New Clause
18
Local
arrangements for assessment, conveyance and admission of urgent
cases
‘In the 1983 Act, for
Section 140 (Notification of hospitals)
substitute—
“140
Local arrangements for assessment, conveyance and admission of urgent
cases
(1) It shall be the duty
of every Primary Care Trust, in conjunction
with—
(a) the NHS Trusts
contracted to provide in-patient mental health services and ambulance
services within its area,
(b)
the police authority or authorities within its area,
and
(c) the local social
services authority or authorities within its
area,
to prepare, publish and
maintain a comprehensive, up-to-date scheme for the safe, timely and
effective management of the cases of patients within its area who may
require urgent admission to hospital for treatment for mental disorder,
whether under this Act or
otherwise.
(2) This scheme
shall include details
of—
(a) the arrangements
for the assessment of urgent cases and for ensuring the safety of the
patient, carers, those carrying out the assessment and any other
persons present during the
assessment,
(b) the
arrangements for obtaining a bed, if required, and the criteria for
determining the relative priority of urgent cases awaiting
admission,
(c) the arrangements
for ensuring safe custody and conveyance of patients who need to be
admitted to hospital under Section 6(1) of this
Act,
(d) agreed time-limits for
response by the bodies listed in 1 (a-c) above in cases of urgency
where there is a serious risk to the safety of the patient or
others.’”.—[Ann
Coffey.]
Brought
up, and read the First
time.
Ann
Coffey (Stockport) (Lab): I beg to move, That the clause
be read a Second
time.
The
Chairman:
With this it will be convenient to
discuss
New clause
19—Responsibility for conveyance to
hospital
‘(1) The 1983 Act is
amended as follows.
(2) In
Section 11(2) after “sought”, insert “or in the
case of a National Health Service patient, to the NHS Trust responsible
for hospital
provision”.
(3) In
Section 6(1) for “applicant, or any person authorised by the
applicant” substitute “the body to which the application
is addressed, or any person authorised by that body” and for
“convey him to the hospital” substitute “convey
him to the hospital identified by that body as being able to receive
him.”’.
Ann
Coffey:
New clause 18 seeks to substitute, for section 140
in the 1983 Act, a new section that would give duties to primary care
trusts and others in relation to the assessment, conveyance and
admission of urgent cases. New clause 19 seeks to amend section 6(1) of
the 1983 Act to move responsibility for finding a bed from the approved
social worker or the new approved mental health practitioner to the
hospital trust.
I
thank the Minister for meeting me to discuss the proposed new clauses,
and I thank the approved social worker leads’
network—particularly Claire Barcham of that
organisation—for her excellent written submission
which very clearly outlined, with examples, the practical difficulties
that ASWs face in implementing their present duties in relation to
emergency admissions from the community. Claire Barcham gave many
examples of those difficulties, and I am sure that that has convinced
members of the Committee of the strength of their
arguments. ASWs are
involved in approximately 47,000 admissions each year, of which 27,000
are admissions from the community, so they know what they are talking
about. The procedures for admitting people to hospital in an emergency
are vital in achieving the principles outlined in clause 10 of the
Bill, about which there has been much discussion in the Committee and
in the Lords, so it is important that we get them right. The principles
set a standard, and we must ensure that those who will have the
responsibility for implementing the Bill are not faced with the
practical barriers that ASWs face at the
moment.
The current
sections 6 and 140 of the 1983 Act place a responsibility on health
authorities to provide a bed, but because of the drafting of the
provisions and the lack of local protocols, the task of finding a bed
and of making arrangements for conveying people to hospital has in
practice fallen to the approved social workers. The code of practice
accompanying the 1983 Act has guidance that mentions local procedures,
but it is clear from the written submission and from the examples that
the code does not always work in practice.
Part of the problem, which is
also the reason why the examples are anecdotal, is that there is no
monitoring to check whether such protocols are in place locally and
whether local health, police and social services authorities are
co-operating with the protocols. Furthermore, protocols do not form
part of any mental health services inspection. The result is that since
introduction of the 1983 Act there has not been any pressure or lever
to ensure that good local protocols are developed. We should not make
the same mistake again.
Examples have been provided in
the written submission by the approved social workers. I spent a day
with a mental health assessment team in London to see for myself the
practical difficulties that approved social workers face. It was
interesting. While I was there, a request was made by the police for a
mental health assessment on a man who had been arrested that morning
after a neighbour had complained. He had already been in the cells for
three hours. He had not yet been interviewed by the police because the
police doctor did not feel able to say that he was fit for interview.
