Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

I beg to move amendment No. 40, in clause 2, page 2, line 4, after ‘disability’, insert

‘or an autistic spectrum disorder’.

I am pleased to speak to the amendment, which is supported by my colleagues. The subject has been discussed in the pre-legislative scrutiny Committee and also in another place. The amendment seeks to add autistic spectrum disorders to those areas that have been modified to accommodate the needs of people with learning disabilities. The Minister and I have shared many a conversation about the matter. I am very grateful that she has agreed to discuss it again on Thursday privately.

I would like to use the opportunity of moving the amendment to clarify the reason why the issue is so important. I should begin by declaring my interest as the vice-president of the National Autistic Society. I also hold positions on other related autism charities.

The purpose of the amendment is to ensure that people with autistic spectrum disorders are recognised in the way that the amended Bill now recognises learning disability. I am familiar with the Government arguments, both in another place and elsewhere, about their reluctance to draw up a list of conditions that are exceptions to the rule. However, given the background on learning disability—its recognition in the Bill and the way in which it is dealt with in the 1983 Act, which I will mention in a moment—this is a special case.

I am sure that the Minister has heard a lot of special pleading from people who are concerned about a range of disabilities and believe that there is a case forthose to be recognised in a Bill, rather than ignored altogether or tucked into a code of practice. However, I want to make a case for making a special exception for autistic spectrum disorders. There are many reasons for that, not just because I have an interest in the subject.

Tim Boswell (Daventry, Conservative)

Does my hon. Friend agree that, notwithstanding my less extensive experience of such conditions, this is a particularly sensitive matter and certain people with autistic spectrum disorders may be rather high performers, whether they have Asperger’s syndrome, and may not, in some definitions—including locally, in my experience—be regarded as learning disabled on account of that? However, both in terms of some of their social behaviour and their need for social support, such people are clearly in this category, without being mentally disabled in any sense.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

My hon. Friend is right. A diagnosis of an ASD does not mean that someone has a mental disorder, but we all recognise that there can be a multiple diagnosis. For example, a person with ASD can have a learning disability and can—frequently,they do—have a recognised mental illness. Sometimes people have a combination of all three things: a triple diagnosis is not unknown. Cases can be complicated and often difficult for the professional psychiatric services to understand properly.

I should like to put on record the concern of the National Autistic Society, which understands the need for a clearer definition of a mental disorder. I do not think that there is any disagreement about that. However, it is concerned that, because of the changes and the lack of recognition of how ASD presents itself—and our greater knowledge of it now, compared to when we legislated on mental health in 1983—more people with an ASD could be inappropriately detained.

I remain to be convinced by the Governmentthat there is a case for people with an ASD being compulsorily detained for treatment if they are not mentally ill or, in the context of the clause, they do not exhibit

“abnormally aggressive or seriously irresponsible”

behaviour. That is why the recommendation of the Joint Committee on the draft Bill, of which I was a member, identified ASDs, in addition to the exclusion for learning disability, as the one condition to which we felt that the Government should pay due regard. We took evidence from a lot of people, representing those with a range of quite legitimate conditions, who made that case. However, autism, which is a complex condition, is different and I should like to explain why that is so.

Autism is a lifelong disability. It is a developmental disorder and is not something that people catch. We do not know yet what causes it, although there is a lot of research being undertaken in this area, but we know that, although it is different in every individual, it presents with three core deficiencies that have a huge impact on people’s lives and behaviour.

Autism leads to a lack of understanding of social behaviour and problems making social relationships. I am putting this in layman’s language, rather than talking about what we sometimes call the triad of impairment, which is language that just floats over people’s heads. For children, that can mean failing to make friends in the playground. Going to a school for children with autism and seeing them at play time is quite a shocking thing. One does not see, as normal, children running around, interacting and playing with each other, or creating any imaginative play. Lack of imagination, of an ability to put oneself in somebody else’s mindset, is part of the triad of impairment. Children in such a school at play time will either stare into the middle distance or be preoccupied with repetitive behaviours.

Tim Boswell (Daventry, Conservative)

Does my hon. Friend recall that one of the celebrated books written by someone who was subject to an Asperger’s definition was entitled “A Martian in the Playground”, which makes her point?

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Indeed. I began by talking about children because it is perhaps the one area in which in the past 10 to 15 years we have started to make some progress. I am not complacent, but we have started to give recognition in our education system and through social services departments. First, early diagnosisis important; the Minister will know how early intervention is key after picking up the symptoms and signs of autism. Early intervention and management of the condition are extremely important. Managementof the condition very often depends on appropriate  resources being available, but certainly in the education scenario we are in a very different position from that in 1983, when the previous Mental Health Bill was drafted. I am old enough to remember that personally—

Tim Loughton (Shadow Minister (Children), Health; East Worthing & Shoreham, Conservative)

Surely not.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

My hon. Friend is most kind, but sometimes it is better to be older and have a longer memory.

Let us recall that excellent report by Baroness Warnock in the late 1970s, which looked at the way in which we educate children with learning disabilities. Back in the early 1970s it was not unknown for children with learning disabilities, which would have included a wide body of children with autism, not to be considered suitable for education at all. The ground-breaking Warnock report led to education legislation that started to introduce the statementing process and to the formal recognition in statute of the rights of children with a learning disability to receive an education appropriate to their ability to receive it. That was within the lifetime of most of us in this room, but at the same time as the Mental Health Act 1983 was being drafted. So, I can fully understand why—although we have a better knowledge of learning disability per se than back in 1983, when the Mental Health Act was being drafted—we were only at that point just getting to grips with how we handle the education of children with a learning disability, which would have included autism.

Meg Hillier (PPS (Rt Hon Ruth Kelly, Secretary of State), Department for Communities and Local Government; Hackney South & Shoreditch, Labour)

It is a pleasure to serve under your chairmanship, Mr. Cook. I am very interested in what the hon. Lady has to say—I have been an advocate for a relative with a learning disability, so it is an area that greatly interests me. I wonder whether the hon. Lady can answer a couple of questions.

