Memorandum submitted by UNISON, the British Psychological Society, the Royal College of Nursing, Amicus, and the British Association and College of Occupational Therapists. (MH 40)

 

Contents

1. Introduction P.1

2. Historical context P.2

3. Background P.2

4. Executive summary P.2

5. Reform of professional roles P.3

- 5.1 Responsible Clinician P.3

Case studies P.5

- 5.2 Approved Mental Health Professional P.8

Case study P.9

6. Supervised Community Treatment P.10

7. Exploding the myths P.10

8. Conclusion P.12

1. Introduction

This submission has been developed jointly by UNISON, the British Psychological Society, the Royal College of Nursing, Amicus, and the British Association and College of Occupational Therapists. While each of these organisations is a member of the Mental Health Alliance, this briefing has been written to articulate our concerns surrounding some of the amendments which were passed in the Lords, that will, we believe have a negative impact on the roles of many health workers and the experiences of many service users using mental health services.

Our members are mental health nurses, psychologists and occupational therapists - professionals at the cutting edge of providing care to mental health patients, who believe that the Mental Health Bill as introduced by the Government would greatly enhance the provision of care to patients in mental health. We believe that the Bill represents a once in a generation opportunity to bring legislation and regulation of professional responsibilities in our sector into the 21st Century and in line with colleagues in other health sectors. Together we represent over 85% of staff working within mental health services, and have throughout sought the views of our members and engaged with them in the development of our proposals.

In addition, since the First Reading, we have taken legal advice from Richard Gordon QC.[1] The advice obtained has re-enforced our view that a minority of amendments, if passed, will cause significant harm to the advances already achieved in mental health service provision.

 

2. Historical context

Reform of mental health legislation is long over due and we should not miss this window of opportunity. The journey began in 1999 with the Scoping Study Committee[2]. In July 2000, the NHS Plan set out the Government's objectives for mental health services, including its plans for reforming mental health legislation.[3] This led to the publication of the White Paper, Reforming the Mental Health Act (DH 2000)[4], which culminated in the Draft Mental Health Bill, which was published for consultation in 2002.[5] In March 2006, the Government announced that having further considered the views expressed about the 2004 draft Bill, it was proposing to amend the 1983 Act rather than replace it. The proposed Bill was introduced in the House of Lords on 16th November 2006[6].

As this makes clear, our health staff members, service users themselves and charities have been actively engaged on these issues for a long period of time.

 

3. Background

We believe that many amendments successfully carried when the Bill was in the House of Lords, which are wholeheartedly supported in public by the Alliance, greatly damage the Bill in ways which undermine the Government's planned reforms where they would positively impact on patients and allow our members to take on greater responsibilities professionally. We have therefore issued this and previous briefings to Members of Parliament in order to ensure that Parliamentarians are fully aware that regarding certain key aspects of the Bill, the Alliance does not speak for our organisations, and that we disagree fundamentally with several of the public statements made by them.

 

4. Executive Summary

We welcome the intention of the original Bill to redefine key professional roles which would have expanded our members' involvement in care. In doing this, the Government was merely strengthening in legislation what already exists in practice. However, several Lords' amendments have the effect of undermining these changes by re-introducing outmoded hierarchies between professionals in decision-making situations which we believe may be to the detriment of patients and the wider community. These amendments therefore do not reflect the multi-disciplinary nature of service provision which is favoured by our members and service users.

Our organisations are especially concerned to overturn amendments in the Lords which concern:

(a) professional roles; and

(b) Community Treatment Orders.

 

5. Reform of professional roles

A key element of the Bill, which we support, is the Government's desire to widen the group of professionals who can take on key roles, which will be central to the operation of the Mental Health Bill when enacted.

5.1 Responsible Clinician (RC) role

This part of the Bill seeks to amend the Mental Health Act 1983 by replacing its "Responsible Medical Officer" (RMOs) with a new role of the "Responsible Clinician". Under the 1983 Act, the RMO is narrowly defined as the registered medical practitioner in charge of the patient's treatment, and is ultimately responsible for taking key decisions. As the 1983 Act currently operates, RMOs are usually consultant psychiatrists. The current Bill as originally introduced, defines the new role of 'Responsible Clinician' as any clinician who has been approved for that purpose (an 'Approved Clinician'). Crucially, this measure means that approval to become an RC would no longer almost exclusively be restricted to medical practitioners, and may be extended to clinicians from other professions, such as nursing, psychology, occupational therapy and social work.

