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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 95 xiv HOUSE OF LORDS House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE JOINT COMMITTEE ON THE DRAFT MENTAL HEALTH BILL
Joint Committee on the Draft Mental Health Bill
Wednesday 26 January 2004 MR ROGER HARGREAVES, MS HAZELANNE LEWIS, MR IAN HULATT, MS GAIL ADAMS and MR OWEN DAVIES
DR DAVID HARPER, PROFESSOR PETER KINDERMAN, MS SUE LEDWITH and DR GRAHAM E POWELL DR MICHAEL WILKS, DR J S BAMRAH, DR ROBIN ARNOLD, PROFESSOR ANDRE TYLEE and DR ALAN COHEN Evidence heard in Public Questions 953 - 1003
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Joint Committee on the Draft Mental Health Bill on Wednesday 26 January 2004 Members present:
Memoranda submitted by the British Association of Social Workers, the Royal College of Nursing and Unison
Examination of Witnesses
Witnesses: Mr Roger Hargreaves, Chair, Mental Health Special Interest Group, Ms Hazelanne Lewis, Member of the Mental Health Special Interest Group, British Association of Social Workers; Mr Ian Hulatt, Adviser, Royal College of Nursing; Ms Gail Adams, Head of Nursing, and Mr Owen Davies, Senior National Officer, Local Government, Unison, examined. Q953 Chairman: Welcome to the Committee. I will ask you in a moment if you would introduce yourselves. Can I just remind you that this is a public session of the Committee and that therefore a transcript will be produced. The transcript will be available on the internet after about one week and it will be open to you to make any corrections to the text but not to the sense. Can I also ask all witnesses to speak up please and straight into the microphones, if you can, otherwise we will not all hear you, which would not be welcome. Can I remind you please ‑ there are quite a number of you here and we have got large evidence sessions this afternoon ‑ that time is of the essence. We will try and get through the questions in this session by 3.30, possibly slightly earlier as we have to adjourn the Committee's meetings this afternoon not later than 19 minutes before five o'clock for procedural reasons. Would you like to introduce yourselves and then if you will allow us we will move straight into questions. Ms Lewis: My name is Hazelanne Lewis. I am a member of BASW. I train approved social workers from seven local authorities and still practise as an approved social worker. I am a lay member of the Mental Health Review Tribunal and until recently for nine years I was a Lead Commissioner with the Mental Health Act Commission. Mr Hargreaves: I am Roger Hargreaves. I am the Chair of the Mental Health Special Interest Group of the British Association of Social Workers. I was the Vice Chair at the time of the last review of the legislation in the late 1970s. I was a practising mental welfare officer under the 1995 Act and then approved social worker under the present Act for the greater part of the period 1971 to 1999. Since then I have been self‑employed, amongst other things doing independent reports for mental health review tribunals and I have also been a member of five independent NHS inquiries into serious incidents. Mr Hulatt: My name is Ian Hulatt. I am the Mental Health Adviser to the Royal College of Nursing. Ms Adams: Gail Adams, Head of Nursing, Unison. Mr Davies: Owen Davies. I am a national officer in the local government section of Unison and I represent our members who work in social services departments. Chairman: Thank you all very much. Baroness Pitkeathley? Q954 Baroness Pitkeathley: My question is for our colleagues from BASW, please. In your evidence you point out that there is an absence of a discretion in the Bill not to take action even where the minimum conditions are satisfied. Surely, if somebody meets the conditions in clause 9 they are going to be seriously mentally ill and therefore in need of treatment, so I am not quite sure what is the purpose of providing a discretion. Mr Hargreaves: The conditions of clause 9 are so broad that they would in fact encompass thousands of people who are definitely not seriously mentally ill in the way that we generally understand that term. In Appendix 2 of our evidence we give as an example two very large groups of people who are constantly coming to the attention of mental health services but who are very rarely detained under the present Act although they are often admitted informally into hospital and who would very clearly meet all the conditions in clause 9 of the Bill. The present Act would also allow many of those people to be detained, although not all of them because some of them would be explicitly excluded by the exclusions. At least they would be detained for the first 28 days until the conditions become tighter under the present Act. However, that does not happen automatically at present because the doctors and the approved social worker have discretion. They are not forced to detain somebody simply because the minimum conditions in the Act are satisfied. The Bill, however, takes away virtually all of that discretion. It is basically a simple tick box exercise. If all the boxes in clause 9 are ticked then compulsion must be imposed and this means that the doctors and the AMHP cannot take into account any factors which have not been explicitly envisaged in clause 9. In particular, they cannot take capacity into account. There has been a lot of talk about the need for a capacity test in this Bill. I think it has been overlooked that the present Act does allow capacity to be taken into account because that is one of the areas where the doctors and the ASW can exercise discretion. In practice, that is one of the most common reasons for not detaining somebody when the minimum conditions are satisfied. The Bill therefore removes the capacity test which is inherent in the present Act even though it is not explicitly stated. Q955 Baroness Pitkeathley: It is your view that no discretion would remain to the professional even though they would have to decide whether the person was seriously ill or not? There is not sufficient discretion? Mr Hargreaves: The discretion is only contained within each individual condition. There is no overarching discretion to not take action even though all the conditions are satisfied. There is some discretion, particularly in this latest draft, within each condition but there is not an overarching discretion as there is at present, so it very much narrows the range of discretion and it would result in very large numbers of people being made subject to compulsion who we would never consider making subject to compulsion at present. Q956 Chairman: Are you absolutely certain what the Bill says is that there is no discretion? Surely, clause 9 merely sets out the relevant