For that reason, a request for a mental health assessment had been
made.
Before the
approved social worker could carry out the assessment, she had to find
two doctors who could be present at the same time. She also had to
arrange for a bed. By the time that we had arrived at the custody
suite, the man had been in the cells for six hours. It was decided that
he did not need to be admitted to hospital as an emergency, and I
expect that he spent several more hours in the cells while being
interviewed with his solicitor. Such an event showed me how practical
things on the ground must work if the high-level objectives set out in
the Bill are to be
achieved.
I take the
point that police cells are not necessarily safe places, but the man
had waited for three hours in
what was a safe place for him. If that man had been in his flat and had
not been arrested by the police at 8.30 that morning and a
request had been made for a mental health assessment because of his
bizarre behaviour, the approved social worker could well have had to
arrange for doctors to go the flat to assess him. The ASW could not
have applied for him to be admitted to hospital because there was no
bed. She would then have had to delay the assessment and rearrange the
time for the doctors. She might have gone on the visit even though the
doctors perhaps could not have come for several hours. She might have
thought that, on balance, it was better to go out to the flat to do the
assessment. She would have had to wait with a very distressed man or
his carers, while arranging for a bed so that she could make the
application. Alternatively, she could have taken him to a place of
safety, which could have been a police cell or an accident and
emergency unit at a hospital, neither of which are good places for
someone in an unstable condition. Additionally, when I left in
the evening there were a further five requests on the approved social
worker’s desk for a mental health assessment of people living in
the community. They were judged to be a risk to others. They had a
history of violent or abusive behaviour, so the approved social worker
rightly was not prepared to see them without police support. The
requests were on the desk because the approved social worker was
waiting for the police to say when they could undertake a risk
assessment.
The
police carry out an assessment of how much of a risk they feel the
person is to them. If they think that the risk is high, ironically the
waiting time for police support might be longer because resources have
to be provided, such as six policemen instead of one. It is not very
easy to collate details to know how many such instances result from the
community and 999 calls, arrests, assaults on the public, carers,
neighbours or self-harm. However, the time between someone becoming
concerned about a person’s behaviour and assessment of their
condition must be the time of maximum
risk.
The
new clauses would put in place a duty to set up local protocols so that
responsibility for making arrangements does not fall solely on the
approved social worker or, in future, the approved mental health
professional. They would ensure that, in future, admissions and
conveyance to hospital took place according to a local protocol, with
agreed time limits for responses, and that requests for assessments
were not delayed unacceptably by inability to obtain police
support.
There are
other issues in relation to admission, such as accessing transport and
ambulances. In new clause 19, the reason for moving the responsibility
from the approved social worker to the hospital trust is to put
pressure on PCTs to have in place proper commissioning arrangements for
their beds. It is also an issue for age-appropriate treatment. Proper
commissioning plans are needed to achieve
that.
6.15
pm
I knew that the
Minister would have concerns about the new clauses, but I hope that she
can reassure us that when the new code of practice is drawn up, there
will be much stronger guidance about the local protocols
that should be in place, including time limits for assessment and
admissions. Those
protocols and any complaints by local bodies or authorities should be
regarded as part of a local inspection of mental health services. That
is the only way we can provide a lever to ensure that local protocols
are drawn up. I hope that the Minister will also consider how the
police can be involved in that, either through discussions with the
Association of Chief Police Officers or as part of their
responsibilities under local crime and disorder partnerships to ensure
community safety. In discussions with officials about drawing up a
stronger code of practice, I would request the Minister to involve the
ASW leads
network.
Ms
Winterton:
I was extremely grateful to my hon.
Friend for giving such a vivid account of some of the problems that
approved social workers face in the field, which she clearly
experienced during her day on the front line. She explained clearly the
issues that underlie the new clauses and responded to the problems that
some approved social workers have experienced in getting ambulance,
police and trust bed managers to co-operate in conveying and admitting
patients to hospital. I sympathise with her concerns and thank her for
bringing them to the attention of the Committee.
It is essential that local
services are co-ordinated to ensure that patients are conveyed safely,
efficiently and in the least distressing way for them and their family.
