| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
There is a growing culture of alarm in this country. The fact that it comes at a time when crime is falling does not make that perception less influential, but this does not mean that we can therefore tolerate witch hunts. Yet the few high-profile cases of people experiencing severe mental ill health who kill receive lurid and disproportionate media coverage. They leave the impression that tragic deaths have occurred because of a failure of the law to protect us. Yet the clear message from official inquiries into these incidents is that the key to avoiding them is not to reform mental health law but investment in mental health services.
There is, for instance, no evidence that extensions in powers to allow compulsory treatment in the community will improve outcomes for people experiencing mental distress or increase public safety. As that is the case, are we not in some way talking about an unfortunate short-term reaction—even a snatch and grab at a problem—and not a detailed address to the realities involved?
There is a definition of mental illness in the Bill. It is a useful starting point, but only if accompanied by exclusions to that definition. It would be absurd, for instance, to claim that there is merely one definition of physical illness. Yet, as those of us in Mind and other like organisations continue to say, the afflictions of mental illness are just as varied as physical illnesses, from the temporarily disabling to the crippling, in both cases.
For compulsory treatment, the Bill removes a current stipulation that treatment should have a therapeutic benefit and requires only that treatment is available as “appropriate”. This is surely too vague a basis for coercive powers and is not based on therapeutic value. In effect, it would allow the incarceration of mentally ill people who have committed no crime. It would also, many psychiatrists say, turn them into jailers. Furthermore, it would allow curfews to be imposed on patients in the
28 Nov 2006 : Column 695
Research suggests that compulsory community treatment is not effective. It even deflects attention from the real issue of providing high-quality aftercare and support. If the Government are looking at what can be achieved in the community then, as well as aftercare and support, they should be looking at tackling those factors that contribute to the social exclusion and isolation of people who have experienced mental distress. It is those factors, as well as lack of care and support—as much as any failure to comply with treatment—that contribute to people relapsing after they have been discharged. To do all this is extremely ambitious, but the ambition to serve the needs of the most fragile is a noble one. I believe that the people of this country will support it.
There are points not in the Bill which should be there. Patients should have the right to a full assessment of their health and social needs before a crisis point, and a right to advocacy services to help negotiate their way through a complex system. Mind’s chief executive, Paul Farmer, said when this Bill was published:
“It’s quality health services that will protect people, not this legislation, opposed by mental health experts across the board. We hope that the widespread concern in Parliament will lead to the essential changes that must be made to give any chance of providing an effective mental healthcare system. It is vital that health legislation is focused on benefiting and treating health problems. Treatment that cannot improve or treat a person's health should not be forcibly given to them”.
The Bill must also address the distressing over-representation of black and minority ethnic people in the mental health system. Again, this is difficult, but essential for individuals and, in the round, for society. The Scottish mental health Act includes measures to provide services and accommodation for mothers, of children less than one year old, with post-natal depression. Surely there should be similar measures for women in England and Wales. All in all, treatment for those with a mental illness must be on the same basis, wherever possible, as with those with a physical illness.
Finally, the Government have a fine record in tackling the difficulties in our overall national health. They have lacked neither courage nor patience. But I hope that this debate will persuade them to reconsider this Bill and their position in this too long underserved part of our health provision.
5.44 pm
Lord Patel of Bradford: My Lords, I begin by declaring my interests. First, I am chairman of the Mental Health Act Commission. Secondly, I was responsible for leading the development and implementation of the Government’s black and minority ethnic mental health programme, “Delivering Race Equality in Mental Health Care”.
