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The MHA says, and I agree, that it is important that any conditions are reasonable and that the patient has the power to challenge any requirements that are unreasonable. It makes the valid point that the responsible clinician and the approved mental health professional may not have met the patient before their crisis, and may not have in-depth knowledge about the patient’s home life or the needs of their carers. That could lead to assumptions about the patient and unreasonable expectations of their carers as to supervision of the patient, transportation for treatment, police conditions and even housing for the patient.
The Mental Health Alliance gives a series of examples of conditions that could be unreasonable. A person could be required to live in a certain place where they might experience abuse or stigmatisation from neighbours. A person under a curfew might find that too restrictive if they find a job requiring them to work after specified curfew time. Although the supervising clinician may be sympathetic, the right to challenge such restrictions would hinge upon the good will of the clinician. That goes to the heart of the European convention. I hope my right hon. Friend will read our report on the matter in detail. It is not good enough to be able to challenge the order as a whole. It should be possible to challenge the conditions if they are specifically unreasonable. I urge her to consider the human rights implications of not providing such a right of appeal.
Dr. Richard Taylor (Wyre Forest) (Ind): I shall speak briefly to amendment No. 89, in my name and that of the hon. Member for Birmingham, Selly Oak (Lynne Jones). It is similar to amendment No. 84, except in its positioning. It seeks to address what I still believe is a gap in the Bill—a gap in the details of consultation with patient, family and carers before a community treatment order is made.
I have read the Official Report of the Public Bill Committee and I know that attempts were made in Committee to plug the gap, but that was felt to be unnecessary. I agree with some of the Minister’s comments and question others. She said at column 328:
“I believe firmly that, without proper consultation, supervised community treatment will not work”. ——[Official Report, Mental Health Public Bill Committee, 10 May 2007; c. 328-29.]
She also agreed that consultation with nearest relatives and carers is important. I agree with her about that, but she went on to say that that should not be prescriptive, but part of routine good practice integral to the operation of the Act.
Again, I agree with the Minister, but that would be in an ideal world. I fear that we are not living in such a world. She and the House are no doubt aware of the recent Healthcare Commission in-patient survey carried out by the Picker Institute. Several questions were asked about communication between staff, patients and the families. It was an extremely large survey—140,000 patients in acute hospitals, not mental health settings—and there was a 59 per cent. response rate, which is incredibly high.
Question 36 put to that large number of in-patients was:
“Were you involved as much as you wanted to be in decisions about your care and treatment?”
On average across England for acute hospitals, 11 per cent. said that they were not involved. Question 38 was:
“If your family or someone else close to you wanted to talk to a doctor did they have enough opportunity to do so?”
The average across the country, 16 per cent., said no, they did not have sufficient opportunity. That was brought to my attention in my local paper because one of my local hospitals was one of the worst, with 25 per cent. saying that they were not given that opportunity.
Those were acute hospitals, where good communication is surely paramount. Poor communication, as many of us hon. Members know, is one of the commonest causes of complaints to us. Good communication is vital, especially when it involves curtailment of liberty or freedom of choice among mental health patients. I would like to have seen provisions like those in the amendment written into the Bill. Consultation cannot be left to routine good practice.
An attempt is made to address the gap in schedule 3 on page 65, but that gives a duty only to managers and it is a duty to inform, not to consult or discuss. Will the Minister deal with the matter in her remarks? The duty of clinicians—doctors and nurses—is to inform and explain things to their patients. Without that being written into the Bill, a large gap is left.
Meg Hillier: I shall speak broadly in favour of the Government position and against the amendments tabled by the hon. Member for Tiverton and Honiton (Angela Browning) and her allies, largely because I have been going out and talking to people in Hackney—practitioners, users and residents who live alongside mental health patients in the community who are not always receiving the treatment that they need. I mentioned that on Second Reading and subsequently, but it has not been voiced enough in the debate. Some of those patients will be bounced back into hospital because their needs are severe. Some do not necessarily need to be in hospital, but they need an element of compulsion to deliver their treatment.
I am not blindly following the Minister’s lead on the matter. I have come to my own conclusion that treatment on the basis of need should be what drives our treatment of people in need of mental health services. That principle pervades the national health service in other areas. The difficulty with mental health is that not everyone can identify their needs, and even if they can, they are sometimes unable, for various reasons, to adhere to treatment voluntarily.
I have spoken to users about this on a couple of occasions. I heard mixed views from them, but they did not rule out compulsory community treatment orders completely. Some said that they would rather have one as an alternative to hospital treatment because it would allow them to continue their family life and their work. Moreover, crucially, it is less stigmatising than removal to hospital, whereby someone is suddenly taken away from their home environment and family, and perhaps away from their workplace if they are able to hold down a job, for a period of time. That identifies them as a mental health patient, whereas in other circumstances they could say that they were in hospital for an operation, without having to go into specifics.
