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Clause 5, as amended, ordered to stand part of the Bill.
Clause
6
Renewal
of
detention
Question
proposed, That the clause stand part of the
Bill.
The
Chairman:
With this it will be convenient to discuss the
following:
No. 60, in
clause 11, page 7, line 10, at
end insert—
‘(11) After that
subsection,
insert—
“( ) No
person can act as a responsible clinician unless he is capable of
providing objective medical expertise of mental
disorder.
( ) Objective medical
expertise of mental disorder shall have the same meaning as in
Winterwerp v The Netherlands (1979-80) 2 EHRR
387.”’.
No.
61, in
clause 13, page 8, line 45, at
end insert—
‘( ) After that
subsection,
insert—
“( ) No
person can act as a responsible clinician unless he is capable of
providing objective medical expertise of mental
disorder.
( ) Objective medical
expertise of mental disorder shall have the same meaning as in
Winterwerp v The Netherlands (1979-80) 2 EHRR
387.”’.
Government
amendments Nos. 22, 24, 25 and
28.
Ms
Winterton:
The Government oppose clause
6 standing part of the Bill. Our policy is to introduce
“responsible clinicians”, to bring the legislation in
line with current practice. We want to remove the rigid demarcation of
professional roles in favour of an approach that ensures that
clinicians with the right skills, expertise and training can use them.
If we can achieve that, frankly, we can reflect modern NHS practices,
which have moved more toward a competency-based approach to roles and
responsibilities.
It is important to look at how
the work force has changed since 1983. Things were different in 1983 to
today. In 1983, the emphasis was on in-patient care and medication in
large mental hospitals. There was a greater focus on the medical model
of treatment, which meant that doctors made most of the decisions.
Since then, there has been a widely welcomed shift to psycho-social
interventions and more treatment in the community. Hon. Members on both
sides of the Committee have so far celebrated the fact that those kinds
of changes have taken place, and they have recognised in their
contributions the fact that patients have a wide range of needs that
require the specialist skills of the range of professionals on the
multi-disciplinary teams. As a result of the multi-disciplinary
approach, the professions, whether psychologists, nurses, occupational
therapists or social workers, have developed interventions. Those
professionals are taking on more functions and adopting leadership
roles. As I said, up until now, all hon. Members have celebrated
that.
Dr.
Gibson:
Will the Minister comment on whether the skills
and professionalism and other aspects of the jobs she described are
part of the training of medical
doctors?
Ms
Winterton:
It is right to say that we have increased the
ability of professionals to take on more responsibility, and that that
has led to an increase in the training. An example of that is the fact
that we now have nurse prescribing, something that was almost unthought
of when I was working for the Royal College of Nursing. Over time, we
have come to know that nurses and others can take on roles that they
would not have taken on before. The example of nurse prescribing is a
good one.
Ann
Coffey:
It is completely understandable why we should have
someone with medical training to oversee a course of treatment for
someone with schizophrenia, for example, which involves difficult
medication, with possible side effects. However, it is not easy to
understand why we would need someone with physical training to oversee
a course of treatment that involves intensive counselling given by
someone who has trained as a clinical
psychologist.
Ms
Winterton:
My hon. Friend is absolutely
right. That is the position that we have been trying to get to via the
changes that we have made by generally developing roles among
professionals. I am thinking particularly of nurse consultants, whose
role did not exist in 1983. Today, a nurse consultant could be
responsible for a 14-bed in-patient rehabilitation unit, teaching,
providing clinical leadership and conducting research. Nurses,
occupational therapists and psychologists can manage multidisciplinary
teams or in-patient wards, or they can provide clinical care for a
patient. Social workers can often be care
co-ordinators.
12
noon
When
we are talking about the Government’s proposal regarding
responsible clinicians, I want to be absolutely clear that only highly
qualified and experienced mental health professionals will be able to
become approved to
become responsible clinicians. It is worth reminding ourselves of the
type of people whom we are talking about. A disturbing attitude seems
to have evolved both in the other place and among Opposition Members
about the proposed changes—I presume that Opposition Members
will be supporting them today—around the view that we somehow
have to revert to a situation in which doctors take all the decisions.
After all the work that has been put in, in conjunction not only with
the Royal College of Psychiatrists, but with the other royal colleges
and professionals working in the field, there is an attitude that they
cannot be trusted to make such decisions. There is a real problem about
turning the clock back. We are trying to achieve new ways of working,
which we have spent many years developing, but the amendments inserted
in the House of Lords with the support of the Opposition turn the clock
back to a unacceptable state of affairs for those professionals, who,
frankly, feel that they have been slapped in the
face.
Tim
Loughton:
The Minister seems to be pre-empting what the
Opposition are going to say. May I ask her where clause 6, as amended
in the House of Lords, implies that all the decisions should be taken
only by
doctors?
