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Baroness Cumberlege: In its present form, the new Section 25A requires the responsible medical officer to be satisfied that the patient's being subject to aftercare

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under supervision is "likely to help secure" that he receives the services he needs. The amendment would require the RMO to answer a negative question about whether the patient was unlikely to accept the services if they were not supervised. We believe that this would be more difficult to interpret than the grounds that the Bill gives at present and would inhibit the sensible use of the new power. We do not believe that it would add anything to the rights of the patient, which the Bill already safeguards very fully. The noble Baroness said that perhaps the amendment over-eggs the pudding and that is our view too. I hope that she will not press the amendment.

Baroness Jay of Paddington: I am grateful for the Minister's reply. The issue is about words, as referred to by the noble Earl, Lord Russell. The phrase which the Minister picked out—that the agreement should be "likely to help secure" aftercare services—is not meaningful as it stands. It does not sound like a particular guarantee of aftercare.

The amendment is an attempt to underline the need to see the new order as an extreme measure rather than something that might become a more customary approach by responsible medical officers and people in the community. I heard what the Minister said, and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Mottistone moved Amendment No. 6:

Page 2, line 14, leave out from ("supervision") to ("that") in line 15 and insert ("for the purpose of ensuring").

The noble Lord said: In moving the amendment I shall speak also to Amendment No. 57. Some of my comments will be similar to those made by the noble Baroness, Lady Jay, in speaking to Amendment No. 5. My amendments are designed to clarify and make more positive one of the reasons why patients can be subject to aftercare under supervision. I believe that replacing the words "is likely to help" with the words "for the purpose of ensuring" is more positive and more in line with other uses of those phrases in new Sections 25B(8) (b) and 25D(1). Both new sections use more positive words to describe what is needed. I hope that this minor change to the phraseology will be acceptable to my noble friend. I beg to move.

Baroness Cumberlege: I believe that I understand my noble friend's intentions in proposing these amendments but we doubt whether they will achieve the effect he seeks. His point, as I understand it, is that the new power should be used only when those concerned believe that it will ensure the patient's receipt of the aftercare services. We are afraid that this will be an unrealistically high threshold. The purpose of the new Section 25A(4) (c) is to ensure that the patient receives the aftercare services that he needs by supervising him in the community. But there can be no absolute certainty in advance that this is going to succeed and if the amendment were passed there would be a risk that responsible medical officers and others would feel reluctant to use supervision because they did not feel sure that it would succeed. That could lead to patients

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who need to be supervised being discharged without any supervision at all. I ask my noble friend to reconsider and to withdraw his amendment.

Lord Mottistone: I thank my noble friend for those remarks. I shall read them with care and perhaps return to the matter at a later stage with something better. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

4 p.m.

Baroness Jay of Paddington moved Amendment No. 7:

Page 2, line 18, at end insert ("who has previous acquaintance with the patient and who is approved under section 12(2) of the Mental Health Act 1983").

The noble Baroness said: In moving this amendment, I shall speak also to Amendments Nos. 8 and 28. All three amendments address the question of the qualifications of those medical officers who will be responsible both in relation to the discharge and the community care of a person who is subject to a supervised discharge order.

Amendment No. 7 aims to ensure that the person who is about to discharge a patient has the necessary acquaintanceship with the case and is approved under Section 12(2) of the Mental Health Act. That brings the new Bill into line with the previous Mental Health Acts.

The other two amendments refer to the organisation and care of the person under the supervised discharge order living in the community. They use the words which are in the Scottish provisions which, in this instance, as I think in some others, are more precise and phrased more clearly than those for England and Wales. The words:

    "who shall be a practitioner having special experience in the diagnosis or treatment of mental disorder",

enable those who are caring for the patient, those who are related to the patient and, indeed, the patient himself to be clear about the substantial post-graduate specialism of the person looking after the patient. That is necessary to ensure that if, as was explained on Second Reading, the new procedure is to be health-driven in the sense that that is something which is based within the health services rather than the community or social services, it must be done on a specialised basis. At every stage, there must be a clear understanding that the medical officer in charge has the necessary post-graduate training to enable a detailed understanding both of the diagnosis and the treatment involved in caring for what will be, as we have already discussed this afternoon, a very small but probably very difficult group of people.

