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At the heart of the Bill are the provisions in chapter 4 for supervised community treatment. When the current law was introduced, the focus of care for people with the most serious mental health problems was in hospital, and the use of compulsion meant detention, and sometimes forced treatment, in hospital. Modern medicine and clinical practice has shifted the whole focus of care into the community and the law needs to follow. The Bill would, therefore, enable a patient who is detained in hospital to be released under supervised community treatment, enabling some patients to be discharged into the community earlier than would otherwise be the case—a real benefit for them and, often, for their carers, too.
Those provisions, of course, are designed particularly for the so-called “revolving door patients”—people who are hospitalised, whether under compulsion or voluntarily, who respond to treatment, who are released, and who then fail to maintain their treatment, producing another crisis and yet another hospitalisation. That pattern features all too often when someone who has been in contact with mental health services takes their own life—some 1,300 people a year. The same is also true in many of the far smaller number of cases—about 50 a year—when someone else dies at the hands of a mental health patient. We will probably never be able to prevent every such death, but supervised community treatment is essential to help ensure that patients who have been discharged from hospital continue with their treatment in the community, helping to keep them well and thereby helping to protect them, their families and the wider public.
Fiona Mactaggart (Slough) (Lab): On that point, I am glad that my right hon. Friend has made it clear that this provision applies where people represent a risk of harm to themselves or to others. I fear that some people, in reflecting on the Bill, think that supervised community treatment following admission to hospital could be applied more widely than that. Will she look further into the Bill’s provisions for victims in those circumstances? I am concerned that victims of those “revolving door patients” who are not dealt with under criminal justice Acts, but quite properly in mental health care legislation, do not have rights under the Bill to information about the person who has made them a victim. That differs from the original draft Bill, so I hope that during the Bill’s passage, my right hon. Friend will write in rights for victims.
Ms Hewitt: My hon. Friend makes an extremely important point about rights for victims in these tragic cases—a matter that the Minister of State, my right hon. Friend the Member for Doncaster, Central (Ms Winterton), will want to discuss with her and others so as to establish how best to proceed.
Lynne Jones (Birmingham, Selly Oak) (Lab):
Supervised community treatment orders have proved controversial, but they were introduced with relatively little controversy in Scotland. Indeed, the ease with which Scotland was able to improve its mental health legislation was related to the fact that legislators accepted the advice of their expert committees. The hon. Member for Tiverton and Honiton (Angela Browning) raised the issue of definition earlier. The Government accepted the recommendations of the
expert panel in this particular case, but they did not accept other recommendations. I believe that some, though not all, of the Lords amendments and other proposed amendments should be made to improve the Bill.
Ms Hewitt: My hon. Friend makes an interesting point, particularly about Scotland, where the scope of supervised community treatment goes far wider than what we are proposing in the Bill. In Scotland, of course, supervised community treatment is available in relation to any patient—not just those who have been compulsorily detained in hospital. I want to stress a point that has often been ignored: under the Bill, supervised community treatment will not be available to a patient who is already being treated in the community or who is a voluntary in-patient.
As hon. Members will be aware, our original proposal was indeed to make supervised community treatment available in all such circumstances, precisely as the Scottish legislation has done, but we considered very carefully the objections of the joint scrutiny Committee and others to that aspect of the 2004 draft Bill and we decided not to proceed in that way.
We have sought to reach agreement with those in the other place on a number of issues, but we are not prepared to accept those Lords amendments that would restrict the use of community treatment orders to patients who have been detained as compulsory patients at least twice. I believe that that would be a wholly unacceptable restriction on clinicians: it would exclude patients whose first compulsory admission had already been preceded by several voluntary admissions; and it would deny the potential benefits of supervised community treatment to patients until there had been a further crisis and a further compulsory hospitalisation. I simply do not believe that that can be justified, and we will therefore seek to reverse that amendment in Committee.
Under supervised community treatment, clinicians will keep a very close eye on people and, if they are in danger of relapsing, take appropriate action to prevent that. Of course, one part of supervised community treatment provision will be appropriate conditions, which might, for instance, state that somebody live in a particular place or abstain from the use of recreational drugs, from alcohol abuse and so on. When one thinks of the situations that can exacerbate or, indeed, help serious mental disorder, one sees that such conditions are simply common sense.
