Summary
DMH 125 Citizens Advice
Submission to Joint Committee on Draft Mental Health
Bill
a. It is regrettable that people with mental
health problems who have capacity will be treated differently
under the Mental Health Bill from others with capacity and from
all other health users. The provisions in the draft Bill are
quite inconsistent with the Mental Capacity Bill's presumption
of capacity at all times for all decisions, unless proved otherwise
on a functional test.
b. The Bill broadens the criteria for compulsory
detention, without any guarantee of treatment and care in the
community. This raises the prospect of people's condition deteriorating
to the point of being treated under compulsion when this could
be avoided.
c. This is of particular concern given extensive
evidence of the sometimes slow and patchy development of services
and from CAB evidence on how services currently fail to help many
people when they most need assistance.
d. The failure of agencies in the community to
take responsibility and co-ordinate help, raises concerns about
'delayed discharges' and people being detained in hospital until
services have organised themselves.
e. Prescription charges mean that some people
struggling on low incomes neglect taking their medicine. If this
is a condition of their being treated in the community they are
at risk of compulsory detention for want of the means to purchase
their medicine.
f. Broader criteria for detention will deter
people from using mental health services for fear of compulsory
treatment, so making it more difficult to ensure that people have
appropriate help early in their illness.
g. Citizens Advice welcomes the provisions for
advocacy but believes greater clarity is needed about the duty
to provide this service. Access to advocacy and a nominated person
needs to be introduced at 'examination' when decisions about eligibility
for compulsory treatment are being made. Advocacy also needs
to be available to voluntary patients.
Submission to Joint Committee on Draft
Mental Health Bill
1. Citizens Advice welcomes the opportunity to
comment on the Draft Mental Health Bill and makes observations
on compulsion, access to service provision in the community and
how this bears on the use of compulsion, and rights to advocacy
2. This response is based on evidence from CAB
advice work. During 2003/4 CAB gave independent and impartial
advice and information from over 3,200 locations, helping people
resolve more than 5.6 million problems. 1154 of these locations
were in health settings such as GP surgeries/health centres (751)
psychiatric hospitals (75) and mental health day centres (165).
More than 100 CABx run special projects for people with mental
health problems and a few without such projects have estimated
that more than half of their clients have or have had a mental
health problem.
3. Of general concern is that the draft Bill:
- loosens the
criteria for compulsory detention with no guarantee that such
action will improve someone's chances of recovery through appropriate
treatment
- extends compulsory treatment to the community
which may contribute to the stigma and discrimination people with
mental health problems suffer across society.
Question 2
Are the conditions for treatment and
care under compulsion sufficiently stringent ?
4. The draft bill broadens the definition of
mental disorder to take in a wider range of conditions than previously
(Clause 9). More people may also be subject to compulsion because
care only needs to be 'available' and 'appropriate' (Clause 9),
and not as now to alleviate or prevent deterioration of a condition.
This broader scope is of concern because Citizens Advice evidence
suggests people will be deterred from using mental health services
for fear of compulsory treatment. This will make it more difficult
to ensure people have appropriate help early in their illness.
5. The registration of a non-resident patient
(Clause 23 [4]) is authority to require him/her to comply with
conditions such as taking medicine. This is often a means of
stabilising a person's condition so enabling them to live in the
community. However, current policy on prescription charging undermines
this. Many people on incapacity benefit for mental health reasons
get only a few pounds more a week than people entitled to free
prescription on income grounds. The length of time for which
a drug is prescribed also affects cost. If a GP moves from a three
month to once a month or even weekly prescription routine for
clients in danger of overdosing, this significantly increases
costs.
6. Citizens Advice has a lot of evidence to show
that prescription charges mean that some people neglect taking
their medicine[14].
As a result not only may their health deteriorate, they are at
risk of compulsory detention for want of the means to purchase
their medicine if taking it is a 'condition'
of their residing in the community. It cannot be right or the
intention that people should be subject to compulsory detention
when ill because they are unable to pay for their prescriptions.
Question 2
Are the provisions for assessment and treatment
in the Community adequate and sufficient ?
