House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

Memorandum by MIND

PROVISION OF NHS MENTAL HEALTH SERVICES (MH 31)

INTRODUCTION

1. Mind is the leading mental health charity in England and Wales. We work for a better life for everyone with experience of mental distress by:

— Advancing the views, needs and ambitions of people with experience of mental distress;

— Promoting inclusion through challenging discrimination;

— Influencing policy through campaigning and education;

— Inspiring the development of quality services, which reflect expressed need and diversity;

— Achieving equal civil and legal rights through campaigning and education.

2. The Inquiry's terms of reference are very wide-ranging. We have therefore chosen in this evidence to concentrate on the first three listed issues only and, in each case, to focus on what we see as particular concerns in that area in the context of the Government's mental health strategy and, in particular, the current consultation paper on review of the Mental Health Act 1983. Thus:

(a) Our evidence in relation to definition deals with the issue of what should be the statutory criteria in any new Mental Health Act used to justify compulsory detention and/or treatment of those who have been given a diagnosis of some form of mental disorder and in particular whether or not the capacity of the detained person to take treatment decisions should be a relevant consideration;

(b) Our evidence on care in the community highlights the success of community interventions for those with severe and enduring mental health problems even at times of crisis. It stresses the need for a statutory right to an assessment of mental health needs as recommended by the expert committee appointed by the Government to advise them on reform of mental health law (the Richardson committee) and for a range of care, treatment and support to be available to meet these needs. It sets out Mind's concerns about the extension of compulsory powers proposed by the Government;

(c) Our evidence on the transition between the acute and secure mental health sectors highlights the over-representation at high security of black and minority ethnic patients; the inappropriate placement of many women in high secure settings and the continuing serious delays in transferring patients to lower levels of security.

DEFINITIONS

3. As indicated above, in this part of our evidence we concentrate on one specific aspect only, namely what should be the statutory criteria in any new Mental Health Act used to justify compulsory detention and/or treatment of those who have been given a diagnosis of some form of mental disorder.

4. Under the Mental Health Act 1983 a person can be compulsorily detained in hospital if:

(a) they are suffering from mental disorder of a nature or degree which either warrants their detention in hospital for assessment or makes it appropriate for them to receive medical treatment in a hospital; and

(b) detention is necessary for the person's own health or own safety or for the protection of others; and

(c) (where a person is being detained on grounds of having psychopathic disorder or mental impairment) the treatment proposed is likely to alleviate or prevent a deterioration of his condition.

5. In their current Green Paper the Government put forward the following criteria for use of compulsory powers:

— The presence of mental disorder which is of such seriousness that the patient requires care and treatment under the supervision of specialist mental health services; and

— The care and treatment proposed for the mental disorder, and for conditions resulting from it, is the least restrictive alternative available consistent with safe and effective care; and

— The proposed care and treatment cannot be implemented without use of compulsory powers; and

— The proposed care and treatment is necessary for the patient's health or the patient's safety and/or for the protection of others from serious harm and/or for the protection of the patient from serious exploitation.

6. In Mind's view, the overall effect of the Government's proposals would be to widen vastly the numbers of people who could find themselves subject to a compulsory order. Under the present system, the fact that compulsory treatment can only be used for those whose condition is sufficiently serious to warrant admission to hospital acts as a limitation. Under the new proposals that limitation is removed leaving all those in contact with the psychiatric system beyond the primary care level potentially subject to compulsion if they do not agree with the proposed treatment plan. This can perhaps best be illustrated by an example.

