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Baroness Jay of Paddington: I am grateful to the Minister for that reply. I understand what she says about the definition of "mental disorder" but I wonder whether she could help me further on the question of mental impairment.

Baroness Cumberlege: I am not sure of the aspect on which the noble Baroness seeks further help. Severe mental impairment is a psychopathic disorder which I believe is clear in the Act.

Baroness Jay of Paddington: I am afraid that I do not understand it in that way. It seems to me that severe mental impairment does not suggest the type of clinical psychosis—obviously I am not an expert in the psychiatric field—and I should have thought that it had a much broader definition than the one the Minister has given of the type of condition which was supposed to be included in this group of, as she rightly said, revolving door patients.

The problem relates to the broadness of the definitions in the Bill as it now stands. There may be a drain on resources. The noble Lord, Lord Mottistone, says that that is irrelevant to the Bill. However, many of us, when considering the terms of the Bill and the broad financial agreements which accompany it, have been concerned that there should not be over-optimistic assumptions about the range of people who would be thought to be subject to the order. So that point is not as irrelevant as he made out.

The definition of the group of patients who would make themselves most readily available for help in this way should be as precise as possible. The Minister says that Amendment No. 3 is too narrow. I heard what the noble Lord, Lord Mottistone, said about someone

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having been in prison. But the question may be whether it is possible—again, perhaps the Minster can help—that someone who had been admitted to hospital once only would be subject to a supervised discharge order.

Baroness Cumberlege: It is a matter of judgment. Provided the patient complies with the criteria set out in the Bill, it would be for the RMO to decide whether the patient should be under supervised discharge.

3.45 p.m.

Earl Russell: It is very, very difficult in this area to achieve any terminology which is precisely right. It is an imprecise area. It matters a great deal more, whatever terminology we use, that it should be used with a great deal of care than that we spend a long time trying to draw up words which will have one set of meanings in medical circles and perhaps another in legal circles. A great deal depends also upon what we think is the purpose of the supervision orders. The impulse to draw the supervision orders, and the group subject to them, more narrowly probably goes back to the original publicity impetus behind the Bill, which was to concentrate upon violent offenders.

In fact, by far the more common problem, especially in schizophrenia, is suicide or depression. If we think about these orders being applied to people who are unable to cope, then the wider definition may have something to be said for it. These are the type of people we see sleeping in doorways as we go down the Strand in the evening, as I often have occasion to do. Many of them might benefit from a supervision order when they do not quite come within the terms of Amendment No. 3. I ask the Minister whether advice has been taken in the drafting of the clause from the groups which deal with homelessness. I imagine that they might well support the wording, but I should be interested to know whether they have done so.

Baroness Cumberlege: I do not have with me the list of people who were consulted, but I know that there was wide consultation in drawing up the Bill. If the noble Earl would like examples of the organisations which were approached, I am very happy to give them to him in writing. Perhaps I may reiterate that the definitions are in the Act. I believe that their limits are well understood by mental health workers. I agree with the noble Earl. Having defined the terms in the 1983 Act, it would be a great mistake to try to redefine them in the Bill.

Baroness Jay of Paddington: As regards definition, I accept entirely what the noble Earl, Lord Russell, says about the different forms of interpretation, but the difficulty with the order is that it imposes a degree of compulsion on patients, which is not included in the 1983 Act. That is why we seek to define the provision narrowly. However, I shall read carefully what the Minister said, and for the moment I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 3 not moved.]

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Earl Russell moved Amendment No. 4:


Page 2, line 10, leave out from ("persons") to ("if") in line 11.

The noble Earl said: The amendment seeks to omit the words in lines 10 and 11,


    "or of the patient being seriously exploited."

Those words are capable of many interpretations. Anyone who was in the House yesterday would think first and foremost about economic exploitation, but that I imagine was not the intention behind the debate. I admit that we cannot be too precise with words, but I am reluctant to put into the Bill words whose interpretation is so very, very doubtful and which could so very easily bear a meaning completely wide of the Bill's purposes.

