Mental Health Bill [HL]

My Lords, I want to declare a number of interests before I make my brief comments about the Bill. I was part of the team that devised the Delivering Race Equality programme already mentioned by the noble Lord, Lord Patel of Bradford. It is worth mentioning the others who have worked hard to deliver that programme and are still working hard on the issues of mental health and black minority ethnic communities. They are Dr Kwame McKenzie, Professor Kam Bhui and Professor David Sallah, who is at this moment working hard on delivering race equality in mental health. Along with the Minister, Rosie Winterton, I am the co-chair of the steering group charged with improving the experience of mental healthcare for black and minority ethnic communities as part of the Delivering Race Equality programme. I am also the chief executive of Turning Point, a social care organisation that works with more than 135,000 people in 250 locations, more than 6,000 of whom have mental health challenges but many of whom have mental health challenges, substance misuse challenges and learning disabilities. Our services span forensic mental health through to learning disabilities and substance misuse. Turning Point is also a member of the Mental Health Alliance already kindly mentioned by the noble Baroness, Lady Bottomley of Nettlestone, and is, I think it is fair to say, a leading member of the Making Decisions Alliance, which is relevant to the Bournewood gap already mentioned by the noble Lord, Lord Rix. Due to time constraints and the wealth of experience already expressed by others in the Chamber, I shall focus my remarks on a few key points. First, I acknowledge the open style in which the noble Lord, Lord Warner, introduced the Bill when he invited the House to engage with the Government to make improvements. We all want a solution that promotes mental health and gets people the right help at the right time—and, with due regard to the remarks made by the noble Lord, Lord Bragg, protects the public. I will be the first through the open door to assist the Government in making the Bill better. I want to refer to several issues: context, service improvement, dual diagnosis, community treatment, the Bournewood gap and personality disorders. That may sound like a long list, but I promise that I shall be quick. As it stands, the perception is that the Bill will not in and of itself improve patient care and promote public safety. It is also the perception that the Government have kept some of the more controversial clauses but dropped some of the more important safeguards, such as advocacy. I believe strongly that services should be improved before compulsory powers are increased. Compulsion should always be a last resort. In that, I agree very much with the remarks of the noble Lord, Lord Warner. This very afternoon, service users and carers from all over the country will no doubt have made similar views known to many colleagues in another place. The Bill is perceived as being about the law of compulsion and not about service delivery. However, it cannot be divorced from the wider context. The fact is that if people can get the right support when they need it, more people will use services voluntarily and compulsory powers will be needed less frequently. The overwhelming evidence is that if people voluntarily seek help, they are more engaged with services and are more likely to get better. Therefore, society is safer. Mental health law should be updated, but services should be improved as an essential first step before increasing compulsory powers. It would be irresponsible for this House simply to rubber stamp the use of further compulsion with no absolute guarantees that that will go hand-in-hand with the essential service improvements. There is evidence that services have improved. There is less discrimination in the use of compulsion in some BME communities. We want a reduction in the widespread cuts in mental health services that have been applied to tackle the great NHS deficits. Universal access to voluntary community treatment, especially preventive and crisis intervention services, will be further evidence of improvement. We want fewer inquiries that cite critical structural failure and lack of resources as key factors leading to homicides or serious incidents, such as the Barrett inquiry, which said that the remedy for what went wrong in that case lies not just in new laws. That would all be evidence that services have improved. Services need to be improved in the following ways. There needs to be a focus on funding prevention; more support on discharge patients and ongoing care; advocacy to help people to express their views on their treatment, as the noble Baroness, Lady Morgan, has already said; and improved inter-agency working through the care programme approach already mentioned by my noble friend Lord Patel of Bradford. The Government should consider giving the CPA framework statutory force, so that services have a legal obligation to follow it and to provide the treatment and support outlined in the care plan. My organisation Turning Point has focused on dual diagnosis in cases where someone has both a substance misuse problem and a mental health challenge. We agree with the Government that people should not be subject to compulsion on the basis of drug or alcohol dependence alone. However, I am concerned that, under the new Bill, people with a dual diagnosis who need help under the Act might still be turned away. It should be clear not only in the code of practice but in the Bill that drug or alcohol dependency should not exclude people from treatment if they also have another type of mental disorder. As has been mentioned, the Bill proposes supervised community treatment in the form of community treatment orders. These can be acceptable only if community treatment is for a very tightly defined group of people—we have already referred to revolving-door patients—and is accompanied by stronger safeguards such as time limits, with the close monitoring of the powers that clinicians will have over patients’ freedom; the condition that they live in a certain place or abstain from particular conduct; and sufficient resources for appropriate—and culturally appropriate—treatment to be available. Discrimination also needs to be acknowledgedand addressed in practice. The Government have acknowledged that there is widespread discrimination in mental health services, and all the evidence is that this is likely to be mirrored under supervised community treatment. Furthermore, under community treatment, more people will be subject to compulsory powers as they will not be dependent on the need for admission. This will mean that more people from black and minority ethnic communities will face discrimination. We welcome the proposals to deal with the Bournewood gap, although it has taken eight years to get to this stage. However, we want changes that simply make that gap fairer. As the noble Lord, Lord Rix, has already mentioned, a simple change would be to change the automatic review period to six months, not a year, and to ensure that the right safeguards are in place to protect people who lack the capacity to give informed consent to treatment. In particular, there must be safeguards for people where depriving them of their liberty is not authorised. Will the Minister agree to meet representatives of the Making Decisions Alliance to discuss the proposals on the Bournewood gap in more detail? My organisation works very closely with significant numbers of people with personality disorders, some of whom have an official diagnosis and some of whom who do not. Of these, most are in mental health services, but some substance misuse services, particularly the open-access services, are reporting an increasing number of them. We acknowledge that there have been problems with the treatability test: namely, that it is often misunderstood, is inconsistently applied, and has contributed to a culture where some patients requiring compulsory treatment are labelled as untreatable and are therefore denied access to the services that they need. This perception also affects people seeking help voluntarily. It also identifies the problem of focusing on certain disorders, and therefore on certain individuals, leading to some people being singled out. Although I agree with the Government’s analysis of this problem, the new proposals may still fail to meet the personality disorder challenge. There is real concern that, whether the treatability test or the appropriate treatment test is used, people will not get access to treatment because there is little consensus on what treatments are appropriate. Services for people with personality disorders are still poor, and staff are not necessarily trained properly to work with people with a personality disorder. The Government are at last addressing some of the glaring inequalities, which have already been mentioned, that some people from black and minority ethnic communities experience when using mental health services. The work of the Delivering Race Equality programme is hugely important. The first Count Me In surveys have already highlighted shocking inequalities, the delivery of focused implementation sites has started to spread good practice, and there are pilot community engagement projects and a coalition of stakeholders to support the better delivery of mental health services to black and minority ethnic groups. The Bill should act to support this work and not militate against it. The sufficient cultural training of approved mental health professionals and responsible clinicians is also critical, and principles are needed in the Bill to ensure that it is implemented in the way in which it is intended to be. This is particularly relevant to black and minority ethnic communities. In conclusion, the Bill needs substantial amendment. As it stands, it will not improve patient care or necessarily promote public safety. Services should be improved before compulsory powers are increased, and compulsion should be used as a last resort. The Bill is the start of the process, and I compliment the Government on at least acknowledging that this process is needed. We are, however, a long way from producing a Bill that will satisfy the needs of many of the people protesting in the other place this evening.