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Finally, I pay an enormous tribute to those who work in mental health. The people who work voluntarily at Hafal in my constituency and those who
deal with many people with very chaotic lifestyles do a job that many of us would find impossible.
Madam Deputy Speaker: Order. Quite a few hon. Members are still hoping to catch my eye, and even though Mr. Speaker has imposed a 10-minute time limit, it would perhaps be helpful if Members could curtail their comments even further, so that all who want to may contribute.
7.50 pm
Dr. Richard Taylor (Wyre Forest) (Ind): I very much welcome the contributions that have been made, particularly by Labour Members, because they show that there is some support for some of the House of Lords additions to the Bill, most of which I support very strongly.
On a light note, I am delighted that the exclusions under the definition of mental disorder include political beliefs. When I stood for election to this place, I was not actually accused of being mad, but I was certainly accused of being a militant activist, a medical dinosaur, Swampy and even King Canute. I am absolutely delighted, therefore, that there is no chance that abnormal political beliefs could be included.
I want to say a little about treatability, because so many Members have concentrated on it. What do we, as doctors, mean by treatment? First, the ideal is a cure. Obviously, infections can be cured, and depression can be cured in many cases. Secondly, if we cannot cure, we want to control. Diabetes and hypertension can be controlled. Schizophrenia can be controlled with the right treatment and the right follow-up, and nobody would argue against detaining people with treatable schizophrenia. The third bit of treatment is palliation. If it is incurable, cancer can be palliated. The neuroses can also be palliated, as can some of the psychoses if they cannot be helped otherwise. With the addition of psychological treatment, some people with personality disorders can perhaps be helped, but it is a very big “perhaps”.
“likely to alleviate or prevent a deterioration”
in the House of Lords amendment; it takes me back to my time working as a physician taking in emergencies. We took in well-known psychopaths from the accident and emergency department, but it was impossible to get one’s psychiatric colleagues to help at all once a psychopathic personality had been diagnosed. I always remember one chap who came in having swallowed a parcel of nails. He was assessed by psychologists and did not have a psychological illness, so we had to let him go. The only way we could have settled our consciences when we let him go would have been by taking his supply of nails from him, but he would not let us take them, because that was robbery. I ended up having to buy them from him, and he no doubt moved on and tried the same trick somewhere else. The point of mentioning him is that no amount of psychological advice or anything else would have dealt with him. Unless we include the House of Lords amendment, such people might be at risk of being locked up for ever and a day, because there is no way anybody would change them.
On clause 4, which deals with impaired decision making, because of the restrictions of time, I will only point out the Law Society’s absolutely excellent paragraph on that subject. It is very short, but it is an excellent, explicit explanation of the Lords amendment, and it should be read by everyone.
Moving on to the renewal of detention, the fact that the Lords want a doctor to be involved has already been mentioned. I was pleased to learn this morning that the Medical Health Alliance has slightly changed its stance and agrees that there is a very strong place for professionals other than doctors to be involved, but at least one of those involved must be medically qualified. I have a fear that, in the national health service as a whole, the moving of certain tasks to professionals other than doctors possibly happens because it is a cheaper option and, perhaps in some cases, as a response to the deficits.
On clause 32, which deals with a doctor being involved in the decision to place the treatment on a community treatment order, I have learned of the tremendous usefulness of assertive outreach teams at home. They are excellent when they are adequately supported, and I am very keen for the Government to consider the support that assertive outreach teams get. As other hon. Members have said, mental health services are always soft targets when one is trying to balance the books, and it should be a target for the Government to help those teams. It has always puzzled me why there is no target for the time taken to see a consultant psychologist. That seems to be a complete gap.
Turning very briefly to young people, a lot has been said. When I was still working, which was a few years ago, to walk into an adult psychiatric ward would put almost anyone off, and to put children into those circumstances would be awful.
