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As an alternative to sectioning, CTOs have some attractions. However, as an extension to coercive
medicine, they pose some genuine dangers. Throughout the process, the Government have been unable to guarantee that the range of coercive treatment would not be increased. The object of critics is to ensure that the threshold of coercive medicine is not lowered unduly. Amendment No. 96 would do that.
Amendment No. 92 is the nuclear option, for when all else fails. Amendment No. 96 would introduce a set of eminently reasonable criteria, including impaired judgment, a record of refusal, and evidence of the medical efficacy of the treatment offered. The individual would have to be sectionable, and at risk to himself or the public. There would have to be evidence that treatment was available and the individual would, in theory, have to be recallable to hospital if he defaulted on his course of treatment.
At least four of the conditions are the same as the Governments proposal. The only genuinely crucial distinction between the Governments proposal and amendment No. 96 is that the amendment would require evidence that the voluntary route was unlikely to work, but that the compulsory route would work. That is a reasonable expectation. It could be argued that the threshold is higher than the current threshold in Scotland. The Scottish legislation has been much admired throughout our discussions, including by many critics of the Bill. Perhaps the amendment would provide for a higher threshold than exists throughout the world, wherever CTOs are used. However, it is not much higher than that that the Government have already set, and it is necessary to allay fears.
I share some of the views of the hon. Member for Hackney, South and Shoreditch, who emphasised the fact that many of the fears that have been expressed about the Bill are grossly unreasonable, unfair and uncharitable towards the legislators. I am genuinely surprised that many of those who, like me, are sceptical about the prospect of CTOs reducing suicide, believe totally and without much evidence that their mere existence will drive people away from seeking help. Worldwide evidence leaves one agnostic on both scores.
It we are to use CTOs for their avowed purpose, not simply as an extension of coercive medicine, the Government must explain why the threshold in amendment No. 96 is too high. Mere stubbornness will not do. The Government have a chore to convince hon. Members on this side of the Chamber that our proposal is unreasonable, given that it supplements theirs with reasonable expectations about the efficacy of treatment and the likelihood that the patient will not be dealt with effectively on a voluntary basis.
James Duddridge: Early in his contribution, the hon. Gentleman referred to amendment No. 101 on ECT. I am not sure why he brushed over it so quickly. It is an excellent amendment, and perhaps he could go into more detail about his reasons for brushing over it. Has he received reassurances, or did he not speak about if for long because of time constraints?
I have spoken about the topic for a considerable time already; I am fearful of acquiring a reputation in the subject. The point that I wish and intend to make is that where compulsory treatment is in place, it should not entail anything as invasive or
uncertain as electroconvulsive therapy. I believe that that is a general common-sense point that we can all accept.
Let me return in conclusion to what the hon. Member for Hackney, South and Shoreditch said. There is a real danger of decrying this legislation because it does not achieve everything. However, I would like to repeat, as an addendum to what I have said previously, that there are many people out there who are rattling around in society with very little insight into their condition, but they are not sufficiently dangerous or troublesome ever to meet the criteria to become eligible for compulsory treatment. My point is that we simply have no solution for those people at the moment. At one stage, they would gradually have drifted towards the institutionalised route, but now they exist in various forms and are by and large untreated.
Jeremy Corbyn: Does the hon. Gentleman accept that the prospect of compulsory treatment might actually be a deterrent to some people, and indeed might deter their friends, family or neighbours from advising them to seek the help that they clearly need and deserve? Might we not end up with more people in an even more vulnerable situation as a result?
Dr. Pugh: I share the view of the hon. Member for Hackney, South and Shoreditch that there is no evidence for that. There is a great deal of worldwide evidence of using community treatment orders, which we can look at to establish whether it does drive people away from ordinary means and mechanisms to secure treatment. I do not believe that the evidence is there, so although the point exists as an allegation, it remains largely just a fear at the moment.
Mr. Walker: I raised my concerns about community treatment orders in Committee and, with the indulgence of the House, I will do so again on Report. I hope that I have the Ministers indulgence and that she will not mind if I raise my concerns with as good grace as I can muster [Interruption.] That sounds pretty good.
