Memorandum from the Mental Health Act Commission
1. The Mental Health Act Commission (MHAC) is pleased to be able to present evidence to the Committee in writing and to have the opportunity to address the Committee and answer the Committee's questions. The Commission recognises the importance the government places on developing a modern regulatory framework for health and social care, and in furtherance of that aim, the establishment of the Care Quality Commission. The government intends that this will be achieved by bringing together some or all of the present functions of the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission, subject to the passage of the Health and Social Care Bill.
2. The MHAC was deeply concerned during the preparatory stages to the Bill that the essential functions of protecting the rights of detained patients may be diluted in the transfer of responsibilities to the new regulator. A number of alternatives were canvassed (including the retention of an independent monitoring body) although none offered the full reassurance the MHAC would have liked. Some compromise is unavoidable; but the MHAC wants to ensure that the vital function of visiting detained patients regularly and frequently is not lost. Visiting services is an essential prerequisite for preventing the abrogation of patients' rights. The price of quality assurance is eternal visiting - to paraphrase Thomas Jefferson.
3. By and large the MHAC wishes to be able to support the transition, but its enthusiasm has been tempered, indeed severely diluted, by concerns about the government's commitment to protecting the rights of detained patients. We were heartened by the Secretary of State's speech in parliament at second reading in which he said,
"I emphasise again that the Bill brings the vital role carried out by the Mental Health Act Commission into the heart of the care quality commission. That will strengthen the monitoring of the Mental Health Act 1983, and offer increased oversight of the treatment of patients subject to compulsory detention. I know that the MHAC places great emphasis on its visiting programme, covering each hospital and each ward that accepts detained patients. I expect the new commission to continue that approach."
4. The MHAC wishes to be assured that the new organisation, the Care Quality Commission, will have the status, resources, commitment and organisational strength to ensure greater provider compliance with the law in meeting the rightful expectations of patients about safety and the quality of care. The MHAC remains worried that the Bill and associated regulatory framework do not ground the MHAC's current functions in ways that will ensure full protection for the rights of detained patients - perhaps one of the most vulnerable groups in society. In the MHAC's view it is essential that its current functions and the way in which those functions are performed are continued within the Care Quality Commission after 2009. In short, the MHAC has been looking for assurances that the legislation and the regulatory framework, the resources available, and the operating arrangements for the Care Quality Commission will be written in a way that ensures explicitly a focus on the civil, legal and human rights of detained patients.
5. The MHAC's remit is established at sections 120 and 121 of the Mental Health Act 1983 (as amended by the Mental Health Act 2007) which outline the main responsibilities. In particular section 120 requires the MHAC, on behalf of the Secretary of State, to monitor the operation of the Act as it relates to detained patients and to visit and interview detained patients in private. This function is performed by some 107 part-time public appointee Commissioners (from a variety of health and social care backgrounds, as well as service users, who have extensive knowledge and experience of the Mental Health Act and services), who visit mainly alone, unannounced or at short notice, and review the care and treatment of patients as it relates to their detention under the Act. The MHAC believes that this must be replicated within the new Regulator, which should also be given functions under the Mental Capacity Act 2005 similarly to monitor the operation of that Act, in particular the determination of capacity of those subject to the 2005 Act and the treatment given to those who lose their liberty as a result of the operation of the Act.
6. There are six functions or sets of functions, and the way in which those functions are performed, that the MAHC considers to be vitally important for the new regulator (the Care Quality Commission). These are:
(i) Visiting and interviewing detained patients in private, and having the necessary breadth and depth of expertise of mental health care such that those undertaking visits and inspections are able to identify shortcomings or difficulties in mental health services (and extending this monitoring where appropriate to assessing regularly the deprivation of liberty safeguards in the Mental Capacity Act 2005 as amended by the Mental Health Act 2007);
(ii) Engaging mental health service users actively as full partners in the enterprise of health and social care assessment, monitoring and inspection;
(iii) Adequate organisational and personal accountability for monitoring and reporting on the needs and rights of detained patients;
(iv) Statutory notifications of admissions, discharges and deaths of detained patients, and other relevant information;
(v) Ensuring adequate and appropriately trained staff, with the establishment of a specialist mental health team or department within the Care Quality Commission incorporating present MHAC staff expertise;
(vi) Having an overarching principle of equality and human rights, focussing at all times on the civil, legal and human rights of patients;
We consider each in turn
(i) Visiting detained patients.
