Frank Cook (Stockton North, Labour)

With this it will be convenient to discuss the following:

No. 60, in clause 11, page 7, line 10, at end insert—

‘(11) After that subsection, insert—

“( ) No person can act as a responsible clinician unless he is capable of providing objective medical expertise of mental disorder.

( ) Objective medical expertise of mental disorder shall have the same meaning as in Winterwerp v The Netherlands (1979-80) 2 EHRR 387.”’.

No. 61, in clause 13, page 8, line 45, at end insert—

‘( ) After that subsection, insert—

“( ) No person can act as a responsible clinician unless he is capable of providing objective medical expertise of mental disorder.

( ) Objective medical expertise of mental disorder shall have the same meaning as in Winterwerp v The Netherlands (1979-80) 2 EHRR 387.”’.

Government amendments Nos. 22, 24, 25 and 28.

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

The Government oppose clause 6 standing part of the Bill. Our policy is to introduce “responsible clinicians”, to bring the legislation in line with current practice. We want to remove the rigid demarcation of professional roles in favour of an approach that ensures that clinicians with the right skills, expertise and training can use them. If we can achieve that, frankly, we can reflect modern NHS practices, which have moved more toward a competency-based approach to roles and responsibilities.

It is important to look at how the work force has changed since 1983. Things were different in 1983 to today. In 1983, the emphasis was on in-patient care and medication in large mental hospitals. There was a greater focus on the medical model of treatment, which meant that doctors made most of the decisions. Since then, there has been a widely welcomed shift to psycho-social interventions and more treatment in the community. Hon. Members on both sides of the Committee have so far celebrated the fact that those kinds of changes have taken place, and they have recognised in their contributions the fact that patients have a wide range of needs that require the specialist skills of the range of professionals on the multi-disciplinary teams. As a result of the multi-disciplinary approach, the professions, whether psychologists, nurses, occupational therapists or social workers, have developed interventions. Those professionals are taking on more functions and adopting leadership roles. As I said, up until now, all hon. Members have celebrated that.

Ian Gibson (Norwich North, Labour)

Will the Minister comment on whether the skills and professionalism and other aspects of the jobs she described are part of the training of medical doctors?

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

It is right to say that we have increased the ability of professionals to take on more responsibility, and that that has led to an increase in the training. An example of that is the fact that we now have nurse prescribing, something that was almost unthought of when I was working for the Royal College of Nursing. Over time, we have come to know that nurses and others can take on roles that they would not have taken on before. The example of nurse prescribing is a good one.

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

It is completely understandable why we should have someone with medical training to oversee a course of treatment for someone with schizophrenia, for example, which involves difficult medication, with possible side effects. However, it is not easy to understand why we would need someone with physical training to oversee a course of treatment that involves intensive counselling given by someone who has trained as a clinical psychologist.

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

My hon. Friend is absolutely right. That is the position that we have been trying to get to via the changes that we have made by generally developing roles among professionals. I am thinking particularly of nurse consultants, whose role did not exist in 1983. Today, a nurse consultant could be responsible for a 14-bed in-patient rehabilitation unit, teaching, providing clinical leadership and conducting research. Nurses, occupational therapists and psychologists can manage multidisciplinary teams or in-patient wards, or they can provide clinical care for a patient. Social workers can often be care co-ordinators.

When we are talking about the Government’s proposal regarding responsible clinicians, I want to be absolutely clear that only highly qualified and experienced mental health professionals will be able to become approved to  become responsible clinicians. It is worth reminding ourselves of the type of people whom we are talking about. A disturbing attitude seems to have evolved both in the other place and among Opposition Members about the proposed changes—I presume that Opposition Members will be supporting them today—around the view that we somehow have to revert to a situation in which doctors take all the decisions. After all the work that has been put in, in conjunction not only with the Royal College of Psychiatrists, but with the other royal colleges and professionals working in the field, there is an attitude that they cannot be trusted to make such decisions. There is a real problem about turning the clock back. We are trying to achieve new ways of working, which we have spent many years developing, but the amendments inserted in the House of Lords with the support of the Opposition turn the clock back to a unacceptable state of affairs for those professionals, who, frankly, feel that they have been slapped in the face.

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

The Minister seems to be pre-empting what the Opposition are going to say. May I ask her where clause 6, as amended in the House of Lords, implies that all the decisions should be taken only by doctors?