However, it also contains stringent safeguards to ensure that only experienced members of staff working in mental health, and who have met strict criteria to be approved, will undertake the role of responsible clinician. The Draft Approved Clinicians Directions makes it clear that to be recognised as an "approved clinician" you must be competent to provide the objective medical expertise which would satisfy the European Court of Human Rights as to the legality and appropriateness of compulsory powers. We believe that the regulations provide strong safeguards in defining the responsible clinicians who can deprive patients of their liberty. Not every nurse, psychologist or occupational therapist will have sufficient experience or the desire to take on a role of this nature. However, we have been reassured by the Government over the development of best practice guidelines to support clinicians in their new role.

We are highly supportive of these reforms for several reasons. Patients repeatedly demand both multi-disciplinary care and psychological alternatives to medical approaches in mental healthcare. Working as part of a multi-disciplinary team we would expect professionals to consult with each other on the most appropriate course of treatment. In the course of their treatment, service users will encounter a number of clinicians from the broadest range of the multi-disciplinary team, including occupational therapists, nurses, and social workers and psychologists. All members of these professions have developed specialist skills in a range of settings and circumstances to meet the needs of service users and carers. The majority of the daily care which service users receive is overwhelmingly delivered by these groups of professionals, who often have an equal or even better knowledge and understanding about the needs of individual service users than medical practitioners. It is our view that it is these highly specialist individuals who should and can make decisions surrounding their treatment. This fits in with the broad thrust of reform of professional roles in the NHS, in which, where appropriate, it is deemed beneficial to both patients and the professions for decisions to be made by different members of the multi-disciplinary team. We remain committed to the provisions of the Bill which require our members in the healthcare and social work professions, irrespective of their work or clinical background, to always seek advice from professional colleagues where appropriate. However we would argue that professionals already do this as part of their current practice and are professionally accountable for this.

Our members have been taking on specialist roles within mental health settings and have been developing innovative practice by involving service users in the design, delivery and education of staff. These highly specialist individuals are able to assess service users in a range of settings and take appropriate action to facilitate their care. In caring for mental health patients, conditions can change rapidly, and we therefore believe that it is essential for the well-being of the individual that a broader range of members of the care team is empowered to take appropriate interventions.

Furthermore, our members have a significantly higher level of interaction with service users resulting in stronger relationships than doctors are able to achieve. They are therefore able to help ease patients' fears and apprehension about treatment, further minimising the danger of deterioration of the individual situation. We believe that the Bill as amended misses this golden opportunity to enhance the unique capacity of our members' roles within mental health care provision. If this Bill goes through as amended it will overturn the modernisation agenda already achieved in the mental health setting and could take mental health care backwards.

A consultation exercise was undertaken to gauge professionals' reactions to the proposed changes and an article in Mental Health Practice[7] outlined its findings. The process looked in particular at the role of Registered Clinician and Approved Mental Health Professional. Twelve organisations participated during the course of their consultation, with 300 participants from a broad mix of health professions, reflecting the diversity of mental health service provisions including prison in-reach services, personality disorders etc.

The consultation found that clinicians expressed no concern regarding proposals relating to the responsible clinician role. The article indicates that the consultation identified four main themes: "the potential for improvement in patient care; the potential improved career / professional development; the need for role clarification; and the need for clarification on the skills and capabilities that will be required for the role."

The article includes a number of quotes from participants on these issues on the potential for improvement in patient care. For example, one senior occupational therapist said "I feel this is the direction mental health professional should be moving in, ultimately taking a more holistic approach away from a medical model." A service user stated "that they were broadly positive but would like a stronger emphasis on working towards recovery approach and greater emphasis on users' autonomy through advance directive and Care Programme Approach."

On the potential for improved career / professional development, a psychologist stated that "it offers opportunities to share responsibilities across teams, but would have been useful to have in place prior to Agenda for Change". A number of occupational therapists noted that "OT's would welcome the opportunity to develop roles in this area." A nurse stated that the legislation was a "good opportunity for staff to retain clinical function whilst progressing within their career, instead of moving into management."

