I move that the Bill be now read a Second Time. Before proceeding to explain the provisions of the Bill before the House, I would like, briefly, to give a picture of the background to the scheme of laws and institutions at present in existence, so that Deputies may clearly understand the code and procedure which it is the object of this Bill to replace.
It is stated that in medieval times lunatics were treated in monastic hospitals, but to what extent those hospitals dealt with the problem of lunacy it would now be impossible to say. Subsequent to the suppression of the monasteries, the earliest provision for the institutional accommodation of the insane took the form of cells in workhouses or houses of industry. The first of these were provided in the Dublin House of Industry about the year 1728. Cells had been provided in the year 1711 in the Royal Hospital, Kilmainham, for soldiers who were mentally deranged. During the course of the next century the authorities of houses of industry continued to provide cells or wards for the insane. In some few cases asylums were provided at the houses of industry. In connection with the Cork House of Industry, an asylum was erected in 1787 which subsequently became the Cork District Lunatic Asylum. In that year, also, a Prisons Act was passed containing a section which empowered grand juries to raise moneys for the support of wards for destitute insane persons in houses of industry. In 1815 there was established in Dublin an asylum which subsequently became the Richmond Asylum, and many of the insane persons in the house of industry were transferred to it.
Acts were passed in the years 1817 and 1820 providing for the establishment of asylums for lunatics. These were superseded by the Lunacy (Ireland) Act, 1821, which provided for the formation of asylum districts and the establishment of district asylums. This Act formed the basis of the legal code under which lunatic asylums were established and maintained.
An Act passed in 1845 provided for the removal of all lunatics from the houses of industry to the lunatic asylums. Section 15 of that Act gave power for the establishment of an asylum for each of the provinces to be appropriated to any particular class or classes of lunatics. The object was to permit the establishment of asylums for chronic and harmless patients. Section 9 of the Lunatic Asylums (Ireland) Act, 1875, authorised the reception into workhouses of such chronic lunatics as were not dangerous and might be transferred thereto from lunatic asylums.
No advantage was taken of Section 15 of the Act of 1845. It was repealed by the Local Government (Ireland) Act, 1898, Section 76 of which gave power to asylum authorities to establish auxiliary asylums for the reception of chronic lunatics who, not being dangerous to themselves or others, were certified not to require special care and treatment in a fully equipped lunatic asylum. Where an auxiliary asylum was so provided Section 9 of the Act of 1875, relating to the accommodation of chronic lunatics in workhouses, ceased to apply. The Act of 1898 also imposed a duty on the county councils to provide and maintain sufficient accommodation for the lunatic poor.
Concurrently with the development of public institutions, private institutions for the care of mental patients were being provided in different centres of population. The first institution established by private enterprise for mentally afflicted persons was Saint Patrick's, Kilmainham, which was provided in pursuance of the will of Dean Jonathan Swift, and was opened for the reception of patients in the year 1757. Another private institution was provided in Cork in the year 1799. The bulk of the remaining private institutions were established during the course of the 19th century.
The Private Lunatic Asylums (Ireland) Act, 1842, provided for the licensing of private institutions and also for their inspection and the regulation of their management. Institutions, other than charitable institutions supported wholly or partly by voluntary contributions and not kept for profit by private individuals, were required by the Act to be licensed annually by the Quarter Sessions Courts. This function was subsequently taken over by the Circuit Courts.
An Act relating to prisons passed in the year 1826 provided for the appointment of two persons to be inspectors-general of prisons and required these inspectors, inter alia, to inspect periodically every place in which lunatics or idiots were confined, whether the same was a public establishment or a place kept for profit by a private individual, and to report thereon to the Lord Lieutenant. The inspectors-general of prisons could inquire into matters connected with expenditure, discipline and the observance of the rules and regulations prescribed and required to be observed in the institutions. An Act passed in the year 1845 provided for the appointment of one or two inspectors of lunatics and transferred to those inspectors the functions of the inspectors-general of prisons so far as they related to the inspection of lunatic asylums or other establishments for the care of lunatics.
As regards the arrangements for the admission of persons to mental institutions it appears from the report on the census for the year 1851 that towards the end of the eighteenth century a large number of violent lunatics and wandering idiots were committed to the county prisons, a separate portion of each prison being set apart for them. By direction of the Government of the day, given in the year 1816, admission to lunatic cells or wards in the Dublin House of Industry was restricted to such patients as were deemed incurable and had previously been received into the lunatic asylum. Although the Act of 1821, to which I have already referred, provided that all the lunatic poor within an asylum district were to be maintained and taken care of in the asylum for the district, the only provision it contained governing admission to those asylums was one providing for the admission of prisoners found insane.
Dangerous lunatics were dealt with by an Act passed in 1838 for the prevention of offences by insane persons. It empowered two justices of the peace to commit a person to gaol on his being found to be a dangerous lunatic or a dangerous idiot. The Lord Lieutenant could at his discretion order the removal of any such person from the gaol to the district lunatic asylum. Committal of dangerous lunatics to gaols was prohibited by the Lunacy (Ireland) Act, 1867, Section 10 of which empowered any two justices of the peace to commit to the district lunatic asylum any person apprehended or discovered under circumstances denoting derangement of mind and a purpose of committing an indictable crime. The purpose of the section was to provide a substitute for the committal of dangerous lunatics to gaol, but the provisions of the section have been very widely availed of and by far the greater number of poor persons admitted to public institutions are committed in pursuance of that section.
As I have already shown, some of the Acts at present in force date back as far as the year 1821. The general consensus of opinion with persons engaged in administration favours the replacement of those Acts by one complete measure. The Commission on the Relief of the Sick and Destitute Poor, including the insane poor, in their report, which was published in 1927, said:
"The law governing lunacy is as we have shown, to be found in numerous statutes passed in the course of a century. These statutes do not form one consistent whole; they are in some respects obsolete, defective, and even contradictory. We, therefore, recommend that all the existing lunacy Acts be repealed and that new legislation take the form of an amending and consolidating Act."
