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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 95 xvii HOUSE OF LORDS House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE JOINT COMMITTEE ON THE DRAFT MENTAL HEALTH BILL
Wednesday 2 February 2005 MR MIKE FIRN, MR MICHAEL HICKS and MS JUDITH FAIRWEATHER DR PETER PARTLETT and PROFESSOR GRAHAM THORNICROFT DR MICHAEL WILKS, DR JS BAMRAH, DR ROBIN ARNOLD, PROFESSOR ANDRE TYLEE and DR ALAN COHEN Evidence heard in Public Questions 1085 - 1166
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Joint Committee on the Draft Mental Health Bill on Wednesday 2 February 2005 Members present:
Memorandum submitted by National Forum for Assertive Outreach
Examination of Witnesses
Witnesses: Mr Mike Firn, Chairperson, Mr Michael Hicks, Northern and Yorkshire, and Ms Judith Fairweather, London, National Forum for Assertive Outreach, examined. Q1085 Chairman: Welcome to what is, in fact, the last evidence session of the Committee's hearings. Before you introduce yourselves, may I remind you formally that this is a public session of the Committee, that what you say will be recorded and transcribed, that there will be a transcript available on the internet in about one week which you are free to make suggestions for changes of but only in terms of making sense of the text, not in relation to the substance. Could I ask you if you would very briefly introduce yourselves and then we will go straight into questions, if we may. We are grateful to you for attending. Mr Firn: My name is Mike Firn. I am the Chair of the National Forum for Assertive Outreach and I manage three assertive outreach teams in South-West London for an NHS Trust. Ms Fairweather: My name is Judith Fairweather; I am the London Regional Lead for the National Forum for Assertive Outreach. I am also the team manager in South‑West London, St George's, for an assertive outreach team. Mr Hicks: I am Michael Hicks. I am the Northern and Yorkshire representative for the National Forum for Assertive Outreach, and I also work for Selby and York Primary Care Trust in assertive outreach as a community nurse. Chairman: Can I ask all witnesses to speak up, please, because the acoustics are not always terribly effective. Lady Pitkeathley. Q1086 Baroness Pitkeathley: Can I begin by asking to you describe very briefly what is assertive outreach and how does it differ from more traditional arrangements in managing the treatment of mental illness? Mr Firn: Assertive outreach is a targeted approach to people with severe and enduring mental illness. Essentially the difference from standard community mental health follow‑up is that it is a multi‑disciplinary team whereby each worker would only have a small number of patients (12 to 15 patients) and they will be required to provide very comprehensive health and social care for that small group of patients. There is a criteria for referral, so it is a tertiary referral, to the specialist assertive outreach team based on typically people with psychotic illness of long standing, revolving door patients with very complex needs, often with chaotic lifestyles, co‑morbid problems around substance abuse or physical illness essentially. Baroness Pitkeathley: In your submission you have set out the advantages and disadvantages of section 25a of the 1983 Act providing aftercare and supervision. What changes need to be made to the existing system to turn them into an effective community treatment system? Q1087 Chairman: Could everyone speak up, please, including Committee members for the benefit of the older males, including me, on this Committee! Mr Firn: Certainly. Our essential concern about section 25a is that there is an ambiguity around section 25a in that it provides for supervision follow‑up of people who are discharged from hospital who meet certain criteria, and the supervision is intended to be for the purposes of delivering health and social care treatments, although it does not allow for the enforcement in itself of those, particularly health treatments, and often a major part of treatment is maintenance anti‑psychotic medication. We feel that the lack of clarity is unhelpful. Only being able to supervise people means that you are often still in a position whereby you are observing somebody following a predictable pattern of deterioration, which has implications for their health and well‑being, and the safety sometimes of other people, but ultimately, in order to provide treatment, you are forced to fall back on older powers, such as section 3 of the Mental Health Act, and that causes a delay which can cause concerns for health and safety. Q1088 Baroness Pitkeathley: I believe it is the case that many clinicians hardly ever use the powers under section 25a, and I gather from your first answer that there were particular types of patient for whom this approach was more suitable. Is that right? Mr Hicks: I supervise patients under section 25 in the community. My experience of it is that it works well for people who agree to it and it does not work very well at all for people who do not agree with it, so we end up with the conflict and the ambiguity that my colleague referred to in his answer previously. Q1089 Baroness Pitkeathley: Is it also right to assume that this takes a long time, this treatment: months rather than weeks? Mr Hicks: Could you say that again? Q1090 Baroness Pitkeathley: Is it right to assume that this treatment is of a long‑standing nature: months rather than weeks? Mr Hicks: By nature of the client group that we work with, they are all long‑standing needs, they have established serious mental illness over years and will have it long‑standing into the future. Yes, it is a long‑standing treatment. Q1091 Ms Munn: You have just said it works well where people agree to it and it does not work well if they do not agree to it. This kind of gets to the heart of the matter. If they are agreeing to something, thinking ahead to a possible Community Treatment Order, why would you need an order? Mr Hicks: Sometimes it helps people frame their own care and agree to a plan. After a period of stability in care in in‑patient circumstances people can see that there is a need for an agreed care plan. That is where the agreement comes into it, where people can disagree. They can use it to suspend treatment just for ease of getting out of hospital. That is my experience. Mr Firn: The issue, if I may try and clarify, is that some people have a natural respect for authority and therefore a supervised discharge order has almost a psychological impact because it forces both you, the service user and the other people involved to frame very clearly what you consider the concerns and the risks are. When we use the term "persuading the persuadable", the sort of social consensus of doctor or professional may know best that they will ago along with that. There are many people that we come across who have very difficult problems, very serious problems, and they do not appreciate that either they have a mental illness or that they have a long‑term need for maintenance treatment and health and social care follow-up, and it is for that smaller group that the ambiguity of section 25 is exposed. Q1092 Ms Munn: I suppose that begs two questions: one is so what do you do about people who could benefit from that kind of approach who are not agreeing, and other one is more fundamental. We have had quite a lot of discussion about issues of principle. If one of the principles was, which certainly in the Mental Capacity Bill talks about, the least restrictive alternative, those kinds of issues, if that was a principle you were going with, that would cut across the agreement to be on a compulsory order, if you see what I mean? Mr Firn: We certainly agree with the principle of treatment in the least restrictive environment. I think for members of the panel who are not‑‑‑ Q1093 Ms Munn: It is not just environment, is it, because "community" is talking about at home? I am talking about just the difference between if somebody is agreeing, if the principle was in terms of the Bill that you do not force somebody or have compulsion where somebody is agreeing, how could you have a Community Treatment Order if they were agreeing, if you see what I mean? Mr Firn: Yes. Q1094 Ms Munn: I respect what you have said about psychological benefit of it, I am just saying that if that were a principle that was either in the Bill or in the Code of Practice, you are getting into a really difficult situation? Mr Firn: I think there would need to be safeguards. The safeguards would need to be that somebody has a history of repeated compulsory admissions recently, that they have a severe and enduring mental illness, that they have an impairment of their ability to appreciate the need for maintenance medication. I am not quite sure if I understand the‑‑‑ Q1095 Ms Munn: I am just saying there is a dilemma which you are describing, and I absolutely understand what you are saying. If somebody says "It would be helpful to me to have a clear plan and to know that I have got to follow this and, therefore, I am happy to be", as it is on under the powers of section 25 at the moment, or transposing it to a new situation of a Community Treatment Order, whereas I am saying we might actually want to see in the Bill something which says use the least restrictive, or the least invasive, or whatever the word is, and that would cut across that; because if somebody is agreeing to it by definition you would not need an order? Mr Hicks: I do not think we disagree with that. Ms Fairweather: I think I understand a bit about what you are saying. Why do you need it if somebody is agreeing to the treatment? Q1096 Ms Munn: Yes. Ms Fairweather: Initially some people will not agree to it and section 25 is put in place to engage with that person in another way. You probably will not need a section 25, but then they agree to the engagement but they will not necessarily agree to the treatment. Q1097 Lord Mayhew of Twysden: Going back to the "persuading the persuadable" line, we are talking about treatment-avoidant patients, are we not? Mr Firn: Yes. Q1098 Lord Mayhew of Twysden: I understand the point I think you are making, but I want to ask whether you would think it the case that there are some treatment-avoidant patients who are more likely to be treatment avoidant and dig their heels in if they are under detention than if they are out in the community under a provision which enables them to be recalled if they do not take their treatment, their medication. Do you see what I mean? I have not put that very clearly, I am afraid. Are you more likely, do you suppose, to be in the persuadable class if you are living at home though you know you can be compelled to go back into hospital if you do not take your medicine? Mr Firn: I think essentially we need to recognise that the majority, even of acute care, can take place in the home environment, and we are moving away from care which is centered around a hospital setting. If we are trying to think ahead to legislation which potentially could last for a generation, I think this is an opportunity to clear up the ambiguity of section 25a and to put in place lasting legislation that will be effective for the treatment of the unpersuadable. As assertive outreach practitioners, we go to great lengths through having very intensive well‑resourced teams with small case‑loads, visiting people every day, if necessary, and offering them medication for maintenance every day, if necessary, taking care to minimise the side‑effects, which are a real issue for patients on anti‑psychotic medication, providing for social care, taking people out recreationally, helping people with money, benefits, in order to foster a positive relationship. There are a very small