EXCLUSIONS FROM THE DEFINITION OF MENTAL DISORDER

Mr Chinyere Inyama

Senior Paartner at Inyama & Co. Solicitors - specialist mental health law practice

Legal member of the Mental Health Review Tribunal

Member, interviewer & assessor of the Law Society Mental Health Review Tribunal Panel

Assistant Deputy Coroner for Essex and Thurrock

Dr Eric Metcalfe

Director of Human Rights Policy

JUSTICE

Dr John O'Grady

Consultant forensic psychiatrist in Hampshire

Chair of the Forensic Faculty of the Royal College.

Member of DoH's Mental Health in Prisons Expert Group

IMPAIRED DECISION MAKING

Mr. Paul Bowen
Barrister at Doughty Street Chambers, London, specialising in public and human rights law, with a particular interest in health, mental health and disability issues.

Dr George Szmukler

Consultant Psychiatrist, Maudsley Hospital

Chairman, King's College London Health and Society Network

Formerly, Dean of the Institute of Psychiatry, King's College London.

Dr Tony Zigmond

Consultant Psychiatrist

Honorary vice-president, Royal College of Psychiatrists

TREATABILITY

Dr David Hewitt

Partner, Hempsons Solicitors

Visiting Fellow at the University of Northumbria and the University of Lincoln

Professor Nigel Eastman

Professor of Law and Ethics in Psychiatry, University of London Honorary Consultant Forensic Psychiatrist, St George's Hospital, London

Professor Kwame McKenzie

Professor of Mental health and Society University Central Lancashire

Senior Lecturer in Psychiatry, University College London

Consultant Psychiatrist, Barnet Enfield and Haringey NHS Trust

Member of Ministerial Advisory Group on BME mental health

RENEWAL OF DETENTION

Lucy Scott Moncrieff

Mental Health solicitor in private practice

Member of the Law Society's Mental Health and Disability Committee

Dr Shantanu Datta

Deputy Chairman of the BMA's Psychiatric Sub-Committee

Specialist in Old Age Psychiatry at Birch Hill Hospital, Rochdale

Peter Kinderman

British Psychological Society

Ian Hulatt

Mental Health Advisor

Royal College of Nursing

PROCEEDINGS:

The Chairman (Tim Loughton MP): Welcome everyone. I will be chairing this impromptu committee. Andrew Lansley MP, the Shadow Secretary of Health for Health, and Sandra Gidley MP wish to make some introductory remarks and then we shall get going with what is a very tight timetable.

Andrew Lansley MP: I thank you and your team, Tim, for organising the meeting and also parliamentary colleagues from both Houses for participating. After the 45 hours of debate in the House of Lords, the Commons is now considering the Bill, which is very different from the Bill that was introduced into the House of Lords. I am sure that their Lordships will acknowledge that there has never yet been a piece of legislation that is incapable of improvement. The Commons has two important tasks ahead: first, if the Bill is capable of improvement, then securing such improvement. Secondly, as will become obvious during the debate and in light of the way in which amendments have been submitted to the Standing Committee, it is clear that the Government are intending to reverse all the principal amendments made in the House of Lords.

When we look at the amendments, which we shall do in some detail in this committee, they will bring up issues of policy which will sometimes be confusing. On the face of it, the Government's policy and that adopted by the Lords seems to be the same, such as in relation to community treatment orders. Our intention is that they should be limited to those styled as "revolving door patients". The Lords went to some trouble to construct the Bill around such a definition.

We must work out whether there are differences of policy and, if there are, to expose them. If there are not differences of policy, matters come down to tricky questions of whether the definitions and structure of the legislation will have the effect that they are intended to have. It is always possible to work that through and the more that we in the Commons are helped by expert organisations considering with care how the definitions would work, the better it will be both for when the Bill is considered in the Commons and when it returns to the Lords.

It is always important to set the structure of the legislation in the context of clinical practice. During the debate on Second Reading in the Commons, Tim and I clearly had discussions with those on the Government Front Bench about the extent to which it was necessary to have supervised community treatment orders in place so that the appropriate patients can access treatment. We argued that specific safeguards and limitations were needed in respect of supervised community treatment orders of the sort that the Lords proposed and that that would give far greater confidence to patients, their families and carers that they were not accessing services in a climate of coercion.

That does not mean that patients do not access services, but the question arises as to whether there are difficulties in accessing services and whether enhanced supervision is required in the community. Furthermore, to what extent is supervised community discharge being used; to what extent is supervised discharge of patients into a community and supervised community treatment available with coercion? Although the Bill is, in the Government's terms, a framework for bringing people under compulsion, it must always be set in the context of what is available in the community and how we can maximise the effectiveness of mental health services generally and, by doing so, minimise the necessity for coercion and compulsion.

I hope that, by discussing such matters in this committee, not only will you better inform the Standing Committee discussions, but that you will also produce something that will have an impact on hon. Members across the House. I say "across the House" advisedly because I hope that Labour Members will take some care to look at what we produce. I get the sense from the debates on Second Reading that significant numbers of Labour Members who, like us, just want to end up with a Bill that is effective and that will be something that we can live with for the next 25 years without feeling that it will have unintended consequences that we cannot live with. It is therefore very important that we create the best possible Bill and I thank everyone here for their participation in enabling that to happen.

Sandra Gidley MP: I endorse Andrew's comments. This is quite an unusual experience for me. Most of the Bills that I have worked on during my parliamentary career have been occasions when all parties have worked together to achieve a consensus, so this situation in which one party is actually dead set on not co-operating it somewhat unusual.

I thank Tim for organising the committee. It will form a useful basis from which we can all go forward. It is my regret that Labour Members are not present, because the meeting is a genuine attempt to get some cross-party working to achieve a better Bill. I do not understand why the Minister thinks that she knows better than the 79 organisations that comprise the Mental Health Alliance.

The Chairman: I thank everyone for coming along. We are on a tight timetable, which we have blown already, but I shall endeavour to keep us to order. I stress that this is not an official committee, but we thought that, in the interests of better informing the Committee proceedings of the Bill, we would set up a further witness sitting specifically to concentrate on the six areas that the Lords have amended because what we are about to scrutinise in the House of Commons is a very different Bill from what started in the House of Lords. It was on that basis that we set up this committee.

We have invited all the members of the pre-legislative scrutiny Committee chaired by Alex Carlile, which produced an excellent report. We invited all members of the Standing Committee in the House of Commons, and we sent a general invitation to members of the Lords involved in such matters, such as Baroness Meacher, Lord Williamson and Earl Howe. A couple of other people will join us this afternoon. We have fought to be a cross-party meeting, but unfortunately all the Labour MPs who were invited had reasons for not attending. The Minister has, during the last half an hour, written a letter explaining why she will not be attending-although we asked her to be the first witness today.

The proceedings are being recorded and a transcript will be made of what has been said. It will be forwarded to the Standing Committee to be written into the record and it will be submitted to be part of the Hansard record. Can people please be clear when you speak? When you speak, will you explain who you are for the record? We have split the proceedings into six main areas. The first area is about Age Appropriate Treatment. We have witnesses organised by YoungMinds and a representative from the Children's Commissioner Office. I ask them to make their statements and answers to questions as concise and succinct as possible. I am sorry if we have to cut you off, but it is the quality and the punchiness of your contributions that will count and will get your points over as effectively as possible to enable us to use them in our proceedings in Standing Committee. Does anyone wish to make an opening statement? Some witnesses gave some fantastic testimonials at the meeting organised by YoungMinds. Unfortunately, that was not recorded, but we now have the opportunity to make some of those points again.

AGE APPROPRIATE TREATMENT

Kathryn Pugh (Head of Policy and Innovation, YoungMinds): Each of us has prepared a statement because we all represent different perspectives on this important amendment.

Claire Phillips (Director of Policy and Research at Office of Children's Commissioner): I wish to draw attention to the fact that this was the first piece of research that we commissioned because we feel that it is such an important issue and that young people have the right to age appropriate care. That is clear from the United Nations Convention on the Right of the Child and the national service framework standard on child and adolescent mental health services, which address the issues raised in the Kennedy Report on cardiac surgery at Bristol Royal Infirmary.

We are concerned that, despite massive investment in child and adolescent mental health services and having a clear target, there is still a long way to go. When talking to young people-some of whom we will hear today-we find that services were not age appropriate and that quite a lot of young people who were accommodated in adult accommodation facilities were badly let down. They were frightened. They did not feel safe. In some cases, they had their property stolen and the environment was totally inappropriate. Members of the staff were unfriendly. Some of them had no education - as is an inalienable right under UN convention. Above all, the environment was not therapeutic so the young people were not even given proper care.

We want the amendment tabled by the House of Lords retained and consider that it is very important. We understand that legislation is not always the usual mechanism for specifying how services should be delivered, but there are clear arguments for retaining it in this case. We do not think that the code of practice would achieve the commitment to change services that we want to see. We really want the provision retained in the Bill.

Kathryn Pugh: YoungMinds has a long-track record of interest and research into such a difficult area. We published "Whose Crisis?" and then worked with the Office of the Children's Commissioner on "Pushed into the Shadows". We receive on a regular basis emails and phone contacts from young people, parents and professionals asking for advice on how to handle the difficult issue of children on adult wards. The emails detail their traumatic experiences on adult wards in which they witnessed and experienced verbal, physical and sexual abuse.

I agree with Claire that the Government's policy is clear and unambiguous, but unfortunately it has been so for years and the policy has failed for years. We know from the figures that approximately 1,000 children are failed each year by such policies. We therefore utterly support the peers' amendments. To reflect on experiences as a Commissioner in the NHS, we used to have four categories in respect of spending commitments. Category 1 concerned whether we would be sued if we did not do it; category 2 was whether there was a target; category 3 was do we know we should be doing and category 4 is what we would like to do. During my entire time at the NHS, I never got beyond category 2. If you want matters to be changed, they must be placed in the law.

Marcelle Aarons (Approved Social Worker, New Beginning): I am based at a psychiatric adolescent in-patient crisis service based in north London. We cover five London boroughs and we only have 12 beds. At a grass roots level, we have made a huge impact in reducing the number of adolescents who have to go to adult beds because they are not enough children's beds. However, a number of adolescents have to go to adult beds because 12 beds are not just enough, especially given that cover five London boroughs.

