Health Committee - Minutes of EvidenceHC 584

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Oral Evidence

Taken before the Health Committee

on Tuesday 12 March 2013

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Andrew Percy

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Dr Hugh Griffiths, National Clinical Director for Mental Health, Bruce Calderwood, Director of Mental Health, Disability and Equality, and Anne McDonald, Deputy Director of Mental Health, Department of Health, gave evidence.

Q68 Chair: Good morning and thank you for joining us. This is the second evidence session we are holding on postlegislative scrutiny of the Mental Health Act 2007 to seek to examine the impact of that piece of legislation five years after it was implemented, to work out what learning experiences are available to us from that. Could I ask you to begin by introducing yourselves and telling us very briefly what the scope of your responsibility is within the Department, please?

Bruce Calderwood: I am Bruce Calderwood, the director of mental health, disability and equality at the Department of Health. That means that my team provides advice to Ministers on mental health strategy and mental health policy. We produced the Government’s mental health strategy "No Health Without Mental Health". We also provide advice in particular on autism and learning disability. So it was my team that carried out the review of what happened at Winterbourne View. We are responsible for leading on issues of equality in the Department of Health to make sure that we are fulfilling our equalities duties properly.

Dr Griffiths: I am Hugh Griffiths, the national clinical director for mental health. I am also a consultant psychiatrist and have been for longer than I would probably care to admit, but it is well over 25 years. I have been in the Department for nearly 10 years. I was deputy national clinical director for six or seven years and for the last three years I have been national clinical director. To summarise, my main role is to provide the clinical input and advice for the policy team.

Anne McDonald: I am Anne McDonald. I am the deputy director. I work directly for Mr Calderwood. My branch deals mainly with mental health legislation and secure services.

Q69 Chair: Thank you very much. I would like to start by asking you what your assessment is of the effect of the change from treatability to appropriate treatment as the test for sectioning. It was one of the issues years ago: there were groups of individuals with personality disorder that psychiatrists were unwilling to detain under the Mental Health Act. Has that gone away as an issue, and indeed, more broadly, what has been the effect of the change of definition on the practice of psychiatrists when making sectioning decisions?

Dr Griffiths: I remember the debate at the time. The problem with the old Act-and I think most clinicians did agree-was in the exclusion, the treatability tests, because it asked clinicians to make a prediction of treatability before assessment, very often. There was a concern that some people who legitimately needed treatment would be denied access to it because of the nature of their illness-that they were not getting treatment. The debate was around an alternative to the treatability test. Of course we needed something because the other legitimate concern everyone had was around preventative detention-and this has to be about healthcare-so the concept of appropriate treatment was brought in.

The evidence that we have-and some of it is still provisional-seems to be that it has not made a significant material difference. The main evidence for that comes from a yettobepublished study-so these findings are still provisional-called the AMEND study, which is something that was commissioned through the Policy Research Programme, specifically looking at the change in the definition of mental disorder and, of course, the change to appropriate treatment. It looks as though clinicians have not significantly changed their practice, which is what you would expect because it is enabling legislation; it is just to make it clearer and more helpful. It has not made any difference to the proportion of people with personality disorders being detained, so it does not seem to have had the effect that some people feared and it does appear to be working.

Q70 Chair: Is it still an issue in the psychiatry profession that there are some cases where care and extra safety could be provided to the patient and to the community appropriately but where individual psychiatrists are unwilling to use sectioning powers?

Dr Griffiths: Clinical opinion and practice vary, but, by and large, I do not think that’s a problem. I know of no evidence to suggest that that is a significant problem. In some ways, the change in the Act makes clearer and more honest what people are expected to do. Unless anyone knows different, I have not come across that as a significant problem.

Q71 Chair: If we look at the increases in the number of occasions when sectioning powers are used over the period since the Act came in, what do you attribute that to?

Dr Griffiths: We have discussed this and the short answer is that it is unclear. It is not at all clear that it is down to the change in legislation. There was the trend of a small increase prior to the legislation. There could be all sorts of factors to account for it. There is another study that we expect to be published in the late summer or autumn. It is the English National Study of Compulsory Admission, by Warwick university, looking at some of the granular details as to what may lie behind that increase in detentions. So we have no evidence that it is down to the change in legislation, but it is something that we and everyone would be concerned about. I do not think there is a right number of detentions-we do not know what that would be-but any significant change has to mean we ask questions.

Bruce Calderwood: What we can say is that the trend in detentions applies not just in this country but also in other European countries. Even in Scotland, where after their Act there was a slight reduction in the number of detentions, in recent years it has gone up again. There seems to be something broader there than just the application of the legislation in terms of what is going on.

Q72 Mr Sharma: My questions relate to voluntary admission. The CQC records over 90% bed occupancy in over 50% of wards. With such pressure on beds, is it the case that people are being sectioned in order to gain access to beds as it is not possible by a voluntary admission? In addition to that, are detentions under the Mental Health Act increasing because patients do not wish to voluntarily admit themselves because they are aware that wards are overcrowded?

Bruce Calderwood: There is a range of factors there. The CQC certainly pointed to evidence that wards are running "too hot", as it were. A number of people are certainly suggesting that that is affecting the behaviour of both patients and clinicians. There are other factors that need to be thought about, one of which is around communitybased services and whether they are of the right quality. Again, the CQC made some recommendations around what community services need to be like. The conventional view would be that what one needs are extremely good community services that are there when people need them and enough beds, because clearly there is a case for voluntary inpatient care for when people need it. I do not think anyone would pretend that at the moment the optimal balance is there across the country.

Dr Griffiths: No. Can I add to that? We know there is some research evidence that there appears to be an inverse relationship between the number of beds apparently available and the number of people being detained, so that may well be one of the factors that underlies the increase for some of the reasons that you say. The other thing to add is that there is enormous variability up and down the country. The Audit Commission-as it was-used to run a thing called the Benchmarking Club for mental health service providers and they would look at the occupied bed days in acute mental health wards. What they found and what the CQC found was that some places are definitely running "too hot". Over 90% and certainly over 100% occupancy is "too hot", too high. The Royal College and others have suggested it should be around 85%, and I think that is about right. The Benchmarking Club also found that there is immense variation; there are a number of places that are running like that but there are some with relative underoccupancy, which, of course, is not right either, because inpatient beds are expensive and the opportunity costs and potential for investment in more appropriate services can be lost. So there is a balance and it seems like it is not being struck right at the moment on the evidence from the CQC. There may be a relationship between that and rates of detention.

Q73 Barbara Keeley: A comment has just been made about community services, but mental health patient groups have reported cuts to community services, like peer support, and lack of access to therapeutic services, with some very long waiting times there. Have you made an assessment of those elements being contributory factors to the increase in detention numbers? Indeed, is it the case that the threshold for admission to hospital increased and that we are now seeing people that are much more unwell when they go into hospital than was previously the case because of the two factors-lack of those community services and very tight pressure on beds?

Bruce Calderwood: There is a variety of ways in which that can be interpreted. It is fairly clear that the level of severity of illness of people in hospital has increased over time. That could be down to having more effective community services that are keeping people out of hospital.

Q74 Barbara Keeley: Let me make the point clearly. That is not what we heard. We heard that there was a lack of community services, they were not effective and they were not available even.

Bruce Calderwood: Community services have expanded dramatically over the last 10 years. It has been one of the big investment areas within the NHS. That does not mean necessarily that they are of the right level of quality that you would expect to see everywhere, but, if you were to look at something like early intervention in psychosis, that was a major success story in terms of providing the kind of support that young people need on the first onset of psychosis, to keep people healthy and out of hospital.

Q75 Barbara Keeley: You are not answering the question I asked. The question I asked was about groups reporting cuts to services. Unless you are willing to address the fact that we have been told that there are cuts to services, it is not going to be helpful. If you are telling me they have expanded, you are disputing what the patient groups have told us.

Bruce Calderwood: I apologise in that case. What there has been over a 10year period is a growth in communitybased services. What we are not sure about currently is whether that growth has continued, reversed.

Q76 Barbara Keeley: My point was that, in our taking evidence, groups told us that there were cuts. So we have to start from the position of not looking further back but saying there were cuts.

Bruce Calderwood: Certainly. There will certainly be reductions in services in some areas. In other areas, there may well be increases in services. We do not know what the overall balance is.

Dr Griffiths: Can I add to that? I think I know what you are getting at because I have people saying the same thing to me. Bruce is absolutely right that the investment, in 20112012 prices and the 10 years up to that, went up 59%. Most of that was in community services, particularly crisis resolution, early intervention, assertive outreach teams and so on. The latest figure we have for the last year’s investment to 2012 shows that, although there was a cash increase of, I think, 1.5%, that is actually a realterms reduction of 1%. So some places are reporting reductions, which is something that does disturb me.

One of the things that we need to keep an eye on in the future-because I think it is worrying that people are starting to report this-is what local commissioners will do under the new arrangements. PCTs commissioned mental health services in the past and I have to be honest and say they have done that variably. Mental health commissioning is something that I think we have felt could improve. There has been good practice around the country, but it could be improved and I think we have an opportunity to do that with commissioning moving to CCGs.

Something that we have done in the mental health strategy, its implementation framework, and indeed the mandate, is to call for parity of esteem for mental health services across the board. Particularly that will apply to commissioning, where I do not think it has been true in the past that it has necessarily had that, which is why we may see mental health services disproportionately affected. The other thing that can lead to that is that we have had block contracts for mainstream mental health services and not a paymentbyresults tariff system that exists for acute hospitals. It is much easier to cut a block contract budget than it is a paymentbyresults system and we are bringing in payment by results. It is a little harder to do in mental health, but we are bringing in a system and it is evolving as we speak. The data are now being collected.