7. Regular and frequent visits to providers is the only way to ensure patients' rights are protected, the potential for abuse of patients is minimised, and appropriate care is provided at all times. Experience of visiting services demonstrates all too readily that the quality of care at a provider unit (notably at ward level) can deteriorate very quickly and is heavily dependant upon good middle and senior management staff. Recent scandals such as those at Cornwall, and Merton and Sutton, illustrate what can happen if services are not visited on a regular basis.
8. We are mindful of the emphasis that is placed by the Optional Protocol to the Convention against Torture and other Cruel, Inhuman and Degrading Treatment or Punishment (OPCAT) (2006). OPCAT is an important addition to the UN Convention Against Torture (1984) and establishes an international inspection system for places of detention. The objective of Article 1 of the Protocol is "to establish a system of regular visits undertaken by independent international and national bodies to places where people are deprived of their liberty, in order to prevent torture and other cruel, inhuman or degrading treatment or punishment". Article 1 describes important concepts, including the importance of:
· preventive visits,
· undertaken on a regular basis; and that
· form part of an overall system of visits.
Given the potential for patient abuse, and the importance of the MHAC's role as one of the contributory monitoring bodies ensuring compliance with OPCAT, it is essential that the Care Quality Commission continues to perform these functions and is able without fear or favour to fulfil the government's obligations under the Protocol.
9. The MHAC is Ministers' (and indeed parliament's) 'eyes and ears' and an important check on the possibility of patient abuse. Even with a Commissioner visiting resource that equates to only 15 whole time equivalent staff the MHAC finds abuses of patients and misuse of the law on a weekly basis. We do not suggest that many of these abuses are the result of deliberate evil, though some undoubtedly are; but as John Adams noted in 1788, "It is weakness rather than wickedness which renders men unfit to be trusted with unlimited power." When patients have lost their liberty and are suffering from severe mental health problems that destroys their capacity, albeit temporarily, then the scope for abuse is great, and the power of the staff, at that time, is in effect unlimited.
10. Visits must be frequent and regular, with the opportunity for unannounced and short notice announcement visits. Visiting must be sufficiently frequent to ensure compliance of providers with the law and to give visiting inspectors the chance to see a sizeable proportion of detained patients in any year (approximately 45,000 people are detained on admission or following admission each year). The MHAC visits all hospitals or significant sized units once each year, and every ward with detained patients at least every 18 months. We interview around 6000 detained patients during these visits and check the legal documentation of roughly the same number. Ironically the MHAC remit does not cover de facto detained patients and this places Commissioners in the paradoxical situation of having to walk past patients who are detained in all but name, but have informal status, in order to meet with patients that are lawfully detained. Table 1 shows this information for the last full year for which statistics are available.
11. Commissioners see extremely worrying aspects of poor patient care on a daily basis and find many examples of unlawful detention. These range from inappropriate and unlawful seclusion practices to lack of respect for patients dignity or culture. Women are often particularly affected. Commissioners were asked at a recent conference to give examples of things they had seen in the previous six months - May to October 2007 and what follows is a tiny selection of their concerns which underline the importance of the MHAC's visiting programme. Commissioners reported: a Hindu woman offered Halal meat; a woman held in seclusion denied sanitary protection whilst menstruating; a female patient photographed by a male staff member on his mobile phone whilst she was naked in the bathroom; a Black female patient subject to racist abuse by another patient with no intervention from staff; lack of a mother and baby unit that would take a woman with psychosis, leading to separation of the mother and baby at birth; a patient given a contraceptive injection against her will without an assessment of her (cognitive) capacity; patients allowed to use a razor belonging to another patient who was HIV positive; vermin and cockroach infestation in an adult acute admission ward; and a deaf man held in a high secure hospital ward for 60 years.
