The Opposition are providing part of our Supply Day time, time of which we have no great abundance, to discuss the mental health service. We have decided to do so on the Adjournment, which means that there will be no vote. The reason for this is that the greatest task here is to widen public understanding, and we believe that that is probably better achieved by a united effort by both sides of the House. For example, if the hon. Member for Woolwich, East (Mr. Mayhew), who is associated with me on the National Association for Mental Health, or my hon. Friend the Member for Cheltenham (Mr. Dodds-Parker), who is a member of the Mental Health Research Fund, is fortunate to catch your eye, Mr. Deputy Speaker, or others of my hon. Friends, we can by a united effort probably achieve a wider public understanding than in a debate which ends in a Division and automatically has a devisive effect, throwing the Government on the defensive and, perhaps, causing unnecessary criticism to be made. The Government will understand, and I do not think they will resent in any way, that it in no way inhibits the robust and constructive criticism which it is the Opposition's duty to deploy.
The public conscience about the mental health services has been awakened in recent months, but sadly awakened only by a whole series of tragic events. These events have highlighted some of the difficulties and focused some public concern on the mental health service. We must be very careful not to make one or two nurses or one or two hospitals scapegoats for our own failings. The basic responsibility for these troubles lies not in some remote hospital ward, which is unvisited, which is overcrowded, which is under-staffed and where the conditions are completely archaic. The basic responsibility lies on the local communities and on the public as a whole who tend to ignore these services. It lies on the system itself. It lies on the lack of encouragement, the lack of inspection and the lack of contact with the outside world. Indeed, the basic responsibility lies on ourselves as representatives of the general public.
In case any hon Member should try to make any dreary partisan point out of what I am saying, may I emphasise that the Mental Health Act, 1959, was not only a landmark in the care of the mentally ill but is still one of the most imaginative and forward-looking pieces of legislation on the Statute Book. As a result of it, nine out of ten patients suffering from mental illness seek treatment voluntarily and informally whereas, before my right hon. and learned Friend the Member for Hertfordshire, East (Sir D. Walker-Smith) introduced the legislation, such informal admission to the mental hospitals was very rare indeed.
In so far as responsibility lies on society as a whole, as I believe it does, it is not due to any lack of tolerance. It is due much more to a lack of knowledge. People do not know the scale of the problem. It is not common knowledge, I believe, that very nearly half of the hospital beds in this country are occupied by those who are mentally ill or mentally handicapped. It is not general knowledge that the total number of admissions of patients to psychiatric beds has increased from 62,000 in 1952 to 175,000 in 1968, although the length of stay in hospital has been dramatically reduced and discharge and readmission are much more common than they used to be. Indeed, because so many of the mental hospitals are nowhere near the town centres, it is true to say that many local people do not realise how archaic their own local hospitals are. Again, I do not believe that it is general knowledge that, whereas there is one consultant for every 19 patients who suffer from physical disorders, there is only one consultant for every 130 patients who are mentally ill and only one consultatnt for every 570 patients in the mental subnormality hospitals.
It rather surprises me that this is so in respect of the mentally ill because I can think of no field of medicine in which the advance in treatment and cure is more exciting and more dramatic than the medical treatment of the mentally ill.
All this leads to my general conclusion that far and away the most important matter and the greatest priority is that there should be a widening of the public knowledge of the scale of the problem. We need, region by region, to build up a public understanding of what facilities are good and what facilities are grievously unsatisfactory. We owe this to the nurses working in the long-stay hospitals. We owe it to the doctors and, above all, to the patients, very few of whom, by very definition, are able to articulate the problems for themselves.
A few months ago, I said in the House—I apologise for quoting my own words:
I believe that the past 12 months will have their place in history because these tragedies have awakened public conscience. It has been hurt, and I can only say, 'Thank God for that'. I make absolutely no partisan point. It is the duty and, with public conscience now awakened, the opportunity for leaders in public life to hammer home the fact that the facilities for the care of the mentally ill and the mentally subnormal are very unsatisfactory. I happily give the Secretary of State for Social Services credit for his speeches on this subject." —[OFFICIAL REPORT, 31st October, 1969; Vol. 790, c. 524.]
After that glowing and rather unexpected tribute to the Secretary of State, he must not let me down. He is now, I believe, making a blunder, and I hope that he will make one of those quick changes of mind which is such an endearing feature of his administration.
After the announcement of the events at Farleigh, the Secretary of State issued what I thought was a very sensible message to the hospital staff saying that he would constantly call to the public attention the enormous improvements which have taken place over the past 20 years. He wanted to pay tribute—as, indeed, I and every hon. Member wants to do today —to the patience and devotion of the nurses and medical staff who work in these long-stay hospitals. He went on:
I shall go on doing my utmost to arouse the public conscience about the stress to which you are subject in your hospitals …".
The public will have an understanding of what those stresses are only if we hammer home time and time again the inadequacy of the facilities that exist.
After the Ely inquiry, the Secretary of State called for a report on the long-stay hospitals. This was not just a routine report. The noble Lady the Minister of State in the other place said on 12th November:
… because of the urgent need of the situation which the report on Ely revealed, we immediately called all regional hospital boards into consultation and asked them to undertake an urgent comprehensive review of conditions in our long stay hospitals."—[OFFICIAL REPORT, House of Lords, 12th November, 1969; Vol. 305, c. 729.]
A day or two ago, when I asked that the report of this comprehensive review should be published, the Secretary of State dismissed the idea. He implied that I was asking for publication of routine monthly reports, a suggestion which, he said, was too vulgar to be considered. I am not asking for that at all. We all expected that the report of the comprehensive review of long-stay hospitals would be published. By failing to publish it, the right hon. Gentleman can inadvertently give the impression that he is trying to hush it up. I do not believe that that is his wish, and I hope that he will meet the request which I made a day or two ago.
The comprehensive review will be published, I hope to have a State Paper giving a full analysis, followed by proposals for action. That will be the comprehensive review.
I am glad to hear it. My understanding and that of the House was that the right hon. Gentleman had said that he would not publish the report of the review by the hospital boards.
Let us be clear. There was a misunderstanding. In referring to monthly reports, I took it that the noble Lord had in mind my request, made in July, immediately after the Ely inquiry, for an urgent report. That report was given. That is the first thing. After that, I told the regional hospital boards to look again and do a thorough job. We are getting the job ready now.
I am glad to hear it.
There is much which is good and exciting in the mental health services, but I am not over-impressed by the success of the efforts made to shift additional resources into mental health. There is an increase in spending on local health and hospital provision, but the amount spent, namely, £143 million 1967–68, seems too small a proportion of the total spending on health amounting to £1,490 million. In fact, the proportion is less than 10 per cent.
What disturbs me most is that, apart from the extra £3 million announced last December, I sec no real driving force to secure higher priority for the mentally ill. The last Annual Report of the Department of Health and Social Security listed 85 major building projects each over £1 million which had been completed or started in 1967–68. Only four of those are said to include a psychiatric unit, and only one of them is a mental subnormality hospital.
Projected into the future, an equally disturbing picture emerges. The Minister's own Departmental report on the subnormality services shows that only 4·4 per cent, by value of all the starts on capital schemes over £75,000 from 1968 until 1973 will be for subnormality departments. The Government may reply that the great advance will be in the community services—
Indeed, it should be. I shall return to the subnormality hospital services in a moment, but I think it best to have all the figures out of the way now, since the argument that there will be a dramatic expansion in the community services does not stand up.
The Government have decided that for 1969–70 the increase in spending on local authority services for the purpose of the Exchequer rate support grant should be an increase of 3 per cent. in real terms instead of the 6 per cent. which has been the usual figure for many years past. This is bound to have an impact in slowing down the development of the local authority health and welfare services.
Moreover, the White Paper on public expenditure, which we debated only a few days ago, estimates that there will be an average annual increase of 3·8 per cent. in expenditure on health and welfare up to 1971–72. In fact, that is a slight drop on what obtains at the moment. However, tentative figures projected yet further into the future show a further slowing down to 2.4 per cent. between 1972–73 and 1973–74. In face of this slowing down of expenditure on the health and welfare services, I fail to understand how one can even maintain existing standards, let alone secure the improvement which we all want.
Returning to the subnormality hospitals, one can reasonably say that possibly at least half of the 60,000 patients in subnormality hospitals are not in need of constant nursing care, although they do need some kind of residential care. For instance, of the 700 autistic children who, the National Society for Autistic Children tells us, are in mental subnormality hospitals, none should be in such establishments. Again, the number of admissions of mentally confused senile ladies into mental subnormality hospitals is frightening—frightening to the individuals concerned, as it must be frightening for the hospital administrations.
The emphasis should be on the development of domiciliary services. For mentally confused elderly people, day admission would, surely, offer a much better solution to their problems than permanent care in an institution.
I agree entirely with what the noble Lord has said on this subject, but does he not think that there is a lot of work to do to convince practitioners that this kind of care is desirable, and to advertise it so that they use it?
I agree entirely. It is one of the purposes of this debate to bring a greater public understanding of the need to develop these services and to bring them to the notice of the general public.
To provide for these patients more appropriate care, there must be an expansion of the psychiatric units attached to the general district hospitals, and there must also be an expansion of the community services to which we have just referred. I am speaking of sheltered lodgings, sheltered accommodation with families, hostels, sheltered jobs, special training—all those services which are designed primarily to meet the need for care and training rather than medical attention.
Just as we were right to pull down the walls which surrounded the mental hospitals, it is essential that we pull down the walls which divide the hospital service from the local authority health and welfare services. If the Government's proposals published in the Green Paper will effectively achieve that, they will be doing a good job. The only trouble at the moment is that their Green Paper is not available in the Vote Office, so that I have not yet been able to study its real meaning and intent.
May I explain? Because it is not a Command White Paper, we are not allowed to have it distributed through the Vote Office. That is why I sent every hon. Member a personal copy. I apologise for the rule of the House which forbids us to distribute it through the Vote Office.
I understand, and we shall look forward to our post in the morning with added interest.
Equally, while emphasising the importance of community care, one must accept that there are violent and difficult patients. There are, for instance, children suffering from various psychotic disorders who completely defeat the junior training centres, who defeat the pediatric clinics, and who cannot be cared for in ordinary children's homes. There are also adults who are similarly disturbed and extremely difficult to help. These patients, who are often very violent and difficult to help, seriously jeopardise the open door policies which are best suited to the great majority of those who are mentally ill and which are the policies which most psychiatric hospitals are trying to adopt.
Here the key is to set up special units and the emphasis should be on smaller units. This is probably difficult for the Government, but I should like them to take an absolutely firm decision that, by a certain date, no unit of care should be allowed which houses more than, say, 30 adults or 20 children. Many of us who go around these hospitals find it terribly difficult to walk around any more of these vast, overcrowded, barrack-like wards. And for us, it is just an odd visit or two: for the nurses and doctors, it is their working lives, and for the patients, all too often, it is their entire life. If the Government could set a firm date by which small units would be established, this would give them a worth-while target.
I wanted to inquire what the noble Lord felt about such places as Leybourne Grange, where there are small units but there are too few nurses to cope with the terrible problems, where the beds are too closely placed together and where one nurse is left on duty at night to look after perhaps 40 or 50 people—in one small unit.
We are all very well aware of this kind of problem. There is, I believe, one nurse for every physically disordered person and only one nurse for every five mentally disordered people. We are aware of this problem, and the purpose of the debate is to try and move towards easing the problem.
I agree with my hon. Friend about the special units. The Newcastle Regional Hospital Board recently agreed some new units for St. George's Hospital at Morpeth, but the last unit is down to be provided in 12 years' time. This has shaken the hospital management committee to the core.
I am sure that that has shaken the committee to the core, and I hope that my hon. Friend's remarks are taken to heart by the Ministers responsible, who are present today.