Q77 Barbara Keeley: I have to say, Chair, I find it concerning that we have had this debate here about the cuts. If you are not aware of cuts, that is concerning. I cannot just advance my own anecdotal evidence in support of that, but I have had constituents taken off therapeutic programmes that have been cancelled. Mind told us that one in five patients has had to wait over a year for access to treatment. We heard that delays were actually leading to mental health professionals saying to patients, "The only way you can get access to treatment is via A and E." If you, from the Department’s point of view, are saying you have this rosy picture that there has been an increase of-

Bruce Calderwood: No, that-

Q78 Barbara Keeley: That is what you said. I asked you about cuts and you talked to me about expansion. You need to accept that this Committee, which is responsible for accountability, has had reports of cuts. I, as an individual MP-I do not know about others-have had experience of cuts affecting my constituents and you need a better map of what is going on out there if you do not accept that there are cuts that are causing one in five patients having to wait a year with mental health professionals saying, "The only way you are going to get treatment is if you go through A and E." That was my question.

Bruce Calderwood: I do not deny that there are cuts in some places. What there has been, though, is a pattern over quite a long period of growth in communitybased services and that pattern has still been accompanied by growth in people being detained under the Mental Health Act. So it is not as simple as, "There has been a reduction in communitybased services and that has caused the growth in the number of people detained under the Mental Health Act." The picture is very variable. The other thing that has happened-and this makes it difficult to interpret the evidence-is that there was a growth in lots of different types of communitybased teams and recently those teams have started to be amalgamated. It is then not clear whether that is a reduction in service or a simple increase in efficiency and a reduction in cost. In some places, doubtless, it will be a reduction in service and I would not possibly deny that. In the mandate that the Secretary of State has set the NHS Commissioning Board, it says specifically, "We want you to put mental health on a par with physical health, and we specifically want you to look at access to mental health services and at the times that people wait for mental health services because of the concerns that people have that waiting times can be too long in some areas."

Q79 Barbara Keeley: A year is too long. If Mind were reporting to us that one in five patients is having to wait a year and-

Dr Griffiths: I would want to look behind that. That sounds extraordinary and utterly unacceptable. I do not understand that figure. We have good relationships with Mind and I would be very happy to talk to them about it and find out what lies behind that.

Q80 Barbara Keeley: My other question was that we have had these reports and that is the evidence that was given to us, but how can this be clarified? How can we get a better picture? We are being told two things: there are cuts to community services and access to therapeutic services is a problem-people are waiting long periods of time and being told by mental health professionals, "You will have to go through A and E if you want treatment." But that does not seem to be the picture that you have, and you are looking at whether things happened in alternative ways. We need a better picture.

Dr Griffiths: I am not sure that it would be reasonable to characterise all services that way. The fact that it may happen at all-and there may be anecdotes to support that-is unacceptable. As to waiting a year for treatment, I would want to know what that is. Certainly, we are aware that there have been very long waits for specialist psychological treatments for some people with certain conditions. In my own area, in the past I’ve had 18month waiting lists for specialist CBT, for example, and that is unacceptable. It is one of the reasons why the Government introduced the IAPT programme-the Improving Access to Psychological Therapies programme-so that people with common problems to begin with can have better access. I’d want to understand that "year" figure more-what lies behind it. I am very happy to talk to Mind and find out what it is they are referring to, but I entirely agree with you that it is unacceptable.

Q81 Barbara Keeley: It was not just Mind. Naomi James of the National Survivor User Network made the point that the impact of these delays-so not a delay, not a single anecdote, but "delays"-is that patients are apparently routinely being informed by mental health professional that the only way they can access treatment is by A and E. That sounds like a pattern, doesn’t it?

Dr Griffiths: I want to know what data lie behind that; that is the point I am trying to make.

Q82 Barbara Keeley: The Department ought to have a picture is what I am saying to you.

Bruce Calderwood: The reason why we have set through the mandate this particular request to the NHS Commissioning Board is that we want from them an assessment of what waiting times there are for mental health services and what the access levels are, and we want them to give us that assessment so that something can respond to it, so that we have a better sense, therefore, of-

Q83 Barbara Keeley: We need that too in this Committee.

Bruce Calderwood: You clearly do.

Q84 Chair: Is there something you can provide to us in terms of-

Bruce Calderwood: At the moment there is not something that we can provide to you because waiting times data for mental health services are not collected routinely in the same way as they are for acute services. That is part of the reason why we are saying to the NHS Commissioning Board, "We want you to put mental health services on a par with physical health services."

Q85 Barbara Keeley: I would like you to accept that we have evidence that sounds a bit more than anecdotal and that this is something-

Dr Griffiths: But I want to understand the data behind it is my point.

Q86 Barbara Keeley: Can I move on to readmissions? The Mental Health Alliance did not have access to data on readmissions. Do you in the Department have evidence that can tell us whether a growth in readmissions has contributed to an overall rise in detentions?

Dr Griffiths: I missed what you said.

Barbara Keeley: Does the Department have evidence that tells us whether a growth in readmissions has contributed to the overall rise in detention? There has been an overall rise in detention. Is that due to readmissions?

Bruce Calderwood: By "readmissions" do you mean the same people coming back over and over again?

Barbara Keeley: Yes, that is what readmission means.

Bruce Calderwood: I was about to respond to a different question in that case. I do not think we have accurate information on the same people coming back over and over, but mental health conditions are longlasting conditions and they reoccur. It will not be the complete explanation for why there has been the growth in the number of detentions that there are, but you would expect a large number of those detentions to relate to the same people.

Barbara Keeley: Again, that sounds like something you might want to look at.

Q87 Rosie Cooper: If I may, I will quickly try to paraphrase an email I have asked my office to send me after listening to your exchange with Barbara. I recently had a letter from a constituent whose daughter was schizophrenic, had come off her medication and was in a very distressed state, so bad that the police were called and they handcuffed her. An ambulance was called and she was taken to Southport and Ormskirk hospital. She was assessed and told she could go home. The family disagreed because her behaviour was completely irrational-she was trying to unscrew screws from the door, trying to take a kettle away from a doctor-so much so that the doctor threatened to call the police.

They then could not get any help, so the parents decided to take the daughter home but left instructions with the partner to contact the Red Team and the Crisis Team at Chorley. They left messages on the answering phone, giving mobile numbers. The parents had to drive round with their daughter in the car for two and a half hours, eventually getting home at one o’clock in the morning. They got her upstairs with the intention of getting her to bed but she became uncontrollable. They then had to ring the police again. Three officers arrived and she was again handcuffed-and how frightening all this must be-and detained. They explained to the police what had gone on.

The police contacted the Scarisbrick unit and were told to get an ambulance, put her in the ambulance and take her to Southport and Ormskirk hospital where this had all started the evening before. Because they had no help, there was no choice but for it to be left to the police to arrange for an ambulance to take her to the custody suite. She was kept and seen by a police doctor and psychiatric nurse. They left at 4.40 am. The father rang the police station for information and was told that she would be seen by a police doctor at 8.00 am. Then they were told she would be taken to a psychiatric hospital in Bradford where she is receiving treatment.

Can you tell me how that meets your vision of what is going on in the health service and is different from that which Barbara and I see-or any MP may see-on a daily basis? How do you explain that kind of response from the health services you are, in essence, running?

Bruce Calderwood: That is completely unacceptable. It is just appalling.

Q88 Rosie Cooper: But it is not unusual.

Bruce Calderwood: It happens and I accept that it happens, but what you have just described is completely unacceptable. That should never have happened in that way, shape or form. It is completely at variance with what we are attempting to do. It is completely at variance with the strategy that we have outlined. My personal view is that that should be regarded as appalling practice. There is, we know, an issue in some areas about crisis care, the involvement of the police and the overuse of police facilities to handle crises. It is not as acute as it used to be. It is getting better, but it still happens. There is a lot more to do and we are working with the Home Office and the police forces to make it better. The pattern of events that you have described is awful and unacceptable.

Q89 Rosie Cooper: The parents’ letter finishes by saying, "When the duty doctor discharged the two officers and said she could go home we felt greatly let down for both [our daughter] and ourselves. We feel the duty doctor was incompetent in his duty of care and that he wanted no more to do with the situation. He gave the impression of ‘not on my shift’. If he had diagnosed her problem the second incident would not have occurred, which compounded our distress greatly. As for the Crisis Team it is a team in crisis; we received no help or return phone calls. It is not fulfilling its obligation as a twenty-four help line in West Lancs. With regard to the Red Team, they saw [our daughter] on Friday 1 March, reported that she was well and had never appeared better."

Do we have serious shades of, "We don’t have a clue what is going on in the service we provide," and perhaps Mr Francis should come and look at mental health services as they are being delivered? You three are telling me how it might and should be, but I have not heard you really address how it is for my constituents and, I have no doubt, other people around this table. This is real. Lancashire Care is seen to be one of the better mental health providers-that and Lancashire social services. However we get to it, this is what they are delivering to my constituents, not once, but over the years I’ve had many cases. This was only sent to my office on 6 March 2013, which is why, when I heard that exchange, I quickly asked for it. Yes, you are right, it is appalling. What I need to know is do you really know what is going on, on the ground?

Dr Griffiths: Can I respond to that? I still work on the frontline. I still see patients every week. I work in a general hospital and we go and see people who have generally come in through selfharm or attempts to kill themselves. I see problems both in my own service and other services. What you have described is truly appalling and there is never any excuse for bad practice. Where I differ from you is that what people will generally write to their MPs and to us with are the problems, and we see a great many problems. They do not tend to write to people when things are going well. Where I differ also is that to characterise the entire service as functioning in an unacceptable way like that is, I think, a misconstruction.

Q90 Rosie Cooper: Forgive me, but I do not characterise that at all. What I characterise is the fact that you are at the head of this organisation and you have not addressed the issue in any way, in spite of repeated questioning by Barbara about cuts, effects and the downsides to it. We are just presented with the theory of how it should run. I do not characterise the whole service like that at all. What I am saying is, if you do not recognise that this is going on, how, as Francis might suggest, are you addressing the problems if you do not know that they are there?

