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All hon. Members know of cases where relatives and carers have had to stand by while somebodys condition deterioratesone of their loved ones who has a mental
health problem, who has perhaps been discharged from hospital, and who may not stay in touch with mental health professionals and continue taking their medication. That persons condition deteriorates and they end up back in a hospital setting or worse, perhaps committing suicide or doing harm to others. That is what we are trying to avoid through supervised community treatment. The Opposition must decide whether they will back us on that or not.
Tim Loughton: If CTOs are so vital to prevent suicides or to prevent homicides, can the Minister cite a study anywhere in the world where CTOs have led to a reduction in suicides, a reduction in homicides or a reduction in hospital readmissions when people fail to take medication? I would be fascinated if she can, as no evidence exists.
Ms Winterton: As we have always said, it is difficult to prove a negative. We do not know what the outcome would have been if the circumstances had been different. The recent report on avoidable deaths looked at homicides and suicides by mental health patients. As I noted, there are about 1,300 suicides a year by people who have been in touch with mental health services. The confidential inquiry into suicides examines all those suicides individually.
We know, therefore, that in the first two weeks after discharge from hospital, if a patient is not taking medication, the medication is still in their body and is still effective. In the second two weeks, if somebody has stopped taking medication, the effect is felt. We know that 56 suicides took place during that time after discharge from hospital because the person had stopped taking their medication. Nobody is saying that all those suicides could have been prevented, but we know very well that that is a point at which not taking medication will have an effect, and there has been a direct effect on people who commit suicide during that time.
Why do we not owe it to those people and their families and carers to take steps to enable us to supervise people in the community to make sure that they take medication and stay in touch with health care professionals, if the clinician believes that that is the right thing to do? In the case of John Barrett, who had a long history of non-compliance with medication in the community, which as hon. Members know resulted in the dreadful killing of Denis Finnegan, the inquiry team commented that in its view,
the only means of securing John Barretts compliance with treatment as an out-patient would have been a community treatment order.
I can certainly see that there is a role for CTOs. I did not get the impression that the psychiatrists at that meeting were lapdogs to the Minister, and I am quite astute at identifying people who toe the line. They said what their experience was. Contrary to the impression that may have been given by the last couple of interventions I have made, I have some sympathy with amendment No. 96. Will my right hon. Friend address the point that CTOs are meant for a small number of patients who lapse from their
treatment and do not take their medicationthe revolving door type of patient? What is the Governments objection to the amendment, which is about there having been one occasion on which a patient has refused to accept treatment and has subsequently deteriorated? We will have the discussion about impaired decision making tomorrow, so I will not go into that now.
Ms Winterton: Essentially, we do not believe that the amendment is necessary, given that we have moved so far in terms of supervised community treatment by saying that it must be preceded by one period of detention in hospital. That is completely different from what happens in many other jurisdictions, including Scotland. There have been suggestions about restricting that, which is what the amendment would do. As the House will know, in Committee we reversed the amendments introduced in another place on the criteria for SCT, which would have meant that it was not available to patients at risk of suicide, and would have limited it to patients who had had two previous compulsory admissions to hospital. I am glad that the Opposition have conceded that SCT can be helpful in preventing suicide, and that their amendment reflects that. However, I still strongly believe that the suggested restrictions would go too far and are unworkable in practice.
The Opposition are in effect trying to limit the availability of SCT. Amendment No. 96 would restrict health professionals ability to make the decision, and make the scheme impossible to operate. It would demand an assessment of a previous relapse, including, crucially, whether compulsory admission to hospital would have been necessary, regardless of whether that admission had taken place. How is it possible for a clinician to look back over a five-year period and decide whether an admission would have been preferable irrespective of whether it took place? Are we asking them to say that the previous professional was wrong in not having admitted the person for compulsory treatment? How do they make an assessment about something that occurred as long beforehand as five years ago, without knowing anything about the precise circumstances?
