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Lord Montagu of Beaulieu: My Lords, I thank the Minister for his reply and other Members of the House who have joined in the debate this afternoon. I believe that we agree with most of the report but are worried about its omissions, which we hope can be dealt with in years to come. The historic environment should lie at the heart of all government policies. Although everybody is interested in our heritage, there is concern about the future and not the past. We have a great international responsibility, as England's heritage is in many respects the world's. We shall have a richer future if we recognise the value of our historic environment and manage it thoughtfully, efficiently and proudly. I beg leave to withdraw the Motion.
Lord Hunt of Kings Heath: My Lords, with the leave of the House, I shall now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:
"Millions of people--perhaps as many as one in six of the population--face a mental illness at some point in their lives. About 630,000 patients with serious mental health problems are being cared for by specialist mental health services across England and Wales at any time. For every individual with serious mental health problems, there are many others--families, carers, friends, and the wider public--who are affected, sometimes with tragic consequences.
"First, we have made investment a priority. For the first time, ring-fenced funding is expanding what have for too long been Cinderella services within the NHS especially for those who are most seriously ill. By April next year we will have in place almost 500 extra secure beds, at least 320 extra beds staffed 24 hours a day, 170 assertive outreach teams and every patient with complex mental health needs will have access to services 24 hours a day, seven days a week.
"We have already recruited 3,000 new staff in mental health services. The NHS Plan we published in July announced a further #330 million investment in those services over the next three years. There will be further substantial increases in staff and new investment in specialist community health services and improved primary care services for all people with mental health problems. This investment will ensure public safety and improve patient care.
"Secondly, we have made reform a priority for mental health services. Last year we published the Mental Health National Service Framework to give local health and social services for the first time clear national standards. It will tackle the lottery in care which means some patients in some areas missing out on services and treatments that others receive as of right. It provides a clear statement for patients and their carers about what services they can expect wherever they live. It has been widely welcomed by patients, carers, clinicians and managers.
"Good quality care and treatment is the key to making sure that most people with mental health problems never need to fall within the scope of mental health legislation. Despite public perceptions to the contrary, the overwhelming majority of people with mental illness are a threat to no one. Indeed, many mentally ill patients are among the most vulnerable in the community. Reducing the stigma which attaches to people with mental illness should be a priority for any caring, civilised society.
"There will always be some people, however, with serious mental disorder who do not seek care and treatment when they need it. Sometimes they do not recognise how ill they are; sometimes they are so disabled by their mental illness that they are not able to seek help; and sometimes they choose not to do so. In some cases, this means that a person with serious mental disorder will pose a significant risk to other people in their family or in the community as well as to themselves.
"The current 1983 Mental Health Act is largely based on the last major review of the mental health legal framework which took place in the 1950s. Since then the way services are provided has dramatically changed. More seriously the current laws have failed properly to protect the public, patients or staff.
"Under existing mental health law, the only powers compulsorily to treat patients are if they are in hospital, but the majority of patients today are treated in the community. Public confidence in care in the community has been undermined by failures in services and failures in the law.
"The policy lost public confidence because in too many cases neither services nor the law properly protected either patients or the public. There have been no requirements for local health and social services to exchange relevant information about patients. Services have too often worked in isolation from one another. Too often, severely ill patients have been allowed to drift out of contact with mental health services altogether. Many patients have failed to comply with treatment. Clinicians have had to wait until patients in the community became ill enough to require admission to hospital. This has prevented early intervention to reduce the risks to both patients and the public. In particular, existing legislation has failed to provide adequate public protection from those whose risk to others stems from a severe personality disorder.
"As a result, patients and the public alike have been put at risk. They have been denied the protection they need. The tragic toll of over 1,000 suicides and 40 homicides every year involving patients who have been in touch with mental health services in the previous 12 months graphically illustrates the failure of the old legal framework. It is outdated. It is in desperate need of reform.
"Our proposals clarify the circumstances when care and treatment should be provided without the consent of a person with mental disorder either in their own interests or in the interests of public safety. They introduce new safeguards to protect a patient's rights where care and treatment is given without their consent.
"We have consulted widely over the last year on our plans for reform. They will mean major changes in four areas. First, safeguards will be improved for patients. Removing an individual's liberty against their will is a very serious step to take and must be balanced by suitable safeguards which are fully consistent with the Human Rights Act.
"For the first time then all decisions to apply compulsory powers to treat a patient for more than 28 days will be subject to independent scrutiny by a judicial body--the new mental health tribunal. The tribunal, which will be chaired by a senior lawyer, will consider the care and treatment plan proposed by the clinical team. It will take independent advice from medical and other experts and from patients or their representatives. Its decisions will be binding on the NHS and will be regularly reviewed. Patients who are subject to compulsory powers will as now have the right to free legal advice. They will also for the first time have a right to help from a specialist independent advocacy service.