conditions before a section can be made? It does not require, does it, that every person who complies with the conditions in clause 9 should be made subject to compulsory treatment? Mr Hargreaves: It states that if those conditions are met the AMHP examiner must then register that person as either a resident or a non‑resident patient. It does not say "may register". If it said "may register" then that would restore the discretion but it does not allow for a situation where all the conditions are satisfied but the three examiners can nevertheless agree not to register. Q957 Dr Naysmith: Following up that point, as I understand it, psychiatrists were worried about exactly the same point that you have just made, that it would be a tick box exercise and you would have no discretion. They have been assured and reassured and they gave evidence to that effect before the Committee that they will be able to exercise clinical judgment, which is an aspect of discretion, and they seem not to believe what you believe. Mr Hargreaves: I have to say that is not my understanding of their position. Q958 Chairman: Forgive me for interrupting. We want to be sure that we are talking about the same Bill. Could you look at clause 14. Clause 14 provides for "the appropriate authority, if requested to do so by any person, to determine whether all the relevant conditions appear to be met in a patient's case". Let's just get to the fundamental point because we may have to clarify this. You are saying that your understanding of the Bill is that if a person satisfies the relevant conditions there is a requirement that they be sectioned. I am not sure that the Bill says that at all? Mr Hargreaves: It is clause 16 (3) that is the crucial one. Q959 Chairman: Sub‑sections 16(4) and 16(5) apply "if, on examining the patient, all of the examiners determine that all of the relevant conditions are met in the patient's case". So there has to be an examination? Mr Hargreaves: They have to determine that all of the conditions are met. Q960 Chairman: Being the unanimous determination of all the examiners? Mr Hargreaves: Yes, correct. Q961 Chairman: Is that not quite a substantial gateway? Mr Hargreaves: Not given that the conditions are themselves so wide. It is the width of the conditions which creates a large part of the problem. The conditions would apply, as I have set out in appendix two of our evidence. If you apply them to the people that social workers and doctors see every day, these conditions would apply to tens of thousands of people who are not made subject to the Act at present. It is the width of the conditions coupled with the lack of discretion to narrow the effect of those conditions which together widen the effect of the Bill. Q962 Chairman: So can you just remind the Committee of the main narrowings of the conditions which you would require. Mr Hargreaves: There are two possible ways of doing this. One is to define the conditions more precisely. The other is to define the conditions very widely but allow discretion. The present Act follows the latter course. The present Act, certainly for the first 28 days, has very broad conditions indeed, in some ways broader than the clause 9 conditions. In some ways the clause 9 conditions tighten up the conditions of the present Act. So we start at the moment with a very broad funnel which is narrowed down in practice by the use of discretion. What is missing in this formulation is that narrowing down because the discretion can only be exercised to a limited extent within each condition and not globally. In particular, it cannot be used to take into account factors that are not envisaged in the conditions, capacity being one of them, the views of relatives and carers being another. There is very extensive provision in the Bill for consultation with relatives and carers but if all the conditions are satisfied and the carers nevertheless say "we would like to carry on caring" that discretion to allow that to happen does not exist because there is no provision for that to be taken into account. At the moment that is one of the main reasons why ASWs do not proceed with an admission. ASWs only admit about two‑thirds of the people who are referred to them for possible admission. One of the commonest reasons is that they are satisfied that existing care arrangements can continue, that the person's needs can continue to be met, and that the carers are willing to carry on. That is not provided for here. Chairman: You have helped us to clarify an important point. Can I advise the Committee that I have had advice that if the examiners are unanimous that the conditions are met then clauses 16(4) and 16(5) provide that the patient is then automatically liable to assessment as a resident or non‑resident patient pursuant to clause 16(4). We might have a note about that please. Baroness Murphy? Q963 Baroness Murphy: I would like to ask all three of our organisations about the job of the approved mental health professional as set out in the Draft Bill. Is it workable and will it be attractive to your members to become one of these new creatures? Ms Lewis: I would say it is unlikely to be workable and certainly speaking for ASWs it is not seen as very attractive. Why is it not workable? There are three areas to consider: one is independence; the other is the workforce; and the third is the practicality of implementing the Bill. When I am talking about independence I am not saying the AMHP cannot be independent if they are not a social worker, although many of our social work members do say that. I am saying that the structure when all the AMHPs are employed by the same authority that will be the detaining authority will put pressures on the AMHPs. At the moment the local authority will appoint and train the AMHPs but they have no given responsibility for monitoring performance and checking that AMHPs are retaining their independence. The second area of independence is the Act allows for a doctor who does not work with the clinical supervisor or a member of the team to be independent, but it does not allow for an independent AMHP, so if you have a CMHT where you have an AMHP and a clinical supervisor, where the two have had a case conference and decided that a user needs to be admitted, two people who have already made up their minds more or less will be going to assess someone with a third person who may in rural areas quite often be a GP who will accept advice from the experts. I do think that there needs to be some provision for the AMHP to be independent from the clinical supervisor or vice versa when you are coming to the assessment. In terms of practicalities, the job as I read it (several times now) is larger than the current ASW's job and there is no requirement for the