Tim Loughton: Can the Secretary of State name one physical health condition to which similar circumstances currently apply?
Ms Hewitt: No, I cannot. No doubt the hon. Gentleman will wish to develop that point later in the debate.
Let me turn to the other changes in the Bill. Under the Mental Health Act 1983, people can be detained only if very strict criteria are met. In brief, the patient must suffer from a mental disorder, which must be of such a kind or degree that detention in hospital is appropriate and assessment or medical treatment must be needed to protect the patient or others. In addition, we propose that appropriate treatment—treatment
appropriate to the circumstances of the individual—should be available before that person can be detained for treatment.
The new appropriate treatment test will replace the so-called treatability test. That, too, is a point on which we shall seek to reverse amendments made in another place.
Justine Greening (Putney) (Con): Is the Secretary of State not concerned, as I am, that organisations such as the British Medical Association are still concerned about the Bill as currently proposed? In saying that she is going to oppose the Lords amendment, is she not overriding what is probably the best medical advice?
Ms Hewitt: No. I think that there is a very real problem with the treatability test as interpreted in current law and in practice. The problem is that people with personality disorders often have enormous difficulty getting the services that they need, because they are too often dismissed as untreatable on the basis of what people think the treatability test means.
Mr. Andrew Lansley (South Cambridgeshire) (Con): I am grateful to the Secretary of State for giving way on that point, because it is one that she and Ministers of State constantly reiterate. In how many cases in which the Act has not been misinterpreted—that can clearly be dealt with by putting people right—are patients with a personality disorder actually denied treatment on the specific grounds that they are not susceptible to treatment?
Ms Hewitt: Our estimate is several thousand, but, in any case, it is too many. I am afraid that there is a perverse incentive inherent in the treatability test—it is inherent in any test of the likely effect of treatment, rather than its purpose—for some patients to refuse to engage with treatment in the hope of proving that it will have no effect on their condition.
The hon. Gentleman, who is muttering away on the Opposition Front Bench and clearly does not like my answer, needs to recognise that the treatability test is taken into account by the courts in sentencing offenders, as well as by clinicians in deciding whether detention is appropriate. I do not know whether he is aware of this, but let me refer the House to the case of a man called Richard Ley, who was sentenced to life imprisonment in 2005 for setting fire to his own flat in a suicide bid. The judge who sentenced him, Judge Sean Overend, said:
“You were trying to self harm and did not care about the safety of others. I pass the life sentence with a heavy heart because it seems to me that to send you to prison for life when you have a disorder within the Mental Health Act is an inept disposal. But it is forced on the court because the consultant psychiatrist says that your personal disorder is untreatable so I cannot make a hospital order.”
That is precisely what is wrong with the treatability test. [ Interruption. ] I do not know why Opposition Front-Bench Members seem to think that this is a matter for laughter. It was a tragic case. Modern clinical practice is that treatment is possible for people with personality disorders. The current combination of the four different categories of mental disorder—which we are going to get rid of—and the misunderstanding or current interpretation of the treatability test is having precisely the wrong effect.
Mr. Lansley: The Secretary of State has just demolished her own argument. She says that modern treatment is available for people with personality disorders. She has quoted cases. The case of Reid v. the Secretary of State, in 1999, made it perfectly clear that anger management alone could constitute treatment that would justify the imposition of a section. Why can she not accept that, if the law is being misinterpreted and people are not being detained where they should be, that is one thing, but to say that the law is wrong on those grounds is a completely different argument?
Ms Hewitt: I am afraid that the hon. Gentleman is ignoring the fact that, because of the assumption that people with personality disorders were not treatable, services to treat them have not been properly developed over a period of many years. But, of course, as he and I would both recognise, such disorders can be treated. Those services need to be developed and we do not need an unnecessarily complex piece of law, which has been interpreted in the way that I have described, getting in the way of the treatment needed by patients who are seriously ill.
