I beg to move, That the Bill be now read a Second time.
As the House knows, I am very strong on productivity in the NHS, and I apply that to the ministerial team as well.
The Bill has been the subject of more debate and consultation than most Bills that come before this Chamber: there has not only been the 45 hours of debate that has already taken place in another place, but there has been eight years of public consultation and parliamentary scrutiny, including the work of a joint scrutiny Committee on an earlier draft Bill.
The debate has been intense and it has also been effective, leading us to change substantially our original proposals—a point that many of our critics, including some Opposition Members, tend to ignore. It is unsurprising that the debate has been so intense as we are dealing with the law as it applies to some of the most vulnerable people in our community—people whose mental illness is agonising for themselves and their families—and with restrictions on people's liberty, and often with matters of life or death.
On that vulnerability point, one good aspect of the previous draft Bill was the right to advocacy for all those who were at risk of being detained compulsorily, and that does not appear in the current Bill. Is there a commitment to add that right to the Bill before it completes its passage?
My hon. Friend raises an extremely important point and, as Lord Hunt said in another place on this Bill, we are looking in detail at how we can best move forward on patient advocacy services. I am sure that we will return to that matter in Committee.
At any one time, one in six adults—some 9 million people—reports a mental health disorder. One in every four GP consultations is about mental health. More than 1 million of the people who are out of work and claiming incapacity benefits list a mental health problem as their main disability. Every Member will have dealt with constituents whose lives have been affected, often tragically, by mental illness. Many of us, too, have cared for a family member suffering from mental ill health—as I did over many years for one of my sisters. Our debates on the Bill will therefore be affected by the experiences of our constituents and, for many of us, by personal experience as well. Therefore, although I do not endorse all the views expressed about the Bill, I entirely respect the strength of those views. [Interruption.] In that spirit, I shall give way.
I thank the Secretary of State for being so generous in giving way. She is right that many constituents who come to us need our help as their MPs and the help of the mental health services. Sadly however, many wards around the country are closing, such as the St. Julian's ward that caters for my constituents, so such people have nowhere to go even when they want to put themselves forward for help. What plans do we have to open more units, and where will the secure units that the Bill's provisions require come from?
I will address that point in detail shortly, but let me say now that over the last 10 years or so there has been a radical shift in the nature of the care given to many people with mental illnesses. There has been a great shift in emphasis from hospital treatment to community treatment. As I shall explain, there has also been a substantial increase in the resources available to address the needs of such patients. We are also undertaking a review of provision for secure accommodation, to which the hon. Gentleman also referred. In the light of his intervention, before I turn to the provisions of the Bill it might be helpful if I refer briefly to the wider context of mental health services.
The Secretary of State mentions that she had personal experience of caring for someone with mental illness. Does she therefore agree with the findings of the YouGov poll announced today that 88 per cent. of people who knew somebody with a mental illness admitted that those people posed no danger whatever to themselves or anybody else?
There is no controversy or disagreement about that. Those who pose a risk to themselves or to others are a very small minority of the large numbers of people with mental health problems.
Eight years ago, with the new national service framework for mental health, we embarked on a substantial programme to improve mental health services—a programme that in England has been backed by an extra £1 billion investment in the last five years alone. According to the European Commission, the UK now has one of the highest proportions of its overall health budget devoted to mental health of any EU member state. As a result, the NHS has more than 9,000 more psychiatric nurses, more than 1,000 more consultant psychiatrists and more than 3,000 more clinical psychologists than we had in 1997. Because the national service framework signalled a decisive shift of emphasis towards treatment in the community rather than in hospital, the NHS now has 343 new home treatment teams, more than 250 new assertive outreach teams, and more than 100 early intervention teams.
I thought that that might be the hon. Gentleman's point and I was just about to say that in Wales the Assembly Government's Health and Social Services Minister announced £5 million additional recurrent funding for mental health services, to help implement the revised national service framework for Wales, and an additional £75 million capital investment. That demonstrates the Assembly's commitment to improving standards in our mental health services.
Of course there is more to be done: there always will be. But I pay tribute—as I hope we all would—to the outstanding care that is being given by NHS staff to extremely vulnerable and sometimes very difficult and challenging patients. That work is reflected in the fact that the number of suicides is at the lowest level since records began, and is among the lowest in Europe.
My hon. Friend makes an important point. We have already made the decision to give 16 and 17-year-olds with mental health problems more rights than they previously had. In relation to the amendment by the other place, unfortunately changing the law does not always change the reality on the ground. My understanding is that since the new law was introduced in Scotland, with a requirement for age-appropriate accommodation, the number of young people and children being treated in adult wards has actually increased, not fallen, which is the opposite of the intention of the amendment —[ Interruption. ]
Order. It is important that interventions are made in the normal way, not from a sedentary position, if we are to have a civilised debate.
The truth about the point that the right hon. Lady made is that before the arrangements for young people under the 2003 legislation the numbers entering adult wards were not counted, so how can she make that comparison?
I am not sure whether we were counting at that stage, so I shall come back to the hon. Gentleman on that point. I was simply pointing out that the provisions introduced in Scotland, which were the subject of an amendment to the Bill in another place, have not so far had the intended results.
As I indicated a moment ago, we have had mental health laws, including compulsory powers, for more than 150 years. Most countries have similar laws, so I hope that we are debating not the principle of compulsion but the form it should take, and how best to strengthen the safeguards that are essential when someone is deprived of their liberty or treated without their consent.
The main provisions of the Bill deal with the very small number of patients—fewer than 15,000 at any one time—whose problems are so severe that they need to be detained in hospital for assessment or treatment and to protect themselves or others from harm.
The difference between the right hon. Lady's proposals and the Mental Health Act 1983 is not just to do with the compulsion elements, which I agree were already in place; the difference is that the Bill couples them with a redefinition of mental disorder. Broadening the definition from a clinical to a behavioural judgment and combining it with the Bill's powers is what makes the measure so dangerous.
I completely disagree with the hon. Lady. Far from broadening the clinical definition of a mental disorder, what we are doing—by simplifying the definition of a mental disorder in the 1983 Act—is removing four legal categories that have no particular correspondence to clinical categories. The categories of definition of mental disorder in the 1983 Act are not clinical, so by removing that confusion and having a single simplified definition we will ensure that people who need treatment in such circumstances will actually receive it. The Bill will bring the law into line with modern developments in mental health services, deal with human rights incompatibilities and strengthen patient safeguards.
If ever there was a piece of legislation that proved that we cannot please all the people all the time it is this Bill. However, is my right hon. Friend aware that many Members on both sides of the House have been convinced by the advocacy of the mental health charity, YoungMinds? The charity is looking for reassurance during the passage of the Bill that we will never again allow children as young as 10 to be treated in the same way as older people; we do not want to see them on adult mental health wards.
I completely agree with my hon. Friend. Of course, we do not want to see young children treated in adult wards, but nor do we want to put clinicians into a kind of legal straitjacket that could have the wholly unintended result that a young person in desperate need of care is turned away because a child bed or a child ward is not available for them. In my view, we need to focus on continuing to improve the services we provide for children and adolescents rather than believe that simply making changes to the law will solve the problem.
At the heart of the Bill are the provisions in chapter 4 for supervised community treatment. When the current law was introduced, the focus of care for people with the most serious mental health problems was in hospital, and the use of compulsion meant detention, and sometimes forced treatment, in hospital. Modern medicine and clinical practice has shifted the whole focus of care into the community and the law needs to follow. The Bill would, therefore, enable a patient who is detained in hospital to be released under supervised community treatment, enabling some patients to be discharged into the community earlier than would otherwise be the case—a real benefit for them and, often, for their carers, too.
Those provisions, of course, are designed particularly for the so-called "revolving door patients"—people who are hospitalised, whether under compulsion or voluntarily, who respond to treatment, who are released, and who then fail to maintain their treatment, producing another crisis and yet another hospitalisation. That pattern features all too often when someone who has been in contact with mental health services takes their own life—some 1,300 people a year. The same is also true in many of the far smaller number of cases—about 50 a year—when someone else dies at the hands of a mental health patient. We will probably never be able to prevent every such death, but supervised community treatment is essential to help ensure that patients who have been discharged from hospital continue with their treatment in the community, helping to keep them well and thereby helping to protect them, their families and the wider public.
On that point, I am glad that my right hon. Friend has made it clear that this provision applies where people represent a risk of harm to themselves or to others. I fear that some people, in reflecting on the Bill, think that supervised community treatment following admission to hospital could be applied more widely than that. Will she look further into the Bill's provisions for victims in those circumstances? I am concerned that victims of those "revolving door patients" who are not dealt with under criminal justice Acts, but quite properly in mental health care legislation, do not have rights under the Bill to information about the person who has made them a victim. That differs from the original draft Bill, so I hope that during the Bill's passage, my right hon. Friend will write in rights for victims.
Supervised community treatment orders have proved controversial, but they were introduced with relatively little controversy in Scotland. Indeed, the ease with which Scotland was able to improve its mental health legislation was related to the fact that legislators accepted the advice of their expert committees. Angela Browning raised the issue of definition earlier. The Government accepted the recommendations of the expert panel in this particular case, but they did not accept other recommendations. I believe that some, though not all, of the Lords amendments and other proposed amendments should be made to improve the Bill.
My hon. Friend makes an interesting point, particularly about Scotland, where the scope of supervised community treatment goes far wider than what we are proposing in the Bill. In Scotland, of course, supervised community treatment is available in relation to any patient—not just those who have been compulsorily detained in hospital. I want to stress a point that has often been ignored: under the Bill, supervised community treatment will not be available to a patient who is already being treated in the community or who is a voluntary in-patient.
As hon. Members will be aware, our original proposal was indeed to make supervised community treatment available in all such circumstances, precisely as the Scottish legislation has done, but we considered very carefully the objections of the joint scrutiny Committee and others to that aspect of the 2004 draft Bill and we decided not to proceed in that way.
We have sought to reach agreement with those in the other place on a number of issues, but we are not prepared to accept those Lords amendments that would restrict the use of community treatment orders to patients who have been detained as compulsory patients at least twice. I believe that that would be a wholly unacceptable restriction on clinicians: it would exclude patients whose first compulsory admission had already been preceded by several voluntary admissions; and it would deny the potential benefits of supervised community treatment to patients until there had been a further crisis and a further compulsory hospitalisation. I simply do not believe that that can be justified, and we will therefore seek to reverse that amendment in Committee.
Under supervised community treatment, clinicians will keep a very close eye on people and, if they are in danger of relapsing, take appropriate action to prevent that. Of course, one part of supervised community treatment provision will be appropriate conditions, which might, for instance, state that somebody live in a particular place or abstain from the use of recreational drugs, from alcohol abuse and so on. When one thinks of the situations that can exacerbate or, indeed, help serious mental disorder, one sees that such conditions are simply common sense.
No, I cannot. No doubt the hon. Gentleman will wish to develop that point later in the debate.
Let me turn to the other changes in the Bill. Under the Mental Health Act 1983, people can be detained only if very strict criteria are met. In brief, the patient must suffer from a mental disorder, which must be of such a kind or degree that detention in hospital is appropriate and assessment or medical treatment must be needed to protect the patient or others. In addition, we propose that appropriate treatment—treatment appropriate to the circumstances of the individual—should be available before that person can be detained for treatment.
The new appropriate treatment test will replace the so-called treatability test. That, too, is a point on which we shall seek to reverse amendments made in another place.
No. I think that there is a very real problem with the treatability test as interpreted in current law and in practice. The problem is that people with personality disorders often have enormous difficulty getting the services that they need, because they are too often dismissed as untreatable on the basis of what people think the treatability test means.
I am grateful to the Secretary of State for giving way on that point, because it is one that she and Ministers of State constantly reiterate. In how many cases in which the Act has not been misinterpreted—that can clearly be dealt with by putting people right—are patients with a personality disorder actually denied treatment on the specific grounds that they are not susceptible to treatment?
Our estimate is several thousand, but, in any case, it is too many. I am afraid that there is a perverse incentive inherent in the treatability test—it is inherent in any test of the likely effect of treatment, rather than its purpose—for some patients to refuse to engage with treatment in the hope of proving that it will have no effect on their condition.
The hon. Gentleman, who is muttering away on the Opposition Front Bench and clearly does not like my answer, needs to recognise that the treatability test is taken into account by the courts in sentencing offenders, as well as by clinicians in deciding whether detention is appropriate. I do not know whether he is aware of this, but let me refer the House to the case of a man called Richard Ley, who was sentenced to life imprisonment in 2005 for setting fire to his own flat in a suicide bid. The judge who sentenced him, Judge Sean Overend, said:
"You were trying to self harm and did not care about the safety of others. I pass the life sentence with a heavy heart because it seems to me that to send you to prison for life when you have a disorder within the Mental Health Act is an inept disposal. But it is forced on the court because the consultant psychiatrist says that your personal disorder is untreatable so I cannot make a hospital order."
That is precisely what is wrong with the treatability test. [ Interruption. ] I do not know why Opposition Front-Bench Members seem to think that this is a matter for laughter. It was a tragic case. Modern clinical practice is that treatment is possible for people with personality disorders. The current combination of the four different categories of mental disorder—which we are going to get rid of—and the misunderstanding or current interpretation of the treatability test is having precisely the wrong effect.
The Secretary of State has just demolished her own argument. She says that modern treatment is available for people with personality disorders. She has quoted cases. The case of Reid v. the Secretary of State, in 1999, made it perfectly clear that anger management alone could constitute treatment that would justify the imposition of a section. Why can she not accept that, if the law is being misinterpreted and people are not being detained where they should be, that is one thing, but to say that the law is wrong on those grounds is a completely different argument?
I am afraid that the hon. Gentleman is ignoring the fact that, because of the assumption that people with personality disorders were not treatable, services to treat them have not been properly developed over a period of many years. But, of course, as he and I would both recognise, such disorders can be treated. Those services need to be developed and we do not need an unnecessarily complex piece of law, which has been interpreted in the way that I have described, getting in the way of the treatment needed by patients who are seriously ill.
Is not a further difficulty that many clinicians, when faced with the question, "Will there genuinely be a therapeutic benefit for somebody with a personality disorder?" will not in the first instance be able to guarantee that and will in fact be able to state that in the first two or three months, there will almost certainly be a deterioration in the person's condition? That is the problem that we have to face.
My hon. Friend is absolutely right and that is why we have come to the conclusion that it is much better to focus on the intention and the availability of appropriate treatment, rather than on whether a particular benefit, over a particular time scale, can be predicted.
I have some sympathy with what the Secretary of State is talking about, because I am familiar with a case in which someone with a severe personality disorder was excluded from treatment—as is so laughingly dismissed by Members on the Conservative Benches. [ Interruption. ] I will return to the case later in the debate and I will explain how that was exactly the case. The person was excluded from treatment—there is no question about it—but he was not excluded simply by the treatability test. The issue is, as the Secretary of State mentioned, the interplay between that test and the narrow definitions of mental disorder. Does she not accept that, if those definitions are removed, the treatability test has lost a lot of its sting and therefore the modest amendments that have been produced by the Lords will still safeguard the interests of people such as James Green?
The hon. Gentleman is quite right that we have to look both at the treatability test and the definition of mental disorder. As I have indicated, we propose to change both. But I do not accept his point that, in the light of the changes that we wish to make to the definition of mental disorder, we can therefore be comfortable with retaining the treatability test. The way in which it has been defined in the amendment made in another place would have thoroughly unhelpful—and in some cases, quite disastrous—consequences, of the kind that he describes in relation to, as I take it, one of his constituents.
I am conscious of the fact that I have been generous in giving way and that there are many other hon. Members who wish to speak in the debate, so let me just turn briefly to the other key provisions in the Bill. I have referred already to the changes to the basic definition of mental disorder in the Mental Health Act 1983—as have others. We also intend to remove all the exclusions from the definition of mental disorder—except the one for alcohol and drug dependance—again in the belief that the simpler we can make the law, the fewer arbitrary obstacles there will be to the proper use of the legislation, thus ensuring that people who are seriously ill and need treatment get that treatment.
The Bill will update legislation in line with new ways of working in health and social care. Many of the statutory functions under the 1983 Act have to be carried out by a psychiatrist or social worker. However, of course, the world has moved on. For example, nurses are now taking on a wider range of roles and gaining additional qualifications in a way that simply was not happening 20 years ago. The Bill thus opens up several such functions to people who have the right skills and experience, regardless of their professional background. I know that those provisions have been warmly welcomed by the Royal College of Nursing, Unison and others.
We will strengthen safeguards for patients who are subject to the compulsory powers of the 1983 Act. At the moment, all patients under compulsory powers have the right to apply to a mental health review tribunal. However, the Bill will establish a maximum period after which all civil patients must be referred to an independent tribunal, even if neither they nor their nearest relative has made such a request. We will also take a power to allow the Secretary of State for Health and Welsh Ministers to reduce that period.
I hope that I can reassure my hon. Friend on that point. We have agreed that it would be desirable to reduce the six-month period, which is why we will take order-making powers in the Bill so that as resources become available—we will, of course, need to expand the capability of the mental health review tribunals—we can reduce that period.
We will amend the Mental Health Act 1983 to remedy a human rights incompatibility regarding the nearest relative. We will also change the Mental Capacity Act 2005 to introduce the so-called Bournewood safeguards, following the Bournewood case in the European Court of Human Rights. Those new safeguards will be important for people who lack capacity and whose care unavoidably, and in their best interests, involves a deprivation of liberty, but for whom detention under the Mental Health Act 1983 would be quite inappropriate.
I have already indicated that we tried, whenever possible, to reach agreement in another place, where the Bill has been extensively debated. In particular, we tabled an amendment in another place to ensure that the code of practice required under the Bill will contain principles and that the Bill will set out the issues that must be covered by those principles. I hope that the new clause, which I welcome, will reassure many of those who were concerned about the provisions of the original Bill and called for principles to be included in it. However, we believe that other amendments made in another place would damage patients and create the risk of harm to them, their families or the public. We cannot accept those amendments and we will try to reverse them in Committee.
My right hon. Friend will be aware that concern has been expressed by approved social workers about the way in which resources are managed locally and that compulsory admission can be a fraught affair. Will she consider ways of addressing such concerns and improving local arrangements?
My hon. Friend has extensive experience in the field and I hope that she will develop her point during the debate. Of course that is a matter that we need to consider, although it is primarily the responsibility of primary care trusts, working closely with local councils, to ensure that they have the correct resources available. In an emergency, they must be able to ensure that an assessment is made so that an authorised social worker—under the Bill, an authorised mental health professional—can decide whether to apply for detention in hospital for the purpose of assessment or treatment. I have no doubt that we shall return to that point.
I stress that we have substantially increased the investment that the national health service makes in mental health services, as a result of which many thousands of mentally ill patients are getting far better care and treatment than was the case 10 or 20 years ago. However, there are still people with serious mental health problems who are not getting the treatment that they need, not only to protect them, but sometimes to protect the public from harm. We need to make changes to the legal framework to help to ensure that they get the necessary treatment, not only in hospital but, in line with modern medical practice, in the community. I believe that the Bill—or rather the Bill as amended in Committee as I hope and intend it will be—will strike the correct balance between modernising the legislation in line with the development of clinical practice, improving patient safeguards and protecting more people from harm. I commend the Bill to the House.
It is interesting to hear the Secretary of State move the Second Reading of a Bill whose principles now diverge substantially from those that the Government proposed, but such is the nature of today's debate. It probably will not be well understood outside that we will manage to have an argument while all agreeing that the Bill should be given a Second Reading, but we will carry on and do so anyway.
The Government always say that the Bill is not about mental health services but, like the Secretary of State, I want to start by paying tribute to the people who work in mental health services. Hon. Members on both sides of the House will in a personal context, a family context and a constituency context have met people who work in mental health services, who do an often difficult job in difficult circumstances. People with psychological illnesses may present in similar ways to those with physical illnesses, but in some cases they can be very different—and very difficult to handle. The skills required of those who work in mental health services are remarkable, as are their forbearance and their patience in delivering those services. We should therefore start our debate by recognising what they do. The Conservatives think that, as a consequence, such people should be especially listened to. That has happened during consideration of the Bill in another place and, as it passes through this House, I hope—I know—that Members of this House will take a lot of trouble to ask people working on the front line in mental health services what they feel about the provisions. That may well change a few minds that might have started out a bit too set.
I do not want to discuss at length the state of mental health services. You will recall, Mr. Deputy Speaker, that in February last year we had a debate in Opposition time in which we set out the issues in some detail. I hope that that will be taken as read. We acknowledge that additional resources have been provided for mental health services. Ministers often chide me, but I am prone to say that health services generally and mental health services have improved. From experience in my local area, I especially welcome the creation of crisis resolution teams and the introduction of early intervention and assertive outreach. Those are important innovations, as has been the development of the care programme approach. However, I hope that Ministers will be equally even handed and acknowledge that significant problems remain.
Those problems include reductions in the number of in-patient beds and financial pressures on mental health trusts—even if they are not in deficit, they have to make savings as a consequence of deficits elsewhere. Despite the introduction of the care programme approach, only 50 per cent. of patients are subject to care planning. In addition, as the "Count Me In" census demonstrated, there are continuing problems relating to the discriminatory effects of the use of compulsion, especially in relation to black and minority ethnic patients. Those are all problems that we have to deal with, but as I am sure that Ministers would remind us, the legislation is not specifically designed to deliver services; it is designed to establish the legal framework under which people are brought under compulsion.