7. The Bill proposes the use of compulsion
to wider categories of illness with no guarantee
of treatment and care. Without such guarantees, people's conditions
may deteriorate and lead to compulsory treatment. Citizens Advice
has examples of people unable to access help prior to a crisis
in their illness. We have the prospect
of control when illness becomes severe in a wider range of conditions
than previously but without the guarantee of treatment and care
in the early stages to minimise that prospect. This is of grave
concern.
8. It is of paramount importance that full
health services in the community are available and properly complemented
with advice and support to cover benefits, income and housing
which helps people with mental health problems to manage their
lives[15].
Without these services people's condition may deteriorate[16].
This seems more than likely given the patchy and sometimes slow
development of new critical services such as early intervention,
assertive outreach and crisis resolution teams. Proposed multi-disciplinary
teams offer alternatives to hospitalisation but shortfalls put
people at risk of hospitalisation and the number of mental health
trusts without any star rating has doubled[17].
9. Citizens Advice evidence raises concerns
in particular about:
- access to treatment and care
which is limited because of staffing issues, long waits, withdrawal
of care, poor attitudes, lack of interpreters and some GPs refusing
to register patients in case they become violent
- lack of non-medical therapies and
long waits when it is available leave people without choice and
the help they may need
- a focus on clinical issues
with the system failing to refer clients for advice to maintain
benefits and housing at hospital discharge and other times. Community
mental health teams and psychiatrists do not always support benefit
applications. Large numbers have to struggle with debt as well
as cope with illness
- discharge and after care where
patchy and poor services give rise for concern as this can lead
to unnecessarily prolonged stays in hospital.
10. These failings are important because of the
personal consequences to the individuals who need help. The stress
of coping with such difficulties puts people at risk of becoming
more unwell. Citizens Advice has evidence of:
a. people not having access to services as a
crisis develops and their condition deteriorating to the point
of self harm and/or hospital admission[18]
b. withdrawal of services leaving clients unable
to manage their illness and their affairs[19]
c. lack of co-operative working between agencies
and confusion about responsibilities leaving clients without support[20].
11. The draft Mental Health Bill makes provision
for a deferred discharge where no after-care plan has been made
and gives hospital managers the right to detain patients for up
to 8 weeks until such a plan is in place (Clauses 63-67). Patchy
and sometimes poor services can lead to unnecessarily prolonged
stays in hospital depriving people of their freedom and putting
them at risk of future re-admissions because of the lack of adequate
support[21].
12. The right to free aftercare is to be restricted
to six weeks (Clause 68). It is the experience of Citizens Advice
that for clients with severe and/or long term illness, this is
far too short a period to facilitate their accommodation into
the community and setting up structures to help them manage their
daily lives.
Question 3
Does the draft bill achieve the right
balance between protecting the personal and human rights of the
mentally ill on one hand, and concerns for public and personal
safety on the other ?
13. With its single definition of mental disorder
without exclusions, the Bill extends to more people than the 1983
Act the possibility of being compulsorily treated and/or detained
but :
- it does not address the issue of distinguishing
between capacity and non-capacity. Especially worrying is the
possible use of compulsion on the loose definition of considering
a person to be in serious neglect of their health or safety when
they may have full capacity. (See para. 19)
- guidance refers to 'clinically appropriate' treatment[22]
without defining what is meant by this. Clients can be detained
if treatment is 'available' and 'appropriate' but the Bill makes
no references to choice of suitable treatment - a huge problem
given some of the very damaging side effects of some medicines.
In some areas, therapeutic services are not available on in-patient
wards[23].
14. The provision that medical treatment is warranted
'for the protection of other persons' (Clause 9) is very wide
and could be argued to include protection from verbal abuse.
This should be tightened to 'prevent serious harm or violence
to others'.
Question 4
Are there any important omissions in the Bill
?
15. Citizens Advice welcome the opportunity created
for nominated persons and for advocates to help and represent
people. We hope the right to access specialist advocacy translates
into real provision on the ground but are concerned that this
will not be the case.
