The
Chairman: Order. The hon. Gentleman has gone rather wide
of the
mark.
Ms
Winterton: I understand that the hon. Gentleman wants to
guard against a future Government that might put pressure on clinicians
who are already working hard and well with the Mental Health Act.
However, is it really the case that, having been leant on by the
Government, those clinicians might become completely different people
and detain people who make comments that are not in line with
Government policy? I must say—to return to the point made by my
hon. Friend the Member for Stockport—that it is unlikely that
waving the Mental Health Act around will stop a draconian
Government.
5.15
pm As I said,
including something that is not a mental disorder in a list of
exclusions of mental disorders is not only unnecessary but,
particularly in matters such as sexual orientation, gives the
impression that we do think that it is a mental disorder and therefore
must be excluded. It is stigmatising in that
respect.
Angela
Browning: The Minister will be aware thatthe
scrutiny Committee recommended exclusions because the definition of a
mental disorder was being broadened. In respect of cultural, religious
or political beliefs, it is not a matter of somebody saying something
and being locked up by a draconian Government butof how those
beliefs might manifest themselves in behaviour. It is the movement from
a clinical diagnosis to a behaviour that will now determine a mental
disorder under the new definition.
Ms
Winterton: As I tried to make clear this morning, we have
not broadened the definition of a mental disorder. We do not expect
that many more people will be included. I gave two specific examples of
people whom I believed were currently not included—those with
acquired brain injury in adulthood and those with some form of
personality disorder. It is a tiny number of people. We are not trying
to expand the number of people who could be brought under the Act. I
know that it is a popular argument that the two go together, but both
are wrong. We are not broadening the definition immensely, and we do
not want to include exclusions for conditions that are not mental
disorders in the first
place.
Chris
Bryant: I am terribly sorry for not saying thank you, Lady
Winterton. It is a great delight to serve under your chairmanship. Now
that I have rectified that, will the Minister respond to the point made
differently by the hon. Member for Daventry, who is probably one of the
nicest Members of the House? He said that one of the difficulties is
that some people, because their faces do not fit, end up in the mental
health system when they might not otherwise have done. The exclusion
worded in terms of cultural beliefs might, in the view of some, fit the
need to rectify the situation whereby many black African and Caribbean
people are detained who probably would not be if they were not
culturally different from
others.
Ms
Winterton: That is an important point. As my hon. Friend
may know, we have a whole programme of work to deal with some of the
issues involved in black and ethnic minority detention, of which there
is a disproportionate amount. Some evidence suggests that that is not
necessarily because psychiatrists do not agree with an
individual’s beliefs but because, very often, that individual
has late access to services in the first place. It is also sometimes
due to the route by which people come in—through the police
system rather than through accessing services earlier.
The Government have a series of
pilots to examine the reasons. The way to deal with that issue is to
take a good look at the clinical practice and how we can reach out more
quickly to people at an earlier stage so that they do not feel
frightened of coming forward for services, and to try to do that
through the Bill. My hon. Friend may know that we have included in the
code of practice principles on non-discrimination that must be
considered. There are ways in which we can show that.
It goes back to my
earlier point about some of the good work on how to have values-based
practice. My Department has worked closely with
psychiatriststo put together training works and written
communications about how to ensure that practice is not based on
judging someone else because of their cultural values.
I hope that I have tried to
answer the point made by the hon. Member for Daventry. First, it is
important to remember that a series of conditions have to be fulfilled
before detention can take place. Secondly, as those conditions
obviously include risk to self or others, any case involves a
risk-based assessment of whether somebody should be detained because of
the riskthat they pose to themselves or to others.
Underthe Government’s proposals, appropriate medical
treatment has to be available.
If the hon. Gentleman was asking
what the medical treatment would be for a cultural disagreement, such
matters would be noticed fairly quickly. As I have said, two doctors
have to agree to someone being detained and such an individual can
appeal to the mental health review tribunal and say that they have been
wrongly detained and do not have a mental disorder but rather a
different point of view. That is why we need safeguards that are clear
to everybody, so that there is a clear path down which people can
go.
