I move that the Bill be now read a Second Time.
Before I deal with the Bill proper, I would draw attention to a printing error which crept into page 4 of the explanatory memorandum as circulated with the text of the Bill. Deputies doubtless will have noted it when reading paragraph 9 of the memorandum. The sixth line of that paragraph is clearly an intrusion, which in the context does not make sense. It is in fact an accidental repetition of a line, the proper place of which is 9th from the bottom of the page, where in fact it correctly appears.
The purpose of the Bill is two-fold: it proposes in the first place to make some desirable, but not fundamental changes in certain of the provisions relating to patients which are contained in the Mental Treatment Acts; and in the second, to bring mental hospital staffs within the general scope of the Local Government (Superannuation) Act, 1956.
The Mental Treatment Act, 1945, introduced what were then fundamental and far-reaching changes in the law in regard to the care and treatment of people sufferng from mental illness. I think we can reasonably claim that its provisions were, at the time of its enactment, in line with what was then progressive thought in regard to the mentally ill. The intervening period has, however, been a time of considerable change and development in psychiatric thought, because of which I propose to institute a comprehensive examination into our provisions for the treatment of the mentally ill.
In our district mental hospitals at present, we have more than 19,000 patients. Our aim must be to cure, as speedily as is possible, as many of these as is possible. Many, of course, at the present level of medical science, are not capable of cure and must be retained in custodial care. But the outlook for very many others is much more hopeful. They can be cured, or their condition may be sufficiently ameliorated to permit them to return to their homes, their families and their friends. Many, however, who could otherwise be discharged with advantage to themselves, have no relatives who will accept them and no homes to go to—and these must be provided for otherwise. Up to the present very many such cases have been retained in the mental hospitals where they contribute greatly to the present overcrowding, thus impeding the treatment of other patients and retarding, even, it may be, preventing their recovery.
The problem, of course, does not end with the 19,000 patients at present in the hospitals. New cases are coming forward daily and have to be dealt with. Very many of these are suffering from disorders that are now susceptible to treatment, and these may be either completely cured or, at worst, be considerably alleviated. It is most important that patients in these categories should not be retained longer in hospital than is necessary. Indeed it should be the aim of those responsible for our mental health services to keep out of custodial or even therapeutic institutions as many as is feasible of those who may be suffering from mental illness—with due regard, that is, to the interests of the patient himself, his family and the community. With this in view, there is now an increasing emphasis on out-patient treatments; which may be given in general hospitals, at clinics, or even in specially provided psychiatric day hospitals to which the patient goes each day, returning each evening to his home. This is a concept which was scarcely thought of, even so recently as a decade or two ago, when treatment was generally regarded as being secondary in importance to custodial care.
We have made very considerable advances in health matters in the period I have mentioned. Our general hospitals, on the whole, bear comparison with similar hospitals anywhere as regards staffing, facilities and structure. We have done much to improve specialist hospitals, so that, to mention only two specialties, our T.B. sanatoria and our orthopaedic hospitals are now of the highest standard. The facilities in such homes for mentally handicapped as exist are likewise good—the difficulty is that we have not enough of them to cater for those needing care. Our homes for the chronic sick, the county homes, are not good; but at least we are getting down to the problem of improving them on a nationwide comprehensive scale.
Regrettably, we have as yet no such programme for the mental hospitals. It is true that major improvements have been carried out in a number, and these are now of reasonable standard; but the general picture is one of overcrowding and inadequate facilities. Much more extensive improvements than have been attempted up to the present are necessary and will be undertaken with all the speed that our resources and the competing demands on them permit. In the meantime, as I have said, the advances in psychiatric medicine, which have taken place since the Mental Treatment Act of 1945 was enacted, justify an investigation into our existing facilities for the treatment of mental illness, so I am setting up a Commission of Inquiry to undertake it. It will be the first comprehensive examination of the problem in this country to be undertaken in the light of modern knowledge.
