DMH 259 Memorandum North Derbyshire Forum
for Mental Health Carers
1 INTRODUCTION: This submission
is made on behalf of the North Derbyshire Forum for Mental Health
Carers. The Forum is a properly constituted body that meets monthly.
Between them, members have lengthy experience of caring for people
with mental health problems; many either share or, in the past,
have shared, their homes with a relative needing care but caring
does not end with a move to a separate dwelling. These carers
help and support someone with mental illness on a daily basis.
They know what it is to care 24 hours a day, seven days a week
for someone they know and love well. They have learned to work
with professionals and cope with crises. They are well-informed
about diagnoses, prognoses, systems, services and treatments and
invite a succession of speakers from the statutory and voluntary
services to keep them up-to-date. They may also participate in
a self-help group. The Forum circulates a regular newsletter to
60+ carers of people with mental health problems. The Forum is
fully recognised by the Derbyshire Mental Health Trust. Members
represent carers' interests on NIMHE (East Midlands) and various
Forums and management committees of the Trust.
2 SUMMARY OF CONCERNS:
Whilst an updating of the 1983 Mental Health Act is generally
to be welcomed, the current draft is a missed opportunity to enshrine
the improvements in mental health care that have been developed,
albeit slowly and painfully in recent years. Given that suicide
rates amongst people with mental illnesses are above average,
whilst homicide rates are significantly below, our position is
that the balance in favour of providing appropriate support and
care for people in distress is being heavily outweighed by the
occasionally necessary requirement for detention and compulsory
treatment. Our concerns are:
- the current Bill has no focus on entitlement,
only on compulsion;
- the definition of "mental disorder"
is too wide and ambiguous;
- the powers of the Mental Health Tribunal have
been extended to the detriment of patients rights to appropriate
treatment;
- there are no details about how the Care Programme
Approach will be implemented;
- in leaving details to the Code of Practice, the
Bill allows future developments to avoid any effective parliamentary
scrutiny;
- there is nothing about integrating the Mental
Health Bill with the Mental Capacity Bill;
- reducing aftercare to six weeks ignores the need
for long-term appropriate services for patients with severe and
enduring mental health problems;
- treatment safeguards in the original draft have
been dropped without consultation, thereby reneging on promises
the government made to safeguard the interests of informal patients
following the Bournewood case.
3 ENTITLEMENTS TO SERVICES: The
Bill fails to address any question of entitlement to service provision.
One in four people seek help for mental health problems at some
time in their lives. Yet the Bill focuses only on compulsory treatment
both in hospital and in the community. Whilst compulsory treatment
is sometimes essential, it is inevitably a traumatic process known
to exacerbate existing symptoms. It is generally agreed that,
wherever and whenever possible, compliance with treatments, including
hospitalisation is best achieved within relationships of trust,
on a voluntary basis. The Bill ignores the current shortage of
both hospital beds and community-based services for those seeking
informal help for themselves. Unrealistically, it supposes that
people in crisis who will not consent to treatment, may yet comply
with the kind of conditions that may be imposed by a "clinical
supervisor", in order that compulsory assessment may be carried
out in the community (26 (3)-(8)). Most re-hospitalisation
occurs because of failure to take medication, yet the current
system means people with mental illness have to remember to re-order
medication from their GP before it runs out. There is no recognition
of the importance of community-based services for ensuring medication
compliance in trust relationships, only an unwarranted concentration
on compulsory treatments.
4 DEFINITION: The definition
of "mental disorder" is far too ambiguous and wide-ranging;
indeed, the definition could well include anyone, not least someone
with a learning impairment. The use of this definition in association
with the Bill's focus on compulsion, is likely to result in an
unnecessary, costly and counter-productive extension of compulsory
treatment. The provisions associated with this definition in the
Bill will deter people from seeking help at an early stage and
will work generally to the detriment of patients' proper entitlement
to appropriate informal care in either hospital or the community.