First, how many people with autistic spectrum disorders have been detained under the Mental Health Act 1983? Secondly, is she not effectively arguing against the amendment? She is saying that our understanding of autism is so much greater nowadays that the idea of a psychiatrist considering anyone with autism to have a mental disorder is as remote as their considering someone with a learning disability to have a mental disorder. Back in 1983 there would perhaps have been more argument to have included autistic spectrum disorder in the Bill.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

The point that I am trying to make, which I hope to expand, is that because our understanding is so much greater—I am beginning with children, but I will move on to adolescents and adults—we should be looking at the mental health legislation in a totally different way to how we looked at it in 1983.

The hon. Lady asked me how many people had been detained. There have been two bigger pieces of research recently, one by the National Autistic Society and the other a report, from which I will quote in a moment, by the Royal College of Psychiatrists. We know the figures for people with an identified autistic spectrum disorder who come within the criminal court system. However, a  huge number of people in our prisons almost certainly have an ASD. We are looking at that as a body of work at present. There is a big debate to be had about how appropriate it is for such people to go into the criminal justice system. It is difficult to put a number on it in quantifiable terms.

I know that this has been put to the Minister before, but can she identify the number of people with an ASD diagnosis who are deemed potentially dangerous and therefore cannot be treated in the Bill in the same way as those with a learning disability? At the moment, we have seen only the tip of the iceberg in terms of adults; as you go up the age scale, the available statistics are certainly fewer and fewer. We still have a great many people in the latter half of their lives who are in the community but as yet undiagnosed. Not until they come before the criminal justice system, or until there is a huge breakdown in their mental health, or social services suddenly become involved with them for some reason are these individual cases picked up. The figures are not collected so we do not know the exact number, but it is severely underestimated at present.

Meg Hillier (PPS (Rt Hon Ruth Kelly, Secretary of State), Department for Communities and Local Government; Hackney South & Shoreditch, Labour)

Does the hon. Lady really fear that people with autistic spectrum disorders will be detained under this Mental Health Bill? Does she want ASD included for completeness’ sake, or is there a realthreat that a psychiatrist would have such a lack of understanding of the seriousness and the range of such disorders that they would section or recommend sectioning somebody, rather than recognising that the person had autism?

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Yes, I do believe that there is such a threat. I raised the first Adjournment debate in this House on Asperger’s syndrome a few years ago, and followed it up the next year with one on the psychiatric treatment of people with Asperger’s. Indeed, I thoroughly welcomed the 2005 report of the Royal College of Psychiatrists. It is absolutely essential that the professionals get to grips with that condition, of which there has been only a restricted understanding until now. The point that the hon. Lady just raised is my point exactly. However, there are more complexities to it, and I am coming to them.

I believe that ASD should be recognised alongside learning disability under clause 2. We are not trying to prevent people with an autistic spectrum disorder from receiving appropriate mental health services nor, for that matter, are we saying that they should never be detained since, like the rest of the population, in certain circumstances they would need the security of detention. There are behaviours associated with ASDs that do not have a psychotic base but are normal and triggered by events.

I turn to a particular example. Later on, in part 2, we will deal with how the Government are going to deal with the Mental Capacity Act 2005 to take account of the decision of the European Court of Human Rights in the Bournewood case. We should not forget what Bournewood was about. It involved an adult man named HL with an autistic spectrum disorder—a gentleman whom I have met. It was quite clear that the episode leading to his detention was event-triggered rather than an underlying psychosis. His carers had the perseverance to take the case through every court in  this country and eventually to the European Court of Human Rights, and as a result the Minister will now amend the law to ensure that the experience of HL is not replicated and that there is more protection in future legislation for people in his position. I, of course, support that and I hope to contribute to that process of amendment when we reach that clause of the Bill.

I have personally heard first-hand accounts about how HL went from a day centre to being detained for a very long time, to his detriment, without the people who knew him best having an opportunity to explain to medical professionals why it would have been, in their view, normal behaviour for him to have presented in the way in which he did when an event triggered an episode. I remind the Minister that that is how, very often, even the most able people on the end of the spectrum can behave in a different set of circumstances.

So what is autism and why is it different? We know from the figures that, of the population of working age, there are about 330,000 people with autism. Of course, there are more children with autism coming through and people often ask why autism is more prevalent today. Personally, I believe that it is because we are much more aware of it, have a greater knowledge of it and there is more early diagnosis.

I have mentioned the fact that we have had a history of late diagnosis, but why is that? It is because autism is a spectrum. If we examine our early understanding of autism—that is what the Mental Health Act 1983 would have considered—we see that Kanner identified autism in 1943. The Kanner definition of autism influenced psychiatric understanding in this country for some years, although it was not until the 1960s that there was much recognition of the distinction between autism and other conditions. Perhaps more prevalent in recent years has been the understanding of Asperger’s syndrome, which is on the more able end of the spectrum. Asperger identified Asperger’s syndrome at about the same time in the 1940s as Kanner defined autism, but it was never really recognised, and it was not part of psychiatric teaching and training until very recently.

It is the strange combination of an autistic spectrum disorder with that triad of impairment that leads to the very distinct diagnosis that is an autistic diagnosis. However, in the case of Asperger’s syndrome, it means that there can be people who present who are extremely able indeed. In fact, from an educational perspective, many can go on to university degree level, so that gives an idea for the range of abilities. Indeed, I have been told by the faculties of some of the Oxford colleges that most of their mathematics and physics departments are well populated with people who might have, or who might be diagnosed with, Asperger’s syndrome. There is nothing detrimental about that.

Furthermore, if we consider some of the footage that we have seen of the people who cracked the Nazi codes in the UK during world war two, I recall seeing what looked like an amusing piece of footage. It showed someone who was intelligent enough to crack the codes but who would also, every afternoon at four o’clock,  walk down through the grounds of the HQ to the lake, carrying his cup of tea, drink his cup of tea and then throw the teacup and saucer into the lake. That was repeated on a regular basis.