I should like to say a word about the provision of facilities outside the hospitals. If there were a proper medical assessment and the facilities were available, many people who are being directed into hospital could be helped in what one might describe as family-like homes; in hostels or in training centres. Increasingly, the emphasis should be on training and care and treatment in a domestic atmosphere, rather than an institutional setting. This is particularly true of young children. Every help by way of counselling, by developing the child care services, by developing the psychiatric social work services, even by simple things like baby sitting and day nurseries, and by developing the junior training centres, should be given to support families with a mentally ill child. I hope that Seebohm legislation will help us along this road.
The work which is being done in the junior training centres is probably the most exciting work being done in any country in the world. But my impression is that the impetus to develop the adult training centres is lagging very far behind. There is, of course, no strong emotional involvement of parents to bring pressure to bear. I should like to hear, perhaps today, a policy statement about the future of the adult training centres—the more particularly because the junior centres are to be transferred to the Deparment of Education and Science.
The adult centres should be closely linked with work opportunities for other disabled people, but the staff must be given better backing than they have at the moment. There is, for example, no agreed salary scale for the staff in adult training centres. They are given training by the Training Council for the Teachers of the Mentally Handicapped, but what is the future of that council now that it will no longer be responsible for the junior training centres?
Also on the subject of training and the transfer of the junior centres to the Department of Education and Science, the Secretary of State must know that great concern exists among those who are training to be teachers of the mentally handicapped. They are being trained by the National Association for Mental Health and by the Training Council. Their present training, which is recognised by the Department of Health and Social Security, involves two years' supervised experience in the junior training centres after they have obtained their diplomas. But the Secretary of State for Education and Science now proposes that, after they have received their diploma, five years' work in the training centres will be necessary before he regards them as being "qualified teachers", whatever that might mean in the context of teaching the mentally handicapped. This is a very silly decision, as everyone knows who is conversant with the training of these teachers. I hope that this matter can be cleared up as soon as possible.
I assume that the Department shares our worries about the deficiencies, and we should like to share their pride in the achievements of the mental health services. But, going around the country, I have it borne in upon me ever more forcibly that the problems facing the mentally ill cannot be solved only by the National Health Service and local authorities. Indeed, many of the very finest units in the country belong to, and much of the most exciting pioneering work is done by, the voluntary organisations.
The Spastics Society, whose extremely valuable article in the last edition of its newspaper is well worth reading, is well aware that 25 per cent. of spastics, suffering from cerebral palsy, are in the mental subnormality hospitals. The National Society for Mentally Handicapped Child-rent, the Mental Health Research Fund, the League of Friends, the National Association for Mental Health and many other organisations can provide an expertise which is of the utmost value. They bring a flexibility of approach, they bring a knowledge and experience and a warmth of friendliness which is invaluable in helping the mentally handicapped. I believe that it is essential that in the reform of the next decade they should be regarded as partners with the statutory authority in helping the mentally handicapped.
Perhaps it would be convenient if I intervene now to present my report to the House. Like the noble Lord the Member for Hertford (Lord Balniel), I want to speak in a non-controversial way. I am grateful to him for having provided the time for this debate and for having given me a chance to make this first report on this problem.
We are agreed on the problem of the very dangerous children. Only a few nights ago, replying to an Adjournment debate, my hon. Friend the Parliamentary Secretary described the new special homes which were being designed—they might be called Home Office homes, but on our inspiration, I think—in which these specially difficult children can be kept in proper children's conditions. Other areas are not for children at all, and some need is met in this way, in addition to the three special security places which we have for adults.
I entirely agree about having children in small units. I have a passionate belief that we should give top priority to getting as many children as we can out of big institutions into small institutions and converted houses, nor far out in the country but in a suburb where life is ordinary and simple. I am very pleased to find how enterprising regional hospital boards and local authorities are in making experiments in adapting old property, which save vast sums compared to the erection of brand new buildings and which produce something much nearer to the life which the children really need.
I know there are difficulties about the teachers who are being transferred from junior training centres to the D.E.S. and I have discussed them at length with my right hon. Friend the Secretary of State. I know his difficulties, and I know the convictions of the teachers. I have a great deal of sympathy for those who feel in a sense slighted by what is happening, but we have to remember the status which teachers mind about. My right hon. Friend is now in charge of this matter, not my Department. It is one which the noble Lord should discuss with the Secretary of State for Education and Science. In fact, I have some sympathy with their case.
Was there not a Question asked in the House last Thursday of the Secretary of State for Education and Science who was adamant on the subject? Is it not a fact that the teachers who have been training under the right hon. Gentleman's Department believe that they were given a pledge by the Prime Minister which he has repudiated?
I would not accept that for a moment. It is true that my right hon. Friend put the point of view on teaching and teachers' status and salaries. By the way, they probably will be better paid than they were when they were working for us. However, these are problems handled by my right hon. Friend.
I could not agree more on the third point about voluntary organisations. It is not only that we desperately need voluntary help, but in the break-through from the isolation of the lunatic asylum it is the local community which has an absolutely therapeutic task which is of help to the staff and to the patients. I find that there is great confusion of terms. Mental health services include both psychiatric hospitals for the mentally ill and subnormality hospitals for the mentally handicapped. The psychiatric hospitals cover mental illness on the one side and subnormality hospitals cover the mentally handicapped on the other.
As the noble Lord said, this has a formidable effect on the number of patients treated inside and outside hospitals. I will not quote all the numbers, but they have not been falling. We have to see this, however, against the historical background to see the gravity of each problem. I want to measure the problem of the mentally ill and the mentally handicapped and the geriatrics which are also linked.
The mental illness hospitals were the first to be built. Many were built in the mid-Victorian or early-Victorian age at a time when the philosophy was that of treating them as the permanent home of the mental outcasts from society. They were built for that purpose as permanent homes or asylums. This meant that their structure and distance from centres of population produced a major problem. The hospitals for the mentally handicapped were somewhat different. It was 30 years later that their building took place. As distinct from hospitals for the mentally ill, they were based on agricultural colonies. There was a dream that these people should be put in agricultural colonies, housed in one-storey structures in lovely beech woods where they could do agricultural work and this would help them in some way. At that time Epsom and Elstree were deep in the country. That is why we have concentrations of hospitals in what now are suburbs. The tremendous concentration arises from the fact that the colonies were once in the country, but now they are in parts of towns and this produces great problems.
Since 1948 there has been an encouraging decline in in-patient numbers as first extra-mural hospital services and later community services developed. Numbers dropped from 150,000 in 1953 to 120,000 in 1968. Simultaneously, and again encouragingly, the number of consultants has increased as the number of in-patients has declined. In 1960 there were 632 consultants to these hospitals and by 1968 the figure had increased to 938. One may think that that is not a great increase, but compared with the position over mental subnormality there is a significant difference.
The nurse-patient ratio has also improved. In fact it has fallen from one to 4·9 in 1960 to one to 3·5 in 1968. Encouragingly again, revenue has risen sharply and we are spending appreciably more on these hospitals. I mentioned that extra-mural hospital activity has recently been reinforced by community activity of the local authorities. This encouraging development is a direct result of the 1959 Mental Health Act. I am glad to see the right hon. and learned Member for Hertfordshire, East (Sir D. Walker-Smith) in his place. I pay my tribute to him for what I regard as an outstanding Act. It came simultaneously with a clinical break-through in psychiatric treatment, which it accelerated. That break-through could have run into the sand, but this Act came with a great discovery which doctors could use on a major scale to change the whole attitude to mental illness. This was due to tranquillisers and drugs which enabled people to have out-patient treatment rather than going into hospital.
This was a tremendous revolution. Although of course I admit there is overcrowding in many of the hospitals and of course there are unsatisfactory conditions in that area of mental illness, the atmosphere is one of hope. It is not perfect, but doctors, nurses and patients feel that this is an area in which there is a future because something has really been started and there is a real change.
It was the Mental Health Act and the Royal Commission's Report which created the atmosphere and I pay tribute to what the local authorities have done. The so-called lunatics expelled from society and detained in these institutions could then return to their homes, or at second best live useful lives in hostels, if the hostels are there. If there is a training centre for day-time occupation they can live at home, and if there is a hostel they can live and work in the hostel. In the last 10 years local authorities have done a remarkable job and their building up of this service in this decade has been remarkable.
When the Council for Training in Social Work was established in 1962 there were only 248 qualified social workers in the whole of the local health and welfare services. This had grown to 942 in 1968 and the numbers are rapidly growing now. In addition, there are now a large number of mental health social workers who are not qualified. In the same period the establishment of homes and hostels has been going on encouragingly.
I have talked up to now about mental health and mental illness without once mentioning old age. Everybody knows that a large number of the patients in psychiatric hospitals today are old people. People also know that a great number of the old people in geriatric hospitals are actually psychiatric cases. There is a considerable overlap between geriatrics and psychiatry.
I have mentioned the size of the problem of mental illness and mental handicap. The geriatric problem—that is, the number of people so ill that they must be in hospital, or who are old—is also pretty big. There are 56,000 geriatric patients in our National Health Service hospitals—that is 14 per cent. of all Nations Health Service in-patients making up a total of 24 per cent. of long-stay patients.
In this area I shall talk encouragingly. Just as we had the break-through in treatment in mental illness, there has been an equally encouraging break-through in the treatment of illness in old age. Anybody who has seen the work of Dr. Cosin at Oxford or of Dr. Roth at Newcastle knows what this small group of original thinking doctors have done. They have simply made outmoded the view, though it still exists, that there is nothing to be done for the elderly except to tend them while they die slowly in their hospital beds. Dr. Cosin and Dr. Roth have demonstrated that this is not all that can be done. It must be very exhausting to nurse with these doctors, because they require of the nurses more than mere care and nurses quietly watching over death. The doctors and nurses involved have to do the most tremendous form of nursing to inspire and convince people that they can get out of bed and out of hospital. It is one of the most rigorous disciplines now being practised.
I was very cross that one of the hospitals that was attacked in "Sans Everything" was one of these outstanding hospitals—the one at Cowley Road. There is always a danger in innovation, that nurses will not carry out instructions. I pay my tribute here to those who have carried out this wonderful work in giving inspiration to old people and helping them to get well. It has given even to the gloomiest Victorian buildings an atmosphere of cheerfulness and hope comparable to that we find in the best of our psychiatric hospitals today. They are no longer gloomy asylums. They are places where a medical revolution of an exciting and encouraging kind taking place.
I said all that very fast, but that was not because I do not care about it. I have to attend to the gloomy part. I wanted to get the background and say that in the mental illness and geriatric sections there is room for thinking that we know our way, we know our goals, and what we want to do is to spend more money and have more nurses.
The hon. Gentleman concentrated on subnormality and mental handicap. This is the area in which I cannot say that there has yet been a break-through. This is an area where we must consider a policy. The hon. Gentleman was right to say that an adequate policy is needed here, but it is not needed in geriatrics and psychiatrics, because there we know the policy. The doctors and nurses have agreed it and it is simply a case of carrying the policy through. In the case of the 58,000 mentally handicapped patients, there is not the same sense of knowing what to do.
May I start by saying that I think that one of the things that we could do is to get rid of the word "subnormality". As long as we talk about subnormal hospitals, we utterly depress the relatives, we depress the nurses, and we depress the patients. It is a shocking word. We should get rid of that word, because it is an utterly demoralising word and it is quite untrue. It has implications for nursing of very great danger. We should call these people what they are—mentally handicapped people. They are not subnormal or subhuman or sub anything. They are fellow citizens who have a certain mental handicap which is a disadvantage to them and which means that they need more care.
I agree wholeheartedly with what my right hon. Friend has just said, but the phrase "mental handicap" is also widely used in a broader sense to cover people who are mentally sick. Rightly or wrongly, it is so used. Does my right hon. Friend mean to stop it?