There are huge resource issues with CTOs. From the piles of briefing that we have read over the past couple of months, it seems that there are currently about 32,000 people a year receiving some form of in-patient hospital care. With the introduction of CTOs, it is estimated that the numbers involved could be in the region of 25,000 a year. The figure is disputed, but a number of organisations that submitted evidence as part of the consultation process and then as part of Public Bill Committee scrutiny believe that the threshold for CTOs in this country will be set at a far lower level than that in many of the other 70 jurisdictions. It is anticipated that about 50 people per 100,000a significant numberwill be eligible to be placed under CTOs in this country. I am well aware that the Minister disagrees with the figure and will probably come back with a counter-bid, but if we could work on the basis of 25,000 people for the next few minutes, I would be grateful.
Angela Browning: Psychiatric ASBOsand I am grateful to my hon. Friend, who is as astute as ever on the Front Bench and listening to my every word. If they are not to turn out as psychiatric ASBOs and if they are to stand a chance of working effectively, what about the resource implications, which my hon. Friend the Member for Broxbourne (Mr. Walker) has just mentioned? How will they manifest themselves and what will be the impact on other community-based psychiatric services?
Mr. Walker: My hon. Friend makes an excellent point. We are perhaps in danger of commanding mental health armies that do not existor do not yet exist. We need to be aware that huge resource issues are involvedwe are talking about 25,000 people in England, which is about 500 for each county, and many will require additional support to what is already being provided by the existing excellent mental health service professionals. We thus need to explore the mechanism for delivery at greater length. Perhaps the noble Lords in the other place will do so when the Bill returns to them.
The hon. Member for Finsbury Park [Interruption.] The hon. Member for Finsbury, North [Interruption.] I mean the hon. Member for Islington, North (Jeremy Corbyn), I am sorry. I wanted to leave Finsbury Park in, because it is one of my local train stations on the way through to the House. I apologise as no slight was intended. The hon. Gentleman made an important point about the concerns of black and ethnic minorities. I have a briefing from the Commission for Racial Equality, which is concerned that certain communities will be more prone than others to CTOs. Of course, we hope that that will not be the case, but we need to have procedures in place to ensure that the concerns of minority groupsand indeed the concerns of hon. Membersare properly reflected in the implementation of CTOs. We do not want to disfranchise huge parts of our community so that people feel that the Bill is yet another measure unfairly applied against them. That is not where we want to be.
I return to the point made by my hon. Friend the Member for Tiverton and Honiton (Angela Browning). Who will actually deliver CTOs? Will it be community mental health nurses, or will there be CTO teams working together to ensure that the orders are applied and work fairly in the community? CTOs will have significant training implications; the orders will be new to this country so we shall want to be sure that they are subject to best practice and effectively delivered. Who will be responsible for providing training? How much will it cost and how will it be given? Will it be on the job or will front-line practitioners have to be taken
away from their patients to spend time learning about the new techniques? I hope that the Minister does not think I am being churlish when I raise these concerns [ Interruption. ] I am sure she does not; she is too generous.
Lynne Jones: I am rather perplexed by the hon. Gentlemans argument. By and large, the people we are talking about will already be in the mental system. Unlike the Scottish system, this proposed system is more liberal in that people have to be detained in hospital before they can be subject to a CTO, so has it occurred to him that some patients might think that a CTO would guarantee them services they cannot receive because they have been discharged and will be forgotten until the next time they exhibit difficult symptoms?
Of course, CTOs will be applied only to people who have been in hospital, but how long will the orders last? If 32,000 people are seen in hospital over a year, how many will be subject to CTOs and for how long? Will the orders last six months, a year, two years or three years, or will they be indefinitealmost life sentences? The hon. Lady makes an important observation, but I do not think I am being hostile in arguing my concerns. I am raising legitimate questions to which mental health professionals have the right to an answer.
Many of the people who would be subject to a CTO will be known to the mental health services, but we are not talking about business as usual; CTOs will introduce a whole new regime and a whole new system for dealing with people, and they will require a whole new set of skills.
