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[Amendments Nos. 39 to 41 not moved.]

Clause 25 [Community treatment orders, etc]:

[Amendment No. 42 not moved.]

On Question, Whether Clause 25 shall stand part of the Bill?

Earl Howe: In Clause 25 and the other clauses and schedules grouped here, we have reached what is perhaps the final major area of controversy in the Bill: supervised treatment in the community. Before going any further I should say that the Minister need not be alarmed unduly by the fact that this is a clause stand part debate; it is not my intention to divide the Committee on this occasion. However, I think that a useful purpose would be served in Committee by avoiding a series of debates on a sizeable clutch of smaller amendments and concentrating instead on the broad issues of principle.

The Government’s intentions in promoting the concept of community treatment orders are, I believe, entirely honourable. They want to create a means of preventing re-admissions to hospital and to provide a less restrictive alternative to in-patient treatment. If we agree that those are good aims, there seem to be only two questions of any substance to be settled. First, will the policy have any unintended and unwelcome consequences? Secondly, will the policy work? As to whether it will work, the evidence for this is pretty thin. Such evidence as we have is, at best, inconclusive. The problem is that it is very difficult to draw comparisons between what happens overseas and what may happen here, as we are dealing with different mental health systems. In some countries where there are CTO arrangements in place, there is far greater support from community services than there is in Britain. Studies carried out in the USA, where CTOs are used in a number of states, prove very little. The conclusion of one major study said:

I am unaware of any other study that points to a more positive conclusion; the Minister may wish to correct me.

The point about relative efficacy is important. It could indeed be true that early intervention and assertive outreach are just as effective in achieving good outcomes as involuntary treatment. If so, those are surely the services we should be strengthening, rather than making patients wait until they reach a crisis and then forcing them to receive the services. There is a false logic at play here. Indeed, to the extent that service users found CTOs beneficial, it may in some cases have been because, as a result of the order, services were made available to them which they would have used voluntarily but were not given access to until they were compelled. If so, that is not a very good argument for the introduction of CTOs.



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Do CTOs prevent readmission? A Cochrane meta-analysis of the data found no difference in readmission rates and calculated that it would take 85 CTOs to prevent one re-admission to hospital. A Canadian study reached a rather more positive conclusion. Another study in Western Australia found that CTOs increased the likelihood of readmission. Much depends on the attitude of the patient. Regrettably, in a further study, it was found that patients who lacked insight into their condition were less likely to consider community mandates to be fair and effective. Yet those are exactly the kind of patients targeted by CTOs, because they fail to comply with treatment.

If we need to worry about the evidence base for CTOs, we should be equally worried about their unintended down side. The first down side is that CTOs are likely to lead to an increase in the use of coercion. That, at least, is what the evidence currently suggests. It is a point of particular concern in the context of black and ethnic-minority patients. In Scotland, where CTOs were introduced with slightly different conditions, the anticipated total number of people who might need to be placed on a CTO was reached almost within six months of the provisions taking effect. Another recent study estimates, on the basis of the Scottish experience, that between 6,000 and 9,000 people are likely to have CTOs applied to them in the first six months. If that is right, the Government’s longer-term projections of use may underestimate the real numbers by a factor of two or three.

Unfortunately, the provisions in the Bill lead us to a very similar conclusion. They do not do enough to ensure that only a limited and strictly defined group of patients could be made subject to CTOs, which is what the joint scrutiny committee recommended. The criteria for making a person subject to a CTO are significantly wider than in other jurisdictions such as Australia and New Zealand, both of which have a much tighter definition of mental disorder and a broader range of exclusions. In Scotland, too, the definition is tighter.

By contrast, in the Bill we have not only a wide definition of mental disorder; we also have limited exclusions, a wide definition of treatment, wide entry criteria to a CTO and greater numbers of clinical staff, including occupational therapists, who can keep people under compulsion. If one adds to that what most of us acknowledge is a pervasive climate of defensive practice, the cumulative effect points to CTOs being used far more widely than Ministers are making out. We and many others wanted some clear reassurance in the wording of the Bill that CTOs would apply only to genuine revolving-door patients. But the Bill contains no such wording, and I cannot help feeling that that is deliberate.

