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We are discussing one of the less impressive tales of policy making of the last 10 years—and there is some competition on that score. It has long been acknowledged that the Mental Health Act 1983 needs to be brought up to date. A generation has passed since it was enacted, and as the Secretary of State rightly said, there are a number of issues that need to be dealt with, but let us consider the stages that we have been through. There has been a so-called blue paper, a
Green Paper, and a White Paper—oh, and I left out Professor Genevra Richardson’s expert committee report in 1998. I should not have done so, because it would have been a jolly good thing if the Government, who received that report right at the start of the process, had actually listened to what was said in it, rather than trying to cherry-pick from it.
There was a 2002 draft Bill and a 2004 draft Bill, and a subsequent Joint Committee on the Draft Mental Health Bill report. Finally, in March last year, a few weeks after our debate on mental health services, Ministers acknowledged the inevitable—the fact that the legislation would not fly—and moved to an amending piece of legislation, which is what is before us now. I did not find, in any of the recent stages in which I have been involved, that the Government appeared genuinely to listen to the independent expert consensus that is emerging on how the legislation should be framed.
It is true in a literal sense that the Bill is about the legal process for bringing people under compulsion, but there is a clear relationship between service provision and the case for compulsion. Those two things do not live in isolation from each other, and there is an important document, which was published in December, that needs to be read in that context. It is the five-year report of the national confidential inquiry into suicide and homicide by people with mental illness, which for convenience is called “Avoidable Deaths”. In that report, clinicians were asked to identify the factors that they believed would have made homicide less likely. Let us remind ourselves what the results were, starting with the factor that they were most likely to cite. They were: better patient compliance, which is not surprising; improved staff communication; closer contact with the patient’s family; closer supervision of patients; and better liaison between different services. In more than 20 per cent. of cases, those were cited as factors that might have made the homicide less likely.
Mark Pritchard: Of the 1,300 people who sadly killed themselves last year who had exposure to mental health services, many would previously have been admitted to accident and emergency units. Does my hon. Friend agree that accident and emergency units should have a standard operating procedure, whereby people who present themselves who have self-harmed automatically receive counselling, through voluntary or charity groups, or perhaps even as a result of increased resource in the NHS?
Mr. Lansley:
I am interested in my hon. Friend’s point. From my recollection, most accident and emergency departments with which I am familiar have staff who are trained in mental health issues available; they would be able to make judgments about what kind of onward referral is appropriate for people who present themselves to accident and emergency. Clearly, where that is not the case, the accident and emergency department would need to consider the position. If one goes abroad, I know that in accident and emergency departments in north America, nursing staff who work in accident and emergency departments are required to
have had a period of mental health training. We have to bear it in mind that it is an important aspect of service provision that mental health services are not a separate service from the national health service; they are an integral part of it, and that needs to be true of staff training, too.
To revert to the point that I was making, among the factors offered to clinicians as making a homicide less likely was the availability of new powers under the Mental Health Act. In 6 per cent. of cases, clinicians cited that factor, so let us at least get the matter in proportion. There are circumstances in which clinicians said, “We would like to have new powers,” but equally, if one looks at the matter subjectively, from the point of view of what clinicians believe about the cases with which they are familiar, they see a whole range of other factors that would be more important.
Fiona Mactaggart: The hon. Gentleman cited clinicians as saying that better patient compliance was the top factor that would improve services. Does not he agree that community treatment orders are precisely a way to get better patient compliance among the narrow group of patients concerned?
Mr. Lansley: I am grateful to the hon. Lady for making that point, but I was about to come on to that issue, because patient compliance is indeed precisely what it is all about. I will come to that point in a minute, and I promise that I will answer it, but we all need to ask what factors matter most, and how we can best achieve them. The way in which the Ministers represent their case—the Minister of State, Department of Health, the right hon. Member for Doncaster, Central (Ms Winterton) has done it repeatedly—is to say that there are 1,300 suicides and 50 homicides a year, and those, by implication, would be prevented by their proposals.
The Minister of State, Department of Health (Ms Rosie Winterton) indicated dissent.