I wish to conclude with two very important things. First, as has been mentioned several times, the Mental Health Alliance—the broadest coalition in the mental health world, with 79 members, and a unique alliance of all the groups—supports the Lords amendments with slight provisos, one of which is about doctors’ opinions, but it cannot be swept aside. The Mental Health Alliance says that reform
“must be fair and workable”.
The Royal College of Psychiatrists says that reforms must
“command the support of the professional groups and patients”.
To conclude, I can say as an independent what party members possibly cannot say, and this is an appeal to the Government that this is not a political issue; it is an issue that we must get right for the good of all the patients who suffer from such illnesses. I shall leave the House with some words from a far more eminent independent MP than myself: A. P. Herbert, who was the independent MP for Oxford University before world war two. He wrote in his book:
“I have even thought that, on great occasions where the parties were furiously raging together, the votes of Independents, cast with, of course, more conscience, might be as straws in the wind and show the party leaders which way the pure air of free opinion blows.”
I think that the pure air of free opinion blows in favour of a lot of the House of Lords amendments, and I should very much like the Government to support some of them.
7.59 pm
Meg Hillier (Hackney, South and Shoreditch) (Lab/Co-op): Time is short so I will not go into some of the details of mental health issues in Hackney. I managed to mention some of them in an intervention. People in Hackney are three times more likely to be admitted to hospital with schizophrenia than people across England as a whole. I highlighted in my intervention particular issues about people from black and minority ethnic communities. Although that was the reason why I began to look in detail at the Bill, this is not the Bill that tackles those many concerns. However, the Bill does deal with the important area of compulsory treatment and how and when it is applied.
I have had the opportunity to canvass opinion from a wide range of sources and I pay tribute to the people I spoke to for their time and expertise. In particular, I pay tribute to Hackney Mind and the service user group there, and members of the staff of the East London and The City University Mental Health NHS Trust, including nurses, approved social workers, consultants and other mental health professionals. I also pay tribute to some people who have not been mentioned so far in the debate: tenants, residents and housing managers, who have to deal a lot with the reality of mental health issues on a daily basis.
Because time is short, I am going to focus on only two issues in the Bill. I hope that, if I am lucky enough to serve on the Committee, I will get the chance to probe these and other issues in more detail. The first issue is the compulsory community treatment order, which is one part of the Bill that I welcome. Treatment on the basis of need is a principle that pervades the national health service. Even when consent is not possible, because somebody has not got the capacity to identify their need, that treatment should still be forthcoming. That basic principle protects patients with mental health problems. The patients and service users that I spoke to had mixed views about the matter, as one might expect. The main concern of mental health users that I spoke to was to ensure that the care package, whether it be voluntary or compulsory, was properly delivered. There is further debate to be had—but again the area is not properly part of the Bill—about the way in which care packages are delivered. I hope to go on to that in more detail in the second half of my comments.
I will give some comments from users themselves, because their voices have not been heard enough in the debate. One of them said to me: “At least in hospital there is monitoring, but in the community you can feel lost.” Possibly with compulsory community treatment orders that feeling of being lost may be addressed. Someone else said: “It would be better if people were not going to hospital so often.” That individual’s view was that, if compulsory treatment in the community was forced upon them, that would be better than being forced to go into hospital. That comment came from somebody who had a mental health problem and who, when she was not in her worst condition, was aware of the problems and had the capacity to judge her situation. Others had concerns about being forced to take medication—because of the bad side-effects. That is obviously a huge issue for people who have to suffer the many uncomfortable side-effects of medication. One person said that, in her case, medication may quiet the voices, but it caused a range of problems for her.
There is a place for compulsory community treatment orders, but it depends on the individual. That was the message that came loud and clear from service users in Hackney. Interestingly, the overriding view of the service users that I spoke to was that, when someone needed police involvement in their case, there was therefore a strong case for compulsory treatment. When I spoke to people—not just in Hackney—in the course of my research it was interesting to note that, in effect, compulsory treatment currently exists and is allowed under case law. Under section 2 of the 1983 Act, people can be detained for 28 days, and under section 3 for six months, in hospital. But then they can be released on long leave. Long leave presents people with the possibility that they may be once again admitted to hospital. In effect, clinicians are addressing the difficulty of not having compulsory community treatment orders by finding ways through that, through case law. If we get things right in the Bill, it will make it easier for clinicians to provide that option and that choice.