The work of the Commission will be complementary to the work of the Commission on the mentally-handicapped which has just been set up, and the two Commissions will, I hope, work in close conjunction. It may be said indeed that their investigations, starting from opposite ends of the wide spectrum of mental infirmity, will ultimately overlap and merge. This may involve some problems in the reconcilement of their respective recommendations; from which it might be argued that the problems could be better examined by one commission rather than two. But when all its aspects are considered, the field to be covered is so wide, that if it were to be examined in detail by a single commission, the labour of that body might be unduly prolonged, and the benefits which should accrue to afflicted persons from developments in mental therapeutics might be unduly deferred. In these circumstances, I decided that the advantage lay with the establishment of two commissions. The establishment of the new Commissions will not, of course, operate to defer the carrying out of improvements in the existing hospitals.
While a comprehensive review of the entire position in regard to the mentally ill is proceeding, it would be inappropriate that I should propose any radical amendment to the Mental Treatment Act of 1945. Experience has shown, however, that it is very desirable in the interim to make some minor changes in those of its provisions which regulate or prescribe the procedures for the certification, chargeability, custody and registration of patients; and these are proposed in this Bill.
Unfortunately, this procedure involves a good deal of "legislation by reference"; and this no Deputy any more than myself welcomes, involving, as it does, the need for reference back to an original provision which, itself, may have been amended already. The explanatory memorandum circulated with the Bill should be of help to Deputies in that connection. More recently, however, following discussion in my Department, it was felt that it would be desirable to publish eventually a booklet setting out the procedure in relation to the reception and detention of patients and quoting the relevant statutory provisions as they will be amended if this Bill is passed. A preliminary draft of that booklet is available now to Deputies. I trust that not only will it obviate much of the labour of looking up the parent sections, but that it will give a better picture of what the code will look like if the amendments now proposed are accepted by the Oireachtas. The value to Deputies of the draft booklet will, of course, be greatest when the Bill is being considered in Committee and on its later Stages.
There is one respect in which the booklet will not be of value. It does not cover the superannuation provisions. These are explained in detail in the explanatory memorandum already circulated with the Bill.
The principal change which the Bill will make in relation to patients is the extension to all medical practitioners of the power to make a recommendation, or to sign a certificate, in respect to the admission of a chargeable patient to hospital. This extension is provided for in Sections 6 to 12, and in Sections 16 and 19. A chargeable patient is, broadly, a patient in a local authority hospital who is in the lower or middle income group and is, therefore, eligible for hospital service free, or at less than the full cost. At present, whenever a recommendation or certificate is required for such a person, only the authorised medical officer can provide it; and he normally is the district medical officer of the dispensary district where the patient resides.
The effect of this restriction is to preclude a patient, or his relatives, from availing himself of the services of the family doctor, should he not be the local district medical officer; in this way, it debars the majority of doctors, including psychiatric specialists, from providing their patients with the necessary certificate or recommendation. I am satisfied that this disability should be removed and that the power to make a recommendation, or sign a certificate for reception, in the case of a chargeable patient should be conferred on all medical practitioners, subject, however, to certain disqualifications— grounded mainly on relationship to or financial interest in a patient.
Section 3 gives the Minister power to make regulations authorising the making of payments to patients in respect of work done. There is at present no specific statutory power for this, although, in practice, payments are made in some places. In general, I visualise the making of token payments to encourage patients and to offer them an incentive to occupy themselves usefully, that is to say therapeutically.
Section 9 is intended to operate in cases where it is believed that a person is of unsound mind and, as a matter of urgency for the public safety or the safety of the person himself, should be placed under care and control. It puts beyond doubt the power of a member of the Garda Síochána to enter upon premises and to take into custody such a person and to bring him, if necessary, to a Garda Síochána station. This is a power which should, of course, be used in very exceptional circumstances only. It is true that Section 165 of the 1945 Act, as it stands, may be construed as conferring it. Nevertheless, in view of the fundamental right which is involved, it is desirable to remove any possible doubt as to the legal position.