Ms A has been to see her GP because she is feeling very low and tearful and frightened at having suicidal thoughts. The GP is relatively inexperienced in mental health matters and, because of the mention of suicidal thoughts, refers her to specialist mental health services. Ms A is not keen on taking medication and would like access to talking treatment of some kind. The only talking treatments in the area have long waiting lists and the psychiatrist therefore only offers anti-depressants. Ms A does not want to go along with this and attempts to disengage from services and seek the assistance she wants elsewhere. Under existing law Ms A would not come within the scope of compulsory powers because there are no grounds for believing that she needs admission to hospital. However, under the government's proposals she could meet the criteria for a community order because:

(a) She has been referred to specialist services;

(b) taking medication is, in the doctor's view, necessary for her health and is the least restrictive alternative available other than doing nothing which the doctors argue would not be effective care;

7. The Government may argue that in practice the powers would not be used in such circumstances. However, it would appear to be both bad and dangerous legislative practice to extend the scope of such draconian powers wider than those to whom it is specifically intended they should apply.

Capacity as part of the test

8. One way of limiting the scope of compulsory powers which was recommended by the Richardson committee and is supported by Mind is the inclusion of capacity as part of the criteria for compulsory intervention. The Richardson committee recommended a higher threshold for the imposition of compulsion on those with capacity. They recommended that in such cases the grounds for compulsory treatment should be that "there is substantial risk of serious harm to the health and safety of the patient or to the safety of other persons if she/he remains untreated and there are positive clinical measures included within the proposed care and treatment which are likely to prevent deterioration or to secure an improvement in the patient's mental condition." The Government is seeking views on the merits of this alternative approach. Mind believes that, as is the case with physical health, there is no justification for allowing compulsory intervention on grounds of a person's health alone where they have the capacity to make healthcare decisions. If capacity is not included there seems to be a risk that people leaving hospital who would currently be free of compulsion will find themselves routinely subject to compulsory community orders on discharge "just to be on the safe side". Including a capacity test would therefore help ensure that community orders were confined to the high risk group at which they are really aimed.

9. Leaving aside the Mental Health Act, the general position in relation to medical (or other) treatment for adults aimed either to improve health or save life is that it can only be given with a person's consent even if a refusal risks permanent injury or premature death unless a person lacks capacity. Adults are presumed to have capacity but this is rebuttable. The test of capacity centres on:

(a) being able to comprehend and retain treatment information;

(b) being able to believe it;

Thus the law will not intervene if:

— (As in the case of Re C) a person with a diagnosis of schizophrenia refuses amputation of a gangrenous leg which doctors argue is necessary to save his life;

— A person refuses to take prescribed medication because it makes them feel sick or their hair drop out.

In these situations the law respects a person's autonomy.

If a person is found to lack capacity for whatever reason then medical treatment can be given in a person's best interests which are essentially determined by the clinical team.

10. Compare this with the situation in relation to mental health. Under the Mental Health Act 1983 the law allows a person's consent to be overridden regardless of capacity. The only safeguard, after medication has continued for three months, is a second opinion from a doctor appointed by the Mental Health Act Commission who will be concerned only with whether the treatment proposed is in accordance with good medical practice. The Government appears to propose that this should continue by retaining a person's health alone as justification for use of compulsory powers regardless of capacity. Take, for example, a person with a diagnosis of schizophrenia who takes the view that the medication which has been prescribed is dulling their perceptions and ability to function or having physical side-effects such as shaking or dribbling. They may decide that they prefer, say, to hear voices and find other strategies for coping with this than to suffer these side effects. Under the Government proposals such a person could be compulsorily treated with powerful anti-psychotics by a doctor who had a negative view of voice hearing and substituted their values for those of the patient. Indeed, the Green Paper specifically states that best interests should be determined by the professional opinion of the care team and not by the patient.

11. Mind believes that there is no justification for the continuing legal discrepancy in relation to medical treatment decisions between physical and mental health. In both cases, we believe that treatment should always require consent unless the person lacks capacity. Where the person does lack capacity then, subject to certain safeguards, treatment should be allowed in a person's best interests. Where they are capably refusing treatment and assessed as posing a high risk to others then compulsory detention may be justified on grounds of public safety where treatment is available (see paragraph 17 below).