Bruce Calderwood: Can I respond to that? I am sorry if I sounded complacent. The Francis report applies as much to the mental health service as it does to any other part of the NHS. There are examples of fantastic service and there are examples of absolutely appalling service. The job of the CQC is to take a look at where the appalling services are, to actually assess them, to tell the trust about them and to expect the trust to bring them up to adequate standards. The job of the NHS Commissioning Board-and then in future CCGs-is to make sure that the services that are commissioned are of the highest quality. Our job as the Department of Health is to hold them to account and to make sure that they do it. We cannot do it on an individual basis, but certainly, in terms of an overall look at the service, that is what we intend to do. I apologise if what I said sounded as if I do not understand that really bad, poor quality practice happens-and happens not just occasionally but far too often. That is not the impression I intended to give and it is certainly not something that we are complacent about. People write to us about such things. People tell us about such things. It makes me personally very angry and our job is to try and improve the overall standard and outcomes in the system.

Q91 Barbara Keeley: Let me come back to the questions I asked because I think it is important. You mentioned that it is the job of the CQC, and the CQC has made recommendations about excellent community services. It is very important that we have debated this point about the state of community services. I would be very surprised if anybody thought that they had been improving in their area, because the stories you tend to hear, aside from awful examples like the one my colleague has just given, are of people losing services, people being taken off therapy, of therapeutic services being taken away. That is the evidence that patient groups gave us.

The second point I made was about readmissions. If it is the case that the pressure on beds is so great that people are more unwell when they go into hospital and are possibly more unwell when they are being released, that is serious. You do not seem to have a picture of readmissions, an understanding of whether that is the issue there. Those two areas are very important, but we will have to leave it because there are lots of other questions I am sure the Chair wants us to move on to. This exchange has not been satisfactory; we need better information and you need better information.

Bruce Calderwood: I agree absolutely that we need better information. We are about to move to a new, much more regular dataset. It is called the Mental Health Minimum Dataset. We hope that that will give us much more finely-grained information about what happens locally, much more regular information, but I very well accept that the kind of standard information that we have on mental health services is not nearly as good as it needs to be.

Chair: Barbara has accurately predicted my thought that we have a range of other questions.

Q92 David Tredinnick: But they are all related, I think. Going on from what Rosie and Barbara have said, if you look at commissioning by local authorities, when the Mental Health Alliance came to us, they said that there could be a problem with commissioning of services, not least because the Department of Health, although it will maintain funding for the independent mental health advocates, will not ringfence that service. Do you think that is a potential problem?

Bruce Calderwood: In general, this Government have decided not to ringfence budgets on the basis that the people in receipt of them need to be able to manage them and their priorities. There are statutory duties, however, that they need to fulfil. In practice, the amount of money that we are giving to local authorities in respect of IMHAs is larger than they were anticipating.

Anne McDonald: It has increased to £9.2 million from the £7 million that the NHS had received previously.

Q93 Chair: That is an allocation in a theoretical local authority funding formula. It is not a spend by local authorities.

Anne McDonald: No. It is the addition that has been made from this coming April to local authority budgets to reflect that new duty-that they have to commission IMHAs.

Q94 Chair: But is this money spent by local authorities or is it an allocation through some national funding formula?

Anne McDonald: It is allocated through the national funding formula, but it is an addition for next year to recognise this new duty that they have.

Bruce Calderwood: So it is not ringfenced.

Anne McDonald: It is additional allocation, yes.

Q95 David Tredinnick: The problem with the lack of ringfencing may be exacerbated because it seems to create a variation in local services. Certainly, this is what the Mental Health Alliance has said-that there is a variation in access to advocacy services across the country. Do you agree that not all patients who should have access to independent mental health advocates do have that access?

Bruce Calderwood: Yes; there is variation. The CQC report points to a considerable amount of variation there. The responsibility for commissioning mental health advocacy services has rested with PCTs; it is about to move to local authorities. So local authorities have not been responsible for that variation. Local authorities do commission other forms of advocacy services, and they commission the advocates for the Mental Capacity Act.

Q96 David Tredinnick: Thank you. I understand that variation might be acceptable if there is an area, possibly a more affluent area, where there is less of a need for services, and maybe there is a relationship there. Do you have a system of guidelines that are issued to try and look for anomalies?

Bruce Calderwood: There are statutory duties about advocates. People have a right to them in certain circumstances. Any variation that means that people do not have access to a statutory right is an unacceptable variation. That’s the first thing to say. The duties apply both to the commissioners in terms of what they need to commission but also, I think, to providers, in making sure that people are aware of their rights.

Q97 David Tredinnick: Isn’t this also linked to the increase in the rate of detention? Independent mental health advocates are not available to support patients, according to the National Survivor User Network, because as the rate of detention increases there are fewer people to go round.

Bruce Calderwood: I don’t think that there is any evidence about that. Actually, the evidence seems to be that the problems of lack of access are reducing over time, so the CQC has pointed to improvements. They are not nearly where they should be yet. But I don’t think it seems to be related to the rise in detentions.

Dr Griffiths: What we do know is that there is another problem that underlies that. That is shown in the preliminary results from, I think it was, UCLan, wasn’t it, who did the research into IMHAs? That is the practice actually, people not telling people, as they are supposed to, about their rights for an advocate. So what the researchers have proposed is, rather than having an optin system, where you are told you can have it and then apply, you automatically get one unless you say you do not want one. That is something-I don’t know if you want to say more, Anne-we are considering at the moment. If that is part of the problem that may well make sense.

Q98 Rosie Cooper: I have just heard that exchange and I want to say, going further than that, the Department has suggested that the assessment of diversity and local need will be considered in the handover of commissioning responsibility to local authorities. What will you do to support local authorities in assuming those commissioning responsibilities? These are big. Where will local authorities get that realtime expertise? I have links with this in that both my parents were deaf, so I have grown up in a deaf world. Deaf people will often tell you that they struggle, one, yes, to get advocacy but, two, to get anybody to help them who is more than just an interpreter.

Anne McDonald: I think the University of Central Lancashire’s research found that it was almost an inverse issue, that the more you needed an advocate, the more difficult it was to access them for exactly some of the reasons that you say. What we are considering with the researchers who did that work is how we can take some of that learning out and work with the local authorities as they take on this duty to build their ability to provide the right diversity of all sorts-cultural as well as disability-into their advocacy services. There are areas of good practice where people have developed what they call noninstructed advocacy exactly so that they can work with people who find it difficult to instruct an advocate. It is a skill to work with people with, perhaps, learning disabilities, so we are building on that to work with the commissioning-

Q99 Rosie Cooper: What is going to happen to these poor souls while you are building?

Anne McDonald: There will be an advocacy service. This is about building a service. There will be people with skills now who can work with professionals to provide that advocacy.

Dr Griffiths: The service hasn’t changed; it is the commissioning that is changing, isn’t it, not the service?

Anne McDonald: Yes.

Rosie Cooper: It is no wonder we are in a mess.

Bruce Calderwood: Local authorities already commission independent mental capacity advocacy services and other advocacy services. So what we are doing in moving this particular commissioning function to them is, in a sense, building on the ability that they already have. Advocacy services exist currently. They are clearly not being delivered in sufficient quantity. In some areas, it is clear that wards are not actually telling people about the advocacy rights that they have. The research that Anne has spoken to has been widely publicised. We are working with the researchers about how to transmit the messages of that through the system, and they have also made recommendations to us that we need to look at, one of which, as you have said, is around whether to have an optout service rather than an optin service. If we do that, that would reduce the pressures on the advocacy system.

Q100 Mr Sharma: There was a very interesting response to the previous question. The £9.3 million allocated to local authorities across England and Wales is not ringfenced. What measures will you implement to track the use of this resource to ensure that it is used for its intended purpose?

Bruce Calderwood: With ringfenced money you do not track, if you like, whether they spend exactly that amount of money. However, through the CQC, which monitors the availability of advocacy services and whether people have advocacy services, we will know whether advocacy services are there in sufficient numbers to meet the statutory duty. But we will not physically track the pounds because you do not do that with nonringfenced budgets.

Q101 Mr Sharma: But you have agreed that there is evidence, and many people have the experience, that when money is not ringfenced then it can be misused or abused by the system, used somewhere else, but the intended purpose is to use this money for the advocacy.

Bruce Calderwood: What we have done is put into the local government settlement enough money for advocacy services in the way in which many Government Departments put money into the settlement for a broad range of services, but it is then down to local government to decide how to spend that money, rather than spending it in exactly the proportions that we have allocated to them. Some authorities may spend more and some may spend less than that. The crucial thing is, do they provide the advocacy services, not exactly how much money-

Mr Sharma: Adequate advocacy services.

Bruce Calderwood: Yes. The crucial thing is, "Do they provide adequate advocacy services to meet the statutory requirements?", not, "Have they spent the exact amount of money that is buried in the allocation?"

Q102 Mr Sharma: We have heard evidence that staff on wards will, on occasion, decide whether it is in a person’s best interests to have an independent mental health advocate. Is this in keeping with the aims and the wording of the legislation? Additionally, if you confirm that, to what extent do you expect clinicians to facilitate access to independent advocacy, or are they simply expected to inform patients of their entitlements?

Anne McDonald: This is the other side of the equation that staff, the professionals, should be facilitating people’s access to advocates. If the first time they explain it to somebody is in the first few days of confusion, then they should be explaining it again and facilitating it. It is not for them to act in somebody’s best interests in that way, but they should be facilitating the-am I misunderstanding your question, I am sorry?

Q103 Mr Sharma: I do not know whether I am misunderstanding the answer or you misunderstood the question, but certainly there is some misunderstanding here.