That commission made other suggestions for the amendment of the law, particularly in regard to the procedure by which admission to mental institutions was obtained and to the question of provision for early treatment of incipient mental disease. Their views in these matters are endorsed by medical practitioners engaged in the treatment of mental disease. They support the opinion that the law on the subject requires radical reform. There is no provision in the law to enable a poor person to submit himself voluntarily for mental treatment, nor is it possible for a patient to be admitted to an institution for treatment for temporary mental disorder. Furthermore, very little latitude is given as to the nature and kind of mental institutions which may be provided by mental hospital authorities.
In the Bill before the House it is proposed to remedy these defects and to make other amendments in the law to secure for mental patients the benefits of the advances made in medical science and treatment in the present century. It is proposed in the Bill to substitute for the law at present in force relating to the prevention and treatment of mental disorders a new code in harmony with modern views on the treatment of mental illness.
In the first three parts of the Bill there is little that calls for special explanation. Necessary definitions of terms used in the Bill are given in Section 3, and, in this connection, I would point out that it is proposed to depart entirely from the term "district lunatic asylum" and to continue the use of the term "mental hospital" provided for in Section 79 of the Local Government Act, 1925. It is proposed also to use the term "person of unsound mind" instead of the term "lunatic". Provision is also made in Parts I to III for administration by the central and local authorities. The existing administrative districts are continued, but the Minister is given power to alter them subject to the limitation that an administrative county or a county borough shall not be divided for the purpose of the formation of a new district. A mental hospital district shall consist of an administrative county, or two or more administrative counties, or a county borough, or a county borough and one or more administrative counties.
The local authorities for the purposes of administration are the county council, where the mental hospital district consists of one administrative county, the corporation where the district consists of a county borough, and, in other cases, a joint board appointed by the council or councils of each administrative county and the corporation of the county borough, if any, included in the mental hospital district. Any such joint board will be the successors of the joint committee of management at present administering the law in the mental hospital district and the property, assets, liabilities, officers and servants of the joint committee of management are transferred to the joint board.
In Part IV of the Bill it is proposed to make it the duty of a mental hospital authority to give chargeable patients in their district any mental hospital assistance which such patients may require. A "chargeable patient" means a person who, by reason of mental illness, whether known or suspected, requires treatment, maintenance, advice, or services, and is unable through lack of means to pay the whole of the cost thereof. "Mental hospital assistance" includes—
(a) any treatment, maintenance, advice, or service, given to or arranged for a person by a mental hospital authority, and
(b) any payment made to or in respect of a person by a mental hospital authority.
Part V of the Bill, which relates to the provision and maintenance of institutions by mental hospital authorities, proposes to extend the powers of those authorities in this matter. Hitherto each mental hospital authority maintained a district mental hospital, and they might also provide an auxiliary mental hospital for persons suffering from chronic unsoundness of mind who did not require special care and treatment in a fully equipped mental hospital and who were not dangerous to themselves or others. The mental hospital authority had no power to provide an institution of any other description.
The provisions of the Bill in this matter are much more elastic. Each mental hospital authority is required to provide and maintain proper and sufficient accommodation for the purposes of their functions under the Bill. They are required to maintain a district mental hospital for their district, but they may also provide other institutions and must provide other institutions if so required by the Minister, such as auxiliary mental hospitals, consulting rooms and clinics and such other institutions and accommodation as the Minister may direct.
The provision of consulting rooms and clinics has been strongly urged in recent years by medical experts in the treatment of mental disease. Modern medical science favours the early treatment of mental illness in clinics or out-patient departments of hospitals where patients can seek medical advice and treatment without being formally admitted to a mental institution. Under the existing law, a poor patient must be certified and received into a mental hospital before he can be submitted to treatment by the medical staff of the hospital. This formality acts as a deterrent to persons who would be prepared to avail themselves of the facilities afforded by an out-patient clinic. The clinic gives an opportunity to patients suffering from nervous or mental disorders to seek expert advice before the disease becomes fixed or static. In the opinion of medical authorities, the treatment of incipient disease should provide a hopeful prospect of permanent cure and should have the effect of substantially reducing permanent or prolonged mental illness.
The Commission on the Relief of the Poor referred to this matter in their report published in 1927 and recommended—
"the establishment of dispensaries for outpatients with which medical officers of the mental hospital would be associated and through which they would be brought into contact with patients at a stage when treatment might be more hopefully undertaken."
The Hospitals Commission also wrote at length on the subject in their Second General Report.
It will be noted that, under Section 24 of the Bill, a mental hospital authority may provide consulting rooms and clinics in their district mental hospitals and elsewhere. A mental hospital authority may wish to provide a clinic at a general hospital where the services of specialists in psychiatry would be available. Such an arrangement would also have the effect of dissociating the clinic from the mental hospital.
Other special powers, given in Part V of the Bill to a mental hospital authority, are: the power to provide accommodation for temporary patients and voluntary patients, the power to provide residential accommodation for staffs, the power to provide a burial ground for the burial of chargeable patients who die while being maintained by a mental hospital authority, and the power to contribute to the capital cost of a public water supply for the purpose of enabling them to supply water to, and to the capital cost of a public sewerage scheme for the purpose of enabling them to obtain disposal of sewage from, any institution maintained by them.
The reasons for giving these powers can be easily understood, except, perhaps, in the case of the last-mentioned one—the power to contribute to the capital cost of public water supply and sewerage schemes given by Sections 31 and 32 of the Bill. In explanation of these sections, it may be stated that it is possible to visualise a case where, while the public water supply and sewerage services would be quite adequate to meet the needs of the area for which they were provided, they would not be capable of serving a new mental institution in addition. The public health authority might be reluctant to incur expenditure on improvements solely to meet the needs of the mental institution, but they might be induced to undertake the works if the mental hospital authority were in a position to defray portion of the capital cost.
