We say again, Scotland is the model to follow

4th May 2007
By Andy Bell

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The government’s controversial Mental Health Bill is now being debated in House of Commons committee. The Bill began in the Lords and has already been amended considerably. It now includes a test that requires a person to have some impairment to their decision-making abilities to be brought under compulsory powers. It requires that treatment imposed under compulsion should have some likelihood of helping the person. And it places limits on the use of supervised community treatment: the new regime of compulsory care outside hospital.

The Bill was subject to impassioned debate at Second Reading in the Commons. Many MPs brought with them personal experiences as family members of people who had experienced severe mental illness, as professionals working in health and social care, or as constituency MPs helping those in tough times.

It is indeed vital that the debate is informed by evidence and experience. Every year, 27,000 people are subject to the Mental Health Act. Their experiences of detention, and those of their families and the people who work with them, are key to framing legislation that is not only fair but that works for patients, their families and the communities around them.

What is remarkable about those groups is the breadth of agreement between them about the right way forward. Working collectively through the 80-member Mental Health Alliance, they are clear that a fair and workable (if not perfect) Bill is still possible but that it is some way away from the government’s current plans.

There are some signs of progress. In the Lords, the government made a small number of improvements to the published Bill, including giving more rights to 16- and 17-year-olds to make decisions for themselves. In the second reading debate, ministers also signalled a willingness to explore bringing back independent advocacy to the Bill: having dropped it last year from both of the draft Bills.

Beyond that, however, there are still many serious concerns about the government’s rejection of all of the amendments made so far.

One of the key issues is that of treatability: the condition that currently stipulates a person must be likely to benefit from any treatment imposed on them. Ministers have argued that this test has caused people with personality disorders to be ‘excluded’ from treatment.

At second reading, the Secretary of State claimed that, ‘people with personality disorders often have enormous difficulty getting the services they need, because they are too often dismissed as untreatable on the basis of what people think the treatability test means.’

The numbers affected by this misunderstanding, she added, were thought to be ‘several thousand’. The evidence on this matter is less clear-cut. There are no statistics showing whether or how often people with personality disorders are not given compulsory care because of a misunderstanding about the law.

There is some evidence of bed rationing, of priority over scarce resources being given to people with more readily medicated mental health conditions such as schizophrenia. Either way, we believe that this is not sufficient justification for broadening the scope of detention so far that a person could be sectioned with no hope that any treatment given to them would have any benefit.

Another source of great contention is the creation of supervised community treatment (SCT) orders. Many conflicting claims are made about community treatment orders. The minister, Rosie Winterton MP, stated recently that 56 suicides could have been prevented last year if such orders were available to compel people to comply with medication outside hospital.

Yet an international review, published last month, concluded there was no evidence from any country as to whether such orders are either ‘beneficial or harmful’. Instead, the availability of good quality community mental health services is a far more important factor in improving outcomes for service users and their families.

Lack of evidence is not enough in itself to argue against SCT per se. For people who quickly relapse on discharge from hospital, and who are a risk to others, SCT may be a better option than frequent hospitalisation. But we should not ask health professionals to predict which people will come into those categories.

The government’s approach to SCT would see it being used more often than necessary, and for longer. There will be no right of appeal against any of the conditions imposed upon the person: conditions that can include not just treatment compliance but abstention from ‘particular conduct’.

These can all be put right without losing the principle of SCT as a least restrictive alternative for the small group of people for whom it might be appropriate.

There is much we all agree upon. Mental health legislation should always be about balancing individual freedom with patient and public safety. The issue is how that can be achieved most effectively. In our view, we do not have to look far.

The 2003 Scottish Mental Health Act managed not just to balance rights and safety but to attain a synergy between them. By giving people enhanced rights to services, more limited use of compulsory powers and extra safeguards while under compulsion, the Act enjoyed the support of professionals, patients and the public.

The Scottish Act has a clear test of therapeutic benefit as well as defining principles and a right for the public to be assessed for their mental health problems upon request. In so doing, it makes the Scottish public no less safe but gives those of the public who have mental health problems the confidence that they will not be subject to unnecessary powers.

It is a model on which we need to draw before we miss the chance in a generation to create a genuinely modern Mental Health Act for England and Wales.

Andy Bell is chair, Mental Health Alliance.

Filed Under: Mental Health
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