Ms
Winterton:
Let me be absolutely clear. It is important to
remember that clause 11, which the Opposition want to delete, takes
away completely the role of the responsible clinician. Let me give an
example. Subsection (2)(b) of clause
6—
Tim
Loughton:
There is no subsection
(2)(b).
Ms
Winterton:
I am sorry, I mean proposed paragraph (aa)(ii)
to section 20(3) of the 1983
Act:
“if no such
practitioner is available, a registered medical practitioner who is an
approved
clinician”.
Within a
multidisciplinary team that is established to look after a patient, as
they are nowadays, the responsible clinician is the psychiatrist,
because the patient in those circumstances needs the kind of
intervention that my hon. Friend the Member for Stockport has talked
about. The effect of proposed paragraph (aa)(ii) is that if the
psychiatrist is not there, the responsible clinician in those
circumstances would have to go to somebody who was a doctor—the
hon. Member for Southport is a doctor—who may have no knowledge
whatever of the individual patient, because they have to consult
another approved, registered medical practitioner. That means that if
the person on the team who has been working with the individual cannot
go to the registered medical practitioner within the team, they will
have to go somewhere else. That means that somebody who has not been
involved with the care of the patient at all would have to be involved
and approving. It is the stamp of approval that Opposition Members are
endorsing that we find objectionable, because with the high standard of
approved mental health practitioners that we have talked about, we do
not see why it is necessary to consult another doctor in order for
detention to be renewed.
Tim
Loughton:
Clause 6 quite clearly
says
“to arrange for the
patient to be examined
by—
(i) the
registered medical practitioner who has been professionally
concerned”.
That is the
preferred option, and only if that person is not available must the
person involved go to somebody else who is a medical practitioner.
However, the Minister has not addressed the question that I asked just
now. She stated that all the decisions about the care of the patient
would be made only by doctors, but that applies only to decisions about
detention and renewal of
detention.
Ms
Winterton:
Does the hon. Gentleman accept, however, that
his proposed deletion of clause 11 would take away the role of approved
clinicians and responsible clinicians in the first
place?
Tim
Loughton:
I do not deny that. In the circumstances
surrounding the renewal of detention, the matter would rely on a
medical person, which is the point that we are making. Again, the
Minister has not answered my question. Why does she think it
acceptable, therefore, that the decision about the original detention
should be taken only by a medical person, but six months down the line,
when we are looking at a possible renewal of detention at a time when
it might be rather more difficult to form a judgment on
somebody’s condition—they might not be in the agitated
crisis state that they were in at the time of the original
detention—it can be taken by someone else? Why is it appropriate
for a medical person to make the decision at the beginning of the
process, but not at the time of the renewal? That is the inconsistency
that the Minister must
address.
Ms
Winterton:
Not at all, because the medical practitioner is
more likely to be trained in making the original diagnosis. They will
have a broader training in that area. Let us examine what we are asking
the original medical practitioners to do. We are asking them to decide
whether somebody has a mental disorder. It may then fall to a
psychologist to talk about the treatment of that person. If that
treatment includes providing community treatment, it may fall to a
community psychiatric nurse, who is looking after the individual. That
point—we are talking about the renewal of detention—is
where we are saying that it is the psychologist, for example, or the
community psychiatric nurse, who will have been in contact with the
patient during that time and will surely be able to make a decision as
to whether detention should be renewed.
That is the difference, because
we are talking about whether the treatment continues to be suitable
andnot about the original diagnosis, which is about
establishing whether somebody has a mental disorder. Opposition Members
are saying that when that treatment is under way with the psychologist
providing it, the psychologist must go back to a psychiatrist, but
under proposed paragraph (aa)(ii), if the psychiatrist is not on hand
in the multidisciplinary team, that person must go somewhere else. The
relevant words
are
“arrange for the
patient to be examined by”.
An entirely new psychiatrist or
doctor would have to be brought in to examine a patient whom they may
have had nothing to do with. The Government believe that it is
important to trust the judgment of professionals. Let me say again how
highly qualified they are. To take away from them responsibilities that
we have tried to develop is, as I said, a slap in the face. For
example, the community psychiatric nurse whom Unison brought to see me
said—
Ms
Winterton:
I know that the hon. Gentleman will not support
an organisation such as Unison. However, I should point out that the
people who are opposed to such matters include psychologist
organisations and many health care professionals, who say that they
represent 85 per cent. of the people who work in mental health
services. The Opposition are saying that they want to revert to a
doctor decision. I draw the attention of the hon. Member for East
Worthing and Shoreham to the fact that the Bill says
“to arrange for the patient to be
examined by,”
and that
is the difficulty for the
individual.
Ms
Winterton:
I shall give way to the hon. Member for
Daventry, because I think that he may be a little more supportive of
the Government on this issue. I will be surprised if he is
not.