Another special provision in relation to institutions is that contained in Section 36 of the Bill which enables two or more mental hospital authorities to provide and maintain jointly an institution for any class of patients who are not dangerous to themselves or others. This section should facilitate mental hospital authorities in providing jointly for any particular class of patients, such as chronic patients, where the numbers in each mental hospital district would not warrant the provision of a separate auxiliary mental hospital for the district. Power to enable two or more mental hospital authorities to unite for the purpose of providing and maintaining a laboratory for pathological research in connection with mental and nervous diseases is contained in Section 37 of the Bill.
Part VI of the Bill contains provisions relating to the finances of mental hospital authorities. Where a mental hospital district consists of an administrative county or a county borough the moneys required are to be raised equally over the whole of the county or county borough as the case may be. In any other case the moneys are to be raised severally off each administrative county and any county borough included in the mental hospital district in proportion to the average daily number of chargeable patients maintained in the mental hospital from the respective functional areas. The Bill gives a mental hospital authority power to borrow, and fixes the limit to the total amount which may stand at any time borrowed at one-fourth of the valuation of the districts served.
As regards the acquisition of land it is proposed to give mental hospital authorities powers similar to those given in the Public Assistance Act, 1939, to public assistance authorities. Under the Bill a mental hospital authority may acquire land by agreement or compulsorily. The usual provisions of Lands Clauses Acts are incorporated and procedure is laid down for acquiring land compulsorily. A mental hospital authority is also empowered, subject to specified conditions, to appropriate land for a purpose other than the one for which it was acquired and to dispose of surplus land.
Part VIII of the Bill proposes to make new provisions for superannuation in respect of officers and servants of mental hospital authorities and for their compensation when they lose employment but I think it well before discussing these proposals in detail to explain briefly the laws relating to superannuation which have already been enacted.
The first statutory provision for the superannuation of officers and servants of lunatic asylums was that contained in Section 8 of the Lunacy (Ireland) Act of 1867 which empowered an asylum authority with the approval of the inspectors of lunatics, or of one of them, to grant a superannuation allowance to any officer or servant on his retirement, provided that he devoted the whole of his time to the service of the asylum.
The Pauper Lunatic Asylums, Ireland, Superannuation Act, 1890, provided that, where an officer or servant of a district lunatic asylum, who devoted the whole of his time to the asylum, became by confirmed sickness, age, or infirmity, incapable of executing his duties in person or had been an officer or servant for not less than 15 years and was not less than 50 years of age, the governors of the asylum might, in their discretion, and with the approval of the inspectors of lunatics or of one of them, grant such annuity as they thought fit proportionate to the merits and length of service of the officer or servant, but subject to a maximum of two-thirds of the annual salary and two-thirds of the value of the lodgings, rations and other allowances payable to the officer or servant.
The Asylum Officers' Superannuation Act, 1909, introduced a new scheme of pensions the main features of which were that—
(i) the officers and servants employed in district lunatic asylums were divided into two classes, namely:—
(a) established officers and servants who had the care or charge of the patients in the usual course of their employment, and
(b) all other established officers and servants;
(ii) an officer or servant of the first class was entitled to superannuation if he had not less than 20 years' service and was not less than 55 years of age. The allowance was to be calculated at the rate of one-fiftieth of the salary or wages and emoluments for each completed year of service;
(iii) an officer or servant of the second class was entitled to superannuation if he had not less than 20 years' service and was not less than 60 years of age. The allowance was calculated at the rate of one-sixtieth of the salary or wages and emoluments for each completed year of service;
(iv) both classes of officers and servants were entitled to superannuation after ten years' service if permanently incapacitated for duty;
(v) there was provision for other allowances in special circumstances;
(vi) the salary or wages and emoluments were calculated according to the average amount of the salary or wages and emoluments for the last ten years of service;
(vii) the maximum limit to an allowance under the Act was two-thirds of the salary or wages and emoluments;
(viii) the scheme was a contributory one.
In the superannuation provisions of the Bill an effort has been made to assimilate the law relating to officers and servants of mental hospitals to that applicable to other services. The more modern tendency in pension schemes is to provide for the payment of a lump sum on retirement together with an annual allowance calculated at a lesser rate than would be allowed if no lump sum were paid. There is much to be said in favour of the lump sum on retirement. It provides the officer with a substantial sum in ready cash at a time in his career when, on the change from employment to retirement, conditions may arise which are likely to impose a strain on his resources. An official of a mental hospital who is lodged in the institution is required to take up residence elsewhere when he retires, and he may then have to undertake the expense of acquiring a new dwelling or, at least, of furnishing one. In such circumstances a lump sum could be usefully applied.
In the Civil Service, pensions of officers eligible for superannuation were formerly calculated at the rate of one-sixtieth of the salary and pensionable emoluments for each completed year of service subject to a maximum allowance of forty-sixtieths of the salary and pensionable emoluments. The Superannuation Act of 1909, which applied to civil servants, introduced a new scheme of allowances under which a pensionable officer could be given two allowances on retirement: one a lump sum calculated at the rate of one-thirtieth of the salary and pensionable emoluments for each completed year of service subject to a maximum of one and a half times the yearly salary and emoluments, and a pension calculated at the rate of one-eightieth of the yearly salary and pensionable emoluments for each completed year of service subject to a maximum of forty-eightieths of the yearly salary and pensionable emoluments.
As already shown, officers and servants of mental hospital authorities who had not the care or charge of the patients in the usual course of their employment could, under the Asylum Officers' Superannuation Act of 1909, be granted pensions calculated in the same way as the superannuation allowance given to civil servants before the passing in 1909 of the Superannuation Act relating to civil servants. It is considered that officers and servants of mental hospital authorities who had not the care or charge of the patients in the normal course of their employment might now be dealt with in the same way as civil servants were provided for by the Superannuation Act of 1909. Provision has been made accordingly in the Bill.
