Joint Committee on the Draft Mental Health Bill Written Evidence


DMH 286 Memorandum from NOTTINGHAMSHIRE HEALTHCARE NHS TRUST

1. INTRODUCTION: The Trust is one of the largest providers of mental health care in Europe and probably the largest single provider of assessment and comprehensive treatment services for people with a personality disorder, in the world. We have almost 6000 employees and operate from more than 100 sites across the East Midlands. The new Mental Health Act will have a very significant and direct impact on the way we provide services and assess and treat our patents. This paper is compiled by the Chief Executive of the Trust having taken contributions from colleagues in clinical practice and management over a number of weeks.

2. SUMMARY: We welcome this reform of the 20 year old Mental Health Act, and particularly this opportunity to contribute to the Committee's deliberations on the draft Bill. We wish to stress the need for the Committee to examine adequately issues of reciprocity, also we believe that greater clarity is needed around the definition of mental disorder. We wonder if the use of the term "appropriate treatment" should be confined to the particular locality or region in which service is delivered and have general concerns about the level of resources that will be guaranteed to be made available for the new approach. We are concerned at the potential loss of expertise locally with the abolition of MHA Associate Managers and the MHAC, and the potential marginalisation of expert medical opinion. We welcome particularly the formalising of the contribution that carers and advocates will make and the independence and professionalism of the new tribunals, although we have concerns at the logistics that are required to establish the new system. The proposed bill does not address "the Bournewood gap" and the recent ruling by the European Court means that this Bill or the Mental Capacity Bill will need to be altered.

The mental health services in the UK have delivered remarkable change over many years and there is the willingness, professionalism and expertise to deliver a new service within the bounds of this new legislation. We ask that we be accorded the necessary time and resources to deliver that service.

3. SPECIFIC POINTS

3.1 The principle of reciprocity is acknowledged within the Human Rights legislation and implicit within the draft Bill, but there is for any provider of care under the Mental Health Act the question of whether there is sufficient guarantee of resources being available for their to be full reciprocity for the denial of liberty such that might require the provider to ensure that the care plan is delivered under, potentially, pain of legal penalty.

3.2 We employ over 250 psychiatrists within our organisation and can foresee circumstances where there may be no medical opinion available to the new Tribunals, with the replacement of the Responsible Medical Officer role by that of clinical supervisor and the clinical member of the tribunal not necessarily being a qualified medical practitioner. Mental illness frequently, indeed almost always, requires medical intervention and whilst we may be moving away, quite reasonably, from what might be termed a strictly "medical model" we nevertheless believe that there is a danger that medical opinion may be marginalised.

3.3 With the abolition of the role of the Managers' Panels and the absorption of the Mental Health Act Commission (MHAC) role into the Healthcare Commission we have a fear that much expertise may be lost to the process of hearing appeals and considering issues of safety and quality of care, locally. MHAC members and Non-Executive Trust Board Directors, along with Associate MHA Managers, provide a largely volunteer workforce of hundreds of individuals across the country who have developed considerable expertise in making non-judicial judgments which are an aid to both patients and local managers. Is all that expertise and considerable public spirit to be lost, and at what cost to the process of delivering an effective and equitable mental health service in England and Wales?

3.4 The foregoing serves to underline the significance of the change that the government wishes to introduce. That change is manageable and indeed we are experts in managing change in the NHS given the revolutions that we have delivered over many years in the development of mental health and learning disability services. However, change requires time and resources to be achieved. These must be available, both in terms of ensuring that there are a sufficient number of professionals available to service the new tribunals and in planning the change themselves, on the ground. An adequate run-in period, with plenty of opportunity to develop and understand the new Codes of Practice will be essential.

3.5 We believe that our clinical colleagues are right to express concerns to you about the proposed definition of mental disorder and would therefore wish to echo their calls for a clear statement that a person cannot be detained solely for their political, religious or cultural beliefs, their sexual orientation or drug or alcohol misuse. We believe that the Bill itself should more clearly describe what is meant by "appropriate treatment" and "significant risk of serious harm to others". The balance between public safety and personal liberty is, of course, extraordinarily difficult to chart in statute, but we share the concerns of Psychiatrist colleagues that under the proposed definitions a manic patient with impaired judgement resulting in personal over-spending would not meet the criteria for detention. Likewise, the proposals suggest an increased potential for a person with impaired capacity but only moderate risk to themselves or others not receiving the treatment from which they would derive benefit, should they not agree to this.

3.6 Staying with the issue of "appropriate" treatment and considering circumstances in which a clinician decides that there may not be treatment that is appropriate available locally, but that there is treatment available elsewhere (for example in the case of local PD services there are 10 national pilots operating at present around the country) would it not be reasonable for that practitioner to declare that there is appropriate treatment available though not within the immediate locality, but elsewhere, perhaps regionally, perhaps nationally, thus generating unplanned demand for those local service from out of area referrals?

3.7 With the exception of a few services, such as our own in Nottinghamshire and the wider East Midlands, there is little provision for those with Personality Disorder (PD) unless they are also suffering from a mental illness. Under the proposed legislation someone with a PD could be detained on account of their criminal behaviour in the absence of evidence that they would benefit from such treatment. If that remained so in the statute it would be reasonable to conclude that those with a similar PD but who had not offended had an entitlement to treatment on a voluntary basis along the same lines as that available to the patient detained for the offending behaviour. Again the issue of reciprocity raises its head - but also the issue of resources. Have these considerations been fully explored by the legislators?

3.8 On the matter of Tribunals, whilst welcoming a reinforcement and expansion of the role that is currently carried out in an independent and professional judicial capacity by the Mental Health Review Tribunals, there are some issues of detailed concern particularly around the assessment and development of care plans. It is unclear who would have the power to agree changes to the care plan, whether that would be the independent expert or the tribunal itself. If it were to be the tribunal itself there is a danger that significant delays might ensue, or that "all purpose" care plans might be submitted.

3.9 On the issue of requests for examinations we share the concerns of many other bodies, practitioners and individuals that anyone can request someone is examined for use of compulsory powers of detention. This seems likely to lead to an increase in the number of inappropriate examinations and have an impact on the capacity of NHS Trusts. We would endorse calls for clear guidance on this issue to ensure that the potential impact of this increased demand is properly understood and incorporated into the workforce and financial planning associated with the new MHA.

3.10 There are many aspects of the new Bill we welcome and would particularly applaud the intention to maximise the formal role and contribution of carers and advocates - the latter in the form of the Independent Mental Health Advocate, although this must not be at the expense of a patient's right to legal representation and legal aid for that representation. We have experience over a number of years in our High Secure and local mental health services of working very closely with carers and advocates and have learned the value that they can bring to the difficult and challenging process of delivering effective mental health care on a partnership basis.


Jeremy W E Taylor

Chief Executive

Nottinghamshire Healthcare NHS Trust

For, and on behalf of, the Trust Board of Directors

30th October 2004

1507 words


 
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