12. It may be that Paul Boateng is right in this respect to say that the current Mental Health Act reflects a bygone age in that it assumes either that all people with mental health problems who are compulsory detained must lack capacity to take treatment decisions or at least that their views should be assumed to have less weight than the views of those responsible for their care. Research shows however, that most people with mental health problems are as capable as any other member of society of taking decisions about their lives. Mental health and incapacity are not inextricably linked, although there are times when mental health problems do affect capacity. The MacArthur Treatment Competence Study[2] found that:

— Patients hospitalised with mental illness more often showed deficits in their decision making performance compared with hospitalised medically ill patients and non-patient control groups. This was especially true for patients hospitalised with schizophrenia, and to a lesser extent for patients with depression;

— Nevertheless, the majority of patients hospitalised with schizophrenia performed adequately on any particular measure of decision making ability, and about half did well on all the measures combined. When patients with schizophrenia performed poorly, they usually had more severe psychiatric symptoms, especially disturbances of thought and perception (eg disorganised thinking and delusions). In contrast, decision making performance was not associated with simple demographic variables (eg age, gender, race) or other mental status variables (eg degree of anxiety);

— Patients hospitalised with depression showed intermediate levels of decision making performance, with about three quarters performing well on all measures combined. Patients with more severe depression did not necessarily perform more poorly than those with less serious depression;

— Medically ill patients, although hospitalised with a potentially life threatening condition, performed about as well as healthy persons in the community, although a small proportion of these patients did show some decision making deficits;

— When patients hospitalised for schizophrenia were retested after a two week period of treatment, substantial improvement in decision making abilities was observed for patients whose psychiatric symptoms had decreased in severity.

13. If Mind's approach were adopted clear definitions of both capacity and best interests would be required. Mind accepts the view of the Law Commission[3] that any definition of incapacity must be a functional one. In other words capacity must be assessed separately in relation to each type of decision. At any one time a person may have capacity in relation to one decision but not another. They may, for example, have capacity to buy goods in a shop but not to enter in to a more complex contractual arrangement such as a mortgage. Capacity must also be reviewed over time especially when dealing with fluctuating conditions such as mental distress. The focus of definition should not be on the content of the decision made (ie Is this decision sensible? Does this person accept my advice?) but on the process by which it was made (ie Does this person possess the ability to understand what this decision is about, to take in relevant information and use that information to reach a decision?) Mind supports the definitions of capacity and best interests proposed by the Law Commission as set out in Annex A.

14. The other issue here is whether compulsion is always justified to save a person's life. Attempted suicide ceased to be a criminal offence in 1961 and the law does not currently see fit to intervene in all situations where a person is putting themselves at risk of serious harm. For example:

(a) A person has the right to refuse a blood transfusion on religious grounds even if such refusal means inevitable death;

(b) A heavy drinker has the right to refuse to go for detoxification or stop drinking even though, without this, a doctor says they will die of cirrhosis of the liver within six months;

15. However, the Mental Health Act 1983 does allow a person to be detained and treated against their will if they are deemed to be suffering from a mental disorder and their safety is at risk whether from self-neglect or more active self-harm/attempts at suicide. Under the Government's proposals this justification would continue.

16. Mind again believes that the key issue here is capacity. As before, the question is, can the person understand and retain information relevant to the decision including information about the reasonably foreseeable consequences, and can they make a decision based on that information? For example, if a person is hearing voices telling them that they should kill themselves or cause themselves serious harm then they would not, in our view, meet the Law Commission's proposed definition of capacity because they would be making their decision as a result of an external influence and not based on relevant information. If, however, a person had weighed up all the relevant issues and been offered services to help, but still decided that their preferred option was to kill themselves then, difficult as that may be, their autonomy should be respected. That is not to say that every effort short of compulsory intervention should not be made to prevent this outcome.