Bruce Calderwood: They should not be judging whether it is in someone’s best interests to have an advocate, but it is people’s statutory right to have an advocate and therefore they need to be able to explain the statutory rights if the person does not understand. If the person is in a state of confusion and anguish, which will be quite common when people are first admitted, then they should explain regularly, until the person does understand it. The code of practice is very clear on that. Perhaps I should have said earlier that one of the things we will be doing over the next year or so is rewriting the code of practice to take account of the evidence from the various studies we have been talking about, and also what people are telling us, to make it absolutely clear what best practice is in the way in which the Mental Health Act should be implemented.

Dr Griffiths: The evidence seems to be that they are not doing it as consistently as they should, hence the question around, "Should it be an optout system rather than optin?"

Q104 Chair: Who is responsible for developing the concept of best practice in that context? Is it the psychiatry profession? Is it the policy people in the Department, the Commissioning Board? Where does the concept of what "good" looks like come from?

Bruce Calderwood: The concept of what "good" looks like comes from what good clinical practice is, which is primarily-

Q105 Chair: No. I am thinking more specifically about this access point to IMHAs.

Bruce Calderwood: Right. Here is one of the things where there is a join between what the law says and what the policy intent of the law is and, if you like, how that then connects up with good practice, both good practice in terms of what psychiatrists, psychologists and nurses and other health professionals do-

Q106 Chair: I understand that, but it is precisely because it is at that kind of crossover that I ask the question, who-

Bruce Calderwood: So it will be the Government’s code of practice.

Q107 Chair: So it is the Department.

Bruce Calderwood: Absolutely. It will be the Department’s code of practice, but we will develop it in consultation with professional bodies, patient groups and others.

Dr Griffiths: That is exactly how the original code of practice was developed.

Bruce Calderwood: Yes, exactly.

Q108 Chair: So it is an issue for your division in the Department.

Bruce Calderwood: It is an issue for us, but it will not just reflect our own civil service views of what the world ought to be like.

Rosie Cooper: Independent mental health advocates can make representations on behalf of patients but cannot formally advise patients or propose a particular course of action even if they believe it is in the patient’s best interests. Have you considered extending the remit of the independent mental health advocate, and what do you see would be the downside of allowing them leeway in advising patients? I am sorry.

Chair: Shall we do Barbara’s question first?

Q109 Barbara Keeley: There was a final point on that link between what staff do and what the advocates do. There is the CQC warning that clinical staff are actually in some cases retreating from their obligations to inform patients of their legal rights. You have talked about the code of practice, but is it the situation that we need safeguards to check that a patient has been made aware of their rights? It is quite clear that the CQC say that in practical terms nursing staff have much greater contact with detained patients than advocates. They may not have an advocate and they may never get to think about or be aware that they could have an advocate, so the staff are best placed to ensure that patients get this opportunity to understand and exercise their rights. But, if it is the case that staff are retreating from that, then we need another check, don’t we, somehow?

Bruce Calderwood: The check is effectively the CQC. It is its job to say, "Are essential standards being preserved?" and to see that the Mental Health Act is being operated properly. What it does is goes and talks to the hospital when it finds things that are wrong.

Q110 Barbara Keeley: I understand that, but it is saying that staff are retreating from their obligations to talk about rights. Because of the existence of the independent mental health advocates they are saying, "There are advocates and we do not need to do this," but in fact they are best placed to give that advice. The CQC is saying they are not always doing it and are saying, "Because there are advocates, we do not need to do this," but in fact they do. Whether or not an advocate exists, in terms of advising patients of their rights, the staff who see them every day and have better access to them are better placed to do that and the CQC is now saying that staff are retreating from that. How can we deal with the issue that staff are moving away from what they did before?

Dr Griffiths: I had misunderstood your point to begin with, but I think I do get it now. That is alarming, actually, and maybe that is something for the code of practice because clearly the intention of IMHAs is to enhance people’s advocacy and the information they get, not to somehow have it impeded by staff.

Q111 Barbara Keeley: But we need additional checks or safeguards, don’t we, because if the CQC is finding that staff are retreating from what they should be doing-"Because there are advocates, we do not need to do this"-then we need a further safeguard? A code of practice does not mean that staff stop doing something that they have started doing.

Dr Griffiths: That is right.

Q112 Rosie Cooper: In fact, if I might be so bold as to piggyback on to that, the question is, what assurance do you as leaders in the mental health profession have that employees, clinicians, are not withdrawing or retreating from their duty?

Dr Griffiths: The answer is that we do not. That is why I think it is a fair point and it is also worrying that people are not discharging their responsibilities to tell people about their rights to IMHAs. That is why, as I say, we think an optout system would work best. I am struggling to see what kind of assurance mechanism would work because the main one we have around regulation and inspection is, of course, the CQC-that incorporates the Mental Health Act Commission. Maybe it is a conversation with the CQC. I do take the point but I am just trying to think what those additional safeguards would look like.

Q113 Rosie Cooper: Okay. I have chaired a hospital. Assurance: what would I require if I ran a mental health service? I would be saying on every case note, or wherever, "Has this person been given"-as Barbara might suggest-"access to an advocate?", a tick box, and you look at the notes and know whether it is done or not and each level of people dealing with the patient will be able to see that. If questioned by a board or whoever, they would know. I would see that as basic in providing this kind of service. For me, it is frightening. Every time you speak to anyone in the health service these days you hear, "This is not working. Whose responsibility is it?", then, hey ho, bring in the cavalry-it’s the CQC-and they will say whether it is good or not. They look at a model. They do not investigate every case.

Dr Griffiths: I see.

Bruce Calderwood: Whose responsibility is it? It is the trust’s. It is the hospital trust that has to make sure it happens and it is the clinical responsibility of the professionals within that to make sure it happens. The CQC’s job is to be the regulator and to say, in general terms, whether this is happening or not. What it does is look at the case notes. That is where it derives its evidence from. But it then becomes the hospital’s job to make it happen.

As to whether or not there should be national measures for that, I am deeply sceptical. The thing about the Francis inquiry was that he pointed to a whole series of national measures that everyone was looking at and actually what that took away from was the responsibility of hospitals and professionals to do a decent professional job. So in terms of how things get better, there is stuff that we can do, and I think we can do it in terms of the code of practice; there is stuff that the CQC can do, and it is doing it, and the CQC I know wants to strengthen the way in which it is regulating mental health providers. There is a conversation to be had with professional bodies, the Royal College of Psychiatrists and the Royal College of Nursing, around what professional standards are, but I don’t think we will be, in a sense, looking at people’s records all the way up the system.

Q114 Rosie Cooper: I am sat here as a Member of Parliament doing what I have just said to you: I am looking for assurance that we are delivering out there, and we are not, are we?

Dr Griffiths: What you have described is a local governance and assurance process that trust boards should have in place. That is what you are describing.

Rosie Cooper: "Should".

Q115 Barbara Keeley: Could you not be reminding them of that? Don’t you see a role for yourselves in even drawing this issue to their attention? How are all the local boards going to become aware of it if you do not take responsibility for letting them know, "What we are bringing to your attention is that there is an issue here"? There are two things, aren’t there? One is staff retreating from their own professional responsibilities for advising of rights and also, we were told, in some cases making a decision on behalf of a patient whether they will or will not have an advocate. In fact, Naomi James of the National Survivor User Network said that she sees that as potentially pointing to a human rights problem. If this exists and is being reported to us, then there must be some responsibility on the Department to get that message out and to make clear to local trust boards what they should be doing.

Bruce Calderwood: The Department does not manage local trust boards. It is very clear that it does not have that responsibility.

Barbara Keeley: I am not suggesting that you do.

Q116 Chair: This is not about managing trust boards, is it? This is about making certain people have their civil rights that are secured by Act of Parliament.

Bruce Calderwood: Okay. Our vehicles for doing that are through the code of practice, which we intend to rewrite, and through talking to and holding the NHS Commissioning Board to account. The NHS Commissioning Board, we hope this week, will be announcing their new clinical director for mental health services. One of the things we want to do is sit down with them and go through things like the CQC report to say, "Well, what is going on here? Where are the areas that we can improve?"

Q117 Barbara Keeley: Then it has been useful our discussing it because the issues are that the CQC pointed to the fact that staff are retreating from telling patients about their rights, staff in some cases taking over the decision about whether a patient will have an advocate or not and the earlier issues that we talked about of cutbacks and bed pressures causing the earlier problems that we talked about. Those are all issues that it would be very useful for you to raise.

Bruce Calderwood: Yes, these are issues that we need to hold the NHS Commissioning Board to account for.

Q118 Rosie Cooper: I want to quickly go over the question I asked before, which was about allowing independent mental health advocates to offer advice to patients.

Anne McDonald: They can certainly offer advice to patients about the safeguards within the Mental Health Act and explain to them how to take advantage of the tribunal and various other safeguards around their detention, but as an advocate it is that they are speaking for the person. So they can advise about the issues around the detention, but they have to speak on behalf of the person in terms of advocating for them.

Q119 Rosie Cooper: When I send for a lawyer, I don’t expect the lawyer to translate that I am telling whoever to go away. I would expect them to give me advice about how I should express that view within the legal structures. I don’t expect them just to be an interpreter. I am really trying to find out if you think an independent mental health advocate is simply an interpreter.

Anne McDonald: No, I think that they are advising the patient and helping them take advantage of the safeguards that surround their detention under the Mental Health Act.

Q120 Rosie Cooper: So the notes we have here say they cannot formally advise a patient. Is that your understanding?

Anne McDonald: I think "formally advise" is referring to legal advice. They work with the patient to explain-

Q121 Rosie Cooper: Okay, so what you are saying is that, as well as an independent mental health advocate, they also need a lawyer in the room in order to deal with a mental health professional. Is that what you are really saying?

Anne McDonald: No. I am saying that, if there is a legal issue to do with the legal points, they cannot formally give legal advice because they are not a lawyer.