I was saying that mental illness and mental handicap seem to me to be a distinction as clear as one can say about physical illness and physical handicap. I suggest that we use the phrase "mental illness" in the case of people who are ill and "handicap" for those who are not ill. This is the essence of what I was talking about. For the real truth about the people who live in these hospitals—this is precisely the difficulty about this—is that these are people who are not ill. Some of them may be ill, granted; but they are there, not because they are ill, but because they are handicapped and because society has found no way of enabling these handicapped people to live in society. They have been decanted there. I must be blunt. These people have been decanted into these isolated hospitals because society cannot or will not cope; this is the blunt fact about it.
The noble Lord spoke of the high percentage, but I thought that he was a bit too high. The latest analysis I have made in a very large and good mentally handicapped hospital—Boroughcourt, which is one of our best—was to the effect that 39 per cent. of all those in Boroughcourt have nothing wrong with them, except that they are handicapped. They could perfectly well live outside if they either had homes with relatives to go to or if there were hostels or such places in which they could reside. If the community provided them with a place to live, they could go because there is nothing ill about them.
There are mentally handicapped people who are also deeply physically handicapped. They are likely to be chronic patients. There are also, I am sorry to say, mentally handicapped people who have become psychiatric patients because of the institutionalisation of their lives. For I am afraid that if a mentally handicapped person who has nothing wrong with him except his mental slowness or backwardness, and who needs love as much as anyone else, and who can understand the difference between good food and bad food and good relations and bad relations, is suddenly taken out of the community and stuck in a 100-bed ward with no locker and no private property, a psychological case is created. This is the awful thing that we know about institutionalisation. This is what the noble Lord rightly said about children, because the crime about ever permitting a child to be institutionalised is that it is almost impossible to deinstitutionalise the child after some years. This is the problem which we face in these hospitals today where those who have been rejected by society are concentrated.
I want to put on record the facts about the under-privileged at these hospitals. I know that the House will allow me to do so. We should be clear about our figures. Fact 1—in 1968, 43 per cent. of patients in hospitals for the mentally handicapped were in wards of more than 50 beds and 58 per cent. had less than 50 square feet of bed space and 31 per cent. had no locker. To see what that means I must say that the standards for our buildings are not exactly luxurious. We lay down minimum standards. My Department's standard is a maximum of 30 adult beds to a ward against the average of 50. We have a standard of a minimum of 70 square feet of bed space against the average of 50. So we must admit that in our hospitals the standard of living, so to speak—the standard of accommodation—is far below the minimum standard we set ourselves long before I was Minister—indeed, it was set in about 1963–64.
I turn now to costs. Of course I do not expect the costs for a patient in a long-stay hospital to be identical to those in an acute hospital. It is clear that acute hospitals must have more consultants, more nurses, and more expensive treatment. I know all that. Nevertheless, the difference is inexplicable except on grounds of under-privilege1 will give the House the facts.
The cost per in-patient week in a large regional hospital board, an acute hospital outside London in 1968 was just over £50 and in a London teaching hospital was £73. The comparable cost per in-patient week in a mentally handicapped hospital was £13 10s.—just under one-fifth. Whatever allowances I make for extra equipment and extra staff, there is a fact of under-privilege shown by that one figure.
In coming to the question of provisions, the figures are even more incredible, particularly when one considers that we are living in the year 1970.
Before my right hon. Friend continues, may I inform him that a great privilege is being conferred on him? I had intended to make a speech attacking him, but that will now not be necessary in view of the sympathetic and eloquent way in which he has dealt with the matter so far.
I would, nevertheless, like my hon. Friend to rub the point in, because we must all try to educate public opinion to see that change takes place.
I was about to say that the figures relating to provisions are even more remarkable. In 1968 the cost of provisions—not the cost of providing a cooked meal but the mere cost of the ingredients—was £1 6s. a week for the mentally handicapped, £1 11s. for the psychiatric patient and £1 15s. 3d. for all other regional hospital board hospitals.
When I asked why this position prevailed I was told, in effect, "After all, they are not fussy about their food". That is under-privilege and subnormality, for the one thing that these people know about is food. They know the taste of a bit of meat in the soup and when there is no meat in it. They know the taste of a fresh orange.
I have given instructions that this year, at a cost of £1 million, there shall be no discrimination in future between the mentally ill and the mentally handicapped. However, there is still a big gap between them and the others in regional hospital board hospitals, though this may be accounted for by the extra cost of acute hospitals. Nobody will, I am sure, begrudge my having given for this purpose £ 1 million of the £3 million which I collected in revenue. About £300,000 will go to improve kitchens, and this will help to make the improved provisions even better. I must say that I have been shocked that, as a nation, we have allowed this state of affairs to persist.
I do not think that it would be wise to say that as a general fact. I do not believe that that applies in those that I know.
When I published the Ely Report I observed that
… this class of hospital still remains a deprived area within the Health Service, as, indeed, it was long ago, when the Service came into being".
These hospitals must be given their fair share of manpower and money, even if this means, as it will, a reallocation of money within the Health Service. I shall be considering with the boards ways and means of starting this difficult operation as soon as possible.
I will now give the House a report on what we have achieved in the 10 months since I gave that assurance; and we must remember that the boards have done these things in a period of great financial stringency.
It is no good spending money unless we have an objective, a break-through and a goal in our minds, just as we have about the mentally ill and geriatric patients. We must know what we must do with these 58,000 people; how we want to handle this group of patients. To do this we must understand the problem, which is that these people are in hospital suffering from something which cannot be cured because it is not an illness but a handicap.
It is true that many of them are psychiatrically ill and that many of them suffer from associated physical handicaps as well. We should remember, therefore, that we shall have patients permanently in long-stay hospitals. We must agree, first, that, on a cautious estimate, about one-third of the inmates of these hospitals could, the moment we make provision for them outside, live outside hospital in the community.
We must bring these people out because what they are suffering from is, precisely, the rejection of society. What is wrong with them, poor things, is that they are rejected, isolated and treated as sub-normal. This isolation can be cured only by bringing them out, if that is physically possible, thus ending the institutionalisation of their lives.
If the institution, as is often the case, is physically isolated from the community, then, in the appallingly overcrowded conditions which are now so common—and often the result of misdirected kindness of the staff in admitting as a last refuge patients for whom they have no room; that is not real humanity—the effect of chronic institutionalisation and isolation is staggering.
I wish to add my tribute to the staff. The figures relating to staff are terrible. We have about 100 consultants in total, covering the whole of these subnormality hospitals and we had only 8,000 nurses for the 53,000 people in 1953, and now we have about 14,000. The relationship between these figures and the figures for any other part of the Service is dreadful, and only the heroism of these few doctors and nurses has kept the thing going.
I have visited hospitals with terrible buildings and staffs with sagging morale. However, I have visited many more hospitals with buildings that are just as bad, with overcrowding just as desperate, but with staffs which have an astonishing esprit de corps and an astonishing sense of service and devotion to the patients.
The staggering thing that always happens with a challenge of this sort is that it brings out heroism in some people, though there are disastrous failures among those who do not have the capacity for heroism. The better the staff, the better the quality of the nurses and doctors, the more insistent they are in their demand not just for help but for the physical improvements that are required to enable them to become real nurses and to do some really serious nursing.
They ask, "How can we nurse when we have 100 patients in a dormitory? Nobody can nurse 100 people like this at the same time. All that we can do is to be keepers". They say that they can merely try to keep order, keep the patients tidy, get them through their baths and little more. They cannot nurse or care for them in those conditions, they say, and they are right.
I come to what I believe is the heart of the problem. Of course money is important, but money is not the only thing. Money will be wasted and the staff will become demoralised unless we can persuade the medical profession, which sets the standards, that these hospitals cannot be permitted to remain a medical backwater and dead-end to which able, ambitious and sensible young men will not go.
One of our problems is the view that there is no career in a hospital of this sort for the really able and ambitious young man. He wants to go somewhere where he will see results; and as long as we have the position in which there can be no results, since results in this sphere cannot at present be medical in the general run of cases, the problem must be solved in another way.
In this sphere what is needed is tenderness, and so on. However, miracles can be worked by relieving tension, providing greater happiness and getting people out of hospital. I want the medical profession, and particularly psychiatrists, to realise that they have a profound responsibility and that they could change matters to a great extent. If they could transform the status of these hospitals so that they would no longer be regarded as backwaters, ambitious young men would then come to them.
This picture of mental handicap would be one of unrelieved gloom were it not for one feature, which is the growth of the community services of local authorities. This growth in the last 10 years has been remarkable, and I pay tribute to the local authorities for it.
For example, the number of mentally handicapped children living in hostels and homes increased from 225 in 1962 to 1,350 in 1968, and the record in the provision of training centres for mentally handicapped children living with their families at home is even more impressive. The number attending has grown from 13,500 to no less than 20,000 in this period. Imagine if that had not happened. Imagine the pressure that would have been put on hospitals. We must be grateful to the local authorities for what they have done in relieving pressure by creating a possibility for children to live at home and go to school; or, if the child's mother dies, for the child to live in a hostel.
This is one area where I see light because I see something new and constructive. It is not only that there have been these developments but that there have been great developments in teaching methods, in attitude, in the design of buildings; there has been originality in this sector and the hospital service could learn a great deal from it. I want the closest possible collaboration, integration and overlap here because decisions must be taken about what are hospital cases and what are local authority cases. I comment on this in my Green Paper.
The right hon. Gentleman says that 20,000 children are at training centres as compared with 57,000 mentally handicapped children in hospital. Does this indicate a growth in the number of patients we shall have to deal with in the next generation? Should we not be giving long-term thought to the numbers of people mentally handicapped?
I am giving such thought. The number of children surviving with mental or physical handicap is growing every year. This, of course, is one of the main reasons why I am so keen on the development of vaccines for dealing with rubella, for instance. If we are to have 200 children in rubella cases surviving their handicaps each year from now, we must look at methods of reducing the number by pre-natal treatment if we can. We have to expect serious mental handicaps of this kind to increase and not decrease. This makes it all the more important to reduce the numbers in hospitals who do not need to be there and to concentrate nursing attention on those who cannot do without it.
I turn now to a review of services for the mentally handicapped. I have put in hand a major review. I hope to publish a region-by-region review and also get the comprehensive national picture of the state of the hospitals and what has to be done, working out a five-year plan. But it is no use our merely setting minimum standards. One must set a time by which stages in the programme must be reached. We must get away from this abysmal situation to something better. I am thinking of two-year by two-year periods, calculating each time how much it will cost and how much staff will be needed. I am preparing a paper on this now and it will cover the first stage of what is required.
When we come to the question of buildings, I must plead guilty in the sense that it is true that I have not gone ahead quickly into a programme of big new buildings for the mentally handicapped. This is because I do not know what kind of big new hospitals, if any, are required. I have put all my energy into small repairs because what is really urgently needed now is help for the staff in letting them upgrade their wards—to get such things as carpets, for example. We are spending much more on the smaller things of life which make life more tolerable in these hospitals.
I am actually holding back one or two regional hospital boards which wanted to commit themselves to building new 500-bed hospitals for mentally handicapped, because I doubt whether we shall ever need such hospitals again and because I think that we should look at the problem on a smaller scale. I have been having a rethink on the whole subject and part of the process is a monitoring of all the building done in the last 10 years. A group of architects, nurses, doctors and engineers are going around each region, examining what has been built and whether it works and considering whether, for example, a nissen hut "tarted up" is not as good an answer as expensive buildings. We really need to examine what is needed, to examine our mistakes and learn from them.
I find that these reports, which I am prepared to publish, are interesting and lively reading already in touching upon our past experience of building. We have done many expensive things with no clear calculable results and I have been trying rapidly to draw the sensible deductions from past experience.