"A new commission for mental health will also be established with a clear remit to monitor the quality of decision-making and whether the powers in new legislation are being used in a way that is consistent with the key principles that underpin it. The commission will provide new safeguards to protect the rights of people with long-term mental incapacity who are in need of specialist treatment for mental disorder but who are not able fully to participate in decisions about how that care is provided. The commission will be fully independent and will report annually.
"Secondly, there will be new safeguards to protect patient and public safety by extending compulsory treatment powers from the hospital ward into the community. The complexity of current laws which mean that there are several routes to compulsory treatment will be simplified. In future there will be a single entry point to compulsory treatment based on a full and fair assessment of each individual's care and treatment needs.
"New care and treatment orders will mean that patients subject to compulsory treatment, whether in hospital or in the community, will have to comply with the terms of their treatment programme. Refusal to do so could result in the patient being readmitted into hospital. Care plans will take into account a patient's best interests and any risk that they pose to other people. Compliance with treatment and contact with services will both be enforced under the new legislation in a way that was never possible under the 1983 Act.
"Care and treatment orders in the community will allow clinical teams to intervene earlier to prevent a patient's condition deteriorating. The risk that patients may pose to themselves or to others should be reduced as a result.
"Thirdly, public protection will be further strengthened by introducing new duties, backed up by robust safeguards, to cover the disclosure of information about patients suffering from mental disorder. Inquiry after inquiry has demonstrated that a breakdown of communication between local services responsible for a patient's care has been a significant factor in many of the homicides and suicides committed by severely mentally ill patients. This situation cannot be allowed to continue.
"The Government are also committed to improving the level of service provided to victims generally and to giving proper recognition to the needs of victims of mentally disordered offenders in particular. The new legislation will allow victims of mentally disordered offenders to be given appropriate information about the offender's discharge as well as his detention. We also aim to enable victims to make representations to the mental health tribunal when it considers discharging the offender from hospital.
"Fourthly, there will be new criteria giving clear authority for the detention of patients who pose a significant risk of serious harm to others as a result of a mental disorder. That will include the detention of dangerous people with severe personality disorder. The Government are determined to deal with the challenge to public protection posed by this small group of people.
"Our proposals have been the subject of extensive consultation following publication of the joint Home Office and Department of Health document in July 1999. At present neither the law nor services are geared to cope with the risks posed by dangerous people with severe personality disorder. Many cannot be compulsorily detained in hospital because under the current law they can be defined as untreatable. Many are sent to prison after committing a serious crime and are a danger to the public on release. As a consequence, there has been a gap in the protection that mental health laws should afford the public, a gap we will now close.
"In place of the flawed concept of treatability, new criteria will separate those who need treatment primarily in their own best interests from those who need treatment because of the risk they pose to others. In cases involving those who present a high risk of harm to other people, the use of compulsory powers will be linked to a care and treatment plan which describes how to treat the underlying mental disorder and manage behaviours arising from that disorder. Compulsory treatment can go ahead only
"Similarly, my right honourable friend the Home Secretary will have powers to direct those already serving a prison sentence for assessment and treatment. Subject to the new mental health tribunal, dangerous people with severe personality disorder will be able to be detained for as long as they continue to present a high risk to others--if necessary, indefinitely. It should go without saying that the full range of safeguards which I outlined earlier to the House will apply to this group of people.
"The Government recognise that taking new powers to deal with those posing the greatest risk to the public will not by themselves be enough to safeguard the public. New specialist services are needed too. In the recent spending review, #126 million has been allocated across the Department of Health, the Prison Service and the Home Office to develop assessment and treatment services for this high risk group.
"The extra resources will allow extra staff to be employed, provide 320 new specialist places in high security settings within the Prison Service and the health service as well as 75 specialist hostel places. New approaches to the assessment of this group are currently being piloted in both the Prison Service and the NHS. Treatment pilots will begin next year. The evidence will be used to inform future decisions about how best new services should be structured.
"These changes amount to the biggest shake-up in mental health laws in four decades. They will strengthen the current law. They will introduce new safeguards for patients. They will improve protection for the wider community. Taken with the major investment and reforms that are now taking place in our mental health services, these proposals will enhance the safety both of patients and of the public. I commend them to the House".
The House should be in no doubt of the importance of these announcements for the future of mental health services in this country. I agree with the Government that mental health is a clinical priority for the NHS and that the legal framework is outdated and in need of reform. The Opposition will back fully many of the proposals and aims adumbrated in the Statement. In particular, we agree that as much as possible should be done to reduce the stigma attaching to mental illness. Get rid of the stigma, and you are more than half way to achieving what in general we lack at present, which is an attitude of acceptance and tolerance of mentally ill people by the community at large.
