Tim
Loughton: My hon. Friend is right. That is why we did not
just do it without recording it. We wanted something that people could
use. I have to say that that is not unique. There was a similar sitting
for the Offender Management Bill.
The
Chairman: Order. I think that we are all very clear in our
minds—or we should be—what has happened and the intention
behind it. If the written summary of the proceedings is submitted to me
before the final sittings of this Committee, I shall consider whether
it should be presented or not. If that satisfies the Committee, may we
continue with the debate on the
motion?
Tim
Loughton: I am very grateful for that
answer. Question
put and agreed
to Ordered, That,
subject to the discretion of the Chairman, any written evidence
received by the Committee shall be reported to the House for
publication.
Written evidence to be
reported to the
House MH 01 Martin
Jeremiah MH 02
National Children’s
Bureau MH 03 Rutlands
Healing Group MH 04
Children’s Commissioner for
England MH 05 Mental
Health Act
Commission MH 06
British Psychological
Society MH 07 National
Early Intervention
Programme MH 08
National Perceptions
Forum MH 09 Dr George
Szmukler MH 10 Royal
College of
Psychiatrists MH 11
The Princess Royal Trust for
Carers MH 12
Hafal MH 13 Shaun
Johnson MH 14 Mental
Health Foundation MH
15 Nacro MH 16 Social
Perspectives
Network MH 17
YoungMinds MH 18
MIND MH 19
Bro Tâf Voluntary Sector Mental Health
Network MH 20 The Law
Society MH 21 Mental
Health Alliance MH 22
Professor Genevra
Richardson MH
23 National Black and Minority Ethnic Mental Health
Network MH
24 Association of Directors of Adult Social
Services MH 25 British
Association of Social
Workers MH 26
Rethink MH 27 British
Medical Association MH
34 Hywel Davies MH 35
Craig Nelson MH 36
Kevin Fane-Saunders MH
38 United Response MH
39 The Sainsbury Centre for Mental
Health MH 40 Joint
submission from British Associationof Occupational Therapists,
the British Psychological Society, the College of Occupational
Therapists, the Mental Health Nurses Association (part of Amicus), the
Royal College of Nursing and
UNISON MH 41 National
Assembly for Wales
MH 43 General Medical
Council MH 44 Alan
Capps MH 45 The Zito
Trust MH 47 National
Autistic Society MH 48
BMA and Royal College of
Psychiatrists MH 49
SANE MH 50 The Royal
College of
Nursing
The
Chairman: We will now begin to consider the Bill
proper.
Clause
1Removal
of categories of mental
disorder Question
proposed, That the clause stand part of the
Bill.
Dr.
Pugh: I want to take the opportunity to ask the Minister a
few questions. I understand that the new definition of “mental
disorder” is a heck of a lot better than what was in the Mental
Health Act 1983. Having read that Act with care, I do not object to the
change. The new definition is more colloquial and less misleading. The
previous one dwelt on behavioural issues and confused a number of
causally quite different conditions.
Specifically, under the
definition, “mental disorder” appears to be something
that results from illness rather than from any structural impairment of
the brainor genetic deficiency. It is very helpful to draw
that distinction. Lord Rix in the House of Lords was particularly
pleased to see references to mental impairment disappear.
One assumes that by
“mental disorder” one simply means the
common neuroses; the psychoses, of which the symptoms are normally
delusory states or hallucinations; bipolar disorder; personality
disorder, which is understood in a wider context; and psychopathy.
There are certain organic conditions, such as Korsakov psychosis and
the like, which are definitely a consequence of the structural
impairment of the brain in one way or another. Are they included in the
definition of mental disorder? After all, we are not in an area in
which there is absolute clarity. Even now, there are debates about
whether schizophrenia is one condition or several. If there is a mental
disorder that results from structural damage and is not genetic or
inborn, is that included as a mental disorder in the Bill or
not? I have a
constituent whose behaviour causes great concern. His parents are
extraordinarily worried about him. He cannot get treatment from the
health service because, although his behaviour is aberrant in many
respects, it is a product of physical damage to the brain as a result
of an accident, and not something inborn or a genuine impairment that
he started off life
with.
Ms
Winterton: Perhaps it would be helpful if I gave some
background to the clause and explained why we have taken the decision
to abolish the four separate categories of mental disorder, which are
used in parts of the Mental Health Act 1983 as it
stands. What we have
tried to do with the clause is to simplify the definition, so that we
have a single
definition of mental disorder throughout the Bill.
The clause also simplifies, although it does not change the effect of,
that basic definition
to “any disorder or
disability of the
mind”. The reason why we
wanted to remove the four categories is that they serve no useful
purpose at the moment. They do not help with people getting the
treatment that they need, when using the Act is the only
option left, and they do not protect patients against inappropriate use
of the Act. They are legal and not clinical terms. They do not relate
directly to clinical
diagnoses.
Mr.
Boswell: I think that my intervention will be supportive
of the Minister’s point. Can she give the Committee any evidence
as to where clinical freedom is being inhibited or made more difficult
by the existence of somewhat archaic
distinctions?
Ms
Winterton: I certainly will do. As I was saying, the
definitions do not relate directly to clinical diagnoses. What counts
legally as psychopathic disorder goes well beyond what the person in
the street would probably mean by a psychopath, for example.
Clinically, in many ways the legal definitions are a distraction. A
clinician does not need to know which of those categories a
patient’s disorder falls into in order to decide on treatment.