Mr.
Boswell:
I would advise the Minister not to jump to
conclusions. I hope that I come to the matter with a fresh and
objective mind. She needs to remind herself and acknowledge to the
Committee that the provision is about the compulsory detention of
individuals and not their treatment. However desirable and necessary it
is to incorporate a range of professionals, it seems very odd to set
one criterion—examination by a registered medical
practitioner—for the initial detention and then to set different
criteria for any subsequent detention. The Minister needs to explain
that to the Committee.
Ms
Winterton:
I shall have one more go at explaining
the issue. The hon. Gentleman does not realise that the clause is about
the renewal of detention. The important point is that the professional
clinician who has been working with the individual and who knows them
best will decide whether the treatment is still working and take that
responsibility without having to revert to a doctor who may have had
nothing to do with the individual.
Mrs.
Moon:
Does the Minister agree that it
would seem confusing to say that it is appropriate to have another
professional, such as an approved social worker, involved in the
initial detention, while saying that when it comes to deciding whether
detention remains appropriate, other professions do not have the same
validity as a medical practitioner, who may have no knowledge of the
individual? Other professions already play a key
part.
Ms
Winterton:
That is absolutely
right.
Tim
Loughton:
The Minister said two
contradictory things. First, she said that the issue was about
treatment, which my hon. Friend the Member for Daventry pointed out was
not the case. Then she said it was about the renewal of detention,
which it is. Will she stop trying to impose a hierarchy on the matter?
As I have said, the person who comes first and who would normally be
expected to make the decision is the registered medical practitioner.
It is only if that person is not there that another medical
practitioner, who has not been closely involved, can be called in. That
practitioner can take advice from a whole range of other professionals.
Will the Minister acknowledge that after six months of compulsory
treatment, other medical conditions can arise—perhaps resulting
from some of the drugs—which makes a medical practitioner the
best person to decide whether detention should be renewed and in what
form?
Ms
Winterton:
There may not be medical interventions if
somebody is not on medication. We have made it very clear that the
appropriate person is the one who is responsible for the treatment
course that somebody is undertaking. That is what distinguishes what
happens in the initial phase, which is detention, sometimes for
treatment but very often for assessment. The decision that has to be
made by the first two doctors is the broad diagnosis. It is then up to
individuals who are most experienced in that person’s care to be
able to say, “This is the experience over the past six months.
We believe that the appropriate treatment is still available because I
am administering that treatment. Therefore the treatment is
right.” The psychologist is able to say, “We have made
good progress.” We need to recognise how teams work nowadays,
because there is a multidisciplinary rather than a one-person
approach.
The hon.
Member for East Worthing and Shoreham mentioned clinical interventions.
In reality, the approach taken is to have multidisciplinary discussions
about the individual. Like everyone present, I would expect that any
physical side-effects, such as those from medication, say, would be
dealt with during those discussions. That does not mean that somebody
who is under detention and who is being looked after by a psychologist
is never considered by any other team member—that is not how
practice operates, nor should it. The person to have responsibility
should be the person who is the most appropriate person for the
individual’s needs; that is how psychological therapies and
increased incidence of prescribing by nurses have been
developed.
12.15
pm
Opposition
Members have talked a lot about how to develop a greater number of
psychological therapies and about getting more psychologists involved.
I am sure that they want to that to happen, but if that is their honest
intention, why on earth are they supporting an idea that would take
away the work that we have done? Interestingly, it is called
“New Ways of Working”, and we have involved the
professions init, including the Royal College of
Psychiatrists, occupational health services and the Royal College of
Nursing. Why get to that point and then snatch everything away? It is
astonishing.
Mr.
Boswell:
I assure the Minister that I am not seeking to
subvert the new ways of team working, because clearly they are
sensible. However, let us consider the case of a patient who has been a
voluntary patient for a number of months and who has worked with a
number of professionals—not necessarily a clinician or a
registered medical practitioner. It might have become apparent to the
other professionals or clinicians that that person needs detention.
What is the logic of the Minister’s position that that detention
following a period of voluntary treatment must be approved by a
registered medical practitioner in the first instance, when on her own
analysis there might well be other people in the team who are more
familiar with the individual concerned and therefore in a better
position to give approval?
Ms
Winterton:
In a sense, the hon. Gentleman helps me make my
point. I shall come in a second to the situation that he
described.
We
want to preserve the situation on initial diagnosis as it stands, and
we believe that our proposals provide a clear framework for what should
happen when someone is detained for the first time. There might be
instances in which someone has had no contact with mental health
services, and we believe that the broader diagnostic skills of a
medical practitioner should be brought into play in such cases. We want
to preserve that procedure in situations of voluntary treatment so that
there is consistency at the initial point of
diagnosis.
In the hon.