Mr. Lansley: The Minister shakes her head, but let us be clear: the evidence does not support anything like that proposition. The ability of clinicians to identify risk is very limited. The Mental Health Alliance estimates that up to 2,000 people with schizophrenia would have to be detained in order to prevent one homicide. The “Avoidable Deaths” inquiry illustrates that point; in only 1 per cent. of cases was the estimate of immediate risk of violence high at the last contact with the patient before they were responsible for a homicide. In nearly half of cases, there was thought to be no immediate risk of violence. There are similar figures for suicide risk: only 2 per cent. of patients were thought to be at high immediate risk. Let us not get carried away with the thought that there is certainty, and that clinicians know what will happen in the case of any particular patient; they have no such certainty.
Ms Hewitt: Is the hon. Gentleman aware that the same “Avoidable Deaths” report concluded last year that 56 of the suicides among people who had been in touch with mental health services could indeed have been prevented by supervised community treatment?
Mr. Lansley: Occasionally, I read the notes that I have prepared beforehand, and my next page says that the “Avoidable Deaths” inquiry identified what it regarded as the potential for prevention, and it mentioned 56 cases a year of suicide and—a figure that the Secretary of State did not mention—eight cases a year of homicide, because those cases related to the criteria for community treatment orders. Of course, the “Avoidable Deaths” inquiry was also clear about the lack of evidence, so we have to be understanding. In precisely the paragraphs to which the Secretary of State refers, it says:
“We have no reliable way of calculating how many suicides would be prevented by a community treatment order”,
and it says precisely the same thing about homicides.
That brings me back to my point about the Bill being about service provision as well as compulsion. If we are concerned to ensure that suicides, homicides and violence to others are minimised, what really matters, first and foremost, is the availability of services and the degree of appropriate supervision available to patients. The care programme approach and the availability of enhanced CPAs seems, on the face of it, and indeed on the basis of the “Avoidable Deaths” inquiry, to be the factor that is most likely to mitigate the risks.
The Government ought to know that, because they went out looking for evidence to support their argument. They looked for evidence on community treatment orders, and that evidence was published just after the Bill’s Third Reading in the House of Lords, so it was too late to be of any benefit to those proceedings, but I think that it would probably have reinforced their lordships in their conclusions. The review of evidence, by Churchill et al, which was published in 2007, said:
“It is not possible to state whether community treatments orders...are beneficial or harmful to patients.”
It went on to say that there was
“very little evidence of positive effects of CTOs in the areas where they might have been anticipated.”
The result is that the Government last week announced a further research project, which is to be undertaken by the university of Oxford and others. The Government have been proposing supervised community treatment orders for several years, and now they think it necessary to undertake research into their potential effectiveness. The Secretary of State was perfectly open about the Government’s objective. She wants the Bill to complete its Second Reading, but then she wants to change most of it and overturn the amendments made in the Lords. I suggest to Members wishing to participate in our debates that they read the debates in the Lords carefully. Those debates lasted for 45 hours, so I know that that takes a long time, but I urge them to do so, as they will find that powerful arguments were made and a great deal of expertise was brought to bear on the issue. I pay tribute to my colleague, Freddie Howe, to Lord Carlile, Lord Williamson, Baroness Murphy, Lord Rix, Lord Adebowale, Baroness Barker, Baroness Neuberger and all those who contributed their considerable weight of expertise and authority in the Lords.
The Government tried to represent the argument as one between the rights of patients on the one hand and the protection of the public on the other, but that is a false dichotomy, as we can secure the rights of mental
health patients and protect the public better than we have done until now. The Government, however, want to propagate that false dichotomy, because they want to force the argument in the direction that they want to take. Their attitude that they should have unrestricted access to powers is best seen in the assertion by the Minister of State, Department of Health, the right hon. Member for Doncaster, Central that
“Every restriction is a patient untreated”.
That is both illogical and misleading. Compulsion is not the only route to treatment. Thousands of patients access services without compulsion. In the case of Michael Stone, the fundamental issue was not whether he was placed in a hospital under detention and regarded as not treatable but whether the services were available to provide the treatment that was regarded as necessary. Ministers go round talking about those cases—they do not do so openly; they do it privately—and if that does nothing else, it propagates the stigma experienced by mental health patients, which must stop.
