Clause
5
Replacement
of “treatability” and “care” tests with
appropriate treatment
test
Ms
Winterton:
I beg to move amendment No. 17, in
clause 5, page 3, line 13, leave
out from ‘is’ to end of line 14 and insert
‘appropriate in his case, taking
into account the nature and degree of the mental disorder and all other
circumstances of his
case.”’.
The
Chairman:
With this it will be convenient to discuss the
following: Amendment No. 59, in clause 5, page 3, line 13, leave out
‘likely’ and insert
‘intended’.
Government
amendments Nos. 19 and
20.
Ms
Winterton:
The purpose of amendment No. 17 is again, I am
afraid, to change what was put into the Bill by the other place. It
will restore the appropriate medical treatment test to its original
form and once again remove the so-called treatability test that was
reinstated in another way in the other place. While the amendment will
change the position of the House of Lords, amendment No. 59 is an
attempt to compromise between the two. Amendments Nos. 19 and 20
restore the changes that we wish to make to the test that second
opinion appointed doctors must apply when deciding whether to authorise
certain
treatments.
3
pm
The so-called
treatability test is one of the criteria for detaining people for
medical treatment, if their medical disorder is categorised as either
psychopathic or mental impairment. It requires the doctor recommending
detention to state that treatment is likely to alleviate or prevent
deterioration in the patient’s condition. The treatability test
is not one of the criteria for detaining patients categorised as having
a mental illness or severe mental impairment. In other words, it is not
one of the criteria for detaining the vast majority of patients, either
under the civil system in part 2 of the Bill or the provisions in part
3 relating to offenders.
The current wording derives from
the Mental Health (Amendment) Act 1982. The origins of the treatability
test go back to the 1959 Act and the Percy commission, which preceded
it. At the time, it was based largely on the notion that society owes a
greater duty to protect people with mental illness or more serious
learning disabilities than it does to those suffering from psychopathic
disorders or less serious learning disabilities. The idea was that
those in the former groups might deserve to be protected by being
housed in a hospital even if their disorder could not be expected to
improve as a result of
treatment.
Over time,
attitudes have changed, and we no longer judge the value of the
treatability test by those criteria. The debate now is about whether we
should persist in talking about the concept of treatability at all,
given what we know now about the options for treating people, and about
whether it is right to have a test that requires clinicians to predict
whether treatment is likely to have a beneficial effect before they can
detain someone. For the Government, the salient questions are: does the
test help people to get treatment, whether voluntary or compulsory?
Does it help clinicians to treat people? Does it provide the necessary
safeguards for patients that cannot be provided any other way? Those
are the questions that we are addressing at the
moment.
Treatability
is not the sole bulwark against non-therapeutic detention; there are
other criteria. In fact, the treatability test in the Bill does not
even apply to those detained for assessment—nearly half of all
detentions under the Mental Health Act—and it does not apply to
the large majority of the rest until after they have been detained. The
test cannot guarantee therapeutic benefits. No one can guarantee that
treatment will work. Appropriate medical treatment, which we want to
introduce, does not mean that people can be locked up without
treatment. That is precisely why the Bill states that appropriate
medical treatment must be available. Of course, it would be wrong to
detain people for treatment without actually offering them any, but the
Bill does not require or allow
that.
The problem with
the treatability test is that it has stood in the way of a number of
people in need of treatment. It has had quite a pervasive effect in
mental health services. Leading forensic psychiatrist Professor Tony
Maden summed it up when he wrote in a letter to The Guardian
recently that the treatability test
“was included in the 1983 Act for
the best of intentions, but proved a disaster in
practice.”
The key to
that disaster is the way in which the test has contributed to a culture
in which certain groups of patients, particularly those with
personality disorders, are too often simply written off as untreatable
without regard to whether potentially effective treatment is available.
Such treatment is increasingly available but its development is being
impeded by a culture, fostered by the treatability test, of dismissing
people as untreatable when their needs cannot be met by general
psychiatric
services.
