Memorandum submitted by Martin Jeremiah (MH 1)

 

Summary

 

1. Introduction

2. Comments on coercive delivery and current safeguards

3. Case study - A patient's experience of compulsory treatment

4. Inadequacies of current safeguards - comments relating to the 2005 MIND annual conference and the case study

5. Conclusions

6. Footnote

1. Introduction

 

1.1 My name is Martin Jeremiah and I am a freelance management consultant. I am also a member of MIND. I am submitting evidence to the Committee on the basis that I stood in the UK General Election of May 2005 to highlight what I considered to be a severe abuse of compulsory treatment concerning a mental health patient.

 

1.2 I am therefore concerned that the new Mental Health Bill threatens to:

 

a) make the NHS more restrictive and coercive in its delivery of mental health services;

b) fail to provide carers and patients with the safeguards expected of a twenty-first century system of care.

 

2. Comments on coercive delivery and current safeguards

 

2.1 Wherever coercive delivery exists, it logically follows that there is enhanced scope for abuse. In respect of medication there are many potential motives for drug choice which may include:

a) commercial pressures on an NHS trust that might lead them to accept incentives from drug companies;

b) possible involvement of individual medical practitioners with drug companies e.g. the acceptance of hospitality.

 

2.2 Patients detained under Section 3 of the 1983 Mental Health Act can already have medication imposed upon them via a second opinion from a Second Opinion Approved Doctor (SOAD). On the basis of experience highlighted in this submission, I currently have a concern that the possibility to dictate inappropriate medication schemes to a patient will be further enhanced by the new Mental Health Bill.

 

2.3 The above would not be a problem if safeguards were extended to combat enhanced scope for abuse perhaps? In this respect, I offer this case study as an example that current safeguards:

 

a) are too bureaucratic and complex to be effective;

b) cannot be enacted in the timescales necessary.

 

3. Case study - A patient's experience of compulsory treatment

 

3.1 A drug that was unlicensed in the UK at the time was imposed on a UK patient, allegedly via second opinion, after the patient had refused it. The patient had initially, verbally agreed to take the unlicensed drug, but had changed her mind due to a perception that there might be un-stated possible side effects. The dosage was subsequently raised to 30 mg. which was in-line with a trial being conducted at that time. This was the maximum allowable dosage by manufacturer's recommendations. There was no obvious therapeutic benefit to this dosage as there was much American research available over the internet at that time to illustrate that there was no difference in efficacy between 10 mg, 15 mg. and 30 mg doses.

 

3.2 The patient became very ill with extreme side effects of psychosis, agitation, sweating and shaking; as well as exhibiting violent and aggressive behaviour. Her family begged the medical staff to take her off of the drug (both verbally and in writing) to no avail. Instead, a forensic assessment was arranged with a view to sending the patient to a secure unit because of her behaviour. However, a family member managed to bypass the medical staff and make the independent assessors aware of the drug issue. The move subsequently failed. Once off of the drug and onto Clozaril (which should have properly been prescribed under National Institute for Clinical Excellence guidelines rather than the unlicensed drug) the patient recovered.

4. Inadequacies of current safeguards - comments relating to the 2005 MIND annual conference and the case study

 

4.1 There were no safeguards to protect the patient at the time that the patient needed them. The complaints department of the NHS trust said that they "could not interfere in clinical decisions". The complaint went through two written rounds at local resolution over a period of four months before being escalated to the Healthcare Commission.

 

4.2 A workshop on complaints at the 2005 MIND annual conference concluded that nine out of every ten complaints were dropped by mental health complainants at the local resolution stage, even though they were still dissatisfied. People felt that they generally did not have the stamina to cope with the two written rounds of correspondence. The experience of the overwhelming majority of workshop participants was one of the NHS trust setting out to "crush the complaint" rather than resolve the issues being raised. No service user present was able to say that they felt satisfied with the investigation of their complaint. Why should this be the case?

 

4.3 Firstly the NHS trust may be aware that roughly only one in ten complainants will have the determination to escalate the complaint to the Healthcare Commission. The NHS trust may also know that according to figures published by the Commission, only 8% of cases will be referred for full investigation. The odds are overwhelmingly in favour of the NHS trust getting away with taking no action as a result of a complaint therefore.

 

4.4 With reference to this case study, enforcing an unlicensed drug was against national clinical trial guidelines, in that the action breached the principle of "informed consent". However the Healthcare Commission still ruled "no further action" after a year had elapsed, on the basis that allegedly three psychiatrists had agreed with the move. In doing this, the Commission ignored evidence questioning whether the second opinion ever took place by proper procedures and the fact that one of the psychiatrists initially refused to treat the patient with the unlicensed drug. The latter had been subsequently persuaded by a claim that its prescription on a "named patient basis" had been approved by a committee of the NHS trust. No evidence has yet been forthcoming to support this assertion and I feel that it is unlikely that any committee of the NHS trust would put their name to prescribing unlicensed drugs on a non-consenting basis.

 

4.5 In dismissing the complaint, an "independent psychiatrist adviser" for the Healthcare Commission ruled that this was part of "normal" treatment. However he worked from the Healthcare Commission's offices and met with the Case Manager before the final report was produced. There was perhaps scope for the alleged 'independent report' to be developed jointly therefore. The complainant was given no opportunity to question the appropriateness of the adviser to this particular case, or establish whether any of the medical practitioners involved in the case was known to him. Much of the adviser's advice was unsubstantiated. The written briefing from the Case Manager to the adviser was also thought by the complainant to be highly prejudicial. The complainant was given no opportunity to question the scope or terms of reference for the Healthcare Commission adviser's deliberations.

 

4.6 After three years since the complaint was launched, the complainant awaits the Healthcare Commission's bizarre ruling to be over-turned by the Parliamentary and Health Ombudsman. Additionally, at the time of writing, the Medical Health Research Agency (MHRA) has so far been unable to confirm that the drug trial was properly certified or that any Suspected Unexpected Severe Adverse Reaction (SUSAR) was reported concerning this patient as per established procedures.

 

5. Conclusions

 

5.1 It is concluded that:

 

a) there will be increased possibilities for the imposition of inappropriate drug treatments under the new Mental Health Bill - both due to the coercive emphasis of the Bill and the apparent failing of existing safeguards - particularly within the timescales necessary to address any issues effectively;

b) the current NHS complaints system is too bureaucratic and complex to be effectively pursued by the majority of mental health service users. Additionally, what is perceived to be the very low probability that issues will be resolved efficiently and fairly, also provides a deterrent to raising such issues in the first place. This situation removes an important potential driver for the ongoing improvement of mental health services;

c) any increased possibilities for the imposition of inappropriate drug treatments, including inappropriate dosages, would be likely to increase risks to the safety of patients and possibly, others around them. This undermines what is perceived to be one of the Governments key motivations for introducing the new Bill.

 

6. Footnote

 

6.1 The author wishes to emphasise that there is no implication that the drug company behaved improperly in this case. Indeed, the company is likely to be unaware that the drug was prescribed to a non-consenting patient. The author is fully aware that at recommended lower doses, the drug is generally effective and as a whole, causes no significant side-effects above other drugs of its type. Indeed, there may be some possible benefits in relation to certain side-effects exhibited by other drugs in its class.

 

April 2007