Protection of others

17. It is important to state at the outset that a mental health diagnosis is not a predictor of violence and that there has in Mind's view been serious misreporting in the media of the risks represented by people with mental health problems. A recent report by John Gunn and Pamela Taylor[4] which analysed the data extracted from Home Office statistics for England and Wales between 1957 and 1995 and found that, despite media and public perceptions there had been little change in the number of homicides committed by people with mental illness. In fact, the research shows that since 1957 there has actually been a steady three per cent annual decline in the proportion of homicides committed by people with mental disorders. Nevertheless there will be occasions when people with mental health problems do present a risk to others and may not be prepared to accept treatment.

18. There are physical health powers based on imposing compulsion to protect others. The most obvious example is the Public Health (Control of Disease) Act 1984 which allows for the compulsory medical examination of persons suffering from specified notifiable diseases such as tuberculosis and for their subsequent compulsory detention (but, interestingly, not treatment) in hospital if they are likely to spread the disease in the event of being allowed to leave. In physical health these powers are the exception rather than the rule. For example, there are health conditions which, if not properly managed, can put others at risk. There was a case last year of a diabetic who did not properly manage his insulin and drove at a time when he was passing in and out of consciousness. As a result he mounted the pavement and killed two pedestrians. Yet no-one suggests that there should be compulsory treatment of diabetics. Is this because the risk of the spread of tuberculosis and other notifiable diseases is virtually certain whereas other types of risk are much less predictable?

19. The current Mental Health Act allows both compulsory detention and treatment on the grounds of protection of others. The Government not only propose that this should continue but propose extending its scope by removing any requirement of treatability. Under present law, there is a requirement for those detained under the categories of mental impairment or psychopathic disorder that the medical treatment proposed for them is likely to alleviate or prevent a deterioration of their condition. The Review Team similarly recommended that before confirming any long-term compulsory order in the case of a person with capacity the Tribunal would have to be satisfied that three were positive clinical measures within the proposed care and treatment plan which were likely to prevent deterioration or secure and improvement in the patient's mental condition. None of this appears in the Government's proposals. Under their scheme any one with a diagnosis of personality disorder would fall within the widened definition of mental disorder. If such a person were receiving treatment from specialist mental health services who concluded that although there were no positive interventions which could assist them they posed a risk to others and should therefore be kept in a secure setting they would appear to be able to be indefinitely detained. Why should this group alone be subject to a preventive detention regime when other groups which pose as high—if not higher risks—are not covered? Is this really the remit of mental health law?

CARE IN THE COMMUNITY

20. Mind does not believe that community care has failed. Where it has been properly funded and managed it has made the difference between wasted lives in institutions and opportunities for people to develop their own lives as they want and need.

Surveys consistently show that the public supports the principle of community care—although they rightly believe that it is not working well enough in practice because it is under funded. A Mind/Research Surveys of Great Britain (RSGB) survey in 1994 found 72 per cent of the public supported community care; most would be prepared to pay a little more in tax to make it work.[6] Mind is concerned that repeated claims of the failures of community care may suggest that it is somehow wrong for people with mental health problems to be in the community and add to the stigma and discrimination for this already excluded group.

21. Much of the debate around the future of community care is conducted in the light of tragic incidents highlighted by the media. It is therefore important to stress that a diagnosis of mental illness is not in itself a predictor of violence.[7] The factors associated with violence are being young and male (by age 31, one in 14 men born in 1960 had a conviction for violent crime);[8] and being under the influence of alcohol or drugs. Of the homicides studied by the National Confidential Inquiry into Suicide and Homicide by people with a mental illness 39 per cent involved people with a history of alcohol abuse and in 51 per cent alcohol was thought to have contributed to the offence. The figures for drug abuse were 35 per cent and 18 per cent.[9] Other studies show that in 66 per cent to 80 per cent of homicides, alcohol is involved.[10] As indicated in paragraph 17 above, a recent report by Pamela Taylor and John Gunn[11] found that, despite media and public perceptions there had been little change in the number of homicides committed by people with mental illness and that there had actually been a steady 3 per cent annual decline in the proportion of homicides committed by people with mental disorders. Despite this, a 1993 study found that two thirds of all media references to mental illness focussed on violence.[12] Users of mental health services are very distressed by their problems being constantly linked to danger in the public mind. A recent Mind survey[13] found that almost three quarters (73 per cent) of respondents felt the media coverage of mental health issues over the last three years had been unfair, unbalanced or very negative.