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

Let me be absolutely clear. It is important to remember that clause 11, which the Opposition want to delete, takes away completely the role of the responsible clinician. Let me give an example. Subsection (2)(b) of clause 6—

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

There is no subsection (2)(b).

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

I am sorry, I mean proposed paragraph (aa)(ii) to section 20(3) of the 1983 Act:

“if no such practitioner is available, a registered medical practitioner who is an approved clinician”.

Within a multidisciplinary team that is established to look after a patient, as they are nowadays, the responsible clinician is the psychiatrist, because the patient in those circumstances needs the kind of intervention that my hon. Friend the Member for Stockport has talked about. The effect of proposed paragraph (aa)(ii) is that if the psychiatrist is not there, the responsible clinician in those circumstances would have to go to somebody who was a doctor—the hon. Member for Southport is a doctor—who may have no knowledge whatever of the individual patient, because they have to consult another approved, registered medical practitioner. That means that if the person on the team who has been working with the individual cannot go to the registered medical practitioner within the team, they will have to go somewhere else. That means that somebody who has not been involved with the care of the patient at all would have to be involved and approving. It is the stamp of approval that Opposition Members are endorsing that we find objectionable, because with the high standard of approved mental health practitioners that we have talked about, we do not see why it is necessary to consult another doctor in order for detention to be renewed.

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

Clause 6 quite clearly says

“to arrange for the patient to be examined by—

(i) the registered medical practitioner who has been professionally concerned”.

That is the preferred option, and only if that person is not available must the person involved go to somebody else who is a medical practitioner. However, the Minister has not addressed the question that I asked just now. She stated that all the decisions about the care of the patient would be made only by doctors, but that applies only to decisions about detention and renewal of detention.

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

Does the hon. Gentleman accept, however, that his proposed deletion of clause 11 would take away the role of approved clinicians and responsible clinicians in the first place?

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

I do not deny that. In the circumstances surrounding the renewal of detention, the matter would rely on a medical person, which is the point that we are making. Again, the Minister has not answered my question. Why does she think it acceptable, therefore, that the decision about the original detention should be taken only by a medical person, but six months down the line, when we are looking at a possible renewal of detention at a time when it might be rather more difficult to form a judgment on somebody’s condition—they might not be in the agitated crisis state that they were in at the time of the original detention—it can be taken by someone else? Why is it appropriate for a medical person to make the decision at the beginning of the process, but not at the time of the renewal? That is the inconsistency that the Minister must address.

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

Not at all, because the medical practitioner is more likely to be trained in making the original diagnosis. They will have a broader training in that area. Let us examine what we are asking the original medical practitioners to do. We are asking them to decide whether somebody has a mental disorder. It may then fall to a psychologist to talk about the treatment of that person. If that treatment includes providing community treatment, it may fall to a community psychiatric nurse, who is looking after the individual. That point—we are talking about the renewal of detention—is where we are saying that it is the psychologist, for example, or the community psychiatric nurse, who will have been in contact with the patient during that time and will surely be able to make a decision as to whether detention should be renewed.

That is the difference, because we are talking about whether the treatment continues to be suitable andnot about the original diagnosis, which is about establishing whether somebody has a mental disorder. Opposition Members are saying that when that treatment is under way with the psychologist providing it, the psychologist must go back to a psychiatrist, but under proposed paragraph (aa)(ii), if the psychiatrist is not on hand in the multidisciplinary team, that person must go somewhere else. The relevant words are

“arrange for the patient to be examined by”.

An entirely new psychiatrist or doctor would have to be brought in to examine a patient whom they may have had nothing to do with. The Government believe that it is important to trust the judgment of professionals. Let me say again how highly qualified they are. To take away from them responsibilities that we have tried to develop is, as I said, a slap in the face. For example, the community psychiatric nurse whom Unison brought to see me said—

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

Very good.

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

I know that the hon. Gentleman will not support an organisation such as Unison. However, I should point out that the people who are opposed to such matters include psychologist organisations and many health care professionals, who say that they represent 85 per cent. of the people who work in mental health services. The Opposition are saying that they want to revert to a doctor decision. I draw the attention of the hon. Member for East Worthing and Shoreham to the fact that the Bill says

“to arrange for the patient to be examined by,”

and that is the difficulty for the individual.

Mr. Boswell rose—

Tim Loughton rose—

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

I shall give way to the hon. Member for Daventry, because I think that he may be a little more supportive of the Government on this issue. I will be surprised if he is not.