Anxiety has also been expressed about the casualness of some of the references to medical practitioners. For example, on page 3 at line 44 of the Bill, where it is discussing whose written comments shall accompany a supervision application, at the end it refers merely to "any registered medical practitioner". I understand that that is not somebody who will be in a position of responsibility vis-o-vis any patient; but these amendments aim to make it very clear and very specific

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that those persons who have responsibility shall be clinical specialists at a post-graduate level and have the necessary qualifications.

As the Royal College of Psychiatrists pointed out, that is particularly important in relation to the community responsible medical officer. That is a new term which it feels is inadequately defined in the Bill. I hope that the Minister will listen to that detailed, clinical approach of those who are most involved with the care of patients. I beg to move.

Lord Mottistone: Unfortunately Amendment No. 136 is not grouped with these amendments but it falls naturally into a grouping with Amendment No. 28. Both of those amendments refer to the community responsible medical officer. If the Committee agrees, I shall speak now to Amendment No. 136.

I have great sympathy for what the noble Baroness, Lady Jay, said about all four amendments. I merely suggest that Amendment No. 136 is rather fuller and more definite in dealing with the problem which arises in relation to Amendment No. 28. I should have thought that my amendment provides a better line of approach for that particular need. Schedule 1 provides the definitions for the new post of community responsible medical officer. It may be that that is the right place for it. At this stage, I shall go no further than that.

The Earl of Longford: I shall speak to Amendment No. 9, which is on the same general issue. I go a little further than my noble friend Lady Jay because I submit to the Committee that the person who takes the crucial decisions should be a registered psychiatrist. It is the same argument but it goes rather further. The decisions are crucial. We are talking about mentally sick people. The only people who can make a decision, which will be imperfect in this wicked world but which is the best we can provide, are registered psychiatrists.

Earl Haig: I support the amendment. It is extremely important because it concerns crucial moments in the lives of patients. If medical decisions are made without proper knowledge, patients may regress, and that may have very serious consequences. Whoever is responsible must have the right knowledge and qualifications. If that is so, he will be able to instil the necessary confidence in his patients, which is of great importance.

Baroness Cumberlege: There seems to be some informal grouping going on here and if I over-egg my arguments, I hope that the Committee will forgive me.

The term "responsible medical officer" is clearly defined in Section 34 of the 1983 Act. For those patients liable to be detained in hospital this is the registered medical practitioner in charge of the treatment for which they have been detained. Under our proposals, that is the practitioner who would make the application for aftercare under supervision. It is hard to envisage a situation in which this would not be a consultant psychiatrist.

The community responsible medical officer appears for the first time in the present Bill and is defined in paragraph 4 of Schedule 1, as my noble friend said, as

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the registered medical practitioner in charge of the medical treatment provided for a patient subject to aftercare under supervision.

These amendments seek to require that only certain categories of people may act as the responsible medical officer. With regard to the hospital RMO, I am afraid that does not make sense because, as I have said, the RMO is already defined in the 1983 Act. If he did not meet the requirements, it would mean that there would be no one in a position to make a supervision application in respect of the patient.

As regards the community RMO, the amendment identifies a principle of good practice. We agree that it is desirable that a doctor who is to act in this role should have special experience in the diagnosis or treatment of mental disorder. Doctors approved under Section 12 of the Mental Health Act 1983 have a special knowledge of how the legislation works and an expertise in dealing with the kinds of patients to whom it may apply. We propose to emphasise in guidance that it would be desirable that the community RMO should be Section 12 approved.

I recognise that the provision for Scottish community care orders, in Clause 4 of the Bill, includes a requirement that the special medical officer—the Scottish equivalent of the community responsible medical officer—should be approved by a health board under Section 20 of the Scottish Act. But that is consistent with the existing provisions of that Act under which the responsible medical officer in a hospital is required to be approved under Section 20. Here, as in other areas, the difference reflects differences in the way practice has developed in the two jurisdictions and we think it is quite reasonable for that difference to be carried through into the present Bill. Given that explanation, I hope that the noble Baroness will withdraw the amendment.

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