 

5.1.2 Case studies relating to the Responsible Clinician role

5.1.2.1 Consultant Mental Health Nurse

Prior to the Lords amendments I saw the powers of the responsible clinician as an essential addition to my role as a nurse consultant for people who have schizophrenia. As a prescriber and advanced practitioner, the skills of assessment, diagnosis and delivering or supervising treatments are part of my role. I offer consultation to colleagues, and frequently engage in discussion on the ethical, legal and medical considerations relating to the use of the Mental Health Act

In my view the extension of powers to review and discharge patients from an order would lead to a more responsible use of the Act. Patients and the public will benefit from decisions being made by clinicians who know them and their families well. They will have a greater appreciation of the complex ethical, medical and psychosocial issues their patients present with. They will also have a sound knowledge of lines of communication with the teams who provide week-to-week supervision and care for the patient.

Removing the powers of review and discharge from the role of the responsible clinician wastes the talents of consultant grade staff. Furthermore it makes the role wholly unattractive and maintains the flaw in the present system that assessments and decisions are being made by people who, despite their clinical competence, are least informed about the patient. It does nothing to enhance public confidence in mental health services and does nothing to reduce waiting, improve decision making, or facilitate continuity of care for patients and their families.

 

5.1.2.2 Psychologist acting as a Responsible Clinician (RC)

This is a hypothetical case study of how the Government's proposed new role of Responsible Clinician, as in the Bill as introduced, could operate.

K is a 30 year old woman with a diagnosis of schizoaffective disorder, who has been detained in an intensive care unit, has now stabilised, and has returned to an effective medication regime, but has outstanding problems with coping in the community, due to her experience of abuse as a child and young adult. She has been assessed by her present team as needing a period of rehabilitation within a low secure environment, as she has recovered from the effects of her illness with the help of medication, but has not been able to address the distress she endures as the result of her traumatic experiences. She is not willing or able to commence psychological therapy at this point, but accepts the value of a psychologically informed nursing perspective. She has self harmed in the past, and recognises that she will be at risk of self harming in the future, especially if she is exploring alternative coping strategies, so needs to be detained in order to safely pursue the rehabilitative treatment she needs.

She has complied with medication in the community, and her problems were precipitated by the loss of a significant other, rather than non-compliance with medication.

The psychologist as RC is able to assess:

a) The links between past events and her difficulties, and to help K have a framework to understand what benefit future treatment might bring. She is recovering from her illness, but still may need a safe and supportive environment to address the issues of loss and security, in order to develop more helpful coping strategies;

b) The nature of the impact that the traumatic events have had on her, and what needs to be worked on by the care team;

c) The nature and degree of risks related to her experience of trauma, and whether these can benefit from psychologically informed intervention;

d) The psychologist would be able to consult and support the care team in providing a care package that met K's needs, as K's symptoms have stabilised, then the primary questions will be related to management of her psychological difficulties, such as relapse prevention, rather than management of her symptoms, which are controlled with medication;

e) The psychologist would aim to work towards a collaborative framework, and this may mean that K can become more confident in developing her own risk management plan, and the team would then be able to develop a risk management plan based on relational security, rather than relying on physical detention.

 

The psychologist as RC requiring a second opinion from a medical person would still be able to provide this knowledge, and the second opinion form a medically trained doctor, could support this understanding. There may be clear agreement that K has psychological difficulties that are of a nature and degree to require detention.

However, the focus of a medically trained opinion will be on risks related to the presence of symptoms of mental illness, and these have been controlled with medication. The medical opinion could be that, since there are no outstanding symptoms of mental illness, that K is no longer detainable. The expertise of the medically trained opinion is in identifying and treating mental illness. Mental health services work with people with a variety of difficulties, not all attributable to the effects of an illness, but which are mental disorders in the wider definition of the Mental Health Bill. Having a medical opinion in these circumstances could mean that appropriate and effective management of risk and psychological difficulties could be compromised.

 

5.1.2.3 Psychologist acting as Responsible Clinician

Provided by British Psychological Society

This hypothetical vignette reflects a realistic situation in a wide range of settings both in hospitals and the community where the broadening of a competency based deployment of mental health practitioners will enable patients to get the right treatment from the right person and to improve mental health provision especially for those most vulnerable patients who require treatment under conditions of compulsion.

Dr E is a consultant clinical psychologist working in a forensic in- and out-patient service for people with intellectual disabilities (mental impairment). He has 15 years post-qualification experience and has been a consultant for the past 9 years in this specialty. His training spanned 10 years and he holds 3 degrees: Honours in Psychology, Masters in Clinical Psychology and a PhD in Forensic Psychology.