Rosie Cooper: I get that.

Anne McDonald: But they can advise, because they have been trained in the aspects of the Mental Health Act, on how to use-

Dr Griffiths: They cannot provide formal legal representation, can they?

Anne McDonald: No.

Q122 Rosie Cooper: Okay. Let’s leave that. We are not going to go anywhere with that either.

What is the logic behind limiting the mental health advocates only to those patients detained under the Mental Health Act or subject to community treatment orders? When I asked that of the last panel, they indicated that voluntary patients-I am not going to say often-had been told by clinicians that, if they tried to leave hospital, then they would be sectioned. Does that go back to the point we have just been making that there is a need for formal advocacy to be extended to voluntary patients as well?

Dr Griffiths: I think they have extended IMHAs to voluntary patients in Wales. The reason given at the time, in my understanding, was fairly clear because there already had been advocacy services for all patients in some services. There is some very good practice out there. At the time, it was felt that extending the formal IMHA role to all patients could destabilise some already existing good advocacy services. As far as detaining people in hospital who are voluntary patients is concerned, it is very clear. There are circumstances where voluntary patients who are inpatients need to be detained, for whatever reason-their mental state has changed, the risks have changed or whatever circumstances have changed-and there are of course sections 5(2) and 5(4) in the Act in order to do that, but it is utterly unacceptable to threaten anyone with it. The code of practice makes very clear that it is unacceptable practice to threaten someone. If someone’s circumstances have changed, they are thinking of leaving, they meet the criteria for detention and it is appropriate, then, yes, but what you don’t do is threaten it and coerce people in that way. I am aware, as you obviously are, that it still happens. To be honest, when I was in training many years ago, it happened more and it was not reported. There weren’t figures on it, but it definitely happened. I have to say that I know it does occur and I do not have detailed figures on it, but certainly in talking to colleagues and in my own experience it has reduced very considerably, but it is always unacceptable.

Q123 Rosie Cooper: Can I ask about limiting independent mental health advocacy to those patients detained under the Mental Health Act or community treatment orders? What about everybody else?

Dr Griffiths: I did explain at the beginning, I thought, that there was a good reason for that, which was not to destabilise existing advocacy services. However, they have extended it in Wales and it will be interesting to see what their experience of doing it is. What I do not know is the extent to which they had those preexisting advocacy services. That is something I cannot say. But we would be interested to see what happens in Wales.

Chair: Andrew, I think, is going to talk about community treatment orders.

Q124 Andrew Percy: Yes, and I apologise for being late. When the Committee heard from the Mental Health Alliance, there was considerable criticism made by them of community treatment orders. That was based around them being largely a way of compelling patients to take their medication. Could you give us your view on whether that is a fair assessment but also perhaps expand on that to explain what you feel community treatment orders should encompass?

Dr Griffiths: Shall I start on that? They caused a lot of debate at the time and a lot of criticism that they were just about medication and so on and so forth. The intention at the time was very clear and it is the same where they have been introduced across the world. The intention was not just to make sure that people take tablets or injections. The intention was to bring mental health legislation much more in line with modern practice. The previous Acts of 1959 and 1983 were very predominantly based around inpatient care. Up until then, that had been the predominant focus of services. By the 1983 Act, it was becoming much more community-orientated but less so than it is today. Since then, modern services are very much more based and focused around community settings. Therefore, it makes sense to have mental health legislation that reflects that. The intention of community treatment orders was first of all to do that and, secondly, to try and maintain people well in the community, who otherwise might not have been, when they had left hospital.

In my own experience-and psychiatrists differ about this-the majority of my colleagues are marginally in favour of CTOs, it is fair to say. If you speak to different professional or patient groups, you will get different views. I changed my opinion about them over many years. I started off being for them, then against them-I won’t tell you why-but the point is I ended up being, overall, in favour of having CTOs because I have had too many patients in the past with longterm and severe conditions who, for whatever reason, once they have left hospital, even with some of the best services around, have really struggled to maintain themselves well and keep engaged with the services. Having some kind of provision that might have enabled us to do that better, I think, I would have supported.

Whether CTOs work or not in the way that we want them to work is another question. Experience around the world in Australia and the States is, frankly, a bit equivocal if you look at the data. There is not really good evidence even though, as a clinician, I think that would be useful. However, the NIHR has commissioned-I think it is the world’s first-a randomised controlled trial of CTOs. That is called the OCTET study-the Oxford Community Treatment Order Evaluation Trial. It is led by Professor Tom Burns from Oxford, but it is a national study. That, unfortunately, has not yet published its results. I know they have finished the yearlong trial and they are due to publish next month. What they have done is a controlled trial of community treatment orders against section 17 leave, which is what a lot of people would use under the old Act. There were three kinds of provisions before, section 17 leave, guardianship and-I think it was called-after-care under supervision, which was a sort of provision to try and ensure that people stayed in contact with services, which was not used greatly. The point is that we will know, when those results come in, to what extent it may or may not prevent readmission compared with section 17 leave. I am aware that they are contentious, but the issue is about maintaining people well. It is not just about trying to ensure that they take medication.

Q125 Andrew Percy: It is interesting because your response was broadly around preventing readmission, what Ministers at the time called the revolving door. One thing the Mental Health Alliance raised at the Committee that they were concerned about was the fact that 30% of people on a CTO have only come into contact with mental health services for the first time. That leads to the question: are they therefore being misused and is that a failure of the-

Dr Griffiths: Readmission is what the OCTET study is measuring. I have been very clear that it is about maintaining people well, which is a slightly different thing from just preventing readmission. I have read that figure as well. It is difficult to say because the idea of a community treatment order is not just for people who have already become revolvingdoor patients-it is a terrible phrase, but I think we all know what I mean when I use it-but also to prevent people becoming revolving doors. So we cannot extrapolate just from that figure and say that it is being used inappropriately. But, again, we will learn more from the OCTET study.

Can I say one other thing? CTOs are being used much more extensively. There was an initial prediction at the time of the Mental Health Act about the number of likely CTOs. I do not know why someone felt it necessary to try and predict the number, but it looked at the time like a hopeless underestimate, which is what it has proved to be. So we do not know and there does not seem to be a right number for CTOs. We would expect them to stabilise over time, but what they do show is that clinicians think they are useful because they are using them. It is a clinical decision as to whether or not you put someone on to a CTO.

Q126 Andrew Percy: What you are saying is that you are comfortable with the idea that a CTO is suitable and appropriate for somebody who has come into contact with mental health services for the first time, that it is perfectly acceptable and was the original intention of the legislation. So for somebody who has no history of failing to take medication or relapsing, it is completely appropriate for-

Dr Griffiths: No, I am not saying that it is completely appropriate and should automatically be a treatment or a measure of choice. I can see there are circumstances with people who are relatively new where it may be, but it does not mean that it always is. Yes, it is an alarming figure and clearly the intention was to try and help support people who were in and out of hospital to remain better and more stable for longer. But it does not mean that it has to exclusively apply to people who have already been in hospital many times. You do need to have been detained in the hospital before you can go on a CTO.

Q127 Andrew Percy: There is also-we heard from the Mental Health Alliance as well, I think-considerable variation across the country by professionals in the use of these. One of the figures we were given at the time was that 45%, or something, was the highest utilisation of them; 4% was the lowest. The "Lowest reported ‘discharge rate’ on to a CTO was 4% and the highest was 45.5%." Are you comfortable with that variation?

Dr Griffiths: It is a lot of variation, but then, again, we would expect variation because different areas have different services, different demographics and are configured in different ways. So you would certainly expect some variation and there is some disagreement within my own profession about CTOs. There are some people who are very uncomfortable with them and others who are very comfortable with them. When you combine the other variables, plus the varying professional practice, it is not surprising. Am I comfortable with it? Actually, I am probably not because they are there for a purpose. On the other hand, it is enabling legislation and these are clinical decisions.

Q128 Chair: Is there a school of thought within the profession that would argue for CTOs being available without a patient first having been detained in hospital?

Dr Griffiths: I think-and I cannot remember which it is-there is a country that has done that.

Anne McDonald: It is Australia, I think.

Dr Griffiths: I may be wrong. There is an argument for it. I cannot tell you the Government’s view on it, but I can tell you mine, which is that I think it is a bit of a dangerous road to go down. It really does open up a whole series of very uncomfortable questions and potential problems in practice. My own view would be-and if there is more positive experience of it in other countries then I would like to learn from it-that I personally would be uncomfortable with that.

Q129 Chair: So it is a discharge or recall mechanism. It is not a form of freestanding treatment, in your view.

Dr Griffiths: Absolutely, yes.

Bruce Calderwood: It is based on a clinician’s view on risk. Fundamentally, that is what it is all about.

Anne McDonald: I was going to go back to the "original intention" question, because when the 2007 Act was originally debated there was an amendment that tried to restrict it to people who had been detained more than once. That amendment was not made, so Parliament’s intention was not to restrict it to just that group but to put it to the clinical decision about the risk in the community rather than that group of patients.

Q130 Chair: But it is still true that the patient has first to have been detained as a patient in hospital.

Anne McDonald: Yes. It is just this question about revolving doors.

Q131 Andrew Percy: The Mental Health Alliance point was about using them for people who do not have a history of noncompliance and the appropriateness or otherwise of that.

Dr Griffiths: Can I add another thing which may be driving some practice? It was mentioned by the Alliance, and a couple of tribunal chairs I have spoken to have told me this as well. Tribunal practice appears to have changed a little bit in that when reviewing patients on section 3, which is one of the things that many of them routinely do-at least, that is what the tribunal chairs tell me-they ask the question, "Have you considered a CTO?", because they are anxious that people should consider the least restrictive option at all times. It seems to me that what some clinicians may do is interpret that as meaning the tribunals expect them to be put on a CTO. The tribunals say that is not what they are saying but that they are merely asking whether they have considered it. To what extent that may be driving behaviour is unclear and is perhaps something we need to consider in the future code of practice and so on, but it may well be that tribunals have had an effect as well.