6.30 pm

It is not surprising that service users are fearful of these provisions. They see them as increasing their chances of being made subject to compulsion; they fear that compulsion will be used when people are not severely unwell; they fear that they will not receive

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what they need in the way of support; and, perhaps most of all, they fear that it will be difficult to come off a CTO because clinical staff will play safe to ensure compliance. The danger is that these realistic fears about CTOs will drive people further away from the services and treatment that they need. The delicate relationship between service users and doctors requires trust to keep it afloat. If the fear of CTOs is as I understand it to be, then the end result could be exactly the opposite of what we want to see—an increasing level of disengagement from mental health services and a higher risk of relapse and readmission to hospital.

I expect that the Minister will think me something of a prophet of doom, but I simply say to him that we have to base our thinking on the available evidence. Unless the Minister has some different evidence, the introduction of CTOs in the manner proposed seems to me to be a leap in the dark that carries huge risks. If the criteria for compulsion were narrower, and especially if we could somehow restrict the applicability of CTOs to revolving-door patients, I would feel a good deal easier. As it is, I have to say that the Government have further work to do.

Lord Carlile of Berriew: I wish to add a few words to what has been said. In my view, the noble Earl has made a very strong case against the provisions for CTOs as they are described in the Bill. The Joint Committee set out its views very clearly at pages 70 to 72 of its report and I do not propose to repeat its conclusions here. I emphasise that the committee heard a great deal of evidence on this matter. We looked for evidence from abroad, and the evidence that we received supported the conclusions summarised by the noble Earl a few moments ago.

I emphasise the concern of the committee that, unless CTOs have some kind of finite time limitation, there is a real risk that patients will find it very difficult ever to be removed from a CTO. At lines 9 to 14 on page 19 of the Bill, subsection (3) of proposed new Section 20A makes it absolutely clear that community treatment periods may be extended initially for six months and then for a further period of one year. There is no particular objection to that, but it goes on to say,

That is precisely the kind of provision about which the committee was deeply concerned. It is precisely the kind of provision that could lead to the sort of cautious approach of which the noble Earl was speaking. We were not opposed in principle to CTOs with appropriate circumscription—that has already been discussed—but we invite the Minister to respond positively by saying that the Government will in some way revisit the possibility of CTOs being extended time without end.

Baroness Murphy: I added my name to those who oppose the clause because I am concerned that the Committee is sleepwalking into compulsory community treatment orders without taking the evidence into account. As it is all on the record, I had

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better confess right at the start that I have changed my mind at least twice on these provisions. Like many others, I have at times thought that they might be a solution to a very restricted problem but, as they are currently outlined in this Bill, I do not support them. I hope that, in any case, Members of the Committee will appreciate that it is the mark of a proper scientist to change his or her view when faced with new evidence.

First, I want to talk about the problem that we are trying to solve. There are two possible reasons for supervised community treatment. The first is a belief that we will improve compliance with medication for the general well-being of people with severe mental illness. The second—let us face it, this is what the tabloid press would like us to do—is that we will reduce the incidence of violence and harm, specifically homicide.

The Government have already declared this to be a public safety Bill in part, rather than a mental health Bill pure and simple, so I shall talk about the violence issue. The Government may be surprised to hear that I find myself very near to their position on the importance of the violence and public safety issue. There is an association between violence and schizophrenia that is reflected not just in the homicide statistics but in the countless episodes of lesser violence and threats to family and others, which can ruin the lives of family and carers. What emerges from reviewing homicide inquiry reports involving patients with schizophrenia is an attitude problem by some general psychiatrists. I shall not be very popular with my colleagues for saying this but someone has to.

Violence in serious mental illness is like sex before Freud—we cannot talk about it openly and we want to dismiss or disown the risk. Service user groups do not like us talking about it either because it tends to heap stigma on the majority of innocent law-abiding, non-violent patients. So doctors sometimes use any lack of clarity in the law to avoid taking the initiative, even when there is a long history of previous violence and they are seriously worried.

