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Tim Loughton:
I greatly respect the hon. Gentleman’s position—he and I have been heavily involved in this issue from the early days of this legislation—but the fact is that the majority do not agree with him. The
Royal College of Psychiatrists and the British Medical Association do not agree with him. There are some psychiatrists who do agree, including a predictable dozen whom the Minister troops out at every opportunity to talk to us, as if they represent the entire psychiatric field. But they are, with perfectly good intentions, in a minority—
Lynne Jones: It is unfortunate that the hon. Member for Hackney, South and Shoreditch (Meg Hillier) raised the current powers, because she has been hoist by her own petard on this issue. I have a letter from Professor Sarawan Singh, one of the psychiatrists who came to the meeting. I have talked to him, and he quotes a survey published in the British Journal of Psychiatry in 2000, which showed that 46 per cent. of psychiatrists responding were in favour of CTOs, 35 per cent. were not in favour and 19 per cent. were unsure. I do not know whether there have been any subsequent surveys, but it would appear that claiming that the majority of psychiatrists are against CTOs is not necessarily true.
Tim Loughton: They had every opportunity to influence the position of the Royal College of Psychiatrists and the Mental Health Alliance, but they have not been able to do so. I remember Professor Singh, when he came to that briefing with his 11 colleagues, together with Dr. Swartz, who was flown over at Government expense from the US—
Ms Winterton: That is not true.
Tim Loughton: Well, he was flown back at Government expense. I do not have a copy of the Minister’s admission, but Dr. Swartz, from Duke university, North Carolina, was shipped in to speak alongside several other so-called professionals to tell us how wonderful CTOs were in North Carolina, but the CTOs there are rather different and he did not even know what sort of CTOs the Government are trying to promote in this country. For that, the Minister has admitted that we had to pay part of his airfare and his other travelling expenses, and that was a poor deal.
There are two other important issues. Amendment No. 103, which is coupled with amendment No. 90, provides the right for patients to apply to the mental health review tribunal to vary or suspend the conditions of their CTO or the period for which it is in force. The tribunal can therefore recommend that those conditions should be varied or suspended and can follow up the issue if the responsible commission does not make the changes that it recommends. That is important, because if we are to have some form of CTOs, we need flexibility so that they are sensitive to individual patient’s needs, especially given the great powers to impose all sorts of conditions even within the diluted form of CTOs that we will now have. In the interests of balance and fairness, patients must be able to challenge the conditions of the CTO imposed on them.
Amendment No. 87 goes back to Genevra Richardson’s original expert committee, and her reference to the lobster pot analogy. People can be subject to CTOs, but it is not clear how they can have them removed. CTOs can be renewed every six months
or year, in perpetuity. If a CTO is still going after three years, it has clearly failed and is not the solution for the patient concerned, so we need to go back to the drawing board and review the best form of treatment for them. It is also natural justice that if we are to impose criteria that restrict the liberty of an individual, he or she needs to know how they can avoid getting into the lobster pot and, equally, how they can get out of it when their condition improves and they no longer need to be subject to the same strict criteria.
The lobster pot is a good analogy. It is easy to get into it, but difficult to get out of it, and that is why we need the checks and balances in amendments Nos. 103, 90 and 87. If we are to have CTOs, people must know how they can justifiably avoid them, or have them removed. That must be in the best interests of those people for whom a therapeutic benefit is intended and who need to trust the clinicians treating them.
9.15 pm
Ms Rosie Winterton: We have had a thorough debate. I hope that I will be able to address all the concerns that hon. Members have raised and to explain why we reject several of the amendments that have been tabled. I also hope that I will be able to indicate that we have examined the matter carefully, which is why we have tabled specific amendments on the conditions of supervised community treatment. That has occurred because concerns have been raised about supervised community treatment during extensive debates in the House of Lords and in Committee.
Let me set out some of the background to supervised community treatment because it represents one of the most important changes that we wish to bring about through the Bill. We want to reflect what takes place in other countries and the fact that more services are now delivered in the community. We want services to support patients effectively so that they can live safely and successfully in the community in the least restrictive environment that can be achieved under compulsory treatment. Such an approach means that patients will spend less time in a hospital environment and more time with their families and loved ones. If we can achieve that without bringing any harm to patients and while protecting others from harm, we should certainly do so.
When we began this debate many years ago, we intended to allow patients who had not been detained in hospital at all to be on supervised community treatment, which is what happens in Scotland. Legislation was recently introduced in Scotland to provide that people can be detained if a clinician thinks that that is right and to allow people to undergo compulsory treatment in the community, irrespective of whether they have already been detained in a hospital setting. We accepted that there was a great deal of concern about that and listened to the views of the pre-legislative scrutiny Committee. We thus brought forward measures to provide that patients would have to undergo a period of detention in a hospital setting before they could be subject to a supervised community treatment order. Several clinicians criticised us for moving too far and said that we should not restrict clinicians’ ability to allow patients to benefit from supervised community treatment if they felt that that was the right thing for the patient. However, we recognised that there was concern about the proposals.
