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I wish briefly to pay tribute to my hon. Friend the Member for East Worthing and Shoreham (Tim
Loughton) on his huge contribution and to those professionals from the Mental Health Alliance and other organisations who briefed those of us who do not claim to be experts on this issue. We should not be cynical about legislation, because we have made some genuine progress here. The issue is whether we have made enough progress.
I come to the Bill not as an expert in mental health issues—although I have a real interest in them—but because of my general interest in some of the issues of rights it involves. Indeed, through a member of my family, this is something of a family trade, and I was also involved in the Mental Capacity Act 2005 and the development of such concepts. One tries to test them, but my judgment is that, as my hon. Friend implied, with this legislation we have squeezed the lemon as far as we can. There may be another lemon to squeeze before long, when my hon. Friend is the Minister, but—remembering the treaty of Versailles—there may be some gloves to leave on the table in the way of concerns about the human rights implications of the Bill.
Those are, first, in terms of the best interests of the individual, to use a phrase from the Mental Capacity Act, and concerns about whether that principle has always been enacted, especially when an individual does not have impaired decision making and is, in effect, being subjected to compulsory treatment against their will. I still have some major concerns about that, as does my hon. Friend the Member for East Worthing and Shoreham.
Equally, or even more importantly, the Committee expressed real concern about the differential impact on black and minority ethnic communities. That has to be tackled; whatever the legislation says, it is not acceptable in practice. The Minister’s commitment to a diversity amendment is helpful in that regard, and deserves to be singled out.
We are now at the small-print stage of our scrutiny. That is quite proper, as I believe that legislation should be considered in detail, but we must not overlook the big picture. Legislation is part of that, but it is also about delivering services effectively. No single amendment at this stage would make a huge difference in that respect. All of us who were involved in the Committee know that mental health provision in this country remains poor. It is still a Cinderella service: I must choose my words carefully but, at least in relation to other priorities, it is inadequately resourced. We need to give it a better emphasis, which means that we must establish the right sort of legal regime.
Gradually, we have edged our way to a structure that does not challenge the rights of the individual in most cases. We have softened some of the Bill’s rough edges, and although it has taken eight years, the process has been worth while. We can let the Bill go forward, in the belief that it will be enacted and implemented in the most sensitive way possible. No longer will we be able to make assumptions about people who are mentally ill, let alone give the impression that we are consigning them to a lifelong sentence of compulsory control and stigma.
James Duddridge (Rochford and Southend, East) (Con):
I begin by echoing the welcome extended to the Minister, who I am sure will lead us through the final breaths of the Bill as ably as the right hon. Member for
Doncaster, Central (Ms Winterton), who is now Minister of State at the Department for Transport, did in its earlier stages.
The Minister said that it had been a long journey to get this far with the Bill, and it certainly has been. I only joined when I became a Member of Parliament two years ago, and the many constituency cases that I encountered sparked my interest in mental health matters. However, if the road has been long, our route has not been direct and the vehicle that we have used has not been the most efficient. We did not ride in the Government’s Toyota Prius, with all its economy and value; instead, we have taken an old banger to move from left to right. Yet we are where we are, and we have our Bill nevertheless.
Mr. Boswell: Does my hon. Friend accept that at certain points along the road, we appeared to have broken down altogether?
James Duddridge: That is true, but we managed to crank up the old car so that we could move forward again as we approached the end of the Bill’s passage through the House.
I welcome the Government’s latest concessions, and I was especially pleased with earlier amendments on electro-convulsive therapy and age-appropriate treatment. It was with some sadness that I must relate that this is the only one of all the debates that we have had for which I did not receive a briefing from the Mental Health Alliance, which has otherwise given fantastic help throughout.
I am grateful for the amendments that have been tabled—and especially the one dealing with respect for diversity—although they are weaker than I would have preferred. In addition, it makes an awful lot of sense that the amendment dealing with the renewal of detentions should specify two clinicians. I welcome those changes, and the strengthening of the power to recall patients in the community, although I have some caveats as to how that can be done.
However, I retain some deep concerns about CTOs, and especially about the ones that, year in and year out, will not work. I would have preferred a three-year limit on such orders. I would also have preferred the Lords to include a Government amendment to provide an acceptable balance on impaired decision making.
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Unfortunately, I still feel that this is a bad Bill overall, but we have managed to make some progress in the end. I say that it is a bad Bill because people in my constituency—health service professionals—are still opposed to it for solid reasons. I believe that they are still confused by it in many ways, because of the peculiar processes involved in the old banger’s long journey, which has finally come to “The end”.
Mr. Ivan Lewis: With the leave of the House, Madam Deputy Speaker, I shall respond to some of the points made during the debate. There have been some constructive contributions.