The current law forces the clinician to spend time thinking about the
categories. Importantly, they can also be a legal distraction. Time can
be taken up by tribunals, especially when dealing with restricted
offender patients, who might be trying to gain some advantage by
arguing about classification when it has nothing to do with the risk
posed bytheir disorder or the treatment needed to tackle it.
Obviously, we believe that compulsion should be determined by a
patient’s needs and the degree of risk posed by their disorder,
not by the particular legal label
applied. The four
categories in the 1983 Act create arbitrary and unnecessary
distinctions between patients. Also, coming to the points raised by the
hon. Member for Southport and the hon. Member for Daventry, the
categories may leave some patients out entirely from certain parts of
the Act. In other words, patients could be detained for assessment but
not then detained further for the treatment that they need. I should
emphasise that we are talking about a very small number of people here.
There have been some misconceptions that somehow, by changing the
categories, we are widening the number of people who might come under
the detention provisions. That is not the case. A very limited number
of people are not covered by the current “disorders”;
they almost certainly include certain mental disorders arising from
brain injuries acquired in adulthood. That may be the difficulty to
which the hon. Member for Southport
referred.
Dr.
Pugh: The Minister’s contributions are very
helpful. Is it fair to say that the “mental disorders”
described by the Bill do not match any particular set of clinical
diagnoses, but are simply what psychiatrists at any one time in our
culture define as a mental disorder?
Ms
Winterton: The hon. Gentleman is right. There are certain
guidelines and international classifications of mental disorder, but
essentially he is right that there is clinical discretion. It cannot be
said that something that is not in any classification is not a mental
disorder. 11.15
am Likewise, to
expand on some points about those small numbers who may not be covered,
there may also be certain types of personality disorder that would not
legally be mental illness but do not meet the current definition of
psychopathic disorder, as they do not result in seriously irresponsible
or abnormally aggressive conduct. Even so, to go back to the cases that
the hon. Gentleman has raised, such a disorder could cause the person
concerned great suffering—serious enough to make serious
self-harm or suicide a real possibility. Therefore, in practice, I
suspect the reality is that people are found ways of getting that
treatment. I am sure that there are some people who would say,
“Well, somebody can be put under that category”. However,
given that we are trying to improve and to modernise our legislation,
it is important to take this opportunity of having real clarity
here.
Dr.
Pugh: With regard to psychopathy, I understand that that
term is becoming almost clinically unfashionable. It is being replaced
by “personality disorder”, in much the same way that
manic depression was replaced by bipolar disorder. As a result of the
amendments, will the term psychopathy retain any legal significance or
value whatever in legislation?
Ms
Winterton: No, it will not.
I should also assure the
Committee that there has been a general welcome for the changes that we
are considering in clause 1. There is general agreement that these
legal categories have not necessarily contributed anything particular
to treatment or care and, again, for the small number of people who are
excluded, it is important to have clarity.
Tim
Loughton: The Minister mentioned just now that the
new definitions will not broaden the net. However, is it not the case
that the new definition covers all the diagnoses listed in the
international classification of diseases 10—some of which
eventhe Government acknowledge may be appropriate for
compulsory powers—and that nothing in the Bill confines the
definition to the conditions listed in ICD 10 or the American
diagnostic manual?
Ms
Winterton: No. As I have said, there are international
classifications. That does not mean that those are the only things that
can be counted as mental disorders. Clinicians can make diagnoses. I
emphasise that, within the Mental Health Act 1983, there is the obvious
ability to appeal to a tribunal. First, though, two doctors have to
agree that a mental disorder is present. If that is disputed—if
the patient believes that they have no mental disorder—they can
take it to a mental health tribunal to challenge
it.
Angela
Browning: In the regulatory impact assessment for this
proposal, the Government outlined the risks and benefits and I note
that the Minister does not regard that there will be any additional
costs as a
result of a change in this part of the law. Does she
not think that advocating the opportunities for appeal and tribunals
will mean that there will be more challenges, which will have a cost
impact? I raise that matter because this change, and what its
consequences may be, has been sadly neglected in the regulatory impact
assessment. If the funding is not there, the safety blanket that she
has just described will not be met, through lack of
resources.
Ms
Winterton: I am sorry, but the hon. Lady may have
misunderstood what I was saying. I was simply pointing that, if a
patient disagrees—it is important for them to have those
rights—and if they feel that they do not have a mental disorder
and want to challenge that, they can appeal to the tribunal.
Personally, I think that it would be difficult to start saying,
“Let’s not talk about the tribunal, in case people start
appealing to it”. I am simply saying that that is the path which
people would
follow.
Mr.
Boswell: My colleague may also want to intervene on the
Minister but, to put a gloss on my interpretation of what she said, it
seems self-evident that, if one is making more flexible the definition
of mental disorder, a larger number of people in the population, albeit
a small number, will be susceptible to the provisions of the Mental
Health Act and will therefore be able to avail themselves personally of
the appeal mechanisms of the Act. My hon. Friend the Member for
Tiverton and Honiton made a point about the resource implications. I
make no judgment as to its merits, but it requires an answer at
least.
Ms
Winterton: I refer the hon. Gentleman and the hon. Member
for Tiverton and Honiton to my previous comments about restricted
patient offenders. One of the current difficulties is when people argue
in front of the tribunal about the classification into which they have
been placed. I want to turn matters the other way round. At present, a
tribunal’s time can be taken up arguing about the classification
of people and, thus, by removing the false categories, we are more
likely to increase the tribunal
time.
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