There was a common and clear view from the mental health service users to whom I spoke, thanks to Hackney Mind and its user group, that compulsion was entirely acceptable if the behaviour of somebody with a mental health problem led to police involvement. That was a universal view, admittedly not from a scientifically representative group of people, but from a group of mental health service users to whom I spoke in preparation for the Committee stage of the Bill. Interestingly—I hope that the Minister has heard this from users too—they were more concerned about consistency, quality and communications in relation to community care in general. The compulsion element was obviously part of our debate, but it was mainly about the quality of community services. If we are to have CTOs, we should also have better community services alongside them, so that someone does not have to have a CTO in order to get the services that they need, but can pick up services in the community as well.
Angela Browning: Does the hon. Lady agree that if people are in the community under CTOs, there should be some parity with the level of service given to in-patients in hospitals? At a recent meeting in my constituency, when I asked 19 immediate carers of mental health patients whether they had ever seen the care plan for the person they looked after, only two of them had ever seen it, let alone been consulted about it.
Meg Hillier: I agree that everybody should be able to see their care plan and have some input into it. Perhaps there are some gaps in services. Certainly the crisis team that I spoke to in Hackney, which includes medical professionals and social workers, does a very good job in intervening at the stage of pre-admission to hospital. I applaud the work done by them, by my local mental health trust and by Mind locally in giving users a voice, but that process is sometimes underdeveloped because there is not a great deal of funding for it. However, much as I would love to have endless discussions about types of treatment and services—issues that are vital to my constituents—this measure is about the narrow area of compulsion and treatment. That must be properly resourced and organised if it is to deliver what is required.
One of the consultants in my area highlighted the part of the Mental Health Act 1983 that deals with requiring treatment “in hospital” for a mental health condition. As he rightly pointed out, adaptations through case history over the years since then mean that a patient does not need to be in hospital day and night. If one replaced the words “in hospital” with, say, “requires treatment”, one would in effect allow for CTOs under current case law—and professionals have told me that in many cases they are already, in effect, in operation, in Hackney and elsewhere.
Under section 3 of the 1983 Act, extended leave after six months in hospital allows for treatment that could mean that someone goes back into hospital if they do not adhere to it. Under section 2, detention for 28 days is allowed, as well as special orders for people who have committed crimes and are released because it was an episodic crime. Section 41 deals with court restriction orders, whereby the person has to report to a psychiatrist every three months. That is far more
restrictive than a CTO—although it does deal with far more severe cases. It can outline where someone lives, who they see and when to take medicine. I would be concerned if some of those matters were covered by CTOs. The Home Office enforces those restriction orders, and usually people placed under them have been in Broadmoor before the order was applied.
Having spoken to a number of professionals, and from what I have heard in the House and in Committee, I would guess that the Royal College of Psychiatrists is split about 50:50 on this. It is perhaps not surprising that its younger members and city-based psychiatrists tend to be more in favour of CTOs. Unfortunately, in constituencies such as mine we have a far higher incidence of mental health problems than we should, but we need to ensure that we are dealing with the situation in the most appropriate way. The same local psychiatrist whom I quoted earlier said:
“The idea that this upsets the relationship between patient and psychiatrist is more theoretical than happening in real life.”
He deals with people on restriction orders and all the other types of leave of absence that I mentioned, and believes that instead of admission, a patient’s relationship with their practitioner can be beneficial. The Royal College of Nursing, among others, is in favour of CTOs as long as they are administered properly.
8.15 pm
An important issue about staff was raised in an earlier debate. It is important that in using CTOs staff are not asked to do something in someone’s home that would put them at risk. We have to get the balance right. It is sometimes more appropriate for somebody to be readmitted to hospital, but it is often better for them to be in the community. However, it is not fair on people in the community who are living with somebody who is not taking their treatment to have to put up with such difficulties when they know, perhaps better than the patient themselves, that something needs to be done that may not be being picked up by the crisis teams.
Another local consultant described sectioning as an act of kindness, and said that it was bizarre to restrict it to hospital. I have come to that conclusion myself. I hope that the hon. Member for Wyre Forest (Dr. Taylor) is reassured by the amendment to which Members agreed earlier, which gives patients going through compulsory sectioning the right to an advocate to argue their case. I hope that some of the points that he raised will be addressed by that, although I have a lot of sympathy with the views that he expressed.
I am in favour of this because of the work that I have done, which shows me that we are only regularising what currently happens anyway. In some cases, we will provide normalcy for patients, beyond mental health issues, so that they can carry on with their normal lives. By happily agreeing to the advocacy amendment—I am delighted that the Government introduced that—we can put in safeguards to ensure that patients in any sort of compulsory treatment, be it in hospital or in the community, have somebody to help them to argue their case for them. That is vital, and makes this a much better measure.