number of patients for whom you exhaust all possibilities over several years and section 25a does not provide an effective solution, and ultimately only a Community Treatment Order or, what I suspect will be less desirable, admitting people into hospital often in rather unpleasant circumstances--- There are occasions when 20 policeman turn up outside people's houses and a social worker and a doctor because these are people that the police have looked up on the computer and they say, "Goodness me, look at all this previous", and they turn up en mass; and it is very distressing for relatives and not least for the patients themselves. I think it is trying to be creative as well as pragmatic to say we do need for a small group of patients to have a community treatment option which is enforceable, and currently section 25a is barely enforceable. That is our central concern. Q1099 Dr Naysmith: We have had a lot of evidence in this Committee critical of Community Treatment Orders ‑ and you have probably heard that ‑ from service users and many mental health organisations and from some professionals as well. They strongly oppose the use of compulsion in the community in almost any circumstances; some of them say "any circumstances". One of the arguments that has been put to us is that Community Treatment Orders will undermine assertive outreach, and, of course, that is related to what we have just been talking about, but if someone was to say to you this will be bad for the kind of professional service that you now offer, what would you reply to that? Mr Hicks: Following on from what Mike has just said, in my practice I would be thinking about a very small minority of my client group for which all the process that Mike has just outlined has taken place over a number of years, which would prove me that assertive outreach as an approach has not helped that person, has not worked for that person, that it has in fact failed that person. I would not feel that my assertive outreach practice is undermined by resorting to what I would call a very last resort having gone through two/three years knowing a client very, very well and having demonstrated that this intense assertive outreach approach has not worked for that person. I can see why people might say that, because of the nature of trying to foster the relationship and a very close working relationship with the client, but if you are demonstrating to yourself and the client that it has not worked, I can see the argument going the other way as well. I take the point, but I would disagree because it is such a minimal amount of my work that I envisage this being used more into the future. Q1100 Chairman: Do you think that if you were pressed you would be able to write a protocol or a list of criteria which would sufficiently limit the group of patients who would be the subject of Community Treatment Orders so as to clearly avoid the risk, as some have put it, of these orders becoming ASBOs for the mentally ill? Mr Hicks: Yes. We have spoken about this as being absolutely critical to this legislation that there is almost a mandatory flow‑chart that somebody must go through from A to B to C to D before you then start looking at them. Q1101 Chairman: But you think it can be achieved? Mr Hicks: I think so. I think there are fairly easily recognisable criteria that you would have to look at over time, over circumstances, over involvement, over different types of care, trials of different types of care, and so on and so forth. Yes, I think that is achievable. Q1102 Dr Naysmith: How would you define that sort of patient, and would there be wide agreement amongst professionals, or would it start another big argument about who should and who should not? Mr Firn: You would need to be very clear that you had an effective treatment for that person. I have mentioned that maintenance medication is a large part of some packages of care for people with very serious psychotic illness? Q1103 Chairman: You mean depo injections? Mr Firn: Not necessarily depo injections, and, in fact, it is possible that--- Depo injections are used often where there are concerns about compliance with medication and depo injections are currently older medications which have more side‑effects. Assertive outreach attempts to give people newer medication, often in oral form, sometimes by daily supervision, and that is effective maintenance medication. We are very keen as an organisation that CTOs would not be used as a short‑cut to this very long‑term process. The other thing that I would like the panel to appreciate is that these patients who would be subject to a CTO would be a small number and would be very well‑known patients with very well‑known histories and the deterioration can be predicted from an earlier point to which currently we are able to intervene. Q1104 Dr Naysmith: We have also heard evidence to argue that people will be admitted to hospital for a relatively short period of assessment, and then, if they fit certain criteria ‑ the sort of thing that you have been talking about ‑ most of them will be allowed back into the community under either voluntary or compulsory treatment orders. What proportion do you think of the ones who would be admitted like that would be able to return early back home or back to the community under this legislation? Mr Firn: I think we already have within the NHS plan and the modernisation of mental health teams which do allow for people to be discharged at an earlier stage from hospital. The problem is there is a very small group of people who immediately upon leaving hospital will say, "I am not taking my medication", and that has happened several times already. Q1105 Dr Naysmith: Can you assess that while they are in hospital, or is it impossible to do it? Mr Firn: My view is that assertive outreach teams know their patients very well and you already know that and you do not need a period of assessment in hospital to determine that. Q1106 Dr Naysmith: For patients you know well? Mr Firn: The patients are very well known, and to some extent, which is why we have mentioned tentatively in the submission the idea of a diversionary CTO or a preventative CTO which does have some international precedents, because the assessment period in hospital would not necessarily tell you anything that you did not already know by long association with this patient, their family and their community. Q1107 Baroness Eccles of Moulton: You have quite largely answered my two questions by your emphasis on the need for CTOs to be restricted to extremely few patients which obviously produces quite difficult legislative problems, but the questions I was going to ask you and I will continue to do so. Firstly, you have painted a very comprehensive picture of the sort of support that assertive outreach teams provide, also covering some of the social aspects of the clients' existence. This morning we heard from the carers, and obviously there are many sides to the environment in which anybody undergoing a CTO would exist; and so really it is a question of the extent to which that sort of very, very high quality environment is practical in most cases. The other point that you made was the horror of a large number of policemen, having looked up the record on the screen, appearing on somebody's doorstep. As I understand it, if a CTO has to be enforced because there is continuing resistance to treatment - the persuadable aspect of it is not present - then, as a last resort, exactly the same procedure might have to be followed, that the police might have to be party to the individual being removed to hospital for forcible treatment? Mr Firn: That is quite likely, but it would give them provision to recall somebody prior to them meeting the necessary in‑patient criteria - what sort of immediate risk they present to self and/or to others - because it would usually be based on default of the conditions of the Community Treatment Order, one of which would often be compliance with maintenance medication. If you have seen somebody stop their medication several times and deteriorate and that followed a well trodden path, then you would be able to recall them at that point which, in our experience, recalling people earlier, leads to a less traumatic, a less hostile and less police officers, if any police officers, rather than at the point at which somebody has lost complete touch with reality, their emotions and is acutely paranoid and therefore thinking that people are coming to kill them. Mr Hicks: Can I just add to that please? Mike is talking about a time-frame that is very important to our client group where they can also become very unpopular in their own community and cause a lot of problems for themselves in a community that that have to return to, and that can happen time and time again so doubling the impact of that time that is lost between cessation of treatment, deterioration of mental health and satisfying criteria that we currently have to bring somebody in. Q1108 Baroness Eccles of Moulton: Do you collectively believe it is possible for the quality environment to be available to somebody under a CTO in all respects, both assertive outreach and carer? Mr Firn: I think the aspirations are there in the NHS plan and the targets of the NHS plan have been partially achieved and are being implemented rigorously. One of the things that we did consider, in terms of effective treatment in the community and linking in with the reciprocity principle, was that somebody on a CTO, it could be written into the legislation that they have a minimum level of input, which might be weekly contact with their supervisor or with their treatment team or a nominated person or fortnightly as an absolute minimum, and I think that would go some way to ensure that people are not put on a CTO and do not receive good quality care. Baroness McIntosh of Hudnall: I just wanted to pick up on something that you have already, in a way, notified to us, which is that you do think that the patients to whom CTOs would be appropriately applied are limited in number and that there are narrow circumstances that would have to be present in order for that to be appropriate. Can I just ask you to give us a bit more of an idea about what the parameters should be. For instance - here are some options - do you think there should be a maximum time limit on the period that somebody can spend under compulsion in the community? Should anybody be able to veto the application of the Community Treatment Order? Should there be limits on the conditions that can be applied to somebody under a Community Treatment Order? For instance, is it appropriate that they should be subject to curfew, that there should be some other restriction on their liberty or that they should be asked to abstain from using alcohol or drugs? I will not go on with a long list. Q1109 Chairman: Could I add one, Lady McIntosh? Do you envision a CTO requiring specific inputs from carers? Do they have role in such care? That picks up a concern that was expressed this morning. Mr Firn: We discussed this as a group, and it is very clear that CTOs should not be used to determine peoples' lifestyle, that people are able to choose a lifestyle however unorthodox. It should be limited to people with very serious, predominantly psychotic, illness if not exclusive psychotic illness, which would be schizophrenia and bi‑polar illness with psychotic features, where there is, for some people with more serious illnesses, a failure to appreciate the need for treatment and care. I think there is a sketch of one criteria which appeared in the Royal College of Psychiatrists' submission and our submission of a recent history of at least three compulsory admissions and obviously people who present very serious concerns particularly around risk to self and