I have stimulated the regional hospitals boards to shift resources. My main job was to summon the chairmen of the boards to a meeting last summer. I told them then, "I am sorry about it. We are all responsible for Ely. We all have Elys. It is not a specially wicked place. That kind of thing can happen in every region and we all ought to feel that Ely is something we are responsible for. If we are, let us make sure that we remove the conditions each within our own region. I want a detailed report from you and I want you to tell me also how much you have diverted this year of extra revenue."
Last year, I got £2 million diverted in a period of stringent financial conditions and a further £3 million this year, only for use for the mentally handicapped. This is actually better than it sounds in total for the long-stay hospitals, because we were only spending £40 million a year on the mentally handicaped and therefore the diversion of this extra money makes a big difference to them. The result is that these hospitals are beginning to have many little extras and every regional hospital board is aware that it has to tackle the problem. We have at least got their consciences aroused and have shown them that they can never push the problem off into the background.
I am vice-chairman of a regional hospital board and I am aware of the advice my right hon. Friend has given to the boards about the movement of resources. Would not he agree that the boards have been placed in some difficulty in that, again on the advice of his Department, they have had to introduce new services and techniques which have been very costly in themselves and that it becomes extremely difficult to reallocate money in face of new techniques and services?
Because it is difficult does not mean that the boards do not have to do it. There will always be new techniques, new laboratories and expensive new equipment to put into the acute hospitals, and consultants will always be determined to put these things in, with the result that not enough money may be available for the long-stay patients. But no solution lies there, because the gap would simply get wider. There has to be a struggle of priorities here. The boards in my view have responded very well—indeed, with great energy.
Now I turn to immediate measures needed to alleviate the situation. The boards have worked out, and will show me, their five-year programmes, and on present calculations I reckon that these programmes are likely to cost £13 million of capital and £11 million of revenue over the five-year period. For the coming financial year, I have arranged for the boards to make an additional £1 million of capital available and have allocated a further £3 million of revenue, representing an increase of 7·3 per cent. of the revenue estimates of the hospitals for the mentally handicapped. This transfer of 7·3 per cent. represents a considerable effort by every board and I pay tribute to them.
I turn now to minimum standards. I am taking as a base line the standards we have had for the last 10 years. Let us make a minimum standard of 30 patients per ward for adults. But it is no good, of course, trying to do that in one go. We shall have to phase it. The hospitals simply cannot jump to that standard in one go. We are working out with the boards a programme for moving towards these standards in a realistic way. The only one I have imposed ruthlessly is that of getting rapidly to the provision of personal clothing for all patients, which is of enormous importance to individual dignity. They do not just want a locker with nothing in it. What matters is the clothing. That costs money, including laundering facilities, because, for example, some patients are doubly incontinent. It is expensive, but we should spend the money so that we can say that not one patient in these hospitals has not his or her own clothes and does not know it.
Under this heading, is the right hon. Gentleman considering the plight at the moment—I know that he has had details and I am sure that he is considering them sympathetically—of Lea Castle Hospital, where the patients sometimes only have pyjamas?
I have been to that hospital. It is one of the outstanding psychiatric hospitals in the Midlands. To be fair to its management committee, the hospital received a higher amount per patient—and has been using it well—than any other such hospital in the area and the amount it was spending on clothing for the patients was four times the average for these hospitals in the region. The hospital's relations with the regional hospital board were unhappy. The fault was not all on one side. I pay tribute to the director as a doctor but perhaps not as a diplomat in his relations with the management committee.
I want to say something else about scrutiny. The hon. Gentleman mentioned an inspectorate and I used the word after the Ely case. However, we very soon found that the idea of an inspectorate, which has been of enormous importance in education, was unwelcome to the professions—the doctors and nurses—and I think that there are good reasons for that. But we have now managed to start the Hospital Advisory Service. It is only as yet on a small scale but it will have visited and reported on every hospital for the mentally handicapped by the end of this year. It is recruited entirely from the Health Service, from among people who will come out for two or three years to specialise in this job of being my eyes and ears. Its head will report personally and directly to me and will not be in the Department. Even his office will be outside. This is important, because he must be seen to be independent of the Department. He will publish his own annual report in due course. It will be a quiet thing. He will not be dealing with patients' complaints—I shall come to them later. He will be making a survey, doing the sort of job which is one aspect of the work of the educational inspectorate, which is to keep contact and to find out and bring back ideas of what is wrong and what is being put right. The service is in its early stages, but I put great importance on its work.
We now have to get the complaints procedure right. We are discussing a new complaints procedure with the relevant people, because it is important for patients and patients' visitors to have a clear understanding of how they should lodge a complaint. When we have these two properly working, we shall have the climax when we have a health commissioner. However, I have promised the doctors and nurses that I will not finalise this—I have sent them a paper about the health commissioner—until we have the advisory service and the complaints procedure working and seeing how well they work. We could then have a health commissioner on top of those procedures.
I was asked how much we had done. I should have liked to have done more, but we have a pretty good record over the last 10 months. I suspect that in 10 months more has been done than in all the previous 20 years put together. We have started moving the mountain. Mostly, as the noble Lord said, it is a matter of getting the public conscience aroused. It is a matter of getting the community around every hospital to have a sense of direct responsibility through leagues of friends and voluntary work. It is a matter of encouraging the local authorities in their good works, and they have a fine record of achievement.
Then we have the Green Paper. I hope that in the new Health Service the planning between the hospital side, the G.P. side and the local authority side can be made infinitely easier in the set-up which I am proposing of a Health Service and local authorities in parallel and interlocking with each other through representation. All that would help.
Having got our clear picture, that 30 per cent. of our present mentally handicapped patients should be placed in the community, we can then start using our nursing resources properly, and in the hospitals the nurses can do some nursing for a change.
Where will the nursing staff come from to staff these hostels? I was at the Royal Eastern Counties Hospital only this afternoon and I was told that hospitals cannot get enough nurses now without nurses working in hostels.
I am glad that the hon. Member mentioned that. Many of these hostels will not need trained nursing or medical staff. We would have two kinds of half-way house. There would be a half-way house with medical supervision and nursing staff. But much local authority work can be done in the other kind of half-way house without trained nurses and certainly in the training centres. In many hostels now there are no trained staff, but only a man and his wife, and people working for them under their supervision.
I am listening to the right hon. Gentleman with profound interest, but this is one point on which I disagree with him. The running of these hostels is a major administrative task and training is necessary, although not necessarily nursing training. I ask the right hon. Gentleman to think again.
Of course training and qualification are necessary. I was talking about nursing training. The implication was that all the staff would be trained hospital nurses, that there would be trained medical staff in the training centres and in the hostels outside for those who were fit for the community, but who had no homes in which to live. Of course trained staff are needed, but their training is very much less complex than the medical training required by fully trained hospital nurses. We need to consider the kinds of training and qualification very carefully. This is why I was not altogether happy when we had large schools and training centres transferred to the Department of Education, for I feared that everyone would be turned into teachers, and I am not sure that we need fully trained teachers of Latin and Greek in these institutions. However, I must not go into that, for it is outside my purview.
I suggest that we take all this up when the Green Paper has been read and studied, because the most difficult point of the Green Paper is the precise distinction between the hostel which should be medically controlled and have nurses and the hostel which can be a community place outside. In Bristol I visited an excellent little inexpensive boarding house where a retired hospital nurse looked after 12 people who came from mental illness hospitals and who were living in this boarding house halfway in the community under a trained staff. They just felt safe there, because the hostel was looking after them; not trained staff, and they did not need trained staff. There are others not so far out into the community for whom a hostel with trained staff is required.
I do not want to concentrate all our efforts outside the hospitals. On the contrary, these huge Victorian buildings will be with us for many years and it must be our prime concern to create a new standard for the patients and for the staff by solving the twin problems of over-crowding and under-staffing. If we reduced the number of patients by 30 per cent., the quality of life would automatically be improved. If we increased the number of nurses and, just as important, domestic workers, that would mean that the quality of nursing would improve. If we inspired a core-of keen young consultants with links with their other professional colleagues to make the break-through here which revolutionised life in the mental illness hospitals and geriatric hospitals, the lead they could give would transform the atmosphere throughout the hospitals service. Above all, if we can break down the isolation by bringing the community to every one of these hospitals, through voluntary workers and through leagues of friends, and if we vote the money, we shall be playing our part.
I am grateful for the chance of intervening in the debate. I am immensely encouraged by the speech of the Secretary of State, as everybody who heard it must be. It was by way of being a landmark in the interest shown by Ministers in psychiatric medicine as a whole, and I congratulate the right hon. Gentleman on it.
There are a number of aspects of this subject which I should like to draw to his attention, not only for their own merit, but because they are symptomatic of the Cinderella status of this side of medicine.
I mentioned the matter of pocket money. I assure the Secretary of State that in psychiatric hospitals there is no allowance for pocket money for destitute patients and that pocket money is supposed to be taken out of the money allocated by the regional board for food. As the right hon. Gentleman has rightly pointed out, that is already inadequate.
Another matter ties in with the Secretary of State's encouragement to the staff not to regard hospitals for the mentally handicapped, for instance, just as places where patients stay until they die, but as places with a therapeutic function and a rehabilitative function. As he knows, it a person in a Government training centre needs the tools of the trade, for instance, a carpenter or a garage mechanic, a trade in which it is customary for the person to provide the tools of the trade, the State will provide the money to equip him. But if a mental hospital requires money for the tools of the trade for a patient medically ready to be discharged after the years in which he may have been in the hospital, and some start as young patients, there is no machinery by which the money can be provided.
The official answer which I have had is that it is improbable that this will happen, but as the president of a league of friends of a large mental hospital I can assure the right hon. Gentleman that it is a problem which has been put to us. It is difficult to feel entitled to spend the limited funds available to a league of friends in large dollops for individual patients rather than spread for the benefit of patients as a whole.
It is true that we cannot allocate State moneys for the purpose mentioned by the hon. Gentleman, but most mental hospitals have endowment funds, with certain moneys available for these purposes, and they try to assist patients who go out into society and need equipment of the kind referred to by the hon. Gentleman.
Yes, but the point is that if a patient goes to a Government training centre funds are made available from public money, but if he does not go to a centre they are not. It seems anomalous that a patient should have to receive training which he no longer needs, because he has already had it, to qualify for a sum which is not otherwise available.
The Secretary of State has covered a large amount of the ground and I want to mention just one risk before I conclude, far more briefly than I should like to have done, but I shall do so because I know that many hon. Members wish to take part in the debate.
If we increase the number of consultants by promoting the junior hospital grades, senior registrars and medical assistants, to consultant status without paying sufficient attention to replenishing the stock of registrars and medical assistants, we shall not increase the manpower available to serve the patients. This point was made to me in a letter which I received today from a consultant at a mental hospital who fears that the economic inducements are so pitiable that it is not possible to get the registrars and medical assistants to replace those who have been promoted to consultant status. It is also a fact, I believe, that many senior consultants, who may have been in psychiatric medicine for as long as twenty years, receive only about £200 a year more than a general practitioner with three to five years' experience, and that consultant may have as many as 800 patients in his professional care.
I welcome the allocation of extra funds, but this must be only a beginning, because I am convinced that many forms of psychiatric medicine are unnecessarily uncongenial to the nursing staff as well as to the doctors working at these hospitals. They have been treated, financially, as the poor relations for a very long time.
I do not want to speak for any longer, because the debate is already half way through. Any support which I can give to encouraging the allocation of further resources within the National Health Service to what has been the Cinderella to date I shall most certainly give.
I shall follow the example of the hon. Member for Tiverton (Mr. Maxwell-Hyslop), and even improve on it. Not on the quality of his speech, I hasten to add, but on its brevity. I shall not make the speech that I intended to make, and what I say during the next two minutes will be off the cuff.