Curiously
enough, two committees of the British Medical Association wrote to me
recently suggesting that personality disorders be excluded from the
scope of the Bill because they are untreatable. That is the kind of
myth that has pervaded services and service delivery because there is a
treatability test. It has led to
people being turned away from services or discharged after a period of
crisis intervention without proper follow-up. It is important to
recognise that because of the changes that have been made in the
treatments that are available, we need to ensure that nothing stands in
the way of getting treatment to people who can benefit from
it. A sad result of
people being turned away from services was highlighted by Baroness
Corston in her recent report about the prison system. She found that
many women with personality disorders end up in the prison system
rather than being diverted into a hospital to get treatment. She
welcomed the changes that weare introducing in the Bill
because they mean that services can be developed and people can be more
appropriately
placed.
Meg
Hillier (Hackney, South and Shoreditch) (Lab/Co-op): My
right hon. Friend may not be aware that I am representing the family of
a mental health patient who had been in and out of the Homerton
hospital in my constituency for two years, being treated for suspected
schizophrenia. On 7 July last year, he murdered a man by pushing him
under a tube train at Highbury and Islington station. Everyone,
including the defence counsel, believed that he would be put in
Broadmoor for the rest of his life under sections 37 and 41 of the
Mental Health Act 1983, but to our surprise, Broadmoor professionals
have judged that because he has a personality disorder he will not be
put in a mental hospital, but will go to prison. Tomorrow, he will be
given a prison sentence, yet he has a clear mental health
problem.
We must
remember the people involved—not just the murder victim and his
family, but the family of the patient and the patient himself. I have
sat through two and a half days of debate listening to legal points
being made, but we are dealing with people. My constituent’s
mother comes to see me in great distress; her distress, and that of her
family and the patient, will not be any less if he is put in
prison.
Ms
Winterton:
My hon. Friend has a very great understanding
of some of the problems that have been caused by the treatability test,
especially because of her constituency work in this case. I am grateful
for her support for our view, which is reflected by others, especially
in Jean Corston’s report, that that test has stood in the way of
people getting treatment. It has also meant that people end up in the
wrong place, with tragic
consequences.
Another
extremely difficult and sensitive consideration is that the
treatability test is also a perverse incentive for people not to comply
with treatment. Tony Maden, a forensic psychiatrist, has spoken to me
about the fact that in Broadmoor, for example, lawyers have advised
their patients not to engage with treatment because if it can be proved
that they are not treatable they have to be released. Naturally, a
mental health review tribunal would not accept that, but nevertheless
there is that perverse incentive at present because of the treatability
test, and people can quarrel about whether they are detainable in
sometimes very difficult circumstances.
Tim
Loughton:
We have heard this story before. On Monday we
interviewed Lucy Scott-Moncrieff, who is a member of the Law
Society’s mental health and disability committee, and we have
spoken to other lawyers and experts on the matter. She said
categorically that she does not believe that it is a problem and that
she could count on the fingers of one hand the number of inmates of
Broadmoor who, in20 years, have been deemed untreatable. Of
those, only one was let out, and that was against the doctor’s
recommendation. The same line came from Alan Franey, the chief
executive of Broadmoor for many years, who also supports our position.
If the Minister has evidence, she needs to produce it rather than come
up with wild accusations that seem to have no basis in fact or
reality.
Ms
Winterton:
I understand that the hon. Gentleman raised the
matter on Monday and that the witnesses said that they had heard of
cases in which that
happened.
Tim
Loughton:
They did not. The Minister was not there, she
does not know. I am telling her that theydid
not.
Ms
Winterton:
I am absolutely prepared to accept that I may
have heard incorrectly, but I was led to understand—it is
certainly something that I have been told—that there is such an
incentive. The hon. Gentleman actually acknowledged even in the story
that he just told that there is an incentive to say, “I am not
treatable.”
Mr.
Walker:
One person in 20
years.
Ms
Winterton:
One person can be one person too
many.
Meg
Hillier:
The point is not about people being let out, but
about people being let in in the first placefor the treatment
that they need. Too many people, particularly black men, and too many
of my constituents, are in prison rather than in mental health
hospitals or long-stay institutions, which are what they need, because
of that
approach.
Ms
Winterton:
It is also important to remember that some
offenders might well prefer to be in a prison setting because removal
to a special hospital, for example, has entirely different
consequences. There is therefore bound to be an incentive for people to
say that they would rather serve a sentence than have treatment. The
implications are extremely
serious.