We are discussing one of the less impressive tales of policy making of the last 10 years—and there is some competition on that score. It has long been acknowledged that the Mental Health Act 1983 needs to be brought up to date. A generation has passed since it was enacted, and as the Secretary of State rightly said, there are a number of issues that need to be dealt with, but let us consider the stages that we have been through. There has been a so-called blue paper, a Green Paper, and a White Paper—oh, and I left out Professor Genevra Richardson's expert committee report in 1998. I should not have done so, because it would have been a jolly good thing if the Government, who received that report right at the start of the process, had actually listened to what was said in it, rather than trying to cherry-pick from it.
There was a 2002 draft Bill and a 2004 draft Bill, and a subsequent Joint Committee on the Draft Mental Health Bill report. Finally, in March last year, a few weeks after our debate on mental health services, Ministers acknowledged the inevitable—the fact that the legislation would not fly—and moved to an amending piece of legislation, which is what is before us now. I did not find, in any of the recent stages in which I have been involved, that the Government appeared genuinely to listen to the independent expert consensus that is emerging on how the legislation should be framed.
It is true in a literal sense that the Bill is about the legal process for bringing people under compulsion, but there is a clear relationship between service provision and the case for compulsion. Those two things do not live in isolation from each other, and there is an important document, which was published in December, that needs to be read in that context. It is the five-year report of the national confidential inquiry into suicide and homicide by people with mental illness, which for convenience is called "Avoidable Deaths". In that report, clinicians were asked to identify the factors that they believed would have made homicide less likely. Let us remind ourselves what the results were, starting with the factor that they were most likely to cite. They were: better patient compliance, which is not surprising; improved staff communication; closer contact with the patient's family; closer supervision of patients; and better liaison between different services. In more than 20 per cent. of cases, those were cited as factors that might have made the homicide less likely.
Of the 1,300 people who sadly killed themselves last year who had exposure to mental health services, many would previously have been admitted to accident and emergency units. Does my hon. Friend agree that accident and emergency units should have a standard operating procedure, whereby people who present themselves who have self-harmed automatically receive counselling, through voluntary or charity groups, or perhaps even as a result of increased resource in the NHS?
I am interested in my hon. Friend's point. From my recollection, most accident and emergency departments with which I am familiar have staff who are trained in mental health issues available; they would be able to make judgments about what kind of onward referral is appropriate for people who present themselves to accident and emergency. Clearly, where that is not the case, the accident and emergency department would need to consider the position. If one goes abroad, I know that in accident and emergency departments in north America, nursing staff who work in accident and emergency departments are required to have had a period of mental health training. We have to bear it in mind that it is an important aspect of service provision that mental health services are not a separate service from the national health service; they are an integral part of it, and that needs to be true of staff training, too.
To revert to the point that I was making, among the factors offered to clinicians as making a homicide less likely was the availability of new powers under the Mental Health Act. In 6 per cent. of cases, clinicians cited that factor, so let us at least get the matter in proportion. There are circumstances in which clinicians said, "We would like to have new powers," but equally, if one looks at the matter subjectively, from the point of view of what clinicians believe about the cases with which they are familiar, they see a whole range of other factors that would be more important.
The hon. Gentleman cited clinicians as saying that better patient compliance was the top factor that would improve services. Does not he agree that community treatment orders are precisely a way to get better patient compliance among the narrow group of patients concerned?
I am grateful to the hon. Lady for making that point, but I was about to come on to that issue, because patient compliance is indeed precisely what it is all about. I will come to that point in a minute, and I promise that I will answer it, but we all need to ask what factors matter most, and how we can best achieve them. The way in which the Ministers represent their case—the Minister of State, Department of Health, Ms Winterton has done it repeatedly—is to say that there are 1,300 suicides and 50 homicides a year, and those, by implication, would be prevented by their proposals.
The Minister shakes her head, but let us be clear: the evidence does not support anything like that proposition. The ability of clinicians to identify risk is very limited. The Mental Health Alliance estimates that up to 2,000 people with schizophrenia would have to be detained in order to prevent one homicide. The "Avoidable Deaths" inquiry illustrates that point; in only 1 per cent. of cases was the estimate of immediate risk of violence high at the last contact with the patient before they were responsible for a homicide. In nearly half of cases, there was thought to be no immediate risk of violence. There are similar figures for suicide risk: only 2 per cent. of patients were thought to be at high immediate risk. Let us not get carried away with the thought that there is certainty, and that clinicians know what will happen in the case of any particular patient; they have no such certainty.
Is the hon. Gentleman aware that the same "Avoidable Deaths" report concluded last year that 56 of the suicides among people who had been in touch with mental health services could indeed have been prevented by supervised community treatment?
Occasionally, I read the notes that I have prepared beforehand, and my next page says that the "Avoidable Deaths" inquiry identified what it regarded as the potential for prevention, and it mentioned 56 cases a year of suicide and—a figure that the Secretary of State did not mention—eight cases a year of homicide, because those cases related to the criteria for community treatment orders. Of course, the "Avoidable Deaths" inquiry was also clear about the lack of evidence, so we have to be understanding. In precisely the paragraphs to which the Secretary of State refers, it says:
"We have no reliable way of calculating how many suicides would be prevented by a community treatment order", and it says precisely the same thing about homicides.
That brings me back to my point about the Bill being about service provision as well as compulsion. If we are concerned to ensure that suicides, homicides and violence to others are minimised, what really matters, first and foremost, is the availability of services and the degree of appropriate supervision available to patients. The care programme approach and the availability of enhanced CPAs seems, on the face of it, and indeed on the basis of the "Avoidable Deaths" inquiry, to be the factor that is most likely to mitigate the risks.
The Government ought to know that, because they went out looking for evidence to support their argument. They looked for evidence on community treatment orders, and that evidence was published just after the Bill's Third Reading in the House of Lords, so it was too late to be of any benefit to those proceedings, but I think that it would probably have reinforced their lordships in their conclusions. The review of evidence, by Churchill et al, which was published in 2007, said:
"It is not possible to state whether community treatments orders...are beneficial or harmful to patients."
It went on to say that there was
"very little evidence of positive effects of CTOs in the areas where they might have been anticipated."
The result is that the Government last week announced a further research project, which is to be undertaken by the university of Oxford and others. The Government have been proposing supervised community treatment orders for several years, and now they think it necessary to undertake research into their potential effectiveness. The Secretary of State was perfectly open about the Government's objective. She wants the Bill to complete its Second Reading, but then she wants to change most of it and overturn the amendments made in the Lords. I suggest to Members wishing to participate in our debates that they read the debates in the Lords carefully. Those debates lasted for 45 hours, so I know that that takes a long time, but I urge them to do so, as they will find that powerful arguments were made and a great deal of expertise was brought to bear on the issue. I pay tribute to my colleague, Freddie Howe, to Lord Carlile, Lord Williamson, Baroness Murphy, Lord Rix, Lord Adebowale, Baroness Barker, Baroness Neuberger and all those who contributed their considerable weight of expertise and authority in the Lords.
The Government tried to represent the argument as one between the rights of patients on the one hand and the protection of the public on the other, but that is a false dichotomy, as we can secure the rights of mental health patients and protect the public better than we have done until now. The Government, however, want to propagate that false dichotomy, because they want to force the argument in the direction that they want to take. Their attitude that they should have unrestricted access to powers is best seen in the assertion by the Minister of State, Department of Health, the right hon. Member for Doncaster, Central that
"Every restriction is a patient untreated".
That is both illogical and misleading. Compulsion is not the only route to treatment. Thousands of patients access services without compulsion. In the case of Michael Stone, the fundamental issue was not whether he was placed in a hospital under detention and regarded as not treatable but whether the services were available to provide the treatment that was regarded as necessary. Ministers go round talking about those cases—they do not do so openly; they do it privately—and if that does nothing else, it propagates the stigma experienced by mental health patients, which must stop.
Thousands of patients access services without compulsion. Supervised discharge arrangements are available, and an enhanced care programme approach does not require compulsion. Discharge into the community should not happen earlier because CTOs are available. The principle should be straightforward: if patients need to be in hospital, they should be there; if they no longer need to be in hospital, they should be discharged. It does not require the legal establishment of a community treatment order for that to be the case. We are not against CTOs in principle, but they should be deployed as a means of securing compliance under strict conditions, and the Lords have put such measures in place where there is a history of relapse after treatment, where there is a history of refusal of treatment, or where there is a clear benefit from treatment if subsequently recalled.
Is there not another consideration, about which the Joint Committee on Human Rights heard very clearly when it scrutinised the Bill? If people go back into the community and live with close associates or relatives, it is important that those carers, which is what they often are, are comfortable with the arrangement, too. In evidence, many of them expressed grave concerns.
I am grateful to my hon. Friend, because the evidence taken by the Joint Committee has been useful, and it will prove useful, too, in our considerations. There is deep concern not only among groups representing individuals with mental illnesses but among those individuals' wider friends, families and communities about the nature of the proposed legislation.
Will the hon. Gentleman tell the House whether he supports the amendment made in another place to restrict supervised community treatment to people who are a threat to others, and exclude people who might harm themselves and who, as he has said, constitute the far larger number of mental health patients who could benefit from supervised community treatment?
First, we need to consider whether it is more appropriate for someone who is at risk of harming themselves always to be under supervised discharge arrangements rather than under compulsion. As for the question of whether we believe that CTOs should be available only if someone is at risk of harming others, the answer is not necessarily. I know that an amendment to that effect was tabled in the Lords, and it is reflected in clause 32. We need to look at that very carefully, and consider whether in theory there are other circumstances. I wish to emphasise the fact that whether it is circumstances in which someone is at risk of harming others or whether they are at risk of harming themselves, we should assert the three R's—that is an easy way of remembering them—namely, relapse, refusal, and the result of treatment.
It is astonishing that Ministers have resisted that. The Minister of State has talked about revolving-door patients. That is the criterion that we are using, which is why we wish to include those measures in the Bill. It is therefore seriously misleading to imply that compulsory treatment offers access to services. I could hear that implication when the Secretary of State said that people were being denied access to CTOs and, by extension, to treatment. That is not true. They need not be denied treatment if services are available, and there is a range of mechanisms to make that happen. Compulsion should be the last resort—and this brings me back to the point made by Fiona Mactaggart—because it does not come without a cost. I do not mean financial cost, but the cost of compliance.
I was going to make the same point as the Secretary of State, and I am pleased that the Opposition do not automatically support the amendment that was made in the House of Lords. While I agree that CTOs ought to be used sparingly, they are necessary. In fact, a majority of clinicians would like to have the option of CTOs and community supervision. I agree, however, that the availability of services is important. It is a scandal that a quarter of people who are compulsorily detained have been refused treatment in the past, and I wonder what the Opposition's view is on the need to introduce measures in the Bill that give people the right to assessment.
I am grateful to the hon. Lady for those points, and I am reminded of an occasion on which I sat with consultant psychiatrists a couple of years ago or more. They said that at the end of the day there are circumstances in which they are under obligations not just clinically to their patients but to the community. There is a point at which to meet those obligations they would either have to put a patient who is in the community into hospital, although they do not consider that they need to be there, or would have to seek additional powers, so they supported community treatment orders. We therefore do not object to the orders in principle, but we must be absolutely sure that we are creating safeguards in the legislation that make the measure a last resort, rather than a first resort.
Lynne Jones spoke about the right to assessment, but we must tread carefully. The Secretary of State made a point about age-appropriate services and assessment, and we must be sparing in the use of a legislative vehicle to mandate services. I do not think that we can go through mental health services trying to specify what they should do in the Bill but, as I shall explain in relation to age-appropriate services, it is sometimes necessary for legislation to express Parliament's firm intentions. I think that that is what the legislation currently does.
We are all after the same objective—people suffering from mental health challenges should gain access to services so that they are treated and get well or return to the community. It strikes me, however, that there is a lack of evidence about the impact of CTOs in the community. There is a risk that the pressure of such orders would stop people presenting themselves for services, so we should look at the studies that have been done around the world to see whether or not the impact of treatment orders is far worse than not introducing them at all.
I am about to come on to that point. Compulsion does not come without cost. Although there is a financial cost, finance is not the principle issue. It is about whether we can deliver mental health services as effectively as we wish, because it matters tremendously whether or not mental health patients and their families and friends, as my hon. Friend Angela Browning reminded us, support compliance. People should want to access mental health services. An environment of coercion will entail the risk that patients will not access services at all. That is precisely the perspective from which many leading professionals approach the issue, and it is among the most dangerous of situations. One need only look at the "Avoidable Deaths" inquiry to see that it is perfectly obvious that the factor most likely to cause problems is a lack of patient compliance. If we put in place an environment of coercion that deters patients from accessing services, we will be in serious trouble.
In the debate about coercion, we have heard little about the actual mental health patients themselves. On a couple of occasions, I have had the privilege of meeting users of mental health services in Hackney, thanks to the support of the Mind service user group. They expressed mixed views on compulsion, but some recognised that a compulsory treatment order in the community is preferable to compulsion and detention in hospital—where that is an option, people often prefer it. As I have said, views were mixed, which is something that I hope to go into when I get the chance to speak, Madam Deputy Speaker, but the issue has not been raised, and I wonder whether the hon. Gentleman wants to comment on it.
The hon. Lady has fallen into the same trap as the Secretary of State that treatment is available only under a CTO. Supervised discharge arrangements are available, and it is perfectly possible for patients to opt for them. Compulsion is not required in such a wide range of circumstances.
The hon. Gentleman has referred several times to supervised aftercare arrangements, but is he aware that they are hardly ever used? Clinicians have made it clear that they do not use supervised aftercare because the arrangements are too bureaucratic, there are too many restrictions on their use and, critically, there is no power to recall a patient to hospital. That is the central difference between supervised aftercare and supervised community treatment, which he should therefore support.
Once again, the Secretary of State is making our argument for us. It is perfectly clear that far from resorting to CTOs, the Government should have been trying to work out how supervised discharge arrangements can be used more effectively. [ Interruption. ] Compulsion is not the same as supervision. What is required in order to promote patient compliance is, wherever possible, to achieve close supervision in circumstances that do not involve compulsion. [ Interruption. ] The Secretary of State has said, "Well, they cannot be recalled." Of course it is possible for a section to apply, which could happen to any patient in the community. That may be for assessment in the first instance, but if the patient has been sectioned before, it may be for treatment. The Secretary of State seems to be making our argument for us, but I do not want to go on for too long, because I know that many hon. Members want to speak.
Even more dangerous than the risk of non-compliance by patients would be if the use of CTOs were extended as an alternative to in-patient treatment, where that is desirable. Over the weekend, I published figures from the Department on the number of formal admissions under the Mental Health Act 1983. The Secretary of State has said that the Government want a shift out of hospitals and into the community. Well, the number of formal admissions has increased since 1997, while the number of in-patient beds has decreased by 20 per cent., including by 5 per cent. in the last year for which figures are available.
With 63 per cent. of finance directors of mental health trusts saying that they are reducing their spending plans, the risk is clear. For financial reasons, rather than for reasons involving patients' interests, early discharge from hospital will involve community treatment orders. Early discharge should never occur because a CTO is cheaper; it should occur only in circumstances in which patients should not be in hospital. Cost saving by limiting in-patient detention is another potentially serious risk.
I do not understand why the Government oppose the Lords amendments to clause 24 on age-appropriate assessment, services and accommodation. They have said that that would not be available in an emergency, but clause 24 is perfectly clear about assessment in an emergency, when it might not be possible to provide such facilities. It is clear that what is required in terms of accommodation is what is sufficient for the needs of children and young people and that what is sufficient for the needs of children and young people might be different in an emergency from what might be available when there is more time. As I said to the hon. Member for Birmingham, Selly Oak, Ministers must accept that Parliament wants to make it clear that it is unacceptable for three children and young people a day to be admitted to adult in-patient facilities. That must stop, and we must find not only the means but the will to make it happen.
I have mentioned the safeguards on revolving-door patients, and I find it astonishing that Ministers will not accept the Lords amendment, which seems to deliver precisely the kind of safeguard that Ministers have called for.
On therapeutic benefit, the Secretary of State and I had an exchange on the issue of personality disorder. That comes down to the question of medical necessity—is it necessary for somebody to be admitted under compulsion? In another place, the Liberal Democrat Lord Carlile, who cannot be accused of treating lightly the protection of the public, quoted Professor Eastman, who is professor of law and ethics in psychiatry at the university of London and head of forensic and personal disorder psychiatry at St. George's medical school. Professor Eastman has said:
"Therapeutic benefit to the individual is of crucial importance in terms of protecting the boundary of what is the business of mental health professionals. I am not at all against protecting the public, of course not, but it must be in conjunction with some benefit to the individual that goes beyond simply stopping them offending. If you adopt a definition of treatability which is simply the reduction of risk or the avoidance of offending, that means that locking somebody up is treating them."
We do not agree with the proposition that locking somebody up is treating them.
This is a health Bill, and it must be about treating patients successfully. We have to protect patients from harm and we have to protect the public, and improving access to and the effectiveness of mental health services is the best way to achieve that. In specific circumstances, compulsory detention and compulsory treatment in the community will be necessary. We have a responsibility in Parliament to define those circumstances with the greatest possible care. I have no doubt that those circumstances must be determined by the therapeutic benefit to the patient as well as the necessity of compulsion to prevent harm to others. We must not widen the scope of compulsion to such an extent that it threatens patients and drives them away from access to services and compliance with treatment. Conservative Members welcome the Bill as introduced in this House, and unlike the Government, we will vote for it on Second Reading while agreeing with its principles.
First, I congratulate my right hon. Friend the Secretary of State and her ministerial colleagues on persevering with this legislation in the face of misleading and, sometimes, scurrilous campaigning, which has led to great fears among those suffering from mental health problems. Those fears were expressed on the radio this morning, when someone who is willingly receiving support and treatment and gaining therapeutic benefit from it stated their belief that the Bill would take away their liberty. It behoves all those who are debating and campaigning on the Bill, with which I have been involved for a number of years, to be careful about what they say in order not to create unnecessary worry. That includes the idea that 2,000 people will immediately be rounded up as though we live in a police state, which we do not.
Secondly, I congratulate my right hon. Friend on the balance that she is attempting to achieve between the liberty of the individual and the protection and needs of the public. As she has rightly pointed out, she has a substantial personal background in this area, which she has brought to bear on the legislation.
Thirdly, as part of the extensive listening that has taken place over the past few years by the Government, I hope that my right hon. Friend will ensure that issues of advocacy, which were originally in the legislation, which are being campaigned on by YoungMinds and which are complicated—for example, a parent would not want a 10-year-old in the same ward as 17-year-olds with particular health problems—are resolved. I know that there is deep concern about that among hon. Members on both sides of the House.
Fourthly, an issue that concerns the Zito Trust is that victims—or, more appropriately, victims' families—have the same rights in relation to murder and distress caused in the circumstances that we are debating as they would if action were taken under the criminal justice system, which was strengthened in that regard by the measures taken in 2003.
We should be wary of presuming that because people have the right intentions they are automatically right. That is clearly demonstrated by the Lords amendments, which would create fear unnecessarily. Let me refer particularly to issues relating to exclusion. Some people assume that if the Bill does not specifically exclude the possibility that there is an evil regime just around the corner—even in my worst moments, I do not presume that that will happen after the next general election, or the one after, or in 50 years' time—that possibility means that issues of sexual identity or orientation, or of people's involvement in disorder or in acts of cultural, religious or political belief, are somehow associated with its measures, leading them to believe that there is another agenda.
When people believe that, they start making up in their own minds about what might happen. Take the shadow Health Secretary's views on therapeutic outcomes. Of course, we can debate an holistic approach and whether we can judge therapeutic outcomes in terms of managing someone's condition. However, in dealing with the question of community treatment orders, it ill behoves us to presume that those who are prepared to continue to receive support in the community, to accept their treatment and to continue to collaborate with the services are at risk of being dealt with under this legislation, because all Members know that they are not. We are not talking about people who would continue to take medication or receive therapeutic outcomes, but about people who would breach the decisions that were taken while they were in compulsory hospitalisation. All of us, perhaps with the exception of the Member who asked an inappropriate question earlier on, would accept that we have had compulsion for the past 125 years. We are debating precisely how we deal with the delicate area of people whom we know are at risk—or at least some psychiatrists would accept that they are at risk—because they have been into compulsory hospitalisation at least once. It is strange that those who rightly argue against revolving doors, and who would be deeply concerned about patients who were continually in and out of hospital without appropriate community action being taken to avoid their returning to hospital, have reversed the coin completely and are saying that they want to continue with a revolving door—presumably to the point where someone demonstrates by their actions that they are a risk to themselves and others. We cannot have it both ways.
Nor do we want there to be a lawyers' field day, as there usually is. I have more than one regret about things that I did as Home Secretary, partly to do with the balance in sentencing and the misunderstanding with the judiciary. Another regret that I had as Home Secretary concerned the nature of people's understanding of what was taking place when we legislated. The more we legislate, the more lawyers make money—there is no question about that. In my view, they would have a field day if we left in place the House of Lords amendments. I should know, because they have had a field day in making money out of me—fortunately with success on my side. However, that does not stop me from being deeply suspicious of anything that means that people have to resort to law to be able to understand what we were trying to legislate about and its interpretation.