I have had a case drawn to my attention in which a psychiatrist consulted his defence union about his personal position because he was worried about the risk that a patient posed, yet he did not request a Mental Health Act assessment. That patient went on to commit two stranger homicides shortly afterwards. There are plenty of other examples where there has been reluctance to intervene, despite lots of warnings. I have mentioned previously in Committee the desperate messages sent by the parents of Andrew Robinson to his psychiatrist and to social services about their son’s increasingly frightening symptoms in the weeks and days before he killed a young occupational therapist—calls for help that were totally ignored. These are not isolated cases.

The great progress in the NHS over the past decade, for which I congratulate the Government, is that mental health patients have been listened to more and their wishes have been respected. There is no doubt that there has been a dramatic improvement in services. But that can lead to team members feeling there is something wrong or improper about

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compulsion or coercion, even for those who really need it. The question, therefore, is not whether there is a problem but how best to fix it, and here I part company with the Government's approach as it is likely to be entirely counterproductive.

I know that the Government hope that, although supervised community treatment may not make much difference on its own, it may serve to change the culture and increase the confidence of doctors in intervening early when necessary. I would almost be persuaded by that if it were not for the fact that the enhanced care programme approach has not helped, supervised discharge—the 1995 new legal provisions—is almost never used, and guardianship is rarely tried. Why is that? It is because they require effort, a lot of intervention, increased resources and a focus on a few very difficult people, which can detract from services for other people. We need a real willingness to grasp when serious risk is present, but that is not the case at the moment.

I know that colleagues of mine, such as Professor Tony Maden, who is a supporter of these proposals, are pressing our college to formulate a violence reduction strategy. I heartily applaud that goal. The difference between us is whether these provisions will be different from any of the others without a substantial change of heart about the proper role of psychiatry. I would be better persuaded if there were evidence from elsewhere that they really helped.

Supervised community treatments are there to make sure that someone can be brought into a psychiatric unit to be given medication by force. There are no treatments that can be imposed on unwilling patients except injectable medications. The only injectable medications we prescribe in the long term in psychiatry are anti-psychotics. There are no compulsory pills, no oral liquids, certainly no compulsory psychological supports or interventions that we would consider ethical.

I want to dispose of the notion that we are dealing with anything except a limited number of people with schizophrenia. They are the only people we might catch. I shall talk about the homicide issue first because the evidence is clear that we are highly unlikely to reach sufficient numbers of the right people. Let us consider the marvellous report from Professor Louis Appleby and his colleagues in the excellent National Confidential Inquiry into Homicide and Suicide by mentally ill people. It is a splendid piece of work, published in November, which most of us will have looked at.

Every year about 50 mentally ill people commit homicide. Only 30 of those have a lifetime risk of schizophrenia and another 15 or so have depressive disorders. The rest have a wide range of conditions that would not be amenable to supervised treatment. Of the 30 a year that we are now talking about, a third have never been in contact with services and of those who have, only 10 have ever been compulsorily admitted. We are perhaps looking at about 20 people whom we might want to catch.

Obviously one cannot supervise the treatment of those who do not go to services. I remind the Committee that of those 20 whom we are trying to

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catch, two or three are already in hospital receiving medication. Another one or two a year will be young women who have killed their children during a period of puerperal psychosis. I suggest that they will not be on supervised community treatment. It is notoriously difficult to try to catch people very soon after giving birth to try to prevent that. Let us put aside the people whom we will catch.

The national confidential inquiry report is fascinating because it points out that of those patients in contact with services, many were not even receiving a formal care programme. Of those who were on enhanced CPA in the community there had been no effective interventions by services at the point of crisis which preceded the homicide.

I am sorry to go on but I hope the Committee will note that I have not intervened previously this afternoon. Let us look at the population figures. Normally in implementing a public health measure, which the new clause is, the Department of Health adopts an epidemiological rather than an anecdotal approach to policy. We shall consider only men for the moment, since it is predominantly young men who perpetrate homicides of the kind that we are trying to reduce and the violence that we wish to try to avoid. The one-year prevalence of schizophrenia in men of the right age—under 50—who are living with this condition in the population is about 10 per 1,000. That is about 600,000 people across the nation, from whom we are trying to identify the 20.

In any one year about 114,000 will be receiving care and about 500,000 will not. Of those who are not receiving care, about 200,000 will have been known to services at some point but will no longer be under supervision. Up to 300,000—possibly with rather mild conditions—will not be known to services, but there will be some who have not been brought to the attention of services.