The hon. Member for East Worthing and Shoreham (Tim Loughton) said that our CTO proposals went wider than those in any of the 52 jurisdictions that he cited. I think that that figure was produced by the Mental Health Alliance, but we have no idea of how its conclusion was reached. It is only in Canada that it is necessary for a patient to be detained in hospital before going on to a CTO. Even in those circumstances, the detention need not take place immediately beforehand, as it must under our proposals. I am thus at a loss as to where that information comes from.
Tim Loughton: The Government have changed their position. Which other country has CTOs that require people to abstain from particular conducts?
Ms Winterton: In a number of jurisdictions where conditions are set, they can extend to specifying certain activities. We are talking about requiring someone to abstain from a particular conduct. If using illegal drugs exacerbates a person’s condition, or if consuming large amounts of alcohol contributes to their mental health deterioration, such matters are set out in conditions. However, I shall deal later with requirements to abstain from particular forms of behaviour, because they are an important part of the changes made in our amendments.
The hon. Gentleman referred to existing powers available under the 1983 Act not being effective. The real problem is that those powers, which I believe come under the heading “supervised aftercare”, do not allow immediate recall to hospital if the patient’s mental health deteriorates to the extent that they become a danger to themselves or to others. I believe that the hon. Member for Broxbourne (Mr. Walker) referred to the problem facing clinicians in having to go back to the beginning—to a completely new detention scenario—to be able to bring someone back to hospital. That is why those powers have not been used as often as they might have been.
Mr. Walker: I am not being argumentative and I hope that the right hon. Lady will take my question in the spirit in which it is asked. To tell a chronic alcoholic or drug addict who also has mental health problems that they will be readmitted to hospital if they break the requirements of their CTO to avoid drugs or alcohol seems unreasonable, unless one provides that person with support that enables them to stay away from their addictions.
Ms Winterton: I hope to be able to deal with that question, because it relates to the points that the hon. Gentleman made about the availability of services.
On whether there are clinicians who support the introduction of CTOs, the new mental health coalition, comprising Unison, Unite, the Royal College of Nursing, the College of Occupational Therapists, the British Psychological Society and the British Association of Occupational Therapists, which together represent 85 per cent. of mental health workers, acknowledges in its briefing that
“there are concerns surrounding the use of Community Treatment Orders, however we also believe that for a number of patients they can provide a real opportunity to be cared for at home. We welcome the Government’s amendment that CTOs should demonstrate a health benefit”.
Those organisations represent 85 per cent. of health workers, as well as clinicians.
The hon. Member for East Worthing and Shoreham may rest assured that I shall certainly apologise to Professor Swartz and the other clinicians who visited the House of Commons for his rather aggressive behaviour toward them. They had given up their time to come and talk to Members of this House and give their views on the Bill, and I felt that the hon. Gentleman dealt with them disgracefully.
Ms Winterton: Please take the opportunity to apologise.
Tim Loughton: I certainly apologise if the Minister thought that I was unduly aggressive. The point that I was making is that she trooped out a dozen or so professionals to give their view, which happened to accord with her view but not with the view of the majority of the professional bodies to which they belonged. She has to admit that Dr. Swartz, who was rather surprised to be here, did not actually know why he was here, or the Government’s position on the legislation that he was supposed to be commenting on. One did wonder why the meeting was set up in that form.
Ms Winterton: The meeting was set up in that form because the hon. Gentleman asked whether there were psychiatrists who supported the Government’s view. Naturally, in my desire to please him—that is usually the thought that is uppermost in my mind—I arranged for a number of highly regarded psychiatrists to come to the House of Commons. I am glad that he has changed from talking about “so-called” professionals to admitting that they were professionals.
Mr. Jim Devine (Livingston) (Lab) rose—
Ms Rosie Winterton: I give way to my hon. Friend the Member for Livingston (Mr. Devine).
Mr. Devine: I am grateful to my right hon. Friend for giving way, and I see my good friend on the Opposition Benches, the hon. Member for Broxbourne (Mr. Walker), wants to intervene, too. As the Minister knows, I have actually worked in primary care psychiatry, and when I was her Parliamentary Private Secretary—before I had to resign, sadly—we had good meetings with psychiatrists who were very positive about the Bill. In addition, she now has the support of Unison and the Royal College of Nursing. Basically, everyone who is a major player now says that this is a good Bill.