Gentleman’s scenario, if a person had been having psychological
treatment and his condition had deteriorated to the extent that
detention was important, it would also be important to ensure that the
diagnosis was right. However, if it emerged thatthe person
giving the psychological treatment was the person who was going to be
in most contact with the patient, and that that person knew the
patient’s needs and had reached the high standard that we have
set for being an approved professional in such circumstances, it would
be right for him to continue in that role and to undertake renewal of
detention if that were considered the most appropriate
course.
Sandra
Gidley:
In her opening remarks, the Minister made a strong
case for interdisciplinary working, and she mentioned consultant
nurses. Is she now, despite having lauded their skills earlier, saying
that they do not have sufficient expertise to make the initial decision
on detention?
Ms
Winterton:
I am saying that it is fair to ask whether that
person can make that detention. We considered the issue of voluntary
patients in the way that has been described. We also considered whether
we could allow the approved clinician to agree the initial detention
for voluntary patients. The problem was that that could lead to
difficulties in legislation, because there would be exceptions.
Therefore, we felt that it was better to keep the status quo in terms
of diagnosis, but beyond that to give greater powers and
responsibilities to the approved clinicians.
If the hon. Lady is going to
support us, she might wish to say that we have not gone far enough. We
would be open to that point. However, it is a bit of a
reassurance to say that we will agree to keep the same system in respect
of the initial detention of people who have not previously been
voluntary patients. Beyond that, as legislators, what we can do is to
ensure that the legislation enables us to put into practice all that
the Committee is hoping for, including giving staff more responsibility
and the development of psychological therapies. We are trying to put
that into legislation so that the people who have spent years
developing new ways of working can have their just rewards.
Itis beyond me why the Opposition want to take that
away.
Mr.
Boswell:
Very briefly, and simply for the sake of
elucidation, will the Minister say whether she agrees that whoever
takes the decision to commence compulsory detention or to continue it,
the criteria for mental disorder will be the same and the diagnosis
will be made on exactly the same
basis?
Ms
Winterton:
Of course. All the conditions that have to be
met remain the same. The responsible clinician, if not a registered
medical practitioner, will not work to a lower set of criteria as to
whether to detain people. That would be unthinkable.
I want to
move on, because I hope that I have made my point. However, I want to
give one further reassurance to the Committee. Let us consider
carefully what we are talking about. Nurse consultants typically have a
masters qualification, and most have specific post-registration
clinical skills training in areas such as cognitive behavioural therapy
or psycho-social interventions, in which psychiatrists tend not to be
trained. They should also be experienced in clinical work, consultancy,
research and supervision. Consultant nurses are often independent nurse
prescribers, which means that they are qualified to diagnose patients
independently and treat them with
medication.
A
consultant clinical psychologist typically has an undergraduate degree
of at least 2:1 grade and at least two years’ experience in the
NHS before being accepted on to a three-year doctorate in clinical
psychology. It is not until they have six years’ experience that
they may be considered for consultant status. I draw hon.
Members’ attention to the document that we have circulated to
the Committee on relevant competencies. They cover the ability to
identify the presence or absence of mental disorder and its severity
and to
“undertake broad
mental health assessment and formulations incorporating biological,
psychological, cultural and social
perspectives.”
The
clinician must have a broad understanding of
“all mental health related
treatments, i.e. physical, psychological and social
interventions”
and
“an
advanced level of skills in making and taking responsibility for
complex judgements and decisions, without referring to supervision in
each individual
case.”
Those
are the levels that we are setting for the responsible clinicians whom
we want to bring in. I find it difficult to understand why the
Opposition would want to remove what we have been working at for many
years. Perhaps I am anticipating the Opposition’s remarks, but
that was certainly the position that was
put in the House of Lords. We want to ensure that highly qualified,
highly motivated professionals get the recognition that we are trying
to give them in the
Bill.
Sandra
Gidley:
In some respects, the debate is unhelpful as it
appears almost to be setting one health professional against another.
We seem to have lost sight of the patient. If patients’ liberty
is to be deprived, surely many of them will want the person with the
greatest overview, who makes the initial decision, as the Minister has
accepted, to be involved in any renewal of detention. Who has asked the
patients?
Ms
Winterton:
Exactly. That is absolutely the point. The hon.
Lady could not have put it better; that is exactly what we are trying
to achieve. The responsible clinician—let us say it is a
psychologist—who has been treating the patient is, as she says,
absolutely the right person to renew the detention. Maybe she does not
realise what the effect of the changes that she supports would be. By
supporting the changes made in the House of Lords, she wishes to remove
that ability to someone else who has not been directly involved with
the patient.
The
renewal of detention should be done by the person who is most
appropriate to the patient’s individual needs and is delivering
treatment. That is exactly the point, and that is why we are opposing
the changes made in the House of Lords, which will set key
professionals back by many years. Our position is not anti-doctor, it
simply recognises that there are now others who can make a contribution
in the relevant circumstances.