I hope that I am getting across the message that identifying the “at risk” population is pretty difficult even if psychiatrists' risk assessments were rather better than they are. The accuracy of clinical prediction is low. For every six patients identified as at high risk of committing a violent act in the future, only one will go on to commit such an act. So, we are thinking of putting in place a measure, which in my opinion is likely to have no impact on rates of homicide or serious violence. Raising a bob or two on alcohol taxes would have a dramatically increased numerical impact on homicide rates compared with this. We will restrict an awful lot of people for dubious reasons. The epidemiological evidence that the Department of Health normally requires for implementation of a disease screening programme for breast or cervical cancer, for example, simply does not stack up.

6.45 pm

I shall not repeat the evidence that the noble Earl, Lord Howe, outlined, except to add that I think there have been two randomised control trials—rather bad ones—including only about 400 people. They did not demonstrate any improvement in health service use, social functioning, mental state, quality of life,

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satisfaction with care or offending. Interestingly, the risk of victimisation felt by patients was improved, which was largely because of the improved delivery of services to those people, as has already been mentioned.

I realise that lack of evidence of efficacy is not the same as evidence of no efficacy. But what is proposed here is a measure on which the jury is still out. We have heard that it would take 85 orders to prevent one re-admission, 27 to prevent one episode of homelessness and 238 to prevent one arrest, although these are American figures and it is extremely difficult to know. It might take about 5,000 or 6,000 to remove one offence of serious violence or homicide. They will not be an effective alternative to good care. It is difficult to conceive of another group to whom we would subject these sorts of measures—to curtail the freedom of 85 people to avoid one admission to hospital or 238 to avoid one arrest.

Others have spoken today about the wide scope of these powers in relation to people who will derive no benefit from them and the fears that they engender in service users, particularly in black and minority ethnic groups. One thing that has convinced me that good services are the answer is the early intervention of services. The noble Baroness, Lady Neuberger, spoke about that some time ago when I had the great honour to chair this initiative for the King’s Fund. I witnessed the change in services that came about in Lambeth when we increased their acceptability. Services in Lambeth were improved by the provision of specialist, sensitive services that were much more usable by young black people who were more willing to take their symptoms to the community. It was a demonstration that services can be designed to attract and engage the right people.

In summary, if we are to have such measures we must accept that we are delivering a wild card, which may not be very effective. It may do no more than serve as a temporary reassurance. But when the next suicide report comes along, we will say, “Why wasn’t this person on a community treatment order? Why was he not receiving it?” The chances are that there is not a hope of getting someone on an order or very few will get on them.

If we are to have community treatment orders, we must make sure that they are difficult to get on to, that people on them have reliable services delivered to them, and that getting off them is at least a bit easier than it is now. Someone could carry on being on a community treatment order pretty well in perpetuity. We must remember too that 20 per cent of people with a first episode of schizophrenia will not relapse. One in five people who have a first breakdown will never have another. If people on a first breakdown are put on supervised community treatment, we have to be clear that we are not subjecting them long term to these horrible drugs without real benefit to the individual and society.

Lord Warner: It is with some humility that I follow that speech. I pay tribute to the courage of the noble Baroness, Lady Murphy, in throwing down a challenge to some of her professional colleagues in

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that way. I am afraid, however, that I come to a different conclusion from the noble Baroness and other noble Lords on some of the evidence we have all seen. I continue to find it surprising that there remains so much opposition to the idea of supervised community treatment orders.

The idea totally adheres to the principle that people should receive the care they need in the least restrictive setting. The Bill introduces a change reflecting the fact that clinical practice has changed since the 1983 Act was passed. In 1983, most acute mental health services were provided in a hospital. The world has moved on, and we have a much wider range of community-based mental health services. Sometimes in this debate, I do not think the full extent of that change has always been acknowledged by some noble Lords.

One thing that has not changed as much as we would like, however, is the continuing number of revolving-door patients. They leave hospital, disengage from mental health services, do not continue with their treatment, their health deteriorates and they end up compulsorily detained in hospital. We may have differences of view about the numbers involved, but that is the cycle we are trying to deal with. If there is an alternative, we ought to use it. For reasons I shall go into in more detail, the supervised community treatment order provides an option.


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