That goes back to the discussions that we had this morning about places
of safety. However, I have to tell my hon. Friend that we may not be
able to solve such difficulties in primary legislation. She was right
when she said that the arrangements for co-ordinating local services
must be a matter for local decision. As a result of our meeting, I have
had discussions with officials about what else we can do in that
regard. We are considering issuing a circular to relevant bodies, such
as local authorities, trusts and police authorities, stressing that it
is their responsibility to ensure that local protocols are working. We
are also considering how to amend the Mental Health Act codes of
practice to make that responsibility clear.
As a result of my hon.
Friend’s suggestion, I have asked for the ASW leads network to
be represented on the steering group of an existing Government project
that is co-ordinating health trusts, local authorities and emergency
services, including police and ambulance services, to develop guidance
on working together to manage people experiencing mental disorder. That
guidance will cover the safe and efficient conveyance of patients to
hospital.
Something
else that I recall from the meeting and should like to consider further
is the issue that my hon. Friend has just touched on, which is the
extent to which we can encourage regulators and inspectors to examine
local protocols and see whether they are working effectively. I wish to
do some further work on that, although I cannot guarantee anything
because regulators have a certain independence. It is certainly
something that I can take away and look
at.
As I have said,
the issue is very important and we want to get it right. I hope that
the way forward that I have suggested will be acceptable to my hon.
Friend and that she will withdraw the
motion.
Ann
Coffey:
I thank my right hon. Friend the Minister for her
positive and appropriate response to the issues that I raised. I agree
with her that protocols must be drawn up locally, and I am pleased that
she is examining ways to tighten them through the code of practice and
ensure that they are monitored and not simply ignored. On that basis, I
beg to ask leave to withdraw the
motion.
Motion and
clause, by leave,
withdrawn.
New
Clause
22
Right
to move hospital (No. 2)
‘(1)
The 1983 Act is amended as
follows.
(2) After section 19
(regulations as to transfer of patients)
insert—
“19A The
right to move hospital
(1) The
appropriate authority shall have a duty to inform a patient and his
nearest relative that a request can be made to move from one hospital
to another if there is a good reason to do
so.
(2) All applications shall
be recorded by the appropriate
authority.
(3) If an
application is refused, written reasons shall be provided to the
applicant and, subject to the wishes of the patient, to the nearest
relative.”.’.—[James
Duddridge.]
Brought
up, and read the First
time.
James
Duddridge (Rochford and Southend, East) (Con): I beg to
move, That the clause be read a Second
time.
I
thank my hon. Friend the Member for East Worthing and Shoreham for the
opportunity to move the motion on the new clause, which would
essentially give mental health patients the right to move hospital. It
breaks down into three parts: a duty to inform the patient or their
nearest relative of that right, a requirement to record when it is
exercised and a request is made and a requirement of authorities to
provide written reasons if a reasonable request is turned down. I wish
to make three broad points: the first on choice, the second on why
there is a need of a little additional bureaucracy and a little
evidence, and the third considering the black and minority ethnic
communities, who have inspired the new clause although it does not
apply exclusively to
them.
Choice is a buzz
word in the NHS generally. For instance, non-mental health patients
will have a choice of four hospitals by 2007 or 2008, which will be a
much wider choice. In fact the NHS website
states:
“You
now have the right to
choose.”
Well, that is
not the case at the moment in mental health. The Institute for Public
Policy Research, an organisation whose work I do not read in its
entirety, has a paper called “Mental Health in the
Mainstream”, which is very insightful. I quote from the
IPPR’s “A Good Choice for Mental Health”, which
states that
“despite
different policy initiatives to promote greater user involvement in
mental health, the choice agenda is yet to have a significant impact on
people’s lives or experience of
services”
in mental
health. The Sainsbury Centre for Mental Health is similarly critical of
the Government and states that choices should be offered
to
“reflect the
individual’s beliefs, values and preferences as well as clinical
need”.
Indeed, it
states:
“Appropriate
information and advice should be available to empower people to make
informed choices.”
I
believe that that should be in the Bill, not in a code of practice.
That would fit with Government policy, and I shall come to that point
later when talking about the Bennett case. The Minister is looking
confused, but I shall explain my rationale as to why I feel that that
fits with the Government commitments made following the inquiry into
the tragic death of David Bennett in
1998.
I turn to the
point about extra bureaucracy, because I recognise that in another
place there were criticisms of a similar amendment because of that.
From my own experience, I know that going into a hospital is a
frightening experience. It is difficult to listen to what a doctor or
professional is saying, process the information and recall it. Somebody
with a mental health problem has a lot more issues to deal with than
someone with a simply physical disability. I feel that recording a
request that has been made, and writing the reasons why it has been
turned down if there is not good reason for a transfer, are worth that
extra bureaucratic
time.