16. The Bill states that 'the appropriate authority
must arrange, to such extent as it considers necessary to meet
all reasonable requirements, for help from persons, to be
known as Independent Mental Health Advocates to be available to
qualifying patients and to their nominated persons.' [Clause 247(1)].
Evidence from ICAS services is that advocacy provision is 'patchy
and ad hoc'[24].
Greater clarity is needed about the duty to provide this service.
17. Access to advocacy and a nominated person
needs to be introduced at 'examination' when decisions about eligibility
for compulsory treatment are being made to ensure that people
who may be compulsorily detained are fully consulted and involved
in the process[25].
Advocacy also needs to be available to voluntary patients.
18. There is no over-arching body for advocacy
services and thought needs to be given to building on current
good practice and establishing minimum standards.
Question 8
Is the draft Mental Health bill adequately
integrated with the Mental Capacity Bill?
19. It is regrettable that the draft Mental
Health Bill's provisions on compulsion (Clause 9) are quite inconsistent
with the Mental Capacity Bill's presumption of capacity at all
times for all decisions, unless proved otherwise on a functional
test. People with mental health problems who have capacity
will be treated differently under the Mental Health Bill from
others with capacity. Citizens Advice is very concerned about
the threat of compulsory treatment for mental health without reference
to capacity, which is at variance to the attitude to all other
health users.
Background evidence to
Citizens Advice submission on Draft Mental Health
Bill
Para. 6
A bureau in Wales is helping a client
who is single, lives alone and suffers from schizophrenia. He
takes Magadon, Valium and has injections once a week. His income
is long-term incapacity benefit of £87.30 per week; he does
not qualify for free prescriptions because his income is too high.
(If he was on income support plus disability premium he would
have an income of £79.35 a week and be entitled to free prescriptions.)
He receives housing benefit and pays £6.80 rent and does
not pay Council tax. He has a National Health debt of £310.00
because he signed as being exempt from prescription charges when
he was liable to pay. He pays this debt off at £5.00 per
week but because he does not have a bank account, has to do so
by postal order which costs him an extra £2.00 per week plus
postage (they will only accept cheques or postal orders). He
pays a lot on prescription charges but does not get all of his
tablets because he cannot afford to pay for them.
Para. 8
A bureau in Wales helped a client with mental
health and addiction problems. He suffers from paranoia, anxiety,
depression, hallucinations and blackouts. He struggles to care
for himself but frequently falls and becomes disorientated. His
neighbour found him during an attack when he was hallucinating.
He had had not taken medicine nor eaten for four days. The local
authority duty officer said referrals could not be taken after
12 noon so a fax was sent for the next day. The CAB was then
told they were in touch with the wrong team and the fax forwarded
to the community mental health team. The referral was then forwarded
to the Community Drug and Alcohol Team. The original request
for help was made on 11th February. On 4th
March the community drug and alcohol team referred the client
back to the community mental health team saying the client was
'inappropriate' for them although they may do a secondary assessment.
The client had still not been visited on 11th March.
Para. 10(a)
A Midlands CAB advised a client
who acted as the main carer for her friend. The friend became
suicidal and the client was very concerned for her safety. Both
met with her consultant to request help but the consultant refused
to admit the friend. The next day she killed herself.
Para 10(b)
A London bureau helped a man originally
diagnosed as suffering from borderline personality disorder who
was discharged as 'cured' in 2001 leaving him without any medical
treatment. He then invested his energy in bringing courts proceedings
against anyone he had had dealings with over the previous 25 years,
- around 80 cases, including his consultant psychiatrist. The
court referred the client to the Official Solicitor who sought
a report from the client's original psychiatrist who refused the
request unless given a written guarantee that there would be no
proceedings against him. The Official Solicitor eventually arranged
for a senior consultant psychiatrist to see the client who diagnosed
him as suffering from psychosis and incapable of looking after
his own affairs, strongly recommended treatment at the Maudsley
and arranged for new more powerful anti-psychotic drugs. In accordance
with NHS procedure, this report went to the client's GP who sent
it on to the local psychiatric service, which employed the client's
first consultant psychiatrist. The client is now very anxious
and unhappy and fears not getting the treatment he needs. His
GP has difficulty setting doses for his new drugs because of lack
of experience with them. The bureau is exploring how the client
can be referred on to the Maudsley hospital.
