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“because of his mental disorder, his ability to make decisions about the provision of medical treatment is significantly impaired”,
which, of course, refers to the patient. In my experience, the amendment reflects exactly what already goes on with Mental Health Act 1983 assessments, where doctors and approved social workers use their skills and knowledge to ascertain through the assessment process whether the person before them is, in effect, unwell and in need of treatment or care, or whether the person should be given choice and take responsibility for their actions and decisions.
I want to provide the House with an example. I spent last Wednesday in the company of approved social workers and observed a mental health assessment in a police station. The gentleman concerned had been picked up by the police at 8.30 after a complaint from a neighbour, and the forensic medical examiner expressed concerns about him and asked for an assessment under the 1983 Act to determine whether he needed assessment or treatment and whether he was fit for interview. During the mental health assessment, he was asked questions to establish the nature of his relationship with the complainant and his understanding of why he was in a police cell. The professionals probed his belief system and his emotional state and sought to determine whether there was an underlying psychosis, depression or anxiety state and the level of risk that he posed to himself, to the person who had made the complaint against him and to the wider public. Although the professionals were clear that the man had a level of mental disorder, when they discussed the issue between them, they concluded that it was not so bad that they needed compulsorily to detain him and that he should receive treatment on a community basis. The outcome of such an assessment is likely to be the same, whether or not the Lords amendment is accepted.
As I have said, we can set the boundaries within which professionals make their decisions about assessment, treatment and responsibility of people who experience mental disorders. We can also—the Government, to their credit, have done this—regulate to ensure that the professionals who are involved in those essential decisions have the knowledge and skills to make informed, professional decisions. Having ensured that, we must then trust the professionals to make such decisions to the best of their abilities. However, we must also ensure that the professionals whom we ask to undertake assessments on our behalf and on behalf of society as a whole have the resources to do so safely and in a timely manner.
Department of Health figures show that 27,353 patients were compulsorily admitted from the community to NHS facilities and independent hospitals under part III of the Mental Health Act 1983 and other legislation in England in 2005-06. As I have said, the approved social worker is responsible for organising the assessment, but the responsibility is greater than that—they have to apply to courts for a warrant if the person will not let them into their home to undertake an assessment, make judgments about
whether to involve the police in the assessment process, consider how quickly the assessment should take place, consult other professionals and family members about their views and, ultimately, make an independent and balanced decision whether admission to hospital is, given all the circumstances of the case, the most appropriate way forward. They decide whether or not to apply for a formal admission, and if they decide not to apply, there will be no admission. The process of admission can be fraught, but representations from approved social workers via the British Association of Social Workers and the ASW national leads network suggest that the situation is being made worse by problems with the way in which resources are managed.
I have mentioned my day with the approved social workers in central London, but I did not mention that when we left the office last Wednesday there were two other mental health assessments that had been waiting since the previous Thursday, which was before the bank holiday weekend, for police support to be available to enable them to take place. That was because the person requiring assessment was known to have been aggressive or had used threatening behaviour, and the ASW and the doctors could have been at risk without police support. There is also the issue of perhaps having to convey an unwilling patient to hospital. That delay of almost a week for police support could have had very serious consequences for the people who needed assessing and those around them. Other issues are involved in the assessment process, such as the identification of the bed and the availability of ambulances.
The British Association of Social Workers points out that although the individual approved social worker has responsibility for managing the assessment process, for making informed and professional decisions about whether to admit someone, and for the safety and well-being of the patient from the time that they sign the section papers to the moment the person is admitted to hospital, the resources they need to complete their tasks are not within their control locally. The Government have said that those issues, including police time, are best dealt with through local arrangements. I hope that in recognising some of the present difficulties there will be consideration in Committee on how to give guidance about what local arrangements Ministers believe should be in place to protect the individual and the public by ensuring that where admissions to hospitals are necessary they happen in a safe and timely fashion.
The Government have made great progress in the provision of mental health services—not an easy area in which to legislate or to work. I hope that the Bill has a constructive passage through the remainder of its legislative process.
8.46 pm
Martin Horwood (Cheltenham) (LD): The other place has a reputation for well-informed debates, but I have been struck by the level of expertise that hon. Members have shown today, sometimes speaking from painful personal experience.
I pay tribute to all those who work in community, day-care and hospital mental health services in my constituency and elsewhere. They work very hard in a
challenging area of health care where their occasional failure is often leaped on by an unforgiving media while their frequent success is much more rarely mentioned.
