill, or raised a number of questions and I do that in no unfriendly spirit. I still think that the Bill has the makings of a good Bill. I say that because everything depends upon the way in which it is implemented. If nothing were done under this Bill it could become a dead letter—a series of pious aspirations. But I am quite sure that everybody would wish this Bill to mark the beginning of 686 a big step forward in the treatment and care of mental disorder. There is a great deal to he done, and this Bill is only the first step. A great deal of money has to be spent. We shall want new buildings. Our doctors, who, it is agreed on all sides, generally speaking have but a lamentable knowledge of mental disorder, must have incorporated in their curriculum a great deal more about this subject. There must be far more research, and generally we must take active steps before we can congratulate ourselves on having made progress in this matter. But I believe that, with good will on all sides—and I think that does exist—and a genuine desire to deal with mental disorder in the way in which we have dealt with many other diseases in the past, which have to-day been almost eradicated, we can go forward and make substantial inroads into this terrible and cruel disease.

LORD AMULREE

My Lords, I should like to join with the noble Lord who has just sat down in thanking the noble and learned Viscount for the extremely clear exposition he has made of this not altogether uncomplicated measure. The Bill, I think, has a great deal of good in it, and it is one to which I am sure your Lordships will give a warm welcome. It follows to a great extent the recommendations of the Royal Commission, and one thing which makes it popular in the country is the fact that people do feel that a considerable number of people have been detained in mental hospitals in these buildings for long periods of time when they have committed no particular crime but have been merely sick. These provisions will make it more possible for them to come back into the world, and I think that that will make the Bill a very popular one when it becomes an Act of Parliament.

One of the things which makes it simpler for the Bill to be put into force now is the great increase in the knowledge that we have of mental disease and the great advances made in its treatment. I trust that under the Bill it will be possible to do a great deal more research into the causes and treatment of such diseases. It is found that fewer people are going to be dangerous to the public than was thought in the past. In the past it was thought that anybody showing any 687 signs of mental illness should immediately be locked up, and kept locked up for a long time, because he was dangerous. We do not hold that view so much now. Therefore it is far simpler to bring in a Bill of this nature.

With regard to compulsory powers of removal, I think that probably some kind of powers must remain, for the protection of the public. Nevertheless, I share Lord Silkin's anxiety that in this respect the powers of the justices of the peace have been taken away from them. As the noble and learned Viscount knows, I have a great respect for the law—probably because I was brought up in a legal family myself—and it has always seemed to me that that requirement did give a certain protection to patients who might be put away by too enthusiastic doctors. I know that a great many members of my profession feel rather worried that they have such enormous power in their hands for the curtailment of civil liberty. I share the apprenhensions of the noble Lord, Lord Silkin, that the civil power is no longer required in the case of compulsory removal. I quite understand that in some cases the order of a justice of the peace was a "rubber stamp" order, and that it made the removal a formal affair; but to some extent I regret the passing away of that requirement. One thing which in my view is a great improvement is that it will be simpler to obtain a person's discharge by means of the Mental Health Review Tribunals, which seem to me a very good thing it will give great protection against such things as have occurred.

Clauses 25 and 26 refer to the compulsory detention of people in mental hospitals, and one reason given is for the sake of the public: that these people must be removed if public safety is involved. But, like the noble Lord, Lord Silkin, I am a little doubtful whether they should be too freely removed for their own sake. I trust that when this Bill becomes law the very great powers conferred here will be used in the very sparing way in which the powers of the National Assistance Act. Section 47, are used now. Under that section, a person can be removed to an institution if he is thought to be dangerous to the neighbours or, in the second place, if it is thought to be of benefit to the person concerned. These 688 powers have to exist, but they must be used extremely carefully. If people wish to remain by themselves in their own room, apartment or lodging, and are not going to be a danger to the public, they should not be bustled away into some institution.

The mental hospitals I know at the present time are far too large; they were built a very long time ago, and they are very uncomfortable. But it is amazing what can be done if you get a new atmosphere appearing. That occurred with the passing of the National Health Service Act in 1948, when a large number of what were the old Poor Law infirmaries, which were in most uncomfortable inconvenient buildings, were modernised. The doors were opened; the buildings were redecorated, and a good deal of modernisation done, thus saving a good deal of money at the time. One would like to renew them all, but one has to be realistic about the cost. I am sure, however, that a great deal can bed one by imaginative repairs and redecoration to make some of these places far more reasonable and comfortable than they are at present.

The whole of the success of this measure appears to me to rest on the local authorities, with the transfer to them of the mental powers under Section 28 of the National Health Service Act. One knows a good deal about the way that section has worked. Where there is a good interested local authority it works extremely well; but in other cases it does not work so well. I share the regret that local authorities were not given more obligatory power instead of a merely permissive power. One has seen that the first-class local authorities do very well indeed, but that the bad ones do not really try at all: they may not be interested in that particular subject; they may want to spend money on other matters. So I feel that the absence of compulsion, although I do not agree with compulsion as a general rule, is not a good thing; I think that obligatory powers are sometimes a good thing for local authorities.

There is a further point. Who will be the people who are going to carry out much of the work under the Bill? There is a person called the mental welfare officer. Is that to be the same man who is now called "the duly authorised officer", who is responsible 689 for bringing people in under emergency orders? If they are to be given wider powers they will need a great deal more training, because they will have very great responsibilities in this matter. I do not myself come across mental illness a great deal, but I have come across a certain number of these duly authorised officers. Some are excellent; but some are not, because they have not had the necessary training and not enough experience in the work they are doing. If they are going to be given more powers they have to be properly trained. Then the greater services provided for the mentally sick patient will mean more work for the psychiatric social workers, and the patients will need to be taken care of much more in their homes and in the out-patient departments. That is a point which came to my notice the other day.