Tim
Loughton:
The Minister is again guilty of talking highly
hypothetically. If she now wishes tobase entire legislation on
one person, that is quite extraordinary. Last year, I visited the
dangerous severe personality disorder section of Broadmoor, which is
relatively new. It was full of people who had been in prison and were
given the opportunity to come to a hospital environment to be treated
and looked after. All of them were there by choice, and they all
preferred that setting to being in prison, which is entirely contrary
to what the Minister has just said.
Ms
Winterton:
I think that the hon. Gentleman will
accept—it is almost universally accepted—that there are
people with personality disorders who are in prison because of not
being taken into a hospital
setting.
James
Duddridge (Rochford and Southend, East) (Con): Will the
Minister give
way?
Ms
Winterton:
In a
moment.
For some of
those people that is because they would prefer to be in the prison
system because they will not be detained there as long. That is a real
issue once a sentence comes to an end.
James
Duddridge:
The Minister has answered my
point.
It is important
that we recognise that the current situation has in some instances
prevented services from being developed and turned some people away
from services as a result, and that it also provides a perverse
incentive to make certain arguments in front of tribunals. It is
because of those problems that appropriate medical treatment is much
better.
3.15
pm
The change will
get rid of the incentive to resist treatment and remove all trace of
the language of treatability. At the same time, it will give patients a
safeguard that is every bit as good—better, in fact, because no
one will be able to be detained for medical treatment unless they are
to be offered treatment thatis appropriate for their disorder
and for them as individuals. The hon. Member for Tiverton and Honiton
and I discussed that issue this morning, particularly when considering
the situation for people with autistic spectrum disorder. The
psychiatrist whom the hon. Lady brought to meet me said that she knew
of people with autistic spectrum disorder and Asperger’s
syndrome who had been turned away from services and told that they were
untreatable, and so she felt that there was a lack of service provision
for them. We needed to ensure that the development of services was not
an excuse that could be hidden behind as regards the Mental Health Act
and the treatability test. I thought that that she gave a good example
of why that had caused problems, in this case not just for people with
personality disorders, but for those with ASD and
Asperger’s.
Sandra
Gidley (Romsey) (LD): I am trying to follow the argument
that the previous law somehow led to a barrier to the development of
services. Surely if a condition was treatable in some parts of the
country, treatment not being available in a particular area would not
be a barrier to detainment—or it should not be. In fact, is this
not a Government problem in terms of not developing the appropriate
services?
Ms
Winterton:
No, I am afraid that the approach has led to a
culture of saying that if a condition is not treatable, there is no
point in developing services to try to treat it. I went to east London
recently, where I met an impressive woman psychiatrist who said that,
for the
first time—she had been there some 25 to 30
years—services were being developed for people with personality
disorders. The Government have tried to pilot several schemes to
encourage the development of services, but there is no doubt that the
test has been a barrier. The psychiatrist with the hon. Member for
Tiverton and Honiton said the same thing.
We are trying to get rid of
that test, as we need to make clear that certain criteria must be met
under mental health legislation. First, does the person have a mental
disorder? Secondly, are they a risk to themselves or to others?
Thirdly, does that treatment have to be given in a hospital setting?
Fourthly, is appropriate medical treatment available for an individual?
We are clear about what counts as appropriate medical treatment. We are
not just asking whether treatment is available somewhere at some point
in the future, or whether treatment could be provided, with wishful
thinking; it must be a treatment that suits the individual at that
time. For the first time, the clause puts that argument on a good legal
footing, and it would enable the tribunal to look at whether treatment
is appropriate for the individual. That is what the psychiatrist whom
the hon. Member for Tiverton and Honiton brought to meet me this
morning said. She spoke about the very issue of appropriate medical
treatment and how important it is that we make that change, so as to
give that legal basis—in this case, to help with and encourage
the development of services. Once we overcome the idea that certain
conditions are untreatable in a culture, we can move to a whole
different level.
Angela
Browning:
The Minister will know that a great deal of our
debate has focused on the more critical end of treatment—she
mentioned crisis management and so on—but it is actually in the
stages prior to that point that services are at a far lower level.