12. These are the tip of an iceberg of appalling NHS and private sector mental health care which not only demands regular and persistent monitoring but cries shame on the mental health services in this country. In addition to many reports of ligature points on wards with seriously ill and suicidal patients, Commissioners reported over-crowding and high occupancy levels (well above 100%), sleeping out practices and lack of space.
One Commissioner said:
Patients decline the offer of s17 leave through fear that if they went home overnight they would not have a bed to come back to the next day. Instead their belongings would be in a bin liner in a cupboard and they would need to stay in a bed in a different hospital the other side of the city.
Another noted the lack of consideration for anorexic patients:
[Patients] were not given specially considered or prepared food, but had to eat cook chill food prepared without their special needs being considered - and had to fight over what food they wanted with other adolescents.
A number of Commissioners found patients where funding problems meant the patient and others on a ward were at risk:
· One detained patient was kept in seclusion for about 2 weeks due to financial closure of the ICU [ Intensive Care Unit] with a knock on effect on the rest of the patients in the ward who had to be 'secluded' in their rooms every time the staff needed to move this patient to bathroom, smoke room etc. One female patient was terrorised being convinced, ''he will kill me''.
· a 54 year old man who was an informal patient on a Psychiatric Intensive Care Ward - the only reason he was there was that his PCT had refused to agree payment for his transfer to a more appropriate unit.
Often staff seem strangely uninterested in patients despite the obvious needs expressed:
· A highly suicidal patient with scaring all over her face and bandaged arms was sent on S17 leave without warning, late in the afternoon. She came coming back for a walk round and was ignored by all staff on the ward.
Another similar incident was reported by one Commissioner:
· A patient on 24/7 one to one observation was able to hang himself in his room with the door open and the nurse outside
Commissioners were also appalled at some of the restraint practices they found:
· Members of staff restraining a patient in a way that involved holding a towel across their mouth and holding arm behind him so that the patient was finding difficulty breathing;
· [a] young man with learning disability, with a double fracture of arm as a result of restraint.
Being a member of staff working in this type of environment is also very stressful and yet there are many dedicated people who work hard and contribute a great deal to caring for this population. Many staff welcome our involvement without which they would not on occasions be able to bring some of these issues to attention of their managers.
(ii) Engage mental health service users actively as full partners in health and social care assessment, monitoring and inspection.
13. Involving service users is an essential step towards a full understanding of the impact of detention and the quality of care at individual providers. The MHAC has made real progress on user involvement, by developing a strategic approach which is translated into practice and is a key priority and responsibility of the Management Board, it is hoped that this aspect of its approach will be maintained within the new regulator. Patients/service users must be able to contact the regulator at any time and to be treated with sympathy and understanding, advice and care. At root, the role of the MHAC is to get the heart of the patient experience, to understand the way the operation of the Act impacts on their lives, and to ensure as far as possible that the way the Act is operated encourages and facilitates improvements in care rather than the reverse. It is only by engaging users as the true voice of experience that the effect of detention can be assessed.
14. As part of its equality and human rights strategy the MHAC established a Service User Reference Panel (SURP) in 2005 and set out to actively involve service users who are currently, or have recently been, detained. This required imaginative, practical solutions to overcome barriers to engagement. Some service users move in and out of hospital; some can not leave hospital; some go through periodic episodes of mental illness during which they may have diminished mental capacity. Some service users have a deep rooted mistrust of public authorities, either because of negative experiences, such as bullying and racial or other abuse, or in part because they have been detained against their will under the Mental Health Act. There are also some quite specific practical needs for communication and support. Some have no email access; some prefer to give views by telephone rather than in writing. Whilst the circumstances of detention under the Mental Health Act are particular, our methods could be replicated usefully with other so-called 'hard to reach' groups in a variety of public services. The Panel is now involved in all new policy development, contributes to the Biennial Report and ensures that the MHAC processes recognise fully the implications of being a detained patient., A recent project -Visiting Together - paired service users with Commissioners, and was highly successful in enabling SURP members to offer the visiting Commissioner a patient's perspective on what they found on the wards visited.