I had a letter from a man I happened to know something about four or five years ago. He had been kept in a mental hospital for the last four years but had just been discharged, and he wanted to resume his original job as a waiter. That seemed to be a very good thing to do. He rang me up and asked where he could get £15, because he wanted to buy a dress suit and two white shirts, and needed his railway fare to the South Coast where there was more chance of getting employment. All that seemed very sensible, and my advice to him was to apply to the hospital for a loan to buy the dinner jacket and to apply to the National Assistance Board to get the railway fare. He did this, but he got only £5 towards the cost of the dinner jacket, although the Assistance Board did offer to pay the railway fare. One cannot do a lot with £5 to buy a dinner jacket and two shirts.

It seems to me that part of the rehabilitation of patients, and particularly mental patients, is in seeing that they get back to work and are not merely discharged from hospital. I should have thought it should be possible for a patient, up to a point, to borrow money from the hospital service for that kind of thing. The hospital would have far more chance of getting their money repaid than a private person like myself would, because they can keep a check on where the person is. If it is not made simple for a man to get work, it will merely lead to his having a further relapse and going back to hospital.

690 There is another point in regard to after-care. If you come down to the other end of the scale, there you have mentally defective children. There is going to be a need for a much greater number of schools for these children throughout the country. The situation is fairly good in London where there are good and numerous enough schools for the mentally defective; but in the country areas certainly it is not so. That is a most important thing to be looked at if we are to get some of these mentally defective people out again into the world; we must have educational facilities for them to go to. Those are two points that I should like Her Majesty's Government to think about when the matter is being considered further.

Another important point is the training of medical students and young doctors. As always, it is the general practitioner who is going to bear the brunt of this work. I do not think you are wise to keep a large number of beds in mental hospitals attached to medical teaching schools. What you want is a large number of facilities, such as out-patient departments and observation wards, where the student can see the person who is being treated before that person gets to the stage of requiring admission to the hospital. In that way the student can see the mental side of the illness before the patient comes into the hospital. I hope that that suggestion will be considered by the Ministry of Health when the Bill comes into force. I am sure that that is going to be a most important need in the training of medical students and doctors. It has been mentioned that mental beds should be attached to teaching schools. I do not think that that is necessary or that it is a very good idea.

I take it that one thing which will occur under this Bill is that it will be possible now for the senile and elderly, confused patients to be treated in a much more "general hospital way" rather than be almost forced into mental hospitals because there is nowhere else for them to go. They do not need the skill of the mental hospital; they need much more general care and attention, and not the skill of the trained mental nurse or doctor. Again, that seems to be a point about which it is well worth doing something. It would ease much of the burden on the mental hospital, and it would make it 691 easier for these unfortunate people to be looked after in a reasonably comfortable way.

There is one other point to which I think the noble Lord, Lord Silkin, referred—namely, in regard to Clauses 29 and 54, where the mental welfare officer or somebody else has to obtain admission of the patient to hospital. The noble Lord, Lord Silkin, put that point very well: that at the present time it is possible to get these people into a mental hospital. If this Bill becomes law we have to see that that facility still remains, because one of the sad things that occurred when the Poor Law finally vanished in 1948 was that the statutory bed for the sick and old person vanished with it. I admit that it was not a very good bed, nor a comfortable one, but it provided somewhere where there was food and rest and a limited amount of care. In the old days under the Poor Law these people would go into the hospital, under some compulsory powers. When this excellent Bill becomes law I hope that that power will not be lost, and that it will be possible to get these people in.

It might appear that I have made some rather carping references to this Bill. I do not really mean to be unkind to it. It seems to me to be a real step towards a better future in regard to the mental health of the people of this country. We must look forward; we must not stop at this Bill, because there are more things to do in the future.

THE EARL OF FEVERSHAM

My Lords, the noble and learned Viscount the Lord Chancellor has presented this Bill to your Lordships' House in the lucid and intelligible way which we have come to expect from him when he has the onerous task of explaining to us the legal and complicated measures that come before us. May I join with the noble Lords, Lord Silkin and Lord Amulree, in paying my tribute to the noble and learned Viscount by expressing my grateful thanks for his analysis of the 151 clauses and eight Schedules of this most important and far-reaching Bill.

The noble Lords, Lord Silkin and Lord Amulree, have spoken with great knowledge and good intent on this Bill, and have given to your Lordships' House an indication of the generous welcome and 692 the warmth of the interest on this Bill that exists on both sides of the House. As one who has been concerned for over twenty-five years in the mental health field, I should like to salute the arrival of this Bill, which, to some extent, marks the fulfilment of the hopes embodied in the pre-war Report of the Committee on the Mental Health Services of which I had the honour to be Chairman in the years 1936 to 1939. More than this, the Bill clears away the legislative undergrowth which is the result of the piecemeal attacks on the problems of mental disorder which have gone on for a great number of years. As such, it recognises the advances both in public attitudes and in medical knowledge which, as the noble and learned Viscount has said, have revolutionised thinking in this generation.

I think that here it is not inappropriate for me to honour the names of those earlier pioneers, by quoting a paragraph in the recently published Younghusband Report which says: Much of the credit for changing public attitudes towards mental disorder is due to voluntary effort, which pioneered new forms of care and after-care for both the mentally ill and defective, and help to bring about a more general recognition of the significance of stress and emotional causes in neurotic symptoms and mental breakdown. In the progress of this Bill in another place the National Association of Mental Health, of which I have the honour to be Chairman, has taken an active part, and we have had the satisfaction of seeing a great number of our Amendments taken up and incorporated into the Bill. I should like to pay tribute to all those, in and out of Parliament, who have worked so hard and so effectively to achieve this end, and I should personally like to thank the noble and learned Viscount the Lord Chancellor for the courteous way in which he has paid attention to various points I raised in the debate on this subject to which he made reference this afternoon. It is most gratifying to be told by the noble and learned Viscount that the important point concerning research has been taken up and that the Medical Research Council has inaugurated two new research units and two new committees to advise on matters relating to this subject. I understand that the noble Lord, Lord Cohen of Birkenhead is going to intervene in this debate, and I am sure that we shall have the advantage 693 from his intervention of learning more on these research problems. Also, the references I made in your Lordships' House at that time are again implied in the decision to set up an investigation of the three State institutions at Rampton, Broadmoor and Moss Side.