The service has a national catchment and patients are typically detained because of seriously irresponsible or frankly criminal behaviour and where treatment can only be provided in hospital.

The patient Mr F, was admitted to the hospital's medium secure facility six years ago and he has gradually traversed the care pathway. Throughout all this time his care has been overseen by a consultant psychiatrist. Because of the shortage of psychiatrists, this doctor has often been a locum of short duration. The psychologist, by contrast, has known the patient from the time of admission. Indeed the patient's treatment has largely comprised a series of psychological and social interventions: two year sex offender group therapy, individual cognitive therapy for anger and a substance abuse programme. Nurses have often been co-facilitators in this work. The most recent has been a detailed nursing and psychology risk assessment for a Tribunal. The patient has not been on psychotropic medication for the past five years. He is in good health.

At the pre-discharge part of the service, which is overseen by the consultant psychologist together with a nurse manager, it is thought appropriate that this psychologist, who has completed the training for Approved Clinician and who possesses the competency to act in such a role, assumes the position of Responsible Clinician. Not only does he know Mr F well and has a thorough knowledge of his risk-needs but, when Mr F moves into the community (under a likely Supervised Treatment Order), he can continue to be overseen by Dr E. Unlike the psychiatry service, which has separate in- and out-patient consultants, the psychological service spans both hospital and community. The patient, his advocate, and his solicitor support the proposal.

The psychiatrist is freed to attend to other patients with complex acute and enduring mental health needs more in keeping with his expertise.

5.1.2.4    Occupational therapist acting as responsible clinician

An occupational therapist acting as a responsible clinician would act in a very similar way to those vignettes already provided by the psychologists and nurses.

Occupational therapists can be employed as consultants and can also prescribe using patient group directives. Occupational therapists will provide a unique professional perspective when undertaking assessments. 

As a result of the intensity of the interface between occupational therapists and their patients they are well placed to understand the current mental health status of their patients and act as a responsible clinicians. 

They have the opportunity at any time to refer to other mental health professionals if a second opinion is required, thus reducing risk.

 

5.2 Approved Mental Health Professional (AMHP) role

The current Bill replaces the "approved social worker" (ASW) role in the 1983 Act with a new "approved mental health professional" (AMHP) role. The House of Lords amendments modify the way in which the responsibilities intended to be exercised by these roles will operate in practice. We feel that the effect of this is to curtail and constrain professionals who are not registered medical practitioners to exercise the responsibilities that the Government intended by reforming these roles in the first place.

The Bill as amended expands the technical definition of roles which our members will be expected to assume, while lessening their function by requiring them to defer to psychiatrists when taking important decisions. This is an invidious position to put our members in, as we would be expecting them to take on the AMHP role, which involves working with some of the most difficult and high-risk patients - when ultimate decisions on patient care will continue to lie with psychiatrists. This would be a retrograde step and contrary to current practice and research evidence. Difficult and high-risk patients are invariably managed by forensic outreach and assertive outreach services where decisions are not taken by one individual clinician.

While there have been concerns from professional groups about the need to preserve the independence of the ASW process - and to ensure that its holistic non-medical social care perspective is preserved as an important counter-balance to the medical approach - we welcome the opportunity to work closely with the Government to manage the professional change outlined in the Bill. In particular we support the development of joint guidelines and best practice for the service and employers. To this end we have been discussing with the Minister and the Bill team the need for safeguards to ensure:

current specialist post-graduate training model and content are preserved, along with consistent requirements for refresher training;

issues of appropriate pay levels for the role are addressed and the need for consistency across employers;

current social-care assessment processes are preserved;

appropriate supervision and mentoring for new entrants by those with an ASW background;

requirement for the local authority to ensure it provides access and support to overcome isolation issues for those employed by Trusts.

 

We have also raised with the Government the difficulties being experienced by current ASWs, in relation to the conveyance of patients for treatment.  The current code of practice requires organisations to have protocols in place which includes accessing support from other services e.g. the ambulance service. The experiences of current ASWs   has been poor as the protocols have often been found to be ineffective.  As the proposals outline a widening of this role to a limited number of other healthcare professionals ,  we would wish to see improvements in this process, to ensure that patients receive treatment as soon as possible and to ensure  that  the health, safety and wellbeing of both the patient and member of staff is protected  .

