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“the prediction of risk whether done by actuarial or clinical methods is at best an inexact science”.
The Department of Health states that in the past eight years, there have been about 400 homicides in which mental illness has been a component. However, about a third were carried out by people who had been judged not to be a risk just days earlier—this is not an exact science. I need say only that the vast majority of professional people in the field do not share the Government’s presumption. Indeed, if the Government’s intentions are enacted, we will run a real risk of detaining a number of people who do not constitute a risk to others, while having no guarantee that some of those who constitute a danger will not be out in the community. That would be the worse of two worlds.
Much has been said about treatability, and the treatability test is there for a good reason. Treatment has developed, and cognitive behavioural therapies and assertive outreach are employed by talented individuals. However, it is clearly the view of professionals involved that the treatment of personality disorders is usually not possible. Incidentally, I fear that more coercive measures will have the effect of putting off some people from accessing mental health services in any way at all. Such measures might thus have a perverse effect.
I have seen at first hand the dehumanising and institutionalising effect of detention in a mental hospital with no therapeutic effect. We have already been there and done that. The advances in drug therapy in the 1950s allowed large hospitals to be closed. However, their closure was also driven by a humanitarian appreciation of the pointlessness of the experience suffered by many long-term patients. Many lives dribbled away to no point, such as those of seven ladies whom I met one day in the back ward of a hospital. They had clocked up between them more than 350 years of hospital life for being moral defectives—for having babies out of wedlock in the 1930s.
If we are to admit people to hospital against their will when they are not capable of being treated, or at least deriving a therapeutic effect, the condition of some who are untreatable on their admission might not change throughout their detention. On what possible basis could they be discharged if there was no change or the treatment did not work? Would we not be in danger of locking people up indefinitely? As Professor Richardson said, we are in danger of compulsion being
a lobster pot—easy to get into, but very difficult to get out of. I fear that the Government’s proposals will lead to people being detained who are then unable to be treated and discharged. In this case, the Government need protection from their own folly.
Compulsory supervised treatment in the community should be possible only when appropriate treatment is available. That is an especially important point for rural Wales—and, no doubt, elsewhere—because of the remoteness of treatment centres. Complying with a community treatment order for a person in a city, where the treatment centre might be a journey by bus of only a few miles, would be quite a different proposition than doing so for a person in Pwllheli, in my constituency, where the local hospital is 30 miles away, or even in Aberdaron, which is 17 miles further on. The same could be said for much of rural north-east and south-west Wales, as well as rural Monmouthshire.
Other aspects of the Bill have a particularly Welsh dimension. For example, there is a disparity between the thrust of the Bill and standard 2 of the Wales national service framework, which is titled “Service user and carer empowerment”.
I hope that the Welsh Assembly will ensure that communication through the medium of Welsh will be available. It is a long-established principle that someone before the courts in Wales should be able to use Welsh “without hindrance”, to use the formulation of His Honour Edmund Davies. People covered by the Bill should be able to use Welsh freely because freedom itself might be at risk. Equally, in the case of compulsory detention, a full apprehension of the meaning of words and the way in which they are used will be essential because someone’s freedom might be at risk.
8.19 pm
Andrew Gwynne (Denton and Reddish) (Lab): I appreciate the opportunity to speak in this debate, Mr. Deputy Speaker. I very much welcome the Government’s proposals to reform the treatment of people with severe mental illness. I recognise that this is a difficult area in which to legislate, given the necessity to meet the needs of many different groups, but I believe that the Bill will make treatments more successful.
Some Members of this House and the other place have criticised aspects of the Bill, especially the reforms to enforced detention and to community treatment on the grounds that they blur the divisions between patients’ rights, patient care and public safety. However, I would argue that we will never adequately resolve those complex issues unless they are discussed and understood together.
One of the overriding reasons why the area is so difficult is that any legislation that we pass will affect so many distinct groups in our constituencies: patients, patient groups, medical practitioners working in GP surgeries and hospitals, our local authority social services working in our communities, and the general public. Taken separately, my instinct is to take account of the individual rights of all involved as far as
possible, but with so many groups to accommodate and because of the nature of this area of law and the need for compulsion, it is our job to take an holistic approach to scrutinising the Bill, rather than to concentrate on the concerns and rights of any single group in isolation.
