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We can, however, acknowledge the successes of the past. The noble Earl, Lord Selborne, mentioned them, as have others, such as the noble Lord, Lord Astor: the discovery of the hole in the ozone layer, and the environmental history book that the Antarctic provides. The importance of the data increases with each year that passes. It is a key barometer of climate change worldwide. As a result of the IPY, the Natural Environment Research Council have also invested an additional £4.9 million in new Arctic international science projects. Thus, we are committed to a leading role in scientific endeavours at both poles.

The resource budget of the BAS, which this year is £38 million, will be £37.8 million by 2009. The difference is £200,000. There are differences in the capital budget, but, as I understand it, and I will check this, the BAS has also received additional funding to construct a new research station at Halley, which should be operational by 2009-10—not an entirely dire picture.

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That raises the question mentioned by the noble Viscount, Lord Montgomery, whether we should draw it all together in a single institution. I have said how much we invest and that we are one of the world leaders in that investment. International Polar Year highlights the importance of scientific understanding in both polar regions and we are well placed to respond to the challenge—we need to do that as well as we can. I ask noble Lords to consider that we should certainly keep our scientific funding levels at the highest level possible. However, there are different scientific and meteorological issues at each of the poles and it is important that the very best scientists, wherever they are—in United Kingdom, in higher education and research institutions—play their role. They will not all be concentrated in one place, so I do not want to see a system that might blight some research, which is often attached to other parts of research, so that it falls away.

We cannot underestimate the work of British scientists on the physics, chemistry, geology and biology of the Antarctic, which is vital for the whole planet. That is why the BAS has set the goal of becoming the leading international centre for global science in the Antarctic context by 2012. It is quite right to do so. Already Britain can be justly proud of its input in the polar regions. I have reaffirmed our commitment and I quote my noble friend Lady Symons, who in February 2005 said:

We are in the same position. The governance of Antarctica is vital for the peaceful co-operation and protection of the continent in every way.

I shall make a few quick points about the vital issues that have been raised. Antarctica is protected from damaging conflicts arising from sovereignty disputes by the treaty which, since 1961, has put all sovereignty claims south of 60 degrees in abeyance. The treaty system seeks to protect the Antarctic environment through the protocol to the Antarctic treaty and other conventions add to it. I say to my noble and learned friend Lord Archer and to the noble Lord, Lord Jopling, that the minerals convention will not enter force in the foreseeable future, but it has been overtaken by the environmental protocol to the Antarctic treaty which prohibits mineral resource activity other than in scientific research.

I say to my noble and learned friend Lord Archer that the Antarctic treaty secretariat will be funded. It is not totally funded at the moment but the obligation to do so by an apportionment measure enters into force and will become obligatory to all parties. It is at about the 80 per cent level at the moment. I say to the noble Lord, Lord Avebury, that the treaty and the arrangements made for International Polar Year should ensure far greater scientific co-operation and we hope that that will be enhanced.

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There are no propositions whatever in the current financial planning to reduce the readiness of HMS “Endurance”. We are considering “Endurance” for the long-term; like every ship, at some point, it will need to be looked at, but there are no propositions of that kind. I believe that we can have a real impact.

To the noble Viscount, Lord Montgomery, to my noble and learned friend Lord Archer and to the noble Lord, Lord Jopling, I make the point that we recognise that tourism is very important. It has grown a great deal and it has to be carefully planned and monitored. We have to consider the safety issues, for which “Endurance” is important, We are working hard and we will use International Polar Year to ensure that the regulations that control and support that fragile environment are at the centre of the debate, as they must be. Those concerns about impact are vital.

I conclude by saying that this country is rightly proud of its polar history. We have sovereign interests and a long-standing interest in Arctic matters which will continue. Scientists will work in those extreme environments and I have no doubt that they will contribute to the global understanding of our planet in a general sense. In my view, having built such great foundations, it would be a tragedy to let them slip. I do not for a moment believe that we have any inclination to do so. The points raised in the debate have focused not just on what has been done but on why that is essential for the future. The Government remain as committed as anyone in the House to ensure that the future of that continent is secure.

Baroness Crawley: My Lords, I beg to move that the House do now adjourn during pleasure for one minute.

Moved, accordingly, and, on Question, Motion agreed to.

[The Sitting was suspended from 8.29 to 8.30 pm.]

Mental Health Bill [HL]

House again in Committee.

Earl Howe moved Amendment No. 20:

(a) he has consented to that treatment up to that dose and either the responsible clinician or a registered medical practitioner appointed for the purposes of this Part of the Act by the Secretary of State has certified in writing that the patient is capable of understanding its nature, purpose and likely effect and has consented to it; or (b) a registered medical practitioner appointed under paragraph (a) (not being the responsible clinician) has certified in writing that the patient is not capable of understanding the nature, purpose and likely effects of that treatment at that dose but that, having regard to the likelihood of its preventing serious risk to the life of the patient, the treatment should be given up to that dose.””