Tim Boswell (Daventry, Conservative)

I would advise the Minister not to jump to conclusions. I hope that I come to the matter with a fresh and objective mind. She needs to remind herself and acknowledge to the Committee that the provision is about the compulsory detention of individuals and not their treatment. However desirable and necessary it is to incorporate a range of professionals, it seems very odd to set one criterion—examination by a registered medical practitioner—for the initial detention and then to set different criteria for any subsequent detention. The Minister needs to explain that to the Committee.

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

I shall have one more go at explaining the issue. The hon. Gentleman does not realise that the clause is about the renewal of detention. The important point is that the professional clinician who has been working with the individual and who knows them best will decide whether the treatment is still working and take that responsibility without having to revert to a doctor who may have had nothing to do with the individual.

Madeleine Moon (Bridgend, Labour)

Does the Minister agree that it would seem confusing to say that it is appropriate to have another professional, such as an approved social worker, involved in the initial detention, while saying that when it comes to deciding whether detention remains appropriate, other professions do not have the same validity as a medical practitioner, who may have no knowledge of the individual? Other professions already play a key part.

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

That is absolutely right.

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

The Minister said two contradictory things. First, she said that the issue was about treatment, which my hon. Friend the Member for Daventry pointed out was not the case. Then she said it was about the renewal of detention, which it is. Will she stop trying to impose a hierarchy on the matter? As I have said, the person who comes first and who would normally be expected to make the decision is the registered medical practitioner. It is only if that person is not there that another medical practitioner, who has not been closely involved, can be called in. That practitioner can take advice from a whole range of other professionals. Will the Minister acknowledge that after six months of compulsory treatment, other medical conditions can arise—perhaps resulting from some of the drugs—which makes a medical practitioner the best person to decide whether detention should be renewed and in what form?

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

There may not be medical interventions if somebody is not on medication. We have made it very clear that the appropriate person is the one who is responsible for the treatment course that somebody is undertaking. That is what distinguishes what happens in the initial phase, which is detention, sometimes for treatment but very often for assessment. The decision that has to be made by the first two doctors is the broad diagnosis. It is then up to individuals who are most experienced in that person’s care to be able to say, “This is the experience over the past six months. We believe that the appropriate treatment is still available because I am administering that treatment. Therefore the treatment is right.” The psychologist is able to say, “We have made good progress.” We need to recognise how teams work nowadays, because there is a multidisciplinary rather than a one-person approach.

The hon. Member for East Worthing and Shoreham mentioned clinical interventions. In reality, the approach taken is to have multidisciplinary discussions about the individual. Like everyone present, I would expect that any physical side-effects, such as those from medication, say, would be dealt with during those discussions. That does not mean that somebody who is under detention and who is being looked after by a psychologist is never considered by any other team member—that is not how practice operates, nor should it. The person to have responsibility should be the person who is the most appropriate person for the individual’s needs; that is how psychological therapies and increased incidence of prescribing by nurses have been developed.

Opposition Members have talked a lot about how to develop a greater number of psychological therapies and about getting more psychologists involved. I am sure that they want to that to happen, but if that is their honest intention, why on earth are they supporting an idea that would take away the work that we have done? Interestingly, it is called “New Ways of Working”, and we have involved the professions init, including the Royal College of Psychiatrists, occupational health services and the Royal College of Nursing. Why get to that point and then snatch everything away? It is astonishing.

Tim Boswell (Daventry, Conservative)

I assure the Minister that I am not seeking to subvert the new ways of team working, because clearly they are sensible. However, let us consider the case of a patient who has been a voluntary patient for a number of months and who has worked with a number of professionals—not necessarily a clinician or a registered medical practitioner. It might have become apparent to the other professionals or clinicians that that person needs detention. What is the logic of the Minister’s position that that detention following a period of voluntary treatment must be approved by a registered medical practitioner in the first instance, when on her own analysis there might well be other people in the team who are more familiar with the individual concerned and therefore in a better position to give approval?

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

In a sense, the hon. Gentleman helps me make my point. I shall come in a second to the situation that he described.

We want to preserve the situation on initial diagnosis as it stands, and we believe that our proposals provide a clear framework for what should happen when someone is detained for the first time. There might be instances in which someone has had no contact with mental health services, and we believe that the broader diagnostic skills of a medical practitioner should be brought into play in such cases. We want to preserve that procedure in situations of voluntary treatment so that there is consistency at the initial point of diagnosis.