For instance, I have experienced situations where people argued after a murder had taken place that the individual had a mental health problem and should therefore not be sentenced normally through the criminal justice system but be dealt with through the mental health tribunal. I have a terrible fear that the arguments are now moving the other way, whereby people would argue that the fact that someone was prepared to commit homicide demonstrated that they had a mental health problem, but were not prepared to accept, even though the person had been in hospital under detention before, that that could have arisen. These definitions and clinical decisions are very difficult. We must be careful that we do not impair people's liberty, but we must also be clear that if we fail to act, we let people down.
I go back to the time when I was shadow Health Secretary, when I first met Jayne Zito. I pay tribute to what she has done over those years since the death of her husband, Jonathan. It seemed to me absolutely crucial that we listened and learned from such events, just as I listened and learned when I went to see the man with a mental health problem who tried to commit suicide, failed and ended up as a paraplegic. Of course, he was having to be supported and treated. He desperately wished that someone, as we would if we saw a person jumping off the parapet of a building, had been prepared to intervene—to grasp his hand and stop him doing it.
We are trying, with difficulty and with all sorts of things being said about us outside the House, to get that balance right. I hope that with the support of this House we will eventually pass an Act that protects people from themselves and from others.
It was good to hear the belated recognition by Mr. Blunkett that passing endless new legislation does not necessarily make the world a better place. The Bill is all about the safeguards that are in place to ensure that people with mental health problems are treated properly and that legislation cannot be improperly abused because it is too loose and does not sufficiently safeguard the interests of the individual.
The proposed legislation has had a tortuous journey to get to this point, and the Bill that we have before us, as amended in the other place, is a good one that will have Liberal Democrat support. The sadness is that the Government will seek to unravel the good work that has been undertaken in the other place. Like the Conservative spokesman, I pay tribute to the extraordinarily well-informed debate in the other place and the scrutiny of the Bill that took place there.
The only point where consensus has been achieved is on the need to reform mental health law. There is widespread acceptance of the fact that the Mental Health Act 1983 needs updating, but nine years on from the Government's appointment of an expert committee back in 1998, it is remarkable that far from building consensus and support for new legislation, we will have a greater divide between the Government's position and that of most people working in mental health services. The Government make a lot of the amount of consultation and debate that has taken place—the Secretary of State mentioned it in her speech—but the problem is that they give every indication of rejecting all the evidence and advice that has come as a result. That evidence and advice have come from a remarkable alliance of organisations working in mental health services—an alliance of, I think, 79 organisations, covering service users, psychiatrists, social workers, nurses, psychologists, lawyers, voluntary organisations, charities, religious groups, research bodies and carers groups. Together, they have expressed their concerns and maintained their opposition to the Bill as originally presented to the other place. The Government ought to take careful note of such a powerful alliance of concern.
Will the hon. Gentleman accept that the alliance of all those professionals—this includes Amicus, the British Association/College of Occupational Therapists, the British Psychological Society, the Royal College of Nursing and Unison—does not agree about the changes made in the House of Lords to move away from the multidisciplinary role and put all power back in the hands of doctors? Will he accept that on that issue that alliance does not represent the views of a large number of people working in mental health services in the health service?
I accept that and certainly we will listen to the concerns as the Bill goes through Committee. I appreciate that there is a divergence of views on that issue.
In 2004, the Joint Scrutiny Committee reached a conclusion that one would have thought would be largely uncontroversial. It said:
"The primary purpose of mental health legislation must be to improve mental health services and safeguards for patients and to reduce the stigma of mental disorder."
That does not appear to be the Government's view. The Government define the purpose of the Bill very narrowly. They say that it is
"about the legal processes for bringing people under compulsion."
Clearly, that is an incredibly important issue, but the divide in perceptions of purposes of legislation is remarkable.
I want to say something about protection of the public. The Government make much of that, and in many respects rightly so. It is of course entirely legitimate and right to consider public safety and to ensure that people are not unnecessarily put at risk, but we need to ensure that legislation is guided by evidence, and it is incumbent on us all not to stir up fear where evidence might provide reassurance.
The Government's approach appears to be based on an assumption that mental ill health, particularly in severe forms such as schizophrenia, is necessarily linked to violence and that the problem is getting worse, caused by care in the community and the inadequacies of the Mental Health Act 1983.
What is the evidence? According to the evidence that I have seen, 5 per cent. of homicides are committed by people who have at some stage had contact with mental health services. That position has remained largely unchanged for the past 50 years. In other words, the emergence of care in the community appears to have had very little impact on those statistics—on those trends. Far more murders are committed by people under the influence of drink or drugs, and there is certainly no suggestion that we should be locking them up on a preventive basis.
If we look at the number of murders committed by people who are currently suffering from a mental health problem, we again find little change. There have been 30 to 40 a year since 1997, yet the overall murder rate has increased by some 30 per cent. in that time, so murders committed by people with mental health problems form a reducing percentage of the total number of murders. Only one person in 20,000 with schizophrenia commits murder.
As I understand it from talking to experts, there is also the problem that it is very difficult, if not impossible, to predict which person could be violent. I understand that attempts to predict are wrong in 97 cases out of 100. We would have to lock up 2,000 to 2,500 people to prevent a single homicide. On the point made by the right hon. Member for Sheffield, Brightside, of course we are not suggesting that we are going to lock up that number of people, but if we do not, we do not achieve the objective of preventing people from being killed.
That is a completely false understanding of how logic works. It is entirely wrong to suggest that we would have to lock up 2,000 people. We might have to lock up only one person to prevent one homicide.
It would be like looking for a needle in a haystack. The point that I am trying to make is that the experts make the case that it is impossible, or certainly very difficult, to determine who might be the person who commits violence at some future point.
Therefore, if the provision goes through, are not we in danger of locking up some people who are not likely to turn out to be murderers, and of not locking up people who are?
Of course, that will always be the risk.
If we look at the findings of the various inquiries that have taken place into the tragic deaths that have occurred, we see that the focus tends to be on the human failures of those providing care and on inadequate resources, rather than on a lack of sufficient powers. The problem is always poor communication, poor care planning, overstretched professionals failing to heed warnings and inadequate service provision.
I was listening to a consultant psychiatrist this morning, who was saying that it is the people who are not in the care of professionals, not the people already in the system, who are often the problem. The findings of the Michael Stone inquiry were typical of that. There was no recommendation for changing the law.
Many observers have highlighted the concern that if the Government get their way, the public could end up less well protected. Two reasons are cited. First, the use of powers of compulsion is resource intensive. It ties up professionals in bureaucracy and skews resources towards acute care and away from early intervention. The second reason is the risk that increased use of compulsion could drive service users away from mental health services.
Dr. Tony Zigmond, the honorary vice-president of the Royal College of Psychiatrists, made that point today. He said that his experience is that the threat of compulsion can drive people away from the very services that can help them and make the public safer.
I was present when Dr. Zigmond made that statement today, but it is not only him as an individual, eminent though he is, who takes that view. It is the official view of the Royal College of Psychiatrists as a whole profession. Those professionals do not want to have to take on the responsibility of picking out the people who just might some day commit an offence. That is an impossible task to ask professionals to do.
I am grateful to the hon. Lady for that intervention. She makes a very good point. It reinforces the point that the Government are playing a very dangerous game in going against the views of so many eminent and experienced people in seeking to force the measure through.
It is true that that is the view of the Royal College of Psychiatrists—Dr. Zigmond is sitting up in the Gallery, listening to us—but the point is that it is quite possible to meet psychiatrists who disagree with that view. I have met many of them. That viewpoint is obviously arrived at through a democratic process, but it is not true to say that it is the belief of every psychiatrist practising today.
I have never at any stage suggested that it is the unanimous view, but it certainly appears to me to be the overwhelming view of psychiatrists.
The conclusion that we should reach is that although it is accepted by everyone—the Government sometimes seem to distort this point—that compulsion is sometimes necessary, it should be used as the last resort and should be subject to effective safeguards to ensure that it is used only where appropriate.
Talking of the views of consultant psychiatrists, one said to me:
"A section is an act of kindness and it's bizarre to restrict it to hospital".
Will the hon. Gentleman comment on that? His remarks seem to be totally about murder, which relates to only a tiny percentage of the people we are talking about. Many patients and families want there to be compulsory treatment. If every other patient who needs it is given treatment, surely mental health patients should have that option, too.
I have made the point that we accept the case that sometimes compulsion is necessary. The point is that it needs to be subject to stringent safeguards. It is the Government who talk the whole time about public safety. It seems to me to be distorting the debate to talk only about those cases. In my contributions, I was seeking to address the point made by the Government that the public will be less safe if the Government do not get their way. That palpably is not the case.
Meg Hillier has put her finger on the problem: the trouble with the mental health system is the lack of accessibility. Everyone should have a right to an assessment, if that could be managed and if the resources could be made available.
I absolutely agree with the hon. Gentleman.
I want to state the clear principle that depriving a person of their liberty when no crime has been committed is a very serious act, and we must always be aware of that. Those people have rights too.
I should like to make some progress, but I would be happy to give way later.
The focus must be on ensuring high standards of service provision. The Government put this rather well in their response to the Joint Scrutiny Committee, in which they said:
"In terms of the small minority of people with a mental disorder for whom compulsion might be necessary, we want to achieve a level and type of service provision that minimises the risk of people with a mental disorder deteriorating to the point where compulsion is necessary. When compulsion has become necessary, we want that service provision to be of a level and type to ensure that everything possible is done to prevent the need for any further episodes of compulsion. In other words, by improving the services to promote better mental health, we want to reduce the need for compulsion."
I completely sign up to that statement of intent by the Government. It is a good basis on which to develop the law and our approach to mental health services.
In the past 12 months, however, the deficits in the health service have had a damaging impact on those very mental health services in many parts of the country. I acknowledge the improvements that have been made in those services over the years, but in the past year, damage has been done. Before Christmas, the Health Committee produced a report on deficits which specifically highlighted mental health services as one of the "soft targets" that was suffering as a result of the cutbacks in funding. It is particularly depressing that those cutbacks should be happening just as the Government's emphasis appears to be on creating more draconian powers. This undermines the fine aspiration that they expressed in their response to the Joint Scrutiny Committee.
I want to highlight the concerns expressed by many people about the potential impact of the original Bill on black and minority ethnic communities. The Minister will be aware of the genuine fear that, without proper safeguards, the Bill could disproportionately affect people from BME communities. Last December, it was revealed that a report by a Government advisory group chaired by Rabinder Singh QC warned that the Bill could lead to more black and ethnic minority patients being subject to compulsory treatment. Already, as a result of the Mental Health Act 1983, in-patients from black Caribbean, black African and other black groups are between 19 and 38 per cent. more likely to be detained compared with the average for all in-patients.
In November last year, the Department of Health published a race equality impact assessment on the Bill. However, on
"uncover the extent to which it is failing to meet its duty to promote race equality under the Race Relations Act 1976".
"We are concerned about the Department of Health as we have reason to believe that they have not been meeting their obligations under the law".
What is going on? That is an extraordinary statement for the commission to make. I hope that the Minister will be able to offer some reassurance on this matter. Improving the way in which people from BME communities are dealt with by mental health services clearly presents a significant challenge. The Commission for Racial Equality has called for amendments to guarantee the effectiveness of the race equality duty. Will the Government consider those proposals in a constructive way?
I represent a constituency in Hackney, and in the City and Hackney primary care trust as a whole, 40 to 45 per cent. of the people detained are from African and Caribbean groups, and are mainly men. We all recognise that many more black people are detained and treated differently, but the Bill is not the place to fight that battle. I am fighting that battle, and I would happily join the hon. Gentleman in fighting it too, but he is wrong to conflate the two issues. The Bill might have an effect on people, but whatever we do to it, it is not going to solve this problem.
I am grateful to the hon. Lady for that intervention, but my point was that, under the existing regime, black and minority ethnic communities are treated disproportionately severely, and that if there is any increase in compulsion as a result of the Bill, there is every likelihood that those groups will be disproportionately affected by it. It is a question of logic. We must take the opportunity of this mental health legislation coming before Parliament to address the concerns about the way in which black and minority ethnic communities are treated, so as to ensure that mental health services do not discriminate against people from those communities.
I want to deal with the amendments passed in the other place which, in the view of the Liberal Democrats, must be preserved. First, there are the exclusions from the definition of mental disorder. The right hon. Member for Sheffield, Brightside talked about exaggerated language being used by those who oppose the Bill, but some of the exaggerated and misleading claims made by the Government have been enormously damaging to what should be a good, high-quality debate.
"by adding a range of unnecessary exclusions, the changes forced through by the Lords will inevitably open up new avenues for patients and their lawyers to use to try to secure the premature discharge for some of the most dangerous patients."
That is scaremongering. The exclusions are about making sure that the powers are not used inappropriately. Similar exclusions exist in most comparable jurisdictions, including Scotland, and there is no evidence of dangerous people roaming the streets as a result of those exclusions being put in place in the Scottish legislation.
I want to deal next with the amendments on impaired decision making. The Bill, as amended, prevents the compulsory treatment, including detention, of people who are fully able to make their own decisions about the provision of treatment. The Government claim that this will result in people who need treatment not being detained, putting them and others at risk. First, the Scottish legislation contains a similar provision and, again, there is no evidence of it causing a danger to individuals or to the public. Secondly, if someone with a physical health problem has the right to refuse treatment, should not the same rule apply to someone with a mental health problem? I think that Mr. Lansley made that point earlier. Thirdly, the Government's own expert Committee, the Richardson Committee, supported an impaired decision making test, as did the Joint Scrutiny Committee. Fourthly, mental health clinicians advise that a person with a mental disorder who is suicidal or who poses a risk to others because of their condition would inevitably be found to have impaired decision making, and so come within the scope of the legislation. So the amendment is a safeguard of real importance to the citizen's human rights, and does not leave individuals or the public at risk.
Next, I want to deal with the treatability test. The Minister made an extraordinary claim on this in her speech to the Local Government Association. She said:
"This safeguard has, on occasions, been misrepresented as meaning that patients can only be detained if they can be cured, rather than treated. This confusion has led to too many patients with personality disorders, which can be treated but not cured, being turned away from services."
If that is the case, the answer is surely to ensure that professionals interpret the law correctly, not to change the law in a fundamental and dangerous way. The amendment addresses the Government's concern to ensure that someone with a personality disorder is covered by the Bill. It is a balanced amendment, and it should stay.
The Richardson Committee said that a health statute should authorise overriding patient autonomy only if there are
"positive clinical measures included within the proposed care and treatment which are likely to prevent deterioration or secure improvement in the patient's mental condition".
Again, the Scottish legislation uses the same therapeutic benefit test, and there is no evidence of disaster in Scotland.
The amendment on the renewal of detention is intended to provide a safeguard that is hard to dismiss other than on cost grounds. A medical practitioner would be required to examine the patient and to agree to their continued detention. Other health professionals have argued that the amendment goes too far, and we will take account of their arguments in Committee.
I join in the criticism of the Government for publishing research on the international experience of community treatment orders the day after the Bill completed its passage in another place, which I thought was extraordinary. We know that the report had been available for a considerable time. Why did the Government wait until the deliberations in another place had finished? Surely it is better to allow informed debate than to deny us valuable information.
The research revealed that there is little evidence of the positive value of CTOs. The Institute of Psychiatry concluded
"there is no robust evidence about the effects of CTOs on key outcomes, such as hospital readmission, length of stay, medication compliance, or the patients' quality of life."
The report advised that enhancing community services was a better way of improving compliance and reducing the incidence of relapse. Surely it makes sense to accept the argument for CTOs in a limited number of cases, along with the safeguards introduced by the House of Lords.
The Minister claims that CTOs are intended to apply specifically to those dubbed "revolving door patients": people who leave hospital, relapse because of failure to take medication, and go back into hospital. The amendment was designed to ensure that CTOs would apply to precisely those patients. CTOs can impose wide-ranging restrictions on patients—many have described them as "psychiatric ASBOs"—and further amendments are needed to make them proportionate. It is important, for instance, to give patients the right to appeal to mental health review tribunals against conditions that have been imposed on them.
Amendments that give health bodies a positive duty to admit children and young people to age-appropriate settings, and to provide specialist assessment and supervision for detained children, are fundamental to a civilised society. The Secretary of State said that it was not possible to ensure that something happened by passing legislation. I wish that the Government had taken more note of that principle during the past 10 years, but in this instance we should surely set a standard. We must all accept that children should not be admitted to adult psychiatric intensive care units. It is nothing short of scandalous that one child or young person has been admitted to an adult mental health setting every day for the past three and a half years. It is also worth noting that the amendments are entirely in sympathy with the thrust of the approach recommended by the national service framework.
The issues that we are debating are of fundamental importance. It is essential that we get the Bill right. It needs to stand the test of time, and it needs to have the confidence of those who work in mental health services. It is remarkable how cavalier the Government seem to be in the face of overwhelming opposition from those with real expertise.
The Bill is not perfect. We want core principles to be set out in it, and I see no reason why that should not happen. I agree with Mr. Kidney that those facing compulsion should have the right to an independent mental health advocate, and should be made aware of that right. But if the Government insist on driving through the removal of clauses added in the other place that provide safeguards for vulnerable individuals, they will make a very serious and dangerous mistake.
Order. I remind hon. Members that it is not permissible for them to refer in their speeches to people sitting in the Public Gallery. I also remind them of the 10-minute limit on Back-Bench speeches.
I agree with Norman Lamb that it is not before time that we are updating our mental health law, as has already been done in countries such as New Zealand, Australia and Scotland.
I support the Government in respect of nearly all the proposals that we have debated. They also deserve the congratulations that they received from even Mr. Lansley on their extra investment in the health service generally, and particularly in mental health. Before 1997 we experienced decades of underinvestment in our national health service, and no service was treated more harshly than mental health services, which is why practitioners described it as the Cinderella of services at the time.
I can give an eye-witness account of the changes that have taken place. For nearly 20 years before I was elected to Parliament I was a solicitor in Stafford, where we have a very successful hospital for mental health treatment, St George's hospital. I regularly advised patients, had discussions and meetings with members of staff such as psychiatrists and hospital managers, and had dealings with the mental health review tribunal. I observed the problems that were created by underinvestment in services, particularly the lack of support for people in the community, which made hospital admissions more likely than they should have been. For the last 10 years I have been a regular visitor to that same hospital as the local Member of Parliament, meeting patients and other service users, doctors and nurses, and hospital managers. Today the story is completely different.
During my time as the local MP, we have also seen the establishment of a private hospital dealing with mental health issues. The hospital, which is in Wheaton Aston in my constituency and is a member of the Huntercombe Group, specialises in acute illnesses and eating disorders in young adults and children. It is experienced in those conditions, and has made valuable comments about the parts of the Bill that deal with services for younger patients. Also in my constituency, Staffordshire university has a centre for national research on older people and mental health. As the local MP, I have seen a good deal that is relevant to today's debate.
St George's hospital is part of South Staffordshire Healthcare NHS Foundation Trust. Let me say something about the way in which it has developed since 1997. It is now an exemplar for national services such as inclusion and regional services such as forensic sciences, and features local excellence in services such as developmental neurosciences and dealing with learning disabilities.
When I visit the hospital, I see a brilliant commitment among its staff. There is evidence of that for visitors in the form of the magnificent modern learning centre—which is proof positive of the commitment of management to staff—and also in what the hospital calls the values exchange, which enables staff to swap experiences and suggestions of ways in which to improve services. That approach extends to service users, who show a fantastic commitment to the hospital where they have received treatment. Much of the credit belongs to the chief executive, Mike Cooke, who is so brilliant that he is leaving us next month to take up a post with a larger trust in Nottingham.
I have also visited Huntercombe Stafford Hospital several times. It has great expertise in dealing with younger patients, and has much to offer this debate.
We have seen two attempts at wholesale reform of mental health legislation in the past, both of which failed. I think it a shame that all our mental health law cannot be kept in one place as a kind of code: it is sad that we could not achieve such a modernisation. This Bill represents a more modest attempt to modernise the Mental Health Act 1983. Psychiatrists at both the hospitals I have mentioned tell me that there are advantages in that. The 1983 Act is familiar to practitioners. The definitions are well known to them, the practices are appreciated, and they like the idea of evolutionary rather than revolutionary change. There is also the opportunity to "mesh" the legislation with other reforms such as the Mental Capacity Act 2005.
Like those practitioners, I ask "What is this law for?" I accept the Government's point that it is intended to provide a legal framework, but I still maintain that the quality of services is at the heart of the issue. With a good framework, services can flourish and meet need effectively; without it, they will be harmed. Like the Joint Scrutiny Committee I believe that
"the primary purpose of mental health legislation must be to improve mental health services and safeguards for patients and to reduce the stigma of mental disorder."
The top priority is to improve services through the Bill and many other means, including investment. The second is the reduction of stigma, which is vital in getting people to engage with services, with voluntary services being just as important as the compulsory ones that we are discussing. Compulsion must be balanced with the proper safeguards. Another important reform, mentioned briefly earlier, is work force reform.