I do not propose to follow the noble Lord, Lord Silkin, in the discussion that he initiated on the possible deprivation of the individual of his personal liberty, by the provision in this Bill of certification by two doctors rather than by a justice of the peace. I feel that others are more qualified than myself to speak on that subject, and particularly we in your Lordships' House have the advantage of receiving the opinion of two eminent men of the medical field by the remarks that will fall from the noble Lords, Lord Taylor and Lord Cohen of Birkenhead. Nor do I mean to follow the noble Lord, Lord Silkin, in his comments on the definition of psychopaths. A great deal of the time taken up in discussion of this Bill in another place was concerned with that definition, and I know that there are those who are going to refer to it to-day. It is an important question and one on which the noble Baroness opposite, Lady Wootton of Abinger, is eminently qualified to express an opinion.

I feel that perhaps the best and most useful contribution I can make to-day is to amplify the essential requirements which are indispensable if the underlying principles of this Bill are to be brought into successful operation. Let me say at once that all our enthusiasm for the Bill, which deals almost exclusively with the legal aspects of mental disorder, must not blind us to the fact that it is only a beginning. As the noble Lord, Lord Silkin, has already indicated, it will not give us better buildings in our mental hospitals; it will not in itself give us the extensive research for which the services crave; and it will do nothing to provide trained staff. Without these three, the development of any health service must be crippled. But these limitations, which, as the noble and learned Viscount clearly brought to our attention, were properly left out of the scope of the Bill, can be overcome if we have the right attitudes in our future thinking; and it is with the influencing of those attitudes that I am principally concerned.

694 The Bill provides a legislative background for doctors working in hospitals to carry out treatment under the best possible conditions: this is to confirm the hospitals in their good work. I have felt, however, ever since the Bill was published, that it is little more than a half-hearted attempt at promoting the preventive services where, to my mind, the future of this whole subject lies. The noble and learned Viscount has told us again to-day that the development of the community services is not written into the Bill itself as a mandatory direction and both the noble Lords, Lord Silkin and Lord Amulree, have made observations on that point. The Association that I represent has also made representations on this point to my right honourable friend the Minister, and I know that he has given the most sympathetic attention to the question.

It may be that the public pressure which has been brought to bear on my right honourable friend has led him to consider this question more deeply than he might otherwise have done, and he has given us the undertaking that, though he will not write any direction into the Bill, he will lay upon local authorities a duty to develop their preventive and after-care services by direction under the section which has already been referred to, Section 28 of the National Health Service Act. I am grateful to the Minister for having gone thus far, but I still have my own reservations about this decision and while I respect the intention of the Minister I shall be one of those who await with the keenest critical interest the effect of his actions. And I reserve the right to raise the question of amending the Bill if, after due time, it is found that the regulations which the Minister proposes do not have the desired effect.

I claim to speak with some knowledge on this question, for during and just after the war the National Association of Mental Health had a preventive and aftercare service, on a national scale, whose success has never been questioned. In many regions, however, when this service was taken over by the local authorities in 1948, it simply ceased to exist. It is true that the Minister has indicated in another place that he intends to act under Section 28 of the National Health Service Act in a way which he has never seen fit to act before; but I should be 695 glad if the noble and learned Viscount could tell the House what kind of lead my right honourable friend the Minister proposes to take in ensuring that local authorities do carry out the duties he proposes to lay upon them. We have not been told hitherto whether the default powers which exist under Section 57 of the National Health Service Act have ever been used. Does my right honourable friend the Minister believe that these powers, and the similar powers contained in Clause 141 of the present Bill, will give him a real weapon in his campaign for better services?

The second point which the National Association for Mental Health have emphasised throughout the debates on the Bill in another place arises out of these considerations. I refer to the need for increasing the prestige and numbers of those employed by local authorities to deal with their new responsibilities under this Bill. It is, I think, very appropriate, when your Lordships are considering the Mental Health Bill, that you should have in your hands the Report of the Younghusband Committee on the Recruitment and Training of Social Workers in the Local Authority Health and Welfare Services. There are sections of this Report which are basic to the proper development of the local authority mental health services. I have pressed in this House on previous occasions for proper training for mental welfare workers—apoint reinforced to-day by the noble Lord, Lord Amulree—and I have pressed for the expansion of psychiatric social work services. My contentions in the past are amply confirmed by the findings of the Younghusband Committee. With your Lordships' permission I should like to quote paragraph 450 of that Report. It says: The Mental Health Service has thus an increasing importance in the community and must play an appropriate part, both in prevention and aftercare of mental disorder and in assisting with other social problems such as absenteeism in industry, the voluntarily unemployed, delinquency and marital or family difficulties of various kinds. I recommend that the Mental Health Service must be comprehensive.

The need for expanded social work is not confined to one service. I am glad to see that my right honourable friend the Minister, in the circulars to which the noble and learned Viscount 696 referred, which are the Minister's first instructions to Regional Hospital Boards and local authorities, asks for joint operation of community services by both local authorities and Regional Boards so clearly both should use the same comprehensive team of trained experts. A key category in this team is, of course, the psychiatrists and, as many of your Lordships are no doubt aware, there is to-day an acute shortage of psychiatrists in the hospital service. At present there is virtually no possibility of increasing the number available to staff the community care services. The best arrangement would certainly be the joint employment of psychiatrists by Regional Hospital Boards and local authorities, but I am told that many hospital authorities complain that there is insufficient staff available for them even to consider such an arrangement.

The Royal Medico Psychological Association tell me that the demands of the Health Service on doctors in this category are increasing much faster than the number of new trainees available to meet them. They say that if an adequate service is to be developed in the next ten years it will require a fivefold to sevenfold increase in medical manpower in mental hospitals. The Younghusband Committee refer to other members of this comprehensive team. The Committee say that they estimate that to provide adequate mental health services, including services in Scotland, would require an increase in the number of psychiatric social workers in the employment of local authorities from the present surprisingly low figure of 31 to a total of 325. They also recommend an increase from 625 to 2,200 in the number of mental welfare officers. These figures indicate conclusively that the existing service is hopelessly understaffed.