Q132 Valerie Vaz: I want to go back to a couple of your comments before we move on to places of safety. I know you are wearing two different hats, as a practitioner and being in the Department of Health, but could you expand on why first you were against and then in favour of CTOs?

Dr Griffiths: I can if you want. At first-and I am going back to when I was a relatively junior doctor and a young consultant-I thought they were potentially too much of an intrusion. The way they had certainly been debated at the time was really as treatment orders, so having treatment enforced at home in the community. I was certainly, and absolutely still am, against that. I thought they were probably a step too far and would be administratively difficult. It was actually when I was a young consultant in the first few years and I did a job-looking back on it, it was an enormous job actually-where, because of the nature of the job, I had a very large cohort of patients with severe and longterm mental illness. I realised how inadequate what we were able to do for them very often was, particularly those who would rapidly lose insight and who were perhaps a little bit more chaotic in how they would take their treatment and so on. To watch them continue to relapse and get worse each time they relapsed was something about which I thought, "We have to do better than this." So, within a relatively short few years, I came to my own personal view that CTOs would be a really useful thing. Certainly, colleagues in Australia have very often said to us in the past, "How do you guys manage without CTOs?"

Q133 Dr Wollaston: Before I start, I need to state for the record that I am married to an NHS consultant forensic psychiatrist, who also provides advice to all political parties on behalf of the Royal College of Psychiatrists. Having got that out of the way, can I follow up on a couple of points? Have you yourself seen the results of the OCTET study and is that something you would recommend the Committee tries to obtain a copy of before we-

Dr Griffiths: We have seen provisional data, but we really cannot talk about the data because we did not commission the study and it isn’t finalised, and won’t be published until next month; it will be in The Lancet, I understand. This Committee will obviously be very interested in the findings of the OCTET study.

Bruce Calderwood: Because of those conditions, we have not been drawing on it in terms of the replies we have been giving you. We have been trying to pretend we have not seen a copy of it, if you see what I mean, because it is confidential to the people writing it.

Q134 Dr Wollaston: Yes, but I think it would be useful for us to know as a Committee whether the findings could have an impact on what we decide.

Dr Griffiths: Absolutely, yes.

Q135 Dr Wollaston: The timing of it is frustrating. Secondly, I understand that there will be variation in the use of CTOs around the country because of different circumstances, but I think what people would be more concerned about is that, if you were a patient in identical circumstances in different parts of the country, how much variation would there be if the circumstances were very similar? In other branches of medicine, we might expect the Royal College to issue best practice guidelines or perhaps for NICE to do so. Do you think that is overdue for the use of CTOs?

Dr Griffiths: That is probably a fair point. Part of the difficulty is that they are so relatively new and the picture has changed very rapidly. We do need to know what the trial tells us, but Bruce has said we are looking to redo the code of practice later this year anyway. That is one of the things we should certainly include. As to whether there should be professionally-led guidance-whether it is NICE or the Royal College-is a very interesting question. My not terribly thoughtthrough answer would be yes, actually, that probably would be a sensible thing to do.

Q136 Dr Wollaston: So it is not something that Parliament should be passing enabling legislation for, but clear guidance would be your-

Dr Griffiths: Yes, and to have that around professional consensus. That makes sense.

Q137 Valerie Vaz: Turning to places of safety and sections 135 and 136 of the Act, you mentioned earlier, in response to a question from the Chair, about the study that has been done by Warwick. Could I ask who commissioned that?

Dr Griffiths: The overall study-England, and I can’t remember what it was called now-was PRP, Policy Research Programme or NIHR?

Anne McDonald: It was the National Institute for Health Research and it is called the English National Study of Compulsory Admissions.

Q138 Valerie Vaz: It is reporting in the autumn.

Anne McDonald: Yes.

Q139 Valerie Vaz: You have no view on whether there is a link between the increase in the number of places of safety and the Act-the causal link between the two-do you? Do you have a view as opposed to the study?

Dr Griffiths: Section 136 was in the old Act. It is not new. I am misunderstanding your question, I think.

Q140 Valerie Vaz: There has been an increase in the number of places of safety. You say that it is not a result of the 2007 Act.

Dr Griffiths: No, because it didn’t-I mean-

Bruce Calderwood: What the 2007 Act did was allow people to be moved from one place of safety to another.

Q141 Valerie Vaz: I am coming on to that in a minute.

Bruce Calderwood: That is what the Act did. Whether that in itself has actually shifted behaviour is unclear. What there was, though, was an investment programme in hospitals to create more places of safety. That was part of the implementation of the Act, so there is a combination between the legislation allowing one thing to happen and an investment profile.

Q142 Valerie Vaz: I am quite keen to hear the Department’s view on that. You said a study has been commissioned but it has not been commissioned by the Department. What is your view?

Bruce Calderwood: Our view is that there has clearly been an increase in the number of hospitalbased places of safety. We have gone from one third of patients going to a hospitalbased place of safety to two thirds of patients going to a hospitalbased place of safety at a time when it looks as if the police are detaining increasing numbers of people. Two thirds is still not good enough because it is very clear-and the code of practice makes it very clear-that it is justifiable at times to take people to a police station as a place of safety, but it ought to be exceptional. So we are not there yet and there is more work still to do, I think with the police forces and the Home Office, to make sure we can get there.

Dr Griffiths: Sorry to interrupt, but-

Bruce Calderwood: I feel I have not quite answered your question.

Dr Griffiths: Can I answer that? I am sure you are aware that there has been a very significant increase in the police use of section 136 and to some extent section 135 too-but certainly 136. It has gone up severalfold. It is not completely clear why that is, but, at the same time as the number of people they are bringing into places of safety has gone up, the proportion of those subsequently being detained has gone down and it is less than 20% now. So, clearly, the police have changed their practice. We are aware that they think there are problems with section 136 and the way they are operating it; so we are in dialogue with the Home Office and the police about section 136 because we need to work with them to overcome some of the difficulties the police are genuinely having and understand how their practice has changed.

Q143 Valerie Vaz: What I want to try and find out is this kind of difference. The police are detaining people under section 136.

Dr Griffiths: Yes.

Q144 Valerie Vaz: Do you have figures or are you aware of how many detentions there are at the police station before they move to another place of safety?

Dr Griffiths: I see what you mean.

Q145 Valerie Vaz: The police are detaining some and then releasing them, and then they are moving them to other places of safety. Is that right? I don’t know. I am just trying to find out.

Anne McDonald: There does not seem to be a huge number of moves. The police have been actively moving towards taking them directly to the hospitalbased place of safety and there are some moves from a police station to a healthbased place of safety, but there does not seem to be a huge amount of that.

Q146 Valerie Vaz: What sort of figures do you have on that? Can you give us those figures?

Anne McDonald: Certainly as to the latest collection we have done with ACPO around the numbers that are going to police stations, they basically then cleaned those out because they would be duplicates, if you see what I mean. It certainly did not look like a very high proportion, but it is very useful for some particular cases.

Bruce Calderwood: It feels like we ought to give you a note on this about what figures we do have.

Q147 Valerie Vaz: That would be very helpful. You talked earlier about only 20% of people are actually detained by-

Dr Griffiths: It is less than that now. It is about 17%, I think.

Q148 Valerie Vaz: What kind of reasons are there?

Dr Griffiths: Once the assessment has determined whether someone meets the criteria and it is appropriate to detain them-and for over 80% it looks like that is not the case-I do not know what has changed in the police’s practice. What I can tell you is that there has always been a relative minority that subsequently get detained. I think there is an issue about how well the police are trained when it comes to dealing with mental health crises. They have a difficult job to do, do the very best they can and it is better that they bring in too many rather than too few, but nevertheless the change is strange. In my own practice, I have seen very variable use of section 136 by the police, very sensible and appropriate kind of things and also some less so: bringing a drunken 17yearold to hospital because it is felt their drunkenness is not appropriate. I am not saying that characterises what the police do, but we need to understand what lies behind an apparent change in behaviour.

Q149 Valerie Vaz: Do you think it is partly a public order issue that they are using section 136?

Dr Griffiths: That is an interesting question.

Bruce Calderwood: We simply do not know. There appear to be areas where the police and the NHS are working very closely together and in a sense both parties are happy with what is going on. There are other areas where, for various reasons, that does not happen and either the NHS party or the police party or both, are discontented about the other. One of the things we are looking at is how we can get not necessarily a better standardisation because we are talking about independent organisations but a better understanding of what good practice is and spread that out across the system. That is what we are talking to the Home Office about.

Q150 Valerie Vaz: You mentioned children. What is the issue about children? It is quite serious. There are a number of children under 18 who are detained, aren’t there, under this provision?

Dr Griffiths: Do you mean under section 136?

Q151 Valerie Vaz: Yes.

Dr Griffiths: I don’t have the figures. Do you have the figures for that, Anne?

Anne McDonald: I think it was 300 and something in a year, and that is probably an underestimate.

Q152 Valerie Vaz: Are those all mental health issues?

Anne McDonald: I don’t know where they then ended up.

Q153 Valerie Vaz: Do we need to know where they ended up?

Anne McDonald: Yes. Certainly there are some areas of good practice like Wiltshire where they have a very close protocol so that, if somebody under 18 is picked up by the police, there is an immediate response by the child and adolescent mental health service to work with them and, as you say, to work out what the issue is and how to resolve it. They may not all be actually mental health issues; they may be conduct or substance abuses that need to be dealt with.

Q154 Valerie Vaz: Who is keeping those figures, that record?

Anne McDonald: The Royal College of Psychiatrists runs an interagency group on section 136 and they are just about to bring out some "what good looks like" guidance but also how police and health service commissioners perform, essentially the flags to look at to see whether your service is delivering what you need for your local people. So it will have raise issues. I am sure that under-18s taken to a police station will be one of those issues that you would want never to happen and if it did, as a commissioner, you would want to know why.