other agencies who are always involved in Mental Health Act assessments to be obliged to co‑operate. For example, currently many assessments require police co‑operation. Section 135 has been lifted more or less word‑for‑word into clause 228 but there is nothing that obliges the police to come out when someone has a section 135 warrant. There are situations now when the police are unable to respond for three weeks. There are other areas in the country where even in cases of emergencies police will only come out on one specified day a week. Unless there is something that requires support by the other agencies the AMHP's job is going to remain very difficult. Section 140, which is emergency admission under cases of urgent necessity, has not been kept in the draft Bill. This means that when you carry out an assessment and you feel a bed is urgently needed, you have no chance of phoning the hospital unit and saying, "I need to bring this person in. It is urgent necessity, section 140. You can guest the person on the ward until you can find a suitable bed." Already we have ASWs waiting nine hours with distressed, distraught people for a phone call to say there is a bed somewhere and then waiting for ambulances. In some areas of the country people are waiting 13 days. There is nothing in the draft that obliges the provision of a bed. Then the third point is practicalities. As I read it, once the assessment has been completed and it is decided that someone meets the conditions for the clause laid out, the AMHP has to leave the person, go to the hospital, register the patient, go back in the hopes that the person will let them in or is still there and possibly get a new 135 warrant because one will be barred by then before they can take the person to hospital. This may have been an oversight in the drafting but the wording does need to be changed. Q964 Chairman: Is this material for the Bill or the Code of Practice. Ms Lewis: This is material for the Bill because the Bill as it is requires the registration to take place prior to the person being taken from their home. Q965 Mr Hinchliffe: I am interested to tease out the extent to which the ASW currently does challenge the proposed admission. Mr Hargreaves suggested about two‑thirds of cases referred to ASWs are admitted so one-third are not admitted. I would be interested to know first of all where you got that figure from because I asked the Department of Health about the role of the ASWs and they did not have any information at all about the extent to which the ASW may be able to point to alternative means of disposal as opposed to a section. Mr Hargreaves: Our evidence in 2001 quotes the research that was available at that time so I could refer you to that. Q966 Mr Hinchliffe: Do you know what research it was? Mr Hargreaves: Without looking it up I cannot remember exactly now. Basically I trawled what research there was at that time. I am not aware of anything since that time. I think that is a fairly reliable figure at that time. Mr Hinchliffe: At the risk of upsetting a fellow Unison member sat round this table who is a nurse I got in trouble last week for suggesting that there are certainly professionals who may be more willing to go along with a doctor's opinion on a section possibly than an ASW would. That was my experience when I was a mental welfare officer many years ago that those who had a nursing background were frequently more willing and sometimes requested to do a section by GPs and consultants because those who did not have a nursing background were more often likely to challenge the opinion of the doctor. That might be profoundly unfair to many of my colleagues and friends who are nurses but I wonder what your thoughts are, from different professional backgrounds as to these distinctions between the professional backgrounds of the individuals who will be the approved professional under the proposals in the Bill, how that might be different from the role of the ASW currently. Q967 Chairman: Before Mr Hinchliffe gets his ear bashing from Ms Moffatt, Mr Davies, do you want to answer the question? Mr Davies: Can I say that if one looks at the current situation, I think there is certainly a fear among the ASW members that I represent that might be the case. I think the crux here ought to be the training that is to be provided for the AMHPs because neither Unison or BASW is saying only social workers can do this but what we are saying I think is there will need to be training of a sort which will give colleagues from other professions (not just nursing because occupational therapists, as I understand it, are also a potential source of these workers) confidence to be able to do their job. Again, if you pose it as standing up to the psychiatrist that may be the wrong way of looking at it because our view is that it is the civil rights of the patient that are the crucial issue here because the patient deserves to have the additional perspective of someone with a social work model or a non‑medical model. As long as that is available through the training of the AMHP we do not see it as a fundamental barrier. There is a danger and a tendency in the people I represent ‑ and Gail may well take me outside and beat me up afterwards ‑ for that worry to be there, but we jointly believe that if the training is correct and the structural solutions are correct (and I would like to agree with what my colleague on the far right said about organisational independence) if those can be done then there is no fundamental reason why nurses and occupational therapists and others should not do this job very well. Q968 Chairman: Mr Hulatt, do you want to add anything? Mr Hulatt: Linking that to the previous question of would members of the Royal College of Nursing want to engage in this role, it would nice to be able to give you an emphatic yes or no but I am afraid I cannot because there is a division of opinion on this. I think there are those nurses who would not wish to take on this role, supporting my colleague's views, because they have seen the rigours of the current role for social workers who undertake it and they may be reticent to engage in it. There are others who would see this as an appropriate extension and development of their nursing role and would be comfortable in that way. The issue of independence and historical and traditional views of, dare one say, subservience ‑‑‑ Q969 Chairman: I think you are safe on this one, Laura Moffatt is on the Committee! Mr Hulatt: I think that nursing has moved a long way and I think part of that movement has been a confident development of a body of knowledge, specific skills, and confidence in those skills, and I would like to assert that that can be independently stated in this role. I think it