I share many of the concerns of other hon. Members, including my hon. Friend the Member for North Norfolk (Norman Lamb), about the initial version of the Bill. I have been strongly lobbied on some of its provisions by constituents, one of whom said:
“Please do whatever you can to stop the Government’s proposals in their tracks and get a law for England and Wales that’s as fair as the law in Scotland.”
However, as the Minister knows, I also share some of the concerns that led to the Government presenting the Bill in its original form, particularly in relation to people with personality disorder, who have suffered from the fatal combination in the Mental Health Act 1983 of very specific definitions of mental disorder and illness and the treatability test. That has led to people with personality disorder being denied treatment, whether in line with the law or, as the hon. Member for Buckingham (John Bercow) noted, based on a misguided view that the condition cannot be treated.
The current law is, by common consent, flawed, but the need to guard the civil liberties of some of the most vulnerable citizens in our communities means that any amendments to it must be carefully worded. That will be a difficult task, particularly in the case of personality disorder, even the definition of which is difficult to grasp. In the words of Mind,
“Slotting people into neat categories is almost impossible, because each individual is unique and personality is very complex. It’s a mistake to assume that giving people a diagnostic label means knowing more about them, and it’s too easy to use these terms in a judgemental way.”
That was certainly so in the circumstances that applied in the case—now, I am afraid, the very public case—of one of my constituents, a young man called James Green. It seemed to me that he was unable to access the treatment that he needed because, in a sense, he did not have a proper mental illness, having been diagnosed with personality disorder. I should like to take a moment to pay tribute to the care, dedication and perseverance of the Green family—Les and Jackie, James’s parents, and particularly Daniel, his brother, who has championed his case tirelessly.
James had a long history of difficult, sometimes very aggressive behaviour involving self harm and of threats to harm his family. As he grew older, he increasingly said that voices were telling him to harm himself and his parents, and he wanted to be admitted to somewhere where he would feel safe. Again and again, though, the situation was that his medication was reviewed and even if he was admitted for a short time he was returned to his family, sometimes with community support but making life increasingly difficult for them.
In July 2005, James set fire to his house, endangering the lives of his parents and his neighbours. He was prosecuted for arson and recklessly endangering life and sentenced to seven months in prison. That was the beginning of a prolonged relationship with the criminal justice system.
Court-appointed psychiatrists examined James repeatedly and diagnosed personality disorder. An assessment in December 2005 clearly concluded that he did not have an acute, chronic or serious mental illness but that he nevertheless ran a “high risk” of harming himself and others. Another stated,
“no mental illness, borderline learning difficulties, personality disorder. Immature, impulsive, substantial risk of re-offending/self-harm.”
Yet the judge in the case found it almost impossible, despite repeated adjournments to seek professional advice, to locate an appropriate setting where James could receive treatment.
During that time, I met the partnership trust with James’s brother, Daniel, and it said that there was a legal framework for treating mental illness but that James appeared to fall outside it. On one occasion, it stated that it believed it
“most appropriate for any consideration of his health and social care needs to be seen within the context of his current offence and resolution by the courts.”
It became clear to me that Gloucestershire probation service and Her Majesty’s prison at Gloucester were familiar with dealing with people with personality disorder.
I discovered a psychiatric morbidity survey among prisoners, which revealed that 78 per cent. of male remand prisoners had some form of personality disorder. We have effectively handed over the care of many people with personality disorder to our prisons and our probation services.
It is typical that James’s case reaches something of a climax tomorrow when he appears before a judge for sentencing, not before a doctor for treatment. However, the family hopes for the outcome that his assessment and treatment at a unit called Kneesworth house in Cambridgeshire will become a more permanent arrangement. James has—eventually—benefited from treatment, which has been more psychological than pharmaceutical. I compliment the staff at Kneesworth on their work with him. They have demonstrated two fundamental truths.
First, no one should be excluded from treatment because of the form of words used in their diagnosis. The Bill, even as amended, appears to prevent such exclusion. It is clear that it covers personality disorders. The draft illustrative code of practice, which would not be affected by the amendments, clearly specifies that personality disorders will be covered.
Secondly, Kneesworth has demonstrated that, even with difficulty and after years of trying, the current system can provide treatment, with a treatability test in place. The Bill, as amended, would provide a much better and clearer legislative environment, in which we all agree that people with personality disorder should get the treatment that they need.
I said earlier that amendments to law needed to be carefully worded. Such amendments have come from the House of Lords. On the definition of mental disorder, amendment No. 3 stated:
“For the purposes of subsection (2)... a person shall not be considered to have a mental disorder... on the grounds of... substance misuse... sexual identity or orientation... his commission, or likely commission, of illegal or disorderly acts... his cultural, religious or political beliefs.”