I intervene because I have some knowledge of the mental health service as one of the largest mental hospitals in the country is in my constituency, at South Ockenden. I know the medical and nursing staff there, and I look forward joyfully to sending them tomorrow a copy of HANSARD so that they may read my right hon. Friend's splendid speech. I am sorry that he is not here, because it is not every day of the week that I praise him. It was a compassionate speech, without being maudlin. It was full of vision and hard-headed plans, and I am sure that all the staff at this institution will be very glad to read it.
When I interrupted my right hon. Friend on one occasion I indicated that I should not speak at all. The one point that I wanted to make in criticism of him was to point out that the staff at this hospital continually tell me that the mental hospital service is very much the poor relation of the National Health Service. My right hon. Friend said that the cost of keeping a patient in a mental hospital, certainly a long-stay patient, was £13 10s. The figure that I was given today was £13 9s. 9d., so there is not very much between us. My right hon. Friend has raised the matter with far more authority and with far more effectiveness than I could do, but I respond to his invitation, and I repeat what he said.
Both my right hon. Friend and the noble Lord the Member for Hertford (Lord Balniel) paid tribute, as I do, to the work done by local authorities. They relieve the pressure on the hospitals themselves, but there is one doubt in my mind. My information may not be accurate, but these patients who are being treated by the local authorities are, in the first place, or should be, the responsibility of the hospitals. They are transferred to the local authorities because the hospitals are unable to admit them. I agree with this, and I agree, too, that the local authorities are treating them extremely well, but I should like to know—I asked the noble Lord this question but he rightly said that it was not for him to answer it, but for the Government—whether the charge for treating these people falls on the rates or on the Health Service. If it falls on the rates, this seems wrong, and it points to a breakdown in the National Health Service. I should like to be told that in future—if this is not so already—the cost of treating these people by the local authority will be met by the National Health Service.
Those are the two points that I wished to make, and I repeat the tribute which I paid to my right hon. Friend in his absence.
I, too, shall confine myself to a few remarks, and I begin by joining the hon. Member for Thurrock (Mr. Delargy), on this occasion in paying tribute to the Secretary of State. His speech will be of great importance to everybody interested in this subject, and I am grateful to my noble friend on the Opposition Front Bench, my hon. Friend the Member for Hertford (Lord Balniel), for having given us the chance to discuss this matter for a short while today.
I was lucky to be on the Committee which considered the 1959 Bill, and I have followed the working of this Measure with great interest ever since. There is very little chance in the House of discussing these affairs, but, thanks to the initiative of the hon. Member for Billericay (Mr. Moonman)—I am sorry that he cannot be here this evening as he is abroad on public duties—and that of his colleagues who have done a great deal on all-party lines, it has been possible for us to have the Parliamentary Mental Health Information Unit which tries to spread information about this difficult problem when there is no time to debate it on the Floor of the House.
I shall not quote some of the figures which the Secretary of State gave me last July comparing 1958 with 1968, but I think that anybody who looks at them, and at the replies given on 7th July, 1969, will see that, although we must not be complacent, we can look with satisfaction at what has been achieved.
I thought that it was the policy that from now on mental hospital building would, in general terms, be attached to general hospitals, and that mental hospitals as such would not be constructed on their own, but from what the Secretary of State said a short time ago apparently that is not the policy at the moment.
I am grateful for that reply.
After the war, when I began to become involved in this subject, 48 per cent. of beds were for mental illness cases. It is now just over 46 per cent., which is not a great advance, despite the comparative figures which I have just mentioned. In answers which the right hon. Gentleman gave us on 7th July, he constantly used the word "research". It is in that area that I have spent much time since the war, having been lucky enough to play the smallest part in founding the Mental Health Research Fund in the late 'forties.
On 7th July, the right hon. Gentleman told us that, in 1969–70 about £250,000 was set aside by his Department for research into mental illness. I know that other Departments set aside sums for this as well, but in view of the scale of this problem, I and many others think that this amount is inadequate. After all, we looked upon tuberculosis as a scourge 50 years ago, but research has reduced it to such a small problem that the tuberculosis hospitals have ceased to exist.
The Secretary of State said that this should be a career for "ambitious and vigorous men." What has he done since to create a ladder for such men? Many junior doctors go into this work, and some progress has been made in setting up a Chair of Psychiatric Research at Oxford. Can he tell us anything about that? What is he doing about the middle rungs of the ladder? I believe that, although many young doctors are keen to research, they find that, by sticking to research, they are apt to be left behind by their colleagues.
Next in answer to a Question by the hon. Member for Orpington (Mr. Lubbock)—on 7th July, the Secretary of State said:
… I regard the treatment of adolescents with psychiatric problems as tremendously important. We have 30 units planned, of which five are due to open in the next 12 months …".—[OFFICIAL REPORT, 7th July, 1969; Vol. 786, c. 939.]
I have had, I am afraid, a rather hot exchange with the right hon. Gentleman's Department about our adolescent unit in North Gloucestershire. With the tremendous generosity of local people, over £30,000 was raised, including a substantial sum from the Aberystwyth Rag Week, which shows how interested the young are in this problem. We have been
trying for eight months now to get a site for this adolescent unit. The first was turned down and, according to an Answer which I was given on Monday, there has been a delay of six months from the time I asked the Ministry to help till reference was made to the local planning authority who must decide. I urge the right hon. Gentleman to get on with this, because this is a substantial sum and many people want to help. This is a project which the Minister himself says is tremendously important.
I hope—it is probably a vain hope—that we can discuss this problem again, although the Minister's very full statement and the Green Paper will give us much to think about. But, in the growing stress and strain of modern life, perhaps when mental illness is overcome—as I hope and pray it will be, along with physical illnesses like cancer—there will still be the problem of those whom the right hon. Gentleman does not like to be called the "subnormal", which will be with us for some time, and of the staff, who do not yet have a proper career structure. I congratulate again my noble Friend the Member for Hertford on having raised this matter, and the Minister on his speech.
I imagine that a number of us have heard our speeches made—far more eloquently—by the Secretary of State, and I, too, will be extremely brief.
My right hon. Friend's speech managed to be comprehensive and logical and compassionate all at the same time, which was a tremendous achievement. Whether we would all have been so optimistic, whether our praise would have been so warm for the local authorities' record over the last ten years, I am not sure. Some local authorities are better than others and in relation to the need, their efforts are still not enough. In particular, the Secretary of State did not mention the adult training centres but only the junior training centres, where, undoubtedly, tremendous improvements are being made.
My right hon. Friend instructed us to change our terminology in the field of mental health. I believe that the Royal Commission and the 1959 Act abjured us to use not the phrase "mentally deficient" but the phrase "mentally subnormal" or "severely subnormal". We are now told not to use that, but the phrase "mentally handicapped". I am willing to conform, but I do not believe that it is the words themselves which confer the stigma: it is the public's attitude to the subject which puts the stigma on the words. Therefore, we only go around in circles. We are willing to oblige, in changing our terminology, but let us not think that we have made a great liberal breakthrough.
My right hon. Friend touched on the question of the increasing longevity of mentally handicapped children, and the problem of how many there will be in future.
I ask myself whether the time has not come to have a full scale survey made of the prevalence of mental illness and mental handicap in this country today and tomorrow. It seems to me that this might not only make it easier to plan the future of our mental hospital services but might also, through its results, help to bring home to public opinion just how big and how important this whole subject is. Quite honestly, if one looks at Britain with a fresh eye, and looks for the principal cause of misery in Britain today, one sees that it is not bad housing or unemployment or poverty, it is mental disorder in all its forms. This is not only the most prevalent form of misery, it is the most acute form of misery, too. We have only to ask ourselves whether we would rather be unemployed or homeless or poor or physically handicapped, or whether we would be mentally ill or mentally handicapped, and we see instantly that the last thing we would choose to be of all those is mentally ill or mentally handicapped, not only because in itself the experience is so hard, but also because the experience brings in its train other evils such as homelessness, poverty, unemployment, in very many cases. Therefore I think that too little study has been given to the extent of mental suffering in our society.
We all know the familiar statistics, the number of patients in mental hospitals and hospitals for the mentally handicapped. It is a total of 183,500 mentally sick, and 194,000 mentally handcapped. We know, too, that this is simply the visible hard core of the problem and that there are also many hundreds of thousands of mental sufferers who consult their general practitioners without contacting the local authorities or the hospitals.
One study on this basis suggested that there are outside the hospitals about 500,000 people who are seriously mentally disordered.
I would draw the attention of the House to an admirable new book called "Psychiatry in Medicine" by Professor Denis Hill, who will be well known to many hon. Members, published by the Nuffield Provincial Hospitals Trust. In this book are drawn together the results of such few inadequate investigations and surveys as have been made of the extent of mental disorder in this country. The conclusions to be drawn from this sober and scholarly review are alarming. Professor Hill quotes one study as showing:
When the classical and limited view of psychiatric disorder was taken the prevalence rate was found to be 5 per cent. When all patients showing any manifest psychological disturbance were included regardless of the diagnosis, the prevalence rate rose to 9 per cent.
Professor Hill goes on to quote the national morbidity survey set up by the Royal College of General Practitioners as showing no less than 34 per cent. of the population who consulted their doctors did so either for formal psychiatric illness or for conditions listed as psychosomatic. He quotes the Seebohm Committee as computing the number of children in special need of help at over 1 million, and of that number 232,000 are subnormal, 40,000 severely subnormal, and 789,000 have psychiatric disorder.
What are we to make of figures of this kind which sound nightmarish and yet are the best guesses by sober, scholarly people? It seems that the position in the United States is even worse.
As Professor Hill says:
There have been no large scale population studies in this country aimed specifically to answer either the question, what is the prevalence in the population of chronic emotional distress or what is the prevalence of those, who may or may not consult their doctors, who suffer from minor psychiatric disorders such as neurosis?
I believe that these questions require answering. We shall never get precise figures. Obviously, much will always depend on definitions and diagnoses, but the scale of the problem of mental disorder
needs to be better known and appreciated, otherwise we shall never be able to plan and develop the mental health services on the scale we need. Nor shall we be able to bring home to the public just how important the problem is, and how important it is to raise the whole status of mental health in our community.
I ask the Minister to consider making a full-scale inquiry on this subject. From such meagre studies as have already been made, it is clear that the number of people in this country suffering from mental disorder in one form or another has to be counted not in hundreds of thousands but in millions. Nobody who looks at Britain with a fresh eye today can doubt that the greatest causes of misery are mental illness and mental handicap and all the unhappy consequences that flow from them.
How far are these facts reflected in our political thinking? How far are they reflected in the priorities laid down by our political leaders and political parties? An election is on its way and the two major parties have been making their positions and priorities clear. Yet in the last two major speeches of the Prime Minister there was only one sentence—only one sentence—which referred to mental health out of hundreds. In the Press briefing which followed the Opposition's Selsdon Park conference there was no reference to this subject at all. The manifestos of both parties contain planty about taxation, housing, education, production, prices, wages, and industrial relations but virtually nothing about what I profoundly believe to be our major social problem.
Yet there is a mass of things which need to be done by local authorities and by the Government, as the Secretary of State has said. I have nothing but praise for what he said, yet how is it that his subject does not feature in our political thinking and in the priorities laid down by our political leadership?
In this debate we have touched mainly on hospitals, but far more encouragement should be given to research, which is the great hope for the future. The Medical Research Council's expenditure on psychiatric research has quadrupled in the last ten years—good for them; but it is still less than 10 per cent. of the total medical research budget. Only slightly over £1 million was spent on research on this subject, on which the hopes of hundreds of thousands of people depend.