Under the existing code, whenever it is desired that a patient should be admitted to hospital for detention otherwise than as a temporary patient, the applicant must be at least 21 years of age. There is no such restriction in the case of an applicant for the reception of a temporary patient whether chargeable or private. As it is desirable that nobody should be compulsorily detained in a mental hospital otherwise than on the application of a mature person, it is proposed that the age restriction which I have mentioned should apply also to applicants for the reception of temporary patients. Provision is made accordingly in Section 16 in relation to chargeable patients and in Section 17 in relation to private patients.
In addition, Section 17 will remove an inconsistency in the code. The whole basis for the reception and detention of patients is medical certification; but, at present, the reception order in the case of a temporary private patient is made by the person in charge of the private hospital concerned, and he may happen not to be a doctor. The section provides that, in future, in all cases the reception order must be made by a registered medical practitioner.
The change proposed in Section 18 is an important one. The section transfers from the Minister to the chief medical officer of the institution concerned the power to extend the period of detention of a temporary patient. Such a patient is, broadly, a person who is believed to require for his recovery not more than six months' suitable treatment, or an addict who by reason of his habits should be detained for his own sake in a mental institution for a limited period. At present the initial period of detention is six months. Under the 1945 Act, power is vested in the Minister for Health to grant extensions of this period up to a total of 18 months; so that in the case of a continuing temporary patient, the unbroken period of detention cannot exceed two years. In the case of an addict, though the period of detention can be extended to two years, it has been my practice, and the practice of my predecessors, not to grant extensions beyond a period of one year. The practice is based on the belief that if his addiction is not successfully treated within 12 months, there is little prospect that the addict will ever overcome his propensity. In asking the Oireachtas to transfer the power to grant an extension to chief medical officers, I propose, under subsection (1) (a) (i) of Section 18 that, in the case of an addict, it should be restricted to an extension or extensions not exceeding six months. In the case of persons other than addicts, extensions up to 18 months may be granted.
This House has always been, and very rightly so, extremely jealous in guarding the liberty of the subject and, before deciding to transfer from the Minister to the chief medical officer the power to grant an extension, I gave very careful consideration to the question of the extent, if any, to which in doing so I might be withdrawing a safeguard on the freedom of the individual. It will be appreciated that in deciding whether or not to grant an extension of the period of detention of a mental patient, the person who happens for the time being to be Minister has to rely on his professional advisers. In view of the number of extensions involved—about 3,000 per year at present—they in turn have to rely, to a very large extent, on the recommendation of the chief medical officer of the mental institution concerned; for it will be by sheer and rare accident that they will know the patient qua patient. Even in the exceptional case where they may remember having seen the patient, it will usually have been once or twice only and for short periods. Very, very rarely can they be in a position, from their own knowledge of him, to decide whether he should or should not be detained. While in practice all applications are carefully considered, invariably the word of the chief medical officer of the institution has to be accepted and the extension granted. It will be appreciated, therefore, that the present procedure provides very little, if any, real safeguard.
The new procedure which the Bill proposes to substitute for that now in force will, I suggest, not only preserve every possible existing safeguard but will constitute a more effective protection for the patient. Under it the patient and the person who applied for the original reception order must be advised that they can send to the Inspector of Mental Hospitals an objection to the proposed extension. On receipt of such an objection, the Inspector of Mental Hospitals will be obliged to call on the medical officer of the institution to submit a full report on the patient. If, on consideration of this report, the Inspector has any doubt regarding the propriety of the detention of the patient, he must visit the patient, possibly several times, and take such other steps as he may consider necessary to satisfy himself on the matter. If, having done all this, he still feels that the patient is improperly detained, he is obliged by Section 239 of the Principal Act to report this fact to the Minister, who, on the basis of all the considerable information then available, will decide whether or not to discharge the patient. Furthermore, paragraph (b) of Section 33 imposes a duty on the inspector, on the occasions of his statutory visits to mental institutions, to pay particular attention to the condition of those patients in them whose periods of detention have been extended since his previous visit.