22. There are countless examples of successful community care projects across Britain—some of which are considered in detail below. All available evidence—nationally and internationally—shows that properly funded community care services work better than hospital care. Research of all comparisons between the two concluded that "no study found in patient care to be better on any variable.[14] A recent Sainsbury Centre survey[15] of the quality of care in acute psychiatric wards concluded that hospital care was a "non-therapeutic intervention". Key findings from their interviews with patients were:

— Inpatient care is unpopular;

— Wards lack many basic amenities. 55 per cent of patients had no separate bedroom, 71 per cent no secure locker for personal possessions and 47 per cent no quiet area;

— Many patients feel unsafe;

— Women are particularly dissatisfied—they are very concerned about privacy and cleanliness; and also about personal safety;

— Conditions are especially poor in deprived areas.

The report concluded that people's long term, underlying needs, and in particular their social needs, were not being met during their hospital stay.

23. Mind accepts that users of mental health services are not currently always receiving the support in the community that they need, want and deserve. Until recently there has been a particular gap in community care for people in crisis. There are however increasingly a range of projects aimed at supporting people in crisis and those who, for whatever reason, have in the past become disengaged from services and risked repeated admissions to hospital. Examples are:

Home Treatment in Birmingham

A home treatment and crisis resolution services operates within the Yardley and Hodge Hill area in inner city Birmingham. A team is available 24 hours a day, every day of the year to respond promptly to individuals in crisis. Team members visit people and support and treat them in their own homes. The home treatment service is not just concerned with responding to crisis but also resolving it. By this means unnecessary hospital admissions can often be avoided and families, where appropriate are more easily informed and involved. The service has produced:

— Reduced rates of hospitalisation;

— Greater compliance with treatment;

Bradford Home Treatment Service

The Bradford Home Treatment Service was established in 1996 by Bradford Community Health NHS Trust, in conjunction with Bradford social services to provide intensive support for people suffering acute mental health crises. A team made up of psychiatric nurses, social workers, support staff and medical input operates on a 24 hour, seven day a week basis. It is able to offer early intervention in time of crisis across a range of clinical problems and has developed its assessment and risk management skills.[17]

Hammersmith and Fulham Mind Assertive Outreach Service (Impact).

Impact aims to meet the needs of people with serious mental health problems who are very reluctant or refusing to engage with existing mental health services, often because they have found these services unhelpful or unacceptable. It aims to address these problems by using an assertive outreach approach to build relationships with clients, by working intensively, flexibly and continuously with them and by finding ways of actively encouraging user participation. The 10 staff aim to have a maximum caseload at any one time of about 60 clients. They also provide a limited 24 hour, 7 day a week telephone crisis service. Through monitoring and evaluation it has been shown that IMPACT has succeeded in engaging and maintaining contact with the client group most in need. It has intervened effectively to assist clients with their mental health needs and has generally been able to maintain a positive relationship with clients even when they have been admitted to hospital under the Mental Health Act. Staff have been very successful in assisting clients to increase their benefit entitlement, improve their accommodation and avoid them being made homeless, gain access to other services, and help develop social networks.

Partial Hospitalisation and Out reach at Home Scheme (POSH)

The Partial Hospitalisation and Outreach Support at Home (POSH) Team has been run by Pathfinder Mental Health Services NHS Trust since July 1997. The aim of this service is to provide a seven days per week, extended hours, intensive outreach and partial hospitalisation facility for those people who have serious ongoing mental health problems (and often co-occurring drug/alcohol misuse) who also manifest challenging behaviours. In their First Annual Report[18] covering the period 1 October 1997 to 30 September 1998 the Team report that of their 20 clients they have been unable to sustain the community tenure of only one client referred to them and, even in that cast, they were able to ensure his continuing engagement with services.