 

5.2.1 Case studies relating AMHP role

5.2.1.1 Community Psychiatric Nurse

I saw the introduction of this role in part as building on my knowledge and skill. I have been a community psychiatric nurse for 15 years, I manage my own case load in the community and have been evaluated as band 7 under the new Agenda for Pay system.

In managing my own case load I am able to build effective relations with clients and assess them in an ongoing manner, I am able to identify if their condition alters and able to intervene on a number of occasions preventing further deterioration in their condition, I saw this as widening the work that I already do as part of a multidisciplinary team.

I work daily with social workers, and would want access to the same level of training that they receive in order to ensure continuity of standards. I would also welcome access to an approved social worker as a mentor until such times as I had established my self in this role.

5.2.1.2 Occupational therapist

Occupational therapists work as core members of community mental health teams and they already possess a high level of knowledge and skills and are working with complex clients.

The College of Occupational Therapists have no hesitation in confirming that experienced practitioners are able to fulfill the role of an AMHP.

 

6. Supervised Community Treatment

Community Treatment Orders are a key area where we remain very concerned about amendments in the Lords. Peers have amended the Bill at clause 17A (Bill as amended on report, page 19, line 23 onwards) such that the changes listed above, which broaden the number of professionals able to make key decisions etc, is all but obsolete. For example, the original Bill suggested that the RC can not make a CTO unless in his opinion, the relevant criteria are met; and an approved mental health professional states in writing that he agrees with that opinion and that it is appropriate to make the order.

As amended by the Lords, this clause now alters the Bill to ensure that those of our members who may have been in a position to gain more responsibility and, for the reasons set out above, would have been able to use their expertise and understanding of a patient's specific problems and situation, will have to defer to a psychiatrist for final determinations.

 

7. Exploding the myths

7.1 The Bill as originally introduced by the Government was not compatible with the Human Rights Act.

The British Psychological Society has commissioned the eminent Richard Gordon QC to investigate the extent to which the Bill as originally introduced was compatible with the Human Rights Act. The QC has advised that the Mental Health Bill as originally introduced was complaint with the European Court of Human Rights requirements, when you take into account the associated regulations requiring certain competencies of approved clinicians.

The QC is satisfied that "objective medical expertise" is a test of substance, i.e. competencies, rather than professional qualifications. Furthermore, the QC advises against the amendment proposed by the Mental Health Alliance recently, which would leave the law in a state of uncertainty. He does not believe any amendment to the Bill as originally drafted is necessary, but suggested that a possible amendment to meet the concerns put forward in the Lords and by the Joint Committee on Human Rights could be made to S16(5), which provides for clinicians to be approved by the Secretary of State, to add that approval cannot be given unless a relevant competence demonstrating objective medical expertise is shown.

7.2 Nurses, occupational therapists and psychologists are not competent to become responsible clinicians (RCs) or approved mental health practitioners (AMHPs), because they are not able to offer objective medical expertise to justify their decisions.

There are numerous examples from current practice of how our members are successfully discharge greater responsibilities, and often exercise objective medical expertise when doing so.

Since the 1983 Mental Health Act, nurses have expanded their practice to lead and deliver initiatives such as mood clinics, memory clinics and new services created such as crisis resolution services and assertive outreach. Expansion of roles is a reality and further progress can be enabled by progressive legislation such as that proposed by the Government.

In addition, some nurses currently act as independent 'prescribers', and in so doing have to use objective medical expertise.  People such as nurse consultants, who are independent 'prescribers', are a good example of the calibre of people who may become RCs in the future and that they have the competence to take on greater responsibility.

Under the current Mental Health Act, nurses are already able to detain someone using a 'Section 5(4)', until a doctor arrives.  Again, to do so, they must apply objective medical expertise and be able to show evidence justifying this decision. 

There are already nurse-led clinics in operation, in which nurses carry out surgical procedures following expert training from doctors.

Moves to demarcate professional roles have been occurring in all sectors of health care except in mental health. There is no objective reason why professionals in mental health should be denied the professional freedoms afforded to their colleagues in other sectors, especially when they can be shown to enhance the standard of care which the patient receives and the wider benefit to the community.

 

7.3 There are not enough safeguards in the original Bill to ensure that those professionals taking on the RC or AMHP roles will be suitably qualified and / or supervised.