In the hon. Gentleman’s scenario, if a person had been having psychological treatment and his condition had deteriorated to the extent that detention was important, it would also be important to ensure that the diagnosis was right. However, if it emerged thatthe person giving the psychological treatment was the person who was going to be in most contact with the patient, and that that person knew the patient’s needs and had reached the high standard that we have set for being an approved professional in such circumstances, it would be right for him to continue in that role and to undertake renewal of detention if that were considered the most appropriate course.

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

In her opening remarks, the Minister made a strong case for interdisciplinary working, and she mentioned consultant nurses. Is she now, despite having lauded their skills earlier, saying that they do not have sufficient expertise to make the initial decision on detention?

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

I am saying that it is fair to ask whether that person can make that detention. We considered the issue of voluntary patients in the way that has been described. We also considered whether we could allow the approved clinician to agree the initial detention for voluntary patients. The problem was that that could lead to difficulties in legislation, because there would be exceptions. Therefore, we felt that it was better to keep the status quo in terms of diagnosis, but beyond that to give greater powers and responsibilities to the approved clinicians.

If the hon. Lady is going to support us, she might wish to say that we have not gone far enough. We would be open to that point. However, it is a bit of a  reassurance to say that we will agree to keep the same system in respect of the initial detention of people who have not previously been voluntary patients. Beyond that, as legislators, what we can do is to ensure that the legislation enables us to put into practice all that the Committee is hoping for, including giving staff more responsibility and the development of psychological therapies. We are trying to put that into legislation so that the people who have spent years developing new ways of working can have their just rewards. Itis beyond me why the Opposition want to take that away.

Tim Boswell (Daventry, Conservative)

Very briefly, and simply for the sake of elucidation, will the Minister say whether she agrees that whoever takes the decision to commence compulsory detention or to continue it, the criteria for mental disorder will be the same and the diagnosis will be made on exactly the same basis?

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

Of course. All the conditions that have to be met remain the same. The responsible clinician, if not a registered medical practitioner, will not work to a lower set of criteria as to whether to detain people. That would be unthinkable.

I want to move on, because I hope that I have made my point. However, I want to give one further reassurance to the Committee. Let us consider carefully what we are talking about. Nurse consultants typically have a masters qualification, and most have specific post-registration clinical skills training in areas such as cognitive behavioural therapy or psycho-social interventions, in which psychiatrists tend not to be trained. They should also be experienced in clinical work, consultancy, research and supervision. Consultant nurses are often independent nurse prescribers, which means that they are qualified to diagnose patients independently and treat them with medication.

A consultant clinical psychologist typically has an undergraduate degree of at least 2:1 grade and at least two years’ experience in the NHS before being accepted on to a three-year doctorate in clinical psychology. It is not until they have six years’ experience that they may be considered for consultant status. I draw hon. Members’ attention to the document that we have circulated to the Committee on relevant competencies. They cover the ability to identify the presence or absence of mental disorder and its severity and to

“undertake broad mental health assessment and formulations incorporating biological, psychological, cultural and social perspectives.”

The clinician must have a broad understanding of

“all mental health related treatments, i.e. physical, psychological and social interventions”

and

“an advanced level of skills in making and taking responsibility for complex judgements and decisions, without referring to supervision in each individual case.”

Those are the levels that we are setting for the responsible clinicians whom we want to bring in. I find it difficult to understand why the Opposition would want to remove what we have been working at for many years. Perhaps I am anticipating the Opposition’s remarks, but that was certainly the position that was  put in the House of Lords. We want to ensure that highly qualified, highly motivated professionals get the recognition that we are trying to give them in the Bill.

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

In some respects, the debate is unhelpful as it appears almost to be setting one health professional against another. We seem to have lost sight of the patient. If patients’ liberty is to be deprived, surely many of them will want the person with the greatest overview, who makes the initial decision, as the Minister has accepted, to be involved in any renewal of detention. Who has asked the patients?

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

Exactly. That is absolutely the point. The hon. Lady could not have put it better; that is exactly what we are trying to achieve. The responsible clinician—let us say it is a psychologist—who has been treating the patient is, as she says, absolutely the right person to renew the detention. Maybe she does not realise what the effect of the changes that she supports would be. By supporting the changes made in the House of Lords, she wishes to remove that ability to someone else who has not been directly involved with the patient.

The renewal of detention should be done by the person who is most appropriate to the patient’s individual needs and is delivering treatment. That is exactly the point, and that is why we are opposing the changes made in the House of Lords, which will set key professionals back by many years. Our position is not anti-doctor, it simply recognises that there are now others who can make a contribution in the relevant circumstances.