Whatever the Bill determines, appropriate treatment needs to be
provided, because many people will still end up in crisis in these
situations, purely on the basis that sustained and appropriate
treatment was not available to them on the path that they took to reach
the point that she describes. I hope that this Bill and her intentions
will encompass appropriate treatment in the community and will be
shared across agencies.We know that mental health patients
often need multidisciplinary teams often need to address the problems
of mental health patients at a much lower
level.
Ms
Winterton:
The hon. Lady is right. That is why the
psychiatrist whom she brought to see me this morning
welcomed our plans for supervised community treatment and said that it
is important that we have those services in the community and do not
just wait until people get to crisis point. That is a real issue. What
has happened with treatability is that people get to crisis point
because there has not been the service development that we would like
to
see.
James
Duddridge:
If I follow the Minister’s logic, she is
saying that a category of people is going untreated because of the
peculiarities of legislation, and that
although more people will be treated overall, there will remain a
category that will be untreatable. I was going to ask her to put a
number on both figures for those who would be receiving treatment but
do not currently receive it and those whom I would term the
untreatable. Perhaps there are
none.
Ms
Winterton:
The hon. Gentleman needs to recognise that the
problem at the moment arises because of the treatability test and the
pervasive culture that says, “These people are
untreatable”. For example, my hon. Friend the Member for
Hackney, South and Shoreditch mentioned her constituent who was told
that there could not be a particular disposal in terms of the court
because his condition was untreatable. We hear about that time and
again. A woman came to see me in respect of the Mental Health Alliance
lobby and said, “Rosie, I have a multiple personality disorder
and keep being told I am untreatable.” I said,
“That’s exactly why we want to make the changes that we
are trying to make at the
moment.”
At the
moment, many people with personality disorders, for example, are
experiencing exactly what my constituent experienced. It is important
that, overall, in our mental health legislation we try to deal with
that. We want to introduce some supervised community treatment to
ensure that people get treatment when they need it. This is about the
development of services in the community. However, if the untreatable
label is hanging over things the whole time, it is difficult for those
services to develop in the first place. That is why we want to replace
the treatability test with an appropriate medical
treatment.
The hon.
Member for Rochford and Southend, East asked about what is untreatable.
Again, that was something that the psychiatrist introduced to me by the
hon. Member for Tiverton and Honiton mentioned and the Committee
discussed this morning. The psychiatrist felt that the problem was that
the treatability test was interventionist, like giving an individual an
injection or medication, and that people can come to associate that
with treatability. She said, “I can’t cure
Asperger’s syndrome, but I know that there are things that I can
do to help.” Some of those things even boil down to ensuring
that somebody is properly nursed and under nursing
care.
When we talk
about untreatability, it is important to recognise that some people go
through a crisis and, even in the course of detention—this is
where we have a big problem with the amendment made in the
Houseof Lords—it is not always possible to say that
theywill immediately get better. Some people in such
circumstances may deteriorate to start with and get better after that.
In a sense, the treatability test has got in the way of good care
because it implies something much more active and sometimes it just
might be appropriate for the individual to have, as I have said, good
nursing care—observation and somebody to talk to at a
particularly difficult time—as opposed to what some regard as
interventionist
treatment.
Angela
Browning:
This may be an unscientific, layman’s
approach, but there seems to be a tendency to move away from in-patient
care. Having spoken to GPs, I know that they would welcome being able
to refer patients to something that I shall describe as
sanctuary—a safe place in which there may be
support of a non-invasive nature. A lot of our mental hospitals are now
predominantly admitting people in crisis, which makes the environment
inappropriate for people with acute depression, and that would also
apply to my Asperger group.
When the Minister talks about
appropriate medical treatment, can she expand on what it encompasses? A
safe place of sanctuary that is supervised and without lots of
medication or invasive procedures is to my certain knowledge not out
there. It is certainly not out there in sufficient quantity for it to
have any impact on the definition. Can she expand on
that?