I should like to discuss the services available to young adults and children and I aim to speak later about the Lords amendment on age-appropriate treatment. I regret the fall-out between the Government and the Mental Health Alliance. The alliance is formed from a large number of organisations that all attract great respect for their work individually, so together they should be listened to. However, I do not share the alliance's enthusiasm for the Lords amendments on impaired decision making and the question of treatability. I like the alliance's arguments in respect of the overriding principles that it says should be in the Bill. Much of the disagreement between the Government and the alliance could be resolved if we put the principles in the Bill and got the wording right. We could certainly ease worries about the provisions on impaired decision making and treatability by getting those principles right.
I am not sure whether we can get the principles so well stated in the Bill so as to do away with the need for some exclusions. The Government have concluded that the Bill must still mention exclusions for drug and alcohol dependency. I should like the Committee to discuss whether we can get a statement of principles that is so well honed that we do not need a list of exclusions as well. If we could get to that position, we would bring our legislation nearer to that of New Zealand, Australia and Scotland, which we are now falling behind.
Some safeguards are missing from the Bill, and if I am a member of the Committee I will argue for them. The first is the one I mentioned to my right hon. Friend the Secretary of State: the right to independent advocacy for those subject to compulsory powers. The second is the legal recognition of a patient's advance decisions and statements. The third is enabling patients to have greater choice and covers which persons exercise the powers granted to the nearest relative.
On the vexed question of community treatment orders, it is important to bear it in mind that we have experience of some controls over some patients in the community. We have the extended leave and guardianship route and supervised discharge, or aftercare supervision. In itself, the idea of having conditions that enable people to be in the community rather than in hospital is accepted, and has been for many years in this country. However, community treatment orders would be a new provision. They are used around the world, but the research on the beneficial effects of those provisions—let us face it, they are fairly new in most of the countries concerned—is not yet conclusive one way or the other. It makes sense for us to have a cautious approach to the use of those powers and their application. But the Lords amendment goes much too far; the conditions that it puts on the application of the provision might kill it.
On work force reforms, it is desirable to build up the multidisciplinary team that will be responsible for providing services both in hospitals and, crucially, in the community, and to build up people's confidence in it.
I declare an interest, as a vice-president of the National Autistic Society. I wish to refer to the impact of the Bill on people with autistic spectrum disorder.
I shall begin by picking up on the point made by Mr. Blunkett about a lawyer's charter. I agree with him and others that if Ministers put the principles in the Bill rather than in the code of conduct, it would help others to determine Parliament's intention. The Minister of State was reluctant to do that with the Mental Capacity Bill but changed her mind, I am pleased to say. I urge her to put those principles clearly in the Bill.
I am concerned about certain aspects of the Bill, particularly as they affect people with ASD. When the Minister of State gave evidence to the Scrutiny Committee, I expressed such a concern to her. I am pleased that the Government have looked again at the impact on people with a learning disability, but when the last Mental Health Bill was drawn up in 1983 very little was known about the autistic spectrum compared with today. Kanner's autism was well documented but, since then, we have gained a lot more knowledge about the more able end of the spectrum, particularly Asperger's syndrome. The combination of the powers of detention and the change in the definitions in the 1983 Act is a matter of concern in respect of people with Asperger's syndrome.
People familiar with the condition will know that sufferers can from time to time demonstrate quite challenging behaviour, not because there is a psychotic base to it, but because of the nature of their disability. An episode is usually event-triggered, whereby the combination of great anxiety or great fear—something the person concerned would have difficulty articulating—leads the sufferer to behave in a particular way. Interestingly, the Bournewood case involved an adult with autism who was unable to self-advocate and articulate his own condition when he was taken into hospital.
The Government made a concession in the other place to ensure that people with a learning disability are not considered to be mentally disordered unless they demonstrate very aggressive or seriously irresponsible behaviour, and I ask that that same concession apply to those with an ASD.
The Minister is nodding her head the wrong way, from left to right. I want it to go more north to south. I shall make this case again if I serve on the Committee. The Minister has heard me make the point before.
The difference of knowledge of this subject now compared with 1983 is clear. I have been very critical of psychiatrists and I am pleased to say that they are responding in the way in which they treat people with autistic spectrum disorders, particularly Asperger's syndrome. But if we have a combination of diagnoses—an ASD diagnosis and a mental health diagnosis that are quite distinct and separate, or even a triple diagnosis of an ASD, a learning difficulty and a mental illness—we require people with a lot of experience and specialisms to sort out the behavioural messages coming from those different diagnoses.
My worry about the broadening of the definition of mental disorder is that for many people with an ASD, what many of us would regard as "normal" autistic behaviour will be misdiagnosed as psychotic behaviour because there are simply not enough mental health professionals around the country to be able to disaggregate those different behaviours. As I have often said, the result of that is misdiagnosis and mistreatment, which can have a serious and adverse effect on the health of an autistic person and on the environment into which the person is taken. One would put someone diagnosed with ASD into a hospital only if one were 100 per cent. sure that that was truly the last resort, because that environment itself would be extremely disturbing to them.
Advocacy is related to the issue I have been addressing, but it has broader implications in terms of mental disorders generally. I am pleased that under the Bill the Minister has closed the so-called Bournewood gap, about which she and I have had many discussions, by amending the Mental Capacity Act 2005. However, huge advocacy implications arise from closing the Bournewood gap, and other advocacy implications arise from the rest of the Bill. Therefore, it is with some distress that I learn that the Minister has reduced the amount of support—legislative and otherwise—that would give appropriate levels of advocacy to mental disorders both generally within the context of the Bill and particularly in terms of closing the Bournewood gap. In Committee I hope that she will propose impact assessments in respect of advocacy for the Bill as a whole and particularly the advocacy requirements that she anticipates will be needed to do true justice to the way in which she has decided to close the Bournewood gap. I am unsure whether information on that is available now, or if it is being worked on. [Interruption.] The Minister is replying from a sedentary position, but perhaps she could respond to that later.
I have participated in many mental health debates in the House, and I wish to share my experiences not only on the autism front but of other cases that I have dealt with, particularly as a constituency Member of Parliament. I have had many cases where people have committed suicide, sometimes while they were in-patients, unfortunately. Some committed suicide after they had been an in-patient and had received community services. I dealt with one tragic case of somebody who was treated in the community and who ultimately murdered his mother. In all those cases, when I read the medical records—they have been made available to me—it is clear that there are common themes. There is a lack of early intervention: there is a long journey from the moment when the symptoms or concerns first begin to getting the person concerned in front of the professional who might be able to help. Having got to that point, there is also an issue to do with the long, ongoing treatment. Members understand that many people have cyclical conditions where there is a period when they are fairly stable but then go down, as that is the nature of many mental health disorders. However, there is often a lack of continuity in intervention so that such people simply fall through the net. That is a common theme in all the cases I have dealt with, including those ending in suicide and the one case where somebody else was found dead.
The hon. Lady is right that many of us have had experience of such constituency cases. The issue of compliance that she has picked up on highlights why it is important that we introduce supervised community treatment.
I hope that the Minister and I will have an opportunity to talk about that further if I am fortunate enough to serve on the Committee, as it is an important matter.
I pay tribute to the Government for introducing some measures that are beginning to make a difference. For example, a GP practice might have access to a community psychiatric nurse who is associated with the practice. That enables GPs—who often do not have mental health specialisms—instead of merely writing a prescription, which frequently is all that they can do, to make a referral, in the knowledge that the patient will be seen quickly.
I cannot emphasise enough to the Minister how strongly I believe that early intervention in mental health issues can prevent serious cases from arising that grab headlines and are often the result of a failure of services—or of processes—to support the person concerned. If I serve on the Committee, I hope that the Minister will allow me to explore those issues a little more thoroughly with her.
I speak in this debate as the Chairman of the Joint Committee on Human Rights and in support of our report on the Bill. The Bill is of major importance for the human rights of those with mental disorders, which is a highly vulnerable group, including the right not to be subjected to inhuman or degrading treatment, the right of persons of unsound mind not to be deprived of liberty save in accordance with a procedure prescribed by law, and the right to respect for private and family life.
I know that the Government accept that this legislation must comply with our human rights obligations. The Secretary of State has certified her view that the Bill is compatible. My right hon. Friend the Minister helpfully wrote to me on the introduction of the Bill. She also wrote that the Government had conducted "an ECHR audit" of the Mental Health Act 1983, the principal piece of legislation amended by the current Bill, and that in respect of the 1983 Act they were
"not seeking to leave in place any provisions which we know or suspect to be incompatible".
While I commend the Government's approach to human rights in drafting the Bill, there remain issues on which my Committee has a different view.
We reported on the Bill in another place and amendments were made there, responding to some of our points. I am grateful for the Minister's recent comprehensive response to our report, which we will publish soon. My Committee might report further, so it would be helpful to have a clear indication today of whether any of the amendments made in the other place will be accepted.
Mental health law is highly complex, so it is important to set out the arguments behind the JCHR's concerns, to ensure that the House is aware of those human rights considerations. We considered that, broadly, the Bill satisfies the criterion of
"objective medical evidence of a true mental disorder" for psychiatric detention to be lawful. However, we had concerns over the broader definition of "mental disorder" in clause 1. Given its breadth, we believed that it was desirable to include the principles of non-discrimination and proportionality in the Bill. On Third Reading in the other place, clause 10 was added, requiring fundamental principles to be taken into account when revising the 1983 Act's code. Those include "minimising restrictions on liberty" and "avoidance of unlawful discrimination". That was a welcome development, although it would be preferable to see those principles made directly applicable under the Act, rather than indirectly through the code.
As it currently stands, clause 3, which was not supported by the Government, narrows the definition of mental disorder, so that people could not be considered to have a disorder for the purposes of the Act solely on a number of grounds: substance misuse; sexual identity or orientation, which we considered in our report; commission, or likely commission, of illegal or disorderly acts; and cultural, religious or political beliefs. That clause provides an extremely important safeguard.
The Bill replaces the original test for detention of a person for treatment, which was that that treatment was
"likely to alleviate or prevent a deterioration of his condition" with the new rule, that
"appropriate medical treatment is available for him."
In strict convention terms, the JCHR saw no obstacle to that, although we noted the ethical concerns expressed by psychiatrists that they should not be custodians for preventive detention, but should be providing treatment of therapeutic benefit. Clause 5(3) reinstated a likelihood of benefit of treatment, and it would be a pity if the Government were to seek to overturn that.
The JCHR had stronger concerns as to whether the "appropriateness" test was sufficient to ensure convention compliance for treatments without consent requiring a second opinion under section 58 of the 1983 Act, such as pharmaceuticals for mental disorder or electroconvulsive therapy. We also considered that forcible feeding and other treatments invasive of physical integrity such as ECT should be subject to the same second opinion safeguards. In her recent letter, my right hon. Friend the Minister said that she would consider that, which I welcome, and we urge her to implement our recommendations.
On renewal of detention, rather than just the initial decision to detain, we shared the concerns of JUSTICE and the Council on Tribunals that the Bill provides for renewal on the report of a "responsible clinician" who need not be a doctor. That could mean that the decision is not in accordance with the need for objective medical expertise.
Clause 6 prevents a responsible clinician from renewing detention without the agreement of a registered medical practitioner who has examined the patient. We regard that as an important protection, which conforms with Strasbourg case law, and we would be very concerned if the Government opposed this clause.
In the ECHR case of JT, a patient claimed that she had no right to change her nearest relative, who was required to be informed when, for example, she made an application to a mental health review tribunal for a discharge from detention. Her nearest relative was her mother, who was living with a man whom the patient alleged had abused her. The ECHR concluded that the patient's article 8 rights to privacy and family life were being breached, so the Government undertook to introduce legislation, first to enable a patient to apply for replacement of a nearest relative on reasonable grounds and, secondly, to prevent certain persons from acting as the nearest relative.
The Joint Committee agrees that clauses 26 to 29 of the Bill appear to meet the terms of the settlement in JT. However, given that applications to displace the nearest relative may be made by others, including hospital authorities, we had concerns that the new ground for replacement, of "unsuitability", might be used to displace people who were merely seen as "difficult" by those authorities. We also believe that "unsuitability" is too broad a test to meet the Government's apparent intention that patients would be able to displace nearest relatives only in situations of abuse or suspected abuse.
We commented in our report on the procedure for community treatment orders, which place conditions on patients living in the community, and especially the breadth of conditions that may be imposed. In the JCHR's view, any restrictions on conduct should be proportionate, and a patient should be entitled to a review of those conditions by a mental health review tribunal.
Mention has been made of Bournewood patients and some of the most complex provisions are in part 2, which amends the Mental Capacity Act 2005 to meet the Strasbourg judgment in the case of HL. HL was a compliant, incapacitated patient. The ECHR found that his admission to, and detention in, hospital, under the common law of necessity, breached convention articles 5(1) and 5(4). We reported that the procedures for legal authorisation to detain a compliant, incapacitated patient are unduly cumbersome and we doubted whether, even with professional advice, residential care home managers would understand them.
We are also concerned that the effect of Government proposals will be to apply means testing, charging persons deprived of their liberty and living in residential care homes for their care. That raises important human rights issues under articles 5 and 6; as well as discrimination issues under article 14, in that people deprived of their liberty in hospitals will not be similarly charged.
In our report we suggested two enhancements to the Bill. The first relates to the treatment of Bournewood patients, because the inadequacy of safeguards for them is very serious, given that they lack the capacity to consent. We do not believe that the common law and the Mental Capacity Act currently provide sufficient protection for the physical integrity of such patients. In particular, more needs to be done to address the issues raised in the case of Storck v. Germany, which concerned state control over private psychiatric institutions. The Bill would be an appropriate vehicle to introduce such provisions.
Secondly, we were concerned about the use of seclusion: safeguards should be placed in the Bill to ensure that seclusion is only used when strictly necessary and is subject to review.
There are other issues on which we did not comment directly, and the points that have been made about advocacy are very important. We also did not refer to the effect of the Bill on the rights of child mental health patients. I note and support the clause 24 amendment in the other place to require primary care trusts to provide age-appropriate services and accommodation for children and young people. I hope that we will be able to report further on the Bill to take account of some of the additional points that have arisen in the debate.
The Bill, of course, is about much more than human rights, as we have heard in the debate so far. Indeed, I think that this is the first contribution to refer to the issue of patients' human rights in this context. I hope that the House will take into account the human rights of those vulnerable mental health patients who are detained or compulsorily treated by the mental health system in further consideration of the Bill today and in Committee.
It is a great pleasure to follow Mr. Dismore, many of whose concerns I share. Notwithstanding those concerns, my view is that the Bill should receive a Second Reading tonight precisely because of the welcome and protective amendments that were made on a cross-party basis and with great expertise in the House of Lords.
I listened carefully and attentively to the Secretary of State as she introduced the Bill this afternoon. She invoked, in support of the Government's determination to reform the treatability provision, the need to catch within the net people who currently are not being caught. Specific reference was made, and justification was provided, in the cases of people with severe personality disorders. I have to say that I have listened over a period of weeks and studied some of the evidence, and my distinct understanding was that there was a misapprehension about that category of person. In so far as such people have not been treated in the past, it is principally because of a combination of reasons, including an absence of resources; a mistaken and outdated belief that such people could not be treated; and, as the corollary of those two states of affairs, the lack of effective treatments to secure the desired result. If in fact one secures a proper interpretation of the existing legislation and one has the resources to deliver what is necessary, it seems that that fox is easily shot.
I respect the Minister's intentions and her humanitarian philosophy, but I suggest that she is wrong on this issue. The use of the term "appropriate treatment" is far too broad and potentially invasive. I do not think that it can be justified. Ministers were put to the test in the other place by Lord Howe, Baroness Barker, Baroness Meacher, Baroness Murphy and Lord Carlile—to name but a few—who tabled an amendment that said "we don't want that. What we want is to ensure that there is provision that will guarantee that the alleviation of, or the prevention of deterioration in, the condition should be the criterion that has to be satisfied if compulsion is to be deployed." That is entirely reasonable. If the Government think that people will benefit—that a therapeutic gain will be derived, or an improvement or prevention of deterioration in the condition will, in most circumstances be the predictable consequence—I do not know of what exactly it is they are afraid.
I do not doubt the intentions of the Minister and I do not seek to impugn her integrity, but if the Government get their way, the inevitable prospect is held out of an expansion of preventive detention, if not on an industrial scale, at any rate in terms of significant increases in numbers. Simply as a matter of logic that must be what is portended by Government intentions. If the Government do not intend in any way to change the numbers, why do they need to go to such lengths to defy the professional wisdom and change the law?
My view is that the Government are wrong. They should accept the Lords amendment and there is a powerful consensus on that point. It is the view of the Joint Committee and of the Richardson review, which was requested by the Government. It is the considered judgment of the House of Lords and the opinion of the Mental Health Alliance, as well as the determination of the Scottish Executive. In terms of humility, the Minister might like to consider the possibility that she is in splendid isolation for the simple reason that she is mistaken.
I agree with the hon. Gentleman that "appropriate treatment" is inadequate, but is not the problem in the very words that he uttered? One cannot guarantee that treatment will bring about therapeutic benefit or prevent deterioration. I hope that we can find some compromise that will improve on "appropriate treatment" but not go so far as to say that we can guarantee the outcome.
That is a perfectly reasonable point, but I think—I shall stand corrected tomorrow if I am mistaken—that study of the record will show that I went on to say "guarantee" what the "likely outcome" would be. The hon. Lady is absolutely right. I concede the point: there are no certainties in this field and it does not do to be either arrogant or presumptuous, but we have to work on the balance of probability of the effect of one policy as distinct from that which is likely to flow from another. That is one area of concern and I beseech the Government at least to reconsider their position.
My second concern is that we should preserve the judicious amendment made in the House of Lords to bring the rights of people who suffer from mental illness into line with those of people suffering from physical illness. In other words, if someone possesses full decision-making capacity about his or her mental health, I cannot see why he or she should be subjected to compulsory detention and compulsory treatment—compulsorily undertaken, manifestly, against his or her will—when that person has said, "I don't want it". If somebody suffers from a physical condition and is told, "You're ill, you could be treated and it would benefit you", but the person does not want to be treated because of the pain incurred, the side-effects experienced, the financial loss sustained or the family disruption entailed, that individual is entitled to say no. I simply point out to the Minister that if that principle applies in the context of physical illness, it ought in all propriety and equity to apply in the context of mental illness, too.
My hon. Friend is making an excellent case and expanding on the point that I tried to make earlier, but which the Secretary of State clearly failed to understand. On the Government's logic, does not my hon. Friend agree that the 92 per cent. of heart disease patients who fail to take their statins according to prescription, or the cancer patient who declines chemotherapy because of the possible after-effects, should be subject to a degree of compulsion, because they do not agree with the diagnosis and the medication for their physical condition? Why should the two be treated differently?
My hon. Friend is absolutely right. He has reiterated on the Floor of the House a powerful point made by my noble Friend Earl Howe in the other place. I was surprised and disappointed at the paucity of the comeback of Lord Hunt of Kings Heath—an extremely experienced Minister with considerable expertise.
I thank the hon. Gentleman for giving way as there is a point I need to put to him. There are people, particularly young women with personality disorders, who do not lose their judgment—they do not have impaired judgment and do not lose capacity—but if left untreated and uncared for they would commit self-harm and, in some instances, suicide. Is the hon. Gentleman prepared to say that we should turn our backs on those people and not give them treatment?
I did not say that we should turn our backs on them, but that we should have respect for them and be willing to accept the verdict they give. That is where, in a sense, never the twain shall meet between us.
Finally, in terms of the Bill's architecture, I turn to the subject of community treatment orders. Let me say at the outset that there is scope for some consensus on this point, although I do not particularly approve of the way in which the Government handled the matter—the evidence was suppressed and published late, which seems rather a pity—but the suggestion has been made that CTOs could be the way forward for the structure of modern provision in the community. I see some merit in that suggestion although I think that the case is unproven.
My argument is not against the community treatment orders per se, but rather, as articulated by Norman Lamb, against what seems to be envisaged in terms of conditions and restrictions on the lifestyle of the people who would be subject to the orders. What is proposed by the Government in a rather all-encompassing power seems to me quite frightening. It is a disproportionate, far-reaching and adverse provision that could have an impact on a great many people. There is reference to the entitlement to impose a condition that a patient shall refrain from "particular conduct"—conduct gloriously unspecified. Might Ministers have it in mind to say that patients should not be allowed to go to a public house, or that they should have to observe a curfew from six in the evening until six in the morning? I do not know quite what Ministers have in mind, but we have to be careful that we are not guilty of an intolerable infringement of human rights and, throughout the Bill, an approach that would have another damaging effect in practical terms—to drive mental illness underground. We do not want to do that. United across the House would be the conviction that we must avoid that eventuality; the disagreement is about the means to do so. I listened to expert voices, including that of the former chief executive of Broadmoor, who is known to me and who says that is his particular fear. Many others have said the same.