As regards officers and servants of mental hospital authorities who had the care or charge of the patients in the usual course of their employment the question that arises is what special provision should be made for them in the Bill. In this matter there is the precedent of the Superannuation (Prisons Officers) Act, 1919, which provides that in calculating the annual allowance two-eightieths instead of one-eightieth of the yearly salary and pensionable emoluments shall be added in respect of the twenty-first and every subsequent year of service, and in calculating the lump sum two-thirtieths instead of one-thirtieth of the yearly salary and pensionable emoluments shall be added in respect of the twenty-first and every subsequent year of service. In other words, in the case of an officer of this class each year of service given by him after he has completed twenty years' service is for pension purposes double the value of a year's service given by him before he completed twenty years' service.
This system of calculation has been adopted in the Bill for officers and servants who have the care or charge of the patients in usual course of their employment. If such an officer or servant retires when he has completed 20 years' service he can be allowed a lump sum of twenty-thirtieths and a pension of twenty-eightieths of his salary or wages and pensionable emoluments. If he has a service of 25 completed years he can be given a lump sum of thirty-thirtieths and a pension of thirty-eightieths. If he has a service of 30 completed years he can be given a lump sum of forty-thirtieths and a pension of forty-eightieths. In favour of this system of calculation it can be said that it encourages officers to remain in the service of their employers by providing a reward for longer service.
Under Part VII of the Bill the period of service necessary to qualify for superannuation in the case of officers or servants who have the care or charge of patients in the normal course of their employment is the same as that provided for in the Asylum Officers' Superannuation Act, 1909. An officer or servant is eligible for the allowances when he has reached the age of 55 years and has had not less than 20 years' service. The law relating to other officers and servants is being brought into line with that in operation in regard to officers in other branches of the local government service. To be eligible for superannuation an officer or servant of this class must have reached the age of 65 years and had 25 years' service.
An officer or servant belonging to either class who has had not less than ten years' service may be pensioned under the Bill if he resigns or otherwise ceases to hold office or employment on account of having sustained or contracted otherwise than through his own misconduct any physical or mental injury or illness which is certified to have caused permanent in capacity for duty. In the case of an officer or servant with a service of ten years or longer who is permanently incapacitated by reason of an injury directly attributable to the nature of his duties the mental hospital authority may, subject to the consent of the Minister, increase the allowance and lump sum to which he would be entitled under the Bill. If such an officer or servant has less than ten years' service the mental hospital authority may, subject to the consent of the Minister, grant him such annual allowance or lump sum as they consider proper. The Act of 1909 also made special provision for cases of this kind.
New provisions are inserted in relation to officers or servants who had the care or charge of patients in the normal course of their employment and who contract illness in the discharge of their duties and are thereby permanently incapacitated. If any such employee has ten years' service or more, the mental hospital authority may, subject to the consent of the Minister, add a number of years to his service; not exceeding ten years, for the purpose of calculating the allowances. If the employee's service is less than ten years and more than five years he may, subject to the consent of the Minister, be granted a lump sum and an annual allowance in the calculation of which the mental hospital authority may add a number of years to the period of service not exceeding the actual number of years of service.
Where an officer or servant who has had at least five years' service with a mental hospital authority dies whilst in their service such authority may make a payment to his legal personal representative, the calculation of which is explained in Section 68. This is also a new provision.
If an officer or servant dies as a result of an injury sustained otherwise than through his own misconduct while discharging his duties and the injury is directly attributable to the nature of his duties and he is survived by his widow, the mental hospital authority may, subject to the consent of the Minister, grant to the widow such allowance as they consider proper. There is similar provision in the Act of 1909. If the officer or servant was a widower and is survived by a child or children, the mental hospital authority may, subject to the consent of the Minister, grant an allowance in respect of the child or each of the children. The Bill also provides that if there is any subsequent change in the circumstances of the widow or of the child or children, as the case may be, the mental hospital authority may, subject to the consent of the Minister, reduce, increase, cancel, or restore the allowance as they think proper.
Where an officer or servant who has the care or charge of patients in the normal course of his employment dies as a result of illness contracted in the discharge of his duties the mental hospital authority may, subject to the consent of the Minister, grant an allowance to his widow, or if he is a widower and is survived by a child or children they may, subject to the like consent, grant an allowance in respect of the child or each of the children.
Another new provision is that contained in Section 70, to the effect that where an officer or servant resigns and he did not perform his duties to the satisfaction of the mental hospital authority they may, subject to the consent of the Minister, grant him a lesser allowance than one calculated on his length of service and salary or wages and emoluments.
An officer or servant who is removed from office or dismissed on account of grave misconduct shall not be entitled to receive any allowance or lump sum referable to his service. The mental hospital authority may, in their discretion, pay to such officer or servant or to or in respect of any person whom he is liable to maintain a sum equal to the whole or part of the aggregate of his contributions in respect of pension.
In the case of a pensioned officer or servant who is appointed to another position in the public service provision is made similar to that in other Local Government Acts for the abatement or discontinuance of the superannuation allowance as long as he holds such position.
Broken periods of service in different mental hospitals or with different local authorities are to be aggregated in reckoning the period of service of an officer or servant for pension purposes, provided that a period of service of less than twelve months with a mental hospital authority or a local authority shall not be so reckoned. Under the Act of 1909 a period of service of less than two years could not be reckoned. There was no provision in the Act of 1909 for reckoning service with a local authority other than a mental hospital authority. Where in determining the amount of a superannuation allowance or lump sum to be paid to an officer or servant, service with more than one authority has been reckoned, the authority or authorities with which the service reckoned was given are required to make contributions towards the amounts payable.
There is provision also for the calculation of the allowances on joint service in the case of an officer or servant who becomes a civil servant and in the case of a civil servant who becomes an officer or servant, and for a contribution towards the amounts payable by the authority or authorities with whom service was given prior to the service with the authority granting the allowances. Allowances and lump sums granted under the provisions of the Bill will be calculated on the average amount of the salary or wages and pensionable emoluments for the last three years of service.