Frankly, it
is better for patients to know that the person who is looking after
them the most closely is involved in renewing their detention, because
they know that that person will have their history. The hon. Lady
suggests that it should be sent to someone who might have no knowledge
and is brought in at the last minute to examine the patient and renew
their
detention.
12.30
pm
Mr.
Charles Walker (Broxbourne) (Con): On a point of
clarification, who will be responsible for ending the
detention?
Ms
Winterton:
We are talking about renewal. When it comes to
ending the detention, the responsible clinician, in concert with the
multidisciplinary team, would have to say that the conditions of
detention no longer apply, which is what happens all the time:
clinicians decide that the conditions are no longer met and the
detention should end.
We urge the Committee to reject
clause 6 and amendments Nos. 60 and 61, which would create severe
difficulties by limiting the role of responsible
clinicians.
Tim
Loughton:
I became more and more confused about the
Minister’s position the longer she went on. Her arguments are so
inconsistent that she is painting herself into corners.
I have a
number of questions for the Minister, which she might want to answer in
her response. She pre-judged what we were going to say; she came to the
debate with
pre-conceived notions and prejudices about the attitude of Conservative
Members before we had even talked to our amendments or stated our
position on the clause. I do not understand her
insistence on speaking to clause 6 as if proposed new paragraph
(aa)(ii) takes priority over subsection (1). It is clearly stated that
the preferred route on decisions of renewal of detention must be that
the medical person who is familiar with the case should have primacy in
making that decision. Only if that person is not available would
someone else who has not had a close familiarity with the case be
brought in to make that important assessment. It must be a person who
has passed all the medical criteria to be able to make a medical
judgment at an important and difficult juncture—that is, the
renewal of detention.
I have no doubt that all sorts
of people working within the multidisciplinary teams, which we wholly
support, have enormous expertise, experience, dedication and
sensitivity to their patients. Clause 6 does not seek to undermine the
job that those people are doing, but it is a matter of
appropriateness.
It
worried me that the Minister said that the just rewards of the
psychological therapists, whom the Government fully support—we,
too, want many more of them to work in the health service in areas in
which their expertise is appropriate—should be to have the power
to decide whether somebody should have their detention renewed. I am
not interested in just rewards for psychologists, consultant nurses or
anyone else; I am concerned primarily about the patient and whatever is
in their best
interests.
Ann
Coffey:
If the hon. Gentleman is concerned about the best
interests of the patients, why is it in their best interests to be seen
by a doctor who has never met them and has no knowledge of their
treatment, rather than to have a decision made in their best interests
by a clinical psychologist who has undertaken four weeks of intensive
interventions in the relevant hospital?
Tim
Loughton:
For the simple reason that familiarity, however
intense, should not top medical experience. I have a very good dentist,
with whom I am very friendly and who is enormously well qualified. She
does a great job with my teeth.
Ann
Coffey:
That is your
opinion.
Tim
Loughton:
I am very happy with the state of my teeth. My
dentist has a long waiting list, though I shall not say where she
practises, and I trust her judgment implicitly; I have known her well
for many years. However, at the moment I have a problem with my knee,
but I am not intending to go and see my dentist about it. Despite the
possibility that my dentist might be better medically trained, I shall
see a knee consultant, whom I have not met before. That is the analogy
that
applies.
Tim
Loughton:
What is important in that situation is who knows
best how to deal with my knee. The really important consideration in
the situation that we are discussing—secondary to having the
most appropriate and best-trained medical person, who has familiarity
with the patient—is to have someone who knows about the medical
condition and knows how to deal with it in the case of that patient.
That is what is in the patient’s best interests and that is
where the Opposition are coming from.
The Minister’s
suggestion that it is all about “just rewards” for
certain professionals is deeply worrying. It is not a matter of payback
time for Unison members, RCN members, consultant nurses or
psychiatrists or therapists of any description; it is about what is in
the best interests of the patient. Perhaps the Minister will defend her
choice of
phrase.
Ms
Winterton:
I absolutely will defend it, because I am
conscious of the amount of work that has been undertaken over the past
few years to ensure that we can expand the roles that we are discussing
so that the people in them can do exactly what is best for the patient.
Thousands of psychologists and community psychiatric nurses have worked
to develop those roles and we are trying to recognise that in
legislation, and frankly I think that they deserve a just reward for
their work, but their work is good for patients
too.
To address the
hon. Gentleman’s point about his dentist and his knee, I do not
understand why he wants individuals to be examined by registered
medical practitioners who might have little knowledge of the
psychological therapies that should be made available to the patient.
His argument has again made my point, rather than
his.