Thousands of patients access services without compulsion. Supervised discharge arrangements are available, and an enhanced care programme approach does not require compulsion. Discharge into the community should not happen earlier because CTOs are available. The principle should be straightforward: if patients need to be in hospital, they should be there; if they no longer need to be in hospital, they should be discharged. It does not require the legal establishment of a community treatment order for that to be the case. We are not against CTOs in principle, but they should be deployed as a means of securing compliance under strict conditions, and the Lords have put such measures in place where there is a history of relapse after treatment, where there is a history of refusal of treatment, or where there is a clear benefit from treatment if subsequently recalled.
Angela Browning: Is there not another consideration, about which the Joint Committee on Human Rights heard very clearly when it scrutinised the Bill? If people go back into the community and live with close associates or relatives, it is important that those carers, which is what they often are, are comfortable with the arrangement, too. In evidence, many of them expressed grave concerns.
Mr. Lansley: I am grateful to my hon. Friend, because the evidence taken by the Joint Committee has been useful, and it will prove useful, too, in our considerations. There is deep concern not only among groups representing individuals with mental illnesses but among those individuals’ wider friends, families and communities about the nature of the proposed legislation.
Ms Hewitt: Will the hon. Gentleman tell the House whether he supports the amendment made in another place to restrict supervised community treatment to people who are a threat to others, and exclude people who might harm themselves and who, as he has said, constitute the far larger number of mental health patients who could benefit from supervised community treatment?
Mr. Lansley: First, we need to consider whether it is more appropriate for someone who is at risk of harming themselves always to be under supervised discharge arrangements rather than under compulsion. As for the question of whether we believe that CTOs should be available only if someone is at risk of harming others, the answer is not necessarily. I know that an amendment to that effect was tabled in the Lords, and it is reflected in clause 32. We need to look at that very carefully, and consider whether in theory there are other circumstances. I wish to emphasise the fact that whether it is circumstances in which someone is at risk of harming others or whether they are at risk of harming themselves, we should assert the three R’s—that is an easy way of remembering them—namely, relapse, refusal, and the result of treatment.
It is astonishing that Ministers have resisted that. The Minister of State has talked about revolving-door patients. That is the criterion that we are using, which is why we wish to include those measures in the Bill. It is therefore seriously misleading to imply that compulsory treatment offers access to services. I could hear that implication when the Secretary of State said that people were being denied access to CTOs and, by extension, to treatment. That is not true. They need not be denied treatment if services are available, and there is a range of mechanisms to make that happen. Compulsion should be the last resort—and this brings me back to the point made by the hon. Member for Slough (Fiona Mactaggart)—because it does not come without a cost. I do not mean financial cost, but the cost of compliance.
Lynne Jones: I was going to make the same point as the Secretary of State, and I am pleased that the Opposition do not automatically support the amendment that was made in the House of Lords. While I agree that CTOs ought to be used sparingly, they are necessary. In fact, a majority of clinicians would like to have the option of CTOs and community supervision. I agree, however, that the availability of services is important. It is a scandal that a quarter of people who are compulsorily detained have been refused treatment in the past, and I wonder what the Opposition’s view is on the need to introduce measures in the Bill that give people the right to assessment.
Mr. Lansley: I am grateful to the hon. Lady for those points, and I am reminded of an occasion on which I sat with consultant psychiatrists a couple of years ago or more. They said that at the end of the day there are circumstances in which they are under obligations not just clinically to their patients but to the community. There is a point at which to meet those obligations they would either have to put a patient who is in the community into hospital, although they do not consider that they need to be there, or would have to seek additional powers, so they supported community treatment orders. We therefore do not object to the orders in principle, but we must be absolutely sure that we are creating safeguards in the legislation that make the measure a last resort, rather than a first resort.
The hon. Member for Birmingham, Selly Oak (Lynne Jones) spoke about the right to assessment, but we must tread carefully. The Secretary of State made a
point about age-appropriate services and assessment, and we must be sparing in the use of a legislative vehicle to mandate services. I do not think that we can go through mental health services trying to specify what they should do in the Bill but, as I shall explain in relation to age-appropriate services, it is sometimes necessary for legislation to express Parliament’s firm intentions. I think that that is what the legislation currently does.