Ms
Winterton:
It is important to say again that it is very
difficult for us to predict in advance what the appropriate treatment
would be for every single individual. It has to be up to the clinician
to decide what is best. However, if the clinician was detaining
somebody, they would need to be able to say whatwas
appropriate for that individual. That is a very important change. From
the treatability tests, they must be able to say that appropriate
medical treatment is available and that it meets the needs of that
individual. As the hon. Lady said, if meeting the needs of an
individual does not entail direct intervention and that keeping them
safe is the right thing, then that is what should be available. The
problem we have at the moment is that the treatability tests lead
people in the other direction and that is why we want to get rid of
them.
James
Duddridge:
Just for the sake of clarity, what precisely is
medical treatment as opposed to simply treatment? I have noticed that a
number of people, including the Minister and myself, have been bandying
the two around almost interchangeably. Clearly, they are different, but
I am not sure
how.
Ms
Winterton:
Confusingly, the term that is used in clause 5
is “appropriate medical treatment”, yet the title of the
clause refers to “appropriate treatment”. I prefer to
talk about appropriate medical treatment because that is what it
actually says. The parliamentary draughtsman would say that
“appropriate treatment” is fine for the name of the
clause, but our proposal refers to “appropriate medical
treatment”.
Ann
Coffey:
I understand that the words “medical
treatment” include medication, nursing care,
habitation, rehabilitation as well as psychological treatment and
support. It is good that the Government have introduced psychological
treatment as part of medical treatment. Often psychological
intervention can be much more effective than simply giving pills to
somebody.
Ms
Winterton:
That is one of the reasons why we have
said that that kind of treatment should be included. However, it is
very difficult to predict from here what will be right for every
individual in terms of medical treatment.
James
Duddridge:
Such a definition of medical support is very
useful, particularly as it implies broad support. The reason why I was
struggling between the two definitions is that this is at such a low
level. Everyone should deserve support, so everybody should be treated.
Therefore, I do not really understand what the problem is. Perhaps I
did not explain myself first
time around, but I was saying that the definitionof medical
support was helpful, because it included support in general. Surely
everyone deserves such support. People can be given support; as a
definition, it implies a low level of intervention. I do not understand
why there would be a problem with the Bill as it stands after coming
from the other
place.
3.30
pm
Ms
Winterton:
The problem is that of effectively reinstating
the treatability test. That is why it uses the same barriers that have
existed from the beginning. It is saying that the treatment is likely
to alleviate or prevent deterioration in a patient’s condition.
I do not have the wording in front of me. The difficulty is in
predicting that treatment will alleviate or prevent a deterioration.
One of the problems is that we then become mixed up not only in proving
in advance, but in the difficulties caused when talking about
treatability and
curing.
I shall move
on because I want to address amendment No. 59. I am grateful to my hon.
Friends the Members for Rhondda, for Bridgend and for Stockport for
tabling it. It attempts to define appropriate medical treatment as
treatment that is intended to do what I described as the
difficulty—to alleviate or prevent a deterioration in
someone’s condition. The amendment tabled in the other place
would restore the treatability test, which is treatment that is
intended rather than likely to alleviate orprevent
deterioration in the patient’s condition. The amendment is not
dissimilar to the amendment tabled by the Government in another place
to make explicit the purpose of treatment for mental disorder. Unlike
the Opposition, whose amendment appears in the Bill as it is currently
drafted, my hon. Friends have looked closely at whether there is a way
to avoid some of the perverse incentives to which I have
referred.
My main
caveat is that there is more to appropriate medical treatment than
merely a substitute for the treatability test. It is also intended to
provide a new safeguard for patients, namely, that medical treatment
must be appropriate to them as individuals. I am slightly worried that
the amendment would not cover that, so I find it difficult to support
it today. However, I shall certainly take it away and think further
about it, particularly if my hon. Friends can expand a little more on
exactly how they have moulded it and their interpretation of
it.
As for Government
amendments Nos. 19 and 20, I believe that no one has anything to fear
from the changes that we wish to make to the tests to be applied by
second opinion approved doctors when authorising treatment under part 4
of the 1983 Act. We do not expect the changes to make a material
difference to what SOADs can and will authorise, but that does not make
them unimportant. Our amendments make explicit the breadth of what
SOADs must consider but, in so doing, they will not dilute the current
test.
In summary,
Government amendments Nos. 19 and 20 would merely reinstate wording
that more accurately reflects the work of SOADs. By contrast,
Government amendment No. 17 corrects what would otherwise be a serious
mistake and a missed opportunity to improve the criteria for detention
under the Act.
