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12 Jan 2009 : Column 108

Tim Loughton: I am grateful to the hon. Gentleman for giving way, because intervening saves me having to ask to make a speech. Is it not the case that a number of people who need to be sectioned for mental illness are sectioned at the instigation of family members who are acting in their interests but with whom they have fallen out? They do not feel that they can rely on family and friends to advocate for them informally, as they might in the case of other illnesses or in legal proceedings, because not trusting them is part of their illness. That is why the role of an independent advocate who can only have their interests at heart is essential, and why we really must get on with it.

Mr. Drew: I agree entirely, but of course the corollary to that is that occasionally, someone who has been sectioned has every right to distrust their family. There might be a family dispute going on. Too often, people come to us to ask us to intervene, saying that someone is mentally unwell, when nothing of the sort is true. There might be a wider dispute, and the family has sadly taken the ultimate step of saying that the person in question is not of sound mind. They want to get the authorities to intervene so that a course of action takes place that will help them to argue their case.

I have read the Mind briefing on the matter, which is very useful. It asks when the change will occur and whether it will genuinely happen this April. It asks how the change will be funded, who will be trained to do it and which organisations will have the means to undertake advocacy, which are all genuine questions. I support completely what the hon. Member for Broxbourne said, and I hope that as the Minister has a little longer than usual available to him, he can go into some depth in answering those questions.

I wish to dwell on two matters that concern me. First, I would like to think that some of the advocacy could be undertaken by people who have themselves suffered from mental health problems. I never cease to be amazed by the way in which those who have recovered from such problems are the best at knowing about the service, its strengths and weaknesses and, if you like, where the bodies are buried. For all sorts of reasons, the matter has to be handled incredibly sensitively, but I hope that when we hand out the commission for the work that is to be undertaken, there is a genuine effort to use people who have had mental health problems and are prepared to use their expertise to advocate on behalf of those who are currently going through such problems. That can be incredibly powerful. It has to be done carefully, but I would like to think that it will be considered closely.

Secondly, we have to be careful because we can get into something of a minefield. There are those who not only have mental health problems but are dependent on drugs and alcohol. We therefore need to recognise that the advocate’s role involves a range of skills. We must take account, too, of those who also have learning disabilities. The role of the advocate may be not only to undertake advocacy in language that professionals understand, but to work backwards from the professionals to the person who has been taken under mental health supervision. Perhaps that person has no language capability and finds the process alien to their whole being. In my constituency, many caring people are trying to work with those who do not have language understanding but who may not have mental health problems.

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We know that there is an association between extreme learning difficulties and mental health problems, especially in later life. Those with severe learning difficulties can develop mental health problems, and it is vital to have advocates who can genuinely interpret and translate for and work with the sometimes difficult cases of people who do not understand what is happening to them, and why what is happening is anything other than cruel. I appreciate that it is difficult to talk about such matters and that I am considering an extreme, but unless we raise these issues and recognise the problem, there is a danger that advocates will not come forward. The job is skilled and will be difficult, and I hope that we find enough of the right people to do it. The last thing we want is for those people to be overused and drop out quickly because of the pressure. I hope that the Minister has some good things to say about that. I appreciate being able to make a short contribution.

8.56 pm

The Minister of State, Department of Health (Phil Hope): I congratulate the hon. Member for Broxbourne (Mr. Walker) on securing the debate and thank him for raising an important issue. I am delighted that my hon. Friend the Member for Stroud (Mr. Drew) and the hon. Member for East Worthing and Shoreham (Tim Loughton) took advantage of our slightly extended time as a result of the main business finishing early to share their commitment, concerns and passion about getting the matter right. Hon. Members clearly have knowledge and experience—they served on the Committee that considered the Mental Health Act 2007, and some can bring family experience to bring to bear, too.

The remarks of the hon. Member for Broxbourne reflect a key concern, not only in mental health, on which I shall focus, but throughout the health service: how we ensure that everybody, regardless of background or circumstances, gets the best possible treatment and care. My hon. Friend the Member for Stroud mentioned diversity—I shall say more about the impact on black and minority ethnic groups shortly. It is important to convey a strong message, as we did with Lord Darzi’s next stage review, that we put the patient and patients’ needs at the heart of the health service. That is the key to improving the quality of care.

The hon. Member for Broxbourne is right that, for the most vulnerable members of our community—patients suffering from mental health problems—advocacy is one way of helping to ensure that the patient and patients’ needs are at the heart of the health service and to drive forward quality of care.

Giving patients a voice through advocacy or in other ways is about more than simply improving services, although it will have that effect. As my hon. Friend the Member for Stroud hinted, advocacy is about helping preserve a person’s dignity and self-respect, as well as protecting their legal and human rights, and that was considered when the Mental Health Bill was debated in Parliament.