It is difficult to respond to the hon. Member for East Worthing and Shoreham (Tim Loughton), but I pay tribute to him for the way in which, I am told, he led for Her Majesty’s Opposition during the deliberations on
the Bill. I thank him for his congratulations on my new responsibilities, which I hold alongside my responsibilities for adult social care.
The hon. Gentleman asked about monitoring the changes with specific regard to members of black and minority ethnic communities. I assure him that we shall be monitoring the measures, including their impact on people from those communities, extremely closely. However, the existing mental health, criminal justice and education systems raise massive issues for our society in terms of relative access to services, relative deprivation and underperformance, some of which have to do with ethnicity. The changes that we propose will do nothing to make that situation worse, and will indeed make it better, so it is slightly disingenuous to suggest that there are no diversity issues or problems for people from ethnic minority communities in the existing mental health system. We have to address such issues irrespective of the changes we are making in the Bill.
The hon. Gentleman asked about the respective professionals who would be able to make decisions. Amendment No. 4A requires the second signatory to the renewal report to have been
“professionally concerned with the patient’s medical treatment”,
so that person will actually know about the patient’s condition—a point I made earlier. To give some further detail, the second signatory has to state
“in writing that he agrees that the conditions”
for renewal are met. They will not be able to do that unless they have examined the patient recently and are confident that they know the patient’s current condition. We regard that as good professional practice. We shall make it clear in the code of practice that such a person should be suitably competent professionally to make the decision.
Tim Loughton: Can the Minister give some more detail about the meaning of “suitably competent” and provide some examples of the sort of practitioner he thinks will now be empowered to give that additional view about renewals?
Mr. Lewis: As I said, the code of practice will make that clear, but “suitably competent” means —[ Interruption. ] This is important. The Conservatives talk constantly about devolution to the front line, trusting the professionals and professional responsibility, yet they want a definitive list of people who would be regarded by clinicians and senior managers at local level as suitable professionals. It is disingenuous to say that we should not prescribe such things from Westminster and Whitehall, while requiring an exhaustive list in the Bill.
Tim Loughton: This has nothing to do with localism and trusting professionals; it is about compliance with the European convention on human rights. Is the Minister saying that those professionals will not have to comply with the ECHR and that everything will be left to local direction? If so, he has grossly misread the legislation.
Mr. Lewis:
No, I am not saying that at all. We have checked, and it has been confirmed that the situation is
entirely compatible and consistent with the legislative framework. We are clear that we want a different way of working in all elements of the health service. We genuinely want a multi-disciplinary approach through which professionals from different backgrounds and with different expertise can make a contribution according to their knowledge, skills and qualifications. What I am talking about is a classic example of that.
Mr. Boswell: Although I do not disagree at all with the excellent sentiment that the Minister has expressed, does he not appreciate that some Conservative Members, some of those in the other place and others in professional circles can see a distinction between wishing to assist a patient—particularly when there is a voluntary capacity—and seeking to coerce a patient in the interests of the wider community? In the second case, there has to be a proper process that is carefully defined to meet human rights criteria.
Mr. Lewis: With all due respect to the hon. Gentleman, I should say that that balance has had to be struck in the mental health system every day of every week since time immemorial. We believe that the legislation has strengthened the approach to those difficult judgments that professionals have to make. Clearly, they have to make them within a robust legislative framework and according to best professional practice. We believe that the legislation strengthens that framework in that environment.
The issue is not new; professionals make those agonising decisions daily, and 99 per cent. of the time they do an amazing job of getting those judgments right. In the tragic cases, of which we are all aware, the judgments are not always as we would want. However, in the vast majority of situations, specialist mental health professionals with expertise on such issues have to weigh up the considerations as an integral part of their professional practice. The legislation does not change that, but strengthens it. One of the challenges is to ensure that every professional working in mental health services should be properly trained about the implications of the Bill and how they will be expected to work.
Ann Coffey (Stockport) (Lab): Does my hon. Friend agree that professionals will be subject to disciplinary procedures should they fall below the standards expected of them? That, of course, is a safeguard for the patient.
Mr. Lewis: I agree entirely. There are a number of issues about protecting and securing best practice: good leadership, good management, continual professional development and the legislative and professional regulatory frameworks. All those things contribute towards ensuring maximum professionalism at the front line of our mental health services. In time, this legislation will be seen to have added significantly to those professionals’ ability to do the job as they would want.
The hon. Member for East Worthing and Shoreham also raised the question of revolving-door patients. As we have said in the past, attempting to define the clinical group in view, as the Lords amendments have attempted to do, is crude and arbitrary. It prevents supervised community treatment from being available to protect vulnerable patients, as well as other people in the community. SCT must be available to patients
undergoing their first period of compulsory treatment, who may be at great risk if they are discharged into the community without the protection of SCT. The incredibly important point is that the first relapse in the community can often be the fatal one. It would be irresponsible to ignore what is clear from the evidence on making such decisions.