I have been doing a lot of thinking about what Every Child Matters and the Children Act bring up for my practice at grass roots level. Safety of the child is paramount. A lot of young people who have been on adult wards are exposed to physical abuse, sexual abuse and verbal abuse as well as drug addiction or other types of addiction that they had not encountered before. Many of them have been abused or have been part of an abuse dynamic that is re-enacted on the wards and do not feel safe or that there is a reliable or responsible adult to whom they can turn.

As for a therapeutic relationship, in a lot of instances the staff and adult wards do not have the training nor do they have the time. A lot of young and vulnerable children are left in very exposed and dangerous conditions and cannot keep themselves safe. We are letting them down in that aspect. The services are not age appropriate and do not meet their developmental needs, bearing in mind that children between the ages of 13 and 18 have specific developmental needs that are catered for in an adolescent ward environment.

One of the things that came out strongly in the Victoria Climb� inquiry was that no one spent any time talking to her by herself, listening to her and sharing what she had to say as an individual. Again, in adult wards there is neither time nor space to give that respect to young people. Furthermore, in terms of my practice as an approved social worker, I also undertake child protection inquiries. There is not a combination of ASW or child protection roles. The Bill is a first development to combine children and adult mental health services to provide a holistic service. I have the children's perspective as well as the mental health perspective in mind. That is important when looking at the treatment of children.

One of the most important issues in early intervention in respect of children's mental health needs is prevention and, by examining that, hopefully we shall be able to stop the revolving door syndrome or, at least, reduce it so that we would not have young people constantly going into adult mental health services because they did not receive the care and treatment that they needed at an age when they could have received it.

Maurice Vaillancourt (Parent of Service User): I work in the various aspects of the voluntary and academic sector of mental health. I am actually here however for an experiential reason for my son who had a cannabis-induced psychosis when he was 16 years old. Unfortunately, our GP failed to react and where we live has quite a dispersed population and the secondary services were delayed. After 15 days, it was pandemonium and we ended up calling for an ambulance, but 11 police cars with 20 policemen in them were sent instead. We live in a fairly small village with a sixth form college across the road, and my son was arrested in handcuffs and put in a caged police van in front of hundreds of teenagers, some of whom were members of his peer group making their way to college at 9.10 in the morning.

My son was taken to a police cell, but once we persuaded them that he was ill he was taken to a small room at our local hospital in which he was kept for seven hours during while they found everyone necessary for a formal sectioning. They searched for a bed, which was never found. The commissioners refused to pay for an out-of-area transfer, which would have been preferable to what happened, although I am against that generally.

My son was eventually taken 45 miles away to an extremely decrepit adult ward that has now been pulled down at which he was physically subdued by six male nurses. After an escape attempt, two policemen hauled him back from up the road. They were not aware of his age and rough-handled him. The six male nurses just jumped on him and injected with acuphase that effectively knocked him out for nine days. He was continually physically assaulted by the staff, and physically and sexually assaulted by much older male patients. He was there for 12 days.

The most disturbing aspect was that the consultant psychiatrist told us that my son would not be able to remember anything because he was so into a psychosis. He was absolutely frightened out of his wits. He remembers those circumstances probably each day of his life, certainly when he wakes. He refers to them all of the time. Following a lot of protestation-my wife camped out in the vestibule and kept nagging at them-he was finally moved to a modern, adolescent unit that had been open only four months, where-surprise, surprise-he actually responded and began to get a lot better quickly. He stayed there for nine weeks and then came home to us. That was not wholly acceptable because the community support was virtually nothing. Later, he fell through a transition net because when he had to transfer to the CMHD Adult Services, he just dropped straight through it.

Another disturbing fact was that the adolescent unit always had that bed; it was just that it would not accept him because it would be disturbing for children with lesser illnesses. I consider that if that place in a first psychosis only adolescent unit had been available to him, he would not be traumatised by the things that worry him now. We must stop inappropriate in-patient settings.

Lois (Service User): I am a young person who has been treated on an adult ward. When I was 16, I suffered from depression. I was assessed, but no help was given because of my age. Eventually, my parents pushed for private treatment at The Priory, which was granted. I was discharged before my 17th birthday because I was approaching that age and they would not treat me over that age. Having not made a recovery, I overdosed again. I needed treatment and was admitted to the adult ward on the PICU, which is the Intensive Care Unit. It is a mixed ward and meant only for a short stay of four weeks while people get over intense illness. I was kept there for 18 months with very disturbed patients who were a lot older than me. It was a mixed sex ward. Because of the sort of unit it was, I could make any relationships with anyone because of their age, illness and the amount of time that they had stayed. I had a right to education and when I asked the nurses about it, they said, "No", and sent me back to my bedroom.

There was no stimulus on the ward. The brain of a 17-year-old needs to be active, but nothing was offered to me. There was no exercise. I went up 10 dress sizes in the adult ward, which is unacceptable. It was a mixed ward. I shall share one incident with you. The bathrooms did not have a lock. I was having a shower and a male patient walked in. He was unwell. He did not know what he was doing, but it was unacceptable for young people going through puberty and growing into young women to experience such an incident.

The ward was horrible. It smelt of urine. There was no home comfort, but just plastic chairs. It was unwelcoming and nowhere for someone to recover from any illness. Other patients physically, verbally and sexually assaulted me. Thankfully, I was able to control it but people younger than me would not be able to do that. I know people who have experienced such instances at the age of 13, and they could not say no to such men. Halfway through my admission, I was assessed by an adolescent psychiatrist so there was some recognition that I needed to be assessed by such a person. However, nothing came from it even though I was assessed.

The conditions and treatment that I endured were traumatising. I was treated like an animal. It was not what I would wish on anyone. Hundreds of young people are being treated like that every day. Eventually I was discharged into a therapeutic community where I received the help that I needed and deserved, but they only accepted people over the age of 18 so, until then, I was stuck.

I ask you to use your power to help pass the amendments so that what happened to me does not happen to any other young person.

Antonia (Service User): Like Lois, I was also detained as a young person in an adult ward. There is no way in which I could explain in two minutes why that should not happen, but I can guarantee to all of you that if you had been there as a young person you would know that it should not happen. Why should young people be written into the back pages of the Bill? Young people are the future and that is the time when people's confidence in the system needs to be increased from which they could benefit for the rest of their lives. If that does not happen, you would end up with revolving-door patients and people costing social services, the Government and society a lot of money.

Attending an adult ward does far more harm than good. Like Lois, I was sectioned. I was not allowed off the ward into fresh air for more than three and a half months. I was not allowed near an open window. I was on a single sex ward, but that does not make any difference to how safe I felt. I knew that one of the other patients in the ward was in there for killing her daughter. I was kept under constant nursing supervision, but I frequently heard the staff arguing about looking after me because they were not sure whether their registration as a nurse would cover their supervising me as a young person on an adult ward. They recognised that I was in danger and did not know whether they would be covered if anything had happened.

There was a complete lack of stimulation. There was no television. If the staff brought equipment, it was thrown in. There was no education. My day revolved around smoking and eating. In the space of about three and a half months, I was smoking 40 cigarettes a day. I was completely terrified. I was isolated from friends. I was not allowed to see my younger sister, who was 13. I was 16 years old and the reason why I was not allowed visitors of my age group or that of my sister because the policy on the ward meant that under-18s were not allowed to set foot inside the wards.

At 16 years old, I was stuck inside the ward and not allowed to go out. I was completely isolated from everything I knew. There was no structure to my days. They all rolled into one. I received no treatment on the ward to help me get over the reason why I was there, which was because of post-traumatic stress disorder. The only treatment that I received was medication: liquid, tablets or injections by force. I was frequently restrained by up to six people-male and female. I had my trousers pull down to be injected. There was no privacy. Other patients ran around. Such situations should not happen.

One of the amendments that should stand: why should young people who are mentally ill be thrown to the bottom of the pile? They are all at a disadvantage in that they are mentally ill. Those kids need to be given a chance. I am so, so lucky to be here talking about such matters because, like Lois, I am one of the lucky ones who has succeeded. But so many people do not. That is where the Government are failing hundreds of children each year. I could end up costing the Government a hell of a lot of more money yet because I would not approach services, given my experiences so far. If you could stop that now, it is the right time to do it.

The Chairman: Thank you both very much for those powerful testimonies.

I wish to kick off the questions and open up the debate to colleagues. Kathryn, with reference to the Scottish experience where changes were made under the 2003 Act, the Minister is now claiming that since age appropriateness in Scotland, the number of children going into adult wards has increased. What is the experience of Scottish clinicians?

Kathryn Pugh: We have been in touch with Scottish clinicians and those at the equivalent of the Mental Health Act Commission in Scotland, the Scottish Welfare Commission. Their experience is that the numbers have gone up a small amount, but they attribute that to the fact that the numbers have now been counted properly for the first time. Previously, as in this country, the figure of 1,000 children a year was actually based on research. There is no count on the children. The only thing that is counted is occupied bed days. Now, the children on adult wards in Scotland are being counted more robustly although clinicians believe that some are still escaping the count.

Clinicians in Scotland have said that issue have been beneficial to them because people are forced to get round a table and sort out what will happen to the young people when they go into the adult wards, if they still have to do that. They consider that that places a duty of care on people to work together and the important thing is not necessarily whether an adult ward is an appropriate place for people to be, but if there is no where else that there is an appropriate package of care for them, unlike the care that Lois and Antonia received from the odd agency staff, hither and thither. In Scotland, they have been much more systematic and Scottish Services are now planning for many more beds to be open and for there to be much better community services. Scottish clinicians argue how can the situation be improved if it does not come within the terms of the law?

Angela Browning MP: Kathryn, you kindly sent me a list of the child and adolescent mental health service units for the under-14s. I was struck by the strange, geographic spread of such units. There is a cluster around London. There is one down in Kent, but there is nothing west of London. Going north, we have to go as far as Leeds before we find anything. There is a huge part of the country, particularly in the midlands and the far south-west that have no dedicated units. Can you tell us something about the trend of either closure or the development of units? Where in-patient treatment is needed, particularly for very young children under 14, what is the trend? Are we planning to develop more to close the gaps? There are big distances between them.