risk to others. In terms of alcohol and lifestyle, absolutely not even on the horizon, not even part of the equation, and not an ASBO. We had a discussion about ASBOS. None of our 250 patients in South‑West London are on an ASBO, although Michael has experience of one patient in York who is on an ASBO, but that is a different process. It is not initiated or managed by the Mental Health Team. Mr Hicks: Neither was it to do with his mental health problems. It is to do with social problems of persistent begging, which is unrelated his mental health illness. Mr Firn: In terms of time limits, we feel there is a need for a tribunal, obviously, whether automatic or not, but it may be prudent to consider an automatic tribunal. A time limit: these are not treatments and sort of health packages that have immediate results, and six months would be an adequate review period, and there would presumably be the ability to renew it either at the instruction of a tribunal or otherwise, but I certainly want to distance ourselves from any notion, first of all, of conditions around curfew, conditions around drugs and alcohol. Mr Hicks: And also distance ourselves from any notion that people would be forcibly treated in their own living‑room. Chairman: I can see Lady Cumberlege is itching to intervene in your answer, so I am going to let her. Q1110 Baroness Cumberlege: It was really to expand a bit on that, because these are very sick, disruptive people who can wreck families, and I want to repeat your question really, my Lord Chairman, in terms of should unpaid carers have a right of veto? Mr Firn: I think, as with all Mental Health Act legislation, the carers are consulted where there are carers. We have to say in our experience of assertive outreach teams, we are often dealing with isolated marginalised people who do not have carers. Where carers are involved, as with a section 3 application or other Mental Health Act applications, the next of kin or the nominated person in the new Act would have right of veto, and, if that right of veto is felt to be invalid, then, as currently, you have the option of going before a court to have that person removed as the nominated person. I think that would be a valuable safeguard to include. Q1111 Chairman: Can I ask you a question that goes back just a tad on what was said earlier? Supposing that a choice is a stark one between being an in‑patient in, in some parts of the country, really not very acceptable hospital facilities and being the subject of a Community Treatment Order in which there is a condition, because it is a problem, that the patient, for example, will not visit the pub and will not beg, what is wrong with that if the effect of it is going to be that that patient is going to be out of hospital, possibly able to go to work and living a much more generally functional life? Mr Firn: I have an instinctive problem with it, but I am trying to put it into coherent words. It feels wrong morally. Baroness Cumberlege: Can I reframe it slightly, because I think it is the same question. You did say that issues of use of drugs and alcohol and other what you describe as lifestyle issues should not be included. There are circumstances where somebody who is suffering from a mental illness and is also using drugs and alcohol may presumably ‑ I ask the question, I do not assert this ‑ be exacerbating their problem and/or undermining the effect of their medication by continuing to use alcohol or drugs. I make no moral choice about whether people should or should not do that. That is not the issue. The issue is whether the impact of the treatment order can be effective if other issues are left untouched. So I ask you again, can you imagine circumstances in which it might be necessary, as it were to prevent people from going to the pub, in the interests of delivering the community treatment? Chairman: Before you answer, did you want to come in on the same point, Dr Stoate? Q1112 Dr Stoate: Yes. As a practising GP I can think of classic examples. You may see something as morally repugnant to put somebody on a Community Treatment Order, and yet I have had patients in the past with bi‑polar affective disorder who have been perfectly well at home, they then, for all sorts of reasons, decide that their medication is no longer necessary, and we all know what the consequences are ‑ they gradually get more and more irrational, I suppose, for want of a better word, their families get extreme levels of distress, their children get extreme levels of distress, the husbands, if it is a woman, are beside themselves with "What can I do about this?" As a GP my hands are tied, because I cannot ask for a section on this patient until they get to the point where they are a danger to themselves or to others, which can be very far down the line; whereas I know, as a GP, that if that person were forced to take their medication, they would be back to normal again before having to have the distress of a disrupted family, a compulsory admission, a month in hospital. Mr Firn: We are agreeing with you on that. Chairman: Before you answer, because I know it is the same point, Mr Loughton Tim Loughton: It is very relevant. Yesterday I happened to be visiting a mental health establishment for veterans in Shropshire, not held subject to section in that particular case, although people who may have been sectioned previously, and they operate a policy specifically on going to the pub, interestingly, and they grade their patients in three different levels: (1) are allowed to out the pub, (2) may go out to the pub under some sort of supervision, and (3) absolutely nowhere near the pub; and if any of them break it they are not allowed to stay there any more. There is a practical application on a lower level of detention because they know that if they do go to the pub and go completely rampant the tribunal will completely wreck their whole treatment procedures. They operate it very successfully. What is the problem with that? Q1113 Chairman: I feel the Bournewood pint coming on! Would you like to answer the general picture posed by those questions and then we have one other question? We really must finish then. Mr Firn: I certainly agree with the scenario about the manic depressive patient who is following a predictable relapse and the need for some early intervention and, under certain circumstances, possibly could be under a Community Treatment Order. I also agree that the use of drugs and alcohol does undermine the effects of medication, and there is good evidence for that. However, I think, broadly speaking within the profession, the limiting of people's freedom of movement, access to lifestyle choices is a step too far. Q1114 Chairman: That is on instinctive grounds. Mr Firn: That would be social control. Q1115 Chairman: But on instinctive grounds? Mr Firn: That is on instinctive grounds. Chairman: Lady Murphy, you have been very quiet, so get a quick one in. Baroness Murphy: I wonder if what Mr Firn means to say perhaps is that the treatment order is to enable the treating team to get hold of the symptomatology of psychosis, and you are then working with the person who has suffered these symptoms to enable him or her to be as crazy as rest of us in going to the pub, in going out when they feel like it in the evening and choosing where they want to live, but that you hope that by reducing the symptoms and enabling the person's personality to emerge you will be able to enable them to do that and not to confuse it then. Q1116 Chairman: You are about to quit you are winning with a "Yes", are you not, Mr Hicks? Mr Hicks: I was just going to say, that goes back to the flow‑chart, and if that can be seen in the treatment plan as being beneficial to other lifestyles by treating the symptoms in the first place, that fits into the A, B, C flow‑chart in my head. Mr Firn: It is about providing a structure for the delivery of therapeutic interventions, which may in turn have an impact on behaviour, but if the behaviour is to some extent independent of the mental illness, such as often is the case with the use of drugs or alcohol or other persuasions, then generally we would be uncomfortable with stepping outside of a remit of therapeutic activity. Chairman: Thank you. That has been a very interesting aspect of the questioning. Can we have, finally, one brief moment about resources, please, Lady Barker? Q1117 Baroness Barker: Yes, resources and structure. Earlier on the Committee heard about the experience of Community Treatment Orders in Australia. In the Australian system people are required to attend a clinic and to receive their medication there. All I wanted to ask you was ‑ and you used the word "reciprocity" earlier on - whether reciprocity is a crucial element of Community Treatment Orders, i.e. people have to have access to the services that they are being compelled to use? Secondly, I want to ask you about the effect of work load. We have heard from assertive outreach teams working in your area that they can achieve much of what a compulsory treatment order seeks to do, but one of their biggest limitations is having the personnel to do that. Could you comment about that? Mr Firn: I think assertive outreach teams have usually a maximum of 12 patients to each full‑time worker, so the argument about resources would wash not very favourably with some of our community mental health team colleagues and other people working in the field with much larger case loads of people. I think the resources argument is, to a certain extent, how long is a piece of string, but certainly assertive outreach teams, whole treatment teams are another part of the NHS plan which provide for acute care outside of a hospital setting. I think we need to be clear from an assertive outreach point of view that we would be using Community Treatment Orders to visit people in their own homes by and large, rather than asking them to come to an out‑patient clinic setting or to a hospital setting; and that is the way that you actually deliver more effective health and social treatment, because if you do not see the inside of somebody's home often you miss part of the equation about what their difficulties are about surviving in the community, whether their benefits are coming through or whether they have food in the cupboard and those sorts of things, which are the basic sort of survival skills which some people struggle to maintain. Q1118 Baroness Barker: May I ask you one follow up question, which is this. In different parts of the country we have heard that there are staff shortages in particular disciplines. We have also heard about the shortage of psychiatrists. Do you think there is a problem in implementing this system, for example, in rural areas? Mr Firn: I think we are talking about a very small number of patients. From our trust, which serves a population of a million people, there are 35 patients currently on supervised discharge orders. Twelve of those people are from our assertive outreach teams of which we have got three. So that is four patients in an assertive outreach team, which would average about 90 patients. I know from Michael Hicks' figures that for his team, there would be one patient probably in his team who currently would be suitable for a Community Treatment Order. I think the resource concerns are of that order for the treating teams, and obviously, depending on the tribunal arrangements, there will be resource implications for the wider services around ensuring that due process and safeguards were in place. Q1119 Chairman: We are going to have to stop there, but can I thank you for coming to visit us in our own home, and I hope you have some understanding of the problems we face in this environment. You have been most helpful with your evidence. We are very grateful. Thank you.