The debate is a great opportunity to spell out what the Government are doing about improving advocacy services. I hope that I will respond to all the concerns that have been raised. Before I go into detail, it might be useful to put the matter in context and describe how far mental health services have travelled in recent years. That shows why it is so crucial to get advocacy right.

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I hope that hon. Members of all parties recognise that mental health services have improved significantly in the past decade. The national service framework—supported, I am pleased to say, by some sustained increases in investment—has transformed the scale and scope of mental health services in this country. There are now 740 new mental health teams in the community, offering people reassurance and effective treatment at home. There are also some very good early intervention programmes for those experiencing a first episode of psychosis, ensuring that people receive the help that they need.

I was intrigued to hear about the example from the United States that the hon. Member for Broxbourne mentioned. We should look not just to these shores for examples of good practice to spread, but throughout the world, where we see good practice, particularly in preventing people from entering forms of care that might be restrictive. The more that we can do that, the better.

My hon. Friend the Member for Stroud mentioned people with drug or alcohol issues. There is a need not only for outreach services that reach out assertively to people in the community who have other problems, but to see how we can make that connection with mental health services as well.

I am pleased to say that the work that we have done to date—clearly we want to do more—won international acknowledgement in the World Health Organisation’s recent mental health report, which rated services in this country as among the best in Europe. That is quite a turnaround from where we were in the 1980s, with a patchy, Swiss cheese model of mental health services, if I can put it that way, with inadequate and underfunded provision hiding under the cloak of care in the community, which the hon. Member for Broxbourne mentioned earlier. Now, we see an increasingly confident, assertive and innovative sector.

If the last decade has been about putting mental health on the road to recovery, by rebuilding capacity and encouraging diversity, we must respond in the next decade to new challenges. The biggest challenge of all is to ensure that some of the most vulnerable people in our community receive the care and dignity that they deserve. As I have already said, advocacy is key to that.

The hon. Gentleman will know this, but I want to remind the House that mental health advocates have supported patients in many mental health services for a number of years, helping to involve them in decisions about their care and treatment. That may include explaining why people have been detained under the Mental Health Act 2007 and what that means, helping them to communicate their views to medical staff or giving them support as they prepare for tribunals, for example.

Clearly, that is an important part of our duty of care and of upholding patient well-being. That is why we want to ensure that more mental health patients can benefit from mental health advocates. The Mental Health Act therefore seeks to improve and standardise existing arrangements, by introducing new independent mental health advocates, or IMHAs as they are known in the jargon. Such advocates must be available for all qualifying patients.

Let me pick up the point that my hon. Friend the Member for Stroud made about the independence of advocates, which is a central part of the design of the
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service. Hon. Members who scrutinised the 2007 Act will know that that independence is an important part of the role of advocates. Advocates will help individuals to understand and exercise their legal rights and will represent their views and interests in decisions about their medical care and treatment.

Independent advocates will be available to help most detained patients, as well as patients on supervised community treatment or in guardianship. Other patients whose treatment is subject to the special safeguards provided by the 2007 Act, which the hon. Member for East Worthing and Shoreham mentioned, will also be eligible. We estimate that just over 40,000 patients a year will be able to benefit from support from advocates.

Hon. Members have expressed concern about the delay in implementing the measures. The statutory provision for independent advocates comes into force in England from 1 April, as the hon. Member for Broxbourne rightly said. He asked why it had taken so long. My hon. Friend the Member for Stroud summed up the dilemma quite nicely. We want to get on with it and make things happen, but also ensure that we get it right. They say, “Marry in haste, repent at leisure,” and I am afraid the same is true of the more prosaic act of our implementing legislation.

We wanted to ensure that the introduction of the new advocacy service went smoothly, which has meant developing appropriate local commissioning processes and putting training arrangements in place, about which I shall say a bit more in a moment. I want to assure hon. Members that I am as anxious as they are for the measures to be enacted, but we want to get them right, too.

Tim Loughton: I hope that the Minister will forgive me if I do not quite recognise the rosy picture that he paints of mental health services, not least because of the reduced funding, proportionately, that mental health services get as part of the NHS. I want to bring him to the subject of community treatment orders. He will know how contentious CTOs were during the passage of the Bill. From the initial draft Bill, through the further draft Bill and the pre-legislative scrutiny Committee, CTOs were always contentious. They have now come into force. One of the reasons that their opponents were prepared to accept the watered-down version of CTOs—objectionable though they were, in many respects—was the safeguard that would be provided by the advocacy service, for which many of us petitioned for many years. The CTOs and the advocacy service were supposed to start at the same time. Why has that not happened? Why have CTOs gone ahead without that safeguard? The Minister cannot say that he has not had any warning about this, because the Mental Health Bill was many years in the making, and advocacy was always something that many people wanted.

Phil Hope: I had better not get drawn into a debate about which party has given more funding to the NHS to support services of this kind. I think that the hon. Gentleman will probably find that he has voted against supporting more funding for the NHS. But let us not sour the debate by talking about which party has trebled the funding for the NHS from £30 billion to £100 billion a year over the past 10 years.