If the Minister could explain more clearly what the words are intended to do, it is possible that we might arrive at an agreed wording, but it is probably not perfect yet. I beg to move.

Baroness Cumberlege: These amendments seek to alter one of the three conditions which must be satisfied if aftercare under supervision is to be imposed or renewed. The criteria for the new power were considered in considerable depth in out internal review, which looked at legal powers on the care of mentally ill people in the community. The team concluded that the grounds for receiving aftercare under supervision should include the risk of being seriously exploited. This was set out in the report of the review, which we published in August 1993, and was the subject of widespread consultation. These proposals form the basis of the Bill now before the Committee.

The condition that a patient might be at risk of exploitation does not stand alone but is inseparable from the other conditions for imposing or renewing aftercare under supervision, listed at new Sections 25A(4) and 25G(4) respectively. Chief among these is that the patient must be suffering from one of the four forms of mental disorder defined in the 1983 Act. We are trying to identify a small group of mentally disordered patients whose care in the community is less effective than it should be because of a repeating pattern in which they fail to comply with their treatment plan and then have to be readmitted to hospital. There will be mentally disordered patients who are at risk of exploitation who will fall into this group. Such risks might be that they could be lured into prostitution or that they are exposed to the risks of drug abuse.

Furthermore, the concept of risk of exploitation is not new; it is in the 1983 Act already. It is one of the grounds on which detention may be renewed in Section 20(4). If the risk of serious exploitation may be a valid ground for continuing someone's detention, we believe that it must follow that in different circumstances it will be a valid ground for requiring their aftercare to be supervised.

I hope that with that explanation we can reach an agreement on the wording, as the noble Earl suggested.

Earl Russell: I am sure that we can do so. I find the Minister's explanation reasonable, persuasive and compelling. The only problem is that the conditions which the Minister mentioned —the risks of being led, say, into prostitution or drug abuse—extend beyond the

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range of those who suffer from mental illness. I have heard the noble Baroness, Lady Faithfull, speak on the subject in this Chamber several times. How would the Minister respond to a form of words referring to patients at risk of exploitation by reason of their mental condition? That might tie the matter down in a way that I hope is within the Minister's original purposes.

Baroness Cumberlege: I believe that drugs are closely related to mental illness; in fact, we find a close correlation. I am open to discuss the matter further with the noble Earl. Perhaps we can reach an agreement.

Earl Russell: I thank the Minister warmly for her reply. It is a matter not to be continued inside the Chamber, and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The Chairman of Committees (Lord Boston of Faversham): I should point out to the Committee that if Amendment No. 5 is agreed to I cannot call Amendment No. 6.

Baroness Jay of Paddington moved Amendment No. 5:


Page 2, leave out lines 14 to 16 and insert:
("(c) he would be unlikely to accept the after-care services to be so provided if he were not subject to after-care under supervision,").

The noble Baroness said: The amendment is designed to make explicit, and to emphasise, the fact that patients subject to supervised discharge should be only those whose level of severe mental illness makes it unlikely that they would accept aftercare services if there were no order. It may appear to the Minister that the proposal is slightly over-egging the pudding in the sense that it is an implicit understanding in the Bill. However, it appears that many of those who work with people who have the kind of mental illness that makes it difficult for them to accept care agreements are concerned that only in the most extreme circumstances should an order be imposed which may undermine the principles of the so-called therapeutic alliance and non-coercive relationships on which so much effective work in the community is based. The Royal College of Physicians, for example, has stated that a negative effect of the Bill may be the loss of trust in the doctor-patient relationship among patients who could be most likely to be subject to the provisions. Risk could be justified only if the benefit were great enough. At present, the college does not believe that the benefit will be as great as the Government predict.

The problem is that there exists a Catch-22 situation and that precisely those patients most likely to benefit from the kind of supervised aftercare that the Bill describes will be those who, in principle, are most likely to resist it. The amendment would underline and make explicit in the Bill the fact that it is an extreme measure to be employed only in circumstances where people believe that a non-coercive and more co-operative arrangement would fail. I beg to move.


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