As the noble and learned Viscount indicated in the presentation of this Bill to your Lordships, it must be sensible to urge under the principles of this Bill that the maximum attention should be given to keeping people out of hospital, rather than trying to deal with them in overcrowded conditions. This, my Lords, means good social work in the local authorities, and it also means the maximum co-operation with other welfare services, and particularly with general practitioners. I was very glad to note that the noble Lord, Lord Amulree. Paid 697 attention in a great part of his speech to the importance and the position of general practitioners. With your Lordships' permission I will again refer to the Report of the Younghusband Committee, which makes the remarkable statement (it appears in paragraph 235) that in any one year there is a total of 2 million patients suffering from mental disturbance who are under the care of general practitioners.

To-day "G.P.s" everywhere should be familiar with the workings of these teams in comprehensive mental health services. They should be able to take their part in the discussions of case-work committees and should be qualified sufficiently by training to diagnose kinds and degrees of mental illness. It is appalling that so few general practitioners have any training in psychiatry. Few of them need undergo, in their final examinations, a test of knowledge in this subject, and I believe that only in a few medical schools is the subject being adequately taught. Therefore I would urge my noble and learned friend to persuade the Government to insist that this comprehensive idea of community mental health service is universally adopted.

It is good to know from my noble and learned friend that the Government mean to press on with vigour and determination in this field, and I only hope they will succeed. As my right honourable friend the Minister said in another place, and as he has emphasised in the circulars he has already sent out, local authorities must weigh up the priorities. My Lords, priorities are never so difficult as when finance is involved.

Your Lordships will remember that the Royal Commission hoped that the Mental Health Service would in future get a fair share of the nation's resources. Certainly the mental hospitals have had capital grants in the last few years, but those of your Lordships who know about, and visit, mental hospitals cannot but doubt that there is a despondency about their present progress. Certainly more money has been made available for the running of mental hospitals, but a glance at the statistics shows the vast disparity between general and mental hospitals. On feeding patients, general hospitals spend three times as much per patient as do mental hospitals; on treating patients, general hospitals spend nine times more on doctor 698 attention than do mental hospitals. In the case of local authorities, it is disturbing to find that only 6½per cent. of the money they spend is devoted to preventive and after-care services such as I have been describing, while 93½per cent. goes on services imposed upon them by Statute.

It has been said in another place that expenditure on mental health services by the local authorities will be increased next year by £900,000 and the following year by £1,750,000. I should like to ask the noble and learned Viscount what proportion of this extra money the Minister thinks will be spent on expanding the preventive and after-care services. Are the Government happy in the belief that the figure of 6½per cent. which I have quoted will be increased in the direction I have indicated? It seems that without pressure from the centre the right financial road will not be taken.

My Lords, I said at the beginning of my remarks that this Bill is the result of a tremendous change in the attitude of the public towards mental health. Although the Bill deals only, with the mentally afflicted, I am glad that its title is "Mental Health", because I should like to see a more informed opinion in the nation towards positive mental health. On the mental health of every individual depends personal happiness, the welfare of the family and the stability of the community. To-day, because of rapid development in science and technology, and because of the changes in the conditions of living, it is infinitely more important than ever before in our history for the individual to maintain mental stability and rational judgment. Is it not right that man's motives, the reasons why he acts and thinks as he does, should be a study of supreme urgency and importance? Is it not right that mental health should be investigated and explored, without prejudice and without fear, but with clarity and with reason? This Bill lays open the way to our next Mental Health Bill, which must surely be based on the experience to be gained in pioneering real mental health services which are primarily preventive and which have as their aim the happiness of the community and the wholeness of man. This Bill provides the greatest opportunity for the public health services, and this is the hope of the mental health movement.

LORD TAYLOR

My Lords, when I was a junior medical officer in a mental hospital there used to be a distant, but very powerful, figure to whom patients always had the right to address their letters. That was the Lord Chancellor: his Visitors in Lunacy were people whom one never saw but of whom one stood in a great deal of awe. I still stand in a great deal of awe of the noble and learned Viscount the Lord Chancellor, but I should like to join with all the noble Lords who have paid tribute to the clear and sincere way in which he has presented this Bill to your Lordships' House. In particular, he has not claimed for the Bill matters which can be dealt with only by administration. The Bill is a part of the story only, but an important part.

The Bill does one very important thing: it recognises that, in the eyes of the law, there is no valid distinction between illnesses of the mind and the brain and illnesses of the rest of the body. Now this was first positively shown in medicine about forty years ago by a doctod named Wagner von Jauregg, in Vienna, who made a most remarkable discovery. He discovered that if patients who were suffering from a severe form of mental illness, general paralysis of the insane, were deliberately given malaria, one-third of them recovered, in one-third of them the disease ceased to progress, and in the remainder no success was achieved. Until then, every case of paralysis of the insane was quite hopeless. Here was a physical remedy which produced a physical cure of a mental illness. During the early part of the war, I served as a psychiatrist in the Navy, and we were called neuro-psychiatrists just to emphasise that very point—to emphasise that the mind and brain are at one with the rest of the body.

This Bill enables those with illnesses of the mind to be treated in just the same way as those with illnesses of the body, with two important exceptions. The first exception has already been mentioned by my noble friend Lord Silkin, and that is in the matter of censorship of letters. This is dealt with by two clauses in the Bill. So far as it concerns the censorship of letters of patients who are compulsorily detained, I think it is Clause 36: and so far as concerns the letters of patients who are ordinary patients in a mental hospital, 700 it is Clause 133. I must say that censorship of letters is a very distasteful business. I worked during the latter part of the war under the noble Lord, Lord Radcliffe, in the Ministry of Information, where he was responsible for the postal censorship, and I can remember how he adjured us not to make use of the information obtained by postal censorship. It is a very distasteful business.