Sandra
Gidley: Will the Minister clarify what radical treatment
is available for acute alcohol intoxication, which appears to be
covered under ICD10 and therefore could be used for detention under the
Act?
Ms
Winterton: Treatments are available. I am not a clinician,
as the Committee might have recognised, and I would not like to start a
precedent of giving diagnoses and prescriptions for treatment during
the course of the Bill. That would be quite the wrong path to go down.
Treatments are available and it is important, before we move on to that
point, that we reiterate that it is important that we have safeguards.
The hon. Lady asks what appropriate medical treatment is available.
Under the Government’s proposals, for the first time, there is a
legal basis for considering the appropriate treatment. As it is one of
the conditions, the tribunal is given the ability to ask in many more
cases whether the treatment is appropriate for the
individual. The
arguments that have been made about social control are, in a sense, the
gist of the fears. Can the Bill be used for social control? I do not
believe, for all the reasons that we have discussed, that the
exclusions are necessary in that sense. I re-emphasise that nothing in
the Bill, with or without the extra exclusions, would permit action on
any basis except genuine mental disorder. That is what we need to come
back to every time. The important point is the clarification of mental
disorder and the necessity for things not to get in the way of people
receiving treatment, and I shall return to why I think the exclusions
do
that.
Dr.
John Pugh (Southport) (LD): The Minister is genuinely
trying to shed light on quite a difficult issue, but she is slightly
oversimplifying matters. She just said that no psychiatrist would take
a case to a tribunal or anything else and say, “I’m
sectioning this person because of their cultural differences.”
However, a psychiatrist might regard a person’s cultural
beliefs—or, for that matter, their individual beliefs—as
indicative of a delusion. That is what the precautions try to forfend
and
prevent.
Ms
Winterton: I am afraid that I just do not agree. The
exclusions are currently not in place, yet I do not have an enormous
amount of evidence that thousands of people are being detained because
of their cultural beliefs. I take up the point that my hon. Friend the
Member for Rhondda made about our needing to ensure values-based
practice that is non-judgmental on the part of the clinician. In a
sense, however, that is the process of ensuring that the diagnosis is
correct. The other
point that I particularly want to raise is that there is always a
concern in such cases that a series
of such exclusions could not only cause confusion for clinicians, but
create what we might call a lawyer’s field day. If somebody had
the ability constantly to mount challenges on the grounds that they had
been detained for their beliefs, as opposed to the simple mental
disorder test, that would completely open up the Bill to people
challenging it. That could well happen in some very difficult cases.
Let us remember that in such cases we are naturally dealing with people
who do not want treatment, because that is the reason for the
detention. The more exclusions we include that are not about mental
disorder, but which muddy the issue, the more likely it is that time in
tribunals—this relates to the point that the hon. Member for
Tiverton and Honiton properly raised earlier—will be taken up
with trying to untangle what has been advised in order to get in the
way of getting treatment to people. Mr.
Boswell: Very simply, would not the Minister therefore
agree that the right antidote to any claim that the person is being
persecuted because of their beliefs would be to adduce correct medical
evidence to the effect that their disorder is a mental one, which is
presumably the process that the clinician will have undertaken in the
first place? The clinician would then have the opportunity of
expressing that view and overturning the patient’s no doubt
genuinely felt belief to the contrary.
Ms
Winterton: It is absolutely right to say that that is the
process that the clinician should go through, and that is what the
mental health tribunal has to look at. However, there are cases,
sometimes in offender situations, in which people receive quite strong
legal advice on how not to be in the situation that they are in,
particularly if there is a hospital disposal. It is sometimes in the
individual’s interest not to prefer to be in a prison setting,
as opposed to a hospital setting, because of some of the implications
of that. If we simply allow legislation to pass that gives even more
opportunities for such challenges, when the basis of such decisions
should be whether someone has a mental disorder, we have to acknowledge
that there will be a lawyers’ field
day. 5.30
pm
Mr.