5 MENTAL HEALTH REVIEW TRIBUNALS: The
powers of the Mental Health Review Tribunal have been extended
to such an extent that the detained patient's rights have been
reduced to an appeal to an anonymous body. This body will have
no personal knowledge of the patient's history and its concerns
will be primarily the legality of the process, rather than the
appropriate care and treatment of a known individual. The substitution
of the "clinical supervisor", for consultant psychiatrist,
potentially lowers the threshold of expertise the patient has
a right to expect. The scheme to provide, "Mental Health
Advocates", does little more than help to inform patients
of how limited their rights are. The rights of the nearest relative
effectively to oppose compulsory treatment, previously a safeguard
against inappropriate detention, have also been withdrawn. Under
the proposals in the Bill, distressed patients and their formal
and informal carers would be faced with a bureaucratic nightmare,
when they should be focusing on compliance with clinically appropriate
support and care.
6 CARE PROGRAMME APPROACH: There
are no details about how the Care Programme Approach (CPA) is
intended to work, either for compulsory or informal patients.
The good work currently developing with the use of the CPA in
the community has been overlooked as a potential evidence-base
for good practice. Indeed, the interests and entitlements and
welfare of informal patients currently (but still only minimally)
supported by the CPA, have been completely ignored. For example,
homely, welcoming, crisis houses where sufferers can go, voluntarily,
in a crisis are desperately needed, both to avoid the trauma of
compulsory hospitalisation and to take the strain off elderly
carers.
Case Study:
Paul has been diagnosed with schizophrenia for twenty
years. For the last eleven years he has been stable in the community,
living in his own flat only yards from his elderly parents. His
improvement dates from the use of Clozopine, prescribed by a psychiatrist
from another trust (recommended to his mother). Paul's parents,
although both in their 70s and with their own health problems
(particularly his father), have continued to support him with
daily living with no help from the statutory services. When he
showed signs of relapse a few months ago and moved back with his
parents, his mother contacted the local Community Mental Health
Team. The newly minted "Crisis Team" arranged to talk
to him in his own flat and completely ignored his parents. He
moved back to his parents and continued to deteriorate. His mother
managed to get an appointment with his psychiatrist who prescribed
additional
7 CODE OF PRACTICE: In
spite of its length, detailed practices under the Bill are left
to a "Code of Practice", to be drawn up by the "appropriate
authority". In effect, the Bill provides a legal framework
that allows detailed provisions and costs (no doubt influenced
by future Government Directives and Guidance), to come into effect
under this unspecified "code", without further parliamentary
scrutiny.
8 INTEGRATION WITH MENTAL CAPACITY BILL: Questions
need to be raised about how the Mental Health Bill will be integrated
with the Mental Capacity Bill currently before Parliament. There
is particular concern about the right to care and treatment on
offer to people with learning impairments.
9 AFTERCARE: It is unclear
how patients with severe and enduring problems will access appropriate
community care in the longer term (which may be life), under the
proposal to reduce the period of free aftercare to six weeks.
Provision for care during the recovery period, including appropriate
accommodation and support, as currently specified under Section
117 of the 1983 Mental Health Act, has been dropped.
10 TREATMENT SAFEGUARDS: The
treatment safeguards included in the first draft of the Bill have
been dropped without consultation, ignoring the safeguards the
government promised to bring in following the Bournewood case.
Our concern here is particularly with patients who lack capacity
to consent to treatment and we urge that further consultations
are required.
11 CONCLUSIONS: As it
stands, the Draft Mental Health Bill represents a retrograde step
in the support and treatment of people seeking help for mental
distress. There appears to be a low evidence-base for its provisions,
some at least of which appear unworkable. The language suggests
practices are analogous with practices for detaining dangerous
criminals. The Bill perpetuates false stereotypes, stigmatising
mental disorder rather than proposing entitlement to appropriate
care for people in distress.
Gwen Wallace
(Chair: N.Derbys. Forum for MH Carers)
33, Woolley Road,
Matlock,
Derbyshire, DE4 3HU
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