will be something that will require, as you say, very specific training, education and I would suggest as well ‑ and we have not mentioned this yet ‑ a training programme that involves service users as well to challenge values that people may well have. Q970 Tim Loughton: On the problems with the shortage of ASWs at the moment, is it not the case that over the last ten years the number of ASWs to the head of population has more than halved, with the exception of Northern Ireland where I gather there are three times as many ASWs as in England per 100,000 of the population. It would be quite interesting to know why that is. That cannot be explained by the ASWs in a social services department being in some of the new set of intervention outreach teams because there has been a net outflow. Are you not worried therefore that these ASWs are going to be replaced by the new form of mental health social worker and, indeed, could the outflows get worse if the fears you are raising is that it is not going to be attractive to ASW, in which case where on earth do we go from here? Mr Hargreaves: The latest research by Professor Peter Huxley does confirm that the numbers have halved and I think more to the point, they are continuing to decline and that confirms an anecdotal view. It is not universal. There are some places where the numbers are holding up but in other places there is a very serious problem. There is a very serious problem with an ageing workforce. At least a third are over 50 and you can work out the implications of that, so, yes, we are very seriously concerned about the numbers and about whether the present services can actually last until the new Act comes into force. That then raises a question as to whether there will be sufficient ASWs able and willing to transfer over to operate the new Act, bearing in mind that people are in their 50s and in many cases 60s and a lot of them are going to choose to retire. This always happens with new legislation, they will choose to retire at the point of transition. We think there is a very serious numbers problem. We cannot quantify it exactly. We know that after a great deal of pressure from us work is now being done to try and quantify it but we really cannot say more than that at this stage. There may be a very serious problem. That is one reason why BASW is proposing not to continue the present ASW role effectively unchanged into the new legislation but to approach it in a rather different way which would accommodate the decline in numbers and make the transition much easier to achieve. If things carry on as at present we could need literally thousands of new AMHPs who would mostly have to be health professionals and even if potentially they are available and willing to volunteer that is still a massive training problem given that the present system is geared to just 300 or 400 candidates a year. So there is a need to address workforce issues very urgently. Q971 Tim Loughton: Is there not also a problem because the new social work degree qualification has only minimal coverage of mental health within it? Mr Hargreaves: I think you could say the same about the old qualification. It is something that people have to pick up later. The practical problem is that although the new degree has increased the number of candidates and there has been a very welcome increase in the number of people in training because they have to get through the degree, then they have to do at least two years before they can start training as ASWs, we are talking about 2009/2010 at least before that new cohort begins to filter through. Even then there will be big competition from child protection services. It is not as if this is the only area of social work that is short of people. Q972 Ms Munn: Moving on to talk about community treatment orders, I am first going to refer to some of the evidence given by the Royal College of Nursing but I think other witnesses can respond to the general point. The evidence sent to us by the Royal College of Nursing was against community treatment orders, particularly on the grounds that if patients need that kind support and if they are that unwell they should really be in a hospital setting. Throughout the course of the evidence we have had in this Committee we have heard differing views on this. We have heard that view. We have heard views from service users who feel that it is inappropriate. We have also heard from people who feel it is an appropriate response particularly to what is called ‑ I think unhelpfully - "revolving door" patients, so people who find themselves going back into hospital because their treatment regime in the community has broken down. We have also heard from people who work with perhaps some of the most severe and difficult cases saying it does provide a real option for getting people back out into the community and supporting them in the community with appropriate safeguards. Really what I put to the Royal College of Nursing is can you not see if the community treatment orders were drawn up in a particular way it would allow people to be within the community who, if your recommendations were accepted, would have to be in hospital? Mr Hulatt: Yes, I accept your reservations about the term "revolving door". I think it is a pejorative term and an unhelpful one. Before we get to the question of whether with certain safeguards a CTO would be agreeable, I would want to make the point that I think that contemporary nursing practice and other disciplines have more to offer and more imaginative ways of assisting individuals than returning them to hospital and close supervision in the way that this is implied. There are ways of working with individuals, carers and families to have a positive impact on what we might call relapse requiring readmission. As a first point there is implicit within here some sort of belief that if people are properly monitored, they properly consume the drugs for which they are prescribed they are likely not to be revolving. There is good evidence to show that people who are very compliant with medication still relapse and still become unwell. I do not think it is quite as simple as is implied here. I will defer to my other colleagues on this, but I know there are models of community treatment orders that are argued to be successfully used with a small specific group of clients, but I think the reservation that is strongly expressed by members of the RCN is that this element of supervision and possible coercion could be unhelpful Q973 Ms Munn: It has also been put to us that patients in hospital currently go on home leave and essentially during that period that could be deemed to be a community treatment order rather than being seen as home leave and that might be a more honest way