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Mental Health Bill [HL]

moved Amendment No. 22: 22: Clause 13 , page 9, line 32, at end insert— ““( ) In section 45 (general interpretation), in subsection (1), insert the following definition at the appropriate place— ““““care plan”” means a structured plan which sets out timescales, responsibilities and services required to meet a patient’s assessed mental health needs;””.”” The noble Lord said: In moving this amendment, I shall speak also to Amendments Nos. 42 and 46. These three amendments are grouped because they each concern care planning. Amendment No. 22 seeks to provide a clear definition of what constitutes a care plan because it is not presently referred to in statute. This is necessary to ensure it is clear. Amendments Nos. 42 and 46 are intended to strengthen the statutory duty for the use of care planning both for community treatment orders, if the Chamber approves that provision, and for all detained patients, not just following discharge but from the outset of the order or section. I intend to speak to the main intent behind these amendments rather than address each in turn, and should make clear that in common usage a care programme approach, or CPA as it is known, is the term used to describe care planning. CPA is the process that should produce a care plan, but the purpose of these amendments is to make care planning itself statutory. As well as being chairman of the Mental Health Act Commission, I have also had a range of roles over many years in the areas of mental health and black and minority ethnic communities. I am not talking about minority ethnic communities today, although they will be among some of the main beneficiaries of these amendments. I am talking about the main practice standards. Care planning is a fundamental component of good mental health care. I am sure your Lordships will agree that good practice dictates that all detained patients should have a care plan as a reciprocal requirement of detention. The care programme approach, developed and promoted by the Department of Health, is the basis of effective care planning. As the noble Earl, Lord Howe, said in his eloquent speech on the first day of Second Reading, on the principles that should underpin a modern Mental Health Act, "““service users should be involved with their own assessment and care””.—[Official Report, 8/1/07; cols. 13-14.]" One would think that that was a simple enough requirement. One of the stated intentions of the Bill’s drafters is not only that patients should be subject to compulsion under the Act if there is appropriate medical treatment available to meet their assessed needs, but also that the CPA should ensure this takes place routinely, that appropriate treatment is available and that a care plan is drawn up for each patient as soon as possible after admission that informs their continuing care while in hospital and after their discharge. Unfortunately, despite the Government’s intentions, there remain serious problems in providing patients with robust and appropriate care plans. Quite frankly, it is not happening nearly well enough. Recent research evidence, for example the 2005 report ““Back on Track”” by the Mental Health Act Commission and the Sainsbury Centre for Mental Health, demonstrates that implementation of the CPA nationally is at best patchy. Many patients do not have a care plan, or, if a care plan is available in the patient’s record, it is not followed. It is a significant matter for public concern that, although the CPA has been in existence since 1990, care planning is not at present done well. This directly results in the severest of consequences, such as suicide and homicide. Most worryingly, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, published only last month, found that 71 per cent of preventable homicides and 45 per cent of preventable suicides were by patients who were not subject to appropriate CPA plans. This is despite clear evidence of severe mental illness, previous violence, self-harm or admission under the Mental Health Act. The report emphasised the importance of ensuring that CPA is properly used for high-risk groups. Many homicide inquiry reports have found similar evidence of incomplete or ineffective implementation of CPA leading to the most severe outcomes. An example from one of the most recent of these is the MN inquiry. MN stabbed and killed an elderly woman he did not know in her own home. The report concludes that the lack of CPA for MN was a contributory factor to the death of this elderly woman. It concludes, "““even though MN was subject to s3 and on s17 leave this did not ensure he received care according to the basic standards of CPA””." Indeed, it stated: "““The impact of CPA on MN’s care was virtually nil””." The inquiry report adds: "““It is expected that the Government will introduce compulsory … treatment in the community, through amended … legislation. We cannot emphasise too strongly that this must be backed up by an effective framework for community care””." Where a tribunal hears any application concerning a patient, "““this must, in our opinion, include a review or at least a consideration of their CPA care plans””." Similarly, the inquiry into the John Barrett case, published in late 2006, shows once again the need for good risk assessment and properly drawn up and implemented care plans in managing potentially violent or disturbed patients. Gillian Downham, barrister and the chairman of several of the homicide inquiries, including the inquiry into the MN case, was concerned enough about the repeated failings of CPA to commission an examination of CPA nationally. That was followed by a seminar that I chaired and which involved some of the leading people in the health, social care and legal professions to advise on the future of CPA. This resulted in specific national recommendations for strengthening CPA care planning, and what better way in which to do that than by making it a statutory responsibility? Recommendations from the full range of inquiries have consistently included calls for practice to be driven by care planning and review. Most of these reports stress the importance of fully involving patients, service users and carers in care planning, and that this should include adequate risk assessment so that care planning can contribute to the prevention of incidents and ensure patient and public safety. In the Mental Health Act Commission’s most recent biennial report, which is to be laid before this House, we wrote: "““Patients’ care plans under the Care Programme Approach are supposed to anticipate crises, and should take account of patients’ preferences in interventions. If care plans can specify actions on the part of the patient or services that will intervene in the early stages of any crisis and possibly avert it, the need to override the patient’s choices through compulsory admission may be avoided altogether””." Of course, one of the most significant drivers for the Bill has been many people’s concern about public safety. In essence, this means the assessment and management of risk to ensure that people receive the best possible care and treatment. I would be the first to argue that the Mental Health Act should be concerned predominantly with patient care, and I, along with many others in this House, remain concerned to ensure the right balance between the objectives of patient care and public safety. I strongly argue that care planning is central to achieving that balance. Good patient care based on care planning requires that clinicians follow a robust process of assessment and review, with appropriate treatment, care and support identified for the patient, especially on discharge. Care planning, however, does not define a specific intervention or set of interventions; it is a process, and as such it lends itself well to statutory regulation. And although the clear benefit for patients and the public that would result should be enough on its own to recommend these amendments, it would also underpin the community treatment order if the House approves that part of the Bill. Moreover, tribunals would be in a position to check the existence of care plans, ensuring that patients subject to the Mental Health Act in the community are being provided with a service and thus reassuring the public of their safety. The Department of Health has recently issued a consultation document on ways of improving CPA. The current proposals are unlikely to deal with what appears to be one of the main problems: the unwillingness, whether intentional or not, of some services and clinicians to give care planning the importance it deserves. One improvement must be to encourage greater clinical involvement, but I am forced to draw the conclusion, based on the evidence and the continuing spate of inquiries into homicides and suicides that I have highlighted, that effective implementation will be achieved only by giving the process statutory force and by ensuring that good practice is adhered to. After 16 years of Department of Health CPA guidance and guidelines, I also firmly believe this is now the only way in which compliance with CPA can be achieved. As I have already stated, I would be the first to argue that the Mental Health Act should be concerned predominantly with providing the best possible care for the patient, and we in this House are right to be concerned that some of the provisions of the Bill may not have achieved the correct balance between the objectives of patient care and public safety. Yet a very straightforward opportunity to tighten up the present system has been missed. These amendments would provide a straightforward opportunity to address this. Making care planning a statutory requirement would improve care for patients, ensure the safety of patients, and contribute significantly to improving wider public safety. I beg to move.