Chris Bryant (Rhondda) (Lab): Is not a further difficulty that many clinicians, when faced with the question, “Will there genuinely be a therapeutic benefit for somebody with a personality disorder?” will not in the first instance be able to guarantee that and will in fact be able to state that in the first two or three months, there will almost certainly be a deterioration in the person’s condition? That is the problem that we have to face.
Ms Hewitt: My hon. Friend is absolutely right and that is why we have come to the conclusion that it is much better to focus on the intention and the availability of appropriate treatment, rather than on whether a particular benefit, over a particular time scale, can be predicted.
Martin Horwood (Cheltenham) (LD): I have some sympathy with what the Secretary of State is talking about, because I am familiar with a case in which someone with a severe personality disorder was excluded from treatment—as is so laughingly dismissed by Members on the Conservative Benches. [ Interruption. ] I will return to the case later in the debate and I will explain how that was exactly the case. The person was excluded from treatment—there is no question about it—but he was not excluded simply by the treatability test. The issue is, as the Secretary of State mentioned, the interplay between that test and the narrow definitions of mental disorder. Does she not accept that, if those definitions are removed, the treatability test has lost a lot of its sting and therefore the modest amendments that have been produced by the Lords will still safeguard the interests of people such as James Green?
Ms Hewitt:
The hon. Gentleman is quite right that we have to look both at the treatability test and the definition of mental disorder. As I have indicated, we propose to change both. But I do not accept his point that, in the light of the changes that we wish to make to the definition of mental disorder, we can therefore be comfortable with retaining the treatability test. The way in which it has been defined in the amendment
made in another place would have thoroughly unhelpful—and in some cases, quite disastrous—consequences, of the kind that he describes in relation to, as I take it, one of his constituents.
I am conscious of the fact that I have been generous in giving way and that there are many other hon. Members who wish to speak in the debate, so let me just turn briefly to the other key provisions in the Bill. I have referred already to the changes to the basic definition of mental disorder in the Mental Health Act 1983—as have others. We also intend to remove all the exclusions from the definition of mental disorder—except the one for alcohol and drug dependance—again in the belief that the simpler we can make the law, the fewer arbitrary obstacles there will be to the proper use of the legislation, thus ensuring that people who are seriously ill and need treatment get that treatment.
The Bill will update legislation in line with new ways of working in health and social care. Many of the statutory functions under the 1983 Act have to be carried out by a psychiatrist or social worker. However, of course, the world has moved on. For example, nurses are now taking on a wider range of roles and gaining additional qualifications in a way that simply was not happening 20 years ago. The Bill thus opens up several such functions to people who have the right skills and experience, regardless of their professional background. I know that those provisions have been warmly welcomed by the Royal College of Nursing, Unison and others.
We will strengthen safeguards for patients who are subject to the compulsory powers of the 1983 Act. At the moment, all patients under compulsory powers have the right to apply to a mental health review tribunal. However, the Bill will establish a maximum period after which all civil patients must be referred to an independent tribunal, even if neither they nor their nearest relative has made such a request. We will also take a power to allow the Secretary of State for Health and Welsh Ministers to reduce that period.
Dr. Brian Iddon (Bolton, South-East) (Lab): What would the Secretary of State say to people who are critical of the six-month automatic referral period, especially those who argue for a 28-day period, which, I understand, is the length of time proposed in the Bill relating to Scotland?
Ms Hewitt: I hope that I can reassure my hon. Friend on that point. We have agreed that it would be desirable to reduce the six-month period, which is why we will take order-making powers in the Bill so that as resources become available—we will, of course, need to expand the capability of the mental health review tribunals—we can reduce that period.
We will amend the Mental Health Act 1983 to remedy a human rights incompatibility regarding the nearest relative. We will also change the Mental Capacity Act 2005 to introduce the so-called Bournewood safeguards, following the Bournewood case in the European Court of Human Rights. Those new safeguards will be important for people who lack capacity and whose care unavoidably, and in their best interests, involves a deprivation of liberty, but for whom detention under the Mental Health Act 1983 would be quite inappropriate.