of doing it and get round this issue where people go on home leave not necessarily because that is in their best interests but because of pressure on resources and on beds. Mr Hulatt: I think you are making the point. It is home leave not necessarily for the client's benefit but for the service's. That sounds inappropriate. Q974 Ms Munn: There are also some people who go on home leave as part of a programme for returning to the community. That could also be deemed to be a form of community treatment. I suppose what I am trying to get at is are you against some kind of compulsion and treatment in the community per se or is it the specific format within which it is phrased in the draft Bill? Mr Hulatt: I think it was the lack of clarity about it that was unhelpful. I think that our concerns are that clients may well disengage from services and disengage from working with nurses and others because of the fear of return to hospital. I think that community treatment orders, perhaps with very explicit and tight criteria, may well be acceptable to service users and those service providers, but I did not see that clarity and my members did not see that clarity here. Q975 Mrs Blackman: Can I move the questioning on a little bit to Roger Hargreaves. Your Association made the point very starkly that you would support community or non‑resident treatment in a limited sense but certainly not non‑resident assessment. Could you just expand on that a little bit? Why is the assessment so risky, in your opinion? Mr Hargreaves: Basically for two reasons. First of all, if somebody is ill enough and disturbed enough and is at risk to themselves and others enough to justify the use of compulsion as set out in the conditions, then it is hard to envisage a situation where they should not be in hospital, at least initially. If somebody can be left where they are, then the question is do they meet the threshold. Q976 Chairman: You may be able to get them out of hospital very quickly if the community treatment option is available? Mr Hargreaves: As a treatment option as opposed to assessment. That is the difference and that is the nub of the question whether we should be assessing people without admitting them to hospital in the first place. Q977 Mrs Blackman: But it has been put to us that there are certain categories of people, for example homeless people, who if they were having their assessment in a hospital setting that would actually mask the chaotic nature of their experience, their lives. Mr Hargreaves: If their life is chaotic you cannot assess them in the community. In order to be able to assess somebody they have to have stable accommodation, you have to be able to get access, you have to be able to be certain that you can maintain contact with them, you have to be certain that you can keep them safe whilst you are doing the assessment. There would be very, very few circumstances where we could envisage that that would be possible. We could not relate to the case examples that were put in the White Paper stage. They did not relate to the experience of approved social workers at all. The other issue that looms very large now, as you have heard already, is the fact that in some places people who are acutely ill and need to be in hospital immediately are waiting two or three weeks for a bed. The temptation to use non‑resident assessment as an alternative because you cannot get a bed would be extremely high. BASW's view all along has been we should not ever consider non‑resident assessment until there are enough beds to make that not a possibility. What would happen in practice is that examiners because of the lack of discretion, because of the way in which the conditions drive you in a certain direction have to place people on non‑resident assessment even though they thought that that was ill‑advised and possibly dangerous. Q978 Chairman: Does Unison want to put a different view forward? Ms Adams: In terms of the community treatment orders there are some reservations out there about service provision, about the practicalities which link with some of the workforce information, and that is primarily where the concern is coming from. There are implications for homeless people and how the assessment can be conducted and in that context that is where the reservation is based. It is primarily on the workforce; it is not necessarily on the principle although there are occasions where they would not be appropriate. In some ways talking to colleagues earlier it is quite ironic because prior to the supervised practice discharge procedure their initial view was that they wanted compulsory treatment orders. There is no principle opposition but there is service level concern about the practicalities of that and the further dilution that may impact on service provision. Chairman: Thank you. Ms Moffatt? Q979 Laura Moffatt: That brings me very nicely on to the next lot of questions. I would really like to hear from all of you should community treatment orders become part of the proposed Bill. I understand reservations on all sides but should that be part of the Bill? I wonder if you could honestly tell the Committee what resources you believe should be in place for them to work. That is difficult particularly if you are not madly keen on them because there is a temptation to over‑egg the pudding. I would be really keen to ask you what is needed. Also we have been taking evidence in Wales where people have told us that the Welsh system is about ten years behind us therefore they were going to be in a very different position, particularly Powys where they have only got one approved social worker for a huge area and the practicalities of being able to support community treatment orders. Could you help us with that, and I do not mind who starts. Mr Hulatt: I think it may well be the issue, as Gail has alluded to, of resources. There are community psychiatric nurses working with unsafe caseloads in that sense. Q980 Laura Moffatt: Now? Mr Hulatt: Yes, people with very large case loads of very vulnerable people who are not necessarily living in caring and supportive environments or neighbourhoods or families. The community psychiatric nurse may well be the only contact that client has. I think it would be an issue of concern with the community treatment orders in as much as clients under those may well be obliged to have high levels of supervision and high levels of supervision need the appropriate numbers of staff to provide it. I think it really is in some senses as simple as that ‑ the resources and the systems to support nurses and others in making such a system work. Q981 Laura Moffatt: The RCN, as I understand it, have made an assessment of how many extra staff they believe they should have. Mr Hulatt: Our evidence