The rights of patients to refuse treatment must be balanced with patients’ long-term interests and the interests of the public. Given the degree of complexity, all mental health legislation is inevitably a compromise. The 1983 Act was a compromise; the medical norms that have developed from that Act are certainly compromises; and the Bill, if it becomes law, will also be a compromise. What we must ensure is the freedom of local practitioners to work in multidisciplinary care teams, the freedom of GPs and psychiatrists to form a judgment based on their relationship with their patient and, crucially, the freedom of the patient to have easier access to mental health tribunals—something that my right hon. Friend the Secretary of State said the Government would work towards as a priority.
Freedom on the ground will always induce fear that the powers will be misused. We cannot escape the fact that in this area of law such fears are inevitable, but what we are discussing is a system that allows the wishes of mentally ill patients to be overridden for a period by their perceived needs. By broadening the criteria for compulsion, the Bill would allow clinicians the freedom to work across the individual health problems of a patient. Psychiatrists could impose treatments regarded as appropriate, rather than only treatments that are likely to alleviate the specific severe condition of the patient. That is an important change, because it would allow psychiatrists to provide treatment for one mental health condition with the hope of alleviating another. It would, for example, be left to clinical staff to decide whether it is appropriate to treat patients who cannot be cured of their personality disorder, but who might benefit from the treatment of their depression or anxiety. With the correct safeguards, which the Bill provides, such powers give clinicians the freedom to provide better treatment for the sake of the patient and of others.
The Bill is not about turning our doctors into jailers, as has been suggested in the other place; it is about giving front-line medical staff the flexibility to provide the treatments that they think are best. Opponents of the reform ignore the fact that mental health legislation is permissive: it allows doctors to do what they think is correct and appropriate in the circumstances. After all, no reform that we make can override human rights legislation that gives clinicians the final say.
Supervised community treatment orders are the second major innovation in the methods by which clinicians could care for their patients. If we want to find a balance between patients receiving their care in the place that they feel most comfortable and medical practitioners being able to ensure the continuation of treatment so that patients are not condemned to repeated periods of ill health and hospital stays, we require a model for community supervision. Some have argued that treatment should be entirely for the benefit of the patient and that threats to the wider public should be dealt with by the criminal justice system, not by doctors. I would argue that there is a role for doctors to impose treatment on those who pose a danger to
their own health and that of others, and that doctors are best placed to make such decisions. My fear is that if patients are not able to receive their compulsory treatment in the community—treatment imposed for the protection of their own health—clinicians will continue to be forced either to retain patients in hospital, or to risk the decline of their patients’ health in the community.
Increased care in the community will, of course, be a challenge requiring adequate investment in local authority social services and multidisciplinary care teams, but the Bill gives us the opportunity to take great strides in improving mental health care in the community and providing those receiving compulsory treatment with a great say in how and where they receive it. If we are concerned about discrimination against the severely mentally ill, it is the Government’s duty to find a way to enable those receiving compulsory treatment adequately to exercise such choices. It is also the Government’s duty to allow patients to receive their treatment with the least disruption to their lives. Supervised community treatment would allow greater confidence that when patients leave hospital, treatment regimes will be adhered to and the patients will not be made the subjects of repeated readmission to hospital and periods of in-patient care. It is vital that the choice is offered honestly and that past failure to adhere to treatment in the community is not made a precondition of a supervision order.
The Bill also redefines the key professional roles involved in care, allowing a greater degree of valuable multidisciplinary care to take place in the community. The introduction of the roles of responsible clinician and approved mental health professional will allow a range of clinicians from the fields of nursing, psychology, occupational therapy and social work to perform roles that are currently restricted to consultant psychiatrists. That will greatly strengthen the multidisciplinary model of care that has emerged in mental health services in recent years and will allow clinicians to work across disciplines in the way that is most appropriate to the patient. That view is strongly supported by Amicus, Unison, the British Psychological Society, the Royal College of Nursing and the British Association/College of Occupational Therapists, which represent many of the multidisciplinary clinicians and carers who, under the proposals in the Bill, would lead such care.