The hon. Gentleman also said that the criteria for SCT were too broad and would lead to there being too many people in the system. Actually, the criteria set a high threshold for placing a patient under a community treatment order or SCT: first, a patient must be detained for treatment in hospital; and secondly, the amendment now agreed in the other place makes clear the factors that a clinician must consider when placing a patient under SCT. They include the risk of a patient getting worse in the community. In assessing that risk, the clinician must consider the patient’s history. Those are reasonably clear safeguards in terms of thresholds.
The hon. Member for Southport (Dr. Pugh) usually makes measured contributions, and did so again in his brief speech today. [ Interruption. ] We are not that inclusive. However, it is bizarre to suggest that Ministers should announce today the number of people who will end up on treatment orders, or that they should guess or guesstimate such a figure. This is all about best professional judgments in terms of the interests of people with mental health needs, their families, and the wider community. It would be ludicrous for the Government or the House to prescribe the number of people who will end up accessing the new form of treatment.
Dr. Pugh: I did not suggest that the Minister should give us an exact number; I asked him whether there would be an increase or a decline, and whether it would be substantial. He can tell us that.
Mr. Lewis: The only thing I can say about increases and decreases is that, the way things are going at the moment, there is no question but that the hon. Gentleman’s party will see a significant decrease in its representation in the House. I suspect that questions such as that simply reinforce the point. If I cannot be expected to define a specific figure, how can I be expected to say whether it will go up or down? I am afraid that is beyond me, and would be beyond any Member of the House.
Tim Loughton: Perhaps I can help the Minister. I alluded earlier to the experience in Scotland—albeit at an early stage—which is that the number of patients released under CTOs has been considerably higher than was anticipated. Does he envisage that that may be replicated in this country when the legislation comes in? If so, the word “higher” might be what he is looking for.
Mr. Lewis: I want the professionals to use the legislation that this place is passing to best effect, in the interests of patients, their families and the community. Assuming that that is the basis on which decisions are made, the outcome of those best judgments and professional decisions will be in the best interests of our country. That is straightforward and pretty simple. The hon. Gentleman may want to make petty political points to position himself, but that does not do justice to a debate as serious as this.
The hon. Gentleman asked about limits on CTOs, and referred specifically to the concept of a three-year limit. There is a package of safeguards already in place to ensure that a patient does not stay on a CTO for any longer than is necessary. Once again, we do not agree that an arbitrary time limit is appropriate, because it simply has no clinical basis. An arbitrary time limit could mean patients no longer benefiting from a CTO when they need that treatment.
Tim Loughton: What is the package of safeguards that the Minister has just referred to?
Mr. Lewis: The safeguards will be included in the code of practice that we will publish in due course. They will be about assessment, ongoing review, and the right to appeal. The code of practice will clearly spell out people’s entitlements and rights in terms of having the treatment order reviewed regularly. That will be about clinical judgment and the patient’s health.
Ann Coffey: Does my hon. Friend agree that the Opposition are being extraordinary? They agree in principle to community treatment orders, because, like us, they believe that they are a good thing, enabling patients to have treatment in the community that they would otherwise have to be admitted to hospital to receive. The issue is whether community treatment orders are a good thing, and the Opposition agree that they are; otherwise they would continue to vote against them in the House. Predicting whether there will be an increase or a decrease is not the issue. The issue is whether they are going to be properly applied.
Mr. Lewis: I agree entirely with my hon. Friend. Once we have put the legislative framework in place, accompanied by suitable regulation and protection, surely it is for professionals on the front line to make clinical judgments according to their professional expertise. The Conservative party argues, on every matter of public service and public policy, that we should devolve to professionals, allow maximum autonomy at the front line and not command and control from the centre. However, during this debate, Conservative Members have wanted Ministers to prescribe on the Floor of the House what professionals ought to do, which is entirely inappropriate.
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Many people have made a tremendous contribution to ensuring that the Bill will finally make its way on to the statute book, so I do not want the debate to conclude without paying tribute not only to the Ministers who have been referred to, the Opposition spokesmen and the Back Benchers who have made a contribution, such as the hon. Members for Rochford and Southend, East (James Duddridge) and for Daventry (Mr. Boswell), but to the officials in the Department of Health who have navigated us through a difficult and tortuous process incredibly professionally. The Bill will be seen as a historic piece of legislation that not only reflects the best interests of people with mental health needs and their families, but ensures that the community can have confidence in a modern mental health system.
Lords amendments Nos. 4A, 32A, 32B, 41A, 41B, 41C and 41D agreed to.
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