Memoranda submitted by Dr Peter Bartlett and Professor Graham Thornicroft
Examination of Witnesses
Witnesses: Dr Peter Bartlett, Senior Lecturer in Law at the University of Nottingham, and Professor Graham Thornicroft, Professor of Community Psychiatry at the Institute of Psychiatry, King's College London, and Director of Research and Development at the South London and Maudsley NHS Trust, examined. Q1120 Chairman: Welcome to you both. We have been looking forward to hearing from you for some time. I noticed you were sitting at the back, so you will have heard a little bit of an introduction into the international dimension from our previous witnesses. Would you just introduce yourselves briefly and then I think Lord Carter will start the questions. Dr Bartlett: My name is Peter Bartlett. I am currently a Senior Lecturer in Law at the University of Nottingham and from 1 September I will be the Nottinghamshire NHS Trust Professor in Mental Health Law at the University of Nottingham. Professor Thornicroft: My name is Graham Thornicroft. I am a Professor of Community Psychiatry at the Institute of Psychiatry at King's College London, and I am also Director of Research and Development at the South London Maudsley NHS Trust and a consultant psychiatrist working in south London. Chairman: Thank you very much. May I formally remind you that this is a public session. It is being recorded and there will be a transcript which you will have the opportunity to amend for textual reasons only. You are both very welcome. Q1121 Lord Carter: Professor Thornicroft, in your extremely helpful memorandum you take the view that it is a "very serious omission that the fundamental principles are not explicitly stated and are not on the face of the draft Bill". I think we would all agree that practitioners will be using the codes of practice, not the Mental Health Act itself. Why, therefore, should it matter whether the principles are in the Act or not as long as they are actually in the codes of practice? Professor Thornicroft: In my opinion, the mental health policy and in this case mental health law should be based squarely upon the available evidence, that is, the evidence base and the relevant ethical base. It seems to me that the ethical base should be transparent and clearly spelt out in the body of the main Act itself. I would like to tell you briefly why I think that. It is clear that the law will affect practitioners and those subject to the provisions for generations, so it is very important we get this right. We hope it will set the framework for a consensually based set of regulations and we are likely to establish a widespread consensus if the ethical base is quite clear throughout the main body of the main text. I think setting out a clear statement of principles is more likely to assist those in the future who will need to interpret the legal aspects of the provisions where they may not be completely clear in their practical implementation. I think it is helpful to see the extent to which the contents of the law are consistent with other policies within this country, for example, the National Health Service Framework and the arrangements of a social exclusion unit, as I have set out in table 1 of my evidence. It is also important to see the extent to which the content of the law is consistent with other international regulations and policies which I have also set out in my memorandum and summarized within Table 1. In particular, I think it is important to see the extent to which we comply with other various international treaties and obligations. I think it is important for the field of practitioners to have a clear statement of principles so that we are going to emphasise the extent to which all practice in mental health, both the legal and the non‑legal aspects, should avoid abuses of human rights, and I think the more clearly that is spelt out in every aspect of our policy and law, the better that is for the field. I think it sets a framework for independent inspection standards to be set in due course which will be consistent with the meaning as well as the body, so the spirit and the detail of the Act. You can see within Table 1 that I have included within my evidence that of the 12 principles that seemed to come out of my own overview of the international policies which are most pertinent as well as the national policies, it seems to me that the current provisions within the Bill satisfy three of them, that four of these key principles are not clearly addressed and that five of the key principles seem to conflict with the content of the Bill. Chairman: We found the table very helpful indeed. Q1122 Lord Carter: If there were to be principles on the face of the Bill, should one of the general principles be a duty to protect the public from harm by people who are mentally ill, and on whom should this duty fall? Professor Thornicroft: You can see from one of the principles I set out in the table that there is the issue of safety. It is clear that there is a complex balance to be struck by mental health practitioners between direct care and therapeutic benefit to those receiving care, sometimes compulsory care, and the wider duty to society for whom mental health practitioners are acting as a type of legitimised agent and that is a very fine balance to strike. I would agree that safety is an important element. I think to summarize, on the principles question I would refer the Committee to the Millen principles which are set out in the Scottish arrangements. I think they are a very nice statement about principles that are very helpful indeed. Oddly enough, although the principles may seem to be abstract and rather obtuse, in fact they are summaries of an overarching statement of purpose and they are actually very useful tools. The statement of the Millen principles goes on to say why they are important for that Act and not set aside as a subsequent and potentially movable feast as a code of practice. What they say is that the Act will give effect to the principles. Therefore, the details of the Act are based upon those foundation principles. Secondly, they are the basis of executive policy on mental health law and, thirdly, they provide a picture of how mental health law should work. Q1123 Chairman: Professor Bartlett, do you want to add anything to that from your viewpoint as a lawyer? Dr Bartlett: I support broadly what has been said. I think the only thing I would wish to add concerns the Code of Practice. To a Canadian, the notion that we would rely on the Code of Practice for practitioners is simply very odd. Based on a number of codes of practice I have seen, I am actually quite concerned that they do not quite necessarily mirror the actual substance of the main Bill. If I were a practitioner and I followed the Code of Practice and then found myself sued because the Code did not match the Bill, I would feel somewhat aggrieved and I think I would be right to feel somewhat aggrieved. I do not view these as alternatives. I do think that it is appropriate to insist on a Bill that has reasonable clarity and which a reasonable doctor should be able to understand. That is the standard which would be taken as normal in Canada and also the United States. Q1124 Chairman: You will appreciate that it is a feature of regulation to use codes of practice and there is a draft Code being circulated on the Mental Incapacity Bill and on many other Bills now it is common practice. Dr Bartlett: I do appreciate that. I can certainly see an argument where under the Act one has a variety of possible options and a code of practice may be helpful. Let me take as an obvious example the discussion in the Richardson Report about removal to a place of safety, where they were saying we do not much like police stations as places of safety but sometimes we may have to. When we are looking at a variety of options, all of which are legal, it seems to me a code of practice may make some sense. We should not be relying on a code of practice as being what doctors follow. The classical argument is a person with a watch knows what time, but a person with two watches is never sure! Q1125 Baroness Murphy: I would like to turn to the issue of stigma. Many of those who have submitted evidence to this Committee have regretted that stigma still attaches to those with mental illness in this country. I wonder if you could both tell us from your knowledge of international services whether the position in regard to stigma is worse in this country than elsewhere? Can mental health legislation have a role in shaping public attitudes to stigma? Perhaps Dr Bartlett might expand on that from what I know is his great historical knowledge in that area as well. Dr Bartlett: I had not thought of it from an historical perspective so much. I am not convinced that stigma is particularly different here than in North America. I am not sure that I have seen any very good studies of it, but it feels the same. I am also doing some work in Central Europe at the moment and, frankly, I think we enjoy a much lower level of stigma than mental disorder does in much of Central Europe. In terms of the second part of your question, law is part of a much greater range of social arrangements. It would be naive and absurd to pretend that simply by introducing a more progressive or less stigmatizing Mental Health Act we were going to solve the problem of stigma. Certainly in other fields we can see evidence that changing the law does have an effect on public attitudes. Perhaps I might use an example and it is in another field but it is a particularly clear example. I have watched in my lifetime sexual orientation being introduced in non‑discrimination legislation in Canada and we have had to introduce it 11 times before the 11 different jurisdictions. Before it is introduced, people are broadly opposed by about 60:40. After it is introduced, you see those numbers reversing remarkably quickly. There are all sorts of hesitations one could follow through about that, for example, what people say in posters does not necessarily represent how they behave and all sorts of things like that, but I do think law does make a difference. Professor Thornicroft: I am writing a book on stigma at the moment, so I am literally surrounded by the evidence on this. There is very little evidence indeed that compares the degree of stigma between countries in any satisfactory way, so we need to look for indirect measures. One example would be employment rates. If we look at Western European countries, which are reasonable comparators, a recent study found that in Holland, Denmark, Spain and Italy about a quarter of people with schizophrenia were employed either full-time or part-time or in training; the figures in England were six per cent. That shows a significantly lesser degree of social participation and social inclusion, in this case by some people with psychosis, compared with relatively comparative Western European countries. It is clear that the nature of stigma does vary cross‑culturally. For example, in the Indian Subcontinent questions about marriage or blood come into the equation and in the Far East questions of shame and blame are also much more prominent. Broadly speaking, if we think about the trend of stigmatization over the last ten to 15 years in this country, we can see two conflicting patterns. One is that attitudes towards depression and usually less disabling conditions have become slightly more favourable over that time and there have been campaigns, for example, by the Royal College of Psychiatrists and GPs, which have had some limited impact, and we now see increasingly celebrities, including politicians, speak openly about having had mental illnesses themselves. The other conflicting trend is for attitudes toward psychotic conditions to become less favourable over the last three or four years. The Department of Health conducts regular surveys of the population and did it every year from 1993 to 1997 and it has conducted these every three years since 1997. The most recent report, which can be made available to the Committee, was in 2003 and it shows that attitudes towards the mentally ill were stable throughout the 1990s but have become significantly worse in the period between 2000 and 2003, for example, in relation to if the mentally ill are a burden on society, if mentally ill people deserve our sympathy, if they should receive the best possible care, if we should be more tolerant or not, and if they should be the subject of ridicule. There is a real paradox here because among this general population sample 49 per cent said that someone close to them had had a mental illness, but in fact a greater proportion, about 60 per cent, said they thought mental illness occurs only to about ten per cent of the population or less, so there is a very strange distancing and proximity paradox or dilemma that goes on with respect to stigma. In terms of policy, I think it sets an overall framework or an atmosphere, for example, where a law might connect the ideas of mental illness with the idea of dangerousness and I think such a law may act negatively to reinforce and to make worse stereotypical representations of mental illness. Q1126 Baroness Barker: Dr Bartlett, your paper highlighted for us different approaches taken in Canada. Saskatchewan has introduced capacity into the confinement criteria and in Ontario compulsory admission to psychiatric facilities is based on a dangerousness criterion. How does Saskatchewan deal with a person