Frankly, it is better for patients to know that the person who is looking after them the most closely is involved in renewing their detention, because they know that that person will have their history. The hon. Lady suggests that it should be sent to someone who might have no knowledge and is brought in at the last minute to examine the patient and renew their detention.

Charles Walker (Broxbourne, Conservative)

On a point of clarification, who will be responsible for ending the detention?

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

We are talking about renewal. When it comes to ending the detention, the responsible clinician, in concert with the multidisciplinary team, would have to say that the conditions of detention no longer apply, which is what happens all the time: clinicians decide that the conditions are no longer met and the detention should end.

We urge the Committee to reject clause 6 and amendments Nos. 60 and 61, which would create severe difficulties by limiting the role of responsible clinicians.

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

I became more and more confused about the Minister’s position the longer she went on. Her arguments are so inconsistent that she is painting herself into corners.

I have a number of questions for the Minister, which she might want to answer in her response. She pre-judged what we were going to say; she came to the debate with  pre-conceived notions and prejudices about the attitude of Conservative Members before we had even talked to our amendments or stated our position on the clause.

I do not understand her insistence on speaking to clause 6 as if proposed new paragraph (aa)(ii) takes priority over subsection (1). It is clearly stated that the preferred route on decisions of renewal of detention must be that the medical person who is familiar with the case should have primacy in making that decision. Only if that person is not available would someone else who has not had a close familiarity with the case be brought in to make that important assessment. It must be a person who has passed all the medical criteria to be able to make a medical judgment at an important and difficult juncture—that is, the renewal of detention.

I have no doubt that all sorts of people working within the multidisciplinary teams, which we wholly support, have enormous expertise, experience, dedication and sensitivity to their patients. Clause 6 does not seek to undermine the job that those people are doing, but it is a matter of appropriateness.

It worried me that the Minister said that the just rewards of the psychological therapists, whom the Government fully support—we, too, want many more of them to work in the health service in areas in which their expertise is appropriate—should be to have the power to decide whether somebody should have their detention renewed. I am not interested in just rewards for psychologists, consultant nurses or anyone else; I am concerned primarily about the patient and whatever is in their best interests.

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

If the hon. Gentleman is concerned about the best interests of the patients, why is it in their best interests to be seen by a doctor who has never met them and has no knowledge of their treatment, rather than to have a decision made in their best interests by a clinical psychologist who has undertaken four weeks of intensive interventions in the relevant hospital?

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

For the simple reason that familiarity, however intense, should not top medical experience. I have a very good dentist, with whom I am very friendly and who is enormously well qualified. She does a great job with my teeth.

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

That is your opinion.

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

I am very happy with the state of my teeth. My dentist has a long waiting list, though I shall not say where she practises, and I trust her judgment implicitly; I have known her well for many years. However, at the moment I have a problem with my knee, but I am not intending to go and see my dentist about it. Despite the possibility that my dentist might be better medically trained, I shall see a knee consultant, whom I have not met before. That is the analogy that applies.

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

It does not.

Frank Cook (Stockton North, Labour)

Order.

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

What is important in that situation is who knows best how to deal with my knee. The really important consideration in the situation that we are discussing—secondary to having the most appropriate and best-trained medical person, who has familiarity with the patient—is to have someone who knows about the medical condition and knows how to deal with it in the case of that patient. That is what is in the patient’s best interests and that is where the Opposition are coming from.

The Minister’s suggestion that it is all about “just rewards” for certain professionals is deeply worrying. It is not a matter of payback time for Unison members, RCN members, consultant nurses or psychiatrists or therapists of any description; it is about what is in the best interests of the patient. Perhaps the Minister will defend her choice of phrase.

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

I absolutely will defend it, because I am conscious of the amount of work that has been undertaken over the past few years to ensure that we can expand the roles that we are discussing so that the people in them can do exactly what is best for the patient. Thousands of psychologists and community psychiatric nurses have worked to develop those roles and we are trying to recognise that in legislation, and frankly I think that they deserve a just reward for their work, but their work is good for patients too.

To address the hon. Gentleman’s point about his dentist and his knee, I do not understand why he wants individuals to be examined by registered medical practitioners who might have little knowledge of the psychological therapies that should be made available to the patient. His argument has again made my point, rather than his.

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

I cannot see how that is the case. We are comparing psychiatrists, who have had 13 years of training, with other practitioners who might be well suited for giving certain therapies and treatments—but at the treatment stage. The Minister does not seem to understand her own legislation. These provisions are about powers to renew detention, not to ascribe treatment.