I would like to hear my hon.
Friends’ arguments, but amendment No. 59 looks like a helpful
suggestion of compromise and one that I will reflect on
further.
Chris
Bryant:
It is a delight to serve under your chairmanship,
Miss Begg. I normally sit next to you in the House, where you sometimes
run over my foot, so it is nice to be at a slightly safer distance from
you this afternoon. I would like to say a few things before I
specifically talk to the amendment in my name and those of my hon.
Friend the Member for Bridgend, my near neighbour, and of my hon.
Friend the Member for
Stockport.
First, a
lot of stereotypes of different people’s views seem to be
floating around in the debate. Some people stereotype the
Government’s view as wanting to lock up anybody who has any kind
of mental disorder whatever. Sometimes even the hon. Member for East
Worthing and Shoreham slips slightly towards suggesting that the
Government have such motives. In his calmer moments, I know that the
hon. Gentleman would know and say that that is not what the Government
intend at all. Others would seem to suggest that those with a
libertarian point of view believe that absolutely nobody, ever, in a
free society should be detained under a mental health Act and that
people should only ever be detained under the criminal justice system
for things that they have done. Both are stereotypes that we should
eschew. I do not believe that anyone in the Committee holds either
view.
If that is true,
we must believe that some people ought to be detained under mental
health legislation by virtue of their mental disorder. It must also,
therefore, be clear that there must be some form of treatability test.
I say some form of treatability test, because as we have already
removed the two concepts of mental impairment and psychopathic disorder
from the 1983 Act, it seems clear that the old treatability
test cannot survive. Nor, for that matter, do I believe that there
should be a curability test, which is what some people understand the
treatability test to be. We cannot simply say that because we cannot
cure A, B or C conditions, we ought not be able to detain somebody.
What we may believe to be incurable today may not be what we believe to
be incurable or—I hope—curable in 10, 15 or 20
years’ time.
The hon. Member for Tiverton
and Honiton made many references to advances in the understanding of
autism. I believe that there will be significant changes in how we
understand personality disorders in the next 20 to 30 years. It is
probable that in the past we have not invested enough in investigating
the aetiology of such conditions. We probably need to do more about
that, which I hope will pay
dividends.
However, I
am left with some very importantthings that we need to
consider. Yesterday I spent a considerable amount of
time with a lot of psychiatrists—I know that that does not sound
right, but I am sure that hon. Members will understand what I mean.
Some of the psychiatrists maintained that the way the Government were
moving with the clause was inappropriate. Their argument was that the
Government were being driven by some psychiatrists out there trying to
drum up business for themselves, particularly high-profile business,
running new clinics to deal with people with
personality disorders. I had to say to my psychiatrist friends that I
thought that that was really rather good news—it is good if
people are saying, yes, here is a whole area of psychiatric treatment
that we have not yet done enough work on. If there are
psychiatrists—in fact, more likely psychologists, in this
area—who are trying to explore the recesses of how people come
to develop or acquire personality disorders and how those disorders can
be treated, then that ought to be wholly
welcomed. I also think
that, as my hon. Friend the Member for Hackney, South and Shoreditch in
a sense pointed out in her intervention on my right hon. Friend the
Minister, the way in which the criminal justice system overlaps with
the mental health system is an important factor. In too many cases, the
victims of crimes that were perpetrated by people with personality
disorders are let down by one or other system because they are not kept
informed about what is happening to the people who committed those
crimes.
My hon.
Friend mentioned a case in which the criminal justice system went in
one direction and I referred on Second Reading to another in which the
actress Lynda Bellingham had exactly the opposite experience. The
courts said that if she withdrew the charges against the person who had
thrown a fire bomb through her window because that person had a
significant mental disorder, then the judge would commit him to a
hospital. However, in the event, the moment she withdrew the charges,
the court decided that it could not do that because the gentleman had
already been in hospital for some time. He went on to cause further
problems to Lynda Bellingham and on top of that took his own life only
a week later.