who has the capacity to make a decision, is seriously mentally ill, is a clear danger to him or herself but adamantly refuses treatment? Dr Bartlett: I have to be honest, I am an Ontario lawyer, but I have not practised in Saskatchewan, so I have to be slightly careful about answering that question. Certainly my understanding under the Act would be that you wait until the person does something which allows some other form of intervention. There are interesting questions about what "capacity" means, but if we believe what they tell us in the statute, if the person has capacity and refuses treatment, then that is it, they do not go in, you find some other way. Q1127 Baroness Barker: What about if the person does not have capacity? Dr Bartlett: If the person does not have capacity then you are over that hurdle. Assuming the other criteria in the Act are met, which include things like a risk criterion, then you involuntarily admit them. Q1128 Lord Rix: Are people with a learning disability, intellectual disability or autism without allied mental health problems treated under mental health or other legislation in the provinces of Canada? Does the stigma which we have been talking about through mental health problems apply just as much to people with a learning disability in other parts of the world, certainly in Canada, as it does in this country? Dr Bartlett: Let me address the stigma point first. I take Professor Thornicroft's point that this is not well studied. I have not seen any good studies that I would wish to cite to you. I do not have a feeling that it is particularly different to the situation we face here. In terms of intellectual disabilities, in the event that coercion needed to be applied, then again if the person had capacity you would be looking to the Mental Health Act in Ontario. In the situation where the individual does not have capacity we do have separate legislation involving capacity, so there would be a closer connection to here and it would be relatively unusual that you would see somebody with an intellectual disability being brought under the Mental Health Act in Ontario, but it is not impossible. Q1129 Tim Loughton: Professor Bartlett, in your submission, under the subject of dangerousness, you refer to the Ontario legislation and the rather better "precision" of the language rather than the relatively woolly language of the Bill. One thing that struck me is the inclusion of the word "likely" under the assessment criteria, which is certainly something that is lacking under clause 9 in our Bill. One thing that I have taken up before is, just because you have somebody who, on the face of it, is physically giving the appearance of being dangerous or has the physical capacity to pose a physical threat to somebody does not mean that they are any more likely than somebody who is a ten-stone weakling to inflict damage on another person. Do you think that is a fair assessment? Do you think the inclusion of a likelihood condition into clause 9 would help to solve the wooliness of the language that exists in the Bill as it stands? Dr Bartlett: I think that would be of assistance. I share your concern that physical shape is not a determinant of this. I think that if what we are looking at is cleaning up the wooliness of the language, the first portion of those Ontario criteria, which requires the person to have "done something" - and there is litigation in Ontario about what this clause means which gets into the differences between acts and omissions - that is something fairly concrete, it is a shopping list for the doctor to look at. They are told fairly clearly what that hurdle is in terms of a threat or having done something or the inability to care provision. That does seem to me much clearer than what is in the current Act. Q1130 Tim Loughton: So effectively what we are looking at is a middle way between a hypothetical capability and an actual act having been committed? It is a likelihood of an assessment that somebody is capable and showing a likelihood of committing that particular act which would lead to dangerousness, is it? Dr Bartlett: And you have some sort of concrete reason to back that up. If we are thinking, for example, of harm to others, it has got to be either they have done something or they have threatened to. There is a focusing point there. Q1131 Lord Carter: I am sure you are aware that in this country there is concern at times, often whipped up by the media, of a situation whereby mentally ill patients are released from hospital and kill. There are 13 different regimes in Canada for mental health law, as I understand it. Are there any figures at all which link any differences in the provinces in that aspect? Dr Bartlett: Not that I am aware of. Q1132 Lord Carter: I presume murder is a federal offence, is it? Dr Bartlett: That is correct. I have not seen any attempt to link murders by people with psychiatric disorders to individual provincial psychiatric regimes. You are right, it would not be difficult. I will put it on file for an attention paper. Q1133 Chairman: In your general experience, both of you as experienced and distinguished experts in this field, do you believe that there is any evidence at all that the regime for control of mentally ill people, short of an obviously unacceptable regime, has any effect in terms of enabling clinicians to predict the sort of incident that Lord Carter has referred to? Professor Thornicroft: If we look at the time trend in this country over the last 40 years, we see that the total number of homicides has gone up from about 150 to about 600 per year, of which those committed by people who are probably mentally ill at the time has been more or less constant, about 50 to 60 per year. Over that time period we have seen astonishing change from an institutionally based system to a largely community-based system. It would be hard to imagine a greater transition in the pattern of care than the one that we have been through during the last half decade and yet that has had no palpable effect overall upon the number of homicides committed by mentally ill people. I think that is pretty strong evidence. Unfortunately mental health professionals are remarkably poor at being able to predict specifically who will commit a violent act in the future, and one of the best reviews was conducted by a Professor Buchanon and Dr Leese who gave an overview of the literature with respect to personality disorder. The question was how many people would need to be locked up to prevent one severe act from taking place and the answer was seven, which meant that the provision based upon, for example, dangerous and severe criteria would, therefore, lead to six innocent people who would not have committed that act being locked up for no particular reason. Q1134 Chairman: Can we now move on to an important issue on which we feel you, as witnesses, may be able to help us and that is about community treatment orders. We have a number of questions related to community treatment orders of which you have been given notice, but perhaps I can ask you to give us your general comment about whether community treatment orders, in your opinion, should be part of the new law in this country and, if so, whether you think it is possible to set out criteria which would ensure that community treatment orders were used in an appropriate way. Who is going to go first? Dr Bartlett: Let me answer from a Canadian perspective since I think it is probably a different perspective for you. In both Ontario and Saskatchewan we do have community treatment orders but both of them have capacity requirements built into them. One of the fascinating things about moving here and, therefore, looking at Canada from a certain distance is I am seeing that slightly differently than I did when I was at home. There is perhaps a very different image of community treatment orders that the Committee might wish to consider. In Canada I think it is in practice more about creating an environment where a deal can be struck between the patient and carer and, if the patient lacks capacity, between the patient's family member or what you would call a nominated person and a psychiatric professional. As the individual must still be competent to consent to treatment, and that is something that we care very much about in Canada, arguably what it is about is strong-arming better services out of the health care system to create some kind of an agreed plan that both the doctor and patient are content with. That is quite a different image than what I have seen discussed about CTOs here. Regarding the images I have seen here, I very strongly believe, consistent with the Canadian approach, that it is not justifiable to force medication on someone who has capacity and is refusing the medication. I appreciate the problems that causes for families and for practitioners, I appreciate the practical problems, but in the end that is the foundation of what it is to be a person; it is to make it that kind of extraordinarily personal decision. So I would say that if we are going to do it, it would have to be for people lacking capacity only. I do find myself wondering, if we are looking at it for people who lack capacity, what precisely inclusion under the Mental Health Act would add to what is happening under the Incapacity Bill. Q1135 Chairman: Professor Thornicroft? Professor Thornicroft: I want to start with the evidence. There is not strong evidence that community treatment orders or their equivalent are effective. Most of the published work comes from Canada or Australia and there are few European studies. They tend to show conflicting results and they have different objectives, but they do not show consistently that these are effective with respect to any of the particular desired targets, such as increased medication compliance or reduced hospitalisation. One of the most detailed reports came from the RAND Corporation published in 2001 and reviewed arrangements in nine of the United States where now 38 of the states do have outpatient treatment orders or similar arrangements, and they concluded, "There is no evidence to suggest that simply amending the statutory language is likely to produce the required results." I think we also need to look at the wider context within European regions. For example, four of the previous 15 EU States do have outpatient commitment orders. Britain is virtually alone in having an increasing rate of compulsion within its mental health system over the last ten years and although most countries see stable patterns of the use of coercion in these ways, we have seen increasing rates of section 135, which is the compulsory entry to premises, of three times over the last decade, of section 136, which are the place of safety detention orders, of five times, and use of section 3 by 1.4 times over that period. For some reason England is an exception in terms of the trends of compulsory treatment just within the European region, Western Europe in this case. Perhaps I may move on to the ethical aspects. As I mentioned earlier in that summary table, I think the community treatment orders do cross-cut, in fact they violate many of the principles which are established in international as well as relevant national mental health policy, as set out in the relevant documents. I think this is a very difficult balance of judgment. I think the one practical way to increase patient compliance, meaning agreement with a recommended plan of treatment, is to offer choice. For example, in my own practice in south London we now have home treatment teams, we have crisis houses for women and we have acute inpatient treatments. I can ask a woman who is in a crisis, "Would you prefer to go into hospital, to be treated at home or to go to a crisis house?", and this means that we use compulsion less than we would have done five years ago. We now have new arrangements in the form of a crisis card and there is accumulating evidence that these do reduce compulsory admission rates to hospital. I think there is an offset or a balance here: on the one hand, it seems likely that CTOs, if properly and narrowly applied, would probably apply to less than one per cent of one per cent of the population, approximately the same numbers as were applied for supervision registers and supervised discharge orders; on the other hand, we need to understand the wider framework and that is this. Of all inpatients, there is evidence that one third of the voluntary inpatients believe themselves to be compulsorily detained and two thirds are not sure whether they are compulsorily detained or voluntary. So we have got forms of pressure and coercion that go well beyond the narrow legal restraints of the powers that are set by our Government. Therefore, I think, on the one hand, this may provide a limited benefit to a small number of patients, but, on the other hand, I think we need to listen carefully to what service user groups are saying, which is that this will not just stop current patients from wanting to continue with treatment, but it will then reinforce a connection in the public mind between violence and mental illness. We know that of all people with mental illness in England about one quarter are getting effective treatment and that the proportion is far less in many other countries. I suspect that if we were to frame this too widely then we would see more people self‑stigmatizing and not presenting to services because they do not want to be labelled as a mentally ill person because