Clause 1
Mental Health Bill [Lords]
11:00 am
John Pugh (Shadow Minister, Health; Southport, Liberal Democrat)
I want to take the opportunity to ask the Minister a few questions. I understand that the new definition of “mental disorder” is a heck of a lot better than what was in the Mental Health Act 1983. Having read that Act with care, I do not object to the change. The new definition is more colloquial and less misleading. The previous one dwelt on behavioural issues and confused a number of causally quite different conditions.
Specifically, under the definition, “mental disorder” appears to be something that results from illness rather than from any structural impairment of the brainor genetic deficiency. It is very helpful to draw that distinction. Lord Rix in the House of Lords was particularly pleased to see references to mental impairment disappear.
One assumes that by “mental disorder” one simply means the common neuroses; the psychoses, of which the symptoms are normally delusory states or hallucinations; bipolar disorder; personality disorder, which is understood in a wider context; and psychopathy. There are certain organic conditions, such as Korsakov psychosis and the like, which are definitely a consequence of the structural impairment of the brain in one way or another. Are they included in the definition of mental disorder? After all, we are not in an area in which there is absolute clarity. Even now, there are debates about whether schizophrenia is one condition or several. If there is a mental disorder that results from structural damage and is not genetic or inborn, is that included as a mental disorder in the Bill or not?
I have a constituent whose behaviour causes great concern. His parents are extraordinarily worried about him. He cannot get treatment from the health service because, although his behaviour is aberrant in many respects, it is a product of physical damage to the brain as a result of an accident, and not something inborn or a genuine impairment that he started off life with.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
Perhaps it would be helpful if I gave some background to the clause and explained why we have taken the decision to abolish the four separate categories of mental disorder, which are used in parts of the Mental Health Act 1983 as it stands.
What we have tried to do with the clause is to simplify the definition, so that we have a single definition of mental disorder throughout the Bill. The clause also simplifies, although it does not change the effect of, that basic definition to
“any disorder or disability of the mind”.
The reason why we wanted to remove the four categories is that they serve no useful purpose at the moment. They do not help with people getting the treatment that they need, when using the Act is the only option left, and they do not protect patients against inappropriate use of the Act. They are legal and not clinical terms. They do not relate directly to clinical diagnoses.
Tim Boswell (Daventry, Conservative)
I think that my intervention will be supportive of the Minister’s point. Can she give the Committee any evidence as to where clinical freedom is being inhibited or made more difficult by the existence of somewhat archaic distinctions?
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I certainly will do. As I was saying, the definitions do not relate directly to clinical diagnoses. What counts legally as psychopathic disorder goes well beyond what the person in the street would probably mean by a psychopath, for example. Clinically, in many ways the legal definitions are a distraction. A clinician does not need to know which of those categories a patient’s disorder falls into in order to decide on treatment. The current law forces the clinician to spend time thinking about the categories. Importantly, they can also be a legal distraction. Time can be taken up by tribunals, especially when dealing with restricted offender patients, who might be trying to gain some advantage by arguing about classification when it has nothing to do with the risk posed bytheir disorder or the treatment needed to tackle it. Obviously, we believe that compulsion should be determined by a patient’s needs and the degree of risk posed by their disorder, not by the particular legal label applied.
The four categories in the 1983 Act create arbitrary and unnecessary distinctions between patients. Also, coming to the points raised by the hon. Member for Southport and the hon. Member for Daventry, the categories may leave some patients out entirely from certain parts of the Act. In other words, patients could be detained for assessment but not then detained further for the treatment that they need. I should emphasise that we are talking about a very small number of people here. There have been some misconceptions that somehow, by changing the categories, we are widening the number of people who might come under the detention provisions. That is not the case. A very limited number of people are not covered by the current “disorders”; they almost certainly include certain mental disorders arising from brain injuries acquired in adulthood. That may be the difficulty to which the hon. Member for Southport referred.
John Pugh (Shadow Minister, Health; Southport, Liberal Democrat)
The Minister’s contributions are very helpful. Is it fair to say that the “mental disorders” described by the Bill do not match any particular set of clinical diagnoses, but are simply what psychiatrists at any one time in our culture define as a mental disorder?
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
The hon. Gentleman is right. There are certain guidelines and international classifications of mental disorder, but essentially he is right that there is clinical discretion. It cannot be said that something that is not in any classification is not a mental disorder.
Likewise, to expand on some points about those small numbers who may not be covered, there may also be certain types of personality disorder that would not legally be mental illness but do not meet the current definition of psychopathic disorder, as they do not result in seriously irresponsible or abnormally aggressive conduct. Even so, to go back to the cases that the hon. Gentleman has raised, such a disorder could cause the person concerned great suffering—serious enough to make serious self-harm or suicide a real possibility. Therefore, in practice, I suspect the reality is that people are found ways of getting that treatment. I am sure that there are some people who would say, “Well, somebody can be put under that category”. However, given that we are trying to improve and to modernise our legislation, it is important to take this opportunity of having real clarity here.
John Pugh (Shadow Minister, Health; Southport, Liberal Democrat)
With regard to psychopathy, I understand that that term is becoming almost clinically unfashionable. It is being replaced by “personality disorder”, in much the same way that manic depression was replaced by bipolar disorder. As a result of the amendments, will the term psychopathy retain any legal significance or value whatever in legislation?
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
No, it will not.
I should also assure the Committee that there has been a general welcome for the changes that we are considering in clause 1. There is general agreement that these legal categories have not necessarily contributed anything particular to treatment or care and, again, for the small number of people who are excluded, it is important to have clarity.
