APPENDIX 5
Letter from the Director, Zito Trust,
to the Clerk of the Committee (MH 17)
I am writing on behalf of The Zito Trust to submit
evidence to the Health Committee's inquiry into the Provision
of NHS Mental Health Services.
The Zito Trust is a registered charity which
was set up in 1994 following the publication of the independent
inquiry report into the care and treatment of Christopher Clunis,
a patient suffering from paranoid schizophrenia who, in December
1992, killed Jonathan Zito. The Trust's objective is to lobby
for reform to mental health policy and law and to raise awareness
of cases of homicide, suicide and other untoward incidents where
community care services have failed. The Zito Trust would like
to draw the attention of the Committee to the following points:
— Since 1994 there have been in the
region of 65 independent homicide inquiry reports published which
have examined the care and treatment of offenders in previous
contact with mental health services. There are currently a further
40 or so under way.
— The National Confidential Inquiry
into Suicide and Homicide by People with Mental Illness, in its
1999 report Safer Services, make the following points:
Suicide: The National Confidential Inquiry
looked at an initial sample of 10,040 suicides reported to them
over a period of two years, of whom 2,370 (24 per cent) had been
in contact with mental health services in the year before the
death. Of these 2,370 suicides, data were obtained on 2,177. From
this sample it was found that 26 per cent of them were non-compliant
with drug treatment in the month before the suicide, and 34 per
cent were non-compliant three months before the suicide. The report
states that non-compliant suicides had higher rates of schizophrenia,
hospital admission and drug misuse. They also had a higher rate
of distressing medication side-effects, most often related to
the (older) "typical" drugs (see below for more details).
Homicide: The Inquiry looked at an initial
sample of 718 homicides, over about 18 months, which were reported
to the team. In 26 per cent of the total sample, the victim was
a stranger. Of the 500 cases for whom psychiatric reports were
retrieved, 220 (44 per cent) had a lifetime history of mental
disorder, while 71 (14 per cent) had symptoms of mental illness
at the time of the homicide. From the sample of 500 cases, 102
of the perpetrators (14 per cent) had been in contact with mental
health services at some time, with 58 of them (8 per cent) in
contact in the year before the homicide. The report makes it clear
that the figure of 102 represents the minimum figure as it is
likely that some service contacts were not identified, particularly
those who made long-distance moves without making contact in new
localities. The Inquiry was able to male a full analysis of 95
homicides where there had been contact at some time, and found
that 23 per cent of them were non-compliant in the month before
the homicide; and in the 54 cases where there had been contact
with mental health services within 12 months of the homicide,
they found that 30 per cent were non-compliant with drug treatment
in the month before homicide. Unlike the figures for suicide,
no figures are given for non-compliance over a three-month period.
As with homicides in the general population, most perpetrators
were male, single and unemployed. There were high rates of alcohol
and drug misuse and, in a third of cases, there was a history
of violence towards another person. Over half had a history of
self-harm. In a section headed "Personality Disorder",
the Inquiry reports on a sample of 34 homicides by patients with
a primary or secondary diagnosis of personality disorder in the
absence of major mental illness (schizophrenia or depression),
and found that in 20 per cent of them the victim was a stranger.
To summarise, the National Confidential Inquiry
figures tell us that there are about 1000 suicides every year
in England and Wales where the victim was in contact with mental
health services in the twelve months before the suicide. In about
300 cases of suicide (30 per cent) the victim was non-compliant
with drug treatment. There are about 40 homicides every year committed
by mentally ill people who have been in contact with services
in the year before the homicide. Some 30 per cent of them were
non-compliant with drug treatment in the month before the homicide.
The recommendations made by the National Confidential
Inquiry include the following :
Treatments and non-compliance
Modern drug treatments such as "atypical"
drugs and newer antidepressants should be offered to all patients
with severe mental illness who are non-compliant with treatment
because of side-effects.
Mental Health Act
Mental health legislation should allow the enforced
treatment of high-risk patients with severe mental illness who
become non-compliant with treatment or who show indications of
increasing risk, even in the absence of clear signs of relapse.
The Zito Trust is keen that the Committee take
the following points into consideration during its inquiry:
— We support the findings of the National
Confidential Inquiry and its recommendation and urge that action
is taken to ensure that the recommendations are implemented across
the country.
— Most of the reforms which The Zito
Trust has lobbied for during the past six years are now contained
in the Government's green paper, Reform of the Mental Health
Act 1983. We are especially pleased to see the proposal to
introduce compulsory treatment orders for those who do not comply
with treatment, and (Chapter 10, paras 24-26) the proposal that
rights currently contained in the Victims' Charter for victims
and their families to be given information about the detention
and release of offenders in prison be extended to victims of restricted
hospital patients who have committed serious violent or sexual
offences.
— The Trust believes that the new National
Service Framework for Mental Health, proposed legislative changes
contained in the green paper, and the extra funding promised for
mental health (£700 million over three years) will together
have considerable impact on the ability of community care services
to manage and treat those at risk of harm to self or others. There
remains a shortage of acute and medium secure (and long-term medium
secure) beds which has led, particularly in inner cities, to mounting
pressures on clinicians to concentrate on "fire-fighting"
and bed management, rather than therapy and long-term treatment.
We would like to see this addressed as soon as possible.
— There is also the problem alluded
to above which concerns the current prescribing rates of new medication
for the treatment of schizophrenia. We are deeply concerned at
the widespread evidence that access to newer atypical anti-psychotic
drugs is being restricted to patients suffering from schizophrenia
by some health authorities. In the UK the average community dispensing
rate is 11 per cent compared to almost 50 per cent in the US.
The evidence suggests that this rationing is occurring on cost
grounds—despite the new drugs being proven to be cost-effective
in the medium to long term.
Atypical drugs for the treatment of schizophrenia
dramatically improve patient outcomes, have fewer debilitating
side-effects and result in better compliance for patients. In
nearly two thirds of patients, older typical medicines are associated
with a number of terrible side-effects (including muscle tremors,
rigidity, uncontrollable movements and restlessness which in many
cases continue even after the treatment has ended). These side-effects
are one of several causative factors leading to patient non-compliance
that can have serious consequences for both patients and the general
public.
The Government has committed extra resources
to mental health but we believe that the Government should make
more money available for atypical treatments to ensure that all
patients who would benefit from them have access to them.
The Government's absence of any policy decision
with regard to treatment for schizophrenia in the National Service
Framework (guidelines on treatments for schizophrenia are being
commissioned by NICE) has resulted in local policy makers within
health authorities delaying any decisions with regard to funding
until the NICE pronouncement.
I hope that these points are of use to your
Inquiry. Please do not hesitate to get in touch if you would like
any further information.
Michael Howlett
Director
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