Walker: On the measure relating to cultural, religious and
political beliefs, a paper from the British Psychological Society
said: “This
amendment would only serve to exclude people whose mental disorders
were solely expressed in terms of the issues listed. It would not mean
that people engaging in these behaviours or having such beliefs were
immune from compulsion, should they otherwise meet the relevant
criteria.” So the
proposal relates purely to whether somebody’s so-called mental
illness manifests itself in a political expression. If so, action could
not be taken against them, but if they were doing other things and were
a danger to others because of their actions, other parts of the law
would naturally allow them to be dealt
with.
Ms
Winterton: But that is exactly the point that I am making.
The test in all this is whether there is a mental disorder. The more
that that is complicated by other
exclusions, the greater the likelihood that it will become confusing for
clinicians, who make such judgments all the time, apparently without
locking up lots of people for their religious or cultural beliefs. That
is the initial premise; never mind this future Government who are going
to force them to lock everybody up when somehow everything will change
and people will start down the road of saying, “It’s
about your cultural beliefs.”
I reiterate that there will be
two doctors. We are talking about the mental health review tribunal and
about ensuring good clinical practice. I return to the point: the more
exclusions there are, the more potential there is for confusion and for
challenges by lawyers who may well wish, for whatever reason, when they
give legal advice in offender cases, to say, “We are going to
challenge this on all the opportunities in front of us.” That is
not what we should be doing in modernising and reforming this
legislation.
Tim
Loughton: I am grateful to the Minister for giving way,
because I am desperately trying to follow her argument. May I bring her
back to a point that she made about the people who we are considering
may be those most resistant to complying with the legislation? Does she
acknowledge that a large proportion of the people who are subject to
sectioning enter the mental health services on a voluntary basis? Such
people might be deterred from seeking treatment if they think that they
might be pursued because of some cultural or religious belief that they
hold, particularly if they are a member of a black and minority ethnic
community. They might therefore be deterred from seeking any assistance
from mental health services in the first
place.
Ms
Winterton: I am afraid that I do not follow that argument
at all. The hon. Gentleman is saying that without the exclusions,
people are going to be deterred. I venture to suggest that not
everybody in such a situation will be examining the Mental Health Act.
We are talking about people who are at a vulnerable time in their lives
and are seriously ill. We are talking about the attention that should
be given when people do not want to take voluntary treatment or when
they agree to voluntary treatment but there is a worry that they will
not comply with it, which is when sectioning is sometimes
used.
Dr.
Naysmith: Quite a lot of reference was made this morning
to the scrutiny that we gave the previous Bill—the one that was
replaced by the amendment. One of the things that the Sainsbury centre
for mental health argued strongly was that exclusions for alcohol or
drug abuse could be included and supported, because the deterrence
argument would be strong for people who did not have a mental health
problem but did have an alcohol or drugs problem. None of that would
apply to any of the things that have been
discussed.
Ms
Winterton: I agree with my hon. Friend, so I shall be
urging the Committee to support the Government amendment. The amendment
that has come from the other place is unnecessary and potentially
confusing. It has the potential to deny treatment to people who need it
and we might end up in the hands of a long, difficult
arguments over the legal aspects. Such a situation will not be good for
patients, because vulnerable people will not get the treatment that
they need.
Hywel
Williams: Does the Minister accept that some people in
society have, in their terms, a well-founded belief that they might be
persecuted because of their religious beliefs or their cultural
background? Would not having an exclusion on that point reassure such
people that should they be sectioned, it would not be done on those
particular grounds? I make a reassurance
argument.
Ms
Winterton: Again, somebody might have a fear of
persecution because of their religious belief. Where that is
accompanied by a mental disorder and that fear—what they think
is happening to them—is the result of it, the challenge in the
first place for our mental health services should be to try to help
that person with their condition. That should be our approach where, as
the hon. Gentleman is saying, as a result of a mental disorder such
people have a fear of religious
persecution.
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