Mental Health Bill [HL]

My Lords, obviously this is a very important debate. Let me respond to a number of points raised by noble Lords. I come first to the question of evidence. Of course there has been considerable discussion about the evidence that underpins the proposals. We have had a debate about the evidence commissioned by my department—or my previous department—and, as ever with these matters, noble Lords have brought their interpretation to that evidence. Clearly, one has to say that there is a lack of what might be called gold-standard evidence available anywhere in the world. We must rely on the evidence that is available and we sometimes have to accept its limitations. There is no doubt that around the world there is evidence to show the potential of supervised community treatment to prevent harm. Indeed, closer to home, Scotland has been mentioned in this House on a number of occasions, although noble Lords have for some reason been rather quiet about it in relation to supervised community treatment. But there we have it—in Scotland, you do not have to be detained before you are eligible for the benefits of supervised community treatment. Circumstances sometimes make comparisons rather difficult, but throughout the world it is clear that community treatment orders of one kind or another are increasingly accepted. I remind noble Lords that we propose supervised community treatment only after immediate prior detention in hospital for treatment. So we are proposing a system with narrow eligibility, which is found in the majority of jurisdictions that use such orders. In answer to some of the other points raised, I do not think that this has always been recognised. The noble Baroness, Lady Barker, asked about the factors that a clinician must consider when making an initial decision about the patient’s eligibility for supervised community treatment. As part of this process, the clinician must decide whether he needs to be able to recall a patient to hospital. For this purpose, the amendment in the name of the noble Lord, Lord Patel, allows a clinician to take into account factors that are relevant to that decision, including the patient’s history. It is important that a clinician can consider all relevant factors, an obvious example being the patient’s current medical state. Other relevant factors might include the degree of recovery of symptoms, any suicidal ideas or feelings of hopelessness, which will be important predictors of likely risk. In addition, a patient’s insight and attitude to their treatment, and the protective circumstances into which a patient would be discharged, might be relevant. These are all factors that may not be evident in the patient’s history. The amendment has the effect that the responsible clinician must consider the risk of the patient’s condition deteriorating in the community when deciding whether it is necessary for him to be able to exercise the power to recall the patient to hospital. This means that, in order to place a patient on supervised community treatment, the responsible clinician will need to be able to show that he has properly considered and, if appropriate, assessed the risk of deterioration—otherwise, his decision could be open to challenge in the courts. I hope that that clarifies the position for the noble Earl, Lord Howe. The noble Earl, Lord Howe, also asked whether a patient should be able to challenge the conditions of community treatment orders. We discussed this before. My right honourable friend Mrs Winterton, the then Health Minister, said in Committee in the Commons that for supervised community treatment to work a patient must accept and be ready to co-operate with the conditions of a CTO. There would simply be no point in setting a condition with which a patient would not comply, because nothing hangs on a failure to comply. I very much take his point about the code of practice. The code of practice will ensure that patients and those close to them will be involved in agreeing the conditions. On account of that, a third-party appeals process would not be appropriate. In response to the other question that the noble Earl, Lord Howe, raised, I accept that if a patient goes on to supervised community treatment, and it is no longer necessary for that treatment to apply, the last thing that we would want is for that patient to have to remain on supervised community treatment. I understand his point about what I guess he would call defensive medicine by the clinician. We will have to address that through the code and clinical professional practice. I assure him that we will do so. However, given the clinician’s responsibility to themselves, to the patient and in law, they must apply the provisions as laid down in this Act. The Act ensures that, where a patient no longer needs to be subject to supervised community treatment, that patient should no longer be so. A lot of our debate has been about the context of practice within the law. I accept that one of the concerns in this whole mental health debate has been about clinical practice. As we now move forward with a Bill that will, we hope, shortly be an Act, I emphasise again to noble Lords that whatever the disagreements there have been—and there have been many—we have worked hard to try to meet the major concerns. I know that we have not met all those concerns and that some noble Lords passionately argue for further changes. However, I think that we have reached a position where, with the code and with the regulations, we can determine and do everything we can to ensure that the practitioners out there understand the law and good practice, so that we can develop mental health services in the way that noble Lords have expressed a desire to see them develop. Above all, this legislation will prove to be a foundation on which to take forward the provision and development of services in the interest of both the public and the patient. As these are my departing words as a Health Minister, let me say that it has been a great privilege to have served in this position. I am most grateful to all noble Lords who have taken part in these extraordinary debates. I end by paying tribute to parliamentary counsel and to the Bill team, who have done a magnificent job of work under great pressure. On Question, amendment agreed to. Motion, as amended, agreed to.