Q155 Valerie Vaz: What is happening at Department level in relation to this? Are there triggers, alarm bells or flags raised about it?

Bruce Calderwood: Norman Lamb, the Minister for Care Services, quite recently made it perfectly plain in that regard that it is unacceptable for children to be taken to a police station when they are in a state of mental distress. There are circumstances when it might be the right place to take a young person. That is one of the things that we need to work through with the Home Office around what practice is to see if we can reduce to a minimum the numbers of children in a state of mental distress who end up in a police station. Having said that, there will be circumstances where it is the right thing for an individual to do because it is not clear what is wrong. The crucial thing is that something happens fast and that the child is not left in a police station waiting for an assessment, waiting for help to arrive.

Anne McDonald: The other partner in this is the CQC as the regulator. It is part of the work with the Home Office. We may have a notification system perhaps to the CQC so that it could immediately act on what is happening under section 136 in that area if a notification was made of an unacceptable practice; but we need to make sure that those are the right things so that action is taken at the right time.

Q156 Valerie Vaz: When is the Department going to have these important meetings with the police, MOJ and everyone else?

Anne McDonald: Tomorrow.

Valerie Vaz: Excellent.

Dr Griffiths: That is a very concise answer.

Q157 Valerie Vaz: When can you report to us about what has happened?

Anne McDonald: There is an action plan as part of that meeting, so we could report back as to the different actions in that and where they have got to, if that would be helpful.

Valerie Vaz: I think so, yes.

Chair: It would certainly be helpful.

Q158 Andrew George: I want to follow that up with a question about the work that you have been undertaking with the police in reviewing the cases, particularly if it is falling even below the 20% figure that we have for those that are held subsequently being, detained by psychiatrists. Have you tracked cases in the days and weeks after that to find out what actually happens? In other words, how many of those who are released by psychiatrists actually then go on to either harm themselves, for example, or harm others, and thus in fact, in retrospect, perhaps the police’s judgment was more accurate than the psychiatrist’s?

Dr Griffiths: We don’t track those, but we do track suicides and homicides, yes. We do not track people who have not been admitted to hospital because that is just one circumstance in which a decision not to admit someone has been made. It happens in a variety of other circumstances. We do not track all decisions not to admit people to hospital but we do track what happens with suicides and homicides primarily through the National Confidential Inquiry into Suicide and Homicide, which has been going for well over 10 years.

Q159 Andrew George: Does that inform you at all in relation to this particular section of the Act?

Dr Griffiths: It can do in terms of individual cases. There are two things, if you like. The National Confidential Inquiry produces aggregate analysis of data and has done some more indepth studies over time. Of course, if there is something as tragic as a homicide, there will also be an independent inquiry. If there has been some kind of failure around the Act, whether that is section 136 or anything else, that will come out. I can, if you like, give you the latest figures from the National Confidential Inquiry. It reports annually, usually in the summer, July, so the last figures we have from that are July last year.

Q160 Andrew George: It would be very helpful if you could.

Dr Griffiths: I will try and keep it to the main ones. There is a lot in there and it is a public document.

Q161 Andrew George: If you could supply it to us, that-

Dr Griffiths: Yes, absolutely no problem. I will give you the headlines, if you like. I should preface it by saying that there are data for each country in the UK, so there are aggregate UK data and there are data for England, Scotland and so on. I will give you the England data. I can talk about the others if you wish.

Starting with population suicides, the National Confidential Inquiry uses a threeyear rolling average because a completed suicide is not that common. The numbers are relatively low. To try and even out and look for trends, rather than normal cause variation, they tend to use a threeyear rolling average. If you look at the ONS statistics, it is each year’s figures. The last figure that we have is 2010 and that was actually the lowest recorded level. But if you look at the ONS data, it has gone up for 2011. So the figure in 2010 was 4,021 suicides in England and the latest ONS data for 2011 was 4,509. Whether or not that is statistically significant, I have not done an analysis, but it looks it to me. There may be several reasons why the suicide rate may have gone up, but the most likely bet would be economic downturn. It had been falling pretty consistently for a good 10 years prior to that, probably down to two things, one, relatively economic prosperity and, two, a national suicide prevention strategy, which was renewed just last year.

Q162 Andrew George: Can I just intervene because of time and also because the question I was asking was more micro than the macro figures that you are giving?

Dr Griffiths: Sure. Do you want me to come on to the stuff around patients?

Q163 Andrew George: Yes, sort of case handling: in other words, what lessons have you learned in retrospect?

Dr Griffiths: The Inquiry has done a kind of composite report on what are the key themes and lessons, which are generally around the things you would expect and that were in Francis around communication, record keeping, risk assessment and management. There is another piece of research that again has not been published, so it is tentative-it is provisional findings-looking at the risk assessment when people have subsequently gone on to either commit suicide or, more rarely, homicide. Again, treat this as provisional data-shortly to be published-but around two thirds to three quarters look like they have had a good risk assessment and around a quarter to a third, from documentation, look like they have not had a good enough risk assessment. So it is a minority, but that is still too many. However, the trend for patient suicides and homicides is still downward in England. It is less clear in the other countries because the numbers are much smaller but there does not seem to be a trend. But there is a significant downward trend in patient suicides and homicides.

Q164 Andrew George: The one case that is weighing heavily on my mind is one where I know that the police wanted to seek to detain someone-and this is pre-the 2007 Act-because they feared that in this case he was a severe risk, particularly to one individual but to other people in general. In spite of their pleading to do so, that person was not sectioned, was released and went on to murder within 24 hours. With regard to the judgment of the police versus the judgment of the specialist, what I am looking for-while the statistics and the general patterns are of interest and relating them to well-being generally in the population is of course of interest-is whether there is any retrospective correlation between the police and your services so that lessons are learned and whether the precautionary approach is being applied appropriately or too zealously. That is what I am really looking for.

Dr Griffiths: Like I say, when there is a case like that, it is an appalling tragedy.

Q165 Andrew George: There are others that I know of with a similar pattern.

Dr Griffiths: If there has been a homicide, there will have been an inquiry to find out what local services have learned, but also what could be more broadly learned. What the NCI have done, about two or three years ago, is provide a composite of the key messages from those inquiries.

Q166 Andrew George: This is slightly off piste, but, as far as the issue of place of protection is concerned, another pattern which has not arisen in the questions today is that of mother and baby units and those going through the problems of puerperal psychosis and so on. The issue there of the lack of availability of accessible mother and baby units is one that is not down to the police, in this particular case, but, as far as accessibility of a support service that is appropriate for new mothers, is that something that you have been reviewing and looking at to make sure there is adequate support available there?

Dr Griffiths: We are moving to a very new system, and mother and baby units have been specialist commissioned. They will be subject to specialist commissioning by the NHS Commissioning Board. Nationally, there are about 10-10, maybe 15-mother and baby units. There should probably be more. I think you are right that there should be more, but it will be down to the NHS Commissioning Board and its specialist commissioning function to determine what and how many.

Q167 Andrew George: You will be advising them.

Dr Griffiths: No, I will be retired at the end of this month.

Q168 Andrew George: But, joking aside, there is a-

Dr Griffiths: I am sorry; that did sound a bit flippant.

Q169 Chair: Your successor will be advising them.

Dr Griffiths: Yes. They will be appointing a successor.

Valerie Vaz: You sound so happy.

Dr Griffiths: I am aware of that and I am trying to keep it in check. But, seriously, they have appointed a national clinical director. There will no longer be one in the Department of Health. They will be in the Commissioning Board because it will be the Commissioning Board that will be-

Q170 Andrew George: The Commissioning Board will be doing that. I will move on to the BME community and particularly the issue of the disproportionate referral or, rather, representation of the BME community in the population of patients subject to the Mental Health Act: about 3% of the population, 15% of cases. What explains that pattern?

Bruce Calderwood: Shall I start and then Hugh will come in? There are a number of things, one of which is that there is increasing evidence that there are much higher real rates of psychosis among, specifically, the black and AfroCaribbean population in this country. There are higher rates here than there are in either the Caribbean or in Africa, so there is something around the experience of black and AfroCaribbean people in this country as opposed to where they, their parents or grandparents come from, which actually is helping to cause much higher levels of psychosis than in the general population. That accounts for part of the difference. You then have questions around, "What are the issues that clinicians and other people take into account in making the detention?" Some of those questions are around, "Are you living on your own? Are you homeless?" Among the black and AfroCaribbean population, there are some social demographics that account for a lot of the difference. The AMEND study that will be published soon actually goes into that.

If you ask me the question, "Is there racism in the system?", obviously there will be racism in the system because there is not a part of British society where you can say it does not exist. But, statistically, it looks as if the much higher rate of the use of the Mental Health Act can be explained to a considerable extent by some of these demographic characteristics.

The next question is, "What do we actually do about it?" There is a public health question there and one of the things that we would be asking Public Health England to do is to look at that. It is clear also that many black people fear and are really worried about mental health services. So there is something around how the service provision can actually make sure that services are accessible and work better at a much earlier stage in the process than currently exists, because the route into mental health services is often via detention or through the criminal justice system. There are some very real issues here that we need to deal with, but it looks as if some of the fundamental reasons are to do with demographics. I do not know whether Hugh wants to add anything.

Dr Griffiths: Yes. It is a phenomenon all over the world that migrant populations have higher rates of mental illness. The reasons for that are not fully understood, but it is not difficult to think of hypotheses. That is true.