on the workforce was whilst we did not provide a number we felt the notion of 200 extra was woefully inadequate, for reasons I can discuss but I do not think they are relevant to this question. Q982 Mr Hinchliffe: Do you have some notional idea of what a safe case load is? You made a point a moment ago about a large number have unsafe case loads. Does your organisation have a guide level on an unsafe case load? Surely every case is different so how do you come to terms with what is a safe and unsafe case level? Mr Hulatt: I think the term "unsafe" perhaps was unhelpful, perhaps I should say almost unworkable. Q983 Chairman: As in one out of hours ASW on duty in Powys at any one time? Mr Hulatt: That is certainly a challenge for that person over a 120-mile long county but it is the CPNs in urban areas I know who have case loads of 90, and I think that is, frankly, absurd with very vulnerable individuals on that case load. Q984 Chairman: One of our Welsh members is not here but I know he would want me to ask you this question and we have also been Wales. Can I ask you all specifically if there is any evidence of which you are aware of the Welsh Assembly addressing adequately the employee shortages in Wales? Do you know of any such evidence? Have you dealt directly with the National Assembly for Wales on these issues? Ms Adams: None that I see. Certainly if it would be helpful to the Committee we could check with colleagues who deal on a daily basis with the Welsh Assembly to see if they have examples if that would be helpful. We have heads of health for Wales and officers who work directly with the Welsh Assembly. Q985 Chairman: That would be helpful. Ms Adams: By all means we can do that. Mr Hulatt: I can certainly do that. Chairman: Baroness McIntosh? Q986 Baroness McIntosh of Hudnall: I would like to give our witnesses a chance to say what they want to say. Mr Davies: I want to make a point about the health and safety issue which is relevant to this matter. It is my understanding ‑ anecdotally and I cannot give hard evidence - that a lot of members I represent as ASWs go into situations single handed which I as a trade union official would advise them not to. They put themselves in very risky situations. My understanding is that the health and safety policies of the National Health Service are much more rigorous than is the case in some local authorities and it might well be that AMHPs working under NHS rules, as they invariably will be, will not be able to go in single handed and that in itself will have a major impact on the number of AMHPs who it would be necessary to have in the system. Mr Hargreaves: We think that the current ASW practice falls far, far outside current health and safety standards in most parts of the country. It is not sustainable. It simply carries on because that is custom and practice and always has been. I think if it was examined from a modern health and safety perspective then it would be found to be seriously wanting. I agree entirely that the numbers do not permit safe working at present. Q987 Chairman: Examinations often take place after a tragedy, unfortunately. Mr Hargreaves: They do indeed. Ms Lewis: Most known clients have a care co‑ordinator and I know there is no draft Code of Practice but it would be helpful if it was stipulated that the care co‑ordinator was expected to attend all the Mental Health Act assessments and that would cover the lone working, within hours at least. However, that would mean that those people would be taken out of their normal workload. Mental Health Act assessments go on for a very long time and that will have knock‑on implications for staffing for all the disciplines if you have a doubling up. Q988 Chairman: Given that community orders would involve inevitably general practitioners because they are the community clinicians for their patients, what level of confidence do you have that general practitioners would be prepared to be involved with community orders to the requisite level in the daytime given that they no longer largely practise outside office hours anyway? Ms Lewis: I will pick that up and say there are some general practitioners who might be willing but on the whole ‑‑‑ Q989 Chairman: That sounded pessimistic! Ms Lewis: For the community treatment orders I do not know that general practitioners would be prepared to be the prime clinician. They would expect the clinical supervisor or the current RMO to take responsibility for treatment and I think, from my experience and the experience in seven boroughs of local authorities, that on the whole general practitioners do not want to be involved in the active treatment of their clients under a Mental Health Act. They are very interested in their physical health and maintaining a supportive relationship with them? Ms Adams: May I add some information to the work force which I think was the original question. In mental health services it is incredibly difficult. I am not a mental health nurse by background so all of the evidence I have gathered is from talking to different practitioners across the spectrum. There is a huge shortfall in the work force in mental health services which impact across the range and there have been a large number of initiatives brought in my government which have been wholly welcomed ‑ the crisis services are fantastic but the reality is it is being staffed by the very experienced CPNs who possibly could be the approved mental health worker. In order for us to get a feel for the total picture around the workforce we need to look at the numbers and we need to look at it in the context of training for that type of role, whether it is going to generic including approved social workers and other occupations, and also where their location is going to be based, the geographical boundaries of their area. It is incredibly difficult to formulate statistical information which would help the Committee without that detailed information. There is evidence of vacancy short falls in CPNs, in occupational therapists and in a range of specialities but there is an opportunity within mental health services for them to grow their own. We recently had a health care assistant conference and 35 per cent of the audience were health care assistants and 34 per cent of them wanted to access professional training. So it strikes me that there is an opportunity through other mechanisms that the NHS has already established for growing your own for those roles to develop. In terms of the capacity within the Bill for individuals to hit the ground running now with a new role it is incredibly difficult to predict based on the information that we have available. Q990 Baroness Eccles of Moulton: The next question falls very much within what has already been discussed. We