The pension scheme provided for in the Bill is a contributory one, each officer and servant being required to contribute 3 per cent. of his salary or wages and emoluments. This is the same amount as that now being paid under the Act of 1909. The contributions are returnable to the officer or servant in certain circumstances, namely:—
(a) Where the employment terminates for any reason other than misconduct or voluntary resignation and a superannuation allowance is not payable.
(b) Where a female officer or servant retires to get married, and
(c) Where an officer or servant is dismissed on account of grave misconduct. Reference has already been made to this class of case.
An officer or servant or the representatives of a deceased officer or servant aggrieved by the neglect or refusal of a mental hospital authority to make a grant may appeal to the Minister. Any existing officer or servant will have the right to signify within six months after the pension provisions of the Bill come into operation his intention not to avail himself of the provisions of the Bill, and in any such case the provisions of the Bill will not apply. Subject to this the Act of 1909 shall cease to operate.
Amongst the miscellaneous provisions of the Bill relating to mental hospital authorities is that provided for in Section 93 empowering the Minister to set up a joint authority to administer any particular service for two or more mental hospital districts where it appears to him after consultation with the mental hospital authorities concerned that joint management and administration would tend to reduce expense or would be otherwise of public or local advantage. Section 93 would enable the Minister to establish a joint authority to administer a joint auxiliary mental hospital.
Mental hospital authorities are given power to make arrangements for the maintenance of any class of chargeable patients in a special institution not maintained by them. Two mental hospital authorities may make and carry out an arrangement for the reception into the district mental hospital or any other institution, maintained by one such authority, of patients maintained by the other authority.
A very important provision made in Part IX of the Bill is that contained in Section 103 which empowers a mental hospital authority where a person is received as a chargeable patient into one of their institutions and is not ordinarily resident in their district to arrange for the transfer of the person to the district mental hospital for the mental hospital district in which he ordinarily resides. The section also imposes a liability on the mental hospital authority for the mental hospital district in which the person ordinarily resides to make payment in respect of the cost of the care, maintenance and treatment of the person in the mental institution to which he was first admitted.
It is well known that some persons when they become mentally unbalanced wander away from home and when they are apprehended as mental patients they may be far removed from the mental hospital district in which they ordinarily reside and there may be urgent reasons for having them immediately admitted to the district mental hospital for the district in which they are apprehended. Section 172, Part XIV, of the Bill provides for the admission of a person of unsound mind to the district mental hospital for the mental hospital district in which he is for the time being in a case of urgency or where the mental hospital district in which he ordinarily resides cannot readily be ascertained. It is very desirable that in any such case there should be power to send the mental patient back to a mental institution for the district in which he ordinarily resides.
The section is also intended to remedy a situation which has long been a matter of much concern to mental hospital authorities in large centres of population, particularly to the joint committee of management of Grangegorman Mental Hospital. Numbers of patients are admitted to Grangegorman Mental Hospital who do not ordinarily reside in the mental hospital district. Many of these patients may be persons who have genuinely come to Dublin in search of employment and have become mentally ill after a short period, but it is understood that some of the patients are brought to Dublin for the express purpose of having them received into a mental hospital far removed from their native place in order to conceal from their friends and acquaintances the fact that they have found it necessary to seek mental treatment. It is undoubtedly unjust that the rate-payers of Grangegorman Mental Hospital district should be required to bear the cost of the care, maintenance and treatment of these classes of persons, and I think that the position calls for remedial measures.
Other sections in this part of the Bill to which I would draw attention are Section 102, which enables a mental hospital authority to provide for the burial of the remains of a person who dies while in receipt of mental hospital assistance from them, and Section 104, which empowers a mental hospital authority to provide by regulations for the admission of paying patients to any institution maintained by them.
Part X of the Bill provides for the registration of private institutions by the Minister. A private institution means an institution or premises in which one or more than one person of unsound mind is or are taken care of and in respect of whom the whole of the cost of maintenance and treatment is paid,
As already stated, such institutions were required to be licensed annually by the Circuit Courts in pursuance of the Act of 1842. The Commission on the Relief of the Sick and Destitute Poor, in their report of 1927, recommended that the power to license these institutions should be transferred from the Circuit Courts to the Minister. The Minister's functions of administration in relation to the care and treatment of mental patients furnish a good reason for the transfer. He is in close touch with those institutions and he is kept informed of the conditions obtaining in them by the inspector of mental hospitals who inspects them periodically.
Part X of the Bill sets out in detail the procedure for the registration of the institutions by the Minister, and the grounds upon which registration or renewal of registration may be refused and the grounds upon which an institution may be removed from the register. An institution remains registered for a period of 12 months, but there is provision for renewal of registration. The Minister is empowered to make regulations for the administration of private institutions and for medical attendance on patients therein and to prescribe the medical staffs to be employed and the records to be kept.
Part XI of the Bill makes provision for the registration of private charitable institutions by the Minister. A private charitable institution is an institution carried on wholly or mainly for the care of persons of unsound mind gratuitously or at less than cost. The proposal to register these institutions is made in accordance with a recommendation by the commission which reported in 1927. The provisions relating to the registration of private charitable institutions are much the same as those proposed for private institutions—the differences are that there will be no power to require private charitable institutions to pay any fees in respect of registration, and these institutions will be required to furnish the Minister annually with an abstract of their accounts. The latter requirement is intended to enable the Minister to satisfy himself that the institutions come within the definition of private charitable institution given in the Bill.
In the case of an institution authorised by special Act or other enactment, including a charter, for the care, maintenance and treatment of persons of unsound mind Part XII of the Bill will give power to the Minister to take steps to satisfy himself as to the competency of the person in charge, the arrangements for the medical attendance of patients, the suitability and adequacy of the food given to the patients, and the accommodation in and state of repair of each institution. Where the Minister is not satisfied on any of these matters he may order the person carrying on the institution to take such steps as he considers proper. Where there has been a conviction for a contravention of any such order the Minister may direct that the care of mental patients in the institution shall be discontinued.