As far as the disproportionate rates that you describe are concerned, it has been a subject of very heated debate and there has been a narrative that it must be down to institutionally racist services because of that differential. The latest comprehensive epidemiological study from a couple of years ago was led by a team from Cambridge looking at the epidemiology, the incidence and prevalence of schizophrenia and other psychoses, and shows very clearly that in this country people from black and minority ethnic groups, particularly people from black African and Caribbean groups, have very high rates of psychosis. Quite why that is-as Bruce says, in their countries of origin or their ancestral countries, the rates tend to be the same as they are for the indigenous population here-again they do not know. They have put forward a number of different hypotheses. Racism in society could have an effect on psychosis rates, but we really do not know.

As Bruce says, there is a public mental health issue there that we expect Public Health England to be taking on. But there is another dimension to it-this comes from the AMEND study and is provisional because it is shortly be to be published-in that what they looked at as well was that, when you detain someone under the Mental Health Act, it is not just about diagnosis and whether you have a mental disorder; it is about risk. There are many determinants of risk, some of which are contained in your social circumstances. If you live alone, for example, and you do not have any social support, then you are likely to be at higher risk than if you have a supportive family and so on and so forth. When you allow for those social variables of risk and the epidemiology, according to the AMEND study, the race effect disappears. It does not mean, however, that there is not an issue about race and racism in mental health. What it does mean is that it looks like the disproportionate detention is not about institutionally racist services.

Q171 Andrew George: I appreciate the fact that there is a lack of evidence, if you like, of the absence of racism in the system. It is interesting that you defined that as "therefore, there must"-or you suspect that there must-be racism in the system. But, as far as evidence which was brought to us by the Mental Health Alliance is concerned, there seems to be a disproportionate use of restraint and coercion with regard to the treatment of the BME community within the system itself. Is this something that you have yourselves identified?

In view of the time, I will wrap up a second question in that as well. In terms of their own experience of the system, that is an accusation that has been made to us and that we are aware of. Secondly, with regard to the correlation between patterns of diagnosis within that community that are particularly high, you were saying that the hypothesis has not been sufficiently developed at present, but I would be interested in whether there was any comparable information with regard to those from more deprived socio-economic groups, whether there are any similar or higher levels of mental health problems within those groups, and whether any other correlations have been undertaken that actually identify a socio-demographic cause.

Dr Griffiths: If I understood the latter part, I will take that first. There are social determinants of mental disorder and deprivation and so on and so forth among those. But, in doing the meta-analysis around epidemiology, you allow for social variables. You factor them in.

As to the first question about coercion, it is not surprising because people are being disproportionately detained, and that in itself is being viewed as coercive. If you are detained and you do have a psychosis, you are more likely-it is still a relatively low likelihood-to be restrained. I am sorry to get back to my bit of paper from the Confidential Inquiry again, but on that question I thought you might be interested in one figure. They have done a recent study looking at sudden unexplained death from 2000 to 2010 in inpatients. These are not just detained inpatients-they are all inpatients. There were 373 sudden unexplained deaths, 42 of whom were from black and minority ethnic backgrounds but with no clear pattern. From 2002 to 2010 there were 15 postrestraint deaths. We do not know whether the restraint caused those deaths. What we do know is that there was a sudden death sometime shortly after a period of restraint. Four of that 15 were people from black and minority ethnic groups. They are very low numbers.

Q172 Andrew George: They are low numbers, but they seem to be high overall. It does seem to be disproportionate.

Dr Griffiths: That is over an eightyear period.

Q173 Andrew George: I know that the numbers are low and therefore it is less statistically valid to draw that conclusion, I agree.

Bruce Calderwood: What there clearly appears to be also is a London effect. The pattern of detention due to the Mental Health Act in London is very different from the rest of the country, and that seems to be, again, to do with social isolation, homelessness and people not having anyone to look after them. It is very difficult to disentangle race effects from the London effects. Indeed, the analysis of the people who are leading the AMEND study is coming close to saying that a lot of the apparent race difference in the use of detentions can be explained by the London effect because London has a very high proportion of AfroCaribbean people living here. So, in future, one of the things we need to do is to look comparatively at different parts of the country and have a much better understanding of the demographics. Having said that, I do not want anyone to go away from here thinking we are somehow saying that race differences do not exist in this and are not a causal factor. That would be far too definite a statement for us to be making. We and mental health providers and commissioners need to be very sensitive to that possibility, not least because that is what the perception is in AfroCaribbean communities and you have to respond to that perception.

Q174 Valerie Vaz: What is the comparison in places in the west midlands like Birmingham?

Bruce Calderwood: We have not looked at that, but there is another study coming out quite soon.

Anne McDonald: AMEND uses Birmingham, Oxford and London as the three cities, and obviously Birmingham has a high Asian population.

Q175 Valerie Vaz: And African Caribbean.

Dr Griffiths: It is not as high as London’s, though.

Anne McDonald: Interestingly, if you present for an assessment under the Mental Health Act, the rates or likelihood of actually being detained are very similar between Birmingham and Oxford but much higher in London. It seems to be this social factor in London and age as well, of young people alone. Also, the major transport hubs in London are driving something, with people arriving in London and then having a crisis. So it is not just the race effect that is driving the London-

Bruce Calderwood: There is a psychiatrist called Geraldine Strathdee, a leading psychiatrist within a London SHA, who has done a lot of analysis recently about what is going on in London in terms of the application of the Mental Health Act-

Dr Griffiths: She is due to complete that soon, isn’t she?

Bruce Calderwood: Yes. We have not seen that analysis yet, but we hope it will throw a lot more light on this.

Dr Griffiths: Can I throw in one other thing to be alert to in the data? Some of the data on this that are quoted use the old census figures as a denominator. In the latest census of 2011, the demographics have changed very significantly and that changes the denominator.

Q176 Dr Wollaston: I want to follow up, going back to the migrant effect that you referred to. Do you have comparative data for first, second generation and third generations? Does this effect change with time or is there a time of maximum-

Dr Griffiths: Yes and it is in that study. I will probably have to send it to you because I do not want to misquote it. It still persists but is less marked in lower generations. But it does not go away.

Q177 Dr Wollaston: So it continues. For the purposes of the inquiry, it would be interesting to know what you feel needs to be done in early intervention so that we can prevent the first point of contact being the point of detention. What would need to change in your view?

Dr Griffiths: I think two things really. First of all we need services that are more sensitive to the expectations and values of different communities, because if people are not accessing them in a timely way there is something wrong in the way they are being presented and so there is an access issue. The second thing is, I think there is-and we have already talked about it-a public mental health issue, which is around I don’t think it is enough to say, "It is explained by higher rates." Why are the rates higher, and what can we do about that in public mental health?

Q178 Dr Wollaston: That is the point I am trying to ask. What do you think we should recommend needs to happen to stop this being a question that comes up again in 10 years’ time?

Dr Griffiths: There are two things. Services must be more sensitive to the expectations and needs of the varied population that they serve. We expect this to happen, but it would be no harm if this Committee said it as well: Public Health England is developing a programme on public mental health and, if a significant part of this could look at this race effect, it would be very helpful. I am sorry to add, but one of the key elements of the Government’s mental health strategy is around public mental health and well-being. Arguably, for too long, the public health narrative has been rightly around obesity, smoking and alcohol, which are very important things and lead to a number of potentially fatal diseases, but actually it has excluded public mental health and well-being in so doing. I think we are now seeing a sea change and expect the narrative for Public Health England to be obesity, alcohol, tobacco and public mental health.

Anne McDonald: The other aspect, again coming from that work that is being done in London, is looking at specific improvement and quality indicators in both community and inpatient services that address the needs of black and minority ethnic people, so again specifically aiming to commission in a way that improves the quality and access for these groups.

Q179 Chair: We have run out of time. There is one quick question, which is nothing to do with mental health, which I would like to put at the end to give you the opportunity to make any points that you want to make. It is to do with deprivation of liberty for people suffering from mental incapacity, which is another element of this piece of legislation. Did that passage of the legislation successfully address the issue that it was trying to address, in your view?

Bruce Calderwood: In legal terms, yes. The problem was that there was not a legal framework for doing it. There now is. It is patchy in terms of its application. Variation is justified up to a point but some of the variation is extreme. One of the things we need to do is to talk to the CQC about potentially doing more to look at the outliers there.

Q180 Chair: Is it an issue where the Department, from a policy point of view, needs to draw up a clearer definition of what good looks like?

Dr Griffiths: Yes.

Bruce Calderwood: I think we need to work with others around what counts as good practice, not just us.

Q181 Chair: Again, that would be the Department acting as catalyst and coordinator, not as the sole fount of wisdom.

Bruce Calderwood: Yes.

Q182 Valerie Vaz: Do you publish the case law?

Bruce Calderwood: We periodically publish information about case law. Case law is changing very fast, as you probably know. There is likely to be quite a significant case going to the Supreme Court in October, which may very well be quite important in terms of the way in which it is interpreted in future. Our sense is that the real experts on this are the people doing the assessment. There is less evidence of people feeling confident about identifying when to make applications to the assessors.

Q183 Valerie Vaz: How often do you publish the case law?

Bruce Calderwood: There is no particular-sorry, we do not publish.

Q184 Valerie Vaz: You used to, didn’t you?

Bruce Calderwood: We have published case law in the past. Again, we have a code of practice. We also work with people like SCIE and others to get information out there. There is not a particular pattern to that publication, though.

Q185 Chair: The legislation includes a provision for you to produce a statutory code of practice.

Bruce Calderwood: There is a statutory code of practice.

Q186 Chair: Presumably, therefore, if there is wide variation, the implication is that the code of practice might be more tightly drawn.

Bruce Calderwood: Yes, potentially. We are not entirely sure what the reasons are yet for the variation and whether it is to do with, in a sense, a failure to understand-the code of practice may make no difference to that-or whether it is to do with the code of practice needing to be tighter.

Chair: Thank you very much. Dr Griffiths told us that it is likely to be his last appearance before a Select Committee.

Dr Griffiths: First and last actually.

Chair: Good luck for the future and thank you, all three, for your attendance.

Prepared 9th August 2013