Talking to professionals, they said that, depending on the relationship the team had with different individuals, the option was sometimes sold as a method of support and sometimes it represented the strong arm of compulsion that was necessary to ensure that people got the treatment that they needed. I have already quoted the consultant who talked about a section being an act of kindness. He and others I spoke to who deal with the issue of sectioning and compulsory treatment on a daily basis believe that, in place of hospital, compulsory treatment orders are a useful and important option, as long as there are safeguards. I am sure that, in Committee, we will look in greater detail at those safeguards. The consultant that I quoted went on to say that the paperwork involved in sectioning was a great discipline for clinicians to justify their decision. I hope that, in any future compulsory treatment that is introduced, that will equally apply.
Among approved social workers and community psychiatric nurses, there was concern—it is a concern that has not really been addressed so far in the debate—about the risk to staff of applying compulsory treatment in the home. I hope that the Minister will look into that. It may not be something that comes up in the precise, narrow aspect of the law that is contained in the Bill, but it is nevertheless an important issue. If we are to introduce a Bill that is workable, we need to consider how compulsory treatment will apply. It may be that, in a lucid moment, the patient is aware and wants to have the compulsory treatment, and that the family and other carers may support that. However, if there is an issue about how the treatment is applied in a patient’s home, for example, we need to look carefully both at the rights of the patient and the safety of the staff involved. It is clear from talking to both patients and professionals that it is chaotic people who prefer self-medication, but then do not take it. They are often at great risk themselves, but they also put staff at risk.
I want to highlight one example from the point of view of residents in my constituency. A tenant leader rang me in some distress because a neighbour of hers in a small estate was behaving rather erratically. It was clear that the individual had mental health problems.
The neighbour was not judgmental. She herself had suffered from mental health problems in the past. At one point, though, the individual was running round the estate with no trousers on. In a worst case scenario, without proper treatment in the community or in hospital, that could have led to the individual being put on the sex offenders register. As far as any of us were aware, that was not the issue for that individual. It seems that sometimes compulsory treatment can protect a patient from worse scenarios and perhaps inappropriate criminal treatment. That is important. It is in the best interests of the individual, his neighbourhood and the other people he has contact with that he gets the treatment he needs. That is not to say that the crisis teams and the current approach to sectioning are not important as well. I pay tribute to those who work in the crisis teams in Hackney, who deal with the sharp end of the issue.
The other key issue that I want to touch on is advocacy. I feel strongly about this matter, partly because of my experience in a different area as an advocate for someone with a learning disability and my awareness of the difficulties of getting through the system. I have not really got time to go into the issues of advocacy in general, but, particularly in relation to the compulsory treatment element of the Bill, it is vital that advocacy is included. I give the Minister notice that, if I am lucky enough to serve on the Committee, I intend to table amendments to try to make sure that advocacy is better enforced and part of the Bill.
Professionals agreed with me that there was a need for more advocacy, although interestingly they had different views about what advocacy should be. Under the Mental Capacity Act 2005, Hackney was granted only £40,000 for the whole borough for advocacy. Clearly, there is a resource issue involved as well. If we make sure that advocacy is written into the Bill— to protect patients who are having compulsory treatment—we should also make sure that the resources follow. That is important. In Hackney, as well as the need for mental health advocacy, many mental health patients have complex needs in relation to language and literacy. Mental health advocacy in a constituency such as mine is particularly important.