Angela Browning rose—

Doug Naysmith (Bristol North West, Labour)

Will the hon. Gentleman give way?

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

I shall in a moment, but I shall give way first to my hon. Friend, who was first in the queue—again.

The logic of what the Minister is suggesting is that a consultant nurse—however good, well experienced or familiar with a particular patient—should have powers of renewal of detention, when the patient’s treatment might have involved strong medication. She is saying that such nurses should have the power to judge the efficacy of that strong medication and to decide whether the patient should be detained for longer—a very important decision over which surely the expertise and medical experience of a psychiatrist or doctor should hold sway.

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

I agree with my hon. Friend. It is disappointing that the Minister suggested that the Opposition are not in favour of Unison. I find that it is mainly Unison members who sit in my surgery and bewail the state of the NHS.

When something goes wrong for a patient, in any area of health care, but particularly in the detention of a person under the Mental Health Act—they might have to appear at a coroner’s inquest or something like that—one question is always asked: “Who’s in charge?” If the consultant psychiatrist was involved in the admission of that patient, surely it should be up to them alone to nominate who takes over such responsibilities. I agree with the Minister: others, such as psychologists and consultant nurses, have a big role to play. However, someone has to be in charge, and if responsibility for a patient’s care is to be devolved, the consultant should be the one who nominates to whom it is devolved. If we take away those powers and say that anybody can do it, who decides—the psychologist or the nurse? It is very confusing.

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

My hon. Friend makes a good point. We fear that the provisions will lead to greater complexity and confusion about where the buck stops. Of course, there are great inconsistencies with the Mental Capacity Act 2005 as well, which I shall come on to.

Doug Naysmith (Bristol North West, Labour)

On numerous occasions in the Committee, the hon. Gentleman has referred to evidence received in the scrutiny Committee. I am sure that he recalls evidence received about clinical teams. Some who gave evidence were not in favour of psychiatrists making all decisions on a patient’s treatment—they were not criticising psychiatrists themselves. They said that patients often expressed a preference for another member of the team—a clinical psychologist, for example. My daughter is a clinical psychologist, but that is not relevant—I thought that I would mention it in case anyone here knows it and brings it up. However, clearly patients often prefer someone whom they see regularly. It has to be said that often a busy consultant psychiatrist dips in and out of hospitals.

I am conscious that you are looking at me, Mr. Cook, but may I make one further point? It has been argued that that person would have considerable training in the discipline. However, under the Lords amendment, a graduate, having left medical school six months previously, could be a qualified medical practitioner. That would mean that they could pronounce on someone whom they do not know, and who has never received treatment from them, because, as the hon. Gentleman says, they know more about the clinical aspect of things. Actually, someone who has treated the patient for six months, and been with them during their psychiatric illness, would know a lot more about them.

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

I hear the hon. Gentleman’s point, but by the same token, under his suggestions, some people without that degree of medical training could make those decisions as well. I refer him back to the clause, which says that the preference is for the decision to be made by a medically trained person familiar with the case. That should be the norm. If the Government  are providing a service that is fit for purpose, we should not be having this debate. The medically most extensively trained person should take the buck and make the decision, having taken advice from others in the multidisciplinary team, many of whom might disagree among themselves as well. It is not an exact science, which is the whole point of our deliberations. The consultant nurse might have an entirely different view to the psychologist of what treatment a patient should receive, which very often happens.

What has amazed us about the Bill is how all sorts of professionals who would never give each other the time of day, and who would certainly not sit down together at dinner, have come together in common cause to communicate. The biggest favour and service to the professions involved in mental health that the Minister has done with the Bill is that she has brought them together—they do not often come together on their professional judgments. I am not saying that there is unanimity; there is less on this point than on the other of the big six amended areas.

I am well aware of Unison’s position. I spoke to and had a perfectly full discussion with the Unison people in my constituency who made representations to me. I am aware of the RCN’s position and of many individuals who have written letters on their own account. I am not in any way saying that there is unanimity about the matter, but part of the division comes from a perception that the amendments try to dumb down non-medical practitioners and in some way undermine their contribution. That is not the intention. I cannot make those reassurances clearly enough.