The Bill does not solve all the issues that I, like my constituents—be they users, professionals or residents—think important, but it goes some way towards tackling them.
Dr. Pugh: The hon. Lady has mentioned the problem of patients who lack insight and do not go for voluntary treatment. Not all those people will be subject to CTOs under any regime. Does she recognise that that remains a big outstanding problem?
Meg Hillier: I certainly do. Without going into details, I am representing individuals in a couple of cases, one involving a victim’s family and the other involving the perpetrator, where there was not that insight, and the individuals concerned would not have recognised that they needed treatment. In such situations the “revolving door” bounce back into hospital may still be necessary.
The Bill would not solve everything. I have moved to being in favour of something that I questioned when I first learned about it, because of the evidence that I have heard directly from people, which has shown me that the measure is being used already, but through different routes. If the Bill is passed tomorrow, it will regularise the current situation and give psychiatrists another method of supporting people on the basis of their need. Through the safeguards on advocacy, among other things, we will ensure that patients get many benefits.
Earlier, the hon. Member for Romsey (Sandra Gidley) raised black and minority ethnic mental health issues, which I have also raised in the Chamber and in Committee. The huge inequalities in my constituency are one reason for my getting involved in mental health issues. The Bill is not the place to solve those problems, and I look forward to working with the hon. Lady, and Members of all parties, on tackling those gross inequalities further.
Jeremy Corbyn (Islington, North) (Lab): There is a serious problem of inequality. The number of black and identified minorities that make up the population of mental health institutions is disproportionate by a long way. Does my hon. Friend not believe that the Bill could tackle that a little more?
Meg Hillier: I have already said that one of the main reasons for my interest in this matter is the inequalities in Hackney. The Bill is narrow and primarily tackles compulsory treatment. It is not the right measure to deal with inequality. The Government have a programme about black and minority mental health issues, which is making some progress. At least we now record and recognise the important problems that exist.
Several people have asked whether compulsory community treatment orders would exacerbate inequalities that are already evident. However, I believe that the inequalities exist and are problematic, and that community treatment orders on their own will not increase that inequality. They may reflect the inequality that currently exists and we must accept that reality. We need to tackle the inequality at its root and ensure that it is not reflected in either detention in hospital or compulsory treatment in the community.
Lynne Jones: I agree with much of what my hon. Friend says, but one factor affecting the disproportionate number of black and ethnic minority people who are detained is reluctance to come forward early and access services. I take the point that we must tackle discrimination, but one problem is the culture within a society that does not trust the system. The Bill is relevant to that. We have heard many scare stories about the contents of the Bill, so we must tell the truth about that, but it is also important to have regard to the impact of the Bill on the stigmatising effect on people with mental health problems.
Meg Hillier: I agree that there have been many scare stories about the Bill, which have not helped the general debate in the wider community—or, indeed, in parts of the House. Conversation with several different groups in my constituency, including Derman, which represents Turkish and Kurdish groups, and the Chinese Mental Health Association, shows that there are many complex reasons for people not presenting with mental health problems. Sometimes it is to do with the culture of the community, and I admit that it is also sometimes to do with the way in which the system deals with people.
However, the Bill, with its narrow focus, will not solve those problems, whatever we do to it. If it were amended to the point of dealing with the way in which we provide services, it would be a different animal. It would be about provision of services, whereas it is about the legal rights of detention and compulsion. It appears that there is some consensus in the House about examining more deeply and radically the way in which we ensure that our mental health services provide treatment on the basis of need, and by ethnically blind means so that gross inequalities no longer exist. Black men in Hackney are three times more likely to suffer from mental health problems than anywhere else in the country—I forget my exact facts, but the instance is higher than average.
I look forward to working with hon. Members of all parties to try to tackle the matter, perhaps outside the Bill, but in the next mental health measure—my right hon. Friend the Minister looks weary at the prospect—in which we may consider direct provision of services and tackling inequality. The debate has at least helped air those matters to a slightly wider audience than those of us who live among people with such difficulties.
Dr. Pugh: It is a pleasure to follow the hon. Member for Hackney, South and Shoreditch (Meg Hillier). We are considering a huge cluster of amendments, and it is impossible to speak about them all—and I should not be encouraged to do that anyway.
Amendment No. 101 is an attempt to remove ECT from compulsory treatment, for which I have given sufficient good reason. I want especially to concentrate on amendment No. 96. Like many hon. Members, I am not against CTOs in principle. I know that they exist in many countries, including Scotland, and that evidence for efficacy is inconclusive. I also accept that they are difficult to assess because clients and jurisdictions differ worldwide.
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