Having expressed my concerns about the Government's intentions on treatability, severe impairment and the conditions to be imposed in CTOs, I conclude on this point. In the media—especially the less responsible and more hysterical elements thereof—there is all too often a single view of the mentally ill as a homogeneous and undifferentiated group who should, almost without exception, be regarded with suspicion, anxiety and probably foreboding, too. That is to do a great disservice to hundreds of thousands, indeed millions, of people who at some time in their lives suffer from mental illness. My appeal to the House is to accept that, whatever our views, Parliament has a duty in this matter not to play to the lowest common denominator—I do not suggest that the right hon. Lady is doing so and I hope others will not suggest that either. We should not in any sense fan the flames of popular and misguided prejudice; rather we should seek to raise our game, to recognise that pertinent and compelling points have been made to us by the mentally ill, by people with extensive professional experience and by Members of the other place who spent a great deal of time in detailed scrutiny and deliberation of these matters. I am sure that some of what the Government intend, and which is in the Bill, will be of benefit, but I worry about Ministers' fixity of purpose at this stage, when they say, "We don't like those amendments, they're bad news and we shall use our majority to get rid of them". I appeal to the Government, in the interests of the mentally ill, the community as a whole and the reputation of the House, to think again. It is not too late.
It is always a delight to follow John Bercow. It is a delight, too, when he joins us in the Division Lobby, which he seems to be doing more regularly of late—I do not know whether it portends anything.
I particularly wanted to speak in the debate because I have had a few experiences of mental illness, although not in my own life. My mother committed suicide after many years of alcoholism and several attempts at suicide. She had been in many psychiatric wards and followed many forms of psychiatric treatment and she died in 1993 from a cocktail of paracetamol and alcohol—she probably took her own life.
One of my first and most difficult cases as a Member of Parliament involved a delightful and sensitive young man called Matthew Davies. He, too, had an alcohol problem and committed suicide on
Another case involved a friend of mine—the actress Lynda Bellingham, whom many Members may know as the Oxo mum. She owned a flat two floors above her home and let it to a tenant in 2001. After a month or so, it became apparent that he was not well when he started to accuse her and her sons of shouting obscenities at him and stalking him. She had to have him removed from the flat and a few months later the police came round to tell her that he had accused her son of firing pellets at him, despite the fact that her son was abroad at the time.
Then there was a solicitor's letter, saying that she had been stalking this man, Mr. George Millar. By the following February, things had gone quiet until one day a home-made bomb was thrown through her window—a brick wrapped in a lit firework and a tee-shirt that had been doused in petrol. Her tyres were slashed and the police mounted an investigation. In fact, they had already mounted several previous investigations. When they arrived at the man's house, the screensaver on his computer said, "Revenge, like Oxo, is a dish that is best served cold".
That story is particularly chilling because although the police and the authorities took action, it took a year for the case to go to court, during which time the man was under detention. He was charged with arson and threat to kill, but the judge said that he was not in a sufficient condition to be judged by a jury and that if the woman was prepared to drop the charges, he would ensure that the man was sectioned. Unfortunately, two days after she had withdrawn the charges, the police came round to her house to say that since the man had been in psychiatric care for the last year, he was well enough to be out on the streets. In fact, his then girlfriend acknowledged a week later that he was not taking his medication as he had promised. He was readmitted to a psychiatric hospital from where he escaped, after hitting one of the psychiatric nurses over the head with a chair. Eventually, he hanged himself in his room.
In that case, it is abundantly clear that the combination of the criminal justice system, forensic psychiatry and the psychiatric health system had failed the man, failed the woman and failed the community. It is thus important to move forward towards a better combination of all those different services so that we serve the individuals better. I believe that this is primarily about the safety and care of the individuals themselves rather than that of the wider community. Several hon. Members have made the point that the number of those who self-harm and commit suicide is far higher than the number of homicides relating to people who have been in psychiatric care, which is why I believe that individuals should be the prime focus of our debate.
My basic principles are pretty simple. The first is that there is still an enormous gap in provision. The Government have done a lot to increase provision, but the talking therapies that are available in wealthier middle-class areas are not available in poorer areas. That is partly because many poorer communities do not produce the number of local counsellors or people trained in these therapies that the other areas do—an issue that we need to address.
Another concern is that in far too many areas of the country, the response to depression and many of the lesser psychiatric illnesses from which many people suffer and which can be cured, is merely pill popping. Many of my constituents are on incapacity benefit because they have got used to years and years and years of taking antidepressants and have become addicted to them.
My hon. Friend, like other hon. Members, is making a powerful speech, recognising the necessity of the measure before us. Does he nevertheless recognise the concerns expressed, for example, by my hon. Friend Mr. Dismore and John Bercow, about the wide powers in the Bill? Those powers are bound to be the cause of concern, so one hopes that there will be a tightening up in Committee.
My hon. Friend makes an important point and I will come on to the specific issue of when detention is right and when we should be reluctant to use it as a means of control.
In pursuance of the point made by Mr. Winnick, may I press the hon. Gentleman on a specific question of the conditions imposed on people on community treatment orders? Given that there is a potentially draconian power here, does the hon. Gentleman agree that people should at least be allowed to appeal against an imposed condition?
That is an important area that needs to be discussed and should be teased out in Committee.
I believe that we do not yet know everything that there is to know about a whole series of mental disorders. Angela Browning made an important point about progress with autistic spectrum disorder and I am sure that the same will apply to many of the personality disorders that, 20 years ago, were considered absolutely untreatable, incurable and beyond the pale. I believe that in 20 years' time we may have a completely different attitude, which is why it is so important to have legislation that is able to meet changing perceptions in the future.
There are two specific areas in which I am not entirely sure that the Government have got it right. The first is the issue of appropriate treatment—the so-called treatability clause. I believe that the amendment passed in the House of Lords places a very high hurdle, but it is not actually the hurdle that the hon. Member for Buckingham gave us, which was actually a variation of the Lords amendment. In fact, his was a much lower hurdle because he put several qualifications into it.
Innovative treatments will come along in the next 10, 20, 30 or 40 years in respect of which no clinician will be able to guarantee that they will ameliorate the condition or, indeed, prevent deterioration of it—certainly not in the first few months. The very fact of detention may lead to deterioration of the condition for a short period, but the mere fact that one cannot guarantee that that effect will be produced, as the House of Lords determined it, should not necessarily lead to an automatic get-out clause. I think that it is possible—
The hon. Gentleman has not been in his place for all of the last part of the debate and I want to suggest a possible line of amendment. The Lords suggested that appropriate medical treatment should be defined as a medical treatment
"which is likely to alleviate or prevent a deterioration" in the patient's condition. Could not the Government consider wording along the lines of treatment "which is intended to alleviate, manage or prevent a deterioration in his condition"? I do not believe that the enormous difference or gulf between the different sides of this debate is as large as others have suggested.
I have been in my place for the whole debate. However, in respect of amendment, the hon. Gentleman seems to be looking for the word "guarantee", but it is not there. The word used is in the amendment is "likely". Surely he can accept that the amendment is asking only for the probability that help can be available or that the condition will not deteriorate.
I doubt whether many lawyers would agree with the hon. Gentleman about the meaning of "likely". That is precisely the problem, as many clinicians have expressed to me.
Another important issue is the exclusions in the 1983 Act, which are not in the Bill. I question—it is no more than that—why it is seen as right and proper to detain someone under the Bill for bulimia or anorexia nervosa, while exempting people in respect of alcohol or substance abuse. In practice, many of the treatments might well prove to be similar. Many of the processes that would have to be gone through would be the same and there is an element of compulsion. Yet many people treating anorexia nervosa and bulimia would say that volition is a very important part of the process of treatability.
I also question the removal of the exemption for sexual identity, sexual deviancy and promiscuity. I understand what the Government are saying, but no one today believes that being homosexual is a reason for putting someone in a psychiatric ward. I entirely accept that. However, if sexual identity or orientation is not such a big issue, why not allow the Lords amendment to retain the provision?
I also question how the treatment of paedophilia is handled. The law may well want to allow a clinician to detain someone whom he believed was about to engage in paedophile activity. However, according to the clinical definition, only 5 per cent. of child sexual abuse cases are actually perpetrated by clinically defined paedophiles. Any clinician I know who felt that a patient had a tendency towards paedophilia would be most likely to refer him to social services or to the criminal justice system. That is the proper place for that to be dealt with. Of course, it is also possible to draw an important distinction between somebody who believes themselves to be God and somebody who believes in God, so it should be possible for us to have an exemption for religious belief. But it is important for the Government to remember that the House of Lords wording retains the word "solely", which is an important hinge in terms of how the provision works.
Finally, I pay an enormous tribute to those who work in mental health. The people who work voluntarily at Hafal in my constituency and those who deal with many people with very chaotic lifestyles do a job that many of us would find impossible.
Several hon. Members rose —
I very much welcome the contributions that have been made, particularly by Labour Members, because they show that there is some support for some of the House of Lords additions to the Bill, most of which I support very strongly.
On a light note, I am delighted that the exclusions under the definition of mental disorder include political beliefs. When I stood for election to this place, I was not actually accused of being mad, but I was certainly accused of being a militant activist, a medical dinosaur, Swampy and even King Canute. I am absolutely delighted, therefore, that there is no chance that abnormal political beliefs could be included.
I want to say a little about treatability, because so many Members have concentrated on it. What do we, as doctors, mean by treatment? First, the ideal is a cure. Obviously, infections can be cured, and depression can be cured in many cases. Secondly, if we cannot cure, we want to control. Diabetes and hypertension can be controlled. Schizophrenia can be controlled with the right treatment and the right follow-up, and nobody would argue against detaining people with treatable schizophrenia. The third bit of treatment is palliation. If it is incurable, cancer can be palliated. The neuroses can also be palliated, as can some of the psychoses if they cannot be helped otherwise. With the addition of psychological treatment, some people with personality disorders can perhaps be helped, but it is a very big "perhaps".
I personally like the phrase
"likely to alleviate or prevent a deterioration" in the House of Lords amendment; it takes me back to my time working as a physician taking in emergencies. We took in well-known psychopaths from the accident and emergency department, but it was impossible to get one's psychiatric colleagues to help at all once a psychopathic personality had been diagnosed. I always remember one chap who came in having swallowed a parcel of nails. He was assessed by psychologists and did not have a psychological illness, so we had to let him go. The only way we could have settled our consciences when we let him go would have been by taking his supply of nails from him, but he would not let us take them, because that was robbery. I ended up having to buy them from him, and he no doubt moved on and tried the same trick somewhere else. The point of mentioning him is that no amount of psychological advice or anything else would have dealt with him. Unless we include the House of Lords amendment, such people might be at risk of being locked up for ever and a day, because there is no way anybody would change them.
On clause 4, which deals with impaired decision making, because of the restrictions of time, I will only point out the Law Society's absolutely excellent paragraph on that subject. It is very short, but it is an excellent, explicit explanation of the Lords amendment, and it should be read by everyone.
Moving on to the renewal of detention, the fact that the Lords want a doctor to be involved has already been mentioned. I was pleased to learn this morning that the Medical Health Alliance has slightly changed its stance and agrees that there is a very strong place for professionals other than doctors to be involved, but at least one of those involved must be medically qualified. I have a fear that, in the national health service as a whole, the moving of certain tasks to professionals other than doctors possibly happens because it is a cheaper option and, perhaps in some cases, as a response to the deficits.
On clause 32, which deals with a doctor being involved in the decision to place the treatment on a community treatment order, I have learned of the tremendous usefulness of assertive outreach teams at home. They are excellent when they are adequately supported, and I am very keen for the Government to consider the support that assertive outreach teams get. As other hon. Members have said, mental health services are always soft targets when one is trying to balance the books, and it should be a target for the Government to help those teams. It has always puzzled me why there is no target for the time taken to see a consultant psychologist. That seems to be a complete gap.
Turning very briefly to young people, a lot has been said. When I was still working, which was a few years ago, to walk into an adult psychiatric ward would put almost anyone off, and to put children into those circumstances would be awful.
I wish to conclude with two very important things. First, as has been mentioned several times, the Mental Health Alliance—the broadest coalition in the mental health world, with 79 members, and a unique alliance of all the groups—supports the Lords amendments with slight provisos, one of which is about doctors' opinions, but it cannot be swept aside. The Mental Health Alliance says that reform
"must be fair and workable".
The Royal College of Psychiatrists says that reforms must
"command the support of the professional groups and patients".
To conclude, I can say as an independent what party members possibly cannot say, and this is an appeal to the Government that this is not a political issue; it is an issue that we must get right for the good of all the patients who suffer from such illnesses. I shall leave the House with some words from a far more eminent independent MP than myself: A. P. Herbert, who was the independent MP for Oxford University before world war two. He wrote in his book:
"I have even thought that, on great occasions where the parties were furiously raging together, the votes of Independents, cast with, of course, more conscience, might be as straws in the wind and show the party leaders which way the pure air of free opinion blows."
I think that the pure air of free opinion blows in favour of a lot of the House of Lords amendments, and I should very much like the Government to support some of them.
Time is short so I will not go into some of the details of mental health issues in Hackney. I managed to mention some of them in an intervention. People in Hackney are three times more likely to be admitted to hospital with schizophrenia than people across England as a whole. I highlighted in my intervention particular issues about people from black and minority ethnic communities. Although that was the reason why I began to look in detail at the Bill, this is not the Bill that tackles those many concerns. However, the Bill does deal with the important area of compulsory treatment and how and when it is applied.
I have had the opportunity to canvass opinion from a wide range of sources and I pay tribute to the people I spoke to for their time and expertise. In particular, I pay tribute to Hackney Mind and the service user group there, and members of the staff of the East London and The City University Mental Health NHS Trust, including nurses, approved social workers, consultants and other mental health professionals. I also pay tribute to some people who have not been mentioned so far in the debate: tenants, residents and housing managers, who have to deal a lot with the reality of mental health issues on a daily basis.
Because time is short, I am going to focus on only two issues in the Bill. I hope that, if I am lucky enough to serve on the Committee, I will get the chance to probe these and other issues in more detail. The first issue is the compulsory community treatment order, which is one part of the Bill that I welcome. Treatment on the basis of need is a principle that pervades the national health service. Even when consent is not possible, because somebody has not got the capacity to identify their need, that treatment should still be forthcoming. That basic principle protects patients with mental health problems. The patients and service users that I spoke to had mixed views about the matter, as one might expect. The main concern of mental health users that I spoke to was to ensure that the care package, whether it be voluntary or compulsory, was properly delivered. There is further debate to be had—but again the area is not properly part of the Bill—about the way in which care packages are delivered. I hope to go on to that in more detail in the second half of my comments.
I will give some comments from users themselves, because their voices have not been heard enough in the debate. One of them said to me: "At least in hospital there is monitoring, but in the community you can feel lost." Possibly with compulsory community treatment orders that feeling of being lost may be addressed. Someone else said: "It would be better if people were not going to hospital so often." That individual's view was that, if compulsory treatment in the community was forced upon them, that would be better than being forced to go into hospital. That comment came from somebody who had a mental health problem and who, when she was not in her worst condition, was aware of the problems and had the capacity to judge her situation. Others had concerns about being forced to take medication—because of the bad side-effects. That is obviously a huge issue for people who have to suffer the many uncomfortable side-effects of medication. One person said that, in her case, medication may quiet the voices, but it caused a range of problems for her.
There is a place for compulsory community treatment orders, but it depends on the individual. That was the message that came loud and clear from service users in Hackney. Interestingly, the overriding view of the service users that I spoke to was that, when someone needed police involvement in their case, there was therefore a strong case for compulsory treatment. When I spoke to people—not just in Hackney—in the course of my research it was interesting to note that, in effect, compulsory treatment currently exists and is allowed under case law. Under section 2 of the 1983 Act, people can be detained for 28 days, and under section 3 for six months, in hospital. But then they can be released on long leave. Long leave presents people with the possibility that they may be once again admitted to hospital. In effect, clinicians are addressing the difficulty of not having compulsory community treatment orders by finding ways through that, through case law. If we get things right in the Bill, it will make it easier for clinicians to provide that option and that choice.
Talking to professionals, they said that, depending on the relationship the team had with different individuals, the option was sometimes sold as a method of support and sometimes it represented the strong arm of compulsion that was necessary to ensure that people got the treatment that they needed. I have already quoted the consultant who talked about a section being an act of kindness. He and others I spoke to who deal with the issue of sectioning and compulsory treatment on a daily basis believe that, in place of hospital, compulsory treatment orders are a useful and important option, as long as there are safeguards. I am sure that, in Committee, we will look in greater detail at those safeguards. The consultant that I quoted went on to say that the paperwork involved in sectioning was a great discipline for clinicians to justify their decision. I hope that, in any future compulsory treatment that is introduced, that will equally apply.
Among approved social workers and community psychiatric nurses, there was concern—it is a concern that has not really been addressed so far in the debate—about the risk to staff of applying compulsory treatment in the home. I hope that the Minister will look into that. It may not be something that comes up in the precise, narrow aspect of the law that is contained in the Bill, but it is nevertheless an important issue. If we are to introduce a Bill that is workable, we need to consider how compulsory treatment will apply. It may be that, in a lucid moment, the patient is aware and wants to have the compulsory treatment, and that the family and other carers may support that. However, if there is an issue about how the treatment is applied in a patient's home, for example, we need to look carefully both at the rights of the patient and the safety of the staff involved. It is clear from talking to both patients and professionals that it is chaotic people who prefer self-medication, but then do not take it. They are often at great risk themselves, but they also put staff at risk.
I want to highlight one example from the point of view of residents in my constituency. A tenant leader rang me in some distress because a neighbour of hers in a small estate was behaving rather erratically. It was clear that the individual had mental health problems. The neighbour was not judgmental. She herself had suffered from mental health problems in the past. At one point, though, the individual was running round the estate with no trousers on. In a worst case scenario, without proper treatment in the community or in hospital, that could have led to the individual being put on the sex offenders register. As far as any of us were aware, that was not the issue for that individual. It seems that sometimes compulsory treatment can protect a patient from worse scenarios and perhaps inappropriate criminal treatment. That is important. It is in the best interests of the individual, his neighbourhood and the other people he has contact with that he gets the treatment he needs. That is not to say that the crisis teams and the current approach to sectioning are not important as well. I pay tribute to those who work in the crisis teams in Hackney, who deal with the sharp end of the issue.
The other key issue that I want to touch on is advocacy. I feel strongly about this matter, partly because of my experience in a different area as an advocate for someone with a learning disability and my awareness of the difficulties of getting through the system. I have not really got time to go into the issues of advocacy in general, but, particularly in relation to the compulsory treatment element of the Bill, it is vital that advocacy is included. I give the Minister notice that, if I am lucky enough to serve on the Committee, I intend to table amendments to try to make sure that advocacy is better enforced and part of the Bill.
Professionals agreed with me that there was a need for more advocacy, although interestingly they had different views about what advocacy should be. Under the Mental Capacity Act 2005, Hackney was granted only £40,000 for the whole borough for advocacy. Clearly, there is a resource issue involved as well. If we make sure that advocacy is written into the Bill— to protect patients who are having compulsory treatment—we should also make sure that the resources follow. That is important. In Hackney, as well as the need for mental health advocacy, many mental health patients have complex needs in relation to language and literacy. Mental health advocacy in a constituency such as mine is particularly important.
The East London and The City University Mental Health NHS Trust is currently working to give service users a greater say in their own treatment. That is clearly the best form of advocacy. But the Revolving Doors Agency—I should declare an interest, because my husband is a patron of the agency—says that half of the people that it is involved with are dealing with six to 10 agencies. Its view is that a lot of people in the criminal justice system are there not primarily because of their mental health, but because of the level of chaos in their lives created by their health needs. For example, they have no GP so therefore no incapacity benefit. Without incapacity benefit, they have no housing benefit. With no housing benefit, they have no hostel or they lose their homes. A lot of things are missing in the system if we do not get that advocacy in place. I hope to expand on some of these issues in Committee.
I have a long-standing interest in mental health having recently been a member of the Joint Committee that found the Government's 2004 draft Bill to be "fundamentally flawed." I was involved in the education and training of social workers for 15 years and, before that, I was a mental health social worker—one of the first to be approved under the Mental Health Act 1983. Methuselah-like, I also worked under the Mental Health Act 1959 for seven years and sectioned under the very old system. I have applied for compulsory admission many times, including while working in extremely difficult circumstances as a member of an out-of-hours night duty team. In my opinion, compulsory admission is essential in some circumstances, but it is a frightening and demeaning experience for the individual concerned and often has profound effects on professionals, sometimes with regard to their physical safety.
Almost any attention to mental health is welcome. I really do not want to hear the resigned admission from professionals that mental health is yet again the Cinderella of the NHS. After all, Cinderella got to go to the ball and the prince to boot, but that is not what has usually happened in mental health. New spending, some of which the Secretary of State outlined, is welcome, but in Wales, as I pointed out in an intervention, we are still far behind the situation in England, with some people reckoning that we are four years behind. We still have some Victorian facilities. For decades, mental health has been denied proper resources that would turn the promise of new drug and behavioural treatments into a reality of a sustainable life in the community for people with severe mental problems. The reform of mental health legislation is thus long overdue. After all, Professor Richardson, who convened and ran the specialist group, began her work in the last century—more than eight years ago.
I share the general disappointment of the Mental Health Alliance and others about the Government's successive efforts to formulate a worthwhile and workable Bill. After all, the draft Bills—miraculously, almost—managed to unite nearly all interested parties in opposition, including the royal colleges, Hafal, which is the mental health alliance in Wales, the British Psychological Society and the local Mind groups that I consulted in the Rhymni valley and in my constituency in Gwynedd. They were all against the 2004 draft Bill, which one gentleman described as a "mad axe man Bill". Others complained less colourfully that the Bill, at least as it was then framed, might just about calm some of the headline writers.