The Wolverhampton African-Caribbean Community Initiative.

The Government acknowledge in the Mental Health National Service Framework that for black people, who tend to be more critical of mental health services, home treatment is more acceptable than a hospital admission and there is better continuing engagement with services.[19] The Wolverhampton African-Caribbean Community Initiative is a voluntary led scheme developed in partnership with local health and social services, providing culturally appropriate support for black and minority ethnic service users. It provides day care, outreach services and supported housing for African-Caribbean's with mental health problems. The initiative often acts as a link between mainstream services and the African-Caribbean section of Wolverhampton's diverse community. Project workers and volunteers maintain contact with some people with serious and enduring mental health problems who otherwise might lose contact with services.

Hull and East Yorkshire Mind Crisis Service

Hull and East Yorkshire Mind provides a very successful three-tier crisis service which has been running since 1998. It consists of a crisis phone-line open between 4.30 and 9.30 Monday to Friday and 24 hours at weekends and Bank holidays. If it appears from the initial telephone call that a person needs face-to-face contact this can be provided at a night centre. Finally, there is a six bed safe house for those contacting the service who have nowhere else safe to go. The service is looking to develop links with NHS Direct in their area.

Rights to assessment and treatment

24. In their White Paper "Modernising Mental Health Services" and in the National Service Framework for Mental Health the Government have accepted the need for a better range of community care services and for more consistent availability of such services across the country. They have also made some additional resources available for this purpose. However, they have rejected the call from a number of mental health organisations for a new Mental Health Act to create a right of access when required, to prompt, effective and high quality care. This right had two parts:

(a) A right for a person to have their needs assessed;

(b) A right for a person to receive appropriate services to meet their assessed needs.

A right to assessment

25. Mind believes that the opportunity of a new Mental Health Act should be taken to give people a right to have their mental health needs assessed. Although there are already duties to carry out assessments of a person's community care needs imposed on health and local authorities under the NHS and Community Care Act 1990 these do not amount to an individual, enforceable right to assessment and treatment. Nor do they seem to be effective in ensuring that people with mental health problems get access to appropriate services when they need them. Mind is aware of many people who have been turned away when they ask for help for their mental health, only to be subjected to compulsory detention and treatment when their mental health deteriorates further.

Like many people I have had experience of asking for in-patient treatment, not having either an assessment or my request granted and subsequently having to be compulsorily detained. (MindLink member responding to questionnaire on Mental Health Act reform).[20]

In a survey by the National Schizophrenia Fellowship, over one in three people (35 per cent) had been turned away when seeking help.[21]

26. The Richardson Committee considered this issue. They concluded that in view of the evidence they had received from users, carers, mental health practitioners and the police about the difficulties in gaining access to the necessary services there should be a right to assessment of mental health needs which would apply to those in contact with services who might, for example, believe that their condition is deteriorating, and to those known to services who believe that they need such an assessment. They envisaged that the right would give rise to a public law duty on the relevant authority.

27. The creation of such a right has strong support among users of mental health services. In December 1998 Mind surveyed its networks for their views on the review of the Mental Health Act—service users and survivors, black and minority ethnic individuals and groups, local Mind associations, individual members and rural and legal networks. Ninety-six per cent of respondents wanted a right to assessment.