I am probably the only Member of your Lordships' House who has had to censor letters in a mental hospital, and I must say that I got the impression that the patients in fact wrote the letters for the censors. They wrote them so that they could be read by us and one got precisely the sort of letters that one expected. Now, as I understand it, censorship of letters has been given up by two-thirds of the hospitals in this country. If that is so, there is no earthly reason whatsoever why it should be continued by the remainder, at any rate as regards patients who are not compulsorily detained in hospital. I sincerely hope that we shall put that matter right during the course of the Bill through your Lordships' House.

The second way in which the treatment of patients under this Bill differs from the treatment of patients in ordinary wards is in the matter of compulsory detention where this is socially necessary—for, in the last analysis, it is a social decision rather than a medical decision. When I was a medical student in 1930 I remember Parliament passing the Act to which the noble Viscount referred, the Mental Treatment Act. It was a very important Act, and it was welcomed widely by those who taught us psychiatry. They had great hopes of it. Some of those hopes have been justified, but some of them have been frustrated by what one can only describe as the realities of the situation and, as I hope I shall shortly show, there is a risk that some parts of this Bill may also be frustrated in exactly the same way and that history may be going to repeat itself.

That Mental Treatment Act did two things. First of all, it made possible the voluntary admission of patients to mental hospitals instead of its being by certificate. By and large, that has worked very well, but it has taken an extraordinary long time to get going; and it has been extremely patchy in its application. The second thing it did was to make possible 701 the admission for temporary treatment of patients, without certification, on the recommendation of two doctors. That procedure, the procedure for temporary treatment under the Mental Treatment Act, 1930, is very like the procedure for compulsory detention for all those who need it which is proposed in the new Bill. But under the temporary treatment provisions of the 1930 Act, which could operate for two years, it was provided that the patient had to lack volition—that is to say, the capacity to make up his own mind. In fact, very few mental patients do lack volition and the power of self-expression so, for practical purposes, it could be applied only to patients who were in a state of stupor or semi-unconsciousness. The non-certificated temporary treatment of patients under the 1930 Act therefore became a dead letter. It was hardly ever used. I have never seen a patient admitted under that particular procedure. In this Bill the same method of detention is provided, but the provision about volition is omittted; and I see no reason at all why it should not work in what we hope will be the limited number of cases where detention is required.

It is worth looking for a moment to see how often detention is likely to be required. This depends not upon the Bill but upon the facilities available. I know one area where there is still a very unsatisfactory mental hospital and where about five out of every ten patients admitted still have to be certified. That hospital is a dreaded and a hated place. I know another area wher nine out of ten patients go in willingly as voluntary patients. That is why the voluntary patient scheme has been patchy. With good facilities, it is possible to get the rate for compulsory detention right down. If we have really good facilities everywhere, we could get the number of cases of compulsory detention down to about one case in fifty admissions, and it would then be a very small problem indeed.

My Lords, it is worth looking also in a little more detail at why some areas have a high rate of voluntary patients and some a comparatively high rate of certification. The first reason has been the problem of getting old people into hospital it has been a sad necessity that, in order to get old people beds, it has sometimes been necessary to certify them. They have been confused; they 702 have in fact been mentally ill; but it has been only a part of their general deterioration. There were no geriatric beds and no proper home-care available, and the hospitals would not take the patients unless they were certified. That has been one way in which the certification rate has been kept up, because of lack of alternative facil ties. The second has been the public attitude towards bad hospitals and hospitals with bad reputations—and some of those reputations have been richly deserved, because hospitals are still grossly overcrowded and in many cases are in shockingly old buildings, for which the only treatment is to pull them down. The third has been inadequate staff—inadequate in number and inadequate in quality; inadequate numbers of psychiatrists, psychiatric social workers and nurses.

The easy way out has always been to certify the difficult patient rather than arrange for the more complicated domiciliary visits and the operation of persuasion. I think that there is something to be said for making compulsory detention a difficult procedure, to encourage the medical profession to exercise every possible persuasive power before they have recourse to the easy way. My noble friend Lord Silkin looked upon a lay magistrate as a safeguard in another direction. I think some form of lay authority is desirable, so as to encourage the doctors and the authorities concerned to take every possible way of persuading the patient to have voluntary treatment. I do not like dictatorships, and I am a little afraid of a medical dictatorship. Finally, if this is going to be a rare occurrence, the lay magistrate or my noble friend's panel, which has many attractions for me, should be able to develop the necessary experience, so as to be able to do it, not as a rubber stamp but as a serious decision on a social basis, which is what it must be.

When the Royal Commission was appointed, one felt that perhaps it had been given the wrong terms of reference—or, at least, that there ought to have been a second Royal Commission set up alongside. What we need is not only a reform of the law but, even more essentially, as the noble Earl, Lord Feversham, has said, a reform of the Mental Health Service. Good law cannot make up for bad administration or for State parsi- 703 mony. Reform of the law is a comparatively cheap form of reform, but reform of the Mental Health Service is going to be a very costly business. It need not be a very prolonged business, if we decide to give it the high priority which it deserves.

Furthermore, the means chosen to implement this Bill are in many respects either non-existent or in embryo existence only. The instruments chosen to work part of it are not provided with the financial means and, as again the noble Earl, Lord Feversham, has indicated, they appear often to be lacking in the capacity to do so. May I illustrate this by two examples. The first is the case of psychopaths. Those who have had experience of psychopaths know how difficult they are to deal with. They are a problem when they are taken to any mental hospital, and everybody tries to get rid of them. There is only one way in which psychopaths can be treated—that is, in special institutions. So far as I know, there is only one such institution in this country—Dr. Maxwell Jones's unit at Belmont. If the provisions of this Bill are to be implemented, we shall need one unit for psychopaths in every Regional Hospital Board area.