I have already indicated that we tried, whenever possible, to reach agreement in another place, where the Bill has been extensively debated. In particular, we tabled an amendment in another place to ensure that the code of practice required under the Bill will contain principles and that the Bill will set out the issues that must be covered by those principles. I hope that the new clause, which I welcome, will reassure many of those who were concerned about the provisions of the original Bill and called for principles to be included in it. However, we believe that other amendments made in another place would damage patients and create the risk of harm to them, their families or the public. We cannot accept those amendments and we will try to reverse them in Committee.
Ann Coffey (Stockport) (Lab): My right hon. Friend will be aware that concern has been expressed by approved social workers about the way in which resources are managed locally and that compulsory admission can be a fraught affair. Will she consider ways of addressing such concerns and improving local arrangements?
Ms Hewitt: My hon. Friend has extensive experience in the field and I hope that she will develop her point during the debate. Of course that is a matter that we need to consider, although it is primarily the responsibility of primary care trusts, working closely with local councils, to ensure that they have the correct resources available. In an emergency, they must be able to ensure that an assessment is made so that an authorised social worker—under the Bill, an authorised mental health professional—can decide whether to apply for detention in hospital for the purpose of assessment or treatment. I have no doubt that we shall return to that point.
I stress that we have substantially increased the investment that the national health service makes in mental health services, as a result of which many thousands of mentally ill patients are getting far better care and treatment than was the case 10 or 20 years ago. However, there are still people with serious mental health problems who are not getting the treatment that they need, not only to protect them, but sometimes to protect the public from harm. We need to make changes to the legal framework to help to ensure that they get the necessary treatment, not only in hospital but, in line with modern medical practice, in the community. I believe that the Bill—or rather the Bill as amended in Committee as I hope and intend it will be—will strike the correct balance between modernising the legislation in line with the development of clinical practice, improving patient safeguards and protecting more people from harm. I commend the Bill to the House.
5.46 pm
Mr. Andrew Lansley (South Cambridgeshire) (Con): It is interesting to hear the Secretary of State move the Second Reading of a Bill whose principles now diverge substantially from those that the Government proposed, but such is the nature of today’s debate. It probably will not be well understood outside that we will manage to have an argument while all agreeing that the Bill should be given a Second Reading, but we will carry on and do so anyway.
The Government always say that the Bill is not about mental health services but, like the Secretary of State, I want to start by paying tribute to the people who work in mental health services. Hon. Members on both sides of the House will in a personal context, a family context and a constituency context have met people who work in mental health services, who do an often difficult job in difficult circumstances. People with psychological illnesses may present in similar ways to those with physical illnesses, but in some cases they can be very different—and very difficult to handle. The skills required of those who work in mental health services are remarkable, as are their forbearance and their patience in delivering those services. We should therefore start our debate by recognising what they do. The Conservatives think that, as a consequence, such people should be especially listened to. That has happened during consideration of the Bill in another place and, as it passes through this House, I hope—I know—that Members of this House will take a lot of trouble to ask people working on the front line in mental health services what they feel about the provisions. That may well change a few minds that might have started out a bit too set.
I do not want to discuss at length the state of mental health services. You will recall, Mr. Deputy Speaker, that in February last year we had a debate in Opposition time in which we set out the issues in some detail. I hope that that will be taken as read. We acknowledge that additional resources have been provided for mental health services. Ministers often chide me, but I am prone to say that health services generally and mental health services have improved. From experience in my local area, I especially welcome the creation of crisis resolution teams and the introduction of early intervention and assertive outreach. Those are important innovations, as has been the development of the care programme approach. However, I hope that Ministers will be equally even handed and acknowledge that significant problems remain.
Those problems include reductions in the number of in-patient beds and financial pressures on mental health trusts—even if they are not in deficit, they have to make savings as a consequence of deficits elsewhere. Despite the introduction of the care programme approach, only 50 per cent. of patients are subject to care planning. In addition, as the “Count Me In” census demonstrated, there are continuing problems relating to the discriminatory effects of the use of compulsion, especially in relation to black and minority ethnic patients. Those are all problems that we have to deal with, but as I am sure that Ministers would remind us, the legislation is not specifically designed to deliver services; it is designed to establish the legal framework under which people are brought under compulsion.
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