We also agree that all patients who are mentally ill should have access to treatment appropriate to their needs in the most appropriate clinical setting. We acknowledge and welcome the new resources that the Government are directing to the delivery of care. That said, we are dealing here with some extremely complex and troubling issues. Since the publication of the Green Paper on mental health just over a year ago, many people have been worried that the prime focus of government thinking and of government pronouncements appeared to be on the issue of dangerousness and on the need to introduce mechanisms for compulsory detention of those with a severe personality disorder who pose a risk to others or to themselves. Although the Statement makes it clear that such people are small in number compared to the large number of people with a treatable mental condition, the whole balance of the Statement is, I think, regrettably skewed towards this subject and away from others of at least equal importance. The impression that this creates is perhaps a little unfortunate. I do not wish to underplay the need to protect the public where that is necessary. This is a very real concern. But it does little to advance the cause of reducing stigma if we dwell too much on dangerousness and compulsion at the expense of those many other people who represent no danger at all and who simply want, and who deserve, better treatment and a better service.
In seeking to protect the public from dangerous individuals, we must also beware of putting new mechanisms in place that lean too far in the other direction; in other words, mechanisms which allow far too readily for the indefinite detention of people who have done no harm to anyone and indeed may never do so.
I welcome the proposals for the creation of a new mental health tribunal and of a commission for mental health. But I should welcome, too, the Minister's clarification of the whole issue of compulsion. Although there may be place for compulsion in extreme cases, both compulsory detention and compulsory treatment should be regarded as a last resort.
Can the Minister also enlarge on a passage of the Statement which is unclear to me? It speaks of introducing new criteria to replace the concept of treatability, which up to now has determined whether or not a patient can be compulsorily detained in hospital. It may be right that treatability is no longer an appropriate criterion in this context; but if that is so, why does the Statement go on to refer to people with severe personality disorder obtaining treatment under a care and treatment plan? I thought that the whole issue with PD was that what we call personality disorder is made up of those categories of mental disorder that are considered untreatable. Can the Minister explain what lies behind this part of the Government's thinking?
Can he also say what place the Bournwood judgment has in the White Paper and whether in particular the Government acknowledge the need to build in a coherent set of provisions to take account of a patient's
In speaking of a single point of entry for compulsory treatment, as the Statement does, what arrangements do the Government envisage for initiating what I could perhaps be forgiven for terming loosely the "sectioning" process in an emergency? Will a psychiatrist or clinician, acting alone, be permitted to detain a patient in the first instance, as the current Mental Health Act provides for?
I welcome the Minister's acknowledgement of the value of advocacy for mental health patients. Does he agree that in this context safeguards should be in place to enable patients to receive full information about the treatment that is proposed for them, including the risks of that treatment and its possible side-effects? As the Minister will be aware, there are strong feelings among mental health charities and organisations that special safeguards should continue to apply to psychosurgery, electroconvulsive therapy and long-term drug treatment and perhaps should be extended to such areas as polypharmacy and force feeding. Does the Minister also agree that if we are to focus, as we should, on the needs of the patient, it is important to provide the patient with access to an assessment of what are his or her needs?
There is much here that we can welcome. We look forward to contributing to the debate on these important matters over the weeks and months ahead and, in due course, to the introduction of the new legislation.
Baroness Northover: My Lords, I thank the Minister for repeating the Statement. I am sorry that our principal spokesman on health matters, my noble friend Lord Clement-Jones, is unavoidably absent and thus unable to reply to the Statement. We welcome much of what we have heard and, in particular, the way in which the Government have progressed from their position in the Green Paper to take greater account of the response of the Select Committee.
This is a very difficult area in which it is vitally important to balance the rights of individuals to their liberty with the rights of those in the wider community to their safety--something which has exercised many, for example, in the Russell case. It also concerns caring for extremely vulnerable people and I agree with the noble Earl when he said that this is a much wider area than simply the protection of the public.
There is much in this White Paper that we welcome and that will be welcomed by clinicians, patients and carers in the field of mental health. We welcome the proposal to establish an independent mental health tribunal to scrutinise, within 28 days, cases in which compulsory powers have been taken to treat a patient. We also welcome the provision of specialist advocates and legal aid to patients.
Given the positive proposals in this Statement, can the Minister comment on how long it may be before parliamentary time might be made available for this legislation, and when it might be implemented? Can the Minister also tell us what might be done in the meantime to provide atypical drugs with less severe side-effects to promote compliance in treatment where appropriate among mental patients?
Will the Minister also give the House further information about the provision of resources to support these measures, especially when bearing in mind the current severe shortage of psychiatrists and psychiatric nurses? However positive some of these proposals may be, if they are under-resourced, they will mean little. Given that the last mental health Acts were passed in 1959 and 1983, I am sure that the Minister would agree that this is a once in a generation opportunity.