As we know, stranger murder, which is so beloved of the tabloids, is thankfully very rare. The number of homicides has gone up over the past 20 years, but, as was pointed out earlier, the proportion of homicides committed by people with mental illnesses has remained constant. However, when there is any assault involving a mental illness component, a great deal more needs to be done to attend to the victim's needs, or, sometimes tragically, the needs of those who are bereaved. I say that as someone who represents a family that has suffered in one of the most high-profile cases, which is often cited, but cited thoughtlessly. I would, however, apply the same principle of care for the victim to cases that do not have such allure for journalists of a certain type.
The focus of the 2004 draft Bill was compulsory detention and treatment, as is the case with this Bill, along with community supervised treatment. The vast majority of people with mental problems are in no need of detention or compulsory treatment. They pose no danger to anyone except sometimes, tragically, themselves. Rather, they face the problem of accessing assessment and treatment in the first place. Hafal correctly points out that there is a right to assessment in Scotland—I leave that thought with hon. Members. However, this long-expected Bill, which it is assumed will last for 25 years, does nothing for the vast majority of people with mental or emotional problems. In that respect, the Bill is a colossal lost opportunity and, worse, it risks stigmatising such people.
The Government seem to presume that it is possible more perfectly than is the case to identify those who constitute a danger to others so that they can be detained. As the Royal College of Psychiatrists points out,
"the prediction of risk whether done by actuarial or clinical methods is at best an inexact science".
The Department of Health states that in the past eight years, there have been about 400 homicides in which mental illness has been a component. However, about a third were carried out by people who had been judged not to be a risk just days earlier—this is not an exact science. I need say only that the vast majority of professional people in the field do not share the Government's presumption. Indeed, if the Government's intentions are enacted, we will run a real risk of detaining a number of people who do not constitute a risk to others, while having no guarantee that some of those who constitute a danger will not be out in the community. That would be the worse of two worlds.
Much has been said about treatability, and the treatability test is there for a good reason. Treatment has developed, and cognitive behavioural therapies and assertive outreach are employed by talented individuals. However, it is clearly the view of professionals involved that the treatment of personality disorders is usually not possible. Incidentally, I fear that more coercive measures will have the effect of putting off some people from accessing mental health services in any way at all. Such measures might thus have a perverse effect.
I have seen at first hand the dehumanising and institutionalising effect of detention in a mental hospital with no therapeutic effect. We have already been there and done that. The advances in drug therapy in the 1950s allowed large hospitals to be closed. However, their closure was also driven by a humanitarian appreciation of the pointlessness of the experience suffered by many long-term patients. Many lives dribbled away to no point, such as those of seven ladies whom I met one day in the back ward of a hospital. They had clocked up between them more than 350 years of hospital life for being moral defectives—for having babies out of wedlock in the 1930s.
If we are to admit people to hospital against their will when they are not capable of being treated, or at least deriving a therapeutic effect, the condition of some who are untreatable on their admission might not change throughout their detention. On what possible basis could they be discharged if there was no change or the treatment did not work? Would we not be in danger of locking people up indefinitely? As Professor Richardson said, we are in danger of compulsion being a lobster pot—easy to get into, but very difficult to get out of. I fear that the Government's proposals will lead to people being detained who are then unable to be treated and discharged. In this case, the Government need protection from their own folly.
Compulsory supervised treatment in the community should be possible only when appropriate treatment is available. That is an especially important point for rural Wales—and, no doubt, elsewhere—because of the remoteness of treatment centres. Complying with a community treatment order for a person in a city, where the treatment centre might be a journey by bus of only a few miles, would be quite a different proposition than doing so for a person in Pwllheli, in my constituency, where the local hospital is 30 miles away, or even in Aberdaron, which is 17 miles further on. The same could be said for much of rural north-east and south-west Wales, as well as rural Monmouthshire.
Other aspects of the Bill have a particularly Welsh dimension. For example, there is a disparity between the thrust of the Bill and standard 2 of the Wales national service framework, which is titled "Service user and carer empowerment".
I hope that the Welsh Assembly will ensure that communication through the medium of Welsh will be available. It is a long-established principle that someone before the courts in Wales should be able to use Welsh "without hindrance", to use the formulation of His Honour Edmund Davies. People covered by the Bill should be able to use Welsh freely because freedom itself might be at risk. Equally, in the case of compulsory detention, a full apprehension of the meaning of words and the way in which they are used will be essential because someone's freedom might be at risk.
I appreciate the opportunity to speak in this debate, Mr. Deputy Speaker. I very much welcome the Government's proposals to reform the treatment of people with severe mental illness. I recognise that this is a difficult area in which to legislate, given the necessity to meet the needs of many different groups, but I believe that the Bill will make treatments more successful.
Some Members of this House and the other place have criticised aspects of the Bill, especially the reforms to enforced detention and to community treatment on the grounds that they blur the divisions between patients' rights, patient care and public safety. However, I would argue that we will never adequately resolve those complex issues unless they are discussed and understood together.
One of the overriding reasons why the area is so difficult is that any legislation that we pass will affect so many distinct groups in our constituencies: patients, patient groups, medical practitioners working in GP surgeries and hospitals, our local authority social services working in our communities, and the general public. Taken separately, my instinct is to take account of the individual rights of all involved as far as possible, but with so many groups to accommodate and because of the nature of this area of law and the need for compulsion, it is our job to take an holistic approach to scrutinising the Bill, rather than to concentrate on the concerns and rights of any single group in isolation.
The rights of patients to refuse treatment must be balanced with patients' long-term interests and the interests of the public. Given the degree of complexity, all mental health legislation is inevitably a compromise. The 1983 Act was a compromise; the medical norms that have developed from that Act are certainly compromises; and the Bill, if it becomes law, will also be a compromise. What we must ensure is the freedom of local practitioners to work in multidisciplinary care teams, the freedom of GPs and psychiatrists to form a judgment based on their relationship with their patient and, crucially, the freedom of the patient to have easier access to mental health tribunals—something that my right hon. Friend the Secretary of State said the Government would work towards as a priority.
Freedom on the ground will always induce fear that the powers will be misused. We cannot escape the fact that in this area of law such fears are inevitable, but what we are discussing is a system that allows the wishes of mentally ill patients to be overridden for a period by their perceived needs. By broadening the criteria for compulsion, the Bill would allow clinicians the freedom to work across the individual health problems of a patient. Psychiatrists could impose treatments regarded as appropriate, rather than only treatments that are likely to alleviate the specific severe condition of the patient. That is an important change, because it would allow psychiatrists to provide treatment for one mental health condition with the hope of alleviating another. It would, for example, be left to clinical staff to decide whether it is appropriate to treat patients who cannot be cured of their personality disorder, but who might benefit from the treatment of their depression or anxiety. With the correct safeguards, which the Bill provides, such powers give clinicians the freedom to provide better treatment for the sake of the patient and of others.
The Bill is not about turning our doctors into jailers, as has been suggested in the other place; it is about giving front-line medical staff the flexibility to provide the treatments that they think are best. Opponents of the reform ignore the fact that mental health legislation is permissive: it allows doctors to do what they think is correct and appropriate in the circumstances. After all, no reform that we make can override human rights legislation that gives clinicians the final say.
Supervised community treatment orders are the second major innovation in the methods by which clinicians could care for their patients. If we want to find a balance between patients receiving their care in the place that they feel most comfortable and medical practitioners being able to ensure the continuation of treatment so that patients are not condemned to repeated periods of ill health and hospital stays, we require a model for community supervision. Some have argued that treatment should be entirely for the benefit of the patient and that threats to the wider public should be dealt with by the criminal justice system, not by doctors. I would argue that there is a role for doctors to impose treatment on those who pose a danger to their own health and that of others, and that doctors are best placed to make such decisions. My fear is that if patients are not able to receive their compulsory treatment in the community—treatment imposed for the protection of their own health—clinicians will continue to be forced either to retain patients in hospital, or to risk the decline of their patients' health in the community.
Increased care in the community will, of course, be a challenge requiring adequate investment in local authority social services and multidisciplinary care teams, but the Bill gives us the opportunity to take great strides in improving mental health care in the community and providing those receiving compulsory treatment with a great say in how and where they receive it. If we are concerned about discrimination against the severely mentally ill, it is the Government's duty to find a way to enable those receiving compulsory treatment adequately to exercise such choices. It is also the Government's duty to allow patients to receive their treatment with the least disruption to their lives. Supervised community treatment would allow greater confidence that when patients leave hospital, treatment regimes will be adhered to and the patients will not be made the subjects of repeated readmission to hospital and periods of in-patient care. It is vital that the choice is offered honestly and that past failure to adhere to treatment in the community is not made a precondition of a supervision order.
The Bill also redefines the key professional roles involved in care, allowing a greater degree of valuable multidisciplinary care to take place in the community. The introduction of the roles of responsible clinician and approved mental health professional will allow a range of clinicians from the fields of nursing, psychology, occupational therapy and social work to perform roles that are currently restricted to consultant psychiatrists. That will greatly strengthen the multidisciplinary model of care that has emerged in mental health services in recent years and will allow clinicians to work across disciplines in the way that is most appropriate to the patient. That view is strongly supported by Amicus, Unison, the British Psychological Society, the Royal College of Nursing and the British Association/College of Occupational Therapists, which represent many of the multidisciplinary clinicians and carers who, under the proposals in the Bill, would lead such care.
I fully understand the fears of some local authorities, including Tameside and Stockport councils, which serve my constituents, that the changes might prove to be expensive. It is vital that resources be made available for reforms to local social care policies, but I am confident that the proposed changes to the legislation will be in the best interests of our constituents who are in need of community care for severe mental illness.
What my right hon. Friend is proposing is that clinicians should be able to offer supervised community treatment in England and Wales as a matter of course, thus not having to wait until their patients have suffered damaging and repeated health decline in the community. As I have argued, we should not forget the aim of mental health law, which is to allow mandatory treatment to be given where necessary for the sake of the health of the patient and the safety of others. There is little point in such legislation if it does not enable clinicians to provide beneficial care to their patients without disruptive breaks in treatment. It is also important not to be transfixed by an orthodox interpretation of individual human rights. The short-term right to refuse treatment and the long-term right to receive appropriate care will often conflict in cases of severe mental illness.
A balancing act will always be necessary in mental health law, but the Bill promoted by my right hon. Friend the Secretary of State offers us the best balance. There can be no doubt that that the law needs to be modernised. Widening the scope for treatment and allowing compulsory treatment in the community, as well as in hospitals, will benefit patients and communities alike. That is why I shall support the Bill tonight.
I am conscious of the amount of time left this evening, so I shall keep my remarks as short as possible.
Many of us entered the House with the motivation of caring for a particular group in society, and from a desire to put things right and to ensure that the state steps in only when it is necessary to protect that group. Sometimes, politicians and Members get a raw deal from the media. We are often painted as self-centred and self-serving people with massive salaries and wonderful expenses who do not particularly care about or want to focus on British citizens, the least well-off and the most vulnerable groups in society.
My experience from my two years in the House is that virtually every Member of Parliament to whom I have spoken, whether Conservative or Labour, is motivated by a profound sense of duty, responsibility and care for particular groups in society. That is why I was delighted that when I questioned each of my colleagues who made it to the House in May 2005, I found that they, like me, were concerned with a specific group in society. We produced a small booklet called "The Forgotten", in which we outlined the key groups that we felt needed support and more thought and concern. Those groups were people with AIDS and HIV, people who suffer from diabetes, the terminally ill, children with state carers and a group that I have always been concerned about—the millions of people who suffer with a mental health challenge.
It is not as though people with mental health challenges are a small group; I am pretty certain, just from the statistics, that there are hon. Members in the Chamber right now who struggle with a mental health challenge. I am also absolutely convinced that every single Member in the Chamber has had experience of a mental health challenge, perhaps through a family member, a work or other colleague, a carer, or a friend. I am delighted that this debate is taking place, and that in many ways the Bill, in its current form, is not party political. We are pretty much all behind the objectives of the Bill in its current form. I hope that we can see our way to agreeing on some minor amendments in Committee, but that we will find a way to push forward with the Bill in pretty much its current state.
From the debates in the other place and from the representations that I have heard from Mental Health Alliance and many other well-respected and well- supported bodies, it seems that the evidence and common opinion point in one direction. They largely support at least five of the six amendments from the other place, so I hope that the Bill will reach Committee in its current state, and that Ministers will keep an open mind and will allow for some movement when we debate the amendments from the Lords.
The biggest challenge that people with a mental health problem face in Britain today is the stigma attached to such problems. There is a danger that when we talk about such matters in the Chamber, and when the media pick up on the issues outside the Chamber, we do damage in that respect, but I have to say that in the majority of contributions made today, hon. Members have done incredibly well in showing our concern to point out that of those patients who suffer with mental health issues, a very small minority are violent or dangerous. I am glad that we have not concentrated solely on the dangerous minority.
The Bill is an opportunity to move forward with the concerns, the plight of those who suffer, the treatments available to them, and issues to do with the people who care for those sufferers. However, I have a couple of concerns. Is it right to detain somebody who has not committed a crime? That is a pretty fundamental question. Statistically, it is possible that at some point in the next few years a Member of the House will do something that is against the law. Do we detain everyone in the House on the basis of that probability, just in case we go on to do something wrong? We would not accept that approach in society, and we should not accept that approach to people who suffer with a mental health challenge. We need to look very carefully at the amendment made in the other place on compulsory community treatment orders, and ensure that we are not introducing such a principle in terms of compulsory treatment, either in an institution or in the wider community.
I do not wish to create division where it does not exist because, as I said, the motivation behind the Bill, which has been a long time coming, is welcome, as it seeks better treatment for people struggling with a concerning problem for themselves and for the rest of society. In its current form, the Bill will certainly rise to meet most of the challenges, but there is an omission concerning the issue of advocacy. If someone cannot represent themselves clearly and fluently, and if they believe that the family member who is automatically their advocate is not the right person so to act, we need to consider tabling an amendment in Committee to introduce the concept of choosing an alternative advocate.
The Bill exists mostly outside of party politics. I am not sure if there will be a Division this evening, but if there is I hope that we all consider the precise issues at stake and vote for the sort of society that we want rather than vote along party political lines. The evidence from the House of Lords and from third-party bodies is practically unanimous on five of the six Lords amendments, and I hope that those amendments will be carried through into Committee. The Bill gives us a great opportunity to take a positive step forward on treatment for patients' happiness and well-being and for society as a whole. I therefore hope that it proceeds, preferably uncontested, to Committee, where we can examine the specific issues more closely.
It is not surprising that the Bill has proved controversial. After all, we are dealing with contentious issues of liberty and personal responsibility, and we have been asked to determine in what circumstances anyone with a mental disorder should be detained against their will. Those and other issues have been the subject of debate since the Government announced their intention to introduce new legislation in 1998.
During the Bill's controversial passage through the other place, their lordships sought to address those problems where they still believed that an individual's human rights were at issue. As elected Members of Parliament, we need to take into account, too, legitimate public concerns about safety. However, given the importance of this area of legislation, it is essential that we find a way forward that addresses the concerns of all parties. We need legislation on the statute book that is, and will be, suitable for our communities in the 21st century. A stand-off between the two Houses on the issue would not be helpful, and we can achieve our aims by considering the way in which the Lords amendments would work in practice, rather than in principle.
I am not a lawyer, but I trained as a psychiatric social worker, and worked as such for many years before moving on to different things. I should like to consider the Bill from the perspective of the approved social worker—or the approved mental health professional under the Bill—who sets up and undertakes with doctors the assessments that determine whether or not someone needs to be admitted compulsorily under the Mental Health Act 1983. Approved social workers are highly trained and skilled professionals who act independently and are personally and legally accountable both for their decisions and for the safety and well-being of the service user who has been sectioned until they are accepted on a ward by nursing or other staff. How will the amendments to the definitions of mental disorder and treatment for it help or hinder that process of assessment?
I have looked at the original Bill and the Lords amendments in relation to the criteria for compulsory admission from the community, particularly the issues of "medical treatment" and "impaired" decision making. The original Bill talked about the availability of "appropriate medical treatment", whereas the Lords amendment used the words,
"medical treatment...likely to alleviate or prevent deterioration" in the patient's condition. In both cases, the term "medical treatment" has the same broad meaning. It includes medication, nursing care, habitation and rehabilitation, as well as psychological treatment or support. One focuses on the notion of availability of "appropriate" treatment, and the other on its likely benefits, but are those two notions very far apart? If the treatment available would not help the patient by alleviating or preventing deterioration in their condition, can it be said to be appropriate? It appears to me that the issue involves interpretation rather than the words themselves.
The Lords have also inserted a new condition into the provision on criteria for formal admission for consideration in the assessment:
"because of his mental disorder, his ability to make decisions about the provision of medical treatment is significantly impaired", which, of course, refers to the patient. In my experience, the amendment reflects exactly what already goes on with Mental Health Act 1983 assessments, where doctors and approved social workers use their skills and knowledge to ascertain through the assessment process whether the person before them is, in effect, unwell and in need of treatment or care, or whether the person should be given choice and take responsibility for their actions and decisions.
I want to provide the House with an example. I spent last Wednesday in the company of approved social workers and observed a mental health assessment in a police station. The gentleman concerned had been picked up by the police at 8.30 after a complaint from a neighbour, and the forensic medical examiner expressed concerns about him and asked for an assessment under the 1983 Act to determine whether he needed assessment or treatment and whether he was fit for interview. During the mental health assessment, he was asked questions to establish the nature of his relationship with the complainant and his understanding of why he was in a police cell. The professionals probed his belief system and his emotional state and sought to determine whether there was an underlying psychosis, depression or anxiety state and the level of risk that he posed to himself, to the person who had made the complaint against him and to the wider public. Although the professionals were clear that the man had a level of mental disorder, when they discussed the issue between them, they concluded that it was not so bad that they needed compulsorily to detain him and that he should receive treatment on a community basis. The outcome of such an assessment is likely to be the same, whether or not the Lords amendment is accepted.
As I have said, we can set the boundaries within which professionals make their decisions about assessment, treatment and responsibility of people who experience mental disorders. We can also—the Government, to their credit, have done this—regulate to ensure that the professionals who are involved in those essential decisions have the knowledge and skills to make informed, professional decisions. Having ensured that, we must then trust the professionals to make such decisions to the best of their abilities. However, we must also ensure that the professionals whom we ask to undertake assessments on our behalf and on behalf of society as a whole have the resources to do so safely and in a timely manner.
Department of Health figures show that 27,353 patients were compulsorily admitted from the community to NHS facilities and independent hospitals under part III of the Mental Health Act 1983 and other legislation in England in 2005-06. As I have said, the approved social worker is responsible for organising the assessment, but the responsibility is greater than that—they have to apply to courts for a warrant if the person will not let them into their home to undertake an assessment, make judgments about whether to involve the police in the assessment process, consider how quickly the assessment should take place, consult other professionals and family members about their views and, ultimately, make an independent and balanced decision whether admission to hospital is, given all the circumstances of the case, the most appropriate way forward. They decide whether or not to apply for a formal admission, and if they decide not to apply, there will be no admission. The process of admission can be fraught, but representations from approved social workers via the British Association of Social Workers and the ASW national leads network suggest that the situation is being made worse by problems with the way in which resources are managed.
I have mentioned my day with the approved social workers in central London, but I did not mention that when we left the office last Wednesday there were two other mental health assessments that had been waiting since the previous Thursday, which was before the bank holiday weekend, for police support to be available to enable them to take place. That was because the person requiring assessment was known to have been aggressive or had used threatening behaviour, and the ASW and the doctors could have been at risk without police support. There is also the issue of perhaps having to convey an unwilling patient to hospital. That delay of almost a week for police support could have had very serious consequences for the people who needed assessing and those around them. Other issues are involved in the assessment process, such as the identification of the bed and the availability of ambulances.
The British Association of Social Workers points out that although the individual approved social worker has responsibility for managing the assessment process, for making informed and professional decisions about whether to admit someone, and for the safety and well-being of the patient from the time that they sign the section papers to the moment the person is admitted to hospital, the resources they need to complete their tasks are not within their control locally. The Government have said that those issues, including police time, are best dealt with through local arrangements. I hope that in recognising some of the present difficulties there will be consideration in Committee on how to give guidance about what local arrangements Ministers believe should be in place to protect the individual and the public by ensuring that where admissions to hospitals are necessary they happen in a safe and timely fashion.
The Government have made great progress in the provision of mental health services—not an easy area in which to legislate or to work. I hope that the Bill has a constructive passage through the remainder of its legislative process.
The other place has a reputation for well-informed debates, but I have been struck by the level of expertise that hon. Members have shown today, sometimes speaking from painful personal experience.
I pay tribute to all those who work in community, day-care and hospital mental health services in my constituency and elsewhere. They work very hard in a challenging area of health care where their occasional failure is often leaped on by an unforgiving media while their frequent success is much more rarely mentioned.
I share many of the concerns of other hon. Members, including my hon. Friend Norman Lamb, about the initial version of the Bill. I have been strongly lobbied on some of its provisions by constituents, one of whom said:
"Please do whatever you can to stop the Government's proposals in their tracks and get a law for England and Wales that's as fair as the law in Scotland."