My second example is the work placed on local authorities. Local authorities have had power under the National Health Service Act to do much of what they are supposed to do under this new Bill, but I know of only five of them which have done anything substantial at all. They are Oldham, York, Nottingham, Croydon and Worthing. I do not share the view that by either directing or ordering a local authority to take a certain action, that action will necessarily be performed or performed well. One experienced so much of this when the health services were in local authority hands, when there seemed to be so little of the necessary enthusiasm and drive, and when there was also a measure of local parsimony, which seemed to hold things up. The wonderful changes which have happened in our mental hospitals since the coming in of the National Health Service Act have been due entirely to the Regional Hospital Boards.

I think that we ought to scrutinise the provisions of this Bill carefully, to make sure that we do not take away from the Regional Hospital Boards the power to 704 continue what they are already doing in the field of after-care, and that we do not prevent them from providing after-care when the local authority fails to provide it. We all hope that the local authorities will respond; but if they do not do so, I think that the Regional Boards should be in a position to do so.

There have been wonderful changes in mental care over the past twenty-five years, since I had my first job as a doctor in the Brighton Mental Hospital, where I had charge of 350 patients. No patient at all was receiving any treatment, and the average duration of stay was a couple of years. Today, I am sorry to say, there are still hospitals where there is only one doctor for 350 patients, but the rate of recovery, the duration of illness, is now more like two months than two years. This revolution has not come about as the result of the processes of law, but as the result of advances in medical treatment. There have been a staggering series of advances in physical treatment, and I have no doubt that those advances will continue. They have been matched by advances in the sphere of social psychiatry and by social change in the hospital itself—the opening and unlocking of doors, the socialisation of the hospital and its relation to the community. The best example I know is Warlingham Park Hospital, where remarkable results have been achieved by Dr. T. P. Rees, who was a member of the Royal Commission. At first when he opened the doors of his wards the nurses did not let the patients come out they did not realise that the idea was to liberate the patients. Yet in the end the results were dramatic and successful.

We now have the knowledge necessary to treat patients with mental illness properly, but we have not the facilities. We have not the buildings, the doctors, the nurses and the psychiatric social workers; and without these, changes in the law will have limited importance only. We need a large number of acute psychiatric units—long-stay units for psycho-geriatrics and separate units for psychopaths. We must develop the after-care service; and I confess that I am not very optimistic that we shall see hostels built very rapidly by local authorities. All these will cost a great deal of money.

There are several minor but important changes which the Bill makes. It gets 705 rid of the statutory responsibility of the medical superintendent; he ceases to be the statutory head of a mental hospital. I think this is all to the good. The Minister has said that he may introduce regulations to reintroduce the medical superintendent. I hope that he will think again, and that we shall run our mental hospitals as our general hospitals are run, with medical committees though I see no reason why the chairman of a medical committee should not function as the medical superintendent, and should not change from time to time. In my view administration is best done by laymen and not by doctors, who ought to be doing their doctoring.

Then there is the position of the patient who is up before a Mental Review Tribunal, with a view to discharge, when the relatives are not really in a position to receive him again. This is happening increasingly as a result of the use of the drug chlorpromazine, which gets back into circulation patients who have been in hospital for twenty years or more. Time and again it happens that there is nowhere for them to go. It is a great problem. The taking into a family of such a patient after twenty years may have disastrous effects on the family. There is no easy solution to this problem, but one wonders whether it would be possible for the Review Tribunals, pending the provision of local authority hostels, to hear about the position of the family as well.

Finally, there is the question of urgent admissions under the twenty-eight day procedure. At present it is easy to get an urgency order through the duly authorised officer. Some general practitioners are anxious about what will happen in the really urgent cases. As one sees it, it will be necessary to get hold of a consulting psychiatrist. The difficulty is that there is a great shortage of consulting psychiatrists for domiciliary visits, and at the present time it is often necessary to wait two or three days before one can be obtained. This point will have to be looked at. If we had enough consulting psychiatrists, that would be an ideal method; but I am not sure that it will work quite as expected.

Dr. Denis Leigh, who is the physician at the Bethlem Royal Hospital and the Maudsley Hospital, said this of the Bill: There is a real possibility that the provisions of the Bill seek to make psychiatry run 706 before it can walk, with a consequent lowering of standards. That is the risk, but I think it is a risk well worth taking. However, unless to-day's legislative action is matched by an expenditure of many more millions of pounds on existing mental hospitals and on acute psychiatric units, long-stay units, on hospitals for psychopaths and, above all, on psychiatrists, psychiatric social workers and other staff, and on research, the possibilities which this Bill opens for the mentally ill will not have been realised.

LORD COHEN OF BIRKENHEAD

My Lords, I would at the outset join with other noble Lords who have spoken in paying tribute to the noble and learned Viscount the Lord Chancellor for the masterly, clear and concise way in which he has expounded the Bill. In the debate on the Report of the Royal Commission which we held in this House some fifteen months ago, I ventured to remind your Lordships of two earlier Commissions. The Radnor Commission, some fifty years ago, reviewed psychiatry and its responsibilities at that time. It made wise and prescient recommendations, none of which were implemented. Then the Commission which sat some thirty years ago under the chairmanship of Lord Macmillan made recommendations which were wholly consonant with our modern concept of mental illness, but again they were not implemented. Both the Reports suffered the fate of being relegated to official oblivion. When my noble and learned friend Lord Shaw-cross wrote yesterday, in the journal which perhaps it is indiscreet and almost imprudent to mention since last Monday, the following words about the Reports of Royal Commissions and Government Committees, I felt perhaps that it applied to those earlier Reports. He wrote: Too often, alas, it has happened that when such Reports have eventually been made, Governments have professed themselves unable to find time to debate, still less to implement, the recommendations made. History, fortunately, does not always repeat itself, and historical situations do not always recur. To-day we all welcome, whatever our criticisms, this invaluable Bill, this tremendous incentive for the betterment of our mental health services, which so speedily and so substantially implements the recommendations of the 707 Report of the Royal Commission. It is right that we should offer our admiration and our gratitude to all who have been responsible for that. To most of us it would have seemed wellnigh impossible, when the Royal Commission reported two years ago, that within this short space of time a Bill would be produced with 150 clauses and eight Schedules, which repealed in part or in whole 54 Acts of Parliament which certainly, whatever merit they may have had in the past, resemble the description Cromwell uttered of the laws of England: that they were "a tortuous and ungodly jumble", a mêlée which I think all of us who have to work these Acts recognise. We now have in this Bill something which replaces a patchwork quilt of chaotic design by a tapestry of a clear plan which is wellnigh universally accepted in its major recommendations.