Lord Hunt of Kings Heath: My Lords, I should like, first, to thank the noble Earl and the noble Baroness for their welcome for the broad principles contained in the Statement and, indeed, for their constructive responses this afternoon. Perhaps I may say to the noble Earl that I very much agree with him as regards the priority which mental health is to be given in the National Health Service. I believe it is significant that mental health is one of the three core priorities of the health service, alongside coronary heart disease and cancer services. It is very important that everything we seek to do in relation to legislation is underpinned by a proactive development of services in the National Health Service. The one goes with the other.
I also accept that the issue of stigma is one that we have to tackle with great energy and perseverance. The fact that so many people in our country suffer some degree of mental illness at any one time is surely the foundation on which we need to build. We need to work together with statutory agencies and voluntary organisations to promote a much more positive attitude towards mental health and towards those who suffer from mental illness.
The noble Earl was right to say that we are dealing with complex and troubling issues here. I felt that the Statement struck a balance between necessary concern as regards safeguarding individuals from self harm and protecting the public in general from risk. However, in order to see a balanced picture of what we seek to do in this area, noble Lords need to take the Statement together with our intention to reform mental health legislation alongside the priority generally being given to mental health services within the NHS and to the publication of a national service framework which will enable us, over the 10-year time-frame of the national service framework, to produce a much higher quality and more robust service.
The noble Earl asked me, quite rightly, about a number of issues relating to the safeguards that necessarily will be made available for people who may be affected by compulsory treatment orders. I believe that the establishment of a new independent tribunal, which will review on a regular basis those decisions, the right of an individual to seek help from independent advocacy, the establishment of a new commission for mental health which, most importantly, will oversee the operation of these proposals, along with tighter criteria on the use of compulsory powers, will all ensure that a proper balance is struck between public safety and individual safety and the rights of individuals.
The noble Baroness went on to ask when legislation is likely to be brought forward. I am afraid that all I can say at this stage is that it shall be done at the earliest possible moment. Obviously, implementation will follow the legislation.
The noble Baroness also asked me about resources and staffing. Both the noble Baroness and the noble Earl were right to pinpoint these particular issues. I believe that there is good news in relation to staffing in the mental health field. Over the past two years we have been able to bring in 350 more consultants and over 2,000 more nurses. It is also significant and important to note that 21 per cent of the total number of new nurse consultant posts that have been approved come from the field of mental health. That is important both in itself and in the leadership that
The noble Earl, Lord Howe, asked about the issue of compulsion. I accept his point that it is very much a last resort. Our aim is to improve the overall quality of mental health services in the NHS so that people who may have come under an order in the past, or even in the present, can be treated in the normal way and an order will be a last resort.
The noble Earl asked about the issue of treatability. The change in approach that we want to make will aim to ensure the flexibility for compulsory powers to be used in whatever way best meets patients' needs and is consistent with any risks that they pose to themselves or to other people. It will also help to ensure that patients who require care and treatment under mental health legislation are not excluded because of too narrow a definition of mental disorder. One of the effects of the change will be to move away from the narrow concept of treatability that applies to certain categories of mental disorder in the 1983 Act.
So far as concerns the issue raised by the noble Earl in regard to the assessment and treatment of people with severe personality disorders, two pilot exercises are currently being undertaken, in Rampton Hospital and HM Prison Whitemoor, which are looking into the assessment and treatment processes and interventions to evaluate what actually works. This will very much inform the process of assessment and treatment in the future. I understand that it will be another 18 months before the pilots come to fruition, but they will be extremely valuable in enabling us to take forward these important issues. I hope that that answers most of the points raised.
Lord Ackner: My Lords, perhaps the Minister will be able to help me on one matter. Over the years, I have drawn attention to the report of Lord Butler's committee in 1975 dealing with the mentally ill prisoner and recommending a reviewable sentence, a new form of indeterminate sentence which would operate on the basis of the prisoner being obliged to be reassessed every two or three years and not being allowed his liberty until the reviewing authority said that it was safe for him to be allowed to leave. On every occasion I have raised this matter, I have been told that the Government are giving earnest consideration to the Butler report and how it can be used and modified. It has been referred to from time to time during inquiries of the kind to which the Minister has referred, where murder has been committed by persons who have been given their liberty after being discharged from prison.
Can the Minister explain how this fits in with these proposals? I heard nothing which indicated that there was to be a new form of indeterminate sentence to deal with this problem. If there is not to be a new form of indeterminate sentence on the basis of or analogous to the reviewable sentence, there would seem to be a large gap in this proposed legislation.
I should also like to know how the compulsory detention of someone who is untreatable, and is known to be untreatable, can fit in with the ECHR legislation and fundamental rights. The suggestion that someone should be incarcerated without limit of time, having committed no offence at all and not being incarcerated for treatment because, ex hypothesi, there is none, seems to raise a very difficult question.
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