Adam Afriyie (Windsor) (Con): We are all after the same objective—people suffering from mental health challenges should gain access to services so that they are treated and get well or return to the community. It strikes me, however, that there is a lack of evidence about the impact of CTOs in the community. There is a risk that the pressure of such orders would stop people presenting themselves for services, so we should look at the studies that have been done around the world to see whether or not the impact of treatment orders is far worse than not introducing them at all.
Mr. Lansley: I am about to come on to that point. Compulsion does not come without cost. Although there is a financial cost, finance is not the principle issue. It is about whether we can deliver mental health services as effectively as we wish, because it matters tremendously whether or not mental health patients and their families and friends, as my hon. Friend the Member for Tiverton and Honiton (Angela Browning) reminded us, support compliance. People should want to access mental health services. An environment of coercion will entail the risk that patients will not access services at all. That is precisely the perspective from which many leading professionals approach the issue, and it is among the most dangerous of situations. One need only look at the “Avoidable Deaths” inquiry to see that it is perfectly obvious that the factor most likely to cause problems is a lack of patient compliance. If we put in place an environment of coercion that deters patients from accessing services, we will be in serious trouble.
Meg Hillier (Hackney, South and Shoreditch) (Lab/Co-op): In the debate about coercion, we have heard little about the actual mental health patients themselves. On a couple of occasions, I have had the privilege of meeting users of mental health services in Hackney, thanks to the support of the Mind service user group. They expressed mixed views on compulsion, but some recognised that a compulsory treatment order in the community is preferable to compulsion and detention in hospital—where that is an option, people often prefer it. As I have said, views were mixed, which is something that I hope to go into when I get the chance to speak, Madam Deputy Speaker, but the issue has not been raised, and I wonder whether the hon. Gentleman wants to comment on it.
Mr. Lansley: The hon. Lady has fallen into the same trap as the Secretary of State that treatment is available only under a CTO. Supervised discharge arrangements are available, and it is perfectly possible for patients to opt for them. Compulsion is not required in such a wide range of circumstances.
Ms Hewitt: The hon. Gentleman has referred several times to supervised aftercare arrangements, but is he aware that they are hardly ever used? Clinicians have made it clear that they do not use supervised aftercare because the arrangements are too bureaucratic, there are too many restrictions on their use and, critically, there is no power to recall a patient to hospital. That is the central difference between supervised aftercare and supervised community treatment, which he should therefore support.
Mr. Lansley: Once again, the Secretary of State is making our argument for us. It is perfectly clear that far from resorting to CTOs, the Government should have been trying to work out how supervised discharge arrangements can be used more effectively. [ Interruption. ] Compulsion is not the same as supervision. What is required in order to promote patient compliance is, wherever possible, to achieve close supervision in circumstances that do not involve compulsion. [ Interruption. ] The Secretary of State has said, “Well, they cannot be recalled.” Of course it is possible for a section to apply, which could happen to any patient in the community. That may be for assessment in the first instance, but if the patient has been sectioned before, it may be for treatment. The Secretary of State seems to be making our argument for us, but I do not want to go on for too long, because I know that many hon. Members want to speak.
Even more dangerous than the risk of non-compliance by patients would be if the use of CTOs were extended as an alternative to in-patient treatment, where that is desirable. Over the weekend, I published figures from the Department on the number of formal admissions under the Mental Health Act 1983. The Secretary of State has said that the Government want a shift out of hospitals and into the community. Well, the number of formal admissions has increased since 1997, while the number of in-patient beds has decreased by 20 per cent., including by 5 per cent. in the last year for which figures are available.
With 63 per cent. of finance directors of mental health trusts saying that they are reducing their spending plans, the risk is clear. For financial reasons, rather than for reasons involving patients’ interests, early discharge from hospital will involve community treatment orders. Early discharge should never occur because a CTO is cheaper; it should occur only in circumstances in which patients should not be in hospital. Cost saving by limiting in-patient detention is another potentially serious risk.
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