have already talked about the fact that the RCN in their evidence have suggested that the number proposed by the Department of Health is not adequate but in your evidence you go on to say that the problems in community care are not the result of the lack of legal powers of compulsion but they are lack of resources, and the lack of resources is a general view shared by everybody, whether supporting CPOs in order to administer them or in order to provide more creative ways of working, as you have already said. We have heard during our visit and taking of oral evidence that the assertive outreach teams and the crisis prevention teams go a very long way to provide the same sort of persuasion and support that a CTO would need to provide. Therefore, could I put it to you that if the increase in resources could be achieved - and it would obviously take time because of the training of CPNs and the availability of people who would be prepared to go into that role - that the need for CTOs could virtually disappear? Mr Hulatt: I suppose a short answer would be yes. At the risk of being considered idealistic I think, yes, with good resources. As you say, assertive outreach teams have made an impact on the client group that would be subject to CTOs where assertive outreach teams exist. That is exactly the point - where they exist. Q991 Baroness Eccles of Moulton: Are we not now in a rather circular situation of saying it would not be possible to administer CPOs effectively without an increase in resources but if we had that increase in resources CTOs would begin to cease to be necessary? Mr Hulatt: It may well appear so. Baroness Eccles of Moulton: We are in a kind of Catch‑22 situation. Q992 Chairman: Can I remind you that a recent study of 26 assertive outreach schemes in London demonstrated no reduction in compulsion at all. That is research published in 2004. How would you comment on that in the context of the question that has just been asked? Mr Hulatt: It did not result in a reduction ---? Q993 Chairman: In compulsion. Mr Hulatt: Did it prevent an increase? Q994 Chairman: I do not know the answer to that. It is a good answer. Mr Hulatt: It is the one I rest with. Q995 Chairman: You would view not reducing compulsion as a satisfactory outcome, would you? Mr Hulatt: No, I would not say that. Q996 Chairman: It was a good answer. Touché. Mr Hargreaves: Can I come back briefly. I was not aware of that particular piece of research but one of the things that concerns me is the Government has been claiming that everything will fit together in two or three years' time because the new services that are coming on board will reduce the use of compulsory powers and it will all work out. I have been in this business an extremely long time and nearly 30 years ago I was the team leader of the very first community mental health team in the country. We assumed that we would reduce the number of admissions to our unit and so we did for the first year or so. After that the effect ceased and the number started going up. A 60 per cent increase in the use of the Act coincided with the greatest increase in the development of community services from the late 1980s to the late 1990s. We simply do not know what the connections are and it is very dangerous to draw optimistic conclusions about the effect of new services on the level of need for beds or the need for compulsory powers. Chairman: With that timely warning, I think we will bring this session to an end but we are very grateful to you for the completeness and conciseness of your answers and also for the written material you have provided us with. I can assure you that all your evidence will be taken fully into account by the Committee. Thank you very much indeed to you all. Memorandum submitted by the British Psychological Society Examination of Witnesses
Witnesses: Dr David Harper, Senior Lecturer in Clinical Psychology, University of London, Professor Peter Kinderman, Professor of Clinical Psychology, University of Liverpool, Ms Sue Ledwith, Consultant Clinical Psychologist and Clinical Lead North Yorkshire Forensic Psychiatry Service, and Dr Graham E Powell, President Elect, British Psychological Society. Q997 Chairman: Welcome to our witnesses from the British Psychological Society. Can I remind you that this is a public evidence session and as a result there will be a transcript kept of everything that is said. It will be published on the internet within about a week and you will have the opportunity to make any corrections to the text although not to the sense of it, if you wish to do so. Can I ask you all please to keep your voices up when you answer questions. I am afraid for procedural reasons connected with some extremely important votes in the House of Commons (and would the Members of the Lords please desist from laughing every time that is said!) we are going to have to curtail this session at about five or ten past four, if you will forgive us but, of course, we do have your written submissions together with your further written submissions with much thanks. Would you like to introduce yourselves and then we will continue with the questioning. Professor Kinderman: My name is Peter Kinderman. I am Professor of Clinical Psychology at the University of Liverpool and Consultant Clinical Psychologist with Merseycare NHS Trust. I am the current Chair of the British Psychological Society's Division of Clinical Psychology and I head the British Psychological Society's Working Group on mental health legislation. I have also had the pleasure of giving evidence to Lord Carter's Committee on the Mental Capacity Bill. Ms Ledwith: I am Sue Ledwith. I am a Consultant Clinical Psychologist and Clinical Lead for North Yorkshire Forensic Psychiatry Services. I have also worked as a Mental Health Act Commissioner for the past five years but I have recently discontinued that. I have worked with people who have been liable to be detained for the past 20 years, so I am appearing from a clinical point of view on some of the issues. Dr Powell: I am Dr Graham Powell and I am President Elect of the British Psychological Society and as such I have a duty to ensure the appropriate training and support of our members to take on new roles. I am a Clinical and Neuro Psychologist with a special academic interest in the reliability and validity of assessments. I work clinically with brain-damaged individuals who have disability of mind and therefore problems in the area of capacity. Dr Harper: I am David Harper. I work on the training course in clinical psychology at the University of East London. I am a member of the British Psychological Society Mental Health Bill Working Party, and I have got a particular interest in alternative approaches to psychological problems