The need for more trained nurses and more training for nurses has been referred to. This is vital, and I wish the nurses good luck in their current campaign. Also vital is the provision of hostels. There is a need for nurses, trained administrators, physiotherapists and speech therapists. There must be many children in hospitals today with undetected deafness because of the lack of trained staff. This shortage is crucial and the Government should do something about it.
I have been visiting and revisiting a few hospitals recently. It is by no means a discouraging experience; on the contrary. It does no good and a lot of harm to paint the picture uniformly black, and to harp constantly on the negative side. I recently revisited Warlingham Park, where 12 years ago I stayed a few days in one of the wards, as a television commentator trying to convey to viewers what being a mental patient was like. Warlingham Park was a fine hospital then under the inspired leadership of T. P. Rees. It is a fine hospital today with an even friendlier and more relaxed atmosphere, and less overcrowding, and I am glad to say that rather better food is provided now. As the Secretary of State said, this is not true for many hospitals and especially hospitals for the mentally handicapped. On this subject the Secretary of State made my speech for me. I will simply say how much I appreciated what he said, especially about the need to try to reduce the number of people who are there. He put the figure of those who should be outside subnormality hospitals at 30 per cent. Others have put this figure at 100 per cent. I do not accept that figure, but the Secretary of State has interestingly put the figure at 30 per cent.
If we are thinking in these terms, the simplest and most obvious thing to do is to stop admitting people who are being admitted, not because it would do them any good to go there, but because there is nowhere else to put them. In terms of priority, in getting something to show for the money expended, this is one of the easiest ways to cope with the problem. I would stop admitting to hospitals for the mentally handicapped people who are only going there because, for example, their parents have died or because for one reason or another they are unable to continue to lead an independent life. These people could continue an independent life with some support from the local authority and with a little domiciliary care. I believe this to be crucial.
As for the people who must remain in hospitals for the mentally handicapped, our basic objective should be to make them feel that they are wanted, and this applies especially to children. One feels least wanted where the treatment is standardised and uniform in a huge institution which contains many people. One feels least wanted, as the Secretary of State said, when one's clothes are drab and uniform and when hospital corridors are widest and longest and make the most noise when people walk along them.
Conversely, where staff are available in sufficient numbers it enables them to form stable personal relationships with individual patients who are mentally handicapped. This is the most important matter of all. It enables the staff to have time to train patients and to teach them to dress themselves and to eat by themselves. One of the paradoxes of mental nursing is that it is much quicker to feed or dress patients than to teach patients to dress themselves. These are central matters in making for a better climate and a more civilised atmosphere in many hospitals for the mentally handicapped.
There is much more to say on this subject, but I must not detain the House too long. I conclude by agreeing with what was said by the hon. Member for Hertford (Lord Balniel) that we should debate these matters a great deal more than we do. It is a huge subject which is dealt with too rarely in comparison with the many other subjects with which we deal, which are important in themselves but which are not as important in terms of human wellbeing. We should debate this matter more, we should question the Minister more and we should give the subject a much higher priority.
We are not fully alive to the greatest paradox in our society. This is that we British today are better fed, better clothed, better housed and better educated than ever before. Yet there is in our society almost certainly more stress, more anxiety, more loneliness, more depression, more violence, more drug addiction and more delinquency. These are facts which should be the starting point of our political priorities. Our children today are taller and stronger than they were in the old days, but I believe I am right in saying more of them are delinquent. Our old people live longer, fewer of them are destitute, but more of them are cut off from their families, more are emotionally deprived or confused in mind. In short, we British look after our physical needs but neglect our mental health. It is time to change the priorities.
Nobody who has listened to this debate and who has heard the statistics which have emerged as to the numbers of people admitted annually into mental homes and hospitals, and the comments about the size of wards and the lack of career structure in that branch of the medical service, could have any doubt about the importance of this subject which is before the House tonight. It should help to arouse the public conscience. Perhaps we are all at fault, as has been said, in not raising this matter far more often in the House in debates on the Health Service.
In any branch of medicine, the profession or calling of a doctor or nurse demands the highest degree of skill and humanity. But in looking after the mentally ill, the degree of skill and humanity and the patience and compassion needed have to be present to a greater degree than in any other form of nursing or medical practice.
I suspect that mental illnesses are the worst of all. With physical illness, there are many methods of alleviating pain and, in the majority of cases, pain does not last very long. In a mental illness, that is not always so. Any hon. Member who has ever had anything to do with a friend or relative who has suffered a mental illness or had a severe nervous breakdown will know the constant worry, distortion and agony of mind that such a person goes through day in, day out, night in, night out, often with sleepless nights.
We are getting away from the era when any form of mental illness carried with it a most unfair stigma. I was glad to hear the right hon. Gentleman touch upon this point. It is one of the most important landmarks in the progress of the medical profession and of public thinking. Until recently, it was always said, "Poor old So-and-so is round the bend and has gone to a loony bin", as if it was not quite nice to talk about it.
Since a mental illness is merely an illness of the brain and a physical illness merely one of the body, and the brain and the body are part of the same human frame, I have never understood why any stigma should attach to one and not to the other. There is no logic in it. However, old prejudices die hard, and it behoves us all to try and get rid of them and regard mental illness in the same way as we look upon any other form of illness, though perhaps with a little more care and compassion.
I recall some years ago quite fortuitously sitting next to a leading psychiatrist at a dinner. I forget the exact nature of the function. He told me how difficult it was to get any sizeable charitable bequest to aid medical research into mental illness. He said that a large number of philanthropists and others were generous with their money and were quite prepared during their lifetime or in their wills to bequeath substantial sums of money to cancer research, research into tropical diseases, to spastics, to instal a new piece of equipment or, in those days, to endow a new wing at a hospital, for maternity patients, for example. They rather liked the idea of a brass plate saying, "This new wing was built by the generosity of Mr. X."
He went on to tell me that a friend of his who was very generous with his money and was getting on in years was asked to consider leaving a substantial sum of money to aid medical research into mental illness. He refused point blank. When asked why, he said, "I do not want people to think when I have died that I had gone bonkers". Although it was some years ago, it was an interesting reaction.
I am glad to feel, with the right hon. Gentleman, that we are doing everything we can to get away from that era of stigma which was both unfair and unnecessary.
That brings me to my last point in this context, namely, whether enough money is being spent upon that section of the medical profession in the National Health Service which deals in the widest sense with the mentally ill. If I got it right, the figure given by the right hon. Gentleman was about 10 per cent. I do not think that that is enough. We must get our priorities a little better.
Great inroads and tremendous advances are being and have been made by medical research into mental illness and knowledge hitherto untapped. In the light of the neglect which Governments of all parties have shown in this sphere in the past, it is right that the rudder should now be kicked the other way.
We are all cutting short our speeches. If I make one or two references which seem critical, they are not in any way intended to disparage my right hon. Friend's deeply humane and moving speech.
In the course of a series of definitions, my right hon. Friend did not try to define or refer to two quite small minorities within the general group of mental patients or mental cases. I want to mention these two classes and ask my right hon. Friend to consider still further what can be done about them.
I refer, first, to the class of people known as psychopaths. Perhaps my right hon. Friend did not mention them because so many end up in the care of the Home Secretary rather than in his care. But it seems that a great deal of social value could be achieved, and public money saved, if more research could lead to dealing satisfactorily with such people.
One constituent of mine has been labelled a psychopath by some of the most competent psychotherapists in this country. But, in conversation with him, I find that he is able, as it were, to stand outside himself and objectively watch himself losing control. I am told by other psychiatrists that that shows he is not a true psychopath, because a psychopath could not do that. I do not know what the truth is about that. It would be valuable if more could be said and done about people so labelled.
The other group—also a minority group consists of the extraordinarily difficult and tragic cases of those known as autistic children. I believe that, cer- tainly in their early youth, these children are not either mentally ill or mentally handicapped. It is only a difficulty of communication, which needs the most extreme patience, skill and care by specially qualified teachers and nurses. The tragedy is that if these children are not dealt with by the time they reach adolescence—perhaps 12 or 14 years of age—it is probably too late to train them.
There is an acute shortage of places in suitable homes for autistic children. That is no doubt because they need full-time care or they become totaly unmanageable. They usually cannot be looked after at home.
I know of a very sad case in my constituency of a mother and father who have done all that they can for their autistic child, one of twins, the other twin being what is called perfectly normal. They have slaved and toiled, the mother going out to work when the father is at home, he being a railwayman on shift work. In the end, because they could not get any suitable institution to accept their child, they had to agree to his returning to the South Ockendon Hospital, which was referred to by my hon. Friend the Member for Thurrock (Mr. Delargy).
I know that there have been great improvements in that hospital and my hon. Friend was entitled to praise the dedication and service offered there by the nurses. But I do not believe that even now there are people on the staff who are qualified to deal with these exceptionally difficult autistic cases. Therefore, I plead with my right hon. Friend to try to get more places made available, not necessarily in that hospital, but possibly in special homes such as the privately-owned Rudolf Steiner homes which do deal with these cases but could not take the case in question for long.
Finally, since I have twice referred to constituents, I hope it is not improper to ask my right hon. Friend to take a special look at the difficulties experienced in my area of Greater London—in Barking and around there—in finding accommodation for mentally ill or mentally handicapped children. These difficulties have been aggravated by the improvemens at South Ockendon Hospital, because that hospital, as my right hon. Friend I think told the House, is no longer accepting so many children who are mentally handicapped or mentally ill. Therefore, they are pushed back on to the local authority which does not have adequate accommodation for them, although it does an extremely good job.
I know of one 14-year-old girl who is totally unmanageable at home—and this is the problem: her mother lives alone with her and the girl has grown strong and violent. She has been sent to temporary accommodation: where it is said that she can stay until April, if her condition is manageable, and then she may be sent home. If the professional staff at an institution cannot manage her, how is her mother expected to manage her?
I conclude with these appeals to my right hon. Friend on behalf of psychopaths and the autistic children and I also ask him to deal with the great difficulties now being experienced by those in my own London borough who are trying their utmost to deal well with the problems of mentally sick children.
I should like to add my tribute to the Secretary of State's compassionate speech and to his tribute to the work of the doctors and nurses in the mental hospitals. I also agree with him that there is a great cheerfulness about these wards which deserve to be seen by as many people as possible.
However, we can, if we are not careful, gloss over the need which there will be for more mental hospitals in the coming years. We are faced with a considerable rise in the number of mentally handicapped, with which the severely subnormal must be included, in the coming years. They are going to demand a greater help and greater care from our hospitals rather than the other way round. It is also dangerous to say that if we can only transfer the 30 per cent. of subnormal patients from the mental hospitals into the hostels we shall be able to relieve the pressure. Only this afternoon I went round the Royal Eastern Counties Hospital, which has associations with my constituency, and at that hospital there is a waiting list of 270 persons. The hospital admits that it will take five years at least for that present waiting list to get into the hospitals and by that time the waiting list will have grown up all over again. In addition, there are the severely subnormal people who are kept at home when they should be receiving hospital treatment because their parents fear bringing them out and giving them the right treatment. Therefore, there may well be a greater need than we imagine, and even when the 30 per cent. go out into hostels, this will not relieve the problem as we should like to believe.
Both at Claybury Hospital and at the Royal Eastern Counties Hospital, when asked the doctors what their main grouses were, they said, "Bad buildings and a shortage of nursing staff." The position at the Royal Eastern Counties gives a good illustration. It dates from 1849. Before then it was a railway hotel. The building was never designed for its present use, and it shows it in every part.
We must, therefore, think in terms of new hospitals. I was sorry that the Secretary of State said that he had started nothing new but had concentrated on improving what exists. I was given an estimate today—perhaps it is wrong—that we may require as many as 60,000 extra beds in mental hospitals by the end of the century. It seems to me that we cannot delay the hospital building programme much longer without running the risk of worse overcrowding and problems of that kind.
