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Baroness Cumberlege: My Lords, perhaps I may seek clarification from the noble Lord. Was he also speaking to Amendment No. 32?

Lord Rea: My Lords, I am extremely sorry. In moving Amendment No. 29, I spoke also to Amendment No. 32.

Baroness Cumberlege: My Lords, I am grateful to the noble Lord. Although I very much appreciate the noble Lord's concern about possibly unnecessary and unreasonable restrictions being placed on patients, I have emphasised the need for consultation and information throughout the procedures that we are proposing for supervised discharge. Before making an application for supervision, the hospital responsible medical officer must ensure that the patient has been consulted, along with members of the current and future care team. Such consultation will include the contents of the aftercare plan and any requirements on the patient thought necessary to help him comply with the plan. Thus, those who are actually discharging functions on behalf of the health and local authority are already under a requirement to consult patients and we do not think that it is necessary to impose a further requirement on the authorities themselves.

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The effect of the Government's amendments to which we have already agreed is that the patient will have to be told orally and in writing that the supervision application has been accepted, and of his rights of appeal to a mental health review tribunal. This represents very full provision for consultation and notification and we do not feel that the additional requirements that these amendments would impose are necessary. Therefore, we shall resist the amendments.

Lord Rea: My Lords, I thank the noble Baroness for her reply. I shall not press the amendments. The clarification that she has just given will be useful because it is now in the Official Report and those who will interpret the Act when it is brought into force will possibly look back to her words. It is good to have them on the record to refer to. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Jay of Paddington moved Amendment No. 30:


Page 6, line 30, after ("that") insert ("after consultation with the patient").

The noble Baroness said: My Lords, this a very simple amendment which seeks to require the aftercare authorities to consult with the patient about where he lives once he has been released from the hospital into the community.

I proposed a similar amendment at Committee, when I asked for a requirement that the authorities should "agree" with the patient. In reply, the noble Baroness pointed out some of the difficulties that might ensue if there were no agreement. However, in the framework of the consensual nature of this legislation, which has been very much extended this afternoon by the Government's own amendments, I believe that this is an amendment which could be accepted.

I also brought the amendment forward again because, on re-reading the Official Report, I felt that the Minister had perhaps misunderstood the very limited nature of the amendment. In her reply to me, she said:


    "The Bill allows those responsible for a patient's aftercare under supervision to require him, if they think it is justified, to attend for treatment, rehabilitation or related purposes at specified times and places. Another requirement is that the patient should live at a specified address. To require the patient to agree beforehand would make the requirements unworkable".

I accept that and that is why the present amendment is drafted with the word "consult". She continued:


    "If the patient were to withdraw his agreement, the provisions would fall entirely and become meaningless. As presently drafted, if he fails to attend when specified, he has failed to comply with the terms of his discharge and a review of his case might ensue".—[Official Report, 4/4/95; col. 149.]

In her reply the Minister emphasised the requirements on a patient to attend for rehabilitation or other forms of treatment. I agree that a patient must be required to attend at a specified clinic, rehabilitation centre or whatever; but there is a difference between that and requiring him to live at a specific place without the right to consult with him before that happens. As I said earlier in Committee, that is an authoritarian position which does not sit comfortably with the other more consensual arrangements to which the Government have agreed and to which they have added

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significantly this afternoon. I hope that in this slightly modified form the Government will be able to accept the amendment. I beg to move.

Baroness Cumberlege: My Lords, I have already commented on the need to be sure that unreasonable restrictions are not being placed on patients. The Bill allows for full consultation before an application for supervision is made. In particular, I am sure that if there was any question of a patient not agreeing to live at a specified place, and if such a requirement was thought to be in his best interests, the application would not go ahead.

I have explained the information the patient is to be given, in writing, when the supervision application has been accepted and his rights of appeal to a mental health review tribunal about the imposition of supervised discharge. I do not believe that a separate process of consultation in respect of this particular requirement—if indeed it is imposed—is either necessary or desirable. The terms of a patient's discharge will be agreed as a package in terms of the aftercare services to be provided to him, the person who will be his supervisor and the details of any requirements thought necessary to help him comply with his care plan. I cannot agree that the additional consultation provision proposed under this amendment is necessary.

I hope that, albeit the noble Baroness explained very clearly the lighter touch she has had on this occasion, she will not press the amendment.