Such behaviour, one might think, is idiosyncratic, so where is the depth of concern about that? However, I would say that that is just one example. I will give another example, again of my own experience—in fact, there are myriad examples—of a gentleman who lived, undiagnosed, with his parents into his 40s. When the second parent died, he was left in the house on his own, completely unsupported, for the first time ever. It was only at that point that he really came to the attention of the social services department. The reason that he came to their attention was because he never went out of the house; the neighbours had seen him a little, but he had never given them any cause for concern. However, after his second parent died, the neighbours noticed, to their great concern, that after it got dark he was to be seen digging up the garden by torchlight. They were concerned that he was burying something, because they found him to be an odd person to deal with andto communicate with, and, therefore, reported his behaviour to the social services department. When the department intervened, it discovered that he was digging up the garden at night because he had a passionate interest in gardening but did not like being around other people. He found that, when it got dark, people did not lean over the fence and ask, “What are you planting there?”, to which he would have to find a reply, and communicate and socialise with them. Therefore, it suited him to maximise his ambition of gardening by doing it at night. I am pleased to say that I have met that gentleman, who is now working under supervision, potting plants in a greenhouse. He has, therefore, maximised the opportunity to do what he always wanted to do.

On first sight, some of the people who present in what may seem to society to be an odd way are intelligent and have other abilities. Despite the idiosyncrasy of that particular episode, in other circumstances, that gentleman could present himself as someone who has the capacity to express a view about what he wants to do.

Ann Coffey (PPS (Rt Hon Alistair Darling, Secretary of State), Department of Trade and Industry; Stockport, Labour)

The hon. Lady is making a good case for more knowledge about, and understanding of, autism. In relation to this Bill, she seems to be concerned that those who are autistic will be diagnosed as having a mental disorder and could be detained in hospital against their will. However, I am not clear about how making an exemption will help. If the assessing psychiatrist does not diagnose people as autistic in the first place, any exemption on the face of the Bill for autism will not protect them. Surely the way forward is to ensure that the psychiatrists who undertake mental health admissions have as extensive a knowledge of autism as possible at the point of assessment.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

The hon. Lady has made a good point, and psychiatrists’ knowledge about this group of people is a matter that I have raised in debate many times. Despite the 2005 report of the royal college, it remains true that we are fortunate in some of ourinner cities, as we have a resource of psychiatrists who  understand autism and who work with people who have learning disabilities. The run-of-the-mill provincial psychiatrist—if I may use that terminology—does not experience enough of these cases to get sufficient working knowledge of what is and is not appropriate behaviour.

The point about the Mental Health Act 1983 does not relate to the sort of situation that I have just described, involving my gardening friend. I raised that example to illustrate the breadth of the situation. However, when these people are in crisis, it is not because they have a mental illness—and if they have a mental illness, of course they should be entitled to the same treatment and services as everyone else—but because the nature of having an autistic spectrum disorder means that many people, including those with a high intelligence quotient, sometimes present in a challenging way, or in a way that may be regarded as inappropriate.

At this point, it would be a good idea to quote from the report of the Royal College of Psychiatrists, which I have referred to many times. I am conscious that I have been critical of psychiatrists over the years, not least because there is a prevalence of people with autistic spectrum disorders who present in a challenging way being admitted as in-patients, sometimes even when they have an autistic spectrum disorder clearly diagnosed by another professional. Psychiatrists commonly believe that those people have schizophrenia, and all too often medicate them accordingly. Given the nature of the drugs used to treat schizophrenia, what happens next is that they start to go through the list. If the first drug does not work, they move on to the next. By the time someone is on their fourth or fifth drug, and that still does not work, it is very difficult to unscramble the situation to get a clear view of whether the initial or ongoing behaviour is a psychosis, or whether it is autistic behaviour, which, if they were harming themselves or others, I quite agree would need intervention.

If I may, I would like to quote from a report by the Royal College of Psychiatrists. It is an excellent report that indicates why, when these people are inappropriately detained or brought within the ambit of mental health services inappropriately, it is not only an injustice in terms of human rights, but is detrimental to the way in which they recover from the incident that caused it. The Royal College of Psychiatrists report states that

“Autistic-spectrum disorders are not an illness but a disability that can have a major impact on the development, presentation and management of psychiatric disturbance.”

The following point is one that I would particularly like the Minister to understand, because it explains why those people are different from other groups:

“They fall into a limbo between the various psychiatric specialties, their ability putting them outside learning disability contracts but with developmental disabilities that, once they have outgrown child and adolescent services, may be unfamiliar to the various specialties dealing with adult mental health or else fall outside their remit. These issues are touched on in the Council report on services for individuals with mild or borderline learning disability (Royal College of Psychiatrists, 2003). This report emphasised that the defining criterion for acceptance by the services provided by learning disability psychiatry should continue to be a measured overall intelligence quotient of less than 70. At the same time it recognised that individuals with an autistic-spectrum disorder were a group who, at times, might be better served by learning disability services.”

The link with the way in which such people present is not unfamiliar to people who deal with learning disabilities, but at the same time you are dealing with people who do not necessarily have an IQ of under 70. In most cases, if you have an IQ under 70, you are regarded as being learning disabled.

I want to draw the Minister’s attention to the point that the prevalence of behaviour and the way in which it is managed is not that far distanced from learning disability, despite the variation in IQ and people’s potential, particularly those who are at the moreable end.

The Government have produced a White Paper, which I certainly welcome. It is called “Valuing People: A New Strategy for Learning Disability for the 21st Century”. When the Government first produced that paper, because of the benchmark of an IQ of 70 or under to indicate learning disabilities, they excluded people with Asperger’s from accessing services from the social services learning disability teams. As a result of a number of people—not only me, but a number of others—jumping up and down when we read this, the Department of Health then issued a circular.