Kathryn Pugh: There is a difficulty with the trend for the under-14 year olds and with the trend for adolescents. For under-14 years old, 30 per cent. more of the beds have been cut during the past three years, and they are being lost. We attribute that to the fact that primary care trusts have so few children a year who need to go into the units that they are not underpinning the units. The units therefore have to scrabble around each year for guarantees of funding some of the mental health trusts, so when they are stuck for cash and are expected to make savings, they are pulling the beds. There is a real problem with a bed base throughout the country for under-14 year olds, but the bed base for adolescents is similar in that there are three time as many beds in London and the south as there are in the north. Letters to MPs from PCTs indicate that, in Lancashire and Cumbria alone last year, for example, 90 adolescents were placed on adult wards. So the experience of London and the south-namely, that they are much better provided for than anywhere else in the country-is mirrored both for under-14s and over-14s.

Lord Carlile of Berriew: May I just ask a practical question that arises from the point made by Mrs. Browning? Supposing a child has an acute episode such as was described by Mr. Vaillancourt in, say, the middle of north Wales, where there is no available facility within a reasonable distance. What are you saying should happen in that situation?

Kathryn Pugh: If that happens at the moment, and if the child is lucky and the PCT or the health services will pay, the child would be sent to an adolescent unit outside of Wales. However, if Welsh was their main language, that would mean that they would be in an environment where their main language was not spoken. It might be helpful to hear from Antonia and Lois about their views on passporting children when the choice is between putting them on an adolescent ward or sending them out of the area to an adolescent ward.

Lois Ward: If the illness is an immediate one, and if the individual is overcome by a severe psychosis, there might be some need to contain them straight away, but that does not last for too long. Having been treated on an adult ward myself, I would much rather go to an adolescent ward than a local adult ward any day-even if it was in Wales, London or Scotland-because people would know how to treat me and I would not be abused as I was in the adult ward. I speak on behalf of a lot of young people in saying that.

Antonia Wilkinson: I have said it before: to be in adolescent services I would rather go to Scotland than be 10 minutes down the road from my home. The distance is not important and it is a ridiculous excuse for not including the amendment in the Bill.

Maurice Vaillancourt: Absolutely not. But distance, of course, creates schisms for families when visiting their children, and that is a huge problem. We need first-episode psychosis units into which 16 to 25-year-olds, perhaps, can be received straight away. Early intervention services are the key, however. I am very involved with our local early intervention service in Hampshire and I am also doing some work in Wales, and we need a presence of that type in every area of the country so that there is a network. That way, if there is a kid in the middle of Wales they can at least be connected to the neighbouring early intervention team, who can ensure that they have somewhere to go. I agree that it is much preferable that they go somewhere out-of-area.

Claire Phillips: May I just add one point to that? The national service paper makes it clear that there are circumstances, such as when an ambulance is called as was described earlier, when a child might first have to be taken to the local acute hospital or whatever-though certainly not the police station, as was also described. In that situation, an appropriate placement should be found. Clearly, the ambulance will not take that young person miles and miles away, so there need to be interim arrangements when there is an acute onset. Units dealing with early intervention in psychosis, such as those being piloted at the moment, are one way to address that, and we support that idea.

Maurice Vaillancourt: The pilots have been taking place for five or more years.

Claire Phillips: The answer to your question as far as Wales is concerned is that people either go out of the area or they are put on an adult ward. That is the choice: there are no emergency beds in Wales at present.

Baroness Meacher: I should like to applaud the contributions that have been made-they have been powerful. If the decision were going to be made on the basis of the child's best interests, there would be absolutely no question that the House of Lords amendment would stand. Unfortunately, I understand that the decision will be made by the Government on the basis of resources, if they can get away with it. As far as I know, there is research that shows that children assessed and placed in a setting related to their age will do much better than those placed in an adult setting, and the savings rendered by such appropriate settings over time could therefore be considerable. My feeling is that if that evidence could be presented loud and clear to the Government, it might meet with success.

Kathryn Pugh: There is also an issue on the resources that are put in, which are hidden ones. Beds on adult wards are not free-they might be booked by a PCT on a block contract but they are still paid for by the NHS. Furthermore, young people on adult wards are often given one-to-one observation, usually by agency nurses. If the average hourly cost of such a nurse is worked out, not including out-of-hours work and bank holidays, it might be �30 an hour. If, like Antonia, you have two people staring at you 24/7, which is what agency nurses do, the amount that that is costing the mental health trust is enormous. That is not reflected in PCT budgets, however, because it is picked up by the mental health trust.

If one adds the cost of placing a young person on an adult ward to the agency costs, and the costs that Antonia described of service users who consequently do not engage with services and who therefore become the "revolving doors" that the Government say that they are trying to support with community treatment orders, one builds up an enormous bill. So the point is not that the resources do not exist, but that they are in the wrong place.

Baroness Meacher: What am I saying is that it is that economic argument that needs to be presented.

Maurice Vaillancourt: I believe that there are some figures that indicate that 7,500 people have first-onset psychosis every year. If they slip through the early intervention net it costs something like �47,000 over three years. Those figures were compiled by Professor Martin Knapp at the London School of Economics. If one does the multiplication, the total comes to something like �300 million a year to keep people in crisis management and afterwards if they are not caught in the early intervention net. So I agree that there is an ongoing cost benefit.

The Chairman: I shall take two final quick questions-one from Sandra Gidley and one from Lord Williamson.

Sandra Gidley MP: Lois and Antonia, you described your experiences quite powerfully. Could you say a bit about whether you felt that the staff treating you had sufficient experience of dealing with someone of your age? Was that a problem or not?

Antonia Wilkinson: Members of staff have no idea how to talk to young people. Most patients have severe mental illnesses that ultimately will respond to medication, rather than to other kinds of therapy or treatment. I was in for something that I needed to talk through and be supported through. I was told that if I had a problem I should go and talk to the agency staff-the two people who sat with me day and night, but they were not trained in children's issues, and, as I said, they argued about having to look after me. So my answer would be no.

Lois Ward: Some nurses cared, and they wanted you to get better, but they were not trained to deal with adolescents, so they talked to you either as an adolescent, which meant that it went over your head, or as a 10-year old child, trying to get down to your level. It was inadequate, no matter how much they wanted to help.

Lord Williamson: As far as I can see, in any further discussions there are two points that the Government are likely to make in arguing against the amendment. The first is that the amendment proposals are not appropriate to the Bill, because services for certain groups should not be included in the Bill. I have already made it clear that I think that that argument is ridiculous; children are treated separately in many different areas of legislation, and that is absolutely normal, so I cannot see any real argument to support the Government's position on that.

The second point is a bit more difficult and I want to put it to the witnesses. It concerns the argument that some people will be refused admission because they have to receive age-appropriate treatment, and none is available. That point is quite tricky. Part of the amendment allows for emergencies-in relation to medical assessment and clinical supervision. Would you like to comment?

Kathryn Pugh: If the amendment is removed, what remains is the Government's own amendment on appropriate treatment. That says that, if appropriate treatment is not available, the person cannot be admitted, which would mean that service users who should be detained under the Mental Health Act for their own protection could be turned away. Without the amendment, therefore, young people would be more at risk. The amendment is carefully worded such that services and accommodation appropriate to the needs of the child should be commissioned by the PCT. It does not present the Government with a menu of services that must be provided, but that an assessment must be made and the relevant services must then be provided by the PCT.

Under certain circumstances, appropriate care might be on an adult ward; the amendment would not stop people from being admitted to adult wards. We have spoken a lot about the downsides of adult wards, but I would not want to forego the opportunity to pay tribute to the many colleagues on adult wards who try hard to sustain support for young people in difficult circumstances. We are not trying to demonise adult wards and say that they should never be used; we are saying that the services should be appropriate to the needs of the child, otherwise, children are at much greater risk.

Lord Williamson: That is very helpful and I think that that argument needs to be developed. We are trying to end the "house of horrors"-no more than that.

The Chairman: Am I right in suggesting that the amendments do not exclude access to an adult ward in an emergency?

Kathryn Pugh: No, not at all, nor at any point if it is appropriate. A 17-and-three-quarter-year-old might be much happier with adults, in which case they could go into an adult ward.

The Chairman: For the sake of the record, the witnesses are all nodding.

We have slightly gone over our allotted time. I thank each of you very much indeed-we have got through an awful lot in a short space of time. It has been exceedingly useful. Thank you for coming and for giving such punchy evidence.

COMMUNITY TREATMENT ORDERS

The Chairman: Our next subject is that of community treatment orders. We have allocated a slightly longer time for this session, because the research on international experience of community treatment orders that was commissioned by the Department of Health from the Institute of Psychiatry was published only the day after Third Reading in the House of Lords. CTOs were one of the more contentious parts of the Bill, and their Lordships did not have the opportunity before their deliberations to see the comprehensive research in the report, which is why we thought that it would be particularly important for Members of both Houses to be able to scrutinise the report. People from the Institute who were responsible for it are here, together with others, and there will be witnesses with views contrary to those in the report.

We invited the Zito Trust, which has a different view on CTOs. The trust was unable to attend, but it asked whether Professor Maden could be here, and I am glad to say that he is, so he will give his perspective in agreement with the Zito Trust, and no doubt he will speak for himself as well.

The amendments made in the Lords would not ban the use of the CTOs, but they would tighten up the criteria under which such orders can be used, as per the recommendation of the pre-legislative scrutiny Committee.

For the record, Baroness Eccles has joined us.

Could each of you give a few short sentences by way of opening, after which we shall take questions? We have, with respect, a disparate group. Perhaps the Institute could kick off, with reference first of all to the actual report.

Dr. Gareth S. Owen (Clinical Researcher, Institute of Psychiatry, Honorary Specialist Registrar, South London and Maudsley NHS Trust): Thank you for asking me to come and present some of the findings from the recent report entitled "International experiences of using community treatment orders", written by Rachel Churchill and others. I am the second author of the report, which was commissioned by the Department of Health.

The report is the most comprehensive and thorough review that has yet been undertaken of the existing international research literature on CTOs, and it relates to civil patients-patients who are not involved in criminal proceedings. The research has been critically appraised to epidemiological standards, and we reviewed 72 studies from six countries.

I shall stick as much as possible to the research. As you all know, prior to the empirical research there was considerable ethical debate on CTOs. Both libertarian and "need for care" positions are prominent and well argued in the literature, and there has been no clear resolution to the debate between them.