Tim
Loughton:
I cannot see how that is the case. We are
comparing psychiatrists, who have had 13 years of training, with other
practitioners who might be well suited for giving certain therapies and
treatments—but at the treatment stage. The Minister does not
seem to understand her own legislation. These provisions are about
powers to renew detention, not to ascribe
treatment.
Dr.
Naysmith:
Will the hon. Gentleman give
way?
Tim
Loughton:
I shall in a moment, but I shall give way first
to my hon. Friend, who was first in the
queue—again.
The
logic of what the Minister is suggesting is that a consultant
nurse—however good, well experienced or familiar with a
particular patient—should have powers of renewal of detention,
when the patient’s treatment might have involved strong
medication. She is saying that such nurses should have the power to
judge the efficacy of that strong medication and to decide whether the
patient should be detained for longer—a very important decision
over which surely the expertise and medical experience of a
psychiatrist or doctor should hold sway.
Angela
Browning:
I agree with my hon. Friend. It is disappointing
that the Minister suggested that the Opposition are not in favour of
Unison. I find that it is mainly Unison members who sit in my surgery
and bewail the state of the NHS.
When something goes wrong for a
patient, in any area of health care, but particularly in the detention
of a person under the Mental Health Act—they might have to
appear at a coroner’s inquest or something like that—one
question is always asked: “Who’s in charge?” If
the consultant psychiatrist was involved in the admission of that
patient, surely it should be up to them alone to nominate who takes
over such responsibilities. I agree with the Minister: others, such as
psychologists and consultant nurses, have a big role to play. However,
someone has to be in charge, and if responsibility for a
patient’s care is to be devolved, the consultant should be the
one who nominates to whom it is devolved. If we take away those powers
and say that anybody can do it, who decides—the psychologist or
the nurse? It is very
confusing.
Tim
Loughton:
My hon. Friend makes a good point. We fear that
the provisions will lead to greater complexity and confusion about
where the buck stops. Of course, there are great inconsistencies with
the Mental Capacity Act 2005 as well, which I shall come on
to.
Dr.
Naysmith:
On numerous occasions in the
Committee, the hon. Gentleman has referred to evidence received in the
scrutiny Committee. I am sure that he recalls evidence received about
clinical teams. Some who gave evidence were not in favour of
psychiatrists making all decisions on a patient’s
treatment—they were not criticising psychiatrists themselves.
They said that patients often expressed a preference for another member
of the team—a clinical psychologist, for example. My daughter is
a clinical psychologist, but that is not relevant—I thought that
I would mention it in case anyone here knows it and brings it up.
However, clearly patients often prefer someone whom they see regularly.
It has to be said that often a busy consultant psychiatrist dips in and
out of hospitals.
I am
conscious that you are looking at me, Mr. Cook, but may I
make one further point? It has been argued that that person would have
considerable training in the discipline. However, under the Lords
amendment, a graduate, having left medical school six months
previously, could be a qualified medical practitioner. That would mean
that they could pronounce on someone whom they do not know, and who has
never received treatment from them, because, as the hon. Gentleman
says, they know more about the clinical aspect of things. Actually,
someone who has treated the patient for six months, and been with them
during their psychiatric illness, would know a lot more about
them.
Tim
Loughton:
I hear the hon. Gentleman’s point, but by
the same token, under his suggestions, some people without that degree
of medical training could make those decisions as well. I refer him
back to the clause, which says that the preference is for the decision
to be made by a medically trained person familiar with the case. That
should be the norm. If the Government
are providing a service that is fit for purpose, we should not be having
this debate. The medically most extensively trained person should take
the buck and make the decision, having taken advice from others in the
multidisciplinary team, many of whom might disagree among themselves as
well. It is not an exact science, which is the whole point of our
deliberations. The consultant nurse might have an entirely different
view to the psychologist of what treatment a patient should receive,
which very often
happens.
12.45
pm
What has amazed
us about the Bill is how all sorts of professionals who would never
give each other the time of day, and who would certainly not sit down
together at dinner, have come together in common cause to communicate.
The biggest favour and service to the professions involved in mental
health that the Minister has done with the Bill is that she has brought
them together—they do not often come together on their
professional judgments. I am not saying that there is unanimity; there
is less on this point than on the other of the big six amended
areas.
I am well
aware of Unison’s position. I spoke to and had a perfectly full
discussion with the Unison people in my constituency who made
representations to me. I am aware of the RCN’s position and of
many individuals who have written letters on their own account. I am
not in any way saying that there is unanimity about the matter, but
part of the division comes from a perception that the amendments try to
dumb down non-medical practitioners and in some way undermine their
contribution. That is not the intention. I cannot make those
reassurances clearly enough.
Angela
Browning:
Does my hon. Friend remain concerned, as I do,
about the process to be undergone in deciding a renewal of detention?