The draft Regulations introduced by the Government to accompany the Bill clearly specify the competencies required by those considered for these roles. In addition to the clear legal opinion that such competencies are sufficient in legal terms (above), these competencies also represent the joint efforts of a large number of mental health experts working together over many months - including representatives of the Royal College of Psychiatrists, the Royal College of Nursing, the College of Occupational Therapists, the British Psychological Society as well as service user representatives and representatives of the Department of Health. They have been widely circulated and welcomed as representing a high threshold of quality.

These discussions have also developed clear proposals for assuring quality-control of these competencies through the independent regulatory bodies (such as the

General Medical Council and the Health Professions Council), as all professionals thus approved would need to be registered with their relevant regulatory body.

Finally, of course, these Regulations relate specifically to the required competencies. This is an additional assurance of safeguards, since it would not be possible for a person to exercise powers merely by virtue of professional qualifications. Under these proposals, the relevant competencies are specifically and directly linked to the issues of mental health themselves.

 

7.4 The Government's original proposals would give an unprecedented power to mental health professionals to treat patients against their will, to restrict liberty or to detain.

The proposed Bill amends the 1983 Mental Health Act rather than introducing new powers. It is true that the changes proposed are significant - in that new definitions and criteria are proposed, and the proposals for Community Treatment Orders are significant. These issues are dealt with elsewhere in this briefing, and are consistent with powers and procedures in other countries. In respect to the exercise of these powers by members of a multidisciplinary team (that is by professionals other than doctors), it is clear that these proposals, in that respect, do not give unprecedented powers, but rather ensure that these powers can be exercised by the professionals most appropriately qualified.

 

7.5 Community Treatment Orders (CTOs) should be reserved for a more limited number of patient categories and should be subject to more stringent safeguards than the Government originally proposed.

In its briefing, the Alliance makes no reference at all to the positive impact on the patient, his or her family and the wider community that we believe supervised treatment in the community would allow. The use of CTOs would enable professionals from our organisations to provide more holistic, multi-disciplinary, often non-pharmaceutical care, in a setting which is far more conducive to treating mental illness. The Alliance's briefing portrays CTOs as draconian and illiberal, while the broader context is that without the Government's reforms, certain types of patient will continue to be discharged into the community, will fail to take medication and will not be receiving any kind of intervention from mental health services, until such time as their condition deteriorates to the extent that acute mental health treatment in a hospital environment is necessitated, often through compulsory detention. Such compulsory detention is an outcome which all professionals seek to minimise.

 

8. Conclusion

This is a once in a generation opportunity to reform the provision of mental health care in a way which reforms the unduly hierarchical, inflexible demarcation of professional roles in a manner which would greatly benefit patients, through allowing medical professionals other than doctors to take greater responsibility for the patients in their care. This will enhance the multi-disciplinary nature of modern medical care teams, as they apply in mental health, and in so doing, will greatly improve the treatment received by patients, who are often among the most vulnerable members of society.

The briefings recently issued by the Mental Health Alliance have in the opinion of our organisations, give the impression that all mental health professionals support statements issued by the Alliance, and that our organisations support the amendments carried in the Lords which could do so much damage to the interests of our members. Unless overturned in the Commons, these amendments will adversely affect the ability of our members who today work across disciplines in the mental health sector, to care for service users in a way which is most appropriate and ultimately most beneficial.

The Bill as amended therefore misses a golden opportunity to strengthen the multi-disciplinary model of care operating within mental health services and the effect of the amendments will be that clinicians will not have been given the framework to do their jobs effectively.

We urge you to support the Government in the likelihood that it amends the Bill such that its initial intention is restored. Our members feel that they have significant expertise to offer and that the Government has committed to go some way to modify the roles in a way which utilises this, within a regulated framework.

April 2007

 

 

 

 

 



[1] Appendix 1 legal opinion Richard Gordon QC Brick Court Chambers 12th April 2007

[2] Department of Health (1999) Review of Mental Health Act, Report of the Expert Committee, Department of Health, London

[3] Department of Health (2000) The NHS Plan, A Plan for Investment. A Plan for Reform, DH, London

[4] Department of Health (2000) Reforming the Mental Health Act, the Stationary Office, London

[5] Department of Health (2004) Draft Mental Health Bill. DH London

[6] Department of |Health (2006) the Mental Health Bill: plans to amend the Mental Health Act 1983 . Briefing sheets on key policy areas where changes are proposed. DH, London

[7] Mental Health Practice, April 2007 vol 10 no 7, Testing the Water