I carry these documents around with me to this day. Every time I give a talk on autism, people come up to me afterwards and say, “Let me have a copy of that Government circular”. I have several copies of this, which I give out. The Government realised, to their credit, that to deny people with Asperger’s syndrome the right to access services through the learning disability team was doing those people a grave disservice. They put out guidelines that said:

“This guidance focuses mainly on action to implement the proposals for improving the lives of all adults with learning disabilities—those with severe and profound learning disabilities through to those with moderate or mild learning disabilities. Adults with Asperger's Syndrome or higher functioning autism”—

those with an IQ of over 70, of which there are a great number—

“are not precluded from using learning disability services, and may, where appropriate, require an assessment of their social functioning and social skills in order to establish their level of need.”

In other words, our knowledge of how people with Asperger’s syndrome function in practice, on a day-to-day basis, is something that we know far more about now than we did when the Mental Health Act 1983 was drafted. It is also something that the Government have picked up on, sometimes with a bit of prompting, as they start to legislate in other areas.

If the Bill is to last another 20 years, we should consider our knowledge of how autistic spectrum disorders are managed and how people with an ASD function in their day-to-day lives, particularly when they come into contact with services, especially mental health services. We should recognise that there is a correlation; it is not that people with an ASD are necessarily learning-disabled, but there is read-across in respect of how we treat people with a learning disability. The point is that they are different. They may have an IQ of more than 70, but they behave differently from how one would expect people with such an IQ to behave.

It is such behaviour that unfortunately all too often brings those people into contact with the mental health services and professionals who do not understand and cannot disaggregate what I would call normal autistic behaviour and a psychotic basis for their behaviour.

Ian Gibson (Norwich North, Labour)

The hon. Lady obviously has an intense interest in the subject and a deep knowledge of it. Having talked to people in the field, can she speculate about how research work is progressing? Such research might relate to genetic causes, for example, and might alleviate some problems. What is likely to happen in that field over the next 20 years is pertinent, as she said.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

I will send the hon. Gentleman details of an excellent Medical Research Council paper that deals extensively with the subject. Having been asked that question, I shall put on record my view of some of the various theories about the causal basis of autism, which I have declined to do before, primarily because—

Frank Cook (Stockton North, Labour)

Order. Anxious as I am to maintain the technical nature of this debate, it is important that we focus our minds on the points in sequence. We are discussing our ability to include autistic spectrum disorder in the clause. We will do ourselves a favour if we concentrate on that, rather than on research which might, or might not, take place in the future.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Thank you, Mr. Cook. I will speak to the hon. Member for Norwich, North privately on the subject as he has shown such an interest in it. You may have noticed, Mr. Cook, that I have an interest in it. I frequently feel that I must apologise for my fixation on it, and for talking about it ad nauseam.

Chris Bryant (Rhondda, Labour)

Is that a disorder?

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Yes, indeed. Many hon. Members know that I have a 35-year-old with Asperger’s syndrome and I sometimes say jokingly to other members of my family when they go on too much about the cricket, for example, “Just remember there is autism in the family.” I think it has a genetic base.

May I move on, Mr. Cook?

Frank Cook (Stockton North, Labour)

Please do.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

I want to make the case for the Bill to treat learning disability and ASD in the same light, despite the differentials in the two conditions, and to move on to the legal aspects of psychiatry in relation to people who have them. I shall draw from council report 136 of the Royal College of Psychiatrists entitled, “Psychiatric services for adolescents and adults with Asperger syndrome and other autistic-spectrum disorders”, which was published in April 2006, not 2005 as I said earlier. I very much welcome the report, which particularly informs this debate. In the section headed “Legal aspects of psychiatry”, the psychiatrists say:

“Most individuals with autistic-spectrum disorders are keen to avoid trouble with the law and most do not offend.”

That is absolutely right. There is no propensity for them to offend more than the rest of society. The report continues:

“This law-abiding respect for rules can be offset by a number of predispositional factors that make the individual more vulnerable.”

There is a vulnerability to such conditions that needs to be recognised as well. As I mentioned earlier, social naivety and misrepresentation of relationships can lead such people into problems with the criminal justice system. The report argues that

“misinterpreting rules, particularly social ones, whereby individuals can find themselves unwittingly embroiled in offences”

and behaviour in which they are led on by others has consequences for them with the criminal justice system. I would also argue that in certain circumstances their behaviour might well bring them to the attention of psychiatric services.

In particular, the report states that

“impulsivity, sometimes violent, that may be a component of a comorbid attention-deficit disorder, a state of anxiety turning into panic or a confusing blend of both. The result is a response that is out of proportion to the situation”—

I would argue that that was the situation in the detention of HL in the Bournewood case. For example, what in children could be regarded as a tantrum, could in an adolescent or adult be believed to be a threatening episode. That is why it is very difficult to explain what I mean by normal behaviour. Clearly, nobody wants anyone to be exposed to a threat, and neither do we want people to self-harm.

More often than not, however, such tantrum-like behaviour in adults with autism is event-influenced, rather than psychotically influenced, as I have said before. I shall give the Committee an example of how such behaviour might present itself. We know that people with autism often follow ritualistic routines. For example, some feel that they must eat at a certain time of day. I know of one young man who, every Sunday, takes two bus journeys to eat at the same restaurant. Most of us would get thoroughly bored with that routine, but for somebody with autism it is a security indicator—they know that next Sunday will be the same as this Sunday. If followed, that pattern provides comfort and security—next Sunday will be predictable.

Tim Loughton (Shadow Minister (Children), Health; East Worthing & Shoreham, Conservative)

Some MPs do that.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Indeed. We will see who eats everyday at 6 o’clock in the Members’ Dining Room.

That predictability might seem pretty benign, but if disrupted by external circumstances, such people do not just have a tantrum in the same way as a small child might if deprived of sweets. In the mind of somebody with autism, such disruption is a major event, and a third party might interpret their response as out of proportion. However, it is a really serious matter for the autistic person that totally undermines how they had reckoned that the day would turn out. As a consequence, for an adult, their response to something as minor as having their routine being disrupted in such a way would come across as totally unreasonable. It is particularly difficult for people with whom the autistic person does not have a confident relationship—there will be very few with whom they do—to rationalise and negotiate their way out of such a situation.