I fully understand the fears of some local authorities, including Tameside and Stockport councils, which serve my constituents, that the changes might prove to be expensive. It is vital that resources be made available for reforms to local social care policies, but I am confident that the proposed changes to the legislation will be in the best interests of our constituents who are in need of community care for severe mental illness.
What my right hon. Friend is proposing is that clinicians should be able to offer supervised community treatment in England and Wales as a matter of course, thus not having to wait until their patients have suffered damaging and repeated health decline in the community. As I have argued, we should not forget the aim of mental health law, which is to allow mandatory treatment to be given where necessary for the sake of the health of the patient and the safety of others. There is little point in such legislation if it does not enable
clinicians to provide beneficial care to their patients without disruptive breaks in treatment. It is also important not to be transfixed by an orthodox interpretation of individual human rights. The short-term right to refuse treatment and the long-term right to receive appropriate care will often conflict in cases of severe mental illness.
A balancing act will always be necessary in mental health law, but the Bill promoted by my right hon. Friend the Secretary of State offers us the best balance. There can be no doubt that that the law needs to be modernised. Widening the scope for treatment and allowing compulsory treatment in the community, as well as in hospitals, will benefit patients and communities alike. That is why I shall support the Bill tonight.
8.28 pm
Adam Afriyie (Windsor) (Con): I am conscious of the amount of time left this evening, so I shall keep my remarks as short as possible.
Many of us entered the House with the motivation of caring for a particular group in society, and from a desire to put things right and to ensure that the state steps in only when it is necessary to protect that group. Sometimes, politicians and Members get a raw deal from the media. We are often painted as self-centred and self-serving people with massive salaries and wonderful expenses who do not particularly care about or want to focus on British citizens, the least well-off and the most vulnerable groups in society.
My experience from my two years in the House is that virtually every Member of Parliament to whom I have spoken, whether Conservative or Labour, is motivated by a profound sense of duty, responsibility and care for particular groups in society. That is why I was delighted that when I questioned each of my colleagues who made it to the House in May 2005, I found that they, like me, were concerned with a specific group in society. We produced a small booklet called “The Forgotten”, in which we outlined the key groups that we felt needed support and more thought and concern. Those groups were people with AIDS and HIV, people who suffer from diabetes, the terminally ill, children with state carers and a group that I have always been concerned about—the millions of people who suffer with a mental health challenge.
It is not as though people with mental health challenges are a small group; I am pretty certain, just from the statistics, that there are hon. Members in the Chamber right now who struggle with a mental health challenge. I am also absolutely convinced that every single Member in the Chamber has had experience of a mental health challenge, perhaps through a family member, a work or other colleague, a carer, or a friend. I am delighted that this debate is taking place, and that in many ways the Bill, in its current form, is not party political. We are pretty much all behind the objectives of the Bill in its current form. I hope that we can see our way to agreeing on some minor amendments in Committee, but that we will find a way to push forward with the Bill in pretty much its current state.
From the debates in the other place and from the representations that I have heard from Mental Health Alliance and many other well-respected and well-
supported bodies, it seems that the evidence and common opinion point in one direction. They largely support at least five of the six amendments from the other place, so I hope that the Bill will reach Committee in its current state, and that Ministers will keep an open mind and will allow for some movement when we debate the amendments from the Lords.
The biggest challenge that people with a mental health problem face in Britain today is the stigma attached to such problems. There is a danger that when we talk about such matters in the Chamber, and when the media pick up on the issues outside the Chamber, we do damage in that respect, but I have to say that in the majority of contributions made today, hon. Members have done incredibly well in showing our concern to point out that of those patients who suffer with mental health issues, a very small minority are violent or dangerous. I am glad that we have not concentrated solely on the dangerous minority.