particularly from a social perspective. Q998 Chairman: I will take what to cricket fans is known at the moment as the "Flintoff" role and start with as fast a ball as I can bowl at you. In your supplementary memorandum you challenged the view of the Royal College of Psychiatrists that for the vast majority of severely mentally ill patients in general adult and old age services it is essential for the clinical supervisor to have a medical training. Why do you not accept the psychiatrists' approach and for what categories of mentally ill patients and for how many patients do you think psychologists would be able to act as clinical supervisors? Professor Kinderman: I am going to take the issue of how many as a second point. For what categories our general answer is for all categories. We believe that not only the competences but the clinical actions of psychologists cover the breadth of mental health problems, and certainly all of the so‑called categories of people that fall under the Mental Health Act but also people outside the Mental Health Act as well. We consider our competencies to be very broad. It is the case in practice that clinical psychologists and other psychologists work with a very large number of people who fall in this category so it is not right to suggest that psychologists only work with a certain select, small number of patients. There is a second point which is that although it may very well be the case that very many people receiving treatment under the auspices of the Mental Health Act require the services of a medical practitioner as part of their team, that is not the role of the clinical supervisor. The role of the clinical supervisor is to do those assessments that are specified by the Bill and draw up as part of the multi‑disciplinary team the care plan. We believe, in essence, that is what psychologists do for a vast array of patients and we think it is right and proper that that should be reflected in the competences of the Bill. In terms of numbers it is true that the role of the clinical supervisor would be a new one for psychologists. It would be a challenging one for psychologists. In our written evidence we suggested that the competences are indeed met by psychologists but we suggested for various obvious reasons that the standards should be set high and therefore at least in the first instance relatively small numbers of psychologists should become clinical supervisors. We have received figures from the Department of Health that they were running on workforce planning estimates of around five per cent of the instances of clinical supervisor being a psychologist, and we do not think that is unreasonable. Q999 Chairman: Given that clinical psychologists do not have the power to prescribe drugs --- which I think is right, is it not? Professor Kinderman: Yes. Q1000 Chairman: --- Do you see that as any kind of disadvantage in carrying out the role of clinical supervisor? Professor Kinderman: No, I would see that as a disadvantage in the role of carrying out the prescription of drugs but that is not the role of the clinical supervisor. What I in fact do when I am the de facto co‑ordinator of care for the patients for whom I am co‑ordinator of care ‑ and those are of course by definition people not detained under the Mental Health Act ‑ then I make my clinical decisions about what I think is necessary and appropriate and I liaise with psychiatrists in terms of the prescription of medication. Psychiatrists and psychologists work very well together in the different parts of the care plan that the two professions are responsible for. I do presume to call on psychiatrists when I believe it is right for them to make the assessment as to whether prescription and medication is appropriate; I think it is right for us to work together on that instance. If I were working as a clinical supervisor then I suspect for a very large number, if not all, of the patients for whom I was responsible, I would not only request but desire and demand the input of a psychiatrist and that would involve the assessment as to whether prescription is necessary, but that is not the role of a clinical supervisor. The role of the clinical supervisor is not to make prescriptions but to plan care and to assess whether the patient meets the criteria, and I think I have those competencies. Q1001 Chairman: From what you have said it sounds as though, in non compulsory cases, clinical psychologists are in many cases carrying out that role in any event. Is that right? Q1002 Professor Kinderman: Yes. For instance, a colleague of mine works at a place called Five Boroughs Trust where he has evolved a system whereby he does, in fact, draw up care plans for patients who are detained under the Mental Health Act. These are effectively signed off by his psychiatrist colleagues. They become legally responsible for what is done but have very limited input into it. The relationship, I stress, works very well. The professionals involved are aware of their responsibilities but the care planning is done by the psychologist, and the law is out of kilter with our competencies. Q1003 Lord Carter: Like many other witnesses that we have had, you have suggested that the principles of the Bill should be listed on the face of the Bill. Further, you said that beyond having regard to the principles there should be a requirement for all parties acting under the aegis of the legislation to adhere to these principles. If you are calling for a mandatory requirement to enforce principles, would that not mean a whole new sphere of expensive law? Professor Kinderman: The Mental Health Act is important; it deals with something around 47,000 cases of people having treatment against their consent per year, and there are many issues of principle behind what we are doing. It is also the case that what you can see with the Mental Health Bill is a question of balance between the rights of the individual to choose their own autonomous future and their right to receive good treatment and their rights versus the rights of wider society, so there are issues of principle inherent in the Bill. What we are discussing when we are discussing the wording of the text of the Bill is about how those principles are rolled out in practice so for that reason we think that adherence to the principles is important, and there are principles about the care of people with mental health problems that are not necessarily reflected in the conditions, for instance, the principle that whatever you do should be in the best interests of the patient, and there is a danger that the practicalities of the arrangements of the Bill might in some instances allow the principles to be lost. Chairman: I think we will have to finish at this point. I am very sorry. |