However, as the Minister knows, I also share some of the concerns that led to the Government presenting the Bill in its original form, particularly in relation to people with personality disorder, who have suffered from the fatal combination in the Mental Health Act 1983 of very specific definitions of mental disorder and illness and the treatability test. That has led to people with personality disorder being denied treatment, whether in line with the law or, as John Bercow noted, based on a misguided view that the condition cannot be treated.
The current law is, by common consent, flawed, but the need to guard the civil liberties of some of the most vulnerable citizens in our communities means that any amendments to it must be carefully worded. That will be a difficult task, particularly in the case of personality disorder, even the definition of which is difficult to grasp. In the words of Mind,
"Slotting people into neat categories is almost impossible, because each individual is unique and personality is very complex. It's a mistake to assume that giving people a diagnostic label means knowing more about them, and it's too easy to use these terms in a judgemental way."
That was certainly so in the circumstances that applied in the case—now, I am afraid, the very public case—of one of my constituents, a young man called James Green. It seemed to me that he was unable to access the treatment that he needed because, in a sense, he did not have a proper mental illness, having been diagnosed with personality disorder. I should like to take a moment to pay tribute to the care, dedication and perseverance of the Green family—Les and Jackie, James's parents, and particularly Daniel, his brother, who has championed his case tirelessly.
James had a long history of difficult, sometimes very aggressive behaviour involving self harm and of threats to harm his family. As he grew older, he increasingly said that voices were telling him to harm himself and his parents, and he wanted to be admitted to somewhere where he would feel safe. Again and again, though, the situation was that his medication was reviewed and even if he was admitted for a short time he was returned to his family, sometimes with community support but making life increasingly difficult for them.
In July 2005, James set fire to his house, endangering the lives of his parents and his neighbours. He was prosecuted for arson and recklessly endangering life and sentenced to seven months in prison. That was the beginning of a prolonged relationship with the criminal justice system.
Court-appointed psychiatrists examined James repeatedly and diagnosed personality disorder. An assessment in December 2005 clearly concluded that he did not have an acute, chronic or serious mental illness but that he nevertheless ran a "high risk" of harming himself and others. Another stated,
"no mental illness, borderline learning difficulties, personality disorder. Immature, impulsive, substantial risk of re-offending/self-harm."
Yet the judge in the case found it almost impossible, despite repeated adjournments to seek professional advice, to locate an appropriate setting where James could receive treatment.
During that time, I met the partnership trust with James's brother, Daniel, and it said that there was a legal framework for treating mental illness but that James appeared to fall outside it. On one occasion, it stated that it believed it
"most appropriate for any consideration of his health and social care needs to be seen within the context of his current offence and resolution by the courts."
It became clear to me that Gloucestershire probation service and Her Majesty's prison at Gloucester were familiar with dealing with people with personality disorder.
I discovered a psychiatric morbidity survey among prisoners, which revealed that 78 per cent. of male remand prisoners had some form of personality disorder. We have effectively handed over the care of many people with personality disorder to our prisons and our probation services.
It is typical that James's case reaches something of a climax tomorrow when he appears before a judge for sentencing, not before a doctor for treatment. However, the family hopes for the outcome that his assessment and treatment at a unit called Kneesworth house in Cambridgeshire will become a more permanent arrangement. James has—eventually—benefited from treatment, which has been more psychological than pharmaceutical. I compliment the staff at Kneesworth on their work with him. They have demonstrated two fundamental truths.
First, no one should be excluded from treatment because of the form of words used in their diagnosis. The Bill, even as amended, appears to prevent such exclusion. It is clear that it covers personality disorders. The draft illustrative code of practice, which would not be affected by the amendments, clearly specifies that personality disorders will be covered.
Secondly, Kneesworth has demonstrated that, even with difficulty and after years of trying, the current system can provide treatment, with a treatability test in place. The Bill, as amended, would provide a much better and clearer legislative environment, in which we all agree that people with personality disorder should get the treatment that they need.
"For the purposes of subsection (2)... a person shall not be considered to have a mental disorder... on the grounds of... substance misuse... sexual identity or orientation... his commission, or likely commission, of illegal or disorderly acts... his cultural, religious or political beliefs."
It is difficult to see who could take exception to that. It would not have prevented James Green from obtaining treatment and it does not reintroduce the narrow definitions of mental illness that the 1983 Act contained.
The amendment on the treatability test would reintroduce the words of the original Act but would not enforce a narrow test. It simply states that, for a treatment to be provided, it must be at the very least,
"likely to prevent a deterioration in" someone's "condition". The condition does not therefore have to be perceived as curable or definitely treatable. The treatment does not have to be guaranteed, simply "likely", to be beneficial. It is difficult to understand how that could possibly have denied someone such as James Green treatment. If that modest test is not passed, how is compulsory treatment distinguishable from detention without treatment?
In Rethink's rather blunt words:
"Hospitals are not prisons. If people are detained for non-health purposes, it must be through the criminal justice system."
The Royal College of Psychiatrists agrees. It described the Lords amendments as "very sensible amendments". It even stated that they would have public support. It conducted a poll in the south-west of England, which found that 75 per cent. of people
"do not think that people with mental health problems should be forced to have treatment from which they cannot benefit."
I have talked to not only doctors and psychiatrists but the Green family about the amendments that were tabled in the other place. Daniel Green studied them before I even spoke to him. Neither he nor I can understand why they pose any risk to people with personality disorder getting the treatment that they need. I hope that the Government will realise the potential for building cross-party consensus on such an important Bill.
As many people have remarked during the debate, this is a complex Bill with a history of controversy, compromise and confusion. That is mainly because the plan to introduce a mental health Bill was replaced by the decision to amend the Mental Health Act 1983, and this has clouded the discussion of what the Bill is saying, as opposed to what many people want it to do, to say and to promote.
I recognise the anxiety felt by families, carers and those with a mental health problem. With at least one in six of the population suffering from depression, anxiety or obsessive compulsive disorder at some time in their lives, one in 22 having a personality disorder, and one in 200 suffering from psychosis, with the resulting loss of contact with reality, mental health issues touch most families at some point and bring them into contact with our mental health services.
It has been good to hear recognition across the House today of the Government's improvements to mental health services. The range, availability and effectiveness of the services has certainly changed. Years of neglect are slowly being counteracted. I also recognise that an increase in budgets is not the only thing that will improve services. Training, new facilities and new partnerships need time to be put in place and to become effective.
The Bill has achieved a high profile specifically because of the voluntary sector, which now receives a huge amount of funding to improve mental health advocacy, raise awareness of mental health issues and provide a new range of services. Organisations such as Hafal, the Mental Health Alliance, Mind, and my own Bridgend organisation, Mental Health Matters, are rightly eager to ensure that the Bill will provide the highest level of protection and rights to those who face compulsion at some time in their lives. Like others, I pay tribute to their unending commitment and creativity in providing a range of services to people who are mentally ill.
Statistics cannot give a realistic picture of the pain, suffering and torment experienced by those with a mental health problem, and by their families and carers. I want to stress that. When considering the Bill, I have borne in mind the fact that, of the 300 people in every 1,000 who experience mental health problems every year in Britain, only six will become in-patients in psychiatric hospitals. In 2005-06, 27,779 patients were sectioned and would therefore have been considered for a community treatment order.
The Bill relates to how we deal with the limited number of people who face formal admission every year. It is about strengthening patients' safeguards and tackling human rights incompatibilities. It is not about improving access to services, expanding the range of community-based mental health provision, or handling housing problems caused by tenants with mental health problems. It is not about tackling mental health awareness. It must, however, signal the Government's commitment to dealing with all those issues if it is to be effective and to reassure those who use mental health services. While only six of the 300 in every 1,000 people who experience a mental health problem are likely to face compulsion, failure to address these issues will lead to the vast majority of sufferers, and their families and carers, fearing that the services will not be there to meet their needs, to help their recovery, to keep them safe, to enable them to live in the community and to avoid compulsion.
It has been alleged that the Bill is driven by media stories of murder and other violent crimes committed by people with mental health problems. There are fears that it is heavily biased towards extending the powers of compulsion and control. I believe that many of those fears have been addressed by changes in the Bill, including a list of exclusions, clarification of impaired decision making and the use of places of safety and time limits in the context of renewal of detention.
Others have already highlighted the fear and anxieties of families such as one in my constituency. A family member was murdered by her husband, who had a mental health problem. The family were frustrated by a system which they felt left their sister vulnerable. Within a very few years of her murder, her husband was seen in the local community in the company of a nurse. The family felt betrayed and insecure, not knowing whether this man would be in their street, shop or pub. They were angry that they had not been consulted about community rehabilitation plans, or made aware of an appeal to the mental health review tribunal. They, and I, feel strongly that victims' families should have such rights.
Like others who have spoken, I welcome the duty placed on health authorities to admit children to age-appropriate settings, and to provide specialist assessment and supervision for detained children. My constituency has the highest suicide rate among young males in Wales. I have spoken to parents of young people who are afraid of being returned to adult wards that are frightening and threatening and increase their vulnerability at the time of greatest need.
Many years ago I lodged an advance directive with my GP. I set out the limits to treatment that I wanted to establish in the event of my losing capacity. I believe that those who are mentally well should be able to write an advance directive nominating the person whom they wish to act as their nearest relative, primary carer or advocate, specifying people with whom information can be shared by medical practitioners, and giving directions about future treatments. Such documents should be taken into account by those making decisions on the provision of treatment and on compulsion. An advance directive gives individuals a voice at a time when they may well be unable to speak for themselves in their own best interests, and can reduce anxiety for patients' families and friends.
For a time I managed a specialist health and social services project for people with dementia. Joint assessments were made by the community psychiatric nurse and me when people were referred to our service. Our assessments and conclusions were different, reflecting our different training and perspectives, but they were better assessments for being joint. I fear that there will be a risk of "medicalisation" of assessments if the social workers and two doctors are replaced by a range of health professionals and a responsible clinician, especially if they work in the same mental health team. I hope that care will be taken in the training provided for that new role, and that advocacy of the service user's perspective will not be lost.
It is in the best interests of the Bill for the fundamental principles to be written into it, and the status accorded to the code of practice clearly identified. I believe that that will reassure users, carers and mental health professionals about the ethos on which mental health services are predicated. It will provide evidence of the Government's commitment to improving services consistently in line with those principles, and demonstrate their commitment to the mentally ill while also protecting the public.
As I have said, the Bill deals only with the very small percentage of people who require compulsion. We should not forget that it is aimed at that small percentage of people with severe mental health problems. It is sad that much of the debate, and the anxiety that has been created, relates to issues outside the areas covered by the Bill. We have sometimes been sidelined into discussing things that are missing from our mental health services, rather than the good aspects of the Bill and the safety and security that it provides for people at their most vulnerable. I trust that the anxieties expressed by Members today will be discussed again in the Committee on which I hope to serve.
I am afraid that I will not be able to do the subject justice, because we have heard excellent speeches from the hon. Members for Rhondda (Chris Bryant) and for Caernarfon (Hywel Williams) and from my hon. Friend John Bercow. However, I shall try my best.
Ever since I came to this place, I have taken an interest in mental illness. We all have our own reasons for pursuing such an interest, but I am always touched and humbled by those people who come up to me and thank me in a quiet way for being their voice and for raising their concerns. Very often, people with mental illness feel marginalised and feel that there is no one out there listening to them.
That was brought home to me when I visited an outreach centre in Cheshunt where, after a roundtable discussion, the director of the centre said that one of the patients would like to have a word with me in private. I went into a room and met a gentleman who suffered from schizophrenia. He wanted to educate me about the illness. I was moved by the conversation—he did not need to validate himself to me—because he said that if someone had cancer or heart disease it would not define them. They would still be Charles with cancer or with heart disease, but he was all too often referred to as schizophrenic. I thought that that was very upsetting.
Mental illness makes many MPs feel a little uncomfortable. I have heard Members talk in the Chamber about personal experiences, but I think that I am right in saying that never in the history of Parliament has a sitting MP admitted to having a mental health problem. That was touched on by my hon. Friend Adam Afriyie. I often wonder why there is a reluctance to come forward.
Many MPs who want to discuss a personal issue must pause for thought and perhaps the following things might occur to them. They might think that mental illness is perceived in our society as a huge weakness. They might wonder how their association would react. "Would it throw a supporting arm around me or would it move to deselect me? How would my children fare in the playground if I, as an MP, admitted to having a mental illness? Would they be teased or possibly even worse? How would the local and national press react? How would my constituents react? What would be the response from my colleagues in this place?" All these factors might weigh on an MP before they discuss a personal issue.
We understand that mental illness does not sell well on the doorstep. If we were talking about heart disease or cancer, the Chamber would be much fuller. I am sure that there are MPs who, in their hearts, would like to be here speaking up for the mentally ill against what might become a fairly oppressive piece of legislation. However, they are risk-averse. What would happen if they had the courage to speak up and one of those isolated tragedies occurred in their constituency? Would they be pilloried by the local press for supporting "loonies and nutters"? Those are not my words, but they are words that are used far too often by the media to describe sick people who deserve our compassion.
Does the hon. Gentleman agree that the fact that we have a ten-minute rule on speeches in this debate and that so many MPs have spoken with passion indicates the huge amount of support and interest in this House for people with mental illness? I am concerned that the hon. Gentleman is suggesting that that interest is not there. I believe that it is, as has been demonstrated by tonight's debate.
I have paid fulsome tribute to the speeches of Members this evening but my views are little different from those of the hon. Lady and I hope she will accept that.
I am concerned that we may be deliberately, or mistakenly, pandering to the tabloid press and validating some its more screaming headlines. I did some research; the Daily Mail had the headline
"Knife maniac freed to kill...Mental patient ran amok in the park", while The Sun had
"Violent, mad. So docs set him free. New community care scandal."
They are appalling misrepresentations of people with mental illness, and it does our media a great disservice that they persist in bringing them forward. However, I believe that we live in a civilised society and that our Government will in their heart not want to regulate in this area to satisfy the tabloid press.
The media reporting of mental illness is shameful. The Royal College of Psychiatrists has stated:
"The media's obsession with reporting cases of mental health patients who become violent has seriously distorted the truth. Mental health is not a predictor of violence against others for almost all diagnosis".
"There is a slightly higher risk of violence with a diagnosis of schizophrenia but this is insignificant compared with the relationship between other conditions and violence—alcohol consumption being the main one."
Before I leave the subject of the press, I wish to say that it is unacceptable at a time when we have consigned phrases such as "cripple" and "retard" to the scrapheap that many of our leader writers still think that it is legitimate to use words such as "nutter" and "loony". Much of the media's reporting can be put down to laziness and avarice to keep their circulation up.
Recent research by the Glasgow University Media Group into the attitudes of senior production staff to the reporting of mental illness resulted in the following conclusions—unsurprisingly:
"News and features emphasise the newsworthy rather than the worthy. Stereotypes are therefore enormously useful and they short circuit the need to spend time understanding a topic. They simply follow a rapid tried and tested formula which is known to work commercially."
"This is consistent with the tendency for people with mental illness, when not shown as violent predators, to be allocated to the category of helpless victim."
One of the tragedies of the Bill proposed by the Government is that there was not much compassion in it. There is a lack of willingness to challenge some of the distortions of mental illness peddled and promoted by the media. I have a great deal of time for the Minister—I have met her privately on a couple of occasions to discuss my concerns about mental health problems in my constituency— but in her ministerial press release of
Let me give a further quote from the Royal College of Psychiatrists:
"The law should seek to reduce stigma and discrimination against people with mental illness. Wherever possible the principles governing mental health care should be the same as those which govern physical care enabling people to feel able to seek help early, to ask about their fears and difficulties, without fearing scorn, humiliation or loss of status, freedom, job and friends is the best way to bring about improvement in their health."
I will not dwell on statistics, but it is worth pointing out that people in this country are almost four times more likely to be killed in a motor traffic accident than to be murdered and 80 times more likely to be killed in a motor traffic accident than to be killed by someone suffering from schizophrenia. In our tolerant society, we cannot live without risk and still call our society free. With the best intentions in the world, the Government cannot legislate to create a risk-free society.
It appears that a different set of rules apply to the mentally ill—that the normal rules relating to limiting civil liberties and rights are suspended. Let us imagine what would be the outcome if we were to follow the advice offered in an article in The Daily Telegraph today. The article is entitled:
"MPs should vote to save innocent lives".
It is written by Philip Johnston, who writes:
"If this Bill will save lives, then Parliament has a duty to support it."
I can think of a couple of Bills—unattractive Bills—that might save lives, and which might have been brought forward in a less enlightened time, such as 30 or 40 years ago. We could introduce a Bill to ensure that people with AIDS are locked up so that they do not pose a public risk. That would be unattractive, but I am sure that it would save a few lives. We could go out and round up young black males in Peckham, which might save a few lives in that area, but that is an unattractive and unpalatable solution. So why is it that when we discuss mental health we too often separate sufferers from everyone else to whom we accord rights?
Things have improved for those suffering from mental illness and I would not be churlish enough to deny that, but the Bill is the acid test, because it deals with some difficult issues. Of course people who pose a danger to others should be given treatment and looked after. But 79 members of the Mental Health Alliance would not be supporting the Lords amendments or opposing the Government's original drafting if the Bill would not massively extend the scope of the existing provisions to people who for good reasons should not be covered by the new legislation. I cannot believe that the 79 members of the MHA have got it wrong, or that the BMA and the Institute of Psychiatry have got it wrong, but the Government have got it right. Surely the Government must recognise that when they are in a minority of one it is time to look at the issue again. The MHA is purely dedicated to looking after the interests of those who suffer from mental illness and I take their advice very seriously.
In any case, Winston Churchill achieved a great deal in his career as a Member of Parliament, and in recent weeks and months various people in public life have said that they have had mental health problems, but they too have achieved a great deal.
I was a member of the Mental Health Act Commission for several years and visited people who were detained in in-patient facilities in London and the south-east. The experience of meeting people who had been sectioned, received compulsory treatment and lived in wards—some of them in appalling conditions—was a salutary lesson for me about how we treat people with mental illness. It is important to remember, as my hon. Friend Mrs. Moon said, that only a very few people end up sectioned and as in-patients in hospital, but they are an important group and we must get their treatment right. For a long time, they have been pushed to one side and not focused on properly. That is why I am really pleased by several aspects of the Bill, including the community treatment orders.
I am not saying that the care and attention given by NHS staff was lacking in any way, but I saw distressing conditions in some wards in some in-patient facilities where some people found it very difficult to hold themselves together. I remember seeing one person who refused to wear clothes and had to be kept in a room with no furniture and restrained for much of the time, because he was so unwell. We must get the treatment of such people right.
I raise that point because it is important to remember that in-patient facilities have improved enormously, but the whole thrust of the NHS reforms is about providing care in the most appropriate place for the person. For some people that will be an in-patient facility, but many people want care close to their home, if not in the home, so CTOs will be a real step forward in giving people with mental health problems that option. We want people to receive other forms of NHS treatment close to their homes, as some already do—so why not people who have mental health problems?
The multidisciplinary approach is prevalent in the mental health field, so it is right that we consider who should make decisions about sectioning people; for instance, amending "responsible medical officer" to "responsible clinician" is the right way forward, as are the provisions amending the role of the approved social worker to include "approved mental health professionals". Such steps will allow psychologists, therapists, nurses and social workers to play a full role, along with clinicians and consultant psychiatrists, and would show that we are taking a much more modern approach to dealing with mental health care, rather than using only a medical model, which is rather old-fashioned.
In Committee, I hope that we can look again at the provisions on nearest relatives to allow patients the option to nominate the person they want as their nearest relative. The list is too prescriptive at present and the patient is allocated a person. Family relationships are often difficult and the patient may not want their actual nearest relative to speak for them and take important decisions.
I was pleased that my hon. Friend talked about the advance directive, as it is an important issue, although it may not be appropriate for the Bill. An advance directive allows the patient some dignity; when they are well they can say, "This is what I would like to happen if I am ill again." That is a positive step forward for mental health services.
It is distressing that sometimes police cells have to be used as place of safety accommodation, although I understand why it is necessary. I hope that the Government will reconsider that practice and think more creatively, especially in light of the massive NHS building programme; for example, some of the local improvement finance trust buildings or provision in the acute sector might be used as places of safety. The police need training. I was shocked to find that most police officers do not receive substantive training in dealing with people with mental illness.
Finally, we need to try to remove stigma. An important development in schools in recent years is the national healthy school standard, a key aspect of which is promoting emotional health and well-being in our youngsters. We should try to raise the issue of mental well-being with our children early on, so that they do not think of mental illness as a frightening, distressing condition to be backed away from. I remember a nurse telling me that if a person has a broken leg the general public will always help; when they see that a person has a physical injury they do everything they can to help because they can see the problem, but if someone has a mental illness, people run away—they do not want to help. We have to try to address that issue with our youngsters in school, by saying that we should not be frightened of mental illness; it is treatable and we can do things to help people. Let us treat it like any other illness and not see it as a distressing, frightening condition.
It is a pleasure to follow Ms Johnson who made a number of salient points, especially about nearest relatives. However, I disagree with her when she said, referring to Mrs. Moon, that the Bill was not the place for considering advance directives. The hon. Member for Bridgend made an impassioned and logical case and I hope that the matter will be discussed in Committee, because it would be wholly appropriate to do so.