Part XIII of the Bill gives the Minister power to approve of institutions for the reception of temporary patients and voluntary patients. These two classes of patients are dealt with later in the Bill. The Minister may approve of an institution for the reception of one or other or of both classes. The reception of temporary and voluntary patients in an institution not approved by the Minister is prohibited. The Minister is empowered to make regulations governing the administration of approved institutions and prescribing the staffs to be employed and the records to be kept in relation to the temporary patients and the voluntary patients received for treatment.
The reception of persons of unsound mind into mental institutions is dealt with in Part XIV of the Bill and this part will require an extensive explanation for the reason that it makes a radical alteration in the existing law and procedure. Hitherto persons suffering from derangement of mind could be admitted into mental institutions under the control of mental hospital authorities in various ways. The usual methods of admission were:—
(1) Committal in pursuance of Section 10 of the Lunacy (Ireland) Act, 1867. The committal order was made by two peace commissioners or a district justice after the person concerned had been certified as a dangerous lunatic by a dispensary medical officer. The expenses connected with the committal, including the payment to the medical officer for his services, were defrayed by the local public assistance authority.
(2) Admission in pursuance of regulations adopted by the mental hospital authority. These regulations contained provision for admission on a prescribed form in which was included a certificate to be signed by one medical practitioner and an order of admission to be made by one peace commissioner. All the costs connected with the certification were borne by the next of kin or the person seeking the patient's admission.
(3) Admission as a paying patient in pursuance of regulations adopted by the mental hospital authority. The regulations prescribed a form of certificate to be signed by two medical practitioners and an order of admission to be signed by one peace commissioner. All the costs and expenses connected with certification were borne by the next of kin.
In addition to these modes of admission there were others which have not much bearing on the consideration of this Bill inasmuch as they relate to a comparatively small number of admissions and it is not proposed to make any change in regard to them. They are: Admission on the order of the President of the High Court in the case of a ward of court; admission of members of the Defence Forces certified on discharge or retirement to be of unsound mind; admission on the order of the Minister for Justice in the case of a prisoner.
In case of mental institutions which are not under the control of mental hospital authorities admission can be obtained in two ways, namely: (1) A patient can be admitted to an institution licensed in pursuance of the Act of 1842 on the order of a relative or other person accompanied by two certificates, each signed by a medical practitioner to the effect that the patient has been examined by him, and that he is of unsound mind and is a proper person to be confined; (2) a patient can be admitted to other private mental institutions on a certificate signed by two medical practitioners accompanied by an order of admission signed by one peace commissioner.
The great majority of poor persons are admitted to district mental hospitals following committal under Section 10 of the Act of 1867. Admission under regulations by the second method mentioned in relation to institutions maintained by mental hospital authorities is largely confined to persons transferred from county homes to district mental hospitals.
Section 10 of the Act of 1867 was based on principles embodied in previous legislation under which a person suffering from mental illness was committed to an institution as if he were guilty of some crime. The Act of 1838, to which I have already made reference, provided that if any person were discovered and apprehended under circumstances denoting derangement of mind and a purpose of committing some crime which, if committed, would render him liable to be indicated, any two justices before whom the person was brought could call to their assistance any legally qualified physician, surgeon or apothecary, and if upon examination of the person or from any other proof, the justices were satisfied that he was a dangerous lunatic or a dangerous idiot, they could commit him to gaol to be kept therein until discharged. Where it was certified by two physicians or surgeons, or a physician and a surgeon, that any such person was insane, the Lord Lieutenant could, if he thought fit, direct by warrant the removal of the person from the gaol to the lunatic asylum established for the county, city or town in which he was in custody.
Although the Act of 1867 prohibited the committal of lunatics to gaols, it will be seen from what I have already said that Section 10 of that Act retained the objectionable features of the earlier Act. It even repeated the language as to the person being apprehended under circumstances denoting derangement of mind and a purpose of committing an indictable crime.
The procedure under the Act of 1867 is that the Gárda apprehend the person and bring him before two peace commissioners before whom evidence is given that the person is dangerous and likely to commit an indictable crime, When it is proved to the satisfaction of the peace commissioners that the person was discovered and apprehended under circumstances denoting derangement of mind and a purpose of committing an indictable offence the peace commissioners call to their assistance the dispensary medical officer and if he certifies that the person is a dangerous lunatic or a dangerous idiot the peace commissioners, by warrant, direct the person to be taken to the district mental hospital for the district in which he was apprehended. This procedure has much in common with that followed in a criminal case. The patient is dealt with as if he were suspected of being guilty of a crime.
The Bill proposes to depart entirely from this procedure and to deal with persons suffering from mental derangement as patients who are mentally ill and who should be arranged for and treated by medical practitioners.
Broadly speaking two methods for the admission of persons of unsound mind to mental institutions are provided for—one relating to chargeable patients and the other to private patients.
The Bill provides that where it is desired to have a person admitted to a district mental hospital as a person of unsound mind and a chargeable patient, application may be made to the authorised medical officer for a recommendation for the reception and detention of the person in such mental hospital. The application may be made by the husband, or wife or a relative of the person concerned, or, at the request of any of them, by the appropriate assistance officer, or by any other person. The authorised medical officer is the medical officer of the dispensary district in which the person ordinarily resides, if he is not disqualified in relation to the person, and if he is so disqualified, then the dispensary medical officer residing nearest to the place where the person ordinarily resides who is available and is not disqualified. Where there are more medical officers than one in a dispensary district the nearest available of those officers who is not disqualified in relation to the person is the authorised medical officer. If none of these medical officers is available or all of them disqualified or some not available and the remainder disqualified then the nearest available dispensary medical officer who is not disqualified is the authorised medical officer. A medical officer is disqualified in relation to a person if he is interested in the payments to be made for taking care of the person or if he is a family connection of the person.