Another important change, similar to that contained in Section 18, is contained in the section on repeals. Sections 197 and 202 and subsection (4) of Section 208 of the 1945 Act provide for the submission to the Minister of a mass of documents. Under the sections, notices of all receptions, departures, escapes, removals and deaths have to be submitted to the Minister. In the case of temporary patients and persons of unsound mind, copies of the reception documents and a report on the condition of the patient 21 days after his reception have also to be submitted. In all, this prescription applies to something like 38,000 documents each year. The requirement is one that has obtained in this country since the middle of the last century. In the circumstances of the times, it was probably assumed to be a safeguard against improper detention. Therefore, when these documents reach my Department, they are examined closely to ensure that the facts recorded on the forms create a prima facie justification for the acts to which the forms relate. But since the patient is not examined by my professional advisers, this routine scrutiny of documents cannot ensure that the statements made on the forms are accurate, or that any diagnosis made is correct. As a safeguard to the patient the value of the whole procedure is, in fact, so limited as to be negligible, and I am satisfied that its continuation is not warranted. I may say that a similar conclusion was reached by an expert committee of the World Health Organisation— Technical Report Series No. 98—and by the recent British Royal Commission on the Law Relating to Mental Illness and Mental Deficiency.
On the other hand, there are in the Mental Treatment Acts real safeguards against the improper detention of patients. Among them are:
1. The right which every patient has to have a letter forwarded, unopened, to any of the following: the Minister, the President of the High Court, the Registrar of Wards of Court, the Mental Hospital Authority and the Inspector of Mental Hospitals. In Section 36 of the Bill, the Oireachtas is being asked to add to these the Visiting Committee of a district mental hospital. Arising out of any such letter, the Minister may arrange for an examination of a patient by the Inspector of Mental Hospitals and for his discharge where justified; while similarly the President of the High Court may require the Inspector to visit and examine any patient detained and report to him.
2. The fact that any person may apply to the Minister for an order for the examination, by two medical practitioners, of a detained person and that the Minister must consider their report and may, if he thinks fit, direct the discharge of the patient.
3. The fact that the law specifically requires that a person who has recovered must be discharged.
4. The penalties which are imposed by the Act for detention otherwise than in accordance with the provisions of the Act.
5. The provision that the Inspector of Mental Hospitals must visit all mental institutions and that where the propriety of detention is doubtful, or where he is requested to do so by the patient himself, or by any other person, he has a duty to give special attention to the state of mind of any patient detained.
6. That any relative or friend may apply for the discharge of a patient and that, should the application be rejected by the medical officer of the institution on the certified ground that the person is unfit for discharge, an appeal lies to the Minister.
7. That every mental hospital authority must appoint a visiting committee, whose duties include a requirement to hear the complaints of any patient, and if requested to do so, to see him in private.
I think that the House will agree that in removing the necessity for the submission to my Department of a great number of useless documents, I am not in any way increasing the risk of improper detention of any patient.
Sections 19 and 20 dispense with the requirement for a medical recommendation for admission of the patient to a mental institution in the case of a voluntary patient, except in respect of a person under the age of 16 years. I consider that a person over that age, who feels that he should enter a mental hospital as a voluntary patient, should not be unduly discouraged by formal procedures, and that in such a case the requirement that a medical recommendation should be produced may be dispensed with.
The purpose of Section 21 is similar to that of Section 13, viz. to provide that a reception order shall be valid irrespective of the place of ordinary residence.
Section 22 and Sections 26-30 transfer to the resident medical superintendent of a district mental hospital the functions hitherto vested in the manager in relation to the release of patients on trial, to the giving of notices of recovery and to the discharge of patients. I think that on consideration it will be generally agreed that the resident medical superintendent should be in a better position than the manager to exercise these functions. He knows the patients and should be in a position to decide, from his own expert knowledge, whether it is appropriate that the particular patient concerned should be allowed out on trial or discharge. Similarly, it is proposed to transfer from the Inspector of Mental Hospitals to the person in charge, functions in relation to the release of a patient for a trial period—initially not exceeding 30 days—from a private mental institution. The inspector will seldom, from his own knowledge, be in a position to say whether a patient should, or should not, be released on trial. It is also proposed that, in a private institution where the person in charge is not a doctor, any notice of recovery must be given by a doctor.