That is complete nonsense. Moreover, what relevance would it have to the persons current circumstances? Under SCT, the clinician considers the patients current circumstances and asks whether they would benefit from it. It is completely ridiculous to ask them to look back five years. That goes back to the issue of having compulsory admission twice. If we, as the House of Commons, were to try to restrict clinicians ability to do what they think is right for a patient in any other circumstances, we would be wrong and the profession would be up in arms about it. The Opposition are trying to restrict the clinicians ability to make the decision. In effect, we would be saying to people, Until you become ill again you cannot have supervised community treatment. Please go away, get ill again, and then come back and we can talk about it. It is almost impossible to imagine saying that to patients, or to relatives of somebody in these very limited circumstances.
Tim Loughton: The Minister is trying to caricature the amendment, which responds to matters that she raised in the first place. There are such things as medical records. She is giving powers to somebody who has never previously met a patient to place that patient under a CTO. She is also trying to claim that the amendment provides that the patient must have two previous compulsory admissions. That is not the case. The amendment refers to the second compulsory admission. She claims that the profession would be up in arms if we tried to impose such a provision on it, but why is it not up in arms at the moment? It does not agree with her about CTOs.
the patient has on at least one occasion within five years previous to the present admission...refused to accept medical treatment for mental disorder...there has been a significant relapse in his medical or physical condition justifying compulsory admission to hospital; (whether or not there has been such an admission).
It would be impossible for clinicians to operate under those conditions. Again, it would put obstacles in the way of people getting appropriate treatment when they needed it. It would stop people getting that treatment. Although the hon. Gentleman has perhaps tried to solve some of the problems that I pointed out to him in Committee, he has not succeeded.
Let us consider the proposal to try to place a time limit of three years on supervised community treatment. As hon. Members know, we have tackled the concerns that patients will find it hard to get off supervised community treatment by making a new requirement that an approved mental health professional must agree to every extension of a CTO. That is a far more sensible method of tackling the matter than imposing another arbitrary time limit. Under the hon. Gentlemans proposal, whether or not a supervised CTO remains the right action in the clinicians opinion, we would say no. That is wrong. It gets in the way of a clinicians ability to make the right decision.
Supervised community treatment contains many safeguards, including the ability to appeal to the mental health review tribunal and the power of the nearest relative to discharge someone from a CTO. Those are the safeguards and it is not for us to limit clinicians discretion as the hon. Gentleman suggests.
Tim Loughton: Is the Minister genuinely saying that she would be happy if a patient were on a CTO after three years? Does not she believe that those orders are for the shorter term? She admitted to an average of nine months. If they remain in force after three years, serious questions should be asked about whether they are the right basis for treating the patient and we should reassess the matter. That is all we propose. We are not trying to restrain the clinician; we simply say that if orders are in force after all that time, they cannot be working.
Amendment No. 100, which would remove clause 30, is disturbing. Clause 30 requires the responsible clinician to consider supervised community treatment whenever longer-term leave is in view for a patient. If leave of absence for longer than seven days is given to a patient, the clinician should consider whether supervised community treatment is the most appropriate way forward. Anxieties have been expressed about the use of leave of absence when people remain under compulsion but are in the community. We want to ensure that clinicians consider whether supervised community treatment is appropriate so that such supervision exists in the community. Opposition Members would obviously prefer patients to go on leave in the community for long periods without the structure and safeguards of supervised community treatment to support them. That is not the best means of managing patients care and treatment. It is therefore unacceptable to try to limit the discretion that we are giving clinicians to determine what they do. That is the point: the powers give clinicians discretion; that does not mean that they have to act.
Further amendments tabled by Opposition Members and by the hon. Member for Wyre Forest (Dr. Taylor) are designed to impose requirements about consultation. I certainly understand the concern, which was also raised by my hon. Friend the Member for Birmingham, Selly Oak (Lynne Jones). It is important for consultation to take place, but I would draw the attention of hon. Members to the statement of matters that should be considered when we are talking about principles in the code of practiceand that includes the involvement of patients in planning, developing and delivering care and the treatment appropriate to them. We believe that that principle should be at the heart of how the Bill is delivered.