A right to treatment

28. Although still welcome a right to assessment is clearly only of limited value if it is not supported by a right to receive appropriate treatment to meet assessed needs. In Mind's 1998 survey referred to in the previous paragraph 93 per cent wanted a right to treatment enshrined in legislation.[22] In the National Schizophrenia Fellowship's consultation 69 per cent ranked the legal right to adequate care and treatment as the biggest improvement that could be made in a new Mental Health Act.[23]

29. The Richardson Committee expressed the view that as part of the right of assessment there should be a duty to keep a register of unmet need. This could then be used to assist in the planning of future service provision. They considered the issue of whether a new Mental Health Act should confine itself to establishing a framework for compulsory hospitalisation and treatment of certain people with mental health problems or whether it should also deal with questions of service quality and provision. They concluded that the narrower remit was more appropriate and that service development issues were being dealt with through other avenues such as the National Service Framework and the National Institute for Clinical Excellence.

30. Mind would argue that the questions of compulsion and service provision are in fact inextricably linked. As indicated above, people end up subject to compulsion because of the lack of available services to meet their needs and this is a key difference between physical and mental health which justifies different legal entitlements. The proposed extension of compulsory treatment to a community setting makes it particularly important that there is a range of services available to meet the needs of people with mental health problems in the community. These are not only health needs but also such needs as proper accommodation, benefits advice, employment or other occupation and assistance at home. Without such a mechanism there is a risk that people will be forced to take unwanted medication within the community merely because the type of support they want and need has not been made available.

31. In 1995 Mind supported a private member's bill introduced by Tessa Jowell MP—the Community Care (Rights to Mental Health Services) Bill. This would have entitled people living in the community who were, or had been, in touch with psychiatric services to comprehensive community health care services including supported accommodation, crisis services, medical services, counselling, practical assistance in the home and facilities for training, recreation and employment. The Bill was supported by a range of organisations including the Association of Metropolitan Authorities, the Association of County Councils, the Royal College of Nursing, the Mental Health Foundation, the Mental After Care Association, the Association of Directors of Social Services, the Association of Community Health Councils for England and Wales, Mental Health Media, Unison and Survivors Speak Out. In Mind's view, the lack of such and entitlement undermines the development of a comprehensive mental health service. The National Service Framework for mental health would have more impetus if it were backed up by a duty to respond to individuals' requests for help and to meet assessed needs from a full range of services.

Community Treatment Orders

32. Another key strand of the Government's mental health strategy is review of the law to allow the introduction of compulsory treatment in the community. Mind (together with a range of other organisations—see attached leaflet) is concerned that this will undermine the development of comprehensive and high quality community care. Care in the community is not just a question of transferring hospital-based care in to the community. It requires a much more comprehensive and user-centred assessment of a person's needs. Mind has concerns about community treatment orders because we believe that they will:

— Drive people away from services;

— Be ineffective in achieving the Government's aim of greater public safety;

— Discourage the development of a wider range of services and encourage over-reliance on drug treatment alone;

— Be applied disproportionately to black people;

— Make it more difficult for service users to have their views heard especially in the absence of any right to independent advocacy.

Details of all these concerns are set out in the attached leaflet.

The transition between acute and secure mental health sectors.

33. Mind has two particular concerns about high secure services which we would wish to draw to the attention of the committee. These are:

(a) The numbers of people in high secure care who do not need that level of security—estimated to be between a third and a half of the current high secure population;

(b) The over-representation at the highest levels of security of black and minority ethnic patients.

Inappropriate security levels

34. Two issues arise here:

(a) The inappropriate placement of people—especially women and people with learning difficulties—in high secure provision at all;

(b) The delays in transferring people from high secure provision once they have been assessed as no longer needing that level of security.

Inappropriate placement

35. Over 26 per cent of women patients compared with 9 per cent of men patients in high secure hospitals are detained on a civil order under the Mental Health Act and their detention is not linked to any prosecuted criminal offence. In 1996 the NHS gave a conservative estimate the 78 per cent of women in high secure required medium secure and 69 per cent in medium secure only required low secure provision. These problems are made worse by the inadequacies of the regimes at both high and medium secure level in meeting the needs of women patients. Reed[24] looked at services for women as part of his review of services for mentally disordered offenders. He stated: "In male-dominated environments, women's needs, including their more personal female needs, are liable to be overlooked. They are sometimes subject to sexual harassment and other demeaning behaviour." He recommended that positive action was needed to deal with these problems. Depressingly it is clear from the most recent report of the Mental Health Act Commission (MHAC) covering the years 1997-99[25] how little has changed. They report: "The hospitals continue to operate in a predominantly male culture and as a consequence women's special needs can be overlooked."

