Draft Mental Health Bill receives frosty reception from professionals

The government’s draft mental health bill will
introduce compulsory treatment in the community and replace the key
role of approved social workers. David Brown
reports.

Alan Milburn appears to have cast a wide net to catch a few
newspaper headlines.

His draft Mental Health Bill, published last week, is described
as the biggest shake-up in mental health legislation for 40
years.

However, its main target appears to be less than 600 people –
those with dangerous and severe personality disorders who can now
expect to face an indefinite period in secure accommodation.

It will also introduce compulsory treatment orders in the
community, which will affect a much greater number of people but
which have received much less publicity.

The government is emphasising the safeguards for patients that
will be introduced alongside these powers. But by replacing the key
role of approved social workers, these powers could in future
reside only in the hands of the medical establishment.

Calls for a reform of mental health legislation have been driven
by a handful of high-profile crimes committed by people with
personality disorders or mental illness.

Michael Stone was diagnosed as having a severe personality
disorder years before he murdered Lin Russell and her six-year-old
daughter, Megan, in 1996. But because his disorder was considered
untreatable, he could not be detained under the current Mental
Health Act 1983.

Other issues had already been raised by an inquiry into the
death of Jonathon Zito, who was stabbed in the eye by diagnosed
paranoid schizophrenic Christopher Clunis in 1992.

A catalogue of errors and missed opportunities in Clunis’s
care, including non-compliance with community treatment programmes,
were revealed by the inquiry.

The Zito Trust, a mental health charity formed following the
inquiry, believes that the new bill is a “major step forward”. “But
it is not going to improve mental health services – it is the
framework that one hopes to see improved services provided within,”
says trust director Michael Howlett.

“It has the potential to improve the protection of the public
and there is a great deal for patients, but it needs a lot of
resources.”

The bill will give the power to order compulsory treatment if it
is necessary for the health and safety of the patient or for the
protection of others. For the first time, people with dangerous,
incurable personality disorders would be detained against their
will, even if their condition is untreatable. The majority of
people diagnosed as psychopaths, estimated at between 2,100 and
2,400, are in prison, but up to 600 people currently living in the
community face being locked up indefinitely without being convicted
of a crime.

In addition, compulsory treatment in the community will apply to
about 26,000 people a year, with assertive outreach teams and
crisis intervention teams ensuring that they comply with the
orders.

Although the bill will compel people to receive treatment, it
does not give them a legal right to treatment. The Department of
Health says no patient has a legal right to treatment, but
campaigners say that mental health should be an exception, as it is
the only area where people can be treated against their will.

Sue Brown, chairperson of the campaigns group at the Mental
Health Alliance, says: “The aim should be to reduce compulsion, and
to do that successfully you have to ensure that services are
available when people are looking for help.

“We are concerned that people will be afraid to approach
services if they fear that they will be subject to compulsion.”

The alliance is also concerned about the broad definition of
mental disorder, which appears to encompass impairment or
disturbance resulting only from drug or alcohol abuse. It has
similar concerns about the broad definitions of treatment.

“There is a risk that you are removing patients’ rights to
make their own decisions on the type of care they want,” warns
Brown.

Milburn admits: “Mental health legislation, by necessity, must
tread a delicate path between protecting those who are the most
vulnerable and ensuring public safety.”

Many people believe he is heading in the wrong direction. After
reviewing the white paper proposing the changes, the House of
Commons health committee said that the language used by ministers
“runs the risk of being highly stigmatising for the many people
suffering from personality disorders, who are not judged by anyone
to be dangerous”. It was “unable to support” the government’s
legislative plans.

The Royal College of Psychiatrists and the Law Society say they
“unequivocally reject” the bill’s proposals, describing them
as “fundamentally flawed”. They say that the wide criteria for
compulsion would lead to the inappropriate sectioning of large
numbers of patients and that there are inadequate resources to
fulfil the bill’s proposals.

Hywel Williams, a Plaid Cymru MP and one of the UK’s first
approved social workers, opposes the proposals to replace the role
of ASWs with approved mental health professionals. Staff in the new
role will include specially trained mental health nurses,
psychologists and occupational therapists.

Currently, an ASW present must agree with two doctors before a
patient can be sectioned. “The ASW is there to give a broader view
than a purely medical model,” explains Williams. “Mental health is
not something that can be looked at in purely clinical terms.”

Paul Jewitt, an ASW who is co-ordinating opposition to the
proposals, says: “ASWs are the only people in the mental health
process to take a holistic approach and actively protect the rights
of the individual. They are able to do so because they are
independent – they are not accountable to hospitals or social
services departments, only to the law.” He is concerned that
without the input from a social worker the decision to section a
patient will be made only by professionals from a medical
background, who will not have much experience of social models.

The medical profession is more hierarchical than social care and
there is concern that too much deference will be shown to
consultants.

Jewitt also fears that people who are not a danger to themselves
or others could be forced into treatment because they are eccentric
or considered bizarre by their community. “Consider the bereaved
man who is shouting in the street and ranting against God because
he has lost his wife. He could be locked up simply because he is
strange,” warns Jewitt.

Draft bill at www.doh.gov.uk/mentalhealth/draftbill2002/index.htm

Steps To Treatment

1 Preliminary examination and decision on whether to use
compulsory powers by a “mental health professional” and two
doctors.

2 Assessment by a mental health tribunal within 28 days.
Treatments requiring special safeguards not permitted at this stage
without permission from the tribunal, except in an emergency.

3 The elements of a compulsory treatment order can be specified
by the mental health tribunal. The first two orders last for six
months each and subsequent orders for a year.

Draft Mental Health Bill – key points

The Bill sets out the proposals for a new legal framework for
the compulsory treatment of people with mental disorders.

Compulsory treatment can be used where it is necessary for the
health or safety of the patient or the protection of the
public.

Compulsory treatment must be provided in the least restrictive
setting, having regard for the safety of the patient and the
public.

People with dangerous and severe personality disorders can be
detained in secure accommodation even if they argue that their
condition is untreatable.

Patients may be subject to community-based compulsory treatment
orders, but will be returned to secure accommodation if they fail
to comply with their terms.

The role of approved social workers in deciding whether
compulsory powers can be used will be replaced by approved mental
health professionals.

Compulsory treatment beyond 28 days will have to be authorised
by an independent mental health tribunal, or by the courts in the
case of offenders.

Carers can request preliminary assessments to ensure that the
right care and treatment is provided, and will be consulted about
decisions including the preliminary examinations and care plans,
unless the patient disagrees.