Whether to continue a person’s detention is a very serious
matter, but the Minister has not pointed out any obvious process. She
nodded in agreement with my hon. Friend when he suggested that the
person making the decision could be a nurse, a consultant nurse or a
psychotherapist, but somebody has to decide. Who decides in any one
individual case? Will it be that a psychotherapist comes in on Monday
and finds that a nurse decided to not to renew detention on the
previous Friday? When a psychiatrist arrives on the following
Wednesday, they might find that somebody else has made a totally
different decision. The process involved in individual patient care
seems to be a free-for-all.
Tim
Loughton:
Hence my earlier comments about the added
confusion and complexity that the measures will bring to the
Bill.
I am aware of
the good work that the Government have done on new ways of working and
encouraging multidisciplinary teams. That has to be right not only for
mental health care but for all sorts of physical health care. The most
important point is that the patient should receive the most appropriate
care from the best qualified professional. Hopefully, and preferably,
that person would be the medical person mentioned in the Lords
amendments. That means that
the psychiatrist should preferably be central to mental health. The
psychiatrist has been central to all previous mental health legislation
on account of their highly specialised training—as I said, the
training takes13 years. The amendments do not intend to
undermine the skill and dedication of the other relevant
professionals.
The
relevant amendment was introduced by Lord Carlile and had cross-party
support. Some passionate speeches were made in favour of the changes.
The Minister is now proposing, according to my documents, that some
approved clinicians would be eligible to become responsible clinicians
and then have overall charge of the patient for the duration of the
detention in the hospital or secure unit. Therefore, it is entirely
conceivable that for some patients there will be no medical input at
all unless the responsible clinician, who is not a doctor, makes the
necessary referral. Is it not an anomaly that once detained, a
patient’s care will be transferred to a psychologist or nurse,
say, without any medical input to their continued detention other than
at a time of renewal or on appeal to the mental health review
tribunal.
Dr.
Naysmith:
Given what the hon. Gentleman has just said, it
is appropriate that I should read out the
following:
“To
be responsible for the overall management of a detained
patient’s case and then to have to seek the agreement of a
consultant psychiatrist to renew a section of the Mental Health Act
significantly devalues the role for non-medical
professionals.”
That
comes from one of the letters to which he just referred and is written
by two consultant psychiatrists, one of whom is Christine Vize, the
second most senior psychiatrist in the Avon and Wiltshire partnership.
I know her well and I know her work. She is a fellow of the Royal
College of Psychiatrists and she is in favour of new ways of working in
mental health that go directly against what the hon. Gentleman
argues.
Tim
Loughton:
Perhaps in response to that I can quote a letter
sent today from Sheila Hollins, who is the president of the Royal
College of Psychiatrists. She
writes:
“I am
responding to a somewhat misleading letter sent by Drs Vize
and Humphries to the recipients of the
email”—
which I
think the hon. Gentleman might have
seen—
“and to the
national press about the role of the RMO. They purport to represent the
views of the Royal College of Psychiatrists. Drs Vize and Humphries
have a training role connected to New Ways of Working but have not
discussed their views with myself or made representations to the
Central Executive of the College. College decisions are reached
democratically as I explain below.
In the College’s view
the issue of who has the competencies to fulfil the RMO role is still
to be determined. Their letters may serve to undermine their work to
introduce NWW—an important initiative which as yet does not have
the complete confidence of the
profession.”
I
hope that the hon. Gentleman is not going to try to pull the trick that
the Minister does of suddenly pulling out a letter from certain
individuals claiming to represent the views of one of the professional
bodies who happen to be part of the Mental Health Alliance because,
pre-empting the Minister, he has fallen for it. I asked right at the
beginning of this Committee stage whether the Minister or other hon.
Members would try
not to use isolated bits of correspondence to suggest that it represents
the views of a body of professionals overall. The hon. Gentleman said
that these were psychiatrists, and there was a suggestion, therefore,
that in some way the psychiatric profession and the Royal College of
Psychiatrists were not in favour of these changes. That is not the
case, which I hope he now
acknowledges.
Dr.
Naysmith:
Of course I acknowledge that, and I never said
that, as the record will confirm. The pointI was making was
that this was a psychiatrist whom I know and whose work I am familiar
with. Although she deals with the Wiltshire side of things, she is part
of the Avon and Wiltshire partnership which is in charge of mental
health in my area. I am quite familiar with many things that go on with
the Avon and Wiltshire mental health partnership. Christine Vize is a
very competent psychiatrist. I am not saying that she represents the
views of the college because the hon. Gentleman has been getting little
bits of paper about that all morning, but she is someone in whom I have
confidence.
Tim
Loughton:
I do not disagree with anything that the hon.