The East London and The City University Mental Health NHS Trust is currently working to give service users a greater say in their own treatment. That is clearly the best form of advocacy. But the Revolving Doors Agency—I should declare an interest, because my husband is a patron of the agency—says that half of the people that it is involved with are dealing with six to 10 agencies. Its view is that a lot of people in the criminal justice system are there not primarily because of their mental health, but because of the level of chaos in their lives created by their health needs. For example, they have no GP so therefore no incapacity benefit. Without incapacity benefit, they have no housing benefit. With no housing benefit, they have no hostel or they lose their homes. A lot of things are missing in the system if we do not get that advocacy in place. I hope to expand on some of these issues in Committee.
8.9 pm
Hywel Williams (Caernarfon) (PC):
I have a long-standing interest in mental health having recently been a member of the Joint Committee that found the
Government’s 2004 draft Bill to be “fundamentally flawed.” I was involved in the education and training of social workers for 15 years and, before that, I was a mental health social worker—one of the first to be approved under the Mental Health Act 1983. Methuselah-like, I also worked under the Mental Health Act 1959 for seven years and sectioned under the very old system. I have applied for compulsory admission many times, including while working in extremely difficult circumstances as a member of an out-of-hours night duty team. In my opinion, compulsory admission is essential in some circumstances, but it is a frightening and demeaning experience for the individual concerned and often has profound effects on professionals, sometimes with regard to their physical safety.
Almost any attention to mental health is welcome. I really do not want to hear the resigned admission from professionals that mental health is yet again the Cinderella of the NHS. After all, Cinderella got to go to the ball and the prince to boot, but that is not what has usually happened in mental health. New spending, some of which the Secretary of State outlined, is welcome, but in Wales, as I pointed out in an intervention, we are still far behind the situation in England, with some people reckoning that we are four years behind. We still have some Victorian facilities. For decades, mental health has been denied proper resources that would turn the promise of new drug and behavioural treatments into a reality of a sustainable life in the community for people with severe mental problems. The reform of mental health legislation is thus long overdue. After all, Professor Richardson, who convened and ran the specialist group, began her work in the last century—more than eight years ago.
I share the general disappointment of the Mental Health Alliance and others about the Government’s successive efforts to formulate a worthwhile and workable Bill. After all, the draft Bills—miraculously, almost—managed to unite nearly all interested parties in opposition, including the royal colleges, Hafal, which is the mental health alliance in Wales, the British Psychological Society and the local Mind groups that I consulted in the Rhymni valley and in my constituency in Gwynedd. They were all against the 2004 draft Bill, which one gentleman described as a “mad axe man Bill”. Others complained less colourfully that the Bill, at least as it was then framed, might just about calm some of the headline writers.
As we know, stranger murder, which is so beloved of the tabloids, is thankfully very rare. The number of homicides has gone up over the past 20 years, but, as was pointed out earlier, the proportion of homicides committed by people with mental illnesses has remained constant. However, when there is any assault involving a mental illness component, a great deal more needs to be done to attend to the victim’s needs, or, sometimes tragically, the needs of those who are bereaved. I say that as someone who represents a family that has suffered in one of the most high-profile cases, which is often cited, but cited thoughtlessly. I would, however, apply the same principle of care for the victim to cases that do not have such allure for journalists of a certain type.
The focus of the 2004 draft Bill was compulsory detention and treatment, as is the case with this Bill, along with community supervised treatment. The vast
majority of people with mental problems are in no need of detention or compulsory treatment. They pose no danger to anyone except sometimes, tragically, themselves. Rather, they face the problem of accessing assessment and treatment in the first place. Hafal correctly points out that there is a right to assessment in Scotland—I leave that thought with hon. Members. However, this long-expected Bill, which it is assumed will last for 25 years, does nothing for the vast majority of people with mental or emotional problems. In that respect, the Bill is a colossal lost opportunity and, worse, it risks stigmatising such people.
The Government seem to presume that it is possible more perfectly than is the case to identify those who constitute a danger to others so that they can be detained. As the Royal College of Psychiatrists points out,
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