Through these roles I have both challenged and worked alongside the many architects of this Bill. It is important and necessary to acknowledge that mental health legislation is a difficult and complex area but nevertheless crucial to get right. Many of us know
28 Nov 2006 : Column 696
Like many of your Lordships, I share a number of concerns about the general issues raised by the Bill. For example, the proposed single definition of mental disorder and the removal of the treatability test must be of concern to this House. I am also exercised by a number of other matters. I flag these up in no particular order: the importance of having guiding principles in the Bill, and not solely in the code of practice; the needs and rights of informal carers; provision of improved specialised advocacy, something not present in this Bill which was in previous Mental Health Bills in 2002 and 2004 and, if I dare say so, one of the few changes broadly welcomed; improving the consent provisions of the Act, which include the role of the second-opinion appointed doctor; the needs of prisoners with mental illnesses who do not currently receive mental health care; the use and abuse of seclusion and restraint; information-sharing between professionals and public bodies; advanced statements by psychiatric patients, allowing them to refuse potentially life-saving psychiatric care; and widening the groups of professional staff involved in compulsion. I am particularly exercised by the idea of losing the specialist expertise of the approved social worker, and I am not simply saying that because I am a qualified social worker.
I expect others will want to discuss these points in more detail, but my intention today is to focus on why we are discussing amendments to the Mental Health Act. The noble Baroness, Lady Barker, referred to this Bill last week as,
Yes, some of the amendments being proposed are about public safety, but let us not lose sight of the fact that this debate should be concerned equally with the protection of patients. People detained under the Mental Health Act 1983 are among the most vulnerable in our society, and I want to address how this Bill will ensure the protection of three of those groups in particular, and how I think we can ensure that this Bill provides solutions that meet their needs.
I shall focus on children and young people, older people and people from black and minority ethnic communities. These are three of the most vulnerable patient groups affected by this Bill. Three cross-cutting themes will help us to ensure that amendments to the Mental Health Act can provide solutions and meet their needs. First, there need to be sufficient and robust statutory procedures of notification—I will elaborate on that in a moment. Secondly, there must be an adequate system for monitoring, especially what I rather loosely term “ensuring that we look under the bed”. Thirdly, we must ensure that CPA—the care programme approach—is given statutory force as the underpinning process of the proposed community treatment order.
The Mental Health Act Commission has voiced concerns about the treatment of children and adolescents under the Mental Health Act within adult mental health facilities in each of its past four biennial reports.
28 Nov 2006 : Column 697
I am sure that your Lordships would agree that these children were not only in an inappropriate environment which did not cater for their basic educational, recreational and social needs, but liable to be bullied, have illegal, non-therapeutic or recreational drugs forced upon them, and witness some distressing and violent scenes. Few staff working on these wards had received any specialist training to work with children or adolescents with mental health needs. The children were as young as 12—that is surely a situation we must urgently address. We must ensure through this legislation that the needs of children and minors, especially those under 16, are protected and that alternative, appropriate care is provided.
Older people are often subject to unacceptably low standards of care, which result in abuse. They, especially those with dementia, are the group most likely to be de facto detained without the benefit of the protections of the Mental Health Act. They are not formally detained, yet they are unable to leave. Their expectations about their rights and protections are low and they put up with treatment that would horrify many of us. I am reminded of the significant, albeit short-term, increase in the use of the Act to detain elderly, incapacitated people as a result of the Bournewood case. Therefore, I welcome the proposals in the Bill to incorporate changes to the Mental Capacity Act 2005 to deal with the so-called Bournewood gap, but I remain concerned that they do not yet provide adequate protections. There is still concern that decisions under that Act will not be subject to independent scrutiny. I wish to propose a solution to this lacuna.