We all recognise that the National Health Service has made an enormous difference to the welfare of patients in mental hospitals, and indeed to the structure of mental hospitals themselves. We all recognise, also, that if we can improve the mental health services in the way in which this Bill suggests we shall have made a contribution which, even in the simplest terms, will be a significant economic gain to this community. But what is perhaps more important is that in terms of human happiness and human welfare the gain will be almost incalculable.

I, too, should like to express my deep regret that the noble Lord who chaired this Commission, the late Lord Percy of Newcastle, is not here to witness the fruits of his labours. I do so perhaps with greater personal sorrow, because a few months before his death I succeeded him as President of the Royal Society of Health, and I then learned for the first time what weighty contributions he had made to the provision of many progressive health measures.

Here I fully concur in what the noble Lord, Lord Taylor, has expressed to your Lordships. In the first exultant flush of joy we must not overlook the fact that this Bill of itself achieves but little. It provides a tool and an incentive which were hitherto lacking to do this job 708 properly. But if it is to be done, then legislation of itself is not enough. We need men, and we need money. I shall revert to that in a moment. We also need (and this is fundamental, and has not yet been mentioned to your Lordships) the closest co-operation and goodwill between all the agencies—the local authorities, the hospital boards, general practitioners and professional organisations—which have a contribution to make to the working of the schemes which this Bill seeks to promote.

We need also a public attitude which no longer regards as it did compulsory detention—call it what you will; and here I agree with the noble Lord, Lord Silkin, that there are too many who to-day "surrender judgment to the fascination of the name" and still regard mental illness as a stigma. I am at any rate helped in this consideration by the fact that, call it "certification" or call it "compulsory detention", the significance is little different. When I last spoke in your Lordships' House on this question I mentioned that in a hospital at Nottingham on March 1, 1957, there were over 1,000 patients of whom only one was certified. I believe that that is the trend which we now see in all our mental hospitals. But it is the public who must understand, and it is our duty to try to ensure that they do understand.

Despite the debate in your Lordships' House yesterday, I believe that both channels of television have made a contribution to the public understanding of the significance of mental illness and the methods of its cure. But it does mean education. We also need education in overcoming the stresses and strains of life which lead to mental illness, but we still have to remember that that is possible only by the amelioration of social and economic conditions which increase mental stress and strain in the vast majority of cases which we meet, and certain factors over which we have little control, such as the marital discords at which the noble Earl, Lord Feversham, hinted. It is these which make a contribution to the mental illness of those who are often genetically predisposed to a mental disturbance. These are the triggers, the detonators, of overt mental illness, and we need relentlessly to pursue our investigations into the causes of mental illness—I do not mean the specific and 709 necessary causes, but many of the environmental factors, because unless these are unmasked then our efforts at prevention will be virtually negligible.

We mislead ourselves and others if we believe that over-night, when Royal Assent has been given to this Bill, with any Amendments which may later be made, all the necessary services will be immediately available. There is—and it must be freely recognised—a wide gap between what we need and what we have. New hospitals cannot rise between dawn and sunset. As has been said earlier in this debate, the barracks-like buildings of so many of our mental hospitals will not encourage the free interchange of the medically and physically ill, such as is envisaged in this Bill. There may be little alteration needed in most of our general hospitals to accommodate the mentally sick, but few of the present mental hospitals would be suited to accommodate the physically ill patients, and they lack the necessary physical and diagnostic facilities. Perhaps this is another reason why we should seek in our future hospital building to ensure a flexibility of design to meet the varying needs.

Again, the shifting of the weight of responsibility over to community care, to the local authorities, will create great needs, as my right honourable friend the Minister of Health pointed out in his recent memorandum. There are to-day, as the noble Lord, Lord Taylor, has mentioned, few of the desirable hostels and residential homes, and yet these in abundance will be necessary, for there are three groups of patients for whom this form of treatment is not only desirable but, indeed, indispensable. There is the group, for example, of the educationally subnormal or maladjusted young people who are in some employment but who need—it may be only temporarily—care and guidance which they cannot be given in their own homes.

Also, it must be recognised that the sudden transition from a hospital to their own homes is an extremely difficult step to be taken by most mentally ill patients and, indeed, is not infrequently a cause of relapse. These hostels should be available as a kind of halfway house for those who are discharged from hospital and who need a period of adjustment during their transition to their restored life in the community. Also, they are 710 needed for the elderly who are mentally infirm but who do not need hospital treatment, and yet who today are occupying a large number of our mental hospital beds. In the past ten years there has been a vast and commendable increase in the provision of occupation and training centres for mentally subnormal children up to the age of sixteen. Indeed, 80 per cent. of those regarded as suitable for training are receiving treatment. But because of the lack of facilities, only 50 per cent. of adults are receiving this instruction.

Frankness also demands that we should take note of what the noble Earl, Lord Feversham, said of the shortage of all forms of trained workers in this field—psychiatrists, psychiatric social workers, those who will be mental welfare officers, nurses, occupational therapists and the like. It may be that this Bill, which gives the incentive and the Minister's promise of finance, will help to make good in some degree that deficiency.