Ann Coffey (PPS (Rt Hon Alistair Darling, Secretary of State), Department of Trade and Industry; Stockport, Labour)

It is, of course, terrible that people are misdiagnosed, whether for physical illnesses or mental health problems, because there can be a stream of consequences for their treatment that put them at a disadvantage and make their condition much worse. However, I do not understand how the hon. Lady’s amendment would prevent psychiatrists who do not understand autism from diagnosing somebody, in a mental health assessment, as suffering from a mental disorder when in fact they suffer from autism. I just cannot see how the amendment would help. We cannot protect through an exclusion unless the mental health professional making the assessment understands that they are dealing with somebody with autism.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

The hon. Lady is right, and that is not actually the basis of what I am saying. What she has just expounded is exactly what happens in some cases. Having been critical of psychiatric services, I must say that I am convinced that the royal college is getting to grips with the problem through training and so on.

The behaviour of people with ASD may well have a qualifying basis. If we are to make an exception for somebody with a learning disability—an IQ of less than 70—unless, as the Bill states, it is

“associated with abnormally aggressive or seriously irresponsible conduct on his part”,

the same should apply to autism because of the way in which it presents itself. It is very different from any other condition, except that one can measure it as a learning disability. There can therefore be quite a read-across, as interventions for those with learning disabilities can apply equally, if resources are available, to those with ASD.

The royal college’s report mentions the services for individuals with a learning disability, and again one can see the comparator used between how we treat people with learning disabilities and those with autism. It states:

“Increasingly, services for individuals with a learning disability have become familiar with autistic-spectrum disorders, and where there is a significant intellectual disability, they are ready to engage with these individuals. When disturbed, their management is often a matter of improving communication, their environment and their level of support rather than of more traditional individual psychiatric treatment.”

In other words, as we learn more about the management of people with ASD we can see some of the lessons that we have learned from the management of people with learning disabilities. We do not just lock them up when they are “having an episode” unless, as the Bill states and I support, they demonstrate

“abnormally aggressive or seriously irresponsible conduct”.

So there is quite a read-across in the management of people. It is not about locking up people who might suddenly in one way present as potentially having a mental disorder, because they might not have a mental disorder any more than does someone with a learning disability who is behaving in the same way. The test for psychiatrists is to disaggregate the two set of behaviour, which is why the matter is difficult and there is a need for specialisms. In some of our hospitals in London and other large cities there are psychiatrists who specialise in autism or in learning disabilities, so they can disaggregate types of behaviour and understand clearly what the appropriate treatment is.

The royal college report continues:

“These issues, while familiar to learning disability psychiatry, also apply to individuals of normal cognitive ability, although their ability may well bar their acceptance by an element of the learning disability service”.

We have discussed that in relation to the Government’s health White Paper. The report also states:

“There is therefore the risk that such vulnerable patients fall between contracts despite their statutory entitlement to psychiatric services”.

The situation, particularly for adults and adolescents who present behaviour that is treated by psychiatric services, is only as good as the knowledge of the people treating them. In managing behavioural episodes, it is clear that although we make allowances for people with learning disabilities, we do not for people with autism because they do not present in the same way or because they have a higher IQ.

Psychiatrists understand that somebody might have great ability in one area of their life but behave in a certain way because they are autistic, not because they have a psychiatric condition. That is why we should recognise in the Bill the fact that that group of people is different. I cannot think of another group who would present in such a way in certain circumstances andyet not have a psychotic base. Very often such people present themselves as intelligent, and despite what people say about autism, they can be quite articulate—sometimes inappropriately so. They are different from other sets of people and we should recognise that.

The Bill is making provisions for the future. It has to look forward and not simply deal with our assessment of how things are now. We already recognise in other parts of government that we have a better understanding of autism than we had 20 years ago, and that should be reflected in the Bill. The fact that it was not recognised in the 1983 Act is no argument. We know from the casework around the country that more and more people will fall within this grouping who need the attention of services. When it is psychiatric services that they require, they need more equality, not less.

More and more cases of people with autism who have been denied access to appropriate services or treatment are coming before tribunals and the courts. The HL case is a classic case in point. People are starting to ask themselves, very often with legal backing, “Is this right in terms of civil liberties? Is this right in terms of what we understand these people need and the sort of attention they should be receiving?” More often than not, particularly when I look at my social services casework, once one has cut to the chase and challenged the social services on behalf of someone with autism, they settle out of court.

The Government would do well to recognise that our knowledge and awareness of autism and what is and is not an appropriate treatment or package of support are increasingly such that when we challenge social services, the courts tend to rule in our favour. The Government should take that on board, because to deny it at the stage at which legislation is being introduced is not merely negligent, but a concession that they know this but are not going to do anything about it. That is indefensible behaviour towards a vulnerable group of people. All the statistics show that  as a group they are not an increased risk to other people, but people who themselves need support and appropriate services.

The Royal College of Psychiatrists points out in its report the need to address inappropriate detention under the mental illness category, detention of this group in inappropriate settings and detention for longer than is absolutely necessary. This group of people is already discriminated against. If that is what psychiatrists identify as the problem, specifically with regard to the interaction of such people with mental health services now, surely the Bill should aim to improve their lot in future. We cannot do anything about the past, but we can do something about the future. The information is there; it is on the record.

That is why I am asking the Minister—colleagues will be pleased to hear that I am concluding my remarks—to think again about whether those with an ASD are different. I believe that they are, and I hope that the examples that I have given show how and why they are and, in particular, why the Bill, rather than the code of practice, should associate the appropriate treatment of their needs by mental health services with the conditions identified for people with learning disabilities.

The hon. Member for Stockport identified the need for better and more specialist services and for better recognition, which is an issue that I discuss all the time. Although we can do nothing about such issues in the Bill, we can ensure that it recognises people with ASD, and I stress that they are people—people who, as a result of whatever fate has befallen them, will live with this condition for the rest of their lives. However, although they are born with it and will die with it, we can make a difference to what happens in between. We need to do more to improve their quality of life and the way in which they are treated between the time they are born and the time they die. At the moment, we are nowhere near getting that right.