Finally, I wish to draw your Lordships’ attention to the continued unacceptable situation, which I believe to be one of the most significant remaining scandals in the health and care system, of the disproportionate rates of admission and detention of people from black and minority ethnic communities in our mental health settings. We know from the 2005 mental health and ethnicity census of in-patients in mental health care—the first ever undertaken by the MHAC and the Healthcare Commission—that black and minority ethnic patients are more likely to be admitted to mental hospitals than their white counterparts. For example, black African and black Caribbean people are between three and five times more likely to be admitted and 30 to 40 per cent more likely to be detained. People in the young black British group of
28 Nov 2006 : Column 698
I am deeply concerned that many young third and fourth-generation black people are more likely than first-generation migrants to have high admission rates. This is counterintuitive. We would expect rates to drop as families and communities became assimilated and integrated, but that is not happening. I am equally worried that we will see higher levels of second and third-generation Muslim young men, in particular, coming into the system. We do not understand all the reasons for this, but we know that these disproportionate rates occur in the context of the present Act. With the Bill, we have the opportunity to make sure that the operation of the Act is equitable in relation to need and to ensure that it is in line with the positive duties enshrined in the Race Relations (Amendment) Act 2000.
There are two issues about the needs of black and minority-ethnic patients that I need to mention briefly. First, despite the fact that it has been a mandatory requirement to collect and record ethnic monitoring data for all in-patients since 1995— 11 years now—the overall state of collection, recording and use of data is disgraceful. The census that we conducted managed a collection rate of 98.9 per cent for ethnic monitoring data through providing training, advice and support to service providers, so we know it can be done. From the MHAC’s regular visiting, we know that the collection, recording and use of data are regrettably not sustained on a day-to-day basis at ward level. Therefore we cannot hope to monitor trends, which raises questions about how care can be adequately provided and how services can effectively plan and develop new service responses.
Secondly, the race equality impact assessment undertaken by a committee that I chaired this summer made a number of recommendations, one of which—I am pleased to say it has been adopted—will allow ethnicity data collection on patients as part of the Bournewood safeguards. However, it is essential that the further actions described in the race equality impact assessment are also implemented; for example, recognising that it is essential to have culturally appropriate treatment and that there must be adequate monitoring of the community treatment order. I am greatly concerned that without that protection, we cannot be sure what will happen. Let me briefly give the House two potential scenarios.
One possibility is that because a disproportionate number of black people are admitted under all sections of the Act, more black people will be discharged on supervised community treatment, with the possibility that the black community will be stigmatised further. An alternative hypothesis is that clinical staff will become very risk averse, and the exact opposite will occur: white patients will be discharged on CTOs, but
28 Nov 2006 : Column 699
In summary, we must strengthen the protections for all those subject to compulsion, including de facto detained patients as well as those correctly detained under the Act, and we must provide enhanced protections for children and older people who are admitted to or detained in mental health facilities.
At the beginning of my speech, I said that I would propose three solutions, and I shall do so briefly. First, enhancing the protection of the rights of service users, especially children and older people, demands that we know where patients are, how many they are, their ethnicity and their specific health needs. In Committee, I will table amendments to give statutory effect to notification of all formal admissions to the Mental Health Act Commission, with a particular emphasis on children under 18 and older patients, and with sufficient resources to monitor their care; and notification of all deaths of patients in mental health and psychiatric facilities, whether detained or not. Noble Lords may be surprised to learn that each year approximately 380 detained patients die in care, and about a quarter of the deaths are termed “unnatural”; that is, they are suicides, occur in suspicious circumstances and so on.
Secondly, I wish to see an adequate and robust system in place to ensure that monitoring of the operation of the Act is fully supported with appropriate information collection. I will table an amendment to ensure that we strengthen the existing monitoring requirements so that all services assess, record and retain for analysis and action data on the ethnicity, age, first language and religion of patients. Ethnic recording remains unacceptably low, despite a mandatory requirement on providers for the past 11 years, and it will be essential for the proper implementation of the Bill that services are required statutorily to record ethnicity, age, language and religion and to report them to the Mental Health Act Commission. I need not remind the House that we are witnessing a growing tide of religious bigotry and discrimination, often directed against Muslim and Jewish members of our communities. Knowing the religion of patients will enable us to monitor and address any discrimination within mental health services on that basis.