The medical officer to whom the application is made is required to visit and examine the person within 24 hours of the receipt of the application, and if he is satisfied that it is proper to do so he shall make the recommendation. The applicant for the recommendation or any person authorised by him may then convey the person to the district mental hospital. On arrival of the person at the mental hospital the resident medical superintendent, or another medical officer of the hospital acting on his behalf, is required to examine the person and, if he is satisfied that he is of unsound mind, to make an order for his reception and detention as a person of unsound mind in the mental hospital.
The expenses of the conveyance of the person to the mental hospital may be paid by the assistance officer. There is also provision enabling the resident medical superintendent of the mental hospital and requiring the Gárda Síochána, to provide an escort if one is required to ensure the safe conveyance of the person to the mental hospital.
Provision is also made to enable the Gárda Síochána to take steps to have a person admitted to the district mental hospital where he is of unsound mind, and should for the public safety or the safety of himself be placed under care and control and also to have a person of unsound mind admitted where he is not under proper care or control or is neglected or cruelly treated.
Where it is desired to have a person received and detained as a person of unsound mind in an authorised institution or a private institution or a private charitable institution, or as a paying patient in a district mental hospital, application may be made to a registered medical practitioner for a private patient reception order. The application may be made by the husband or wife or a relative of the person, or by any other person. If the registered medical practitioner accepts the application he is required to arrange with another practitioner for two separate examinations of the person, one examination by each practitioner, and if they are each separately satisfied that it is proper to do so they shall make an order for the reception of the person in a mental institution. The applicant for the order, or any person authorised by him, may then convey the person to the mental institution mentioned in the order. The person may then be received and detained in such institution. The Gárda Síochána are required in this case also to arrange for an escort, if one is required, to ensure the safe conveyance of the person to the institution.
Part XIV of the Bill also provides for the reception of temporary patients in mental institutions. For the purposes of the Bill a temporary patient is defined as a person who is suffering from mental illness and who is believed to require for his recovery not more than three months suitable mental hospital treatment and is unfit on account of his mental state for treatment as a voluntary patient.
In this connection I should mention that since fixing the period of three months, set out in the Bill as the limiting period for the detention of temporary patients, representations have been made to me, mostly by medical experts who are concerned in the treatment of these patients, that the period of three months is altogether too short. We can deal with that in Committee. We could extend the period and make it six months, I understand that up to 60 per cent. of such cases admitted to mental hospitals are in fact discharged within a six months period. If when I check up on the representations that have been made I find that they are accurate I think it would be a very sound policy to extend the period of detention of temporary patients to six months.
A large number of the patients admitted to mental institutions suffer from mental illness which is of comparatively short duration. Statistics contained in the report of the Commission on the Relief of the Sick and Destitute Poor show that of those discharged from district mental hospitals and auxiliary mental hospitals 30.9 per cent. were discharged within a period of three months of their admission. Many of those patients are never again admitted to a mental institution. They had evidently suffered from a mental illness which responded to treatment after a very short period of care. It is undesirable that in order to obtain treatment such persons must be formally certified as of unsound mind and admitted to a mental institution where they are placed in the same category as persons suffering from prolonged or permanent forms of mental disease.
The Bill proposes to make provision for the admission of temporary patients to institutions approved by the Minister for the reception of such patients. In this connection I might say that approved institutions need not necessarily be mental institutions, although probably a number of them will be mental institutions. It is quite possible that the illness from which the patients suffer may be of a nature that could be treated in a general hospital with special facilities for the treatment of such cases. Sometimes the nervous or mental disorder is directly or indirectly caused or aggravated by disease requiring special medical or surgical treatment. These are aspects of the matter to be examined by the Minister, and if he is satisfied that suitable arrangements are available in a general hospital for the treatment of the diseases from which temporary patients suffer, it will be open to him to give approval to the hospital for the purposes of the admission of temporary patients thereto so as to enable such patients to benefit by the facilities afforded in the hospital.
The Bill provides that where it is desired to have a person received and detained as a temporary patient in an approved institution application on that behalf may be made to the person in charge of the institution. The application may be made by the husband or wife or a relative of the patient, or by any other person, and in the case of a chargeable patient application may also be made by the appropriate assistance officer at the request of the husband or wife or a relative. The apaplication must be accompanied by a medical certificate, which in the case of a chargeable patient must be given by the authorised medical officer. After consideration of the application the person in charge of the institution may, if he thinks it proper to do so, make a temporary patient reception order to have the person received and detained as a temporary patient in the institution.
The applicant for the order or any person authorised by him may then convey the person to whom the order relates to the institution, where he may be detained for a period not exceeding three months. If the person is a chargeable patient the appropriate assistance officer may defray the reasonable expenses of his conveyance to the institution, and if the institution to which the person is to be removed is a district mental hospital the mental hospital authority may cooperate in making arrangements for the removal.
Part XV of the Bill proposes to make provision for the reception of voluntary patients in institutions approved by the Minister for the purpose. A voluntary patient is a person who, being 16 years of age or over, submits himself voluntarily for treatment for illness of a mental or kindred nature, or who, if he is less than 16 years of age, is submitted voluntarily by a parent or guardian.
It is the considered opinion of specialists engaged in the treatment of mental disease that to reduce the numbers in the mental institutions attention should be focussed on the treatment of early cases of mental disorder and that failure to make provision for the treatment of such cases must result in an increase of the numbers suffering from mental afflictions and requiring prolonged or permanent treatment in mental institutions.
The arguments already put forward in favour of the establishment of consulting rooms and clinics apply with equal force to the provision of facilities for the treatment of voluntary patients. Persons suspecting symptoms of mental or nervous disease should be encouraged to seek advice and treatment in the early stages before the disease is too far developed. It is essential, therefore, to remove all formalities such as certification and formal committal to mental institutions which are likely to deter or discourage patients from seeking treatment of their own accord. The Commission on the Relief of the Sick and Destitute Poor held similar views, as they wrote in their report:—
"By establishing a system of voluntary admissions persons in the early stages of mental disease would be encouraged to seek treatment at a time when it can be given with the greatest advantage. There can be no doubt that the objection to certification and to the idea of detention leads to postponement of skilled advice and treatment until the patient becomes obviously certifiable. The presence of voluntary patients would, we think, help in developing the curative function of the mental hospitals and in bringing about a healthier public attitude towards these institutions."