that is connected with violence and we will see fewer people having treatment and that will serve no one for the best in the long term. Q1136 Baroness Eccles: I have a question of clarification for Dr Bartlett and one of opinion for Professor Thornicroft. Dr Bartlett, you made it quite clear that you thought that nobody should be compelled to take treatment in the community unless they have capacity. Presumably the requirement for enforced treatment as an inpatient does not require capacity? Dr Bartlett: In Ontario the treatment decision is completely separate from the admission decision. If you have capacity then you can make treatment decisions about yourself, whether that is for somatic or psychiatric treatment, whether you are an inpatient or an outpatient, whether you are an informal patient or an involuntary patient. In the end that is what I support. I think it is appropriate to emphasise that the concern that this would lead to a warehousing of patients simply has not materialised. In fact, what seems to have happened ‑ and I hasten to add that this is anecdotal, I do not have formal studies on this ‑ is that it creates a more complex playing field where negotiation can happen with a psychiatrist. The patient probably wants to get out, the patient almost certainly understands that they have got some difficulties because, remember, they do have capacity and some kind of an arrangement gets met. The doctor may not think it is ideal treatment, but the doctor is prepared to go along with it, and the patient may not be exactly delighted, but the patient is prepared to go along with it. I desperately want to be able to say that that leads to better compliance in the long term, and I think it should, but I have to be frank and say that I have not seen a study. Q1137 Baroness Eccles: So it is not something you could really write a law about? Dr Bartlett: We can certainly write a law that says if you are in a psychiatric facility and you have capacity you can make treatment decisions. Ontario has done that. Q1138 Chairman: The Ontario situation sounds like a bit of a semantic paradise or nightmare, according to your viewpoint, if one has to define in every case the meaning of capacity. What is capacity in the case of a formally detained patient there? Dr Bartlett: There is a formal definition of capacity and I would be happy to provide it to the Committee. Q1139 Chairman: Is it uncontroversial? Dr Bartlett: I think it is reasonably uncontroversial. Certainly when the system was introduced in 1986 it was extremely controversial, the doctors did not like it at all. I was rather delighted to see one of the leading doctors from Ontario claiming a year or two ago that it had all been the doctors' idea. It was not, but it is an indication of how far we have come to this becoming simply an accepted part of the world. Q1140 Chairman: Let me just try something very simplistic on you because it is the sort of argument politicians like us understand. Let us say you have a "revolving door" patient who has been in and out of compulsion in psychiatric hospitals in south London or in Nottingham. On this occasion they are offered the opportunity not to spend three months or more in the hospital but to go home, possibly back to their job and live with their family as long as they agree to certain criteria and that is called, as a term of art, a community treatment order. What on earth is wrong with that as an option to be used in that restricted group of "revolving door" patients? It sounds to me awfully like something you are doing by different means, Professor Thornicroft, in south‑west London. Professor Thornicroft: I have worked as a psychiatrist for about 20 years now and I have worked in Camberwell, which is one of the more socially deprived areas, and I now work in Croydon, which is a mixed area. From my work in Camberwell, I can think of one or two people at any one time from a caseload of about 400 for whom such a provision might be helpful and in Croydon at the moment I can think of nought or one person in such a category. That may be of some use, but if they completely refuse to go along with it you are left where you started anyway, that is, having to enforce and take them to hospital, and if they are bluffing effectively you are where you are already now with the supervised discharge order, which is that you have a legal provision which you hope will have some leverage or persuasion over the individual concerned. My concern on the other side is what this does to the whole enterprise of mental health services and the degree of trust invested in the service by patients, but also the extent to which practitioners will feel they can practise in goodwill given those legal circumstances. I have heard recently some practitioners say that they may wish, should the new provisions come in as they are written at present, not to let their section 12 be renewed. That would mean that they wish to carry on practising as psychiatrists but not have the power to detain patients under those circumstances. There is this debate going on. We have a form of understood contract between the psychiatric professions particularly and the wider society and outpatient groups and this would substantially change the centre of gravity of that understood contract. Q1141 Chairman: That kind of argument about whether they are going to accept section 12 contracts or not, it is all very well to threaten us all with it, but at the end of the day if the law is changed, they are going to obey the law, are they not? Professor Thornicroft: They will certainly obey the law, but some psychiatrists may not be comfortable practising under those circumstances. Q1142 Lord Mayhew of Twysden: Professor Thornicroft, I am sure it is my fault, but I lost you in the course of your last contribution when you said, as I understand it, that a CTO would serve to increase stigma in the public eye for mentally suffering people. I think the stigma was the propensity to violence. I am afraid I lost you at that point. I did not quite follow the reasoning. Can you help? Professor Thornicroft: There is little evidence about the extent to which popular opinions of mental illness and the views of people with mental illness about their own conditions are related to the law in any country, so this is a matter of opinion. My view is that a law based upon one central tenet, among others, which is the connection between mental illness and violence, further serves to strengthen that view in the wider population and that will serve to deter people from coming forward when they have symptoms of mental illness for assessment and treatment and also may serve to further exclude mentally ill people from within the mainstream of our society. Q1143 Dr Naysmith: Professor Thornicroft, in your opinion, do we need a new Mental Health Act to replace the 1983 Act? Professor Thornicroft: In my personal opinion, the current Act works reasonably well on most counts and the provisions before us would set us back a generation. Q1144 Lord Rix: There have been quite strong representations from your Royal College that we should adapt the 1983 Act, that we should put in the necessary amendments to cover the Bournewood Gap and things of that nature. Would you consider that to be a desirable outcome? Professor Thornicroft: Yes. Dr Bartlett: May I respond to that? Q1145 Lord Rix: Yes, of course. Dr Bartlett: The first thing to say is that I do think that the 1983 Act is well out of date. It is appropriate to remind you, for example, that under the 1983 Act there is nothing legally wrong with treating a patient who is involuntary for the first three months without even telling them why you are treating them. No one would defend that now, it really is out of date. Here, if I may, I will give the historical answer that Lady Murphy was asking for. One of the things which has also happened is that, as a matter of history, with the 1983 Act you can still see the roots of the 1808 County Asylums Act. Chunks of it have never been properly redrafted. As a lawyer, when you stick bits of it together they simply make no sense. I do think it is time for a new Act. I do think it is time for a properly drafted Act. Q1146 Dr Naysmith: But it is not this one - is that what you are saying? Dr Bartlett: But it is not this one. Chairman: On those two extremely challenging opinions I think we will have to draw this session to a close. Can I thank you both for coming and certainly stimulating our thoughts and the discussion. Thank you very much.
Memoranda submitted by the British Medical Association and the Royal College of General Practitioners
Examination of Witnesses
Witnesses: Dr Michael Wilks, Chair, BMA Ethics Committee, Dr JS Bamrah, Chair, BMA Psychiatric Sub-Committee, and Dr Robin Arnold, BMA Psychiatric Sub-Committee, British Medical Association; Professor Andre Tylee and Dr Alan Cohen, Royal College of General Practitioners, examined. Q1147 Chairman: May I welcome you from the BMA and the RCGP, particularly those of you who found yourselves in the middle of a fire alarm last week. Thank you for coming back. I am sorry we have got a fairly short slot. If there is anything we do not deal with that you would like to say that you have not already put in writing then please would you do so immediately after the meeting because this is our very last evidence session and we were conscious of what happened last week. First of all, can I formally tell you that this is a public session, the evidence is being recorded, there will be a transcript produced and you will be free to correct it in terms of the text but not the substance. Can I also very briefly ask you to introduce yourselves, starting with Dr Bamrah, and then we will go straight into questions. Dr Bamrah: I am JS Bamrah, the Chair of the BMI Psychiatric Sub‑Committee. I am a psychiatrist for the elderly and I was a general adult psychiatrist before that. Dr Arnold: I am Robin Arnold. I am the immediate past Chair of the Psychiatric Sub‑Committee. I am a rehabilitation and assertive outreach psychiatrist. I used to be a rehabilitation and general adult psychiatrist. I am also Secretary of the Royal College's Rehabilitation and Social Faculty. Dr Wilks: I am Michael Wilks and I chair the Medical Ethics Committee of the British Medical Association. Professor Tylee: I am Andre Tylee. I am a Professor of Primary Care Mental Health at the Institute of Psychiatry at King's College. I had been a GP for 21 years before taking up that position. I chair the primary care programme of the National Institute for Mental Health in England. Dr Cohen: I am Alan Cohen. I have been a GP nearly 25 years and I am approved under section 12 of the current Mental Health Act. Q1148 Lord Rix: I am sure the Committee will be very relieved that this is the last evidence session because I have repeated this question more or less without cessation since the opening session. The Government has removed the exclusions in the current definition of mental disorder characterized solely on the basis of drug or alcohol use or sexual deviance on the grounds that clinicians are reluctant to diagnose mental disorder if one of the excluded factors is also present. In your experience, is the Government's decision to remove these exclusions justified? What other conditions should be excluded from the definition of mental disorder? Do you consider that learning disability, intellectual impairment without allied mental illness should also be added to that list of exclusions? Dr Arnold: The underlying problem is with the broad definitions, in particular the broad definition of mental disorder. I heard mental illness being referred to quite a lot earlier and in some of the questioning that I read of the Minister the Committee was referring to mental illness, and in his launch on the Today Programme of the Draft Mental Health Bill Professor Lewis Appleby referred to the sole purpose as being mental illness. Mental illness is not mentioned in the Act. People assume that mental disorder is a synonym for mental illness and it is not, the nature of mental illness is very different. Mental illnesses are arbitrated by doctors and doctors work out how to deal with it on a pragmatic basis. Sexual deviance is a rather uncomfortable phrase because it was only in the Sixties that they stopped treating homosexuality with the electric shock treatment. One of the new tinkerings with the Bill that has been introduced instead of a treatability clause was that a treatment would be available and at that time the electric shock was available. Would it therefore be used? Would we be making a mistake now with regard to sexual preference? Obviously it gets very difficult to say with paedophilia. The problem with paedophilia is not the predilection for children, it is the fact that children are abused. If people did it quietly in their own rooms and there was no abuse going on it would not be a problem. I do not want to go down as being a supporter of paedophilia, I just want to highlight the problems. There are many other sexual preferences which are more complex. We now pretty much universally accept that homosexuality is a sexual preference and people's right and choice. Undoubtedly I think this is caught within the very broad definitions and I think pretty well all psychiatrists would not consider mental deviance to be a mental illness of itself. With regard to drug and alcohol use, this is complex, but this is what I referred to as mental illness being a pragmatic