36. Mind believes that there needs to be distinct and entirely separate structure of secure psychiatric services for women modelled around their own care needs. As recommended in a report last year from Women in Secure Hospitals (WISH)[26] the strategy for this service "should be informed not only by clinical needs assessments of women patients but also by gender issues, the social and economic context of women's offending and mental distress, and by listening to women patients and taking their views into account."

Delays in transfer

37. In 1998 the UK was held to be in breach of the European Convention in the case of a patient who continued to be held in a high secure hospital for three years after he had been assessed as no longer suffering from a mental disorder but for whom no hostel place was found as directed by the Mental Health Review Tribunal. The patient was awarded damages of £10,000 plus costs.[27] In their most recent biennial report the MHAC noted that "delays in the transfer of patients out of the high security hospitals continue to remain a very significant problem, the principle contributory factor being the national shortage of medium and long-term secure places." They reported an estimated 200 patients at Ashworth who did not require high levels of security; 112 patients at Broadmoor progressing towards transfer or discharge some of whom had been under consideration by the Home Office for five years; and "many instances of patients being obliged to remain at Rampton despite recognition by clinical teams, and the decisions and recommendations of Mental Health Review Tribunals, that they no longer require the level of security provided by that hospital".

38. As the MHAC points out not only are these patients affected by severe and clinically unwarranted curtailment of their liberty they are also blocking beds which may be urgently needed for others who may otherwise be trapped in an inappropriate prison environment. Mind believes that urgent action is needed to address this situation.

Over—representation of black and minority ethnic patients

39. The psychiatric and criminal justice systems both tend to exert excessive control over black people. Black people, as patients, are likely to receive more controlling treatments and as "mentally disordered offenders" are more likely than white to be detained in higher degrees of security for longer. A recent study in South London found that black populations had a rate of admission to medium-secure care 7-fold higher than their white counterparts: 28 per 100,000 population compared to 4 per 100,000 for white people.[28] In 1998 the breakdown of patients classified by ethnic group in the three high security hospitals was as follows:


Rampton
White	352	(83%)
Black Caribbean	65	(15%)
Black African	3	(1%)
Pakistani	6	(1%)

Ashworth
White	389	(82%)
Black Caribbean	30	(6.5%)
Black African	7	(1.5%)
Black Other	31	(7%)
Indian	7	(1.5%)
Pakistani	3	(0.5%)
Chinese	1	(0.5%)
Other	1	(0.5%)

Broadmoor
White	347	(79%)
Black Caribbean	57	(13%)
Black African	10	(2%)
Indian	4	(1%)
Bangladeshi	1	(0.5%)
Chinese	2	(0.5%)
Other	8	(2%)
Not known	8	(2%)

This compares with census data showing white people making up 94.5 per cent of the population and Black Caribbeans 0.9 per cent.

40. There is also, as with women, an issue about the inappropriateness of services. The MHAC in their seventh biennial report covering the years 1995-97 stated: "Race and culture remains a matter of particular concern at the High Security Hospitals. Adverse comments have been made about the standard of ethnic food, apparent unconcern on the part of staff at racist remarks by patients and the inadequate representation of ethnic minorities among staff." Mind believes that more culturally appropriate services need to be developed as a matter of urgency and that better training needs to be provided to all staff on race and culture issues. Steps also need to be taken to challenge the cultural assumptions that may be leading to over-representation of these groups at high levels of security.

Mind

February 2000

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