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

Does my hon. Friend remain concerned, as I do, about the process to be undergone in deciding a renewal of detention? Whether to continue a person’s detention is a very serious matter, but the Minister has not pointed out any obvious process. She nodded in agreement with my hon. Friend when he suggested that the person making the decision could be a nurse, a consultant nurse or a psychotherapist, but somebody has to decide. Who decides in any one individual case? Will it be that a psychotherapist comes in on Monday and finds that a nurse decided to not to renew detention on the previous Friday? When a psychiatrist arrives on the following Wednesday, they might find that somebody else has made a totally different decision. The process involved in individual patient care seems to be a free-for-all.

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

Hence my earlier comments about the added confusion and complexity that the measures will bring to the Bill.

I am aware of the good work that the Government have done on new ways of working and encouraging multidisciplinary teams. That has to be right not only for mental health care but for all sorts of physical health care. The most important point is that the patient should receive the most appropriate care from the best qualified professional. Hopefully, and preferably, that person would be the medical person mentioned in the Lords amendments. That means that  the psychiatrist should preferably be central to mental health. The psychiatrist has been central to all previous mental health legislation on account of their highly specialised training—as I said, the training takes13 years. The amendments do not intend to undermine the skill and dedication of the other relevant professionals.

The relevant amendment was introduced by Lord Carlile and had cross-party support. Some passionate speeches were made in favour of the changes. The Minister is now proposing, according to my documents, that some approved clinicians would be eligible to become responsible clinicians and then have overall charge of the patient for the duration of the detention in the hospital or secure unit. Therefore, it is entirely conceivable that for some patients there will be no medical input at all unless the responsible clinician, who is not a doctor, makes the necessary referral. Is it not an anomaly that once detained, a patient’s care will be transferred to a psychologist or nurse, say, without any medical input to their continued detention other than at a time of renewal or on appeal to the mental health review tribunal.

Doug Naysmith (Bristol North West, Labour)

Given what the hon. Gentleman has just said, it is appropriate that I should read out the following:

“To be responsible for the overall management of a detained patient’s case and then to have to seek the agreement of a consultant psychiatrist to renew a section of the Mental Health Act significantly devalues the role for non-medical professionals.”

That comes from one of the letters to which he just referred and is written by two consultant psychiatrists, one of whom is Christine Vize, the second most senior psychiatrist in the Avon and Wiltshire partnership. I know her well and I know her work. She is a fellow of the Royal College of Psychiatrists and she is in favour of new ways of working in mental health that go directly against what the hon. Gentleman argues.

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

Perhaps in response to that I can quote a letter sent today from Sheila Hollins, who is the president of the Royal College of Psychiatrists. She writes:

“I am responding to a somewhat misleading letter sent by Drs Vize and Humphries to the recipients of the email”—

which I think the hon. Gentleman might have seen—

“and to the national press about the role of the RMO. They purport to represent the views of the Royal College of Psychiatrists. Drs Vize and Humphries have a training role connected to New Ways of Working but have not discussed their views with myself or made representations to the Central Executive of the College. College decisions are reached democratically as I explain below.

In the College’s view the issue of who has the competencies to fulfil the RMO role is still to be determined. Their letters may serve to undermine their work to introduce NWW—an important initiative which as yet does not have the complete confidence of the profession.”

I hope that the hon. Gentleman is not going to try to pull the trick that the Minister does of suddenly pulling out a letter from certain individuals claiming to represent the views of one of the professional bodies who happen to be part of the Mental Health Alliance because, pre-empting the Minister, he has fallen for it. I asked right at the beginning of this Committee stage whether the Minister or other hon. Members would try  not to use isolated bits of correspondence to suggest that it represents the views of a body of professionals overall. The hon. Gentleman said that these were psychiatrists, and there was a suggestion, therefore, that in some way the psychiatric profession and the Royal College of Psychiatrists were not in favour of these changes. That is not the case, which I hope he now acknowledges.

Doug Naysmith (Bristol North West, Labour)

Of course I acknowledge that, and I never said that, as the record will confirm. The pointI was making was that this was a psychiatrist whom I know and whose work I am familiar with. Although she deals with the Wiltshire side of things, she is part of the Avon and Wiltshire partnership which is in charge of mental health in my area. I am quite familiar with many things that go on with the Avon and Wiltshire mental health partnership. Christine Vize is a very competent psychiatrist. I am not saying that she represents the views of the college because the hon. Gentleman has been getting little bits of paper about that all morning, but she is someone in whom I have confidence.