Many in the CTO community have wished to try to achieve such a resolution by conducting research on effectiveness of CTOs. Our report concludes that the available empirical evidence indicates that there is no robust evidence that CTOs cause either reduction or increase in a range of outcomes. I shall read out some of those outcomes to give an idea of how wide-ranging they have been: hospital admission, hospital bed days, compliance with treatment, violence, symptoms, offences resulting in arrest, social functioning, quality of life, care or satisfaction, and perceived coercion.

Follow-up on studies has typically ranged between six months and two years. There have been two randomised control trials, conducted in the USA. They are the most reliable form of epidemiological evidence, and neither has demonstrated effectiveness.

A considerable amount of secondary analysis was carried out on one of those randomised control trials. Probably the most influential concerned violence, with positive results being reported for patients whose CTO exceeded six months. The secondary analysis suffers from well-established methodological problems, however, which bars any inference on effectiveness, because the analysis is of an exploratory or hypothesis-generating type. The importance of that is that, in clinical trial methods, the use of such analysis as a basis for deciding treatment effectiveness is considered dangerous. If CTOs are considered as an intervention comparable to other treatments, such that they must empirically demonstrate effectiveness, the available empirical research does not lead one to expect NICE approval. The hope, therefore, that empirical work on effectiveness will be the key to swinging policy toward either a libertarian or a "need for care" approach on the CTO question has not been fulfilled.

I want to say a little about criteria, and how the available research relates to that. There are significant design differences between CTOs in different jurisdictions. In north America one can distinguish between so-called "least restrictive", or alternative, CTOs and so-called preventative CTOs. In other jurisdictions, mainly Australasian, that distinction is blurred.

The key feature of the so-called least restrictive CTOs is that the criteria for their use are the same as for detention in hospital. So, for example, Virginia state in the USA has a least restrictive, alternative CTO, which can be applied without restriction as an alternative to involuntary hospitalisation. The key feature of preventative CTOs is that the criteria for their use is different from hospitalisation. Examples would be in New York, where CTOs are restricted to patients with revolving door histories, or histories of non-compliance resulting in violence. North Carolina has a CTO that is restricted to patients with impaired decision making, and Saskatchewan has a CTO that is restricted to patients with both revolving door histories and impaired decision making.

How does the research relate to such CTOs? Least restrictive CTOs appear to have certain sorts of conceptual problems and design difficulties. That is perhaps best expressed by trying to understand from a legal point of view how a patient can be considered dangerous enough to require hospitalisation yet simultaneously safe enough to be treated in the community. There are also reports that CTOs have generated confusion and antipathy between mental health professionals and the courts, and that they might be difficult to use in practice.

Available data on the rates of use of preventative CTOs suggest that those CTOs are used less frequently than least restrictive alternatives and other types. Those data have been collated by Simon Lawton Smith at the King's Fund.

The Chairman: Thank you very much. For the record, we have been joined by Hywel Williams MP.

Professor Graham Thornicroft (Professor of Community Psychiatry, Head of the Health Services Research Department, Institute of Psychiatry, King's College, London): I should like to add some contextualising comments. My name is Graham Thornicroft, and I am a consultant psychiatrist in south London, where I have worked as a psychiatrist for 22 years. I am head of the health service and population research department at the Institute of Psychiatry at King's College in south London, where we try to establish, by way of evidence, what works in helping people with mental health problems.

I should like to make three brief points to set Dr. Owen's comments in context. They are: first, that there is no strong evidence to support CTOs; secondly, that there are no ethical standards to support them; and thirdly, that experiential evidence does not support them either.

To deal first with evidence, you have before you the executive summary of the CTO report. The summary sheet contains a web link to the full report. More than 222 pages of review of 72 studies showed no good evidence that CTOs are effective on any of the counts claimed by the Government. Some might say that the tragic events at Virginia technical college last week provide evidence for why CTOs should be introduced in this country. As Dr. Owen mentioned, however, there are already such provisions in Virginia state, and the evidence that I have just circulated shows that Mr. Cho was subject to involuntary outpatient commitment at the period around 14 December 2005.

The second matter is that of the ethical standards that should pertain. There is at present a 10-year national mental health plan for England, which is called the National Service Framework for mental health. I must declare an interest in relation to it, as I chair the external reference group that wrote that plan, which was carefully and consensually developed among all of the stakeholders. I have set out in the summary sheet the 10 principles that guide current mental health policy for England, and it is clear that the Government's proposals in the Bill conflict with those established, consensually agreed and currently operating principles. They are incompatible with those principles, and if the Bill were implemented it would cause difficult if not irreconcilable conflicts in policy, which would feed through to confusion in practice.

Thirdly, there is the experience of people directly involved in mental health problems. The Mental Health Alliance has now grown to some 80 members, the Samaritans having joined most recently. It is remarkable that the Government continue to persist in the view that the whole, or more than 95 per cent. of the mental health field at least, is wrong, and that they alone are right. To ignore the vast collective experience of the whole mental health field in England is fundamental folly. If the Bill were enacted, there would be great practical difficulties in its implementation.

There are real risks not just of the unamended Bill having neutral effects but causing actual harm. The key such areas of harm would be increased treatment avoidance by people with mental health problems, perpetuation, at least, of current disparities with respect to people from black and ethnic minorities who, as you know, are much more likely to be detained, and huge transaction costs from the implementation of CTOs. Without the evidence that CTOs work, not only would that money be ill-spent, but the opportunity to invest the relevant funds wisely in effective services would be lost.

CTOs, therefore, lack any evidential, ethical or experiential basis, and my view is that there is no foundation for them. Were they to be implemented, the criteria should be made as narrow and stringent as possible.

The Chairman: Thank you. Professor Maden, I hear you may have a slightly different view.

Professor Tony Maden (Professor of Forensic Psychiatry, Imperial College London; Clinical Director DSPD Service, West London Mental Health NHS Trust): Yes. I should say that from my experience in forensic psychiatry, I am quite attached to the concept of the expert witness being independent, and I shall try to make my comments as moot as possible. My sadness about the debate on the Bill is the result of the extent to which opinion as polarised.

The executive summary says that the general quality of the empirical evidence is poor. The first key point says:

"It is not possible to state whether community treatment orders (CTOs) are beneficial or harmful to patients."

In those circumstances, I am not sure that scientists can make a strong recommendation either way. It is a case of "definitely maybe".

There was a bit of a furore in relation to the Institute report. I do not know the ins and outs of whether the Department of Health tried to suppress it or not-I was not involved in any way. I hope, however, that the committee has seen the September 2004 review by Marvin Schwartz and Jeffrey Swanson entitled "Involuntary Outpatient Commitment, Community Treatment Orders, and Assisted Outpatient Treatment: What's in the Data?" The bottom line conclusion of that review is essentially the same as that of the Institute of Psychiatry's report: that the evidence is not brilliant and people cannot say for sure either way. I like that paper for its dispassionate account of the area.

People should not expect too much from science; science cannot tell you what laws should be made, nor can CTOs be expected to correct grave faults in mental health services. Schwartz and Swanson said that a CTO was completely useless if services were poor and if it was not properly enforced. Yet there was evidence to suggest that CTOs made a difference if there were good services and enforcement. So we should not expect too much from law, or from scientists advising on law.

Having said that, my attachment to CTOs derives from a measure that was enacted by a Conservative Government back in 1994. The then Government were concerned about the failings of mental health services, so Virginia Bottomley mandated that, whenever there was a homicide by a psychiatric patient, there should be a homicide inquiry. I think it is fair to say that almost everyone in the room from the psychiatric profession loathes those inquiries. They are universally disliked by psychiatrists, they have ended careers, and they have caused a lot of damage.

Whatever their failings, however, they have been the policy of the Governments drawn from two parties for a long time, and they have produced some evidence. That evidence is not scientific, as we understand science; it is not about numbers and randomised control trials. The process is run by lawyers, who operate according to different rules from those by which scientists operate. However, there has frequently been a debate on whether better compliance with treatment might have avoided the fatal outcome. In a significant number of cases the conclusion has been that that might well have been the case.

Off the top of my head, I mention the Matthew Hooper inquiry and the PH and SS inquiries, which reported last year in east London. I am happy to provide further instances in which a homicide inquiry concluded that the death could possibly have been avoided by a community treatment order. We cannot say that those conclusions were necessarily right, but as far as I am concerned they are a part of the evidence that ought to be thrown into the melting pot alongside the science.

My own minor contribution in the area was a review of 25 deaths that were caused by patients with a previous history of violence, a diagnosis of schizophrenia and contact with services. They were patients with whom, as a service, we should have been dealing; they had a clear psychiatric illness, they were in contact with services, and we knew of their previous violence and hence their risk. In 23 out of 25 of those cases, poor compliance with medication was a major factor in the homicide. Out of fairness to the families of the victims of those homicides, we should take that evidence seriously. It is not the be all and end all, but it would be unreasonable to neglect it completely.

My enthusiasm for CTOs came in the first instance from the homicide inquiries, because those inquiries in many cases said that CTOs were needed. Normally, in medicine, when there is a disaster inquiry we follow the recommendations of such inquiries.

Having said that, I would also look to the scientific research to tell me whether there was any scientific reason why we should not adopt the route recommended by the inquiry. I would ask: would it be harmful to patients and would it prevent them from seeking treatment? At the moment, I do not see any substantive scientific evidence to show that a community treatment order would deter people from seeking treatment or that it would be detrimental to them.

In closing, I repeat the first key point in the report:

"It is not possible to state whether community treatment orders (CTOs) are beneficial or harmful to patients."

In those circumstances, I respectfully suggest that we should follow the recommendations of the many homicide inquiries that have been conducted during the past 20 years or so at great cost-both monetary and in terms of cost to the professionals involved. We should therefore implement CTOs.

The Chairman: Thank you very much, Professor. May we hear next from Dr. Rowena Daw?

Dr. Rowena Daw (Vice Chairman, Mental Health Alliance): I shall confine myself to discussing the alternatives that are on the table before us: the Government proposals and the House of Lords proposals. We in the Mental Health Alliance have, in the past however many years, looked closely at the issues involved and the research, such as it was prior to the international report. It is fair to say that there is a difference of view among members of the Alliance on many of the issues that Professor Thornicroft mentioned.

A significant number of members of the Alliance are totally opposed to community treatment orders because of their over-reliance on drug treatment, the extent to which they might damage therapeutic relationships and bring coercion into the delivery of community care, and so on.