Lastly, I wish to see safeguards that will ensure that the proposed arrangements for community treatment orders are adequately underpinned by the care programme approach. At present, CPA does not have statutory force and, as a consequence, it is inconsistently used and too often used very badly. If we have to have a community treatment order, patients must have a robust care plan to go with it, and the Bill offers the opportunity to make CPA a statutory requirement for the community treatment order and thus extend it to all patients being discharged. An alternative approach would be to focus on the care plan instead of a community treatment
28 Nov 2006 : Column 700
I believe action across these three areas will greatly improve the Bill and will go some way towards providing the protections that are essential for any modern mental health legislation in a decent and humane society.
5.59 pm
Baroness Howarth of Breckland: My Lords, it is somewhat intimidating to follow the noble Lord, Lord Patel of Bradford, because he has great expertise. It is also particularly intimidating to speak at this position in the list because many of the points have been made. I shall try not to repeat them, although, as I know the Minister’s attention is not always long—that was not what I meant, but it woke us all up—I want to begin by congratulating the Government on the present mental health services. I have worked in mental health for nearly four decades, and the change that was described earlier by the noble Baroness, Lady Bottomley, has been outstanding. I worked in large institutions containing elderly people who should have been out in the community, young women who were incarcerated because they had had an illegitimate child and many people who seemed rather more normal than those in community, but we have moved on to a quite different place.
It is clear from sitting on Committee G of the EU Scrutiny Committee considering the Green Paper on the EU mental health strategy that we are leaders in Europe. I am sure that there are many other nations from which we can learn, but we have much to share with the rest of Europe. But we can do better.
Like many previous speakers, I have some disappointment with the Bill. It is a curious mixture and arouses strong and diverse feelings. I think that the noble Baroness, Lady Gibson, is optimistic that we will all agree at the end of the day. Like others, I welcome the Bournewood provisions, but also, like my colleagues, would like to see that the principles of implementation are in the Bill and that there is greater clarification, including exactly how Schedule 6 will work in practice. Having been the deputy chair of the National Care Standards Commission, I have real anxieties about that implementation and who can make the application.
However, I intend to spend my few minutes concentrating on a major gap in the Bill—the mental health service for children and young people—and then to raise some questions about definition and role. The only references I can find to child patients are those in new Sections 64E and 64F. I am unclear if these sections remove the confusion about whether parental consent can be used to admit 17 and 18 year-olds for treatment against their will. The provision clarifying this in the previous draft Bill appears to be omitted in this Bill.
On a more general note, it seems a lost opportunity not to address those issues of child and adolescent mental health that touch on containment and are at
28 Nov 2006 : Column 701
YoungMinds, a charity which I admire and commend, is dedicated to promoting and improving the mental health of all children and young people. It would like to see an assessment of therapeutic benefit and safety of young people if they are admitted to an adult ward. The Minister will no doubt quote Ivan Lewis, who has made the welcome request to the health service to prevent children being held on adult wards as an “unprecedented priority”. But where is the response and the implementation? What are the Government doing to enable that to happen when they do not, as we have already heard, have verified central statistics on the numbers? YoungMinds knows of young people who have witnessed and experienced verbal and sexual violence on adult wards, and been denied access to education. Drug abuse is a major problem. Wards have 30 to 40 patients and are often overcrowded. There is a reliance on sedation and drug treatment, rather than talking therapies. The welcome growth of crisis and other teams which can keep people in the community means that the severity of illness of people on wards is likely to increase. These are not places in which to treat our young.
If resources can be found for the supervision of adults in the community—a response to the media highlighting a few cases, although something I welcome—why cannot they be found for those with less voice; our children and young people? Will the Government consider legislation similar to the Mental Health (Care and Treatment) (Scotland) Act, which says in Section 23 that there should be provided,
There was, after all, a recommendation by the 2005 Joint Committee on the draft Mental Health Bill that:
“There should be a duty on health authorities to provide age-appropriate accommodation for under-18s subject to the Bill or needing in-patient treatment”.
Why has that provision been lost?
| Next Section | Back to Table of Contents | Lords Hansard Home Page |