Frank Cook (Stockton North, Labour)

In presenting her amendment so comprehensively and clearly and with such passion, the hon. Lady obviously had to compare the particular condition of ASD with many others, and she therefore expounded on more general matters in the clause. For that reason, I am happy for the Committee to expand discussion of the amendment into a clause stand part debate. We shall pick the bones out of the Divisions later.

John Pugh (Shadow Minister, Health; Southport, Liberal Democrat)

I support the amendment and pay tribute to the hon. Member for Tiverton and Honiton for all the work that she has done on autism. I noted her example of the man digging the garden in the dark, and there is nothing essentially pathological about that. The last time I did it, I was burying the cat, although I should say that it was dead, and I needed to explain myself to the milkman as he came past.

We are learning that psychiatry is not an exact science, particularly when it comes to the classification of ailments. I think that we all accept that autism covers an extraordinarily wide spectrum, but is genuinely a learning disability. However, it is also linked—this is a key point—with social disabilities,and sometimes with disturbed but non-psychotic behaviour. There is therefore a real danger that it will  not be treated correctly under the legislation, and there is a real case for giving it a proper and appropriate mention. Autism, like many learning disabilities, is essentially hardwired into the soul; it is an impairment, not an illness. If any form of coercion is required, the Mental Capacity Act 2005 is available, although Lord Rix in the House of Lords thought that even that did not give sufficient protection in every circumstance.

The hon. Lady said dual diagnosis was a special problem, but that argument was less convincing. Dual diagnosis crops up all the time, creating clinical and legal challenges, but those challenges are the same, whether we are talking about autism or dementia. None the less, given the link between ASD and often quite disturbed social behaviour, there is a case for including it expressly in the Bill, and I support the amendment.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

I should like to start by paying a warm tribute to the hon. Member for Tiverton and Honiton, who has put in a lot of work over the years to advance the cause of people on the autistic spectrum. As she mentioned on Second Reading, she is vice-president of the National Autistic Society, and the founder member of the all-party parliamentary group on autism. I was on the edge of my seat waiting for the thoughts that had not been put on record before, but that will have to remain between her and my hon. Friend the Member for Norwich, North. I look forward to finding out what they actually were.

I think that it would be helpful, particularly as the hon. Lady set out so clearly the reasons why she has moved the amendment, for me to refer back to why there is the exclusion or exception for learning disability, and why clause 2 exists in the first place. As hon. and right hon. Members know, there has been a lot of debate about learning disability itself and whether it should be excluded. Let me go back to what we have now achieved in terms of the Bill. It will mean that people with learning disabilities can be detained for medical treatment or made subject to guardianship on the basis of their learning disabilities alone only if those disabilities are accompanied by

“abnormally aggressive or seriously irresponsible conduct”

on their part. Similarly, it will ensure that people with learning disabilities cannot be made subject to the new provisions for supervised community treatment solely on account of their learning disabilities, unless, again, they are associated with

“abnormally aggressive or seriously irresponsible conduct”

on their part.

As I said, that provision was not in the 2004 draft Bill. In that Bill, which was submitted for pre-legislative scrutiny, there was no special provision in relation to learning disability. We started from a principle—in many senses it is still valid—that exclusions of any kind were likely to create an arbitrary obstacle to the proper and effective use of the legislation to protect people from the effects of the mental disorder. However, we also know that many people with learning disabilities, and those who work and care for them, were concerned that that would put people with learning disabilities at a greater risk of being detained inappropriately. We do not believe that that is the case, but it is true that historically this has  been a very emotive issue, going back to the 1983 Act. There was great concern that people with learning disabilities could be inappropriately detained, sometimes because of the effect of their behaviour, which might be seen as not the norm.

We listened to what the pre-legislative scrutiny Committee said with regard to learning disabilities. When we decided to amend, rather than replace, the Mental Health Act, we took the opportunity to say that we would preserve the way in which the Act currently works with regard to learning disability. That is why we have preserved that provision in clause 2.

That means that before professionals even begin to think about whether a person whose only mental disorder is a learning disability meets the criteria for detention under section 3 and similar sections, they must first be sure that the disability is associated with

“abnormally aggressive or seriously irresponsible conduct.”

The reference to aggressive or irresponsible conduct does not suggest that either is a normal feature of learning disability—quite the reverse, as I am sure all hon. Members would agree. It is to distinguish the small minority from the rest. The vast majority of people with learning disabilities do not display

“abnormally aggressive or seriously irresponsible conduct”

any more than vast majority of the rest of the population.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Does the Minister agree that, unless it is event-triggered, nor do people with autistic spectrum disorders?

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

That can certainly be the case, and I shall come to some examples, including that one. I hope that I have helped to illustrate my point. Obviously,

“abnormally aggressive or seriously irresponsible behaviour”

is not a clinical concept, but it is something that we understand.

It is also true—again, this goes back to the history of the previous Mental Health Act—that some people believe strongly that learning disability should not be labelled a mental disorder, both on principle and for fear of exacerbating confusion between learning disability and mental illness. Again, that is often raised.

We are clear that the Bill is not about labelling people but about treating people when necessary. I hope that the hon. Lady accepts that if people with learning difficulties were excluded entirely from the definition, that would risk the very small minorityof those people who need compulsion not getting treatment when they need it; or it would meanthat clinicians would end up sometimes applying inappropriate diagnostic labels to ensure that people who need treatment receive it. Again, if we did that, when a learning disabled person committed a serious offence, the courts might have no alternative but to pass a prison sentence. That is why learning disability remains a mental disorder for the purpose of the Bill generally.

There were many detailed and sometimes emotive and sensitive discussions about learning disability. There was no exclusion in the 2004 draft Bill, but we listened to representations, and a key issue that will apply to many of our discussions in Committee is that  we have tried in many instances to retain what is in the 1983 Act. In the case of learning disability, that means that we are maintaining the status quo. We listened to many of the people who said that they would be uneasy about removing it in case it sent the wrong message.We do not believe that it would have done, but wehave listened and we understand the point. We are maintaining the status quo with regard to learning disabilities.