The Bill is an opportunity to move forward with the concerns, the plight of those who suffer, the treatments available to them, and issues to do with the people who care for those sufferers. However, I have a couple of concerns. Is it right to detain somebody who has not committed a crime? That is a pretty fundamental question. Statistically, it is possible that at some point in the next few years a Member of the House will do something that is against the law. Do we detain everyone in the House on the basis of that probability, just in case we go on to do something wrong? We would not accept that approach in society, and we should not accept that approach to people who suffer with a mental health challenge. We need to look very carefully at the amendment made in the other place on compulsory community treatment orders, and ensure that we are not introducing such a principle in terms of compulsory treatment, either in an institution or in the wider community.
I do not wish to create division where it does not exist because, as I said, the motivation behind the Bill, which has been a long time coming, is welcome, as it seeks better treatment for people struggling with a concerning problem for themselves and for the rest of society. In its current form, the Bill will certainly rise to meet most of the challenges, but there is an omission concerning the issue of advocacy. If someone cannot represent themselves clearly and fluently, and if they believe that the family member who is automatically their advocate is not the right person so to act, we need to consider tabling an amendment in Committee to introduce the concept of choosing an alternative advocate.
The Bill exists mostly outside of party politics. I am not sure if there will be a Division this evening, but if there is I hope that we all consider the precise issues at stake and vote for the sort of society that we want rather than vote along party political lines. The evidence from the House of Lords and from third-party bodies is practically unanimous on five of the six Lords amendments, and I hope that those amendments will be carried through into Committee. The Bill gives us a great opportunity to take a positive step forward on treatment for patients’ happiness and well-being and
for society as a whole. I therefore hope that it proceeds, preferably uncontested, to Committee, where we can examine the specific issues more closely.
8.36 pm
Ann Coffey (Stockport) (Lab): It is not surprising that the Bill has proved controversial. After all, we are dealing with contentious issues of liberty and personal responsibility, and we have been asked to determine in what circumstances anyone with a mental disorder should be detained against their will. Those and other issues have been the subject of debate since the Government announced their intention to introduce new legislation in 1998.
During the Bill’s controversial passage through the other place, their lordships sought to address those problems where they still believed that an individual’s human rights were at issue. As elected Members of Parliament, we need to take into account, too, legitimate public concerns about safety. However, given the importance of this area of legislation, it is essential that we find a way forward that addresses the concerns of all parties. We need legislation on the statute book that is, and will be, suitable for our communities in the 21st century. A stand-off between the two Houses on the issue would not be helpful, and we can achieve our aims by considering the way in which the Lords amendments would work in practice, rather than in principle.
I am not a lawyer, but I trained as a psychiatric social worker, and worked as such for many years before moving on to different things. I should like to consider the Bill from the perspective of the approved social worker—or the approved mental health professional under the Bill—who sets up and undertakes with doctors the assessments that determine whether or not someone needs to be admitted compulsorily under the Mental Health Act 1983. Approved social workers are highly trained and skilled professionals who act independently and are personally and legally accountable both for their decisions and for the safety and well-being of the service user who has been sectioned until they are accepted on a ward by nursing or other staff. How will the amendments to the definitions of mental disorder and treatment for it help or hinder that process of assessment?
I have looked at the original Bill and the Lords amendments in relation to the criteria for compulsory admission from the community, particularly the issues of “medical treatment” and “impaired” decision making. The original Bill talked about the availability of “appropriate medical treatment”, whereas the Lords amendment used the words,
“medical treatment...likely to alleviate or prevent deterioration”
in the patient’s condition. In both cases, the term “medical treatment” has the same broad meaning. It includes medication, nursing care, habitation and rehabilitation, as well as psychological treatment or support. One focuses on the notion of availability of “appropriate” treatment, and the other on its likely benefits, but are those two notions very far apart? If the treatment available would not help the patient by alleviating or preventing deterioration in their condition, can it be said to be appropriate? It appears to me that the issue involves interpretation rather than the words themselves.
The Lords have also inserted a new condition into the provision on criteria for formal admission for consideration in the assessment:
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