Mental Health Bill [HL]

My Lords, in a very real sense the provisions relating to community treatment orders represent a leap of faith. The effectiveness of CTOs must surely remain a matter of considerable uncertainty in the light of the published international evidence, which, as the Minister will know, came to some pretty negative conclusions. Of course we hope that CTOs will do good and that they will be seen as having a place for certain groups of patients, but there are still real uncertainties about their implementation. I have two questions for the Minister on CTOs. The first concerns the length of time that a CTO should continue before being brought to an end. We debated that at earlier stages without result. The Minister may say that this is a matter for clinicians and not for Parliament, but at what point does a CTO achieve its purpose? At what point does a clinician know that it is safe to remove the conditions of compulsion under which the patient is living? As Genevra Richardson pointed out, that judgment would be extremely difficult to make, and clinicians may prefer not to make it but instead to play safe by simply letting the CTO run on. We are back to the analogy of the lobster pot. What, if anything, will be included in the code of practice to prevent a CTO from running on indefinitely year after year? How reasonable and ethical is it and how justifiable by reference to the evidence from other jurisdictions is it for a patient to remain on a CTO for years at a time? If the Bill allows this, as it appears to do, I, for one, am not at all comfortable about it, and the amendments passed in another place unfortunately do not meet that concern. My second question relates to the conditions that a clinician may specify in a CTO. It is very welcome that the circumstances in which such conditions may be applied are now more tightly drawn than they were previously, but what if the patient subjected to a CTO thinks that the conditions are unreasonable? When we debated this at earlier stages, the Government did not see that as a problem, but what legal remedy does a person subjected to a CTO have if he thinks that the conditions supposedly placed on him for his own good are an unreasonable infringement of personal liberty? Is it right or just that there is no appeal mechanism for this aspect of his regime? I ask these questions partly as a result of a letter that I received in the past few days from an eminent professor of psychiatry, whom I shall not name. He refers in his letter to the confusion about what CTOs are actually for. The purpose of a CTO, he says, is to get non-compliant patients back on medication and to make sure that they stay there—no more, no less. That, according to the professor, is an end in itself; anything that may follow from it is secondary. I was shocked by that opinion. It may seem extraordinary that at this late stage of our deliberations on the Bill we should debate a fundamental issue of this kind, but I would be glad if the Minister took this opportunity to comment on it. Until now, I had thought that the point of a CTO was to make a patient well again. If the point is no more than to get him to take his medication, we are saying that medication should be forced on a patient even if it is doing him no good and even if it may lead to harm. Such an attitude in the highest ranks of the medical profession shows, I have to say, why patients need protection from certain doctors and why some of us have been arguing strongly for safeguards in the Bill, such as therapeutic benefit. Will the Minister undertake to ensure that the code of practice is quite clear about the ultimate purpose of a CTO? In the light of the attitude reflected in the letter to which I referred, does he not agree that the view recently expressed by the Royal College of Nursing that compulsory medication should not be used as a substitute for adequate mental healthcare is absolutely to the point? To return to the questions that I asked earlier, if a doctor’s sole purpose in using a CTO is, heaven forbid, nothing more than to get a patient to keep on taking his medication, when is the end point reached in that process, how will a doctor know and at what point along the road do the conditions attached to the CTO become inherently oppressive and unfair?