The third point
that I wish to make concerns the black and minority ethnic population.
Lord Patel of Bradford raised this issue in another place. He
said:
“It is
not uncommon for a patient or relative to express a wish for a transfer
between hospitals, whether this is to be nearer home or because of a
preference for one hospital’s regime over another. We should be
mindful that it is current government policy that prospective patients
across the rest of the NHS should be encouraged to express choices in
hospital care and that they should be acted on. If we cannot extend
this agenda around choice to psychiatric patients, even in this limited
way, we risk further excluding them and increasing the stigma of
psychiatric treatment.”—[Official Report, House of
Lords, 17 January 2007; Vol. 688, c.
751.]
That is particularly true
for people in the black and ethnic minority communities.
The Government’s own
Department of Health report “Race equality impact
assessment” states
that
“the effects of
mental health legislation apply disproportionately to some BME
groups.”
To pick four examples,
in BME groups, more people are likely to be diagnosed as schizophrenic;
to be sectioned under the 1983 Act; to be moved from open wards to
closed wards; and to be given higher doses of medication. Given that
the Commission for Racial Equality said that we should avoid all
unlawful discrimination, it is important that the Government include a
provision in the Bill. Although it is not certain that racism forms the
totality of the difference, a reasonable person would believe, as I
certainly do, that absolute racism forms part of the problem. Black
Mental Health UK, which focuses on African and Caribbean communities,
feels that this Bill is “unethical” and
“unworkable”, and a missed opportunity for reforming the
1983 Act.
I hope that
the Minister will accept the new clause. I see that she is looking
positive. This is the first time I have moved such a motion on a new
clause, and it would be gratefully appreciated if the right hon. Lady,
not because of that, but because of the power of the argument,
supported it.
Black
Mental Health UK highlights a number of other problems, such as
linguistic problems. More than 300 languages are spoken in London.
There are
problems of racial differences. If people are moved from urban
centres—the evidence across the board is that ethnic and
particularly black populations are largely in conurbations—to
facilities in the countryside, not only is that a big change for them,
as it would be for anyone, but the practitioners in the institutions
are likely to have less cultural sensitivity and less personal
experience of those various communities. There could be a very good
reason why people in black and minority ethnic communities would much
prefer to be transferred to areas of their
preference. As I said
I would, I turn now to the David Bennett inquiry, following that
gentleman’s tragic death. The independent inquest into David
Bennett’s death
said:
“All
psychiatric patients and their families should be made aware that
patients can apply to move from one hospital to another for good
reason”—
these are
almost exactly the same words as appear in the new
clause—
“which
would include such matters as easier access by their family, a greater
ethnic mix, or a reasoned application to be treated by other
doctors.”
The Minister
will note that we have not gone into this long list of detail; I think
that she would prefer that it went into a code of practice, so that the
provisions are flexible. I hope that not including the full list in the
Bill while nevertheless referring to these matters would give that
degree of flexibility. The inquest went on to say
that
“all such
applications should be
recorded”.
Again, the
words are similar to those in the new clause. The inquest
continued:
“They
should not be refused without providing the applicant and their family
with written
reasons”,
Which is the
third part of the new
clause.
The reason why
I think that Minister is likely to support the thrust of the new clause
is that in delivering their report “Race equality and mental
health care”, following the death of David Bennett, the
Government
said:
“We
accept this in
principle.”
All the
points that I have gone through that have been mirrored in the new
clause. They went on to
say:
“Every
such request should be considered carefully and receive a reasoned
response that takes into account the needs of the service user and
their assessed best interests. A BME patient’s wish to be closer
to their family, or to be cared for in a more ethnically mixed
environment, should be listened to, recorded and met unless there is a
good reason not to meet it. It is good practice for refusal to be
explained in
writing.”
That is the
Government saying exactly what is in the new clause, which is why I
hope that the Minister will be minded to support
it.
6.30
pm
Mr.
Charles Walker (Broxbourne) (Con): Thank you,
Mr. Cook, for calling me to make a brief contribution. I am
in a difficult position in following such an excellent speech by my
hon. Friend, who made some important points about people’s right
to apply to move to different hospitals. I am aware that the Government
are looking to replace beds with greater
community services, which may mean that the distance
between areas or hospitals with beds will
grow.