In the case of voluntary patients also the institutions approved by the Minister for reception of the patients may be general hospitals or mental institutions.
When an institution is being examined for the purposes of approval for the reception of voluntary patients the qualifications of the staff and the facilities proposed for the care and treatment of patients and the general suitability of the institution will be matters for consideration.
The Bill provides that when it is desired to have a person received into an institution as a voluntary patient application may be made to the person in charge of the institution by the parent or guardian, if the person is under 16 years of age, and in any other case by the person himself. The application must be accompanied by a medical recommendation which, in the case of a chargeable patient, must be furnished by the authorised medical officer.
When the application is made the person may be received into the approved institution and treated therein as a voluntary patient. The assistance officer may pay the reasonable expenses of conveyance to the institution in the case of a chargeable patient. Seventy-two hours' notice is required of the proposed departure from the institution of a voluntary patient not less than 16 years of age. Where a voluntary patient is less than 16 years of age the parent or guardian is entitled to remove the patient at any time after he gives notice of his wish to do so.
Special provisions in relation to persons received and detained in mental institutions in pursuance of reception orders are contained in Part XVI of the Bill. There is power to allow any such person to be absent on trial for specified periods and power to send a person of unsound mind to another institution for the benefit of his health or for treatment. One of the sections in Part XVI of the Bill to which I would like to draw special attention is Section 201 which empowers mental hospital authorities to board out in private dwellings persons detained as chargeable patients in district mental hospitals or other institutions maintained by them. This is the first time that statutory authority has been given for such boarding-out in this country.
Power to board-out in private houses has been availed of in Scotland for the past 80 or 90 years. In that country the proportion of boarded-out persons to the total is sometimes as high as one to five. In some areas the proportion has gone up to 39 per cent. Boarding-out is stated to be extensive in Norway where there are practically as many patients boarded-out as there are in mental institutions. In Norway the cost of maintaining persons boarded-out varies from 50 per cent. to 75 per cent. of the cost of maintaining them in institutions.
The Commission on the Relief of the Sick and Destitute Poor wrote on this subject in their report:
"The Lunacy Acts contain no provisions authorising the boarding out of the insane, and, therefore, no experiment in this direction has heretofore been possible. Whether a system of boarding-out could be successfully established is a question on which opinion is divided. Success would largely depend on the manner in which it would be worked, on the kind of guardians who could be got to receive patients, and on the attitude of the community. Where the local authority are prepared to try boarding-out, we think it should be permitted under the safeguards as to inspection which have been found necessary in other countries. It would be prudent in the beginning to board-out patients only in the neighbourhood of the mental hospitals where they could be visited at intervals by the medical officers and also seen by the inspector on his visits, a mode of boarding-out followed in some continental countries."
It is not possible to anticipate how far the system of boarding-out would be availed of in this country. At least one mental hospital authority has asked for legislation to permit of boarding-out. There should be a large number of patients in mental institutions who would be suitable for boarding-out and who would be much happier living in a private dwelling where they could enjoy the freedom and home associations not usually available to them when confined in a large institution controlled by stringent regulations.
Under Section 201 of the Bill boarding-out would be confined to persons who are not dangerous to themselves or others and who do not require treatment in an institution. The section makes detailed provision for the care, inspection and supervision of boarded-out persons.
Part XVI of the Bill also sets out the procedure for the discharge of patients from mental institutions. In this matter I would like to draw attention to Section 212, which empowers a mental hospital authority to direct any of their medical officers to visit, after his discharge from one of their institutions, any person for the purpose of giving him advice as to any mental treatment which he should undergo.
In regard to the recovery of the cost of maintenance and treatment in institutions maintained by mental hospital authorities the provisions of the Bill are similar to those in the Public Assistance Act, 1939. There is, however, in Section 222 a special power enabling a District Court to appoint a person to represent a patient for all purposes connected with proceedings to recover payment.
The powers and duties of the Inspector of Mental Hospitals as defined in Part XVIII of the Bill are similar to those already devolving on him.
There is little that calls for explanation in the concluding part of the Bill. This part deals largely with legal proceedings and penalties. The provisions as regards inquiries ordered by the Minister are set out precisely and in more detail than in existing enactments.
Section 262 relates to members of the Defence Forces who on retirement, relinquishment of commission, or discharge are certified to be of unsound mind. The section is a proposed reenactment of Section 2 of the Defence Forces (Temporary Provisions) Act, 1925, as amended by Section 8 of the Defence Forces (Temporary Provisions) Act, 1942. It is considered that this Bill is the appropriate one to provide for the matter dealt with in those sections.
The Bill does not deal with the law relating to criminal lunatics. Neither does it affect the law administered by the courts in connection with lunatics and their property. Section 272 expressly provides that the Bill shall not affect the powers exercised by the President of the High Court or a judge of the Circuit Court in this matter.
The Bill does not propose to deal with mental deficiency or mentally deficient persons, that is, persons who do not possess their full mental faculties and whose mental deficiency cannot be cured. This class differs entirely from persons of unsound mind who at some time possessed their full mental faculties but who through mental disease or illness have become mentally disordered. Such persons may recover after a period of treatment, either long or short, or their mental faculties may be permanently deranged.
The Bill before the House deals in a comprehensive way with the whole question of mental treatment. It represents the results of some years of study during which I have, in consultation with the officers of my Department, personally examined every conceivable aspect of the problems presented by mental disease. I confess to the feeling that the time and energy devoted to the work has been well worth while, and I hope the Bill that will emerge following our detailed discussions will embody a statutory code that will be well in advance of the corresponding provisions in the countries where legislation dealing with mental treatment is abreast of modern scientific thought.