Ms Winterton:
Scottish psychiatrists have had similar powers to those that we propose for many years, and I think that my hon. Friend would agree that if it was ever suggested at meetings that those powers should be removed because of concerns, they would think that it was an outrageous removal of clinical powers that have been extremely effective in helping
patients to get treatment. That is what the Bill, and what supervised community treatment, is about. It is about getting treatment to people who need it, and who are in very vulnerable circumstances.
Jeremy Corbyn: The Minister will have heard my earlier intervention on the hon. Member for Southport (Dr. Pugh). Does she concede that it could be argued that there is a danger that people will be deterred from seeking any kind of help, support or treatment because they will feel that there is an element of compulsion? That could cause a negative reaction in the community. Additionally, there is the problem, which I am sure that she will address in her speech, of the disproportionate numbers of black and minority ethnic patients who end up with a degree of compulsion in their treatment.
Ms Winterton: My hon. Friend raises an important point about people being deterred from seeking treatment, but one reason why they are deterred is that they feel that they will have to spend a long time in a hospital setting. In actual fact, supervised community treatment is about providing the least restrictive setting that we can, if it is appropriate for a patient. It is about sending a clear message that when we talk about compulsory treatment, it does not always mean having to keep people in a hospital setting; we will allow them to return to their families, if that is appropriate. That is a different message, and it is less stigmatising and less discriminatory than saying that anything to do with compulsion has to involve a hospital setting. I think that the measures will not have the effect that my hon. Friend is talking about.
I believe, too, that there is a series of reasons why a disproportionate number of people from BME communities receive compulsory treatment. There are delays in people coming forward, because they do not access community services. Some of them take a different route into compulsion—for example, through greater contact with the criminal justice system. Very often, their relatives contact the police, but not health professionals. There is therefore a series of complicated reasons for that disproportionate number, which is why we have introduced the “Delivering race equality” programme, and why—I am afraid to use the phrase, but it is what they are called—we have focused implementation sites around the country, including several in London, which are looking particularly at the reasons why people do not come forward for treatment, and why a greater proportion of BME patients receive compulsory treatment. It is not as easy as saying that there are greater numbers because people are frightened to come forward—the position is much more complex.
9.30 pm
May I tell my hon. Friend the Member for Islington, North (Jeremy Corbyn), too, that it is important to remember the fundamental principles? As a result of discussions in the other place, we have included in the Bill the points that should be addressed when we draw up the principles in the code of practice. One of those principles is the avoidance of unlawful discrimination, and we have made it clear in the Bill and the code of practice that racial discrimination must be tackled as part of the way in which clinicians and the measure itself operate.
Ms Winterton: I shall give way to the hon. Lady, but then I must make progress.
Angela Browning: The right hon. Lady has prayed in aid certain groups of professionals who are in favour of CTOs. It is true that last week she managed to find 11 psychiatrists who support the Bill, but the overwhelming majority of members of the Royal College of Psychiatrists oppose the measure. However, there has been no mention of the patients. Only today, Members received a letter in preparation for our debate on Second Reading from Mind, which represents patients and carers, which said:
“Mind remains opposed to CTOs. The case for their introduction has not been made.”
It lists six key points to demonstrate why it opposes CTOs, and the Minister will be familiar with them. What about the patients?
Ms Winterton: Many surveys of patients in other countries say that they and their carers like the use of supervised community treatment, because it allows them to return to a less restrictive environment and into the care of their family. The Opposition must make up their mind: are they are just going to bang on about not liking CTOs or are they going to support them, while expressing concern about some of the conditions? To keep rehearsing the arguments, however, is not helpful. I will explain why we think that the measure is right, but if the Opposition oppose CTOs, it would have been better if they had not tabled amendments but agreed that that is their position.
Mr. Walker: I am not sure that I can be helpful, but I will not try deliberately to be unhelpful. I met an outstanding consultant psychiatrist near Bristol called David Thurston who, for years, has gone out to meet his patients in pubs, at home and in places where they feel comfortable. He is concerned about CTOs which, he believes, may well drive a wedge between him and his patients. He has a method of working that works for him and his patients: will he be obliged to use CTOs, or will that be left to his discretion?
Ms Winterton: I have made it clear over and over again—I hope that the hon. Gentleman acknowledges that, because this is exactly the debate that we had in Committee—that the power is available to clinicians if they think that it is the right thing to do. There is no compulsion on them to use compulsion—it is for them to make the decision, based on a range of issues, and if they think that that is appropriate. May I return to the reason why we believe that supervised community treatment can help to get treatment to people? There are 1,300 suicides every year, and 50 homicides by people who have been in contact with mental health services. We believe that supervised community treatment is vital to helping patients continue to take treatment when they leave hospital and to enable clinicians to take rapid action if relapse is on the horizon.
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