"I have been involved in many projects, each has been different and I felt I had a definite expertise and knowledge to share, which gave a valuable contribution to enhance and improve services for detained patients"
15. One of the most significant issues reported to the MHAC by women who are detained patients is that of safety and feelings of lack of safety. Women feel fearful of physical violence and sometimes of sexual assault. This is often a concomitant of the continued use of mixed sex accommodation in hospitals. Although the government has said it wishes to ensure single sex accommodation, at present information available to the MHAC suggests that 60% of patients are still cared for on mixed sex wards. Many of these have what are ostensibly single sex dormitories and bathroom facilities but these are rarely sufficiently separate or secure and day time demands place seriously ill men and women in close proximity. Many staff members do not appear to understand the difficulties this creates for patients. (see also paragraph 28 below)
"I've been on about twenty different wards, and only one of them was single sex. Mixed sex wards are notorious for incidents of sexual harassment and abuse. They can feel threatening for already vulnerable patients, and they are often far from being therapeutic environments."
Claire Allen - Author of Poppy Shakespeare and former in-patient
The first hand experiences of SURP members concerning the safety and dignity of women patients has added an additional stark reality to our ongoing concerns in this area. By engaging service users actively at all levels with the organisation it has been possible to have a genuine influence throughout the Commission, from Board level to the frontline of visiting detained patients.
(iii) The new Regulatory Framework: adequate organisational and personal accountability for monitoring and reporting on the needs and rights of detained patients.
16. We believe that a specific duty should be placed on the Care Quality Commission, either on the Board, the Chief Executive or an identified member of the Board, to be responsible personally to Parliament for the monitoring of the Mental Health Act 1983 (as amended by the Mental Health Act 2007 and by this Bill), for the protection of the rights of detained patients, and for reporting to Parliament regularly (annually) on the condition of services for detained patients and those subject to compulsion in the community. We understand the difficulties this may cause for the framing of legislation but believe that an appropriate mechanism is required to ensure the Care Quality Commission continues at all times to address these issues. Detained patients are a very vulnerable group and are the only patients within the health service to be detained using civil powers. Extra safeguards are needed that go beyond those that may be right for the rest of health and social care.
17. The MHAC recognises also the difficulty of specifying in legislation the level of resources that should used for a specific function or, indeed, the precise way in which that function will be performed. The Care Quality Commission will be expected to take on a wide range of regulatory functions as described in the Future Regulation of Health and Adult Social Care: Response to Consultation paper. Yet two issues have seemed to dominate discussion in these early stages: registration of health and social care organisations, and risk management, both from an essentially economic rather than rights based regulatory framework. Whilst registration and risk are important, equally important are the rights of patients and the protection, and the enhancement of those rights.
18. Nonetheless the registration requirements will be very important. We believe registration must take sufficient account of existing legislation - in particular the MHA 1983 as amended and the Equalities legislation - and that providers should give equal weight to all requirements placed upon them (as appropriate to the users of their services) with no unintended incentive to focus on the latest priority to the detriment of more long standing statute. We have some disquiet at a "once size fits all" approach for all service providers that differ markedly across the health and social care sectors, and we hope that the registration requirements will focus on the quality of care and the rights of patients, especially where patients have been deprived of their liberty. As we note in other parts of this submission, the quality of care and the way detained patients are treated can vary markedly from place to place. Standards and processes must be chosen carefully in relation to the risks and demands on different services, and to give specific attention to the special nature of services for detained patients.
