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Mental Health Bill [HL]

It is with some humility that I follow that speech. I pay tribute to the courage of the noble Baroness, Lady Murphy, in throwing down a challenge to some of her professional colleagues in that way. I am afraid, however, that I come to a different conclusion from the noble Baroness and other noble Lords on some of the evidence we have all seen. I continue to find it surprising that there remains so much opposition to the idea of supervised community treatment orders. The idea totally adheres to the principle that people should receive the care they need in the least restrictive setting. The Bill introduces a change reflecting the fact that clinical practice has changed since the 1983 Act was passed. In 1983, most acute mental health services were provided in a hospital. The world has moved on, and we have a much wider range of community-based mental health services. Sometimes in this debate, I do not think the full extent of that change has always been acknowledged by some noble Lords. One thing that has not changed as much as we would like, however, is the continuing number of revolving-door patients. They leave hospital, disengage from mental health services, do not continue with their treatment, their health deteriorates and they end up compulsorily detained in hospital. We may have differences of view about the numbers involved, but that is the cycle we are trying to deal with. If there is an alternative, we ought to use it. For reasons I shall go into in more detail, the supervised community treatment order provides an option. Not only we, but other countries have discovered that there is an alternative. As I said at Second Reading: "““We also know that some form of compulsory community treatment is established in jurisdictions in New Zealand, Australia, Canada, Israel, Sweden, Belgium, Portugal and Scotland””.—[Official Report, 28/11/06; col. 656.]" Other countries, including parts of the United States, are also considering it. I am not arguing that they cannot all be wrong—although one might assert that—and I fully acknowledge that there is a mixed range of reports on this experience. A number of noble Lords have drawn attention to that fact that some of the reports are inconsistent—some are not so well founded as others—and different experiences are being reported from different countries. There is also evidence in some reports that the methodologies are somewhat suspect. I accept all of that but, if we look at the range of comparative studies, there is plenty of evidence of significant therapeutic benefits to patients, greater treatment compliance and some reductions in rates of hospital admissions. I do not want to overstate those reports, but that evidence is available. There is also evidence of patient and clinician support for these overseas developments and experiments. Academics will no doubt continue to argue over methodologies. The one thing I learnt as a Health Minister is that plenty of academics will take a different view from other academics; if I may be unkind, that is sometimes how to develop a reputation. Whatever the detailed reservations about particular studies, they do not set aside, in any kind of meta-analysis of these studies, the clear positives I have mentioned. It is perhaps significant that other countries have not ceased using CTOs, and have continued to see benefits in using them. I rather agree with those who argue that the net of compulsion in community treatment should not be cast too wide. The Government have listened on this, however, and tried to restrict the use to a clearly defined and clinically identifiable group of patients. They have put the group to whom CTOs apply in the Bill. If we believe that the drafting is not as good as it might be and can be improved, perhaps we should discuss that further. But it does not damage the underlying case for community treatment orders. The Minister may want to say a bit more on that, but I shall confine the rest of my brief remarks to three key issues: safety, numbers of CTOs and resources. On safety, my clear recollection is that distinguished forensic psychiatrist Professor Tony Maden’s 2006 review of homicides by patients with severe mental illness concluded that there is a need for legal powers allowing compulsory treatment in the community for patients with a serious mental illness and a history of non-compliance with treatment. Common sense, expert opinion and overseas experience all point in the direction of some form of compulsory community treatment for a small, defined group of patients. It seems rather irresponsible of us, as legislators, not to face up to some of that evidence. I am not arguing that the net should be cast wide or that we should not try to improve the drafting of the Bill to get to the groups we are concerned about. However, the underlying thrust of the Bill—that we need community treatment orders for a group of patients—is in the interests of public safety and the evidence for it is pretty conclusive. Some pretty high figures have been bandied about for the number of people likely to be affected. The noble Earl, Lord Howe, rightly raised this. It is important that we should not, as others have said, sleepwalk into a change where we do not know what the implications are in terms of figures. In my speech on 28 November, I said that the number of those subject to a CTO was likely to build up to, not immediately be, "““3,000 to 4,000 per year over a five-year period””.—[Official Report, 28/11/06; col.730.]" That is, by about 2013. That compares with 40,000 mentally ill in-patients a year and is substantially more modest in scale than the 15,000 or more that some have suggested. If in-patient services are so hard pressed and unsatisfactory, as has sometimes been suggested in these debates, I do not understand why proponents of that view should not also support a proposal likely to bring some relief to the in-patient area through CTOs. That is a logical consequence of this change. Finally, on resources, it currently costs the NHS about £1,200 to £1,300 a week to keep a mentally ill patient in hospital. As I recall from my extensive earlier ministerial briefings, the cost to the NHS of a CTO is likely to be substantially under half that. You do not need to be an incredible mathematician on this: it seems more likely to free up resources for other patients and their treatments. Some have argued that CTOs will be funded by drawing resources from other community services, but I have seen no compelling evidence to support that view. It is more plausible that CTOs will free up in-patient costs for use in the community than the other way around. However, I accept that it will be important to be convincing at a later stage about how CTOs will work and how they will be carried out without detriment to other community services. I wonder whether the Minister can throw more light on this issue, probably not today but at a later stage. I have tried to examine this issue from a variety of angles: the impact on patients involved, civil liberty safeguards, public safety, cost to the public purse and overseas experience. Taking these aspects in the round, there seems an overwhelming case for the Government’s measured approach to CTOs, although I do not doubt that with a bit more attention we may be able to secure some improvements in the drafting that give more reassurance. But the underlying case seems to me to be made, and in the public interest we need to pursue the policies and the approaches set out in the Bill.