Section 31 gives a health authority a specific power, though subject to the sanction of the Minister for Health, to arrange for the after-care of patients. At present, apart from the very limited powers contained in Section 223 of the 1945 Act, regarding the visiting of a patient by a medical officer after discharge, there is no specific power in regard to the after-care of patients. The organisation and development of an after-care service under the Section should permit the earlier discharge of patients and, in many cases, obviate the necessity of re-admission.
Apart from those I have mentioned, the provisions in the Bill which relate to patients are mainly of a consequential, technical or administrative nature. I do not think any major principle is involved in any of them; and I would suggest that it would be more appropriate to deal in Committee with any points which may be raised on this Stage in regard to them. So much for patients.
I have already indicated that the main purpose of the superannuation provisions is to bring mental hospital staff within the general scope of the Local Government (Superannuation) Act, 1956. They will also transfer, from the Minister for Health to the Minister for Local Government, functions in relation to the superannuation of that staff.
The Mental Treatment Act, 1945, and the Asylum Officers Superannuation Act, 1909, govern the superannuation of mental hospital staffs and under these Acts functions appertaining to the code are exercised by the Minister for Health. The superannuation of all other local authority staff (with the sole exception of staff employed by harbour authorities) is governed by the Local Government (Superannuation) Acts—in particular the Local Government (Superannuation) Act, 1956—for which the Minister for Local Government is the appropriate Minister. With the exception of mental hospital staff, all staff otherwise engaged on health duties come within the scope of these Acts. Since the coming into operation of the Health Authorities Act, 1960, and the abolition of mental hospital authorities as such, it is, I submit desirable to end the present anomalous position under which two separate superannuation codes are being applied to the two different groups of officers and servants engaged in the health services. Accordingly the Bill provides, by Section 41 and the First Schedule, that mental hospital staff shall be brought within the framework of the code relating to local authorities generally, with the Minister for Local Government as the appropriate Minister.
In the application of the Local Government code to mental hospital staffs, however, it is necessary to make a modification to reflect the special position of mental hospital personnel who have the care or charge of patients in the normal course of their duties. In the Bill it is proposed to apply to them the same provisions as already apply to fire brigade officers and servants. The effect of these provisions will be to continue the arrangement under which in the calculation of superannuation, each year of service in excess of twenty will count as two, and retirement is possible at the age of 55 instead of at the age of 60.
To preserve certain rights of existing officers in the mental health service, however, it is proposed to make a number of special provisions. At present mental hospital staffs pay a 3 per cent. superannuation contribution and other local authority staffs first appointed on or after 1st April, 1948, pay a higher contribution—5 per cent. for officers and 4 ? per cent. for servants. It is proposed that any existing officer or servant in the mental hospital service will not be required to pay a higher contribution than 3 per cent. during such time as he continues to be employed in the local authority service. Furthermore, staff who are now in the service and who have the care or charge of patients in the normal course of their duties and are subject to the superannuation provisions of the 1945 Act, have the benefit of an existing provision which enables a superannuation award to be made to the widow and/or orphan of a person dying in the service from any physical or mental illness contracted in the service —not necessarily in the course of duty. Under the Local Government code, such awards can be made only if death results from injury sustained in the course of duty. The rights, which existing officers and servants enjoy under the 1945 Act, are thus being preserved under the Bill. Officers and servants, however, who are still governed by the 1909 Act have not the right to which I have just referred, as they opted out of the superannuation provisions of the 1945 Act. Under the Bill, however, they are being afforded a second opportunity of acquiring it.
Detailed discussion of the very complicated superannuation provisions is a matter for Committee Stage but it may be convenient if I put on record now the main respects in which, as I see it, mental hospital staffs, present and future, stand to gain or to lose under the present proposals——
I propose to enumerate, first the main gains. These may be summarised as follows:—
1. Allowances and lump sums will be calculated, normally, on the basis of remuneration at the date of retirement and not, as at present, on the basis of an average remuneration over a period of 3 years.