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I had reached the point about why we had delayed implementation. In fact, the Act says that advocacy will not be available in law until 1 April, so we are working within the time scale of that legislation. These matters were debated by the House. As I said earlier, we wanted to ensure that we got this right. We wanted to get the commissioning framework right, as well as the recruitment—about which I shall say a bit more in a moment—and the training. Making these decisions and getting these things right was central, and hon. Members who have contributed to the debate might, like me, not be happy with the delay, but they will none the less recognise that getting these things right is more important than implementing the measures in haste and getting them wrong.

Getting the commissioning framework right was important. We wanted to develop a commissioning process that offered maximum flexibility so that local needs could be met. That maximum flexibility addresses some of the concerns that the hon. Member for Broxbourne raised about the ability of local and small organisations, as well as larger ones, to bid for contracts. In my former role as Minister with responsibility for the third sector, I ensured that the commissioning process across a whole range of aspects of Government policy provided such local organisations with a level playing field when bidding for contracts.

A challenge for all organisations bidding to provide these services will be ensuring that they deliver a consistent, high-quality service, so that people can have confidence in the standard of advocacy wherever they live and whatever organisation is providing the service. During 2007, we consulted widely, including with third sector organisations, on the best commissioning arrangements for delivering the new duty. Last month, I reached the conclusion that primary care trusts were best placed to commission those independent advocacy services. That will have a number of advantages. PCTs can commission jointly with other PCTs, or they can delegate commissioning responsibilities to them. That will provide a powerful degree of flexibility, which will be particularly important when patients are moving between treatment providers in different areas.

The system might also include advocacy services in partnership arrangements with local authorities, which would be useful, given local authorities’ experience in commissioning other types of advocacy. PCTs already commission other specialist mental health services. Many have already commissioned non-statutory advocacy services for patients, for example. Given that the main users of independent advocates will be those receiving in-patient care, PCTs will be best placed to know what services are needed in their areas.

I should like to draw attention to the guidance for commissioners that we published on independent mental health advocacy, as it addresses a number of the concerns that the hon. Member for Broxbourne raised. It also contains details on diversity, which I shall return to in a moment. First, however, I want to turn to funding—without getting into the territory that I mentioned earlier. We have taken into account the new statutory duty when setting PCT allocations for the next two years, so I can tell the hon. Gentleman that there is money in the system to support these measures, and we will expect PCTs to fulfil the duty effectively. Of course, different areas have different needs, and it will be for PCTs and
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their local partners to decide how best to use their resources to meet their statutory duty, but we want to give them plenty of support to help them exercise it.

At the end of last year, the National Institute for Mental Health in England published comprehensive guidance for PCTs. It discusses good practice and sets out recommended processes for commissioning. I have also asked the institute to work with commissioners and with mental health services and advocacy providers to provide ad hoc support and information for those engaged in introducing the new service.

What the hon. Member for Broxbourne said has given me a chance to make the point that independent mental health advocacy is not a replacement for anything, but a wholly new statutory service for a very specific purpose. It is there to provide extra assistance to people subject to compulsory measures under the Mental Health Act 2007. We have been very clear that independent advocates do not replace non-statutory mental health advocacy services. That is why we provided additional funding for PCTs. Advocacy provision is already available on a non-statutory basis, as we discussed earlier, from a number of agencies, and we expect those arrangements to continue.

It is important to get the right people acting as independent advocates, as my hon. Friend the Member for Stroud argued. They must be well trained, genuinely independent and suitably vetted. I remind the House that we have published new standards in regulations that make it clear what qualities we expect of independent health advocates. Training and recruitment are crucial to the success of the programme, as I am sure the hon. Member for Broxbourne would agree. We laid regulations that set minimum appointment requirements and set out who would be responsible for checking that independent advocates met the requirements.

Assuming that any individual—my hon. Friend the Member for Stroud made the particular suggestion that previous service users become advocates—meets the requirements, there should be no barrier to their appointment, but they really must meet the requirements set down in the legislation. Under the regulations, advocates must have appropriate experience or training for the role, and the Department website gives advice on what that involves. I hope that deals with the concern raised about a trainee carrying on when someone has been appointed; the people appointed must have appropriate experience or training for the role. We did not want to be too prescriptive, however; we wanted to be flexible about the experience and qualifications necessary, because we wanted to leave as much discretion as possible to those making the appointments.

My Department is also working with City & Guilds to develop a national advocacy qualification, which will include a specialist module for independent mental health advocates. I anticipate that this qualification and its training materials will be available before independent advocates take up their positions on 1 April, and I expect all of them to complete their training within a year of starting practice. Alongside that, the National Institute for Mental Health in England is producing an effective practice guide, including issues such as patient engagement and working with other mental health professionals.

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