However, the majority of the members of the Alliance have accepted that, if there is to be a change in the law, we need to look at the evidence to see whether it will work. Of course, we have started from the point of view that there are already forms of supervised community treatment-section 25A and conditional discharge and 17b. CTOs will add another level of coercion to the system-a situation in which people can be brought back in to hospital to have a treatment regime forced upon them. We consider that to be a deeply significant change for professionals and patients.

We are mindful of the fact that NICE guidelines on all major mental health conditions state in all cases, as a top-line message, that health care professionals should establish and maintain collaborative relationships with patients and their families so that outcomes improve. Outcomes are best delivered through a partnership between client and professional. We should not underestimate the importance of that.

For that reason, we believe that the Government's proposed regime, at which we will look in more detail in a moment, is the broadest that I have seen, having examined the legislation of the all Australian states, New Zealand, around six Canadian jurisdictions, a number of American jurisdictions and Scotland. Looking at the proposals in that context, we can see that the proposed regime is extremely broad. In that setting, and given that there are already powers of supervised discharge, we asked in what circumstances is it justified to impose and extra level of coercion on patients who are ready to leave hospital, and whether there is any evidence to support that. In conclusion, we identified a group-as have the Government-of what we call revolving-door patients, for whom there might be a case for imposing the new regime, because it might be beneficial to them for the reasons that we know.

However, given the availability of supervised discharge, which provides a graduated return to community life for patients who need extra supervision on leaving hospital, we needed an extra reason to add the coercion. We feel, as did the Lords, that the coercion should be confined to the group about whom the Government were most concerned-those people who are considered to be a danger to others. In a different context-one in which there is a possibility that some of the narrowing of the criteria proposed by the alliance and accepted by the Lords were acceptable to the Government-we might favour a broader reach for community treatment provisions to those who posed a level of serious danger to themselves.

Before I finish, I would like to mention the reasons why we need to understand that when we compare our regime with those of other countries, we are not comparing apples to apples. Looking at the Government's proposals in the Mental Health Bill, we see that they are proposing to introduce a broad definition of mental disorder-disability or disorder of the mind-and to eliminate a treatability test; a broad concept of appropriate treatment; a definition of medical treatment that could include nursing or care or rehabilitation; and to remove all exclusions bar one for substance abuse.

True: they say that patients need to be sufficiently ill to be admitted to hospital, so the proposals are not for an alternative regime. However, a CTO becomes an issue only at the point of discharge. At that point, by definition, the patient is no longer sufficiently ill to require compulsory treatment in hospital, which gives rise to the question of whether they need compulsory treatment at all. The Government's proposed regime that at the point of discharge, the clinician will be faced with the question of whether the patient needs medical treatment. The chances are that a person leaving hospital following a crisis will need medical treatment, certainly in the broader concept proposed in the Bill. The clinician will also need to know whether a patient needs to subject to recall, which is a polite way of asking about the likelihood of a patient not continuing to comply with an imposed medication. Of course, recall powers will last for only 72 hours. In that period, not a great deal can be done except for providing medication.

The proposed regime is extremely broad and it undoubtedly increases the reach of compulsory powers. For the reasons that others have given and will continue to give, we consider it entirely unwarranted and, indeed, dangerous, not only from a civil rights point of view, but because of the damage that it will do to community treatment and the provision of community services, and because of the way in which it will skew those to a particular end. We could explore all kinds of issues around that.

The Chairman: Thank you, Dr. Daw. We now move on to Simon Lawton Smith of the King's Fund.

Simon Lawton Smith (Senior Fellow in Mental Health, The King's Fund): Thank you for the invitation to provide evidence today. I shall restrict my introductory comments to the situation in Scotland. I produced work last year for the King's Fund on the impact of community-based CTOs after six months. I spent three days of last week in Scotland updating that work, so my comments are hot off the press, as it were. As Dr. Daw mentioned, the situation in Scotland is that the criteria for compulsion for both hospital and community-based CTOs are different from what they will be here.

The two key differences are that in Scotland, first, medical treatment has to be likely to prevent the mental disorder worsening or to alleviate the symptoms or affects of the disorder. That is not what is proposed by the Government for England and Wales. The second difference is that the provision in Scotland stipulates that a patient's ability to make decisions about the provision of medical treatment is significantly impaired because of a mental disorder. Again, the Government do not intend to put that provision in the Bill for England and Wales. It is important to remember that.

It is also important to remember that in Scotland, every authorisation of compulsion is undertaken by an independent mental health tribunal, so it is not just clinicians who agree to the imposition of a CTO, it must go to the independent tribunal, whether for a community or hospital CTO.

Bearing that in mind, I shall try objectively to set out a few of the key findings from Scotland. This follows conversations with the Mental Welfare Commission, Mental Health Tribunal, Scottish Executive, National Schizophrenia Fellowship Scotland and SAMH, which are the two big voluntary sector organisations in Scotland, and a small number of front-line mental health staff, including an advocate who works for people subject to CTOs in the community.

Before the law was enacted in Scotland, it was estimated that around 200 people at any one time would be under a community order. As at October 2006-six months ago-245 people were subject to community-based CTOs. The number appears to be going up continually. My estimate is that more than 300 people are now under community-based CTOs. That is a rate of about five per 100,000 which, after one year, puts them in the lower rate of use of such orders as compared to other jurisdictions. An equivalent rate applied to England and Wales would mean something like 2,500 people under community treatment orders, although I stress again that different criteria might apply in Scotland.

No data have yet been collected on when people come off orders. That is frustrating, because I think that it is one of the key issues: how long do people stay on a CTO? I was told that it was too early to say and that the data have not been collected. Clearly, as the numbers-the point prevalence-of people under community orders rises, more people are being placed on them than are coming off.

I was told that to date, there has not been an overall increase in the number of people under compulsion. Taking community and hospital compulsion together, there has not been a increase in the total number, which would suggest that CTOs are genuinely being used as a less restrictive alternative to hospital care, and not to impose conditions and compulsion on people who would not have been subject to that under the previous legislation.

There are between 10 and 20 people per quarter under a community order who need to be re-hospitalised. The point about that is that it would be wrong to imagine that once a person is on a community-based treatment order, they will not need to be re-admitted. Clearly, people are being re-admitted despite being on a community treatment order, including people who comply with their medication, but who nevertheless become so ill that they have to go back in to hospital.

On the conditions that can be placed on somebody under compulsion in the community, there was some concern about the provision in the Bill that allows a condition to be placed on a patient to abstain from a particular conduct. No one I spoke to in Scotland, where such a provision is not available, felt that that was necessary. I asked them whether they would like such a provision and they said that it is not necessary for the effective management of people in the community.

There is quite strong anecdotal evidence that the extra time imposed on mental health professionals both in imposing the process of community treatment orders and hospital treatment orders is an additional burden. In particular, mental health officers-the equivalent of associate mental health practitioners or approved social workers-have spent less time with voluntary patients, whom they might previously have spent a little time with to make sure that they are all right and living in the community, because of the imposition of the new Act and the requirements to provide services under a statutory community order.

The Mental Welfare Commission for Scotland has interviewed more than 100 patients who are subject to community treatment orders and in one case only did it believe that the order had been inappropriately applied. The commission, which has a statutory obligation to ensure that the legislation is followed, has from talking to patients, come to the conclusion that on the whole-in the vast majority of cases-the order was appropriately applied.

That is all that I wanted to say about Scotland. Briefly, on the homicide issue, I saw a piece in The Daily Telegraph in which a former Home Secretary, David Blunkett, suggested that the recent Virginia Tech shootings suggested that the Government's proposals are both right and necessary. I have done some provisional work on the number of homicides committed by people with a mental disorder in Australia, New Zealand and Canada, where community treatment orders have been in place for some time. It is not possible to find any evidence that the number of homicides has gone down as a result of community treatment orders being in place in those countries.

The research is difficult to interpret: the numbers are very small and there are a great many things that might cause someone with a mental disorder to commit homicide; but I think that it would be misleading to give the impression either to MPs who are debating the Bill or to the general public that supervised community treatment will prevent an occasional, rare and unpredictable homicide. It is important to get that message across.

The Chairman: That is very clear. Thank you very much. We have been joined by Charles Walker MP and Doug Naysmith MP.

Doug Naysmith MP: I do not want any part of this, thank you very much.

The Chairman: We can talk about that when we come to ask questions. Last but not least, we have been joined by Kay Sheldon.

Kay Sheldon (Service User): Good afternoon. I am a mental health service user with experience of numerous detentions under mental health legislation. I also work with the Mental Health Act Commission and have a strong background in advocacy and user involvement initiatives. That means that although I am speaking from personal experience, the points that I will make are informed by direct contact with many other service users.

At various points, I have been described by mental health services as lacking insight, as non-compliant and as a chronic revolving-door patient, so I would be viewed as a strong candidate for a community treatment order. That horrifies and terrifies me. It feels as though I might be penalised for the shortcomings of the mental health services, which view me as the problem yet, during all my detentions, I have never had a proper assessment of my needs. My care plans, or those about which I have known, have been minimal and mostly for the benefit of staff. No one has taken time to develop a rapport with me and my point of view is rarely taken seriously. I have ended up being given inappropriate medication, with horrendous side effects, and left at home with next to no support. I am fearful of the services, which I do not trust and in which I have no confidence. Those are common experiences and feelings.

People want good quality services that are approachable, sensible and person-centred. If such services are provided, engagement, compliance, concordance or whatever becomes much less of an issue if it is an issue at all. It seems to me to be fundamentally wrong to underpin our health and social services with the threat of coercion. Even the proposal to limit CTOs to people who are a risk to others is worrying. There is a tendency among people who work for mental health services to write information on forms or in patient's notes that lacks objectivity-it is based on opinion rather than evidence for the sake of convenience.

By way of a personal example, on one occasion on which I had been sectioned, a nurse was trying to get me to take some medication that had previously given me horrendous side effects. I tried to explain, but she did not listen and pushed the medicine pot into my face. As a reflex, I pushed her away. Shortly afterwards, several nurses descended on me, held me down, and forcibly medicated me. Some time later, I gained access to my notes and read on the incident form that I had attacked the nurse without provocation and wrestled her to the ground before being pulled off by a student nurse. That simply did not happen. More worryingly, the student nurse countersigned the form as true. Thus, things can be written to justify actions and to defend decisions without evidence or the service user's knowledge and, hence, without a right to reply.