It is difficult to see who could take exception to that. It would not have prevented James Green from obtaining treatment and it does not reintroduce the narrow definitions of mental illness that the 1983 Act contained.
The amendment on the treatability test would reintroduce the words of the original Act but would not enforce a narrow test. It simply states that, for a treatment to be provided, it must be at the very least,
“likely to prevent a deterioration in”
someone’s “condition”. The condition does not therefore have to be perceived as curable or definitely treatable. The treatment does not have to be guaranteed, simply “likely”, to be beneficial. It is difficult to understand how that could possibly have denied someone such as James Green treatment. If that modest test is not passed, how is compulsory treatment distinguishable from detention without treatment?
In Rethink’s rather blunt words:
“Hospitals are not prisons. If people are detained for non-health purposes, it must be through the criminal justice system.”
The Royal College of Psychiatrists agrees. It described the Lords amendments as “very sensible amendments”. It even stated that they would have public support. It conducted a poll in the south-west of England, which found that 75 per cent. of people
“do not think that people with mental health problems should be forced to have treatment from which they cannot benefit.”
I have talked to not only doctors and psychiatrists but the Green family about the amendments that were tabled in the other place. Daniel Green studied them before I even spoke to him. Neither he nor I can understand why they pose any risk to people with personality disorder getting the treatment that they need. I hope that the Government will realise the potential for building cross-party consensus on such an important Bill.
8.55 pm
Mrs. Madeleine Moon (Bridgend) (Lab): As many people have remarked during the debate, this is a complex Bill with a history of controversy, compromise and confusion. That is mainly because the plan to introduce a mental health Bill was replaced by the decision to amend the Mental Health Act 1983, and this has clouded the discussion of what the Bill is saying, as opposed to what many people want it to do, to say and to promote.
I recognise the anxiety felt by families, carers and those with a mental health problem. With at least one in six of the population suffering from depression, anxiety or obsessive compulsive disorder at some time in their lives, one in 22 having a personality disorder, and one in 200 suffering from psychosis, with the resulting loss of contact with reality, mental health issues touch most families at some point and bring them into contact with our mental health services.
It has been good to hear recognition across the House today of the Government’s improvements to mental health services. The range, availability and effectiveness of the services has certainly changed. Years of neglect are slowly being counteracted. I also recognise that an increase in budgets is not the only
thing that will improve services. Training, new facilities and new partnerships need time to be put in place and to become effective.
The Bill has achieved a high profile specifically because of the voluntary sector, which now receives a huge amount of funding to improve mental health advocacy, raise awareness of mental health issues and provide a new range of services. Organisations such as Hafal, the Mental Health Alliance, Mind, and my own Bridgend organisation, Mental Health Matters, are rightly eager to ensure that the Bill will provide the highest level of protection and rights to those who face compulsion at some time in their lives. Like others, I pay tribute to their unending commitment and creativity in providing a range of services to people who are mentally ill.
Statistics cannot give a realistic picture of the pain, suffering and torment experienced by those with a mental health problem, and by their families and carers. I want to stress that. When considering the Bill, I have borne in mind the fact that, of the 300 people in every 1,000 who experience mental health problems every year in Britain, only six will become in-patients in psychiatric hospitals. In 2005-06, 27,779 patients were sectioned and would therefore have been considered for a community treatment order.
The Bill relates to how we deal with the limited number of people who face formal admission every year. It is about strengthening patients’ safeguards and tackling human rights incompatibilities. It is not about improving access to services, expanding the range of community-based mental health provision, or handling housing problems caused by tenants with mental health problems. It is not about tackling mental health awareness. It must, however, signal the Government’s commitment to dealing with all those issues if it is to be effective and to reassure those who use mental health services. While only six of the 300 in every 1,000 people who experience a mental health problem are likely to face compulsion, failure to address these issues will lead to the vast majority of sufferers, and their families and carers, fearing that the services will not be there to meet their needs, to help their recovery, to keep them safe, to enable them to live in the community and to avoid compulsion.
It has been alleged that the Bill is driven by media stories of murder and other violent crimes committed by people with mental health problems. There are fears that it is heavily biased towards extending the powers of compulsion and control. I believe that many of those fears have been addressed by changes in the Bill, including a list of exclusions, clarification of impaired decision making and the use of places of safety and time limits in the context of renewal of detention.
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