19. We recognise the divergence of views on the extent to which the Care Quality Commission's remit is economic or social regulation. Our approach unashamedly is to seek a balance of economic and rights based regulation noting the wide scope for abuses to occur in places where patients have lost their liberty. Whilst the MHAC cannot say, for obvious counter-factual reasons, what scandals have been obviated by its vigilance, there is no doubt that the paucity of scandals since 1983 compared to the previous period is testament to the impact of that vigilance. The new regulatory framework must pay sufficient attention to patients' rights and not be concerned with economic regulation to the exclusion of other matters.
(iv) Statutory notifications of admissions, discharges and deaths of detained patients, and other relevant information.
20. Setting in place a minimum list of topics on which it will be mandatory for the Care Quality Commission to report every year will have two effects: first, it will reassure patients/service users that the Care Quality Commission will be considering these matters regularly; and second, the Care Quality Commission will be able to make such reports only if it has visited and inspected the care and conditions of patients.
21. To undertake its functions adequately the new regulator will need high quality information on which to base decisions to intervene where it identifies a deterioration of care or the likelihood that patient's rights may be abrogated. Although the MHAC understands that the government intends to give the new organisation the power to obtain information on mental health services the MAHC believes that those powers should include statutory notifications of the following:
(i) all deaths of detained patients and those notified to the coroner;
(ii) all serious and untoward incidents and deaths of informal patients from unnatural causes;
(iii) all homicides by detained or informal patients;
(iv) all incidents of serious injury to patients receiving in-patient care; howsoever caused;
(v) all formal admissions and discharges including discharges to community treatment orders and compulsion in the community;
(vi) all mental health review tribunal decisions whether for continued detention or for discharge.
For all of these categories it will be essential to have information that is currently collected under the Delivering Race Equality in mental health services Census project i.e. ethnicity, age, gender, sexuality, faith and disability. All these factors are vital information in helping managers and staff to put together appropriate packages of care for service users.
22. As an example, the MHAC has been deeply concerned about the level of unnatural deaths of detained patients. Between 350 and 400 patients die during detention every year in England and Wales of which approximately one quarter are considered unnatural deaths. This level - about 80 deaths every year - has remained remarkably constant for the last decade and must give rise to serious concerns that not enough is being done to make services safer for patients. The figures for 2006-07 are shown in the histogram which shows the typical variance by quarter. The notification process is one instituted by the MHAC and is not a statutory requirement even though it raises significant questions about patient management. Similarly, none of the information that we have collected about children detained on adult wards, Black and minority ethnic (BME) patients and their pathways to care, and the way women are detained, has a statutory basis and relies on the goodwill of services to provide the information. It is essential that services are placed under a duty to provide this information which is collected on a regular basis without derogation.
Diagram 1: Deaths of Detained Patients notified to the Commission - England and Wales 2006-07
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Diagram 2: Deaths of Detained Patients notified to the Commission - England and Wales 2006-07 Quarter 4 January to March 2007, by form of death
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Table 1: The recorded ethnic backgrounds of patients reported as having died in detention in 2006-07
Ethnic Background Unnatural Natural Total BME %
British (White) 60 [73.17%] 240 [86.33%] 301 [83.38%] 79.20
Irish (White) 1 [1.22%] 7 [2.52%] 8 [2.22%] 2.20
Any Other White Background (White) 8 [9.76%] 6 [2.16%] 14 [3.88%] 3.10
White and Black Caribbean (Mixed) 1 [1.22%] 1 [0.28%] 0.80
Any Other Mixed Background (Mixed) 1 [1.22%] 1 [0.28%] 0.50
Indian (Asian or Asian British) 2 [2.44%] 2 [0.72%] 4 [1.11%] 1.30
Any Other Asian Background (Asian or Asian British) 1 [0.36%] 1 [0.28%] 0.80
Caribbean (Black or Black British) 4 [4.88%] 17 [6.12%] 21 [5.82%] 4.10
African (Black or Black British) 4 [4.88%] 2 [0.72%] 6 [1.66%] 1.90
Any Other Black Background (Black or Black British) 1 [1.22%] 1 [0.28%] 1.70
Any Other Ethnic Group 1 [0.36%] 1 [0.28%] 1.10
Not Stated 2 [0.72%] 2 [0.55%] 1.20
Totals 82 278 361
23. The MHAC remains concerned about the disproportionate admission and detention rates of Black and minority ethnic patients (see paragraph 26ff below) and this is borne out by the figures for deaths of detained patients. As BME patients are on average (for all groups) more than twice as likely as the proportion in the general population to be admitted to mental hospital it is unsurprising, but of serious concern, that proportionately more BME patients die within services.