In summary, the proposals to broaden the criteria for compulsion and the introduction of community treatment orders are very worrying for service users, and it is not difficult to see that a service based on increasing coercion, together with one or two high profile but unrepresentative inquiries, could lead to a whole underclass of mental health service users on long-term treatment orders in the community. That is not scaremongering; it is the reality that we face.

The Chairman: Thank you very much. We need to make questions and answers concise. On a technical point, the part of the Bill amended in the Lords only makes reference to the necessity of CTOs for the protection of others from serious harm. Can any witnesses suggest whether that should be extended to include those at risk of harming themselves? That came up on Second Reading.

Professor Maden: I would argue strongly that it ought to include "risk to self". One of the complaints levelled against the Bill is that it is a public order measure rather than one aimed at good clinical care. I have talked about homicides-around 50 are committed by patients every year-but there are some 1,300 suicides. The criteria are good for allowing doctors to address such risks and I do not see any good reason to prevent us from dealing with the risk of self harm by the less restrictive and preferred alternative of community treatment.

We have heard a lot of stories today about how bad hospitals are, and in many ways I endorse those views. People do not like being in hospitals, so if we can deliver safe and effective treatment in the community, we should.

The Chairman: Does anybody demur from that?

Professor Thornicroft: Without over-polarising the argument, we are speaking about enforcing medication; we are not speaking about enforcing social treatments or psychological treatments. The crux of the argument is the question of how medication can be better delivered and more often to the people who benefit from it. Whatever we might think about partialities, the independent evidence from the Department of Health-commissioned report is quite clear that CTOs do not increase medication compliance, even though we might wish that they did. I would therefore argue for restricted and highly restrictive criteria that are not expanded to include self harm.

Kay Sheldon: The inclusion of people who are a risk to themselves would be to replace good quality services with coercion-it is just not necessary. We need good quality, accessibly services, not legal compulsion.

Lord Carlile: My question is directed at Professer Maden. I am slightly troubled to hear a distinguished forensic psychiatrist saying that a certain type of order should be made even though we do not know whether it works, which is my summary of what you said. If you were giving evidence in a criminal court, you know that no judge would ever impose a restrictive and coercive order on a defendant because it might work; at least, there would have to be evidence that on the balance of probabilities that it would work.

Returning to the report of the Joint Committee on the draft Mental Health Bill, to which you gave evidence, and which paid close attention to what you said, does anyone disagree with the restrictive approach taken by the Committee? I am a partial because I chaired the Committee, but in my view, the report presented the Government with a template for the legislation, and they have chosen to ignore it.

Professor Maden: There is quite a lot in that question. You raised the question of whether on the evidence available I would recommend a particular order, which is a good question. However, I would distinguish between recommending an order for an individual patient and legislators making a particular form of coercion available to doctors when they think it is appropriate to recommend such orders. All I say is that a number of homicide inquiries-many-have identified as a problem the restriction on doctors that prevented them from ever recommending a community treatment order on the clinical facts. I hope that the distinction is clear. I believe that an option to recommend an order in that small number of cases where they think it is appropriate should be available to doctors.

I was pleased to hear Simon's evidence that we have not seen a vast number of people placed on the orders in Scotland. I think that the absence of vast over use has been the general experience of community treatment orders. My point is that so many homicide inquiries over the years have suggested that the lack of an option for doctors is a problem and that we ought to weigh that evidence in the balance with the other scientific evidence.

The politics of it are not for me to comment on. My line is very much that doctors in this country are on the whole not disposed to take an overly coercive approach to patients-the 1983 Act works pretty well. When doctors are coercive, the mental health review tribunals provide a good safeguard. English solicitors are more aggressive than those in Scotland-at least, I hope that they are. I have no doubt that if it comes to a point at which I am able to recommend a community treatment, the grounds on which I might well be scrutinised intensely by a tribunal, and that if it believes my recommendation to be unreasonable, they will overturn it, which is as it should be.

Angela Browning MP: In their regulatory impact assessment, the Government state that one of three benefits of supervised community treatments flag up is that they "should enhance patient and public safety by enabling a clinician to recall swiftly to hospital patients whose mental health has deteriorated".

I wonder whether the evidence from Scotland and the fact that so few treatment orders have been initiated is because of the geography of that country. I represent the county of Devon, which has two large moors. The idea of anybody being taken anywhere swiftly is something by which we are challenged every day. I wonder whether there is an urban emphasis to the policy. The policy might be easier to implement given the resources and facilities available in a large city area. For the rest of the country-the shire counties, Wales and Scotland-the policy might be totally inappropriate. Does anyone have any views about that?

Simon Lawton Smith: It was put to me that if you were in the Orkney Islands or wherever and you needed treatment because of the deterioration of your mental health, it is unlikely that you would go to hospital because it would be so far away. You might have a higher chance of being placed on a community treatment order. In Scotland, people can be placed directly on a community treatment order without having to go to hospital first and then placed on an order on discharge. In fact, around a third of orders made are made as a variation of a hospital order on discharge.

Both you and Professor Maden said that there had been relatively few orders in Scotland. You might think that 245 or up to 300 people is relatively few. Given the population of Scotland, the fact that the powers have been conferred for only 12 months, and the criteria for issuing those orders are tight-considerably tighter than those proposed for England and Wales-I consider the numbers to be fairly significant. They are already larger than those estimated before the legislation was passed.

Baroness Meacher: I would like to address a question to Tony Maden. What is your attitude to the autonomy of capacitous patients? We have a highly capacitous service user in the meeting. Does it not disquiet you that someone might interfere with a person's autonomy in the way in which a CTO would? You emphasised that your main argument for supporting CTOs-I support narrow criteria-has to do with homicides. There is no evidence from other countries that CTOs reduce the number of homicides. Does the idea of introducing these incredibly broad criteria for CTO in order to reduce homicides, when in fact there is no evidence that CTOs will do so, disquiet you?

Professor Maden: My personal interest and work has been to do with homicide. I emphasised that it is important to remember that the number of homicides is dwarfed by the number of suicides by mental health patients. I am not dismissing that problem, but it is not one on which I have done a lot of work. The issues of "risk to self" are not quite the same as those of "risk to others".

We have to accept that the scientific evidence on community treatment orders is not really clear-both this research and the Schwartz research say that. The Schwartz research, however, shows that there is enough evidence of the benefits of longer-term CTOs combined with good services in reducing the level of violence in people who have previously been violent. That is a small group of patients, but in my part of London such patients are not in short supply. Violence is not rare in mental illness. Homicide was mentioned earlier, and 50 homicides a year is not what I would call occasional, given the severity of homicide, and the general tolerance of risk in medicine. We would ban any drug that caused the deaths of 25 patients a year as a side-effect, yet in mental health we are dismissing as occasional the deaths of 50 people who are not patients but innocent bystanders.

Charles Walker MP: Violence is not a rare occurrence in the black Afro-Caribbean communities. Would you therefore suggest that we go around locking up young black males in case they might commit an act of violence?

Professor Maden: Far from it. That is a ridiculous suggestion and a bit offensive. I did not write the reports of the homicide inquiries, they were written by people such as Louis Blom-Cooper, who does not in my view count as a liberal, and Robert Robinson-a highly respected mental health lawyer. If one considers the homicide inquiries, what is troubling is the often-reached conclusion that death was often the consequence of less than adequate treatment.

I am not interested in violence in society as a whole. I am interested only in that violence that results from less than optimum treatment of mental disorder. That concerns me a lot as a doctor.

I am not suggesting anything like what you propose; I am merely suggesting that services need to take the management of serious mental illness very seriously if the patient has previously behaved violently, and ensure compliance with medication. Over the years, inquiries such as the Matthew Hooper inquiry have found that the lack of a CTO has sometimes obstructed the best services and has led to a tragic outcome. By the way, Matthew Hooper was being treated by the Maudsley.

Medicine generally tends to follow the recommendations of inquiries into people's deaths, and we should not dismiss those recommendations lightly. They are a part of the evidence and they ought to be considered alongside the rather inconclusive science on CTOs. No doctor is obliged to use a CTO, but at the moment they cannot. That is the problem.

Lord Carlile: Is this not a needle in a haystack? I am told that there are approximately 20,000 schizophrenics in this country. Even if you had the resources, you could not have a CTO for all of them just in case you found the 30 or however many it is-it does not matter-who were going to commit a homicide. The logical extension of your answer to what was perhaps a slightly inelegantly phrased question, if I may be forgiven for saying so, was that if a lot of Afro-Caribbean males show psychotic tendencies as a result of the over-use of cannabis, why not put all of them who come before mental health services on a CTO, just in case? That is what worries many of the responsible civil libertarians among us.

Professor Maden: On the same logic, why are doctors not using hospital in-patient treatment in that way at the moment? The reason, of course, is that it would be an absurd way to carry on. The needle in a haystack analogy suggests that the problem has come out of the blue. The public get rightly upset, however, not about the occasional homicide that comes out of the blue, but about those that follow highly dangerous previous behaviour.

The classic example is John Barrett, who almost killed a stranger in a completely unprovoked assault, while psychotic. As a result of very poor care, he went on to kill a stranger after that. That is what the public find unacceptable. The Barrett Report observed that at an earlier point in his treatment, before the first assault, only a CTO could possibly have secured compliance with medication. I cannot give the page number, but that is a quotation from the report and I am happy to supply the reference. I cannot be held responsible for what Robert Robinson concluded, but he concluded that only a CTO could have secured Barrett's compliance before the first assault.

Professor Thornicroft: Professor Maden has referred on a number of occasions to a review paper by Dr. Schwartz, which I need to put clearly in context. That paper refers to one particular study, which was the only randomised control trial to produce a positive finding in relation to violence. The review paper was produced by the same group as the study, and is therefore quite non-independent. The same group was invited to write a commentary paper in yesterday's Observer, and I understand that Dr. Schwartz has been invited to address MPs when he is in the country in June.

The paper is a highly partial account. If we take the generality of the evidence-not just from all 72 studies that were addressed in the Institute report, but from two other independent reviews-one by the RAND Corporation and one by the Cochrane database, which operates at the highest watermark of scientific integrity, the findings are the same. There is no evidence that CTOs reduce violence or increase medication compliance.