Para 10(c)
A Dorset bureau helped a client
aged 68 who had assaulted his wife. A court appearance is imminent
and he has been placed by police in hotel accommodation and must
have no contact with his wife. He came to the bureau in a very
distressed state, threatening suicide. The mental health team
and the social services elderly care team each thought the other
should be responsible for him.
Para. 11
A CAB in Lancashire helped a recovering
alcoholic discharged from a mental health ward with no support.
He had been evicted whilst in hospital and all his belongings,
private papers and furniture lost. When the bureau spoke with
the hospital she was told the GP was responsible for organising
support but the GP contradicted this and said it was the hospital's
job. No one would accept responsibility. The bureau is trying
to get him into a hostel and then a supported tenancy and to arrange
meetings with the local drugs and drink unit.
A CAB in Hertfordshire helped a
client who faced imminent eviction, had difficulties with benefits,
pending court orders and faced possible imprisonment, following
recent discharge from hospital. Social services sent the client
to the CAB rather than helping him, wasting valuable time.
A CAB in Lancashire is helping a client of 81
who is about to be released from a psychiatric ward. She has
been offered no help when she comes back into the community although
she is going to need 24 hours and 7 day attention. She has not
been advised she could or should claim Attendance Allowance.
A home visit has been arranged but hospitals should contact all
relevant agencies to ensure all round support.
Para 13 & Para 10(c)
A bureau in Surrey report that they
are increasingly aware of elderly patients on short term assessment
wards for many months, where there is no family contact, pension
goes unclaimed and problems at home such as broken windows are
not dealt with. Ward staff and social services both deny that
such issues are within their remit.
Para. 16
A bureau in Worcestershire are helping a client,
ill since 1991 with paranoid schizophrenia and depression who
gave up his tenancy because of rent arrears and an inability to
cope despite being in work, paying full rent and £17.00 per
week to supporting people scheme. He went to live with his parents
prior to hospital admission in August 2004 but they refused to
have him back when discharged. The client does not want to live
alone and gets depressed when doing so. His social worker found
a property £50.00 per week rent, plus £25.00 service
charge, plus £150 supported living costs. The client wanted
to return to work but did not want to live in this property because
he could not afford it. Nevertheless, the arrangements went ahead
and he took up the tenancy with help applying for housing benefit.
He stayed only 2 nights and then began sleeping rough. Unable
to go to work, he lost his job because it couldn't be kept open
any longer. Arrangements are now being made for him to move in
with his sister. Her house is not big enough so she is seeking
an exchange. The client is in considerable debt.
Would specialist advocacy have prevented him from
being put in housing that he never wanted, incurring further debt
and in him sleeping rough? With help from an IMHA, would he have
been listened to with regard to his concerns and the choices being
made for him? Would earlier negotiation with his family have
resulted in him moving directly from hospital to his sister's
house?
Para. 18
A bureau in Cheshire describe a client who was
sectioned when she became very upset after losing her cat. Her
father who also has mental health problems called 999 and the
client was taken to accident and emergency where her sister told
the doctor the client was schizophrenic. The client was referred
to another hospital that sectioned her for 4 weeks; the client
objected to this. The client was later diagnosed as having a hyperactive
thyroid and feels her condition was exacerbated by being in hospital.
14
See Background notes for examples Back
15 See Out
of the Picture: CAB evidence on mental health and social exclusion,
2004 Back
16 See Background
notes for examples Back
17
Healthcare Commission, NHS Performance Ratings 2003/4. More than
a third of trusts have failed to set up satisfactory assertive
outreach teams and more than a third have failed to meet care
programme standards on recording information. Only half (175)
of the 335 mental health crisis resolution teams required by NHS
plan for Dec 2004 are in place.
Back
18
See Background notes for examples Back
19 Ibid Back
20 Ibid Back
21 Ibid Back
22 Explanatory
Notes, Regulatory Impact Assessment, section E, para.26. Cm 6305-ll Back
23 See Background
notes for examples Back
24 Ibid Back
25 See Background
notes Back
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