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The noble Earl said: Amendment No. 20 is very much in the same vein as the previous amendment but relates specifically to high doses of psychiatric medication.

Psychiatric medication, as we have said in earlier debates, can have very serious side effects, which can be dose-related. Higher doses increase the likelihood of adverse effects and do not necessarily bring additional therapeutic benefit. When a drug receives its marketing authorisation, it is based on what are considered to be safe levels of use. By definition, if you raise the dose above the upper limit cited in the British National Formulary, you are introducing risk because the maximum dose given in the BNF is often substantially above the usual dose range. Both NICE and the Royal College of Psychiatrists have produced guidance that recognises that key point. The college’s consensus statement says:


The existence of guidance is not enough. We know, for example, from the inquiry into the death of David Bennett, that overmedication frequently occurs, not least when those being medicated are people from black and ethnic-minority communities. Dose levels are often upped if they are not seen to be working but it is not uncommon for that to happen where not enough time has been allowed to let the medication work. It also happens when it would be better to take a step back and consider a completely different approach to the problem. But many psychiatrists like to stick to the medication that they know and do not like to change.

I think we should be quite disturbed by that evidence. It tells us that the mere existence of guidance does not guarantee good practice. What is the answer? The Royal College, through its Prescribing Observatory for Mental Health,has recommended that service users should be informed if they are receiving high-dose or combination antipsychotics, and the joint scrutiny committee on the 2004 draft legislation recommended that doses of treatment above the BNF levels should be allowed only in exceptional circumstances and when all other options have been exhausted. Both these points are addressed in the amendment.

I dare say that the Minister will argue that this is a matter of clinical practice and therefore not appropriate for inclusion in the Bill. Let me say why I think that that is wrong. When the 2004 draft Bill was published, it would have required care plans to set out the maximum dosage of drugs it was proposed to administer, specifying whether this was over BNF limits. That was an important recognition by the Government that there was a serious gap in patient protection. There is a gap. All the amendment tries to do is to address the safeguard that the Government previously agreed to. Doses above BNF limits would be made explicit in the process of consent, but if a patient who has capacity to consent does not give it for treatments that go beyond authorised limits, he should not be forced to receive them. If he does not have capacity, there need to be very good

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reasons why high-dose medication should be given. The hazards associated with it are justifiable only if there is a high risk of harm from not treating with it. The amendment therefore stipulates that in such circumstances the only valid grounds for exceeding BNF doses would be to prevent serious risk to the life of the patient.

I am absolutely clear that these safeguards are right. I am equally sure that they need to appear in the Bill. To force someone to take medication that they do not want is a very serious matter. To force someone to do so when there is real risk involved is something that we would not tolerate in any other branch of medicine, and we should not tolerate it in this area either. I hope very much that the Minister will wish to consider the amendment in a positive light. I beg to move.

Baroness Neuberger: I speak to this amendment from personal experience of chairing an NHS trust with a large mental health component. I hope that the noble Baroness, Lady Murphy, will forgive me if I say that she has sometimes been critical of some of her colleagues. I, too, am about to be critical of some of her colleagues. I refer to a matter that worried me enormously. You would occasionally find consultant psychiatrists and registrars carrying out “heroic” treatment. Having found that a dose up to the formulary limit was not working, they gave more, and they talked of that with pride. That was one of the most disturbing matters that I came across in all my time walking round the locked and ordinary mental health service wards. The noble Earl, Lord Howe, is right to say that this measure must be included in the Bill. Guidance to the effect that this practice should not be followed has been in place now for many years, but the truth of the matter is that it is still done, and is commonly done.

I have looked at the report on the death of David Bennett and listened to the evidence of Dr Kwame Mackenzie, who has studied this matter in detail and is worried that patients who are seen as big and black are still given larger doses. Dr Chandra Ghosh says that if the dose is not working it is illogical simply to give more and more of it. The more you look at that, the clearer it becomes that there is a real problem here. I do not believe that just having the measure in the Bill’s guidance will work. It needs to be in the Bill. I strongly support the noble Earl. I hope that the Minister will recognise that the provision needs to be stated very firmly in the legislation.

Baroness Murphy: The noble Earl and the noble Baroness outlined very clearly why this amendment should be in the Bill. I stress that doses of medications outwith the British National Formulary limits can help on rare occasions. But the amendment does not rule that out. It would merely ensure that there is a secondary certificate to say that this should be done or that the patient has consented to it, so that there is a clear record and clear second opinion. This practice is probably improving. I certainly saw a dramatic improvement in special hospitals’ prescribing of high doses of medication; it did come down. Nevertheless,

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it still goes on. It seems to me that by its nature it cannot be subject to randomised controlled trials, which can be done only with the doses of medication approved by the companies manufacturing the drugs. This would enable it to continue on rare occasions, but only when it has the full support of those who have been considering the case, in addition to the responsible medical officer.