Tim Loughton (Shadow Minister (Children), Health; East Worthing and Shoreham, Conservative)
The Minister mentioned just now that the new definitions will not broaden the net. However, is it not the case that the new definition covers all the diagnoses listed in the international classification of diseases 10—some of which eventhe Government acknowledge may be appropriate for compulsory powers—and that nothing in the Bill confines the definition to the conditions listed in ICD 10 or the American diagnostic manual?
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
No. As I have said, there are international classifications. That does not mean that those are the only things that can be counted as mental disorders. Clinicians can make diagnoses. I emphasise that, within the Mental Health Act 1983, there is the obvious ability to appeal to a tribunal. First, though, two doctors have to agree that a mental disorder is present. If that is disputed—if the patient believes that they have no mental disorder—they can take it to a mental health tribunal to challenge it.
Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton and Honiton, Conservative)
In the regulatory impact assessment for this proposal, the Government outlined the risks and benefits and I note that the Minister does not regard that there will be any additional costs as a result of a change in this part of the law. Does she not think that advocating the opportunities for appeal and tribunals will mean that there will be more challenges, which will have a cost impact? I raise that matter because this change, and what its consequences may be, has been sadly neglected in the regulatory impact assessment. If the funding is not there, the safety blanket that she has just described will not be met, through lack of resources.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I am sorry, but the hon. Lady may have misunderstood what I was saying. I was simply pointing that, if a patient disagrees—it is important for them to have those rights—and if they feel that they do not have a mental disorder and want to challenge that, they can appeal to the tribunal. Personally, I think that it would be difficult to start saying, “Let’s not talk about the tribunal, in case people start appealing to it”. I am simply saying that that is the path which people would follow.
Tim Boswell (Daventry, Conservative)
My colleague may also want to intervene on the Minister but, to put a gloss on my interpretation of what she said, it seems self-evident that, if one is making more flexible the definition of mental disorder, a larger number of people in the population, albeit a small number, will be susceptible to the provisions of the Mental Health Act and will therefore be able to avail themselves personally of the appeal mechanisms of the Act. My hon. Friend the Member for Tiverton and Honiton made a point about the resource implications. I make no judgment as to its merits, but it requires an answer at least.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I refer the hon. Gentleman and the hon. Member for Tiverton and Honiton to my previous comments about restrictive patient offenders. One of the current difficulties is when people argue in front of the tribunal about the classification into which they have been placed. I want to turn matters the other way round. At present, a tribunal’s time can be taken up arguing about the classification of people and, thus, by removing the false categories, we are more likely to increase the tribunal time.
Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton and Honiton, Conservative)
We will debate communication disorders in a minute—something that I seem to be causing myself at the moment—but I wish to pressthe Minister about the fact that, listed under the Government’s risk option 2—the recommendation for a single definition of mental disorder—they identify the new appropriate treatment test. It will ensure that an holistic assessment is carried out in each case. I do not disagree with that. Of course, it is a good thing, but surely there are resource implications in such an approach.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I am not quite sure of the hon. Lady’s point. If we remove the present categories and less tribunal time is spent arguing about the categories, other parts of the Act have to kick in, as they do at the moment. It is absolutely right that appropriate medical treatment is available and that it is part of the conditions of detention. Half of the Opposition’s argument is that, under the Government’s proposals, people will not receive treatment. However, now the hon. Lady is arguing that people will receive too much treatment under the Government’s proposals.
Chris Bryantrose—
Angela Browningrose—
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I shall give way first to my hon. Friend.
Chris Bryant (Rhondda, Labour)
I think that I will misinterpret the hon. Lady a little further. She seems to be suggesting that, because we are changing the definition of mental disorder, each disorder in the ICD 10 list—a long list, as the hon. Member for East Worthing and Shoreham said—would suddenly fall under the Act and therefore everyone might be up for detention. The truth is that the vast majority of those several different layers, both organic and other conditions that are termed in the ICD 10 list as mental disorders, would not be recommended for detention at all.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I give way now to the hon. Member for Tiverton and Honiton.
Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton and Honiton, Conservative)
I am raising matters that areon the record in the Government’s own impact assessments under the heading “risks of option 2”. They themselves have identified those risks. I am challenging the Minister because I am not convinced that she has fully estimated in the regulatory impact assessment the resource implications of the changes. If those changes have not been properly calculated within the regulatory impact assessment, there will be long delays for people wanting to access those parts of the Bill. She herself has identified the risk.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
I want to emphasise that we have undertaken the regulatory impact assessment. We believe it to be accurate, and I think that there are lots of counter-balances in that regard. The hon. Lady says that by advocating tribunals, one increases the costs. I would also say, as I have said before, that by reducing the categories, one spends less time quarrelling about them in tribunals.
Ann Coffey (PPS (Rt Hon Alistair Darling, Secretary of State), Department of Trade and Industry; Stockport, Labour)
Is my understanding correct? The category of mental disorder has not been extended. All that has happened is that the two categories of mental disorder and psychopathic disorder, which were in the 1983 Act, have been brought together under the one category of mental disorder, with the term psychopathic disorder being omitted. Therefore, there is not a new definition of mental disorder. That is my understanding. I do not see why there should be any more resource implications than in the 1983 Act.
Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)
As I have said clearly, we do not believe that the change broadens the definition and brings more people into it. There are small numbers of people who unfortunately fall outside that definition. However, I suspect that in many cases, ways will be found to get help to those people.
Therefore, the change that we propose has generally been welcomed. I hope that the additional information I have given will reassure Committee members that we do not intend to increase the numbers of people who are likely to be treated under the Bill.