I am afraid, however, that there are issues of confidentiality. It is true that there will be occasions in which it is not necessarily right to consult a range of people as the amendments suggest. It has to be the patients right to say who they would or would not like to be consulted, and it would be extremely difficult for us to dictate that from here. These are matters for the code of practice, and I am quite prepared to look further into it and see whether it needs to be strengthened by pointing out that we want consultation. I will look again at that, and I will consult both my hon. Friends and other hon. Members in doing so.
Other amendments were tabled by my hon. Friend the Member for Hendon (Mr. Dismore) and the hon. Member for Oxford, West and Abingdon (Dr. Harris). For example, amendment No. 79 would provide a power for the tribunal to
remove or vary any condition
relating to the patients behaviour. Let me explain that we see CTOs operating through clinicians talking with patients about the conditions that would be contained within a supervised community treatment order. If the patient turns around from the word go and says that there is no way that he is going to accept any of it, supervised community treatment will not work.
It is all about a partnership between patient and clinicianbut with the knowledge that if things go
wrong, clinicians have the ability to bring someone back into hospital. They do not have to do so. If the patient says that he is not taking his medication because he believes it to be too strong and regards the side-effects as unacceptable, the clinician can say, Well, lets try something else. It does not automatically mean that an individual has to come back into the hospital setting. It is, as I say, about a partnership.
I recognise the concerns in all these issues about the conditions of supervised community treatment. That is why we are bringing forward some substantial amendments, which place the focus firmly on the purpose of conditions and remove altogether from the Bill the examples of conditions that could be set for a patient. These put beyond doubt the fact that the conditions must be about either ensuring that the patient receives treatment, or preventing harm to the patient or others. That means that we have responded to the concerns brought forward in Committee and in the other place and made it absolutely clear what the conditions are about. Given that we have tabled these amendments to the conditions [Interruption.]
We believe that these amendments will clarify issues that we have discussed with clinicians and with members of the new mental health coalition who pressed for them, so I hope that hon. Members will not press their other amendments but will acknowledge that we must not limit the ability of clinicians or restrict any further supervised community treatment. It is all about getting treatment to people when they need it, and protecting patients and the public from harm.
As for the amendments that deal with children and supervised community treatment, we debated them fully in Committee, and although we are fully sympathetic to the spirit behind them, we really do not believe that they are necessary, given the package of safeguards that already exists for both adults and children on SCT.
Amendments Nos. 97, 98 and 99 would appear to prevent the treatment in emergencies in the community of children who lack competence. In practice, that would mean that in life-threatening situations, a clinician would not be able to treat a patient until they were brought back to hospital. A delay in treatment could spell disaster, so we must reject the proposals. They would mean that clinicians could not treat patients in difficult situations.
Amendments Nos. 75 to 78, tabled by my hon. Friend the Member for Hendon, attempt to prescribe on the face of the legislation what is meant by competence. We believe that we have enough guidance to meet some of the concerns raised by my hon. Friend.
The problem with amendment No. 92 and new clauses 13 and 14 is that they would affect the use of SCT in practice. In attempting to deal with a concern about the review of medication by a second opinion appointed doctor, the proposals would, in practice,
prevent a patient from being treated without delay on recall to hospital, and would thus render recall useless. That is unacceptable.
Concern has been expressed that a SOAD may not be capable of approving the treatment that may be given on recall, but I must reiterate that the SOADs review of medication in the community is not a mandate for the treating clinician to give that medication on recall come what may. The clinician will need to make an independent judgment about what treatment is necessary.
Amendment No. 101 would achieve a further restriction, preventing the use of ECT where it is necessary to prevent a serious deterioration in the patients condition. We debated that point in Committee and I hope that the hon. Member for Southport (Dr. Pugh) recalls the arguments that were made, especially the example I gave of an anorexic patient, whose problems might not be immediately life-threatening, but could become so if the patient continued to refuse treatment. We cannot stand by and watch such things happen.
The Governments amendments on supervised community treatment address many of the concerns raised by my hon. Friends and the Opposition, and in the other place. Our proposals will make a real difference by clarifying the conditions; there must be a health benefit, or protection for the patient or the public. The amendments proposed by the Opposition would restrict the ability to use supervised community treatment, and would thus lead to harm to patients and, possibly, to the wider public.
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