Dr. Rowena Daw: I just want to quote from the summing-up in the Barrett case. It said that the remedy for what went wrong in that case lies not in new laws or policy changes. There was a reference to CTOs earlier in the Barrett report, but the summing-up did not mention them.

Professor Maden: The reason was that the carer was so incompetent that the disaster occurred despite the fact that Barrett was already the subject of a restriction order, which is the closest present equivalent to a CTO.

The Chairman: There is clearly some difference in interpretation of the Barrett report, to which we shall return. We have overshot our time. Hywel Williams wants to ask a question and we have time for a brief point from Angela Browning.

Hywel Williams MP: I should like to put a brief question to Simon Lawton Smith about the evidence from Scotland. What observations do you have about the bureaucratic burden in Scotland, what effect has there been, if any, on diversion of resources, and what has been the effectiveness of the orders?

Simon Lawton Smith: Consultant psychiatrists find the paperwork very burdensome. However, they appreciate that the system is now fairer for the patient because there is much more patient participation in the process of compulsion. Rather grudgingly, therefore, they have accepted that the legislation is fairer for the patient. Efforts are being made to redesign the forms, so that they will be easier to fill in.

Mental health officers, who provide the front-line care to people on a CTO, are saying-according to anecdote-that they now spend more time ensuring that the care and treatment plan is fulfilled for someone on a CTO, which means that there is less time for other patients. Voluntary patients are therefore beginning to miss out on care and support.

Angela Browning MP: Professor Maden seems to have a lot more faith in the resources that will be guaranteed for provision of CTO services. As a clinician, he would need to be 100 per cent. sure that the treatment that he was prescribing for an individual was going to work. If it did not, and if there was a breakdown in services, we would be back to the story that that breakdown increasingly showed the weakness of the system, both for self-harm and homicide. In every case that I have read, one could see the pattern if one read the notes afterwards.

Professor Maden: I agree with you completely that a CTO is of no use without good services-there is no question about that. The problem that remains is that, in a minority of important cases, good services will not work without a CTO. Our experience in forensic psychiatry has influenced my thinking, in that we operate the closest thing in England and Wales to a CTO-the restriction order system of conditional discharge, which works extremely well. Relationships with patients are not fraught on the whole, reoffending rates are extremely low-even in such a group of high-risk patients-and people are generally pretty satisfied. It is not the only thing to consider, but it is a part of the evidence. We run a perfectly good system of community treatment with only occasional blips-Barrett notwithstanding.

Charles Walker MP: Can we get some consensus on how many people suffer from schizophrenia in this country?

Simon Lawton Smith: As I understand it, the figure generally used, for example by Rethink, which used to be the National Schizophrenia Fellowship, is 1 in 100. That is meant to be a figure that applies worldwide.

Charles Walker MP: So 600,000 rather than 20,000.

Professor Maden: I think that 600,000 is too high.

[Inaudible discussion]

Professor Thornicroft: It is 0.4 per cent. of the whole population.

Charles Walker MP: So if the population of the UK is 60 million, 1 per cent. would be 600,000, and 0.4 per cent. is about 250,000.

[Further inaudible discussion]

The Chairman: On that point, let me thank you for your evidence. We continue with the topic of exclusion.

Person from the floor: Chairman, you have four amendments left to deal with and no identified service users down to speak. Fortuitously, you have three service users in the public gallery. If it is amenable to your committee and to the incoming witnesses, we would be more than happy to cover the four remaining sessions.

The Chairman: Thank you, I shall bear that in mind given the time constraints.

EXCLUSIONS FROM THE DEFINITION OF MENTAL DISORDER

Our next witnesses are Mr. Chinyere Inyama, who is a solicitor, Dr. Eric Metcalfe, from JUSTICE, and Dr. John O'Grady, who is a consultant psychiatrist from Hampshire. This next session is about exclusions from the definition of mental disorder. The House of Lords added a number of categories to clause 3, all of which the Government now propose to remove, with the exception of the references to alcohol and drug dependence.

Dr. Eric Metcalfe: The definition of mental disorder is of course the gateway to the exercise of compulsory powers under the Bill and indeed under the 1983 Act. I understand that you have already heard some discussion of the breadth of the current definition. From the point of view of a human rights organisation in particular, we note that the right to liberty under the European Convention on Human Rights, which is given effect in the UK by the Human Rights Act, specifically guarantees the protection of people who are brought under detention because of mental incapacity. Article 5(1)(e) deals specifically with the definition of people of unsound mind.

The European Court of Human Rights has given a clear judgment stating that the definition of mental disorder must be very clear in order for exercise of detention powers to be lawful. The use of exclusions is a standard feature of most common law jurisdictions in meeting that requirement. They meet the requirements of legal certainty, of guaranteeing individual autonomy and of ensuring that the powers of detention are used no more than strictly necessary.

By contrast, we find that the diagnostic criteria for mental disorder are not determined with those interests in mind. Diagnostically and analytically it might be perfectly sensible to think that a person who is inebriated is suffering from a temporary disorder of the mind, but it is wholly inappropriate for that to be covered by compulsory powers of mental health detention.

The exclusions in the Lords amendment, therefore, reflect a series of established grounds to which it is recognised that the definition of mental disorder should not apply. That is all that I want to say at the moment, but I am happy to go into further details.

Mr. Chinyere Inyama: I broadly agree with Dr. Metcalfe. In the limited time available, I want to focus on the suggested exclusion in relation to cultural, religious and political beliefs.

The Afro-Caribbean or black and minority ethnic community is very vexed by the current situation of disparity in outcomes. The "Count me in" census was published last month and indicated that 50 per cent. of in-patients in London are from the BME community, 40 per cent. of men from African Caribbean backgrounds are likely to be in hospital for more than a year, and the referral rate from the criminal justice system has risen from 5 per cent. to 12 per cent. for that group. African Caribbeans are 44 per cent. more likely to be sectioned and 29 per cent. more likely to be forcibly restrained. The list goes on and on, and the census is the latest in a long line of research that has highlighted such disparities.

The root causes are clearly multi-factorial, and I do not think that anyone has got to the bottom of them just yet. I would suggest, however, that an exclusion could at least counteract potential racial bias, particularly if it targets misdiagnosis as mental disorder those situations in which behaviour within its correct cultural norm could be misinterpreted or could reflect a disordered mental state to an examiner, without there being any clear health or therapeutic care benefit. The exclusion that was passed by the Lords is appropriate, and could be extremely useful in at least trying to tackle the disparities, and I urge that it be kept in.

Dr. John O'Grady: One should not confuse mental disorder as defined by doctors with the definition for legal purposes. Any law will define mental disorder for its own purposes, such as abnormality of mind in the context of homicide, or disability of mind for the purposes of defining insanity. The law is a reflection of Parliament's particular views on mental disorder.

As I understand it, the exclusion for drugs and alcohol dependence has been accepted, so the question now is not whether there should be exclusions, but what they should be. My contention would be that the Lords amendments do not go far enough. My own expertise is in forensic psychiatry. With particular regard to sexual deviancy and paedophilia, the argument I think would be that paedophilia is a criminal behaviour, and if it were not for the fact that there is victim who was suffering, it would not be a disorder. One gets into a hopeless tautological argument about the fact that a criminal behaviour is classified under mental disorder, but for legal purposes is simply criminal.

There is a well-established system for managing such situations through the courts, through the extensive and successful sexual offender treatments in prisons and in the community, through MAPPA (Multi Agency Public Protection Arrangements), and through the sexual offender prevention orders in the civil courts.

If someone with paedophilia wished to have treatment voluntarily, they could do so. So far as I can see within mental health law, the only justification would be if someone were perceived to be such a risk to the community that they needed to be detained. The matter then becomes one of the ends justifying the means; the means being a mental health order. I believe that that has unintended consequences, however. One is the absurdity of people who might be deemed untreatable being detained for treatment, which is difficult for me to square as a doctor. There may also be sexual predator laws such as those in America. The Americans put it very nicely when they say that you check in but you don't check out-because there is no way of getting out of the system if you have an untreatable disorder which gives rise to a risk to the public.

There are major issues of justice and liberty. Forensic facilities are scarce and are needed by increasing numbers of people, and the pressure on forensic psychiatry if the Bill proceeds as it is will be considerable and will pervert the normal course of medical assessment and treatment.

The Chairman: Thank you. You were models of consiseness, which was helpful given the time constraints.

Can I perhaps begin with the BME topics? Mr. Inyama, are there other areas of the Bill in which you think that considerations with respect to BME could be considered?

Mr. Inyama: The issue of principles being set on the face of legislation is not the subject of the Lords amendment, but has been canvassed for some time. I still cannot quite understand the arguments against it. I do a lot of training, and in the training that I undertake on the Mental Capacity Act things get very crystallised with the people who attend the training, when we apply the principles that are on the face of that legislation. There is nothing unusual about that. If there was a non-discrimination principle, it would set the tone for the operation of the Bill and would be one clear way to try to begin to tackle disparities.

Charles Walker MP: Could you please explain the non-discrimination aspect?

Mr. Inyama: When powers are exercised under the mental health legislation, those who look after patients should ensure that they do so without discriminating against anyone on the grounds of race, culture, behaviour, religious beliefs and so on. That is the kind of non-discrimination principle that I am talking about.

Charles Walker MP: Why do you feel that certain ethnic minorities are disproportionately represented in secure units or under section? We have heard that there is an element of racism, which is an ugly word, but it might be the right one to use.

Mr. Inyama: You took the words out of my mouth-it might well be true. There is a lot of work to be done. As I was careful to say at the outset, because I am a lawyer and words are important, the question is multi-factorial. You cannot hang everything on racism; there might well be an element of racism or a need for better cultural competence training, though I am not sure about its effectiveness. What is most important is for the BME communities to feel that the mental health system is one in which they have an equal part to play and one in which they will receive fair and equal treatment.

Angela Browning MP: I served on the scrutiny Committee and on the Standing Committee in relation to the Mental Capacity Act, in which the Government accepted amendments after initial resistance. The Minister's argument on Second Reading for not including anything expressly in the Bill on that topic was that Part 1 of the Bill amends the 1983 Act. The Minister's argument is that because the Bill amends an existing Act, it is legally impossible to put such principles expressly in the Bill, but that they are in the code of practice instead, and that is as far as she can go. I am not a lawyer and I do not know whether there are lawyers present who can tell me whether that argument is legitimate.