I have already touched on the question of hostels and who would man them. I was glad to hear the Secretary of State say that he appreciated that they will need trained staff, even if not necessarily hospital trained staff. Nevertheless, this raises the question of the shortage of nurses, and I have two points to make in this connection.
The right hon. Gentleman said that the present ratio was one nurse to 3·5 patients. At one time, he gave an estimate—or rather, a hope—that it would be 34 nurses to 100 patients, or one in three. I am sorry that we have not reached that. At the hospital which I visited today, the ration was one to four. Moreover, I was told—I think that this is worth saying—that with severely subnormal people, patients who cannot feed, clothe, or do anything at all for themselves, even to the extent of being able to talk, that ratio is not enough, and that they need more nursing, not less.
How shall we meet the need? One observation forcibly made at Claybury is that there are a great many immigrant nurses on the staff whom the hospital like a great deal but who are allowed in only to train and who, once they have been trained, are expected to return to their country of origin within six months. The hospital administration wants those nurses to stay. The nurses would like to stay. I feel that we should not allow them to go back if they want to stay.
Next, the question of nurses' pay, which must be crucial, particularly in this field, and the need for better non-resident nurses' accommodation in the form of one- or two-room flats. At both hospitals I was told that this would be a great encouragement to nurses to come into the hospital area and remain on the staff.
In a short debate, it is not possible to pay full tribute to the inspiring speech of my right hon. Friend the Secretary of State. I shall limit my remarks to one aspect of the problem, the care of the severely mentally handicapped child. This part of the problem is growing. We have by no means managed to solve it over the past decade. If we have little to be proud of in the way our other mental homes have been run, we have still less to be proud of in our failure to provide facilities for the severely mentally handicapped child.
My right hon. Friend says that he has not done any building of new hospitals because consideration is being given to the form which they should take. I know that his Department has been doing great research into the question of children's hospitals, and I pay tribute to that, but I should like to know—
I should like this to be clear. I said that we have not in the recent past, since Ely, started any major projects; we have continued the process. I was speaking only of starting.
I want my right hon. Friend to come to a conclusion about the proper method of dealing with the severely mentally handicapped child. There is little doubt that, if a child's condition can be ascertained at an early age, it is possible to make remarkable strides in its care and development. It appears that the medical profession are concerned only with those of school age and have found it impossible to identify children any younger. Children identified at an earlier age, although they might always have to be looked after, at least could be house trained. Every year which is allowed to go by makes it more difficult to recover these children. Particular regard should be had to assessing these children.
There seems to be a conflict of opinion about how best to deal with children up to the age of 15, after which the problem is different. In the past, until the age of five, they have been kept in the wing of an ordinary hospital, with no adequate provision for them except being looked after. There have been no teachers and they have not been trained. After that, they have been sent, probably, to another children's hospital which also has inadequate training facilities.
I agree that children require a home background, but, when talking of the severely mentally handicapped, we are not talking only of those with a mental incapacity: in nine cases out of ten, they also have one or more physical handicaps. To this extent, it is impossible to keep many of these children in their own homes, so it is all the more important that we provide facilities corresponding as nearly as possible to the homes to which they will probably never be able to return.
I agree that a small home is ideal, but at that age ordinary pediatric services are necessary for these children as well, and they will not be available if we split them up into small groups scattered over the countryside. They must be concentrated to some extent, but not as we have concentrated them in the past. I do not see why an ordinary hospital ground could not have a home with its own surroundings, yet centred on a pediatric hospital.
It is said that the standard of a civilisation is reflected in the way that it looks after the less fortunate members of the community. We have had a little to be proud of her in the past. I hope that, after the inspiring speech of my right hon. Friend, and especially the enthusiasm with which he put it over, at the end of the next decade we may be a little more proud of the civilisation in which we live.
I will be extremely brief, even at the expense of seeming a little crude on a subject on which it is most desirable to be, if anything, extra delicate and tender.
My first point concerns advances in medicine. I would direct these remarks particularly to the Secretary of State, because I was very sorry that he paid no attention to this subject, let alone giving it the attention that it should have. I was, incidentally, interested to hear the hon. Member for Barking (Mr. Driberg) talk about the psychopath, who is at the very centre of the mystery of mental illness. I was surprised that he did not mention that it has just been brought to our attention that this condition of psychopathy has been found to be closely associated with the X chromosome, whatever that may be.
I am convinced—I cannot prove it, but I am none the less convinced—that the next generation will have no problem of mental illness at all. I am talking of "mental disorder" under the 1959 Act and not "subnormality" or "severe subnormality". I understand the Secretary of State dislikes these definitions, but they are the ones given in the Act; and I am talking about mental disorder.
I am absolutely convinced that mental disorder is a purely biochemical problem and that it will be solved. Therefore mental disorder is something which will vanish, although mental handicap, just as any other form of maiming, will remain with us. When the Secretary of State winds up the debate, I hope that he will tell us about any progress being made by the Medical Research Council which may be the solution to the problem.
I am particularly anxious that the Secretary of State should give his approval to these endeavours because, with the best will in the world, I am afraid that in the medical profession there is resistance, particularly among the Freudians, to them. There is resistance, for example, to the idea that schizophrenia may respond to biochemical treatment and that in many areas of mental disorder techniques of analysis therapy have absolutely no contribution to make at all.
My second point concerns psychiatric nurses. They are the Cinderellas of Cinderellas in the National Health Service. It is extraordinary that we should have debated this subject for over two hours, with the Secretary of State making an hour-long speech, and it was not until my hon. Friend the Member for Walthamstow, East (Mr. Michael McNair-Wilson) spoke that nurses pay was mentioned. Psychiatric nurses do more for their patients than any other nurses can do in any other form of nursing, and there are too few of them. What is the reason?
One clue is in the Central Health Services Council's Report entitled "Psychiatric Nursing: Today and Tomorrow". There is a moving reference in paragraph 205 to the inadequacy of staff accommodation and such like. The report says:
We think it likely that the lack of amenities in many psychiatric hospitals is a bar to recruitment.
I thought this restraint was taking pussyfooting almost too far. I hope that the Secretary of State will not overlook the extraordinary disservice we are doing to patients in the lack of facilities we provide for the nurses which benefit the patients so much.
In a recommendation made in this same Report, in paragraph 218, we read:
each hospital should review the role of nursing staff in wards of active long stay patients to ensure that nursing skills are deployed to the best advantage.
In this connection I was looking the other day at the British Journal of Social Psychiatry, Volume 2, No. 3, Summer 1968, and at an article by Nurse Platt. Talking about the administration of oral drugs to 18 schizophrenic patients, she said:
a nurse takes three quarters of an hour. This excludes the time spent finding patients, which obviously varies considerably.
The correct procedure is:
and so on and so on for no less than eight items.
The article pointed out that the time taken to administer the drugs could be cut down so that there would be a total saving of 30 hours and 20 minutes in every nursing fortnight if only the procedure was changed to one of giving an intramuscular injection of long-acting phenothiazine instead of tablets. The saving of time for the hard-pressed nursing staff would be very considerable and would release those available to carry out more important nursing procedures. It is also a more certain method of treatment, for many patients will not take their drugs, and that is half the problem.
Also, when we are getting so many schizophrenics discharged from mental hospitals and getting very encouraging results from treatment so that patients can be allowed to return home while still under drug treatment, all the good is undone if they will not take the drugs which enable them to maintain improvement. Then the rate of readmissions goes up, and there is greater strain on the hospitals and staff. I should like to have heard something of the benefits to mental hospitals accruing from the use of injections of long-acting phenothiazine. I hope that the Secretary of State will deal with this important aspect of the matter when he winds up the debate. It would be helpful to the House if he could say that such influence as he can bring is being brought to bear upon the Health Service to adopt this method of giving treatment to schizophrenic patients which will save constant relapses and waste of time. I hope the right hon. Gentleman will not let this matter escape his mind. I hope that he will give me an assurance that, as well as fundamental research into the biochemical processes of the brain, which I am convinced are responsible for mental disorder, being seriously undertaken, he will be giving attention to the point I have made about phenothiazines.
I have been associated with a regional hospital board and hospital management committees since the 1948 Act came into operation. I therefore have a fair amount of experience in the administration of hospitals; and I should not like the impression to go out from the House that until comparatively recently little was done about improving mental hospitals.
When I became associated with hospital management committee work, the mental hospital I was associated with was enclosed behind 10-feet high iron railings and every door was locked. The railings have been removed and the ward doors unlocked. I think this now applies generally. Patients have an opportunity to go about the grounds and buildings in a manner which did not apply a few years ago.
Like other hon. Members, I was glad to hear my right hon. Friend's views about the future. In recent years there has been a great determination to improve mental hospitals, but whether we have admitted it or not we have been handicapped by lack of finance. Many calls have been made on the revenue available to hospital boards for financing new techniques. The requirements of mental hospitals took second place.
Nevertheless, much has been done at places where management has been reasonably enlightened. I have visited every mental hospital throughout the Yorkshire region and in most of the Eastern counties. I am amazed at the marked improvement that has occurred in mental and subnormal hospitals in those areas. I hope that where, because of the lack of enlightened management, great improvement has not taken place, this situation will now be corrected.
All those associated with hospital management know that the real problem is staff shortage. The question is how to overcome the problem. The question of pay awards to encourage recruitment has been mentioned. I hope that an early settlement will be reached which will give some satisfaction to the nurses.
One problem uppermost in my mind is that of bad publicity. I was delighted with my right hon. Friend's reference to his ideas for dealing with complaints. It is right for the Press to publish complaints. If the reports are made in a reasonable manner, no hospital administrator or anyone else will take exception. However, complaints are highlighted and accorded a drama which in most instances is not justified. This has a depressing effect upon staffs and militates against the recruitment of young people to the service.
During the Summer Recess the officials of a mental hospital on the periphery of my constituency told me, concerning staff recruitment, that, after all the adverse publicity on television and radio and in the Press surrounding one or two mental hospitals, recruitment at that hospital stopped dead. They told me, "We could not get any student nurses to come to this mental hospital".
Many hospitals are suffering as a result of publicity of this kind, and this is a tragedy. I appreciate that publicity must be given to complaints, as and when they arise, but I hope that the Press generally will accept that it has a responsible part to play. By highlighting and over-dramatising complaints—this happens in many instances—young men and women are dissuaded from joining mental hospital staffs, and this makes our chances of ever securing adequate staffs that much less. I do not think that there is a mental hospitial with its full complement of staff. I hope that every medium of publicity will try to encourage people to undertake this work, for it is a profession which is really worth while.
I was glad to hear my right hon. Friend refer to mentally handicapped children. I am a vice-president of the Watford Society for Mentally Handicapped Children and I share my right hon. Friend's aversion to these children being institutionalised.
I frequently witness the wonderful work that is being done for Watford's mentally handicapped children. The society helps them to work and play together, and they are happy. I shudder to think what would happen if they ever became institutionalised.
I commend the work that the Government have been doing in the whole sphere of psychoneurotic and personality disorders. In 1963–64, £103 million was spent in this sphere, while in 1967–68 the sum had risen to £143 million. Although the Government have increased, by about £40 million, the amount of money available to psychiatric hospitals, they are still overcrowded, antique and understaffed.
The Government made a start last year by making additional money available to mental subnormality hospitals, or should I now say "mentally handicapped hospitals"? The North-West Metropolitan Region got about £600,000. Leavesden Hospital, in which I am particularly interested, modernised seven of its wards with the extra money, but still has 30 wards to be modernised. It wants to do this work and also to improve recruitment, particularly of psychiatrists, psychologists, social workers, physiotherapists and speech therapists. In other words, it wants to continue the good work that has been started.