There
are clearly instances in which the mental health system and the
criminal justice system do not interrelate appropriately for the
victims of crimes perpetrated by people with mental disorders or in the
interests of those people themselves. There are even cases in which
there is a direct incentive for somebody to say to his lawyer,
“I would prefer to go to prison than into the mental health
system, because I know that I will be out in two years’ time
when my sentence comes to an end, even though the environment might not
be a therapeutic one”. He might, of course, gain some benefit
from the services that are provided to him in prison. That is an
important issue that we need to bear in
mind.
Ms
Winterton:
It is important to remember that. I take on
board the point made by the hon. Member for Broxbourne about the
release of the wrong person. The fact that the majority of restricted
patients detained under the category of psychopathic disorder claim
untreatability at some point during their detention is a reminder of
that important
point.
Chris
Bryant:
Absolutely. The Minister is right. I would also
make the point that even in respect of conditions that some people
believe to be incurable and many believe to be untreatable, early
intervention by the mental health services is of enormous value.
Indeed, we touched in our debate on Tuesday on black African Caribbean
members of the community, who are probably far too often detained in
the mental health system for psychotic disorders. Many people have
pointed out that the very late presentation of people in
their mental disorder is one of the factors that leads to their eventual
detention. If it were possible to ensure far more early intervention,
with the appropriate treatment, we might be able to avoid the need for
detention. The more that we as a society can avoid the need for
detention, the better it will be in respect of the health of the
individual and the costs to the state.
Angela
Browning:
The hon. Gentleman mentioned costs right at the
end of his sentence. It is very difficult to persuade service providers
that a little investmentin people at a lower level, so to
speak, saves a huge amount at the other end. In terms of human
suffering it is almost unquantifiable.
3.45
pm
Chris
Bryant:
The hon. Lady is absolutely right. One of our
difficulties in persuading mental health services to make that
investment and indeed in persuading people to present is associated
with the stigma that sometimes attaches to specific communities and
individuals. It is a sad fact that a young gay man is six times more
likely than a young straight man to commit suicide under the age of 16.
By definition, those young people find it difficult to come forward to
psychiatric services, because they already feel alienated from society.
The more we can do to transform that situation, the better. It is in
everybody’s interests. We are light years away from where we
were 30 or 40 years ago, as I know from my own
experience.
Mrs.
Madeleine Moon (Bridgend) (Lab): We have had discussions
about early treatability; my hon. Friend has also mentioned the
difficulty that people with personality disorders have had in accessing
treatment and services. Does he agree that the whole point of the
amendment is for the term “intended” to open up the
potential for a lot of people to have treatment, which we hope will
prevent long-term deterioration? It would mean that people would at
least get access, albeit belatedly, to services that they would not
otherwise have
got.
Chris
Bryant:
As is often the case, my hon. Friend puts far more
eloquently than I would do the point that I was about to make. Before I
get to the specifics of the amendment, I want to make a further general
point. Even with what I hope will be the end result of the Bill,
clinicians will sometimes make mistakes about whom to detain and whom
not to detain. I wholly deprecate the fact that the print media in
particular often plays at saying “Let’s search for the
clinician who got it wrong” when somebody commits suicide or
kills someone else after having been through the mental health
system.
In my
experience, everybody who works in the system copes with enormous
stress and strain; the chaotic lifestyles of others descend on them on
a daily basis, which can place huge pressures on them. They are wholly
to be commended. I fear that the blame culture that sometimes surrounds
the issues has made it difficult for people entering medical school to
think about psychiatry as their future career. That is one reason why
we still do not have enough consultant psychiatrists or enough people
applying for vacancies. I hope that we will be able to transform that
situation in the years ahead.
I like the Lords amendment in
part, but I think that it has significant problems. It is in two parts;
I shall deal with them in the wrong order, chronologically speaking.
First, I shall refer to the second element of the amendment, which
relates to
“treatment
which is likely to alleviate or prevent a deterioration in his
condition”.
As the
Minister said, there are many cases in which one knows that the mere
fact of somebody’s detention means that their personality
disorder or other condition will deteriorate. That is a simple point of
fact, because losing their freedom and their volition might well
exacerbate their condition. In many cases, it is therefore difficult in
the short term for a clinician to say unambiguously and without threat
of challenge that the action taken will alleviate or prevent a
deterioration in the condition. In the short term at least, it will
almost certainly cause deterioration.