issue. Lewis Appleby in what he said on the Today Programme acknowledged that personality disorder is not a mental illness, and at a conference in October of 2003 between our faculty and the general adult faculty, with 300 delegates, we had a debate on whether personality is a mental illness and that was defeated at the beginning of the debate by 86 per cent and at the end by 92 per cent. Q1149 Chairman: What was the question again? Dr Arnold: Is personality disorder a severe mental illness? They did say severe mental illness so they may have thought it was a minor mental illness but I do not think so. I do not think learning disability is a mental illness. Our original evidence to Genevra Richardson, which I led, said that personality disorder, mental illness and capacity or incapacity should be separate and should be dealt with separately. At the time we knew the Capacity Act was around but it had gone into a limbo for a while and we did not know what was going to happen with it. The Capacity Act is now there with some adjustments to take account of Bournewood and so on. I think that a pure learning disability can be dealt with. If someone becomes mentally ill who has a learning disability then that should be dealt with as a mental illness. I think that the problem is the broad definition. I think that a pure learning disability should be excluded from these processes but it should only be excluded by narrowing it down to mental illness. That will give the Government a problem because they want to incorporate a severe personality disorder. To some extent that is being dealt with through the justice legislation and other areas, but by pooling it with mental illness you get all of these problems which affects other groups, including those with a learning disability and those with dementia as well. Q1150 Chairman: Can we be clear as to what your view is as to what should be done in the criminal justice aspect of all of this because the Mental Health Act 1983 and this Bill are designed to deal to a very great extent with the criminal justice system and with people suffering from various forms of mental conditions who come before the criminal justice system. What would you do which is not in this Bill? Dr Arnold: We do not have a problem with mental illness which leads to criminal behaviour because there the person should be treated. There is a problem where people indulge in criminal behaviour and have a mental illness either concurrently or later when they get into prison. They certainly need treatment, but there is a problem at the moment, and it would certainly continue in this Act, in that then their criminal behaviour gets excused and it gets treated as though it was mental illness. That brings people with mental illness into disrepute. It also means that later on when they are released the mental illness is not dealt with. I do not know how you can deal with all dangerousness. What people want is that anybody who might be a danger in the future is prevented from being a danger, whether it be mental illness or personality. That is impossible to deliver because we cannot predict dangerousness in that way. So I think even the criminal justice system cannot deal with it. I think what you have to do is wait until someone has committed an offence of one kind or another and then assess the risk and deal with that through the justice system. If they commit the offence because of mental disorder and they lack capacity and so on then, as with the present Act, that should be dealt with through the Mental Health Bill, but that is the problem of confusing personality with mental illness, they are diametric opposites. Mental illness was developed as a social institution to differentiate it from your normal personality and what you do out of that. Q1151 Chairman: Forgive me for asking yet another question but my mind is becoming befuddled perhaps because of the number of evidence sessions we have had. If it is clear to a psychiatrist and social workers that a patient is reaching a high degree of dangerousness which may be quite directed, for example, at their mother or their siblings and it is known that there is a risk that that dangerousness could lead to something that would objectively be described as a criminal act, how are we going to deal with that issue under your prescription? Dr Arnold: Let me take two extremes. If there was someone with a schizophrenic illness at home with their mother and they were developing a whole series of delusions and hallucinations and the voices were commanding them to knife their mother, then you would get them in for treatment, you would get them away from the mother and you deal with the dangerousness. Q1152 Chairman: So you section them? Dr Arnold: Yes. If, however, someone is on their way to commit an armed robbery then they are clearly meeting the question that you gave me, but that should not be an issue for psychiatrists and social workers and others. There are grey areas in between, but the implication of the Act is the person on their way to commit an armed robbery is our problem and we should prevent it and that is the whole issue around the Stone case. Some time ago I asked our parliamentary office ‑ I do not know whether I should be saying this but I will set out the criteria ‑ whether if Stone were found innocent at the Old Bailey at appeal and deemed not to have committed the murders that he committed and walked down the steps of the Old Bailey a free man he should be detained by two psychiatrists and a mental health worker under this Act indefinitely. That is what is facing you in a sense because Jack Straw made it quite clear that he felt that should have happened retrospectively over that issue when he spoke about it and that is the problem facing us. I was told that the issue was too subtle to risk asking the question, but that is what you are asking psychiatrists to do, to predict who is going to be violent and to prevent them doing it. I have no problem with people who have mental illness. Q1153 Chairman: The Stone case is no longer sub judice and it is a very good example to take because we have seen so much detail of it publicly. Dr Wilks, in hindsight is there anything that ethically could have been done by the medical profession or by the criminal justice system that could have led to the prevention of (leaving the detail out) a case like Stone? Does this Bill provide any benefit for dealing with a case like Stone or not? Dr Wilks: I doubt that it does because it is not really an ethical answer to your question, it is more of a psychiatrically based answer and the question of predictability and the extent to which predictability of possible future harm might be a reliable indicator for removing someone's liberty from them. There seems to be a pretty general consensus within the psychiatric community that about the only basis on which you can predict if someone is dangerous is that they have been dangerous and the fact that those people will probably be suffering from a mental illness or mental disorder or a mental condition which may not be treatable. What we are seeing here is a piece of mental health legislation in which the diagnosis is difficult to make, there may be no treatment and the only option, because there is no treatment, is detention. It seems to us that while it is difficult to devise a framework for the detention of people in other areas, it would have to be under some sort of criminalized based legislation, it should not be within the scope of mental health legislation to make those kind of liberty depriving decisions and with the help of doctors on the basis of a condition which is poor predictability to violence and may not be treatable. That does not seem to be the right vehicle in mental health legislation to do that kind of job. Q1154 Dr Naysmith: I do not disagree with much of what Dr Wilks has just said, but is it not true that Stone was known to mental health services and had indeed sought help not very long before he committed the act that we are talking about? Are you saying that there was nothing that could be done? Dr Arnold: I do not know. I have not examined the notes or anything so I am going by what I have heard through the press. My understanding is that he was still receiving help from a community psychiatric nurse. As was reported in the press, he had been admitted for a period of treatment but they had found him not treatable. The only other solution would have been to have kept him indefinitely because presumably sooner or later he would have done something similar. There is absolutely no evidence that you can treat personality against someone's will. You can treat some mental illnesses with antipsychotic in injectable form and with ECT and so on for depression against someone's will, but there is no evidence at all that you can treat these problems. He was still receiving help. Q1155 Dr Naysmith: We probably should not probe this too closely since few of us know the details. There is a suggestion that he had sought help fairly recently before he committed the act and had been turned away and told there was nothing they could do for him. Dr Wilks: What I had understood was that a CPN was still seeing him and was still trying to help him. Chairman: Let us move on and try and tease out whether you have a different view of Community Treatment Orders from the previous witnesses. Q1156 Baroness McIntosh of Hudnall: You have told us that you do have a different view. I have some difficulty in understanding the value of Community Treatment Orders as they are currently envisaged. We heard some very interesting evidence from the witnesses who immediately preceded you, which you may have heard. They were keen to tell us that if they were to be useful, which indeed they thought they might be, it would be for a very, very small group of people. Could you tell us what you feel about Community Treatment Orders as the Bill represents them? I am asking you about that because what I felt about the last lot of evidence was that we were hearing about Community Treatment Orders as the people who gave us the evidence would like them to be but not as they are currently drafted in the Bill. It appears to me that you have some support for the Community Treatment Orders as they are drafted. Could you tell us why? Dr Bamrah: The BMA supports the principle of patient choice and it is really in the context of patient choice that treatment in hospital and in residence given certain conditions could be considered. We heard the last bit of Professor Thornicroft's evidence. The jury is still out on Community Treatment Orders. I think the Supervision Register is less used. The Institute of Psychiatry did a survey on Supervised Discharge Orders a few years ago and found that by and large psychiatrists favoured Supervised Discharge Orders, which are the precursor to the Community Treatment Orders. Given certain criteria, whether it is the Saskatchewan principles or other principles, I understand that these Community Treatment Orders are in use in New Zealand, Australia, Canada and in some states of America and it looks like there are a small number of patients who would benefit from them and they are the "revolving door" patients, ie patients who are currently mentally ill and who could be at home. I can see that if you have a 29‑year old manic mum who has three children at home it may not be appropriate for her, but if you have a 24‑year old schizophrenic with the right support at home, let us say he/she lives with their parents, it may well be the right kind of treatment for them providing they have the enhanced community facilities, not just assertive outreach teams but 24/7 care for them. Q1157 Baroness McIntosh of Hudnall: The difficulty is that we have had a lot of evidence which suggests that as drafted the potential that Community Treatment Orders have to be used in a very wide range of different circumstances is quite significant and each witness who has come before us who has something good to say about Community Treatment Orders has tended to do as you have just done, which is to say that they would be good as long as they were limited, as long as this did not happen, that did not happen and it was only targeted in a very particular way. Could you tell us what you think the Bill should actually say about Community Treatment Orders? Do you think it should say what it says now and then the application of it should be left to guidance and Codes of Practice, or should the Bill itself be much more carefully written to restrict the application? Dr Bamrah: It certainly should be restricted. The whole problem boils down to the definition of mental disorder which I do not need to go into because I think a lot of people before us will have spoken about mental disorders. It is such a broad term that you cannot have recurrent offenders who do have a mental illness being treated at home even on a Community Treatment Order. So you are looking at a small group of patients who are devoid of insight being non‑compliant with their medication, who become ill quite frequently, with a reasonable but bearable risk of a disturbed behaviour, being treated at home. Q1158 Baroness Eccles: Could I try and achieve a bit of clarity here? Dr Arnold made a very clear distinction between mental illness and mental disorder. Dr Bamrah is talking about mental disorder. I just want to know whether that is what he means or whether he is actually talking about mental illness. Dr Bamrah: Mental disorder is a very broad term