Gentleman has said. I am sure that Christine Vize is terribly good, but
let us be clear about this. The Minister has already hauled up a
registered nurse to support her case. We have all received submissions
from the RCN. We have had submissions from the British Psychological
Society, which has been prayed in aid even more than any other member
of the Mental Health Alliance. Presumably its membership will be
benefiting enormously. I made it quite clear that there are people who
do not agree with that position, which is why the alliance is not
taking an official position on
this.
Dr.
Naysmith:
It did for quite a long
time.
Tim
Loughton:
As it stands, the alliance is not taking an
official position on it, albeit that many of the component
organisations of the alliance support the Lords amendment.
I think that I have dealt with
all the interventions, for a change, and now come to the anomaly that I
mentioned. The Government presumably recognise the anomaly as
potentially hazardous to patients, because they proposed an amendment,
prior to Report in the Lords, in an attempt to offer some medical input
to the patients’ care by ensuring that the non-medical
responsible clinician should consult with a psychiatrist at the time of
section 20 renewal. However, the legal status of such a consultation is
dubious, because there would be no compulsion on a non-medical
responsible clinician to act on the recommendations and no authority
for the psychiatrist to oversee his treatment plan. That could lead to
interdisciplinary conflict, as well as unco-ordinated patient care. Why
did the Government find it necessary to introduce a medical angle when
the measure was going through the House of Lords? They cannot have it
both ways. Either they think that a medical input is of great
importance, or they do not. They have come up with a halfway house
which is flawed and leads to more
confusion.
Ms
Winterton:
We were trying to give some
reassurance in those circumstances. As the hon. Gentleman should know,
the working of the arrangement would be that, of course, the
responsible clinician would consult others on the multidisciplinary
team. That is what happens at the moment and it is what will happen in
future. We simply wanted to give some reassurance that there would be
consultation with the doctor. I think that perfectly reasonable; it is
the way we sometimes engage in discussions in this place. The provision
is meant to be helpful, but it is what happens now anyway: there are
discussions with a medical
practitioner.
Tim
Loughton:
The thrust of all that the Minister has said,
backed up by her hon. Friends, is that if she had things her way there
need not be a role for a medical practitioner in the process, because a
consultant nurse, registered social worker or clinical psychologist
would be sufficiently familiar with the case to make decisions about
the renewal of detention without reference to medical opinion at that
stage; thus it is just a bit of an annoyance that it was necessary to
accommodate some medical reference in the
Bill.
Dr.
Gibson:
Does the hon. Gentleman accept that each hospital
has a protocol, under which there is a responsible clinician or group
of people, in tune with the patient, and that that information would be
in medical records and freely available? That is how things happen in
practice. I think that difficulties are being found when in fact
hospitals associate the care of a patient sometimes with a named nurse,
sometimes with a responsible clinician, or sometimes with both. That
varies a lot. There is no real
problem.
Tim
Loughton:
I am sure that there are very
good ways of working that happen now, but, ultimately, decisions are
made by a medically qualified person. We are talking about a decision
on renewal of detention. What I am saying in no way detracts from the
effectiveness of the work of various disciplines within a
multidisciplinary team, and I stress that it should not be seen as
intended to undermine that relationship. However, many people have
raised serious legal problems in connection with
what the Government are trying to do in overturning the clause. The
Joint Committee on Human Rights
stated:
“Initial
detention under the Act as amended will still be based on objective
medical expertise, in the form of reports from registered medical
practitioners. However, renewal of detention will be carried out by the
responsible clinician, who need not be a doctor, furnishing a report to
the managers of the hospital that the conditions justifying detention
continue to be met. If initial detention must be based on objective
medical expertise to be compatible with Article 5 ECHR, there is an
argument, following Winterwerp”—
the case mentioned in my amendment, which
I shall come on
to—
“that the same
should apply to its
prolongation.”
The
Chairman:
Order. I point out to the Committee that there
has been a lot of discussion this morning about bits of paper and I am
aware of the quantity of paper that has been submitted to us—I
think that we are officially on to submission No. 58. Some of the
submissions are 85 pages long, and I have to approve them before they
are distributed to you. I hope that I am not the only person who reads
them— [Laughter.] I am not joking.
The
submissions have been available to everyone, on the table in the
corner, all day. They come from a range of professional disciplines,
from different representatives within those disciplines and other
people, who have a vast range of opinions. There will, therefore,
inevitably be disagreement, and it is the Committee’s task to
examine the legislative proposals line by line to try to distil the
best possible answer from that range of opinions. That may require the
Committee to dance on the head of a pin, as the hon. Member for
Bristol, North-West put it, but it is important that we do so using the
weapons of logic, clarity, patience and tolerance, and that we reject
any suggestion of ridicule. I ask all members of the Committee to bear
those points in mind.
It being One o’clock,
The Chairman
adjourned the Committee
without Question put, pursuant to the Standing
Order.
Adjourned
till this day at half-past Four
o’clock.
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