(v) Adequate and appropriately trained staff, with the establishment of a specialist mental health team or department within the Care Quality Commission, incorporating the present MHAC team.
24. The Care Quality Commission must have a mental health team of appropriately trained and expert staff, deployed specifically to monitor and inspect mental health care. The MHAC team offers one natural receptacle of expertise to complement the skills of those currently working within the Healthcare Commission and CSCI and others as appropriate. Whilst the MHAC's concerns are with detained patients, each person's needs should be seen in the context of the overall patient pathway that includes other forms of community and institutional care. Once the Community Treatment Order provisions have been brought in on implementation of the 2007 amendments, that pathway must include compulsion in community settings.
25. Ensuring adequate communication between inspection staff and Second Opinion Appointed Doctors (SOADs) (and vice versa) will be an important function of this team, helping to identify shortcomings in services and potential abuses. SOADs see in excess of 12,000 patients a year, which provides a ready opportunity to use their skills and expertise more in monitoring patient care. This submission does not deal in any depth with second opinions as this responsibility will not change and is a statutory function that the Care Quality Commission must ensure is resourced and managed adequately. However, the MHAC would be keen to ensure continuation of the recent changes it has made to the quality and manner in which second opinions are undertaken, together with the sharing of information with Commissioners. Being detained compulsorily without court sanction is a disturbing and traumatic experience, made all the more so as it is done at a time when the person is in mental distress. The Care Quality Commission must be able to offer advice on the operation of the Act, and provide patients and their carers with information and advice on their rights, on services available and on remedies for wrongful detention or inappropriate care. The MHAC maintains a small group of staff with over 250 years cumulative experience who are able to give patients advice and to support patients at times of extreme distress. This must continue to be available.
26. The Care Quality Commission must have available to it in future the expertise and breadth of knowledge that is available presently to the Mental Health Act Commission. Visiting staff will need to be comfortable meeting with mental health patients and service users who on occasions may be highly disturbed. This is a specialist role and not one for people without adequate training, knowledge, experience or commitment. Nor is it simply a bureaucratic or organisational function, but is a matter of protecting people who have been detained compulsorily, usually against their will, ostensibly in their own best interests. A vitally important feature of the Commission is the passion and commitment that Commissioners, SOADs and staff bring to the task. Despite the MHAC drawing attention repeatedly to substandard services, sadly many of the hospitals where people are treated compulsorily are not fit places to provide therapeutic care.
(vi) An overarching principle of equality and human rights, focussing at all times on the civil, legal and human rights of patients.
27. The MHAC has been a strong advocate for a regime that promotes and enhances a culture of equality and human rights, recognising the multi-ethnic and multi-cultural nature of British society. Nowhere is this seen more clearly than in mental health care for Black and minority ethnic patients who are significantly more likely than average to be admitted to and detained in mental hospitals. (See Tables 2 and 3 below. Figures given are for 2005 and 2006. 2007 data were released recently (Healthcare Commission, 6th December 2007) but show little difference from these figures). It will be evident from the tables that Black African and Black Caribbean patients are more than three times as likely as the average to be admitted to and detained in hospital; the Black Other group, especially men (largely second and third generation Black British patients) are over 10 times (and as high as 18 times in the 2005 results) more likely than the average to be admitted. There is no epidemiological evidence that suggests Black people are 10 times as likely to have mental illness. Our concern is that either there are some significant problems with the mental health care pathway for Black patients, or there is a largely unrecognised epidemic of mental illness in this community. Whichever it is demands attention and action; and the Care Quality Commission must be at the forefront in tackling these concerns.