Baroness Jay of Paddington: My Lords, I thank the Minister for that helpful reply. In a sense we have a slightly different approach this afternoon in terms of consultation. As the Minister repeated, the oral and written notification to patients of their rights and their specific position under a supervised discharge order was re-emphasised in the group of amendments spoken to with Amendment No. 10. I feel that that would be reinforced still further if this provision were on the face of the Bill. However, I accept what the noble Baroness says. We can only hope that good practice is as good as she thinks it will be. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Jay of Paddington moved Amendment No. 31:


Page 6, line 32, after ("treatment") insert ("including the requirement to take medication").

The noble Baroness said: My Lords, in moving Amendment No. 31 I shall speak also to Amendments Nos. 33 and 35. Noble Lords may think that this amendment and the ones that follow —to which my noble friend Lord Rea will speak—are mutually exclusive. That is true. Noble Lords who were present at the Committee stage will remember that I tabled an amendment similar to Amendment No. 33, to which my noble friend Lord Rea will speak in detail, and that that amendment would have deleted from the Bill the power to take and convey, partly because of the legal doubts about the possible contravention of the European Convention on Human Rights and also because of the important practical question of how community supervisors and responsible medical officers would be

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able to treat patients effectively, even if they had the power to take and convey them to a place where treatment could be given.

As I said at the Committee stage, the proposals in the Bill as presently drafted fall between two stools. First, they offend those whose primary concern is to protect the civil rights of the patient; and, secondly, they do not fulfil the wishes of many clinicians who would like to have powers to treat patients on supervision orders with medication. Amendment No. 31 seeks to fulfil one of those concerns by inserting the taking of medication into the provision of medical treatment. That is included also in Amendment No. 35.

Noble Lords will remember that the community treatment order which was earlier suggested by the Royal College of Psychiatrists included that power. At present the British Medical Association describes the Bill as:


    "limited by the lack of power compulsorily to treat patients should they not comply with their recommended care programme".

Many recent reports on individual tragedies, such as that of Andrew Robinson and Christopher Clunis, emphasise that irregular medication contributed to the patients' instability and unpredictability and often in the end to tragic circumstances. I was interested to read on 6th April —the day we had our second Committee stage of this Bill—two experienced and senior doctors writing on this issue, perhaps somewhat surprisingly, in the London Review of Books. In relation to community treatment orders they said:


    "Keeping someone stable in the community can only be guaranteed if regular medication is part of that process. Since the '60s the basis of community care has been the availability of effective medication, the sine qua non of the business, which does not mean that social support, personal relationships and a psychological understanding are not also vital in psychiatric care. But, if the patient/client suffers from formal thought disorder, little can be done by the comforts of talking".

Of course there is the legal controversy as well as the clinical discussion about accepting some form of compulsory treatment order. Fears about mandatory treatment in the community seem to revolve around dramatic images of men in white coats forcibly injecting people on the kitchen table, although of course the Mental Health Act insists that medication can be given only in hospital. As Drs. Turner and Neave, the authors of the article in the London Review of Books pointed out:


    "Most patients, once they are in hospital, accept the verdict of the law and are compliant with medication. Given the choice between living in their own home and being in hospital, the great majority would prefer to be out of hospital. If it is laid down by an appropriate legal statute that they have to receive regular medication, then that would become part of the deal".

It would obviously only be "part of the deal" in extreme or emergency circumstances.

As to the problem of transgressing the European Convention on Human Rights, I draw your Lordships' attention to the report of the public inquiry on the Andrew Robinson case, The Falling Shadow, where that issue was addressed. I also remind your Lordships that the chairman of that inquiry was Sir Louis Blom-Cooper the distinguished barrister. The view of the inquiry was that European case law appears to demonstrate that a community treatment order with a requirement to take

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medication to prevent a deterioration of health is most unlikely to fall foul of convention obligations. Given that authoritative opinion, it is a little strange that the Government have not gone all the way in this Bill and introduced a provision for compulsory treatment in the community as well as the power to take and convey. The logic is surely that either the power to take and convey should be removed from the Bill, as I suspect my noble friend Lord Rea will argue in his amendment, or it should be extended to include medication. The purpose of this probing amendment is to invite the Government to explain why they have adopted an unsatisfactory middle course. I beg to move.


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