In a place with
fewer beds, most might be occupied, creating a greater need to move
people to a more far-flung location to give them the emergency
treatment that they need. It is important, as with all illness, to have
emotional and family support. If we must move people far from their
homes to receive treatment in an emergency because a hospital more
convenient to them and their family is full, we should consider at the
earliest opportunity whether they wish to move back to a bed nearer to
their family and friends, if that is in their interests, so that they
can derive support from
them.
It is also
important that the convenience of clinicians should take second place
to the patient’s interests. It might be more convenient for a
clinician to put someone in a bed in a certain location, but if it is
in the patient’s interests to be moved, we should be sensitive
to their wishes. It therefore gives me great pleasure to support made
by my hon. Friend the Member for Rochford and Southend,
East.
Ms
Winterton:
The hon. Member for Rochford and Southend, East
is very tempting— [Laughter.] He is particularly so as the
virgin mover of a new clause. However, I am afraid that I might have to
disappoint him, although I want to say straight away that I certainly
understand his reasons for tabling the new clause. It would require the
appropriate authority—I presume that the hon. Gentleman means
the hospital managers—to establish a formal procedure to advise
patients and their nearest relatives that a transfer to another
hospital can be requested if there is good reason.
The new clause is similar to an
amendment tabled in the other place, and it raises important issues of
good practice. As the hon. Gentleman and the hon. Member for Broxbourne
pointed out, it reflects one of the recommendations of the David
Bennett inquiry. I accept the principle behind the recommendations, but
I must again refer the Committee to the fact that it would be better to
put them into the code of
practice.
Dr.
Ian Gibson (Norwich, North) (Lab): As the Minister pointed
out, I was fairly involved in the Rocky Bennett case, as it was in my
constituency, and I met his sister, who had fought hard on the issues
for some time. I seem to remember that the reason why racism reared its
ugly head was that people took Rocky aside and sat on him and not the
other person involved in the altercation, who happened to have a
different skin colour. That was where people picked up on the idea that
a racist element was
involved.
Ms
Winterton:
My hon. Friend is quite right to say that that
inflamed the situation. In our action plan, “Delivering race
equality in mental health care”, which accompanied our response
to the David Bennett inquiry, we certainly reinforced the message that
all requests to transfer to another hospital should be carefully
considered and receive a reasoned response. That should include such
factors as a patient’s wish to be closer to his family or to be
cared for in a more ethnically mixed environment.
As I said, it is not right for
us to introduce the sort of prescribed process for transfer requests
that would
result from the new clause. Information is important, as the hon. Member
for Rochford and Southend, East rightly said. However, we should look
again at the code of practice; there should certainly be no objection
to giving guidance in the new version of the code about the need to
inform patients and their nearest relatives of the possibility of
transferring to another hospital. We could look at whether all transfer
requests should be recorded, and at whether written decisions should
normally be recorded in response to all such requests. It would also be possible to go
a bit further than the new clause seeks to do. We could look at listing
the sort of factors that hospital managers should take into account
when deciding whether a transfer is appropriate. Particularly, in
response to concerns raised by hon. Members regarding BME issues, we
could emphasise more issues of cultural needs, for example. I would
like to look at whether that can be done in the code of practice more
effectively than it is at present, and I would certainly welcome any
views that members of the Committee have on what we could say there. By
doing that, we will be able to get across to hospital managers, perhaps
more effectively than we could in legislation, the wide range of
factors that might be relevant in deciding whether a patient should
transfer to a different
hospital.
Mr.
Walker: Given the mental state of a patient and the
possible lack of awareness of their family, will the Minister actually
introduce measures to empower managers to say to families,
‘There could be a better solution than the one that we are
currently offering you—a hospital nearer your home”?
Under such an arrangement, instead of waiting to be asked, the managers
would go and initiate a hospital move.
Ms
Winterton:
The hon. Gentleman makes a valid point about
the need to talk to carers or family members, as appropriate. In
particular, that is why it is good that we have enshrined in clause 10
the idea that that should certainly happen.
Although I accept that the new
clause is well intentioned, I hope that my response to the hon. Member
for Rochford and Southend, East gives him some reassurance that we take
this matter seriously and will be looking at it in the code of
practice.
James
Duddridge:
Given that this is my first foray into these
matters, you will understand, Mr. Cook, that I am deeply
disappointed. The Minister has let me down gently, however, and she
made a number of reassuring points. I look forward to following the
detail in the new code of practice. I beg to ask leave to withdraw the
motion.
Motion and
clause, by leave, withdrawn.
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