The hon. Lady’s amendment would add to that the condition of autistic spectrum disorder. We are not in favour of it for the reasons that I shall set out. I assure her that I have looked carefully at the amendment because of the many points she has made not onlyin Committee, but elsewhere, about some of the difficulties in diagnosis and the need to ensure that we improve the care available to people with autistic spectrum disorder. She is absolutely right to say that there have been improvements, but that there is still some way to go. One of the key issues that she put her finger on was diagnosis.

We have maintained the general stance that the fewer exclusions in the Bill, the better, because the risk of exclusions is always that someone who perhaps needs treatment will not get it. We want to hold to that general principle because each time an exclusion is added, someone will be at risk of not receiving treatment. The hon. Lady rightly said that others could well make the same case. I am thinking particularly of people with hyper-activity or obsessive compulsive disorders. The same could be said about people with such conditions, so it is difficult for us to pick out a particular group of people and say that we will add their condition to the Bill because others would be well justified to say, “Why not this as well?” I have even heard it said that some people with depression might ask whether their condition should be excluded.

That is the first reason why we do not want to accept the amendment. The hon. Lady was right to refer to some of the discussions that took place when the 1983 Act was drafted. People generally did not understand the full extent of autistic spectrum disorder, particularly Asperger’s syndrome, and some of the other higher functioning forms of autism. I am sure that we all agree that there is now a far wider and better understanding of autistic spectrum disorder than there was in 1983. The hon. Lady is probably aware of a paper byDr. Lorna Wing. It was published in 1981, so by 1983 it had not really received the widespread respect that it enjoys today. It is also true that all forms of autism are now widely recognised as disorders of the mind.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

I wonder whether the Minister would rephrase that description as being a disorder of the brain rather than the mind? There is a difference.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

I am more than happy to write to the hon. Lady about it, but I am strongly advised that the condition is a disorder of the mind.

The hon. Lady rightly referred to the fact that it is only possible to detain people when strict conditions are met. The application for assessment is used when an individual is suffering from a mental disorder of a nature or degree that warrants his detention in hospital  for assessment, or for assessment followed by medical treatment for at least a limited period. Under the Government’s proposals there is an additional stipulation that the patient must be one who ought to be detained in the interests of his own health or safety or with a view to the protection of others.

That is the position on assessment. Under section 3, which is concerned with detention, an application for treatment may be made on the basis that a patient is suffering from mental disorder of a nature or degree that makes it appropriate for him to receive medical treatment in a hospital, or that it is necessary for the health and safety of the patient or for the protection of others that he should receive such treatment. There is a further condition that detention under the section is required for the provision of such treatment and that appropriate medical treatment is available.

The changes that the Government are proposing under section 3 in relation to appropriate medical treatment, and the link between that treatment and individual circumstances, will enhance the care that is available, and in that way will help with some of the points that the hon. Lady made about inappropriate treatment. I hope that that gives some reassurance with regard to the very valid points that she made about ensuring that people are diagnosed early and that they receive appropriate treatment.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Obviously, I accept that thereare people with an ASD for whom detention may sometimes be the appropriate route. Detention is traumatic for anybody, however, particularly for those with an ASD, because it involves a change in routine, environment and so on. I hope that the Minister will consider what the royal college has said about alternatives to detention for such people, because detention often compounds the problem.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

I shall give way to the hon. Member for Southport before responding.

John Pugh (Shadow Minister, Health; Southport, Liberal Democrat)

I understood the hon. Member for Tiverton and Honiton to be suggesting that there was a danger that autism could be undifferentiated from various forms of mental illness. She sought to highlight autism and put, it in a sense, alongside learning disability. Is the Minister now proposing that autism is both a learning disability and a mental disorder, because that seems to be the case? If so, how does the clause deal with it?

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

Autism is recognised as a mental disorder, as is learning disability. However, even at the time of the 1983 Act it was felt important that, although learning disability is a disorder, the message should not be given that everyone with a learning disability might be detained. There was strong discussion at the time between Lord Rix and David Ennals.

Ian Gibson (Norwich North, Labour)

One of the previous MPs for Norwich, North.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

Indeed. The wording that was arrived at to reflect those discussions was, I believe, dictated down the phone by Lord Rix to David Ennals. Those were the good old days. We have decided, for the  reasons that have been raised again, that in a sense it is important to keep what was in the Act at thetime, because that is reassuring for people in those circumstances.

John Pugh (Shadow Minister, Health; Southport, Liberal Democrat)

For absolute clarity, what is being said is that although there are some learning disabilities that may or may not be mental disorders, autism is a learning disability that, in whatever form it takes or however severe it is—[Interruption.] It is a mental disorder.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

As I understand it—I am sure that the hon. Member for Tiverton and Honiton will help me out—learning disability is a mental disorder. Autism is a mental disorder, but autism arrives because of behavioural development.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

It is a developmental disorder with a triad of impairment; all three boxes have to be ticked for there to be an autistic diagnosis. The Minister might be interested to know that the National Autistic Society was formed because a group of parentswho previously were members of Mencap—a very worthwhile charity, which I have a lot of dealings with—felt that although they had been previously been grouped with Mencap on the basis of a learning disability, their group of children were rather distinct, because of that triad of impairment. Therefore, the NAS was born, but there is quite a read-across still.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

I certainly understand that. It is important to examine the rationale behind the clause in the first place in order to be able to address the issues raised by the hon. Lady. It is important to understand that this is a very particular exclusion. People might say that under the application of the Act, if properly used, there would not be this exclusion, but we have reacted to the strong feelings that exist on the issue. The reason why we are concerned about adding further to the list of disqualifications is that unfortunate circumstances would arise if we included people with autistic spectrum disorders within the learning disability qualification. There would be unfortunate consequences where, for example, a person with Asperger’s syndrome committed a serious offence.