I did not enter the House of Commons with a deep knowledge or understanding of mental health issues, but over the last two years—because of the people coming to my constituency surgery and as a result of my travelling around the constituency—I felt compelled to understand more about those issues and how they were dealt with in the House. Indeed, my first meeting with a constituent in this place was with someone from SUNRISE—Services Users Network Representation in South Essex—a mental health advocacy group. He raised with me problems stemming from the Mental Health Act 1983 and asked when there would be a mental health Bill. I tabled a number of written questions to Ministers on that question and I am glad that we are now having a Second Reading debate on the Mental Health Bill.
On the basis of evidence presented to me, I was prepared to oppose—and oppose quite strongly—a mental health Bill, but I am now in the somewhat bizarre position of supporting the Mental Health Bill today, largely because of the amendments tabled in the other place. However, I will be deeply disturbed if, as I think and fear will happen, a number of those very sensible amendments are turned down in Committee.
Looking again to my local area, mental health is covered by the South Essex mental health partnership, whose chief executive, Patrick Geoghegan, does an absolutely fabulous job—
I am glad to see that the Minister shares my view. In fact, the mental health partnership was one of the first foundation status organisations within the sector. The annual report shows that one of the biggest risks over the next five years is this Bill or Act if it passes through Parliament. If Patrick Geoghegan and the South Essex mental health partnership are concerned, I am certainly concerned. Meetings with organisations such as SUNRISE and more national organisations such as Mind and Rethink have confirmed my worst fears. Visiting a local prison did likewise. Martin Horwood referred to a figure in the high 70s in respect of people in prison with mental health problems. On visiting a local prison, I was told that more than 80 per cent. of the male population were suffering from some form of mental illness. That is truly horrific.
Many hon. Members have mentioned the mental health partnership and been extremely complimentary about the organisation—or collection of organisations. The partnership believes that the amendments tabled in the other place "significantly improve" the legislation, in contrast to the Minister's assertion that they "seriously weaken" it. With no offence intended to the Minister, I tend to support the view of experienced health professionals over that of politicians. We could say that professionals always have a narrow or biased view, but they are backed up not only by the Mental Health Alliance, but by the Law Society, which has welcomed the amendments, calling them "measured and judicious changes" and urging the Government not to overturn them. Those are two very eminent societies, as hon. Members on both sides of the House have acknowledged, and what they say is surely right.
Beyond the additional six amendments tabled in the other place, a number of their lordships spoke about independent advocacy, which has also been mentioned in this House. Independent advocacy was included in the 2002 and 2004 draft Bills, but is missing from the current Bill. I would like to see Ministers bring forward more detailed provisions on advocacy in Committee, building on the work already mentioned by my hon. Friend Angela Browning.
The hon. Member for Kingston upon Hull, North mentioned the nearest relative and it is important to expand on who can be nominated by an individual, particularly when they are of sound mind. I ask the Government to reflect on tabling amendments to provide that such choices do not have to be brought before the courts. It is important not to have too much bureaucracy surrounding the process.
In my final minute, I would like to make a point about stigma. Katey J, a local artist, recently invited me to open an exhibition, provocatively named "Sad, Mad and Glad". Katey suffers from mental health problems, but felt a responsibility as a pillar of the community to say that it is possible for people to come out the other side and to talk about mental health problems.
One concern raised by Members, particularly on this side of the House, is that parts of the Bill may drive people with mental health problems underground. That is the very thing that neither side of the House wants. It is, however, a problem that I fear will be significant.
We have had a very good debate, with some very knowledgeable contributions from no fewer than 17 Back Benchers—I have counted—all of whom paid tribute to local projects, local services and local mental health workers, who do an excellent job, often in challenging circumstances. It has been a well-attended debate, as Mrs. Moon said earlier. That might have something to do with the fact that, from memory, it is the first time in my 10 years as a Member that we have had a debate on mental health in the Chamber in Government time. We have had such a debate in Opposition time, courtesy of us.
We have heard some excellent contributions. We started with Mr. Blunkett, who is not in his place at the moment. Rather unfortunately, he chided some of the mental health organisations that are part of the Mental Health Alliance, by saying that they were raising false fears among various sufferers of mental illness. As has emerged time and again, the 79 organisations in the Mental Health Alliance cannot have it all wrong. He made a very good point that we should make provision for the families of victims as well.
Mr. Kidney made an excellent, well-informed speech, as usual, given his experience from his legal background. He said that there have been improvements in mental health services around his constituency—of course, there have—but the amount of extra money going into mental health services does not match the amount of extra money that has gone into the national health service as a whole. He also said that community treatment orders were relatively new and that therefore it is difficult to derive research from them. They are not relatively new in other parts of the world, particularly the United States, where they have been going for some time and where there is no definitive evidence that they are as effective as the Government are trying to make out.
My hon. Friend Angela Browning has enormous experience of this subject, not least with those with learning disabilities, particularly autism. I hope that she will be able to bring that experience to the Committee that considers the Bill; her comments about advocacy were certainly very well made.
The House will agree that my hon. Friend John Bercow made an excellent contribution. He praised the cross-party expertise in the Lords during the earlier scrutiny of the Bill. He said that the Government appear to be in splendid isolation and made the relevant point that I have been trying to make to the Secretary of State, who failed to grasp it, that we should treat people with a mental illness on no different a level from people who have a physical illness. The natural extension of what the Government have been saying is that someone who has cancer treatment and decides that they do not wish to take that treatment will not be subject to some form of compulsion, so why should we treat people with a mental illness differently? That only engenders the stigma that so many other hon. Members have spoken about as well.
Many hon. Members also spoke with real passion about very personal experiences, none less so than Chris Bryant, who rather bravely spoke about his own family's experiences and those of his neighbour. I am sure that many of us will have had similar experiences with constituents facing such problems. What he did not add, however, is why the Bill in its previous form would solve those problems or why the Bill, as amended by the Lords, would fail to do so. There was therefore something lacking from his contribution.
Again, we heard excellent contributions from Meg Hillier. I have visited the Hackney Mind project, and I know about some of the excellent work that it does with the black and minority ethnic community there and about the very real problems that she has in that part of east London.
Hywel Williams spoke, as usual, with great knowledge of the subject. Andrew Gwynne seemed to say that treatment regimes will be adhered to only because of the compulsion parts of the Bill. I failed to understand that. It seems that the Government follow the rather bizarre logic that people can be guaranteed to get treatment only if we raise the number of people subject to compulsion. That should not be the way. Those services should be there for everyone, without having to subject them to compulsion.
My hon. Friend Adam Afriyie summed the situation up well when he said that everybody in the House is concerned for vulnerable people. Ann Coffey brought her own expertise as a former psychiatric social worker to the issue. Martin Horwood spoke about personal constituency cases. He has had to deal with some pretty dire cases, as has Mr. Walker said that people with a mental illness look to him as a Member of Parliament to provide a voice for vulnerable people, and I am sure that that is true of many other Members of Parliament. Ms Johnson, who is a member of the Mental Health Act Commission, was another person speaking with great expertise. My hon. Friend James Duddridge talked about stigmas.
We have had a well-informed debate, following on from the expertise in the other place. We think that we now have a relatively good Mental Health Bill, which we can support, but only thanks to the excellent scrutiny and expertise across all the parties in the other place and the six key amendments that have made a fundamental difference to what started off as, I am afraid, a fundamentally objectionable Bill. Members of the other place sought to compromise with the Government, but all too often that compromise was not forthcoming. It is unprecedented in my time here for the Government to suffer six defeats in a row on a Bill, as they did in the Lords. It is incredible that, after seven or eight years in the making, two abortive draft Bills, numerous consultations, the pre-legislative scrutiny Committee, and all this time under the responsibility of the same Minister, the Government still do not get it. After thousands of representations from mental health professionals, voluntary organisations, service users and the Mental Health Alliance, the Government still do not get it and are intent on trampling over all the good work and scrutiny done in the Lords by reversing all the amendments—despite all the public and press outcry over recent days.
The Observer last week carried an article with the heading:
"Mentally ill deserve more than cynicism".
The article continued:
"A small minority of people who suffer from acute mental illness pose a threat to society. The overwhelming majority pose a threat only to themselves. All are equally deserving of compassionate treatment, but most are being failed by the National Health Service."
Another article in The Observer was headed:
"Inside the violent, chaotic world of our mental wards".
"If I was a parent of one of these children, I would be expecting not only this House, but the Government to take immediate and urgent action".
The Independent on Sunday yesterday carried the headline:
"Insane! Stop the Mental Health Bill".
I think it got the second line slightly wrong. Inside, a father reveals the suffering of his child on a secure adult ward.
Yesterday Sheila Hollins, president of the Royal College of Psychiatrists and a deeply respected figure in mental health, said:
"Overturning the Lords' amendments would be a grave mistake and deeply damaging to the future care and treatment of mental health patients. The Government now has the opportunity to achieve mental health legislation which is ethical, principled and supported by patients, professionals, carers and families, and the public."
Another article is entitled: "The vote for sanity." It goes on and on. These are not reactionary, right-wing publications. They are publications with a serious interest in mental health and, in particular, in patients and the families of patients who are suffering. I hope that the Government will not close their mind and their ears, but will listen to the many voices of reason that have echoed around this Chamber and the wider world in the last few weeks.
Despite all that and the enormous amount of interest shown in the debate today—the first day back after the recess—the Government still do not get it, as was clear from the opening contribution from the Secretary of State, and want to return to their original Bill, which has been condemned as deeply stigmatising, as the latest attack on civil liberties, and as undermining the therapeutic relationship between clinician and patient. It is counter-productive in that it threatens to deter people with a mental illness from presenting in the first place, thereby driving mental illness underground, as many colleagues have said.
I will not, I am afraid, because I have very little time.
Potentially, the most dangerous patient with a mental illness is the one whose condition deteriorates under the clinical radar. We are talking about people who have committed no offence, but just happen to be ill. So, despite all the Government's claims to the contrary, the measures that the Minister of State, Ms Winterton, would have us revert to would not just prejudice the health of the patients, but could put at risk the safety of the public. So, the Government's position is not only arrogant and misinformed, but counter-productive and, perhaps, dangerous.
The fact is that people in this country with a mental illness are being let down by a lack of not coercive powers, but prioritisation in the NHS and the Department of Health. There is an absence of a real champion for mental health in the Department. Whatever the Secretary of State says, mental health is the Cinderella service of the NHS. As many hon. Members, especially Labour Members, have said, services for children and young people are the Cinderella service of the Cinderella service. It is absolutely scandalous that one child a day is still being placed in an adult ward. As the children's commissioner said, putting such vulnerable children in intimidating acute wards cannot have a therapeutic benefit. The report produced by his department was called "Pushed into the shadows".
It is a scandal that mental health trusts are still bailing out other parts of the NHS with deficits. It is a scandal that the number of mental health beds has fallen by 20 per cent. since Labour came to power—in fact, the second largest fall has taken place in the Doncaster and South Humber Healthcare NHS Trust, which covers the constituency of the Minister of State. We are told by Louis Appleby that non-legislative options are being explored for dealing with children, which is why the amendments will be overturned. The Government have had seven years to address the matter, so when will we see results?
It has already been stated that the Government's worst offence has been to pander to tabloid prejudices and ramp up the aura of dangerousness attached to mental illness.
I will not.
Under the original terms of the Bill, clinicians would be turned into jailers. Indeed, the measure has become a Home Office Bill, so it is rather interesting that a former Home Secretary has made a speech and a former Home Office Minister wishes to intervene. We have a focus on locking people up on the false premise of a threat to public safety, rather than a health Bill that is dedicated to giving support and treatment to people who happen to have a mental illness.
The Government have also behaved with contempt towards parliamentary scrutiny with regard to the research that they commissioned in January 2006 involving the Institute of Psychiatry, which was part of a research package costing £236,000. Despite freedom of information requests, they did not publish the research until the day after the House of Lords had finished its deliberations on the subject.
The Government still seem to be in denial. Despite the fact that the report said that there was no empirical evidence from 72 studies in six different countries throughout the world to support the efficacy of community treatment orders, the Minister wrote in a letter to me last week that she would like to take the opportunity briefly to draw my attention to the positive evidence for CTOs that exists. She wrote that we only have to look at what clinicians, patients and families around the world say about their own experiences. The Government are in denial. Where is the evidence? They have failed to produce it, so I hope that we will see more of it.
Let me give the Minister a challenge. The House has had no opportunity to scrutinise her community treatment order research. Next Monday, in the Thatcher Room in Portcullis House, all members of the Public Bill Committee and previous members of the pre-legislative scrutiny Committee will be inviting witnesses to give evidence. We would be delighted if she were the first witness and if she would give us her case for community treatment orders. We will invite expert witnesses to comment on the six groups of amendments that the Lords made to the Bill. I hope that she will listen to the evidence that will be given by experts to a cross-party group of Members with an interest in the Bill next Monday, the day before the Committee stage starts.
We need a Bill that commands the support of professionals and their patients and that achieves a proper balance among clinical discretion, patient safeguards and public protection, not a measure that contributes to stigma and undermines the therapeutic relationship between clinician and patient, thus driving mental illness underground. We need a Bill that uses compulsory powers as a last resort and that does not skew resources towards one group of patients at the expense of others. We are happy to support the Bill as it stands, although there are further amendments and improvements that we would like to make. It would be a great shame for Parliament and the mental health community if the Government were to use their majority in the House to bulldoze the Bill back to the status quo. After so much groundwork over seven years and so many learned contributions in the House of Lords, I hope that the Minister will go into Committee with an open mind.
I am sorry that Tim Loughton ended a thoughtful and sometimes lively debate with a rather mean-minded speech. The debate has emphasised the importance of the Bill and its great sensitivity in dealing with the difficult matter of the law governing people who have a mental illness that has become so serious that they have to be detained, either for their own safety or for that of others.
The figures are stark. Each year, 1,300 suicides and 50 homicides are committed by individuals who have had contact with mental health services. Today's debate has illustrated how controversial the subject is, and I am the first to admit that it is one on which it is difficult to find consensus, but after almost eight years of debate on reforming the current legislation, the Government have listened and compromised. I pay particular tribute to the work of the pre-legislative scrutiny Committee, which expressed concern about the length and complexity of the previous draft Bill, which is why we produced the much shorter amending Bill which is before the House today.
It is important to see the Bill in the context of the much wider investment and inclusion policies that my right hon. Friend the Secretary of State mentioned in her opening speech. They include £1.5 billion more spent on mental health each year than was spent in 2001, 14,000 extra staff, 700 new community teams and a range of measures to improve inclusion in society of those with a mental illness. However, as well as improving services, it is important to make sure that our mental health legislation is updated and modernised. That is one of the points on which consensus has been reached.
Those who have contributed to the debate have made several important points. Mr. Lansley acknowledged the increased investment and paid tribute to the staff, as did the hon. Member for East Worthing and Shoreham. I hope that they will support the amendments that we want to make to the Bill as it has emerged from the other place to restore the multidisciplinary approach. As the Bill stands, every decision will have to be referred back to doctors. The changes that we want to make have the support of Unison, the Royal College of Nursing and the British Psychological Society, so I hope that the hon. Gentlemen will join us in reversing the changes that were made in the other place.
My right hon. Friend Mr. Blunkett spoke of the importance of advocacy and getting services right for young people. He paid particular tribute to the work of Jayne Zito and the need to ensure that victims have proper protection. I am sure that we will return to that in Committee to make sure that we do everything necessary to help victims.
Norman Lamb talked about issues relating to the black and minority ethnic communities. Through the "Delivering Race Equality" project, which we are undertaking now, it is important to ensure that there is no stigma or discrimination against people from BME communities.
Angela Browning spoke about autistic spectrum disorders and the Bournewood clauses. I know that she has a special interest in those subjects, and I am sure that we will return to them in Committee. I hope that she will be a member of the Committee.
My hon. Friend Mr. Dismore referred to the points made by the Joint Committee on Human Rights, which he chairs. I have responded to him in a letter and we shall give those points further consideration.
John Bercow normally makes extremely well considered speeches. He made several important points today and I shall refer to his comments about treatability, but I am concerned about his use of the phrase "catching people." The Bill is about getting treatment to people—not catching them, but ensuring that the people who need it get treatment.
My hon. Friend Mr. Kidney talked about putting principles in the Bill. We returned to that issue, but it has been difficult to put principles in it, because it is an amending Bill. However, what we have done—we have reached agreement with the Opposition in the House of Lords on this—is make sure that the Bill refers to the factors that would be taken into account, in terms of the code of practice principles. I hope that when he looks at clause 10 he will realise that it addresses some of the issues that he raised. My hon. Friend Meg Hillier gave a moving account of experiences in her constituency and made important points about advocacy. I know that she feels extremely strongly about the subject, and I am sure that we will return to it in Committee.
Hywel Williams talked about his professional experience and the situation in Wales, and my hon. Friend Chris Bryant made a moving speech about his personal experiences. I understand that he is running the marathon for Mind, and I congratulate him on that. He talked particularly about exclusions, as did Dr. Taylor. Many of the exclusions inserted in the other place have to do with culture and religion, but culture and religion are not mental disorders. That is why it is inappropriate for them to be exclusions. However, the issue of sexual deviancy was included in previous legislation. There were times when unmarried mothers who had babies were detained because that was felt to be a mental disorder, and homosexuality was considered a mental disorder, too. However, there have been issues around paedophilia, and that is why we need to remove the exclusion for sexual deviancy.
Adam Afriyie made a considered speech about stigma. My hon. Friend Ann Coffey made a number of points about local arrangements, and there are matters that we need to discuss in Committee about guidance that we can issue. Martin Horwood spoke of his constituency case, and I have met the brother that he spoke about. The case illustrates some of the difficult issues that families face in such circumstances. My hon. Friend Mrs. Moon acknowledged that the Bill is not about services, but about how important it is to take a multi-agency approach, and the importance of taking the views of carers into account.
Mr. Walker started off by making a thoughtful speech about stigma and Members of Parliament, but I was taken aback by the fact that he was derisory about an article in The Daily Telegraph that said that if the Bill saved lives, people should vote for it. My hon. Friend Ms Johnson talked about the nearest relatives, and that is an important subject that I am sure we will return to in Committee. James Duddridge talked about his local trust, and the importance of people accessing services.
My hon. Friend Andrew Gwynne talked about the importance of letting clinicians make decisions, and that is a significant point that I wish to address with regard to the general issues that have been raised, especially by Opposition Members. First, on the treatability test, it is without doubt true that the fact that the treatability test is in the Mental Health Act 1983 has prevented the development of certain services, particularly those for people with personality disorders, and has led to people being turned away from services. A woman came to see me as part of the Mental Health Alliance lobby, and the first thing that she said to me was "Rosie, I have a multiple personality disorder, and I keep being told that I can't be treated." We have to get rid of the treatability test to prevent people from being turned away.
Baroness Corston, in her report on the Mental Health Bill, said that she welcomed getting rid of the treatability test because of the number of women who ended up in prison as a result of not being treated for personality disorders. The appropriate medical treatment test that we have inserted is stronger, because for the first time it gives legal status to the provision of appropriate and available medical treatment.
Turning to supervised community treatment, many hon. Members asked for evidence of independent inquiries that had discussed the need for such treatment. The inquiry into John Barrett's treatment said:
"In our view, the only means of securing John Barrett's compliance with treatment as an out-patient would have been a community treatment order, which is not available under the Mental Health Act."
That is why we need to make sure that community treatment orders are available, not only to people who are a danger to others but to people who are a danger to themselves. We know from the evidence that we published last week that 56 people who committed suicide last year could well have been saved if they had received supervised community treatment. It is not right that the Lords amendments should say that someone should have two relapses before such treatment, as someone could have a history of voluntary in-patient non-compliance with treatment, so they should not be required to fulfil the same conditions as an out-patient.
Finally, on impaired judgment, the examples that I am given most often are of young women with personality disorders who have suffered terrible emotional, physical and sexual abuse, but who do not have impaired judgment. If we deny those people treatment because we want to institute an impaired judgment test we would leave them to self-harm and sometimes suicide. It is important to remember, too, that some people have fluctuating capacity—they do not always have impaired judgment, but sometimes they do. If we want to tell people that they can refuse treatment for mental illness in the same way that people can refuse treatment for physical illness, we are making the decision as society, and saying, "It is fine for you to go away and commit suicide. We will take no action." We do not do so at the moment, but the impaired judgment test would allow that to happen. I do not believe that we as legislators should say that that is what we want to do.
As I have said, this important debate has addressed a number of issues raised by right hon. and hon. Members. It has looked at the wider issues of inclusion and the way in which we make sure that a sensitive piece of legislation receives proper scrutiny in the House. I am not saying that it has not been difficult to achieve consensus on the Bill. It has not been easy all the time, but as a political commentator said in The Daily Telegraph this morning, the issue before the House "could hardly be graver". As my right hon. Friend the Member for Sheffield, Brightside said, if we fail to act, we will let people down. Supervised community treatment is a vital part of the changes that we need to make, as is the removal of the current treatability test, which has meant that too many people, particularly those with personality disorders, have been turned away from treatment.
To achieve those changes, we will ask the House to overturn some of the amendments made in the other place, but if the Opposition parties try to water down our proposals that will lead to some extremely vulnerable patients being denied treatment, and to an increased risk to public safety. I am sure that there will be a full and lively discussion in Committee, but I hope that the House will eventually agree that our proposals strike the right balance between patient safeguards and patient and public safety.
Question put and agreed to.
Bill accordingly read a Second time .