as the Bill is framed. Psychiatrists are not experts in dealing with all kinds of mental disorders. I guess I am referring to the kind of mental illness that we are experts in diagnosing and treating, which is very broadly the psychosis and the neurosis. Q1159 Chairman: Can I just target something on the primary care providers here because if we are going to have CTOs it seems to me that primary care providers could find themselves in the eye of the storm. I hope the general practitioners' representatives here will forgive me for putting it as directly as this, but there is a patchy pattern of response by general practitioners, many of whom are over‑stressed around the country, in their response to many extracurricular activities or things that do not fall within their absolute every day pattern of work. Do you think that the introduction of Community Treatment Orders would place an increased burden on general practitioners? If so, is that a burden you think GPs are competent to undertake and would they accept it? Dr Cohen: I think there are a number of issues. First of all, there are large numbers of people with a severe and enduring mental illness which are managed entirely in primary care already and are not in contact with secondary care services, the figures vary from 30 per cent to 50 per cent in different areas, so it is something that GPs do already. The act of sectioning a patient most GPs find an uncomfortable experience. The opportunity offered by a Community Treatment Order or a Non‑Residence Order is an opportunity to maintain a relationship with a patient and it may be quite long lasting. I can think of several patients who I have known for a long time where it would have changed the relationship considerably had a Community Treatment Order been in place. As to whether GPs are able to do it and should be doing it, it is part of their work already and were it to become something special it would be deskilling both the professionals and not in the best interests of the patient either. Q1160 Chairman: Given that GPs in Powys where I live and, I have no doubt, in other parts of the country do not provide services through their practices between 5pm and 7am now and given that florid episodes of mental illness do not always occur in working hours, are you satisfied that under the present primary care system the general primary care is able to cooperate out-of-hours with such crises because, unfortunately for those of us who have experienced mental illness in our families, it is a 24‑hour operation? Dr Cohen: I think the changes in the UTP contract from April 2004 and the change in the out‑of‑hours services and the use of co‑ops means that many co‑ops are now employing a section 12 approved doctor as part of their on call rota. The opportunities for treatment and information are more available now than previously. Certainly in north‑west London where I work the co‑op has a section 12 approved doctor on call. Q1161 Chairman: What about where there are no co‑ops? There are a lot of areas like mine where there is no co‑op and it is a commercial company doing the out‑of‑hours service. Dr Cohen: It would be written into their contracts that they should provide it and be part of the level service agreement and terms and conditions. You are able to get around it. Professor Tylee: I completely support that. It is perfectly possible for despotizing agencies that are contracted to make provision and have trained doctors to be able to help and similarly with the NHS Direct which is now available as the first port of call for most people when they need some help, there has been increasing training at that level so that the people that are the first contact on the phone and who are often nurses are well placed and increasingly trained to be able to know how to advise somebody. Dr Cohen: There are concerns about the Community Treatment Orders. The relationship with the GP, which we see as central, does not seem to be reflected in any of the clauses within the Act about who needs to be informed that a patient is being either assessed or being compulsorily admitted. The Act says very clearly it should be the carer, it should be the appropriate parent or whatever, but it does not mention the GP anywhere in the Bill. I think that is something that we would like to see reviewed if possible. There is a central role for the GP in providing continuing care and this role is not being reflected either in the Community Treatment Orders or in the assessment and compulsory admission. Q1162 Chairman: Do you feel that the number of compulsory orders which are required might be reduced if more GPs followed the successful practice to which you have referred of having primary mental health provision in general practices for example, as happens in some practices, through employing psychotherapists, psychologists and the like at a primary level? Has that been successful? Dr Cohen: It is very successful employing counsellors, psychotherapists and graduate mental health workers in line with the NHS plan but I think they deal with a different set of patients with a different set of problems. I do not think you can say that if everybody who has been sectioned had got counselling for six months or a year earlier they would not have been sectioned. It is a whole broad range of disorder. It may happen for perhaps a small number of patients with depression, but my experience from acting as a section 12 doctor is that most of these people are severely ill and counsellors would have been a part of their intervention but not the only intervention. Q1163 Chairman: I was thinking of something that I think struck a number of the Committee when we went to south‑east London where we came across a significant number of black male patients who had become psychotic as a result of the use of cannabis. I was just wondering whether the kind of provision we have just been discussing might at least have some effect at an early stage in dealing with patients of that kind. Dr Cohen: General practice tends to be a reactive service in dealing with the problems when a patient presents themselves to me. I cannot go out to my entire practice population and offer a service. It is a fact that young men, black or white, do not attend general practice very often and usually when they do it is for a very acute reason. A lot of work is being done around the opportunities of improving substance misuse in primary care, but I am not sure that that would influence the group that you are describing. Professor Tylee: We have undertaken and published some work in Lambeth where practice nurses were trained to undertake mental health assessments and assist with management but also to send out leaflets and flyers to the young men and some of the other important target groups that were registered with the practice and we found that it did increase access considerably. So we know that there are ways of improving access. Also, it more than doubled the adherence with medication that was prescribed for their depression and 83 per cent were still taking their anti‑depressant medication after four months. That is now leading to further work with clusters of practices where we want to replicate that and see whether that is the case across the board. Q1164 Baroness Cumberlege: One of the things that we have heard a lot about is the lack of resources, particularly in terms of psychiatrists and the time it takes for people to be trained etcetera. Bearing in mind the changing role of GPs now and we heard about the research that was done on the workload that GPs have with people with a mental illness and it is quite considerable and it was the area that they felt least equipped in fact to deal with, do you think with the trend now and with GPs with a special interest we could see a changing role in the professions in terms of GPs taking on more of this work instead of psychiatrists? The psychiatrists are shaking their heads! Dr Bamrah: It is a welcome change, although you will not see that change being reflected in many parts of the country where GPs take up special interests. It would be a welcome change if more GPs took an interest in particular areas of psychiatry. Much of their performance targets are non‑psychiatric in a sense, so I cannot see them rushing and queuing up to become specialists in psychiatry. I think you will know already that it takes a minimum of 11 years to train as a psychiatrist in this country and often many of us will embark on other careers in research or in other hospital medicine before we become psychiatrists. So that is a long, long time to turn a ship. I have got some stats for you which might be of interest to you. There are about 30,000 consultants in the UK and 10 per cent of them are consultant psychiatrists, which is 3,200. There are over 400 vacancies in consultant psychiatrists' posts. The DoH has come up with a figure of 130 (recently revised to 200) full‑time equivalent consultants required to implement the new Bill when it becomes an Act. That is a gross under‑estimate. They also estimate that there will be a net increase of 160 consultants every year from 2003 to 2008. That is also a gross under‑estimate because it does not take into account part-timers and many of them, both male and female, are part-timers in psychiatry, and about 40 per cent of consultant psychiatrists are female. Also, it does not take into account things like maternity leave, sick leave and long sick leave and that sort of thing. We also retire early. We are amongst the few privileged people in that we can retire at the age of 55. After 2006 there will be a number of retirements in consultant psychiatrists' posts. I hate to say this, but the number of psychiatrists will be far fewer than the Department of Health predicts, the number of tribunals will be more and there will be more sections. I heard a liaison judge at the Scrutiny Committee saying that the number of tribunals will increase from 12,000 to 14,000 and the number of sections will increase. It is a good thing that sections will be shorter, but it will require more manpower from psychiatrists and that will include GPs as well. Dr Arnold: Certainly since the GP contract came in we have seen even psychiatrists who are interested in psychiatry doing somewhat less and saying that this is a specialist area, it has to be commissioned and that may be solved once the commissioning process gets under way. The patients we are talking about who should be under the Mental Health Act are the people with the most complex problems and they should not go to people who have the least training in psychiatry, which is GPs. For all their benefits, this is not an area they are specialists in. They are people who should have specialist services, not only psychiatrists but nurses and OTs and other people. So the GPs I would see as working in an area which did not impinge on Community Treatment Orders and the Mental Health Act because that should only be attending to the people who are really have severe and complex needs and need the most specialist care. Dr Cohen: It would be entirely appropriate for GPs with special interests to train in mental health. The opportunity that offers is to free up psychiatrists who would otherwise be doing other things. Although I agree entirely that it is not appropriate to have a GP with a special interest dealing with the sort of patients who might need sectioning because they are complex, they are very difficult and you need lots and lots of training to do that, but it does not mean that GPs with a special interest do not have a role doing other things that psychiatrists would be doing instead. It is about skilling up GPs with a special interest or clinical assistants, whatever you want to call them, so that it allows psychiatrists to spend more time with a smaller number of very severe, very difficult to manage patients as part of the mental health team. The answer is that I do think GPs with a special interest have a role. We are trying to develop a training course at the Royal College of GPs with the RCN to create 700 new practitioners with a special interest because there is the demand from people with common and enduring mental illness and who have a whole range of problems that psychiatrists would otherwise be dealing with. There is an opportunity when you look at the whole system not to manage more sections because that is not appropriate but to manage a different group of patients and to free up the time of psychiatrists. Q1165 Chairman: Gentlemen, your oral evidence has provided a rousing coda to what has been a very long symphony of evidence. I think this is our eighteenth meeting and in seventeen of them we have taken evidence. May I thank you very much for your written submissions and for your oral evidence. Dr Wilks: Thank you for giving us the time. I think we have actually dealt with about three‑quarters of what you gave us notice of. One area that we have not looked at is the issue of principles. I think there is a fairly long answer to that based on basic, ethical and human rights evidence that we would like to give you some evidence on but we will do that in writing. Q1166 Chairman: The reason why I omitted that question, it was my decision from the chair, was because we have had a lot of evidence about it. We would be very grateful for your evidence, but it seemed to me that oral evidence on the other matters we have discussed was going to be of more oral value. Dr Wilks: I quite understand. Chairman: Thank you very much. |