Lord Hunt of Kings Heath: This has been an interesting short debate. I do not disagree with the noble Lords and the noble Earl, who commented on the impact of what can be very powerful drugs and on the dangers of overmedication.

However, this is ultimately a matter of clinical practice. There would be real difficulties with putting into legislation what the noble Earl seeks to do. I accept, however, that there are issues regarding clinical practice and the code that need to be addressed. In medicines management in general, in mental health trusts, there are a number of challenges that fall to be met. I will come back to discuss a Healthcare Commission report on that, published last Friday.

The amendment aims to put restrictions on prescribing medications at doses above the limits supposedly set out in the British National Formulary. It is worth pointing out that the BNF does not set, or even purport to set, any such limits. To quote from the BNF itself:

The BNF further states:

It goes on to say:

The BNF does not provide guidance on calculating high doses when combinations of similar drugs are used, referred to as polypharmacy.

The noble Earl, Lord Howe, referred to the Royal College of Psychiatrists council report Consensus Statement on High-Dose Antipsychotic Medications. The statement acknowledges two different mechanisms for determining a high dose when using a combination of different antipsychotics. One method involves converting each drug into chlorpromazine equivalents, while the other method adds together the percentage of the BNF limit for each of the drugs used. The statement uses the latter method in its guidance, which addresses best practice, to limit the need for high doses, and best practice in the use of high doses and polypharmacy.

We believe that, in the end, these matters are best left to clinical judgment, in the light of the various guidelines given. That is the best approach. Noble Lords will see that there are, and would be, severe practical difficulties in using the BNF provisions in statute in the way described, for the reasons that I

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have given. I accept that there is a challenge here to do all we can to ensure that clinicians prescribe doses in the most appropriate way possible. We believe that the code of practice, and all that is associated with it, is the best approach to this matter.

I would also like to take this opportunity to comment on the Healthcare Commission report, published last Friday, Talking about Medicines: the Management of Medicines in Trusts Providing Mental Health Services. I commend that report to your Lordships. It highlights the importance of safe, effective and efficient medicine management as central to the delivery of high quality patient care. I assure the noble Earl, Lord Howe, that the department, the trust and the commissioners will want to review the recommendations in that report. That is one way that we can look to dealing with some of the issues that the noble Earl raised tonight.

8.45 pm

Earl Howe: I am grateful to the Minister for his full reply. While I had not expected him to accept the amendment, I had looked forward to a constructive response, and that is what he gave. I hope that this is an area that the Healthcare Commission will look at. Judging by the contributions around the Committee, it is an issue that concerns a number of people who are in a position to know about it. I thank all noble Lords who have taken part. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 8 [Amendments to Part 2 of 1983 Act]:

Baroness Finlay of Llandaff moved Amendment No. 20A:

The noble Baroness said: This amendment has been drawn up by the British Association of Social Workers through the national network of approved social worker leads. It has been tabled in the light of deficiencies in the current Act, and it aims to tidy up gaps in the legislation. The noble Baroness, Lady Gardner of Parkes, initially tabled this and other amendments, and I believe that she has spoken to the Bill team about them, as has the British Association of Social Workers. I have added my name to hers.

The amendment concerns the effect of guardianship applications. Currently, practitioners face the frustrating situation that where a service user needs to live in a particular place but is unwilling or unable to agree to do so, an impasse can often be reached. While the law provides the power to require him or her to live in a particular place and to be returned to that place if he or she leaves without the

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guardian’s permission, no power currently exists in the Mental Health Act 1983 to take them there in the first place. As a result, guardianship is less well used, and service users are thereby less well protected than they might otherwise be.

The Department of Health’s figures indicate that about 500 people are put on guardianship each year. Overall, about 1,000 people are subject to guardianship at any one time. However, 15 authorities, out of 150 in total, account for over half of those applications. It seems that some authorities do not use this measure at all. The problem with the current legislation is that there is no power to convey the person to the place where they need to live.

The anomaly arises from an oversight during the passage of the 1983 Act. In its original form as the Mental Health Act 1959, guardianship gave the guardian the powers of a parent over a child under 14, which meant that a power to transport was inherent. When this provision was removed in 1983 in favour of a list of specific powers, it was not recognised that a specific transporting power was required. The amendment would increase the scope of guardianship as a less draconian, welfare-driven rather than treatment-oriented alternative to a community treatment order. I hope that the Minister will be minded to accept the amendment as a solution to a current problem. I beg to move.

Baroness Royall of Blaisdon: The noble Baroness clearly and rightly wishes in the amendment to rectify an apparent anomaly in the Act. A patient subject to guardianship may be returned to the place where he is required to reside if he absconds from it, but there is no specific power to take him there in the first place. That is inconsistent, and there clearly is a lacuna in the Act. We recognise that there should be a specific power.

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