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Mental Health Bill [HL]

In Clause 25 and the other clauses and schedules grouped here, we have reached what is perhaps the final major area of controversy in the Bill: supervised treatment in the community. Before going any further I should say that the Minister need not be alarmed unduly by the fact that this is a clause stand part debate; it is not my intention to divide the Committee on this occasion. However, I think that a useful purpose would be served in Committee by avoiding a series of debates on a sizeable clutch of smaller amendments and concentrating instead on the broad issues of principle. The Government’s intentions in promoting the concept of community treatment orders are, I believe, entirely honourable. They want to create a means of preventing re-admissions to hospital and to provide a less restrictive alternative to in-patient treatment. If we agree that those are good aims, there seem to be only two questions of any substance to be settled. First, will the policy have any unintended and unwelcome consequences? Secondly, will the policy work? As to whether it will work, the evidence for this is pretty thin. Such evidence as we have is, at best, inconclusive. The problem is that it is very difficult to draw comparisons between what happens overseas and what may happen here, as we are dealing with different mental health systems. In some countries where there are CTO arrangements in place, there is a far greater degree of support from community services than there is in Britain. Studies carried out in the USA, where CTOs are used in a number of states, prove very little. The conclusion of one major study said: "““There is no study that proves that a court order for out-patient treatment, in and of itself, has any independent effect on outcomes. No randomised clinical trials have examined the relative efficacy of involuntary out-patient treatment and assertive community treatment, the alternative with the best record of producing positive outcomes for people with severe mental illness””." I am unaware of any other study that points to a more positive conclusion; the Minister may wish to correct me. The point about relative efficacy is important. It could indeed be true that early intervention and assertive outreach are just as effective in achieving good outcomes as involuntary treatment. If so, those are surely the services we should be strengthening, rather than making patients wait until they reach a crisis and then forcing them to receive the services. There is a false logic at play here. Indeed, to the extent that service users found CTOs beneficial, it may in some cases have been because, as a result of the order, services were made available to them which they would have used voluntarily but were not given access to until they were compelled. If so, that is not a very good argument for the introduction of CTOs. Do CTOs prevent readmission? A Cochrane meta-analysis of the data found no difference in readmission rates and calculated that it would take85 CTOs to prevent one re-admission to hospital. A Canadian study reached a rather more positive conclusion. Another study in Western Australia found that CTOs increased the likelihood of readmission. Much depends on the attitude of the patient. Regrettably, in a further study, it was found that patients who lacked insight into their condition were less likely to consider community mandates to be fair and effective. Yet those are exactly the kind of patients targeted by CTOs, because they fail to comply with treatment. If we need to worry about the evidence base for CTOs, we should be equally worried about their unintended down side. The first of down side is that CTOs are likely to lead to an increase in the use of coercion. That, at least, is what the evidence currently suggests. It is a point of particular concern in the context of black and ethnic-minority patients. In Scotland, where CTOs were introduced with slightly different conditions, the anticipated total number of people who might need to be placed on a CTO was reached almost within six months of the provisions taking effect. Another recent study estimates, on the basis of the Scottish experience, that between 6,000 and 9,000 people are likely to have CTOs applied to them in the first six months. If that is right, the Government’s longer-term projections of use may underestimate the real numbers by a factor of two or three. Unfortunately, the provisions in the Bill lead us to a very similar conclusion. They do not do enough to ensure that only a limited and strictly defined group of patients could be made subject to CTOs, which is what the joint scrutiny committee recommended. The criteria for making a person subject to a CTO are significantly wider than in other jurisdictions such as Australia and New Zealand, both of which have a much tighter definition of mental disorder and a broader range of exclusions. In Scotland, too, the definition is tighter. By contrast, in the Bill we have not only a wide definition of mental disorder; we also have limited exclusions, a wide definition of treatment, wide entry criteria to a CTO and greater numbers of clinical staff, including occupational therapists, who can keep people under compulsion. If one adds to that what most of us acknowledge is a pervasive climate of defensive practice, the cumulative effect points to CTOs being used far more widely than Ministers are making out. We and many others wanted some clear reassurance in the wording of the Bill that CTOs would apply only to genuine revolving-door patients. But the Bill contains no such wording, and I cannot help feeling that that is deliberate. It is not surprising that service users are fearful of these provisions. They see them as increasing their chances of being made subject to compulsion; they fear that compulsion will be used when people are not severely unwell; they fear that they will not receive what they need in the way of support; and, perhaps most of all, they fear that it will be difficult to come off a CTO because clinical staff will play safe to ensure compliance. The danger is that these realistic fears about CTOs will drive people further away from the services and treatment that they need. The delicate relationship between service users and doctors requires trust to keep it afloat. If the fear of CTOs is as I understand it to be, then the end result could be exactly the opposite of what we want to see—an increasing level of disengagement from mental health services and a higher risk of relapse and readmission to hospital. I expect that the Minister will think me something of a prophet of doom, but I simply say to him that we have to base our thinking on the available evidence. Unless the Minister has some different evidence, the introduction of CTOs in the manner proposed seems to me to be a leap in the dark that carries huge risks. If the criteria for compulsion were narrower, and especially if we could somehow restrict the applicability of CTOs to revolving-door patients, I would feel a good deal easier. As it is, I have to say that the Government have further work to do.