The Government may well have to give urgent consideration to the Younghusband Report quoted by my noble friend Lord Feversham, but I think it must be remembered—and this we sometimes forget—that there is only a limited pool of manpower and of finance in the country, and it has to be used for a large number of purposes. There are more professions than medicine, and certainly more than psychiatry. There are teachers and nurses; technologists and technicians; those who have to carry out the humdrum duties of everyday life those who have to accept managerial posts. It may well be that, sooner or later, we shall have to try to decide what we should do properly to utilise this pool of manpower and resources in order that the most vocal will not receive the highest share. Although the Minister has shown that he recognises these increasing needs, and he has significantly increased the block grant to local authorities, or intends to do so, there are many of us who would have preferred what the Royal Commission recommends—namely, that a special grant should be made to local authorities, particularly to relieve the burden of capital expenditure in the initial development of community mental health services.

It is a well-established practice of Government wishing to initiate a new service, 711 or to stimulate the development of an old service, to do so by offering a percentage grant directly related to each local authority's needs and expenditure. Education, housing, tuberculosis, maternity and child welfare, are well-known precedents; and these grants have been made and earmarked for special services, even though a block grant was in operation at the same time. When the services are firmly established the cost of them has subsequently been merged in the block grant. That is happening this year, for example, in relation to education. It seems to me that the implementation of the provisions of this Bill would have been particularly appropriate for an earmarked grant. The Minister will approve local authority schemes. If sufficient money is to be available for their development, it seems that this would be achieved more readily by a specific grant for this purpose, rather than by increasing the block grant, the disposal of which is entirely at the discretion of various local authorities.

My Lords, I need not reiterate what I said in the last debate of the amazing and spectacularly dramatic advances in mental treatment which have developed during the last two or three decades. I will not subject you to yet another clinical lecture. But I think perhaps in one field I may be permitted to quote what has happened in relation to some defectives. Only this year, in the Lancet of January 31, Dr. Croft reported on a ten-year follow-up of 315 ex-defectives. Five years after their discharge from hospital, 78 per cent. were in employment and 51 per cent. had had continuous employment for over five years;29 per cent. of those were happily married;91 per cent. have committed no further police offence.

Now advances in this field demand research. We are all gratified to hear of the two new Committees which have been set up by the Medical Research Council. But it must be stressed that Committees do not conduct research. They can initiate research; they can direct research; they can assess research. But if research is to be conducted, money is wanted, and men with ideas are wanted. I hope that there will be sufficient money to support the right men with promising and fruitful ideas and provide facilities to develop them.

It is perhaps right that I should tell your Lordships that in some respects 712 there is not unqualified approval from the medical profession for all the provisions of this Bill. Some have felt aggrieved, as the noble Lord, Lord Taylor, has already mentioned, about the status of the medical superintendent, now a feature of most large mental institutions. No one, however, defends or hopes to see perpetuated the type of superintendent who ruled with an authoritarian autocracy, though it was sometimes sweetened by a patriarchal benevolence. What we really need to ensure, perhaps on the lines the noble Lord, Lord Taylor suggested, possibly on other lines, is that there is central responsibility for administration—and this, of course, is possible within the provisions of the Bill. Some have questioned the clause which has been criticised by the noble Lord, Lord Silkin, on a different basis—namely, that it is two doctors who certify a patient. They have felt that this interferes with the normal doctor-patient relationship, particularly if the patient is to be under the care of one of the doctors who has certified him. I confess that I am not greatly disturbed by that fear. Whilst I share in some measure the apprehensions expressed by the noble Lord, Lord Silkin, about the need for a civil authority to be interpolated, as it were, between the doctor and the hospital, I would say this: I have spoken to many of my doctor colleagues and they can, if it be necessary to assure your Lordships, be trusted in this matter. I believe they recognise that no Bill can defend liberty without the integrity of those who implement it, and they will play their part as loyally and justly as anyone.

Again, there has been some question on the validity of the definition of the psychopathic personality—a point raised this afternoon. It is a task from which the Royal Commission recoiled. The Government have attempted it, and I shall refrain from any seraphic analogies. It is only fair to say that if we question the psychiatrists on the definition of a psycopath, we find added support for the truth of quot homines tot sententiae. Those who have doubts will, I think, do well to remember that no definitions are written on tablets of stone. They can be reviewed in the light of experience, for however prescient, however far-sighted draftsmen may be, all the implications of a definition cannot be foreseen.

713 There are many other non-medical topics on which I share some of the anxieties which have been raised by others, but those are matters which have been fully debated in another place and they might well be reopened later in your Lordships' House. But I am satisfied, as indeed every noble Lord who has spoken has emphasised, that those who nurture these misgivings readily concede the overwhelming merits of the Bill. There is, however, one specific point to which I had not intended to draw attention, but on which the noble Lord, Lord Silkin, has drawn me. He spoke of the "lamentable knowledge" of practitioners. Well, I have trained, and I meet thousands of doctors; and I think it is doing them an injustice to say that their knowledge of mental illness is "lamentable". We have not yet emerged, indeed, from a state in which a psychiatrist practising one form of psychiatry may well say to another that his knowledge is "lamentable". Here, we are indeed still confused by the numerous schools in this particular field.

It is suggested that medical students should have additional training in mental disease. This claim is made for every single subject in the medical curriculum. It is true that in 1858 the Medical Act prescribed that, on qualification, a doctor should in effect be efficient in the practice of medicine. surgery and midwifery. That was repeated in the Medical Act of 1886. But we have long grown beyond the stage at which any human mind can encompass in its lifetime, let alone in the few years of the medical curriculum, the whole corpus of medical knowledge. I should like to assure your Lordships that in every medical school with which I am familiar students are given, during their undergraduate career, the basic knowledge of mental disease which enables them to appreciate the nature and the scope of mental disease, the potentialities as to treatment and the responsibilities of a doctor in regard to mental disease; and it is on that basic knowledge that their subsequent experience is developed. I am sure that the noble Lord, Lord Silkin will agree that there are a few pages of Halsbury's Laws of England which are unfamiliar to him. But it is also true that the noble Lord has the knowledge whereby, if he so desires, he can find any additional information he requires and from basic principles he can interpret what he reads. The same is true