Dr.
Pugh:
The Lords amendment does not refer to an immediate
amelioration or worsening of the condition; it simply says that that
will occur. It is therefore perfectly compatible with people being
admitted and going on a downward spiral for a short
period.
Chris
Bryant:
I did not say
“immediately”, so I was not seeking to misrepresent the
Lords amendment. There are many cases in which it is uncertain how long
that period might be. A lawyer would certainly be able to ask a
tribunal, “Is the person’s condition going to get better
in two, four, six or eight weeks?” That is the problem with the
Lords amendment.
Another problem is that a
person’s condition may have many different facets, and for that
matter, many symptoms. A clinician may want to treat some of the
symptoms and some of the conditions, althoughthe treatment may
not be able rectify, in any sense,the underlying causes of
those symptoms and the condition itself. That is why there might be
value in exploring whether it would be better to refer to elements or
symptoms of the condition, rather thanthe condition
itself.
I have also
tabled an amendment, along with my hon. Friends the Members for
Bridgend and for Stockport—they are my friends—on the
issue of likelihood. It is quite interesting that the hon. Member for
East Worthing and Shoreham referred to the hope that, in the ordinary
provision of treatment, one in three people would benefit from the
treatment provided. However, the likelihood of treatment alleviating or
preventing a deterioration in condition suggests a more than 50 per
cent. chance. However, it is rare for any treatment to guarantee more
than a 50 per cent. chance of doing either of those two things. That is
why I do not very much like the word
“likely”.
Sandra
Gidley:
I understand that the amendment is
well-intentioned, but it struck me that it is, to some extent, a guinea
pig’s charter, because, increasingly, we must have an evidence
base for what we do. If a treatment has had some proven benefit in some
cases, there is an argument for accepting that. Surely,
ifthere is a good intent but no proof that
somethingever works, that opens vulnerable patients up to
experimentation.
Chris
Bryant:
The hon. Lady is an absolute genius; she foresaw
exactly what I was going to say next. As a good Jesuit, she would know
that intention must always include an element of likelihood, although
likelihood is not predominant. I could not say that I intend to be good
if I know for certain that what I do will not be good. There is always
an element of likelihood in any degree of intention, but I want to
shift us away from saying that people must provethe likelihood
of ameliorating or preventing the deterioration of the condition
towards considering
intentionality.
Tim
Loughton:
I am following what the hon. Gentleman says; he
is making a very good case. I am slightly enamoured of his amendment,
as it contains a scintilla of the therapeutic benefit that we think is
very important. However, what the clinician intends as appropriate
could be a subjective judgment, and it is important in all aspects of
medicine that there is an evidence base for their intervention. Would
the word “intend” mean that the intention could be
examined by a tribunal to ensure that it was reasonable from the point
of view of its likely effect given the evidence base, because it is the
evidence base that is important in respect of the point that he is
making?
Chris
Bryant:
I am fascinated; there are chinchillas, guinea
pigs and all sorts in this debate—
Tim
Loughton:
Scintillas.
Chris
Bryant:
I am sorry. The hon. Gentleman makes a good point
and it is important. As I was trying to explain, if one intended to do
something that was not in the interests of the patient, clearly one
would not be intending appropriate medical treatment. Obviously, that
must be judgable and verifiable on the basis of evidence according to
treatment that has been provided to others. But the word
“likely” on its own and ofitself suggests not
the one in three benefiting fromthe treatment that is provided
that is a common understanding of where medical treatment will be
appropriate, but one in two. That is a very high hurdle for clinicians
to have to overcome to be able to propose a detention. That is why I
tabled the
amendment.
I realise
that what is most likely to happen is that the Government’s
amendment will be taken first. If that amendment is carried, there will
not be an opportunity to vote on my amendment. However, I hope that, as
we move towards the debates on Report, the Minister will look at
whether it is something that the entire Committee can support. It would
relate not only to this clause, but to clause 8, where exactly the same
words have been inserted by the House of Lords.
Debate
adjourned.—[Claire Ward.]
Adjourned accordingly at
four minutes to Four o’clock, till Tuesday 1 May at half-past
Ten
o'clock.
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