This morning, I received information on some cases from Dr. Nick Land, who is a consultant psychiatrist, with expertise in learning disability and Asperger’s syndrome. If it would be helpful and if it met with your approval, Mr. Cook, I would be more than happy to circulate that to members of the Committee, having first obtained Dr. Land’s permission, and to try to submit it as written evidence. In considering closely the points that the hon. Lady has made, I wanted to consult experts in the field and ask, “What are the possibilities? What might happen if we went along the line of the hon. Lady’s amendment?”

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Will the Minister clarify something for me? If she does not put autistic spectrum disorder alongside learning disability in clause 2, how will people with a dual diagnosis be dealt with? It is, of course, quite possible that someone has an autistic  spectrum disorder and a learning disability diagnosis. Which will take precedence under the Bill? The learning disability? Will the person have protection, as someone recognised as having a learning disability, in terms of

“abnormally aggressive or seriously irresponsible”

behaviour, or will that be waived?

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

In those circumstances, I would expect a clinician to be able to consider the learning disability and whether the person was, because of the learning disability, displaying abnormally aggressive behaviour, as we have set out in the Bill, or whether the autistic spectrum was the reason for the disorder. That, again, connects to all the other aspects of the detention, which would be taken into account. Obviously, if someone needed treatment and fulfilled all the conditions—if that person had a learning disorder and was, in a sense, a risk to themselves or others and if appropriate treatment was available under section 3—that is what one would want them to have. It is important that the clinician should be able to make use of the Act to get care to people who need it.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

Would there ever be circumstances in which, if the person with a dual diagnosis was not demonstrating abnormally aggressive or seriously irresponsible conduct, the learning disability diagnosis could let them off the hook, so to speak?

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

I hope that there will be no letting off hooks if treatment is required.

Perhaps I may discuss a case that I wanted to bring to the attention of the hon. Lady. It is important to recognise that there would be real problems in accepting her amendment in such a case. Mr. H. is a 25-year-old man with Asperger’s syndrome, who lives in a small hostel and attends a sheltered workshop. He has a supportive family and a good relationship with mental health services. A community psychiatric nurse visits him regularly. He is quite withdrawn socially and becomes very anxious around people he does not know. He is fascinated by fire and on three previous occasions has started small fires in public places. This time hehas started a fire in his hostel and although no one has been hurt there has been serious damage to the building and he has been convicted of arson.

His psychiatrist advises the court that Mr. H would be highly vulnerable in prison. In his opinion, Mr. H is not suffering from any other mental illness or personality disorder and his IQ is at the low end of the normal range. He believes that he should be admitted to a mental health unit under the Mental Health Act 1983 where he could be helped to understand the effects of his fire setting. The court questions whethera mental health disposal is legal if his diagnosis is Asperger’s syndrome. What does the psychiatrist do in those circumstances? The point is that if autistic spectrum disorders—autism and Asperger’s syndrome— were excluded from the definition of mental disorder, Mr. H would have to go to prison.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

But surely his conduct is seriously irresponsible. It has to be. If he is a fire setter, that  is seriously irresponsible conduct. Society would be protected and he would be appropriately treated.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

No, because at the moment his only diagnosis is Asperger’s syndrome, which has been excluded from the Act. He has started small fires, but he is not at present covered under the Act as the hon. Lady suggests.

Tim Loughton (Shadow Minister (Children), Health; East Worthing & Shoreham, Conservative)

He would be.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

He would not in those circumstances be able to have a Mental Health Act disposal. The point is that, in such circumstances, if one makes the exclusion one also creates uncertainty for the clinician. In those circumstances, the clinician has to ask whether there was a disposal that we could make from the court. The court is confused because it sees that if it comes under Asperger’s syndrome, the problem would have been excluded from the Act. Therefore, the court is left with saying that if we want to treat the person in a mental health unit, we would have difficulties doing so. The difficulty in those circumstances is that the person then has not to be treated but to go to prison—because they have committed an offence—instead of being transferred.

Such problems have also been raised about learning disability, because many people said that had to be absolutely clear, which is why there were a lot of discussions in the first place, as the hon. Lady knows. If learning disability continued to be excluded, then there would be a problem if someone committed a crime as to whether they could effectively be treated underthe Mental Health Act 1983—whether they would continue to be treated or be kept in a prison setting. That is one of the reasons why we do not want the overlap between the prison setting and the mental health setting.

Angela Browning (Deputy Chairman (Organising and Campaigning), Conservative Party; Tiverton & Honiton, Conservative)

The Minister is talking about the inadequacies of the 1983 Act. If she were to accept my amendment, there would be absolute clarity about ASD, and the Bill would be very clear about how the person in the case she has just described—which Iam quite sure, incontestably, would be seriously irresponsible conduct—should be treated. That would be the reverse of what she has been saying all morning. She could clarify the Act, which would be helpful to the individual, to society and, particularly, to clinicians. That is missing from the 1983 Act. We are now informed about ASD, and she has the opportunity to pick up on that and put it in the Bill.

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

The issue at stake here is whether the court can truly say that the person has abnormally aggressive or seriously aggressive conduct.

James Duddridge (Rochford & Southend East, Conservative)

If that action of fire-setting was not seriously irresponsible conduct, what would be an example of seriously irresponsible conduct?

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

That is exactly the point at stake. We could get into a grey area. We would be trying to ask the courts to define what is abnormally aggressive. There may be instances, as in this case, where  somebody says that they have a fascination with fire—that is their issue—and so there is no guarantee with that individual. The point is that the court then has to look at the case, which might stand in the way of somebody receiving treatment.

Sandra Gidley (Shadow Minister, Health; Romsey, Liberal Democrat)

I am finding the Minister’s logic convoluted. She is now arguing against the exemption for learning disabilities. Surely the  same argument would apply in that case? What isthe problem in extending the definition to autistic spectrum disorder as well?

Rosie Winterton (Minister of State (Health Services), Department of Health; Doncaster Central, Labour)

As I said, we considered removing the exemption.