Mr. Inyama: Well, I am a mental health lawyer rather than a constitutional lawyer, so I shall not venture an opinion without a good deal of reading. It has always been the Minister's position that the principles should not be expressly in the Bill, even when the Bill was in draft form, so I am not sure that I would be satisfied with her answer.

Angela Browning MP: Well, I say to any lawyers who want a bit a cro-bo network, we are open to all suggestions.

The Chairman: Dr. O'Grady, what could be picked up by having such a vague definition without exemptions? You mentioned your expertise on paedophilia. What other interests, or political or cultural beliefs, could be picked up on under the definitions? Would becoming a member of a political party be grounds for being sectioned?

Dr. O'Grady: In a liberal democracy such as ours that might be unlikely. However, the evidence from around the world suggests that wide definitions make it easy for society, or an estate in society, to misuse them for what are seen as reasonable ends. Deviation from the norm in Soviet society allowed Soviet psychiatry actively to participate in a very illiberal and unlawful system. There is always that possibility even in our society, so for the Bill to contain a principle that precludes it must be right and proper. It would be a protection for psychiatry and for our patients for that to be the case.

The Chairman: You have a rosy view of our liberal democracy, if I might say so. We have heard some succinct definitions.

Mr. Inyama: I am the deputy chair of a tribunal. With such wide and vague definitions, with few exclusions, and with a wide and vague treatment definition, it is going to be hard to argue against detention, and that will make the tribunals farcical, to be frank.

Dr. O'Grady: Society has a problem of people with disorder, however one wishes to define that, who are essentially untreatable or will not seek treatment and who pose a risk to others. As a forensic psychiatrist, my view is that the Scrutiny Committee probably got it right in that there needs to be a proper debate on the rights and wrongs of society intervening in that situation, without wrapping it up in the spurious idea that there is a therapeutic benefit to the person involved, which I think is dishonest.

Mr. Inyama: It is important to say that the exclusions would not prevent people from being treated, nor do they tip the balance on public risk in a way that none of us would want.

Dr. Metcalfe: On the scope of the exemptions, the Government have accepted that there should be an exclusion for drug and alcohol dependence, so the question becomes one of the scope rather than whether there should be exemptions at all. It is important to note that the Government exclusion only covers dependence on drugs and alcohol, rather than misuse, as covered by ICD-10. For argument's sake, therefore, it would be possible to come within the scope of mental health powers if one misused alcohol, but not if one were dependent on it. I do not think that I need to illustrate the point any further; but that situation would be manifestly illogical.

There was an exchange between the Government and the Joint Committee on Human Rights on the proposed exemption on sexual identity and orientation. The Government maintained that gender dysphoria, transsexualism, and fetishism, which is cross-dressing, should also fall under the term mental disorder for the purposes of compulsory treatment. In their response, the Government maintained that they could not possibly conceive of a situation in which it would be necessary to apply those powers, none the less they maintain that it is necessary to include those categories within the existing definition of mental disorder.

By contrast, let us look at the position of the Joint Commission on Human Rights, which is to say that if there is no evidence, how can we maintain that it should not be excluded? We feel that it would fall properly under the exclusion of sexual identity and sexual orientation in that it is therefore necessary, given the history of psychiatric treatment in relation to sexual disorders. We have only to go back a short time to see how mental facilities treated homosexuals as a mental disorder. It is important to have such an exclusion for sexual identity and sexual orientation and, similarly, a broad exemption for substance misuse. Both things are properly not within the scope of compulsory mental detention powers.

The Chairman: To come back to the alcohol point, going on an occasional bender of your own volition and making a fool of yourself could be construed as a mental illness. But relying on that on a regular basis, which is a dependency, would not.

Dr. Metcalfe: Under the terms of the Government's proposed amendment. It is striking because the ICD10-the diagnostic criteria of the World Health Organisation for mental disorder-includes alcohol misuse and alcohol dependence. The diagnostic criteria have to accommodate any concept of temporary disorder of the mind. If you were heavily inebriated, you are bound to have a disordered mind and therefore bound under the diagnostic criteria to fall within those terms. That is the problem with the scope of the Government's definition.

The Government might reasonably say that they never plan to section people who are drunk but, with respect, the point of good legislative drafting is to arrive at sensible terms that do not rely on the generous discretion of officials. If the Government can see no reason why alcohol misuse should not be excluded on the same basis as alcohol dependence, they can hardly disagree.

Angela Browning MP: If the Government were to actually include alcohol dependency, the serious implications would be enormous. We all know that if there is one area where we need more resources, it is to deal with alcohol dependency.

Dr. Metcalfe: Yes.

The Chairman: That was a rather interesting session. Thank you very much. It was very valuable. In fact, the exemptions are likely to come up in Committee tomorrow.

We now come to the impaired decision-making session. For the record and to go back to our previous discussion about schizophrenia, the figure that is commonly used is that one in 20,000 schizophrenics may commit a homicide. It is not that there are 20,000 schizophrenics of which one of them may do that, but it is a 1 in 20,000 ratio. We are working on the basis of roughly 250,000 people suffering from schizophrenia in the United Kingdom, if the figures were correct.

IMPAIRED DECISION-MAKING

The Chairman: Who would like to kick off?

Dr. Tony Zigmond (Consultant Psychiatrist, Honorary Vice-President, Royal College of Psychiatrists): In the early days of the Wakefield asylum, there were many recorded admissions of people suffering from political excitement!

There are two issues related to impaired decision-making, the first of which is whether we should have it? Secondly, if it is a criterion, is it practical. Is it one that clinicians can reasonably use? The grounds for saying that it should be there come from trying to do two things: one is to say that the days when people with a mental illness were automatically deemed to be different from those with a physical illness should have gone, in that the same respect for personal autonomy should apply no matter the diagnosis or the illness that someone is suffering from, but what matters is whether or not the disorder interferes with the person's ability to make decisions for themselves. If we are to move away from a 20th century stigma of having a mental disorder, it is essential that we make that a clear statement. It would bring us nicely in line with the provisions in Scotland, so that England and Wales can have the same essential criteria for compulsion. That is a starting point to why it is necessary. I shall now hand over to George to talk about whether it is practicable.

Dr. George Szmukler (Consultant Psychiatrist, Maudsley Hospital; Chairman, King's College London Health and Society Network): I agree with the recommendations of the Richardson Committee, the Milland Committee, the Joint Scrutiny Committee on the Draft Mental Health Bill, the Banford Committee-most recently in Northern Ireland-the Mental Health Alliance, which represents nearly all of the key stakeholders, and the House of Lords, which proposes that an impaired decision-making criterion is an essential feature of a modern Mental Health Act.

As Tony Zigmond has told us, such a measure would bring the treatment of the mentally ill in line with the treatment of other patients with physical disorders, in so far as we can distinguish physical from mental disorders. It would end discrimination against people with a medical disorder. It would also bring to an end the lack of respect accorded to the autonomy of patients with a mental disorder or their self-determination that currently characterises the Mental Health Act, but which is contrary to medical ethics in our society at this time.

The Mental Health Act permits what the Mental Capacity Act 2005 would never countenance: the treatment of a capable patient against their wishes. There needs to be a good reason why we should allow that departure from principles. I cannot see another justification for the treatment against their will other than the fact that they are not able to make those decisions for themselves.

Moving slightly into the area of practice, I can see the difficulties of reconciling the Mental Health Act and the Mental Capacity Act. Those two separate Acts proceeded at the same time, each saying that they were not of definite relevance to each other. Let us consider the code of practice that accompanies the Mental Capacity Act, either at chapter 6 or chapter 7, in which there are extraordinary descriptions of how the Mental Capacity Act should relate to the Mental Health Act. It demonstrates that there is something intrinsically inconsistent and incoherent about having separate bits of legislation.

Moving on to some practical areas, I am quite familiar with research into the assessment of capacity having been in several projects myself. Contrary to what is often said, the ability that doctors to rate impaired capacity reliably is clear cut. In fact, they can rate capacity very reliably indeed, especially if they have been trained to do so. They can rate capacity more reliably than oncologists interpreting mammograms, cardiologists interpreting exercise ECGs and haematologists interpreting visually blood films. There is an extremely high rate of reliable assessment capacity has been shown in about a dozen studies of patients with psychiatric mental disorders. The reliability is as high in psychosis, schizophrenia or effective psychosis as it is Alzheimer's Disease or learning disabilities. It is clear that it can be rated reliably.

Some issues have been raised about training. Well, every doctor needs to be able to assess capacity under the Mental Capacity Act. Every doctor will have to be trained to assess capacity so that the training requirement is already there. Our research has not found that fluctuating capacity was, in practice, difficult. We found that the reliability of ratings by two raters, separated by one day or one week, did not differ. At least over a course of one week, there did not seem to be major changes in the capacity of patients.

It is often asked whether an impaired decision-making criterion would result or more or fewer patients being treated involuntarily. I do not know the answer to that. We found in our research that 85 per cent. of patients who were detained under the Mental Health Act lacked capacity. The overlap is therefore likely to be very high. Some have assumed that the mental capacity criterion would reduce the number of people who would be treated involuntarily, but it is just as possible that the numbers would increase.

What a capacity or impaired decision-making criterion allows is an intervention perhaps at an earlier point in a person's illness. Instead of having to wait for serious risk to emerge before persuading everyone that action must be taken, if the patient loses the capacity to make treatment decisions for himself and treatment is warranted in his best interests, which is the other element in a capacity-based approach, it is likely that treatment could be brought into effect earlier.

The point is that an intervention under those circumstances may be earlier. There may be more people under compulsion; there may be fewer, but the principle underlying the intervention is clearly ethnical and can be easily defended. People who argue against a capacity based or impaired decision-based criterion say that it will miss people who need treatment. That poses an interesting dilemma for me: how do they know that those people need treatment? What are the criteria that they are using to determine that? We need to start with the principles about who should be eligible for compulsory treatment and then worry about whether it is being applied properly rather than start with a view about for whom it is appropriate, based on vague suppositions and then try to manipulate the rules to give that particular answer.

Paul Bowen (Barrister, Doughty Street Chambers): There is very little I can usefully add except to remind everyone that the right of autonomy is one that has been established for many years in this country under common law. John Stuart Mill referred to it when he wrote famously in his essay in 1859 on liberty that the only justification for interfering with someone is to protect other people. He said:

"His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully to do or forbear because it would be better for him to do so,