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

I do not disagree with anything that the hon. Gentleman has said. I am sure that Christine Vize is terribly good, but let us be clear about this. The Minister has already hauled up a registered nurse to support her case. We have all received submissions from the RCN. We have had submissions from the British Psychological Society, which has been prayed in aid even more than any other member of the Mental Health Alliance. Presumably its membership will be benefiting enormously. I made it quite clear that there are people who do not agree with that position, which is why the alliance is not taking an official position on this.

Doug Naysmith (Bristol North West, Labour)

It did for quite a long time.

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

As it stands, the alliance is not taking an official position on it, albeit that many of the component organisations of the alliance support the Lords amendment.

I think that I have dealt with all the interventions, for a change, and now come to the anomaly that I mentioned. The Government presumably recognise the anomaly as potentially hazardous to patients, because they proposed an amendment, prior to Report in the Lords, in an attempt to offer some medical input to the patients’ care by ensuring that the non-medical responsible clinician should consult with a psychiatrist at the time of section 20 renewal. However, the legal status of such a consultation is dubious, because there would be no compulsion on a non-medical responsible clinician to act on the recommendations and no authority for the psychiatrist to oversee his treatment plan. That could lead to interdisciplinary conflict, as well as unco-ordinated patient care. Why did the Government find it necessary to introduce a medical angle when the measure was going through the House of Lords? They cannot have it both ways. Either they think that a medical input is of great importance, or they do not. They have come up with a halfway house which is flawed and leads to more confusion.

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

We were trying to give some reassurance in those circumstances. As the hon. Gentleman should know, the working of the arrangement would be that, of course, the responsible clinician would consult others on the multidisciplinary team. That is what happens at the moment and it is what will happen in future. We simply wanted to give some reassurance that there would be consultation with the doctor. I think that perfectly reasonable; it is the way we sometimes engage in discussions in this place. The provision is meant to be helpful, but it is what happens now anyway: there are discussions with a medical practitioner.

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

The thrust of all that the Minister has said, backed up by her hon. Friends, is that if she had things her way there need not be a role for a medical practitioner in the process, because a consultant nurse, registered social worker or clinical psychologist would be sufficiently familiar with the case to make decisions about the renewal of detention without reference to medical opinion at that stage; thus it is just a bit of an annoyance that it was necessary to accommodate some medical reference in the Bill.

Ian Gibson (Norwich North, Labour)

Does the hon. Gentleman accept that each hospital has a protocol, under which there is a responsible clinician or group of people, in tune with the patient, and that that information would be in medical records and freely available? That is how things happen in practice. I think that difficulties are being found when in fact hospitals associate the care of a patient sometimes with a named nurse, sometimes with a responsible clinician, or sometimes with both. That varies a lot. There is no real problem.

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

I am sure that there are very good ways of working that happen now, but, ultimately, decisions are made by a medically qualified person. We are talking about a decision on renewal of detention. What I am saying in no way detracts from the effectiveness of the work of various disciplines within a multidisciplinary team, and I stress that it should not be seen as intended to undermine that relationship. However, many people have raised serious legal problems in connection with  what the Government are trying to do in overturning the clause. The Joint Committee on Human Rights stated:

“Initial detention under the Act as amended will still be based on objective medical expertise, in the form of reports from registered medical practitioners. However, renewal of detention will be carried out by the responsible clinician, who need not be a doctor, furnishing a report to the managers of the hospital that the conditions justifying detention continue to be met. If initial detention must be based on objective medical expertise to be compatible with Article 5 ECHR, there is an argument, following Winterwerp”—

the case mentioned in my amendment, which I shall come on to—

“that the same should apply to its prolongation.”

Frank Cook (Stockton North, Labour)

Order. I point out to the Committee that there has been a lot of discussion this morning about bits of paper and I am aware of the quantity of paper that has been submitted to us—I think that we are officially on to submission No. 58. Some of the submissions are 85 pages long, and I have to approve them before they are distributed to you. I hope that I am not the only person who reads them—[Laughter.] I am not joking.

The submissions have been available to everyone, on the table in the corner, all day. They come from a range of professional disciplines, from different representatives within those disciplines and other people, who have a vast range of opinions. There will, therefore, inevitably be disagreement, and it is the Committee’s task to examine the legislative proposals line by line to try to distil the best possible answer from that range of opinions. That may require the Committee to dance on the head of a pin, as the hon. Member for Bristol, North-West put it, but it is important that we do so using the weapons of logic, clarity, patience and tolerance, and that we reject any suggestion of ridicule. I ask all members of the Committee to bear those points in mind.