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Mental Health Bill [HL]

I rise briefly to comment on the amendments. The noble Baroness, Lady Knight of Collingtree, has done vulnerable patients in this country a major service. She has highlighted the dangers and disasters that occur when there is bad nursing care and bad basic care. She has highlighted the mixed messages that have come from medicine and have created fear among the public. She has also alluded to her presumption that the Minister will say that the amendments fall outside the scope of the Bill. Indeed, I expect that he probably will come back to her with that answer, but that should not dent her campaign to speak up for the vulnerable. I will try to clarify briefly some aspects for the Chamber. I declare an interest as I am on the BMA ethics committee. It has been said that feeding is a medical treatment. That is a very sloppy use of language. Artificial feeding is a treatment intervention, and we have to be very clear about that. Every patient has a right to have food and fluid. If they cannot swallow, and that is the problem, one has to look at the least burdensome way to maintain their hydration and nutrition. My own view is that fluids and food should be uncoupled. There are many instances where people cannot drink or keep their fluid intake up, which can be critical in some days, but it is not so critical if they cannot eat for some days. It takes much longer for nutritional deficit to come in. However, severe dehydration can result in renal failure very quickly. The artificial means are at issue, which is, basically, whether you put a tube directly into the stomach. In thin people that is quite an easy procedure, but in obese people that can be very difficult. If not possible for some reason, you might end up with intravenous nutrition. That is very complicated and, therefore, a treatment procedure. It is more complicated than much chemotherapy, which is used in cancer care, and must be classified as a treatment. Intravenous nutrition is very expensive and has many potential adverse effects, including the risk of septicaemia. You can make patients desperately ill, or kill them, if you get the mixture you are giving them wrong, either in its composition or the rate at which you give it. We can go right from the simplest, but the most important, feeding and drinking, right through to parenteral nutrition, which is sometimes needed. There will be many hundreds of patients in this country today who will be on parenteral nutrition and whose life will be maintained by it. It is also correct that there are patients who come in and cannot swallow. That swallowing assessment is usually made by a speech therapist. We live in a risk-averse culture, so there is a tendency to veer against trying some fluids again. I have been in a clinical situation with a patient who was not being given anything by mouth, because she had impaired swallowing. She desperately wanted a cup of tea. I made her that cup of tea and sat with her while she drank it. She managed to drink it down. She did not choke on it. She knew the risk of choking and I knew the risk of choking, but it was a risk that we were jointly prepared to take. I worry that the risk-averse culture that we have come to live in has meant that many nurses are finding themselves torn between wanting to let the patient try to drink again and knowing that there cannot be a speech-therapist reassessment—because of a shortage of speech therapists—for several days. It is also true that giving fluids is easy, whereas nutrition is difficult, as I said. You can keep patients at home with fluids run under the skin—subcutaneously—from a drip bag. You just put a nail in the wall—a picture hook will do—hang the bag on that and run the fluid under the skin. It is remarkably safe. You can even teach the family how to change the bag of fluid. Patients can stay at home with fluid going. Again, in our risk-averse culture that does not happen as often as it should, because people get frightened about doing things with drip bags at home. When the Minister responds to this amendment, will he be able to promise the Committee and all the vulnerable patients in this country that inspection standards will look carefully and rigorously at fluid and food for people who are vulnerable? My profession may not love me for saying that he might also want to ask the medical profession to be very clear in its definition of what a treatment is and of what falls under good standard nursing care, which should be the right of every patient. Clarification about advance statements will also be helpful. They will come in and will be important for every decision made for a patient who cannot make a decision for themselves, because those statements will inform that decision-making. They will need to be taken into account as the decisions are formulated. In a debate such as this, we very much miss Lord Carter, who worked so hard on the Mental Capacity Bill and on mental health. He, perhaps more than anyone, had knowledge and an ability to assimilate all the bits of information built up over so many years of experience. I am sure that the Minister will do admirably in his summing up and in his response to this very important amendment—important because of the principle laid out.