Leavesden Hospital received £140,000 but on condition, I understand, that the expenditure was effected by the end of next March. The hospital cannot recruit sufficient nurses by that time, simply because there are not enough nurses to recruit. I pay tribute to the dedication and devotion of the nursing staff there. It is a pity that the end of March limitation was put on and I trust that this time limitation will be lifted.
As I say, the Government have made a start. The hospital now wants to know if it will be allowed to make further progress or if the start that was made was merely a flash in the pan to allay public disquiet. In other words, will the Government be consistent and allow hospitals for the mentally handicapped to go on spending money next year, or will these hospitals find themselves sharing the extra money with geriatric hospitals, which are apparently coming into the extra allocation scheme next year, and with the hospitals for the mentally ill, which are coming in the year after? I urge the Government to make more money available so that each type of hospital may receive something; an amount that it can really use to good effect for the good of its patients.
It may save the time of the House if I answer my hon. Friend immediately. This year we gave £2 million, of which £1 million was for hospitals for the mentally handicapped only. Next year the sum will be £3 million, and that will be exclusively for hospitals for the mentally handicapped.
I am glad to hear that and I thank my right hon. Friend for his good work. I hope that this good work which the Government have started will continue. New hospitals need to be built and others modernised. I also urge my right hon. Friend to encourage the local authorities to build hostels for those who are fit to be discharged from the hospitals.
I shall conclude immediately. These dischargees must have somewhere to live. Many of them have no one to look after them. If there is nowhere for them to go, they have to stay in hospital, which they should not do if they are fit to be discharged. I ask the Government to give a lead here. Thirty years ago, people did not want to know about this problem. Now we have recognised, to a certain extent, our responsibilities. Let us keep going the impetus the Government have started.
It seems in order to congratulate the Secretary of State. Certainly he left some of us with not much to say and with not all that much time to say it. The most notable feature of the debate is the wide range of interest and knowledge displayed on both sides of the House, some of it peculiar in its speciality. As my hon. Friend the Member for Hertford (Lord Balniel) made clear, this is what we hoped to achieve when we initiated the debate, deciding on a form which would enable it to take place on the Motion for the Adjournment without a vote. It was our intention to give an opportunity to the House to make constructive criticisms, to help the Secretary of State and to act, as he himself suggested, as a spur to further action and perhaps give him a little supoprt in his battle with the Chancellor for further allocations of resources to the National Health Service in general and this branch in particular.
One side of the problem which was not perhaps uppermost in our minds and which was not touched upon in the debate, except rather cursorily, is the limiting factor on all our activities of the need for more resources. We have been discussing the needs, but whatever else is done through ingenuity in using resources, the need for more resources is glaring.
The Secretary of State implied that there is still another need—for more information—and he told us how the Government propose to remedy it. I am glad that we shall have reports from the regional hospital boards and the assessment deriving from them. This is all the more important since the publication of the Green Paper, because it is clear from the Green Paper and other sources, including The Guardian of 20th December, that we aim at a halving of the hospital population of mentally sick and an increase in community care. We need more information about the proposal for a single Health Service administration, the care and cash provisions and the ending of the tripartite system. There are very wide differences throughout the country in the rundown of inpatients counted as per thousand of the hospital population. There is need not only for general medical knowledge, but for regional social knowledge.
The debate has shown the size of the problem we are tackling, even if perhaps some of the details of the components of that problem were a little less clear and relevant weights given by various people to different aspects have been glossed over. My hon. Friend the Member for Walthamstow, East (Mr. Michael McNair-Wilson) pointed out the need for more hospital beds and the agedness of so much of our present accommodation.
About three-quarters of our hospital beds are still in pre-First World War hospitals, and of these many must be beds for long-stay mental and subnormal patients and require a large degree of replenishment. The right hon. Gentleman gave some encouraging figures of the general tendency showing increased admissions to mental hospitals but a decline in the number of long-stay patients. I think that the figures are about 16 per cent. lower today than 15 years ago, while 90 per cent. of mental patients, mentally ill as opposed to mentally deprived, leave hospital within a year and about half within six weeks.
But, despite the encouraging picture which the right hon. Gentleman painted and the figures he quoted and despite the undoubted improvements in care and treatment and the advances which have been made, and I join with the right hon. Gentleman in congratulating those concerned, I am not so happy about the future. I am not so happy that what we are doing now will be adequate for the size of the problem which one can foresee for the future.
If the hon. Member for Woolwich, East (Mr. Mayhew) is right and the problem increases with increasing prosperity and increasing population, and there are many others who think that our present way of life is likely to increase rather than decrease the tendency to mental illness, despite the right hon. Gentleman's figures and the progress which has been made, we cannot be certain that enough progress is being made with psychiatric units in district general hospitals and with the development of psychiatric units in hospital building. There is still a danger that old hospitals will have to be with us for far too long unless we devote more resources to hospital building of this nature.
It is true that spending in general terms on the mentally ill and mentally handicapped is improving, but it is still only about 10 per cent. of the total of the National Health Service. The figures show that the problem of dealing with the mentally ill and the mentally handicapped represents far more than 10 per cent. of the effort in the Health Service. Therefore, whatever adjustments might have to be made with some forms of care, particularly for the mentally handicapped who would not require expensive equipment as might some patients in the acute hospitals, nevertheless the proportion is wrong.
The proportion of capital spending on the Health Service against the rest of capital spending is relatively small and the proportion of capital spending on the mentally sick within the Health Service is relatively small and that on the mentally handicapped within the mentally sick is relatively small. This is clearly very much the Cinderella of this part of the Service.
I am a little disquieted by the figure that only four in every five major new building projects include a psychiatric unit. I am alarmed by the planned cutback in the rate of capital expenditure of local authority health and welfare projects which might be considered as an alternative to pure Health Service projects, and a little alarmed by the halving of the rate of increase in spending by local authorities which would rank for Exchequer rate support grant calculations.
The Secretary of State rightly paid tribute to the work of the past, but it is also right for us to draw attention to the problems of expansion and the limited resources which we can see now and foresee for the future. The right hon. Gentleman says that this is a matter of priorities, but I am concerned with the implications of that statement, namely, that this is a matter of priorities and we must continue transferring such funds as are available to the least privileged part of the Health Service. Whatever problems we have, we need more money, and we cannot delude ourselves that this can be obtained by changing over from somewhere else.
I sometimes think that for decades past we have tended to get by the awkward problems that we have faced—not only in the Health Service but in other spheres —by a process of differential neglect, or differential inattention. We look closely at a problem when it comes up, and we tend to channel resources to deal with it, forgetting that we may produce another problem in another sphere by starving some equally necessary and essential part of the service concerned.
It is very difficult to judge over a short period the validity of improvements in figures resulting from such a switching process, and one is tempted to ask who suffers. Is it the nurses, with their pay and conditions? I am grateful to my hon. Friend the Member for Ilford, North (Mr. Iremonger) for introducing this matter so strongly. Is it the holding of hospitals under establishment? Is it the dilution of labour? I thought that the right hon. Gentleman got very near that when he was talking about training, but fortunately he cleared up the point.
My hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) dealt with one aspect of the problem, the medical staffing position in long-stay hospitals, which I thought he suggested, with a certain amount of justice, were prejudiced by policies adopted not only by the Department but by the medical profession, and which could end in the upgrading of junior grades without replenishment, thus merely leading to the same number of people in a slightly higher category. I think that the right hon. Gentleman recognised the difficulty by saying that we must persuade people to regard long-stay mental hospitals as an exciting and valuable part of a doctor's career, but one is tempted to ask how. Unfortunately, the answer again tends to be more money, or at least to involve the spending of more money.
I think that perhaps one can exaggerate the extent to which these problems will be overcome by medical improvements and other advances. I have a feeling that for some years to come there will be a considerable long-stay population in our hospitals, perhaps mostly geriatric, or psycho-geriatric, and those suffering from degenerative disorders of the brain and that sort of irreversible condition.
The Secretary of State divided the operations of the Health Service, and the mental side of it—and the Green Paper makes the same division—into the problem of cure and care, two broad terms. Most of the debate was concentrated on the problems of care. I think that the right hon. Gentleman was right in saying that we have further to go in that direction than we have in the problem of cure. My hon. Friend the Member for Ilford, North, painted an optimistic picture, but one has to face the fact that in this interesting debate, which was useful, and which showed a great measure of agreement, there was one reason why there was so little dissension. It was that we avoided the one topic on which differences arise most easily, that of funds and resources.
I shall not now repeat some of the suggestions which I have put forward to the right hon. Gentleman, but we in this House are fooling ourselves, and this includes the right hon. Gentleman, if we seriously believe that we can deal with these problems by improvements in skill and technique, by switching resources, by patching up and making up, and by relying on the undoubted devotion of those who work in the Health Service—nurses, doctors, almoners, everyone—by any other method in fact but by finding a way of getting more money for people to spend on the Health Service in general and on the care of the mentally sick and abnormal in particular.
I hardly dare crave the indulgence of the House to speak again in view of the length of my first speech, but I am grateful for a moment to answer one or two questions. I would thank the House very much for the reception it has given to what I said and for the useful debate we have had.
When we publish our solid State Paper on the mentally handicapped, there will be another opportunity, I hope, for going in much greater detail into the costed problem of how we actually go about this. I agree that we cannot look forward to a balanced Health Service unless more of our national resources go into it. This is absolutely clear, although we disagree on how we do it.
I feel a conscientious twinge at the remarks of the hon. Member for Tiverton (Mr. Maxwell-Hyslop) about pocket money. He has reminded me of this and I now solemnly promise him that this subject will be dealt with. The people in the box have heard from me because I cannot deal with it and I should be able to by now. It is an uneasy feeling that I cannot clear up this problem. I cannot give a definite negative and I wish that I could.
Some hon. Members have asked about research. There has been a great increase here since I have been Secretary of State; we are spending much more on it. But we could do more. It is very widely spent. We are spending much research money on developing new kinds of buildings. For instance, the temporary accommodation in Coleshill is a piece of research and development to test how effective this is in dealing with overcrowding.
The question of the hon. Member for Ilford, North (Mr. Iremonger) about fundamental research is outside my purview. I am not here to deal with the problem of whether there is a basic cure for all these matters. That is for the Medical Research Council. However, on things nearer at hand, I agree with the hon. Member for Windsor (Sir C. MottRadclyffe). I should like to persuade some philanthropist to finance much more of this. One thing which would help us most is the foundation of an institute which would give standing to the study of this subject.
Another thing which would help is if teaching hospitals would set an example. I have been trying to persuade, even begging, one or two teaching hospitals that their pediatric wards should accept mentally handicapped children and start doing serious work to show what can be done for the mentally handicapped. I am hoping to have a success with a London teaching hospital and one outside. Once teaching hospitals start tackling the problem of the difficult children, we shall get beginnings and solutions. This is how we will raise the standing in the profession. Then the young consultants may begin to see the point, that this is an area which they can enter.
On the survey which my right hon. Friend the Member for Woolwich, East (Mr. Mayhew) asked about, we have a great many going. In Wessex they have done a total survey of the mentally handicapped and are now building—I hope to open one soon—their first half-way hostels. These have been built by the Health Service and not by the local authority. Work is also going on in Newcastle and feasibility studies of mental illness are proceeding in Worcester. These include a survey of the building area, a study of the percentage of people which can be taken out of hospitals, of how links can be established with two district hospitals and of what facilities can be provided inside the hospitals. Plans for bringing people out of hospital and for studies of subnormality are similarly proceeding in Sheffield. These include studies of whether 30 per cent. or 40 per cent. is the right proportion. All these feasibility surveys are proceding and will lead, in two or three years, I hope, to positive action.
I want to conclude as we started. I agree with the House. I am delighted that we have spent three hours educating ourselves and the public on what I am sure will be looked back on in future as one of the most uncivilised gaps in our humanity. I am grateful to the House for the help which it has given me tonight in my task.