Meg Hillier: The hon. Gentleman talks about a whole new system, but in my comments I highlighted the fact that there are already cases of people who are, in effect, on community treatment orders. They are admitted to hospital under a section and when they are released they have to undertake certain treatment or they will have to go back to hospital. Given such examples, it seems to me that the hon. Gentlemans argument falls apart.
Angela Browning: The hon. Member for Hackney, South and Shoreditch (Meg Hillier) may have been referring to a recent meeting we attended with the Minister and some psychiatrists she had invited to the House. When I raised the existing section 25A orders under the 1983 Act, I was told that there are powers that allow people to go back to the community, but with the threat that if, for example, they come off their medication, they can be taken to a hospitalusually by the police. A psychiatrist told us, quite flippantly, that the powers were rarely implemented because the police do not want to co-operate. It is scandalous that powers on the statute book that could be used effectively are not being implemented.
Mr. Walker: My hon. Friend makes an important point. If such powers already exist, we should be asking why they have not been used more widely and why we do not consider using them more widely before introducing CTOs.
Angela Browning: I do not know the exact number, but I raised it only last week with the psychiatrist whom the Minister brought before those of us who chose to attend her meeting. It was a good meeting, but I was interested to know why section 25A orders are not used more frequentlythey have been on the statute book for a long time and the psychiatrist said that it was because the police do not want to co-operate. The situation is extraordinary.
One concern about CTOs is how they will be implemented at local level when there are many hundreds, if not thousands, of them. How will we know if people are not complying with them? Who will be there, day in, day out, monitoring their effectiveness? Will there be a spy camera in someones bedroomI am sure that there will not beto ensure that they are taking their medication, or will people follow them to ensure that they do not go to the pub? Those are Orwellian possibilities, which I am sure will not happen, but the legitimate question is: how on earth will we realistically monitor 10,000, 15,000, 20,000 or 25,000 people on community treatment orders? If someone breaks an order, what will we do? Will we send them a warning letter, will they get a knock at the door, or will they receive a visit from one of their clinical team?
Jeremy Corbyn: The hon. Gentleman should remember that many of the people who do not take their medicine as regularly as they should and so on are often lonely, isolated, have bad relations with their neighbours because of their condition, and do not receive sufficient support. If community care is to be effective, we need a much better system of local, individual, social support for those people.
The hon. Gentleman makes an excellent point. I recall that many years ago when I was a young man there was all-round support for the idea of care in the community, returning people to the community, and closing institutions down. It sounded extremely
good, and in theory was extremely good, but when people got back into the community insufficient care was delivered. PerhapsI am not an expert on thiswe would not need to go down the road of CTOs if we had the proper resources in place to ensure that people with mental illness receive the care and the contact that they need.
It would be interesting to consider how we will measure CTOs effectiveness. Again, I do not have the answer, but I am sure that the Minister has, and I am sure that she will tell us that she looks forward to coming to the House in three or four yearsI look forward to my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) coming to the Houseto tell us how they are working. I hope that they will have achieved what people want them to achieve, and that we will have better delivery of services to the mentally ill in our community.
It has been pointed out that many of the people concerned are known to the mental health services, and that is so, but community treatment orders will often be compulsory, and that will require advocacy, which will have another implication on resources. We talked earlier about advocacy services, but if we are applying community treatment orders liberally around the country to people who do not want to be subject to them, I imagine that the demand for advocacy will be high. We must consider how we will meet that demand and who will meet it.
We have talked about using local charities, such as Powher, which operates in my constituencyI am not sure whether hon. Members are familiar with itbut empowering such charities to help people who are worried about being placed under a CTO might be a way forward.
FinallyI am sure that that will be a great relief to all hon. Members assembled herehow will we protect the confidentiality of patients under community treatment orders? Many of them will have jobs and places of work, and a CTO might stigmatise them. I would be interested to know whether, if someone is placed under such an order, there would be a personal contract between them and the relevant health service, or would the CTO be made known to a wider audience?
To conclude, if such services are to be delivered in Hertfordshire, the Minister will have to take a long, hard look at what is going on with our mental health trust. Its budget has been cut by £5 million a yearlast year, this year and next year. That will have resource implications, which I hope that she will take into consideration. I tried to make that point with extreme good grace.
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