Table 2 (above): Admission Rates by Ethnicity (all persons)
Table 3 (below): Admission Rates by Ethnicity (Males)
[Note: Age and sex standardised. Compared with ONS population Census data 2001. ** are statistically significant.]
28. As we noted in paragraph 15, of very high importance to women patients is the too frequent failure to protect or promote their dignity and their civil and human rights. The MHAC has found a surprising and shocking number of very serious breaches of the right to respect for human dignity and privacy, which on occasion may have amounted to serious ill-treatment. The MHAC will be issuing a report in 2008 drawing attention to what we consider serious abuses of women's human rights and matters of deep concern in the way services are provided. These include:
· The importance of gender separation and single sex accommodation;
· Concerns about the continued practice of detaining small numbers of women (frequently only one or two) on predominantly male wards;
· The public sector duty to promote gender equality;
· The needs of women in secure care and the lack of sufficient places specifically for these women;
· The role of the built environment in supporting the dignity of women in detention;
· The role of nursing staff in supporting women in detention and the importance of improved training for staff;
· Continued allegations of sexual abuse and the failure of services adequately to protect women;
· Physical healthcare for women who are detained under the Mental Health Act
· Women's role as mothers and carers: the essential requirement to maintain family contact during detention.
29. The Care Quality Commission must be at the forefront of protecting patients' rights and freedoms and ensuring the Act is applied without adverse discrimination. The MHAC believes strongly in applying principles of equality and human rights to all its work. A similar principle or set of principles should apply in the new organisation. The Joint Committee on Human Rights Eighteenth Report (2007) commended the MHAC's approach to Human Rights.
'In our view, lessons can be learned from the more systematic approach pioneered by the Mental Health Act Commission (MHAC). We are aware of the recent publication on implementing human rights by the MHAC in partnership with the Department of Health and what was then the Department for Constitutional Affairs. MHAC state that their purpose was to "[..] incorporate a human rights framework fully in the work of the MHAC, so that it becomes a recognised part of regular activity across the organisation."
The MHAC publication contains accessible and practical information on the steps that it took to complete the project and it identifies what people working within the commission learned from it. We are encouraged by the fact that the MHAC is to be merged with the Healthcare Commission and CSCI and urge that the highest common denominator should prevail
30. The MHAC presently covers England and Wales. From 1st April 2009 the countries will have different regulatory and inspectorial regimes. The MHAC has been in close contact with the Wales Assembly Government and the Health Inspectorate Wales (HIW), and is happy that, subject to Welsh Ministers direction, the HIW will be able to take on these functions and manage them competently and effectively.
31. The MHAC has come reluctantly to support merger of its functions into the Care Quality Commission. Undoubtedly there will be benefits - the enforcement powers and sanctions alone will provide the teeth that the MHAC has always lacked. Yet the MHAC has achieved a great deal through persuasion without the need to threaten or compel providers. Initially the MHAC was concerned that there would be insufficient attention to the needs of detained patients, and explored with Ministers and officials a number of alternatives. None offered any overall improvement on the proposals now outlined in the Bill. We now feel much more comfortable that the government intends that the Care Quality Commission will have the resources and the duties to ensure adequate attention is given to the needs of this vulnerable group. We are content to support the Bill - subject to the six areas that we have described in detail in this submission being addressed adequately.
Mental Health Act Commission, January 2008
 Wendell Phillips (1811-1884) said something very similar: "Eternal vigilance is the price of liberty." [Wendell Phillips, abolitionist, orator and columnist for The Liberator, in a speech before the Massachusetts Antislavery Society in 1852]
 Investigation into the services for people with learning disabilities provided by Sutton and Merton Primary Care Trust. Healthcare Commission January 2007
 The final column of this report shows the percentage of in-patients of each ethnic group as recorded in the 'Count Me In Census 2005'. Only those ethnic backgrounds are shown where at least one death has been reported during the period. Consequently the final column will not add up to 100%
 Chapter 6, Paragraphs 188, 189