2. If an officer or servant sustains an injury, in the course of duty, and he dies, within 7 years, as a direct result of the injury, a gratuity or allowance may be paid to the widow or widower, as the case may be, to a dependent father or mother and to, or in respect of, dependent children. Under the mental treatment code the position is, broadly, that not only must death occur in service, but gratuities, or allowances are payable only to widows and children and not to widowers or to dependent parents.
3. A short service gratuity will be payable after 1 year of service. A minimum qualifying period of 10 years is necessary under the 1909 Act and of 5 years under the 1945 Act.
4. An allowance and lump sum will be payable, on reaching an age limit, after 10 years' service. The qualifying period under the mental treatment code is 20 years.
5. In the case of officers added years for superannuation purposes may be granted in accordance with the provisions of Section 13 of the Local Government (Superannuation) Act, 1956. The chief advantages of these provisions are that years may be added in respect of professional qualifications, in respect of temporary service immediately preceding permanent service and in cases where the officer retires due to an age limit imposed after his appointment.
6. Superannuation benefits will be payable to servants who are not continuously employed but who work more than 200 days, in a year.
The items on the debit side I should emphasise apply to future entrants only. They are, I think, two in number.
The first is that future entrants will have to pay the normal Local Government superannuation contribution, 5 per cent. for officers and 4? per cent. for servants as against a flat 3 per cent. as at present.
The second is that future entrants will be eligible for allowances for widows and orphans only if death is due to injury sustained in the course of duty, and not, as at present in respect of death in service, whether it is due to injury or not.
I have not listed as a credit or a debit the fact that future servants will be superannuated on the basis of sixtieths with no lump sum as against the present eightieths plus a lump sum. According to the circumstances of the individual concerned, it could be either.
In general, I am satisfied that the new provisions will be more advantageous than the present ones for existing staff. In case, however, any officer or servant may feel that the existing provisions are more favourable in his particular case, he will have the option of deciding, within 12 months of the coming into operation of Section 41, that the new provisions shall not apply to him—and that instead he shall remain as he is while he continues to be a mental hospital officer or servant. It is my intention, in due course, to have a detailed memorandum prepared in language as simple as so complex a subject permits, setting out the differences between the two codes, so that each officer and servant can decide for himself whether he wishes to exercise his option to remain subject to the provisions which at present apply to him.
Section 40 covers the position of a person who was a civil servant, before a mental hospital officer, and then became a civil servant for a second time. The section is designed to remove a doubt as to whether his first period of service in the Civil Service can now be reckoned for superannuation purposes.
It will be noted from Section 43 that the provision in regard to superannuation shall come into operation on the 1st day of April. This requirement is necessary to keep these provisions in line with those in the Local Government (Superannuation) Act, 1956. It is my hope that it will be possible to have this Bill enacted in time to bring into operation, on 1st April next, the special provisions contained in the Local Government (Superannuation) Act, 1956, in relation to servants who are not continuously employed, but who work for a minimum of 200 working days per year.
There is one further point which I think I would like to mention. Most of the proposals for amendment of the superannuation provisions are contained in the First Schedule. The Bill was drafted in this way solely in order to avoid what could otherwise have been a very clumsy section containing sixteen subsections. On Committee Stage I shall be fully agreeable to whatever latitude the Chair may be prepared to allow to ensure that the many provisions contained in it be debated in as much detail as is desired.
I have already suggested that this Bill is one more appropriate for detailed discussion on Committee Stage than on Second Stage, and I trust that the Dáil will agree with that view. Before the Committee Stage, which I propose to suggest should not be ordered for a date less than a fortnight hence, I shall give careful consideration to any views which may be expressed in the course of the debate or to my Department later. If I cannot meet Deputies in relation to the matters they raise, they will still have the opportunity of tabling their own amendments, and these can be debated in detail in Committee.
