Psychiatrists wish to be an arm of the medical profession not the law enforcement agencies, warns Dr Tony Zigmond
As a practicing clinician what do i think of the Draft Mental Health Bill? It is unethical, dangerous, stigmatising and unworkable. You might think this a rather exaggerated response.
Permit me to assess if you, the reader, meet the criteria for compulsion and, if so, what you could do about it. Please let me ask you a few questions. Don't be embarrassed, you know you can rely on medical confidentiality (actually that won't be true if this bill is enacted).
Do you have "black dog" days? Are you phobic of doctors or needles? Are you unable to study or work properly because of anxiety? Are you addicted to nicotine (you've tried to give up smoking many times but always fail)? If you have answered yes to any of these you meet the first condition to be made subject to compulsion. You meet the definition of suffering from mental disorder.
Have you asked your doctor for help and has he offered it? Your disorder clearly "warrants medical treatment". You meet the second condition necessary to be made subject to compulsion. You might think your "illness" isn't severe enough to warrant specialist mental health care? This criterion was in the white paper but is not in the bill and so is not relevant.
Did your doctor offer you pills which you really don't want? You wish for counselling and so decline the medication. You meet the third condition.If the suggested medication is available the fourth condition is met. You will be made subject to compulsion for assessment and the treatment will be given to you without your consent.
Incidentally the same arguments apply if you suffer from a whole range of conditions including not only schizophrenia and manic-depression but also Parkinson's disease, multiple sclerosis or learning disability.
None of this requires you to seek help. If "any person" requests my Trust to "arrange an examination" then I will be required to examine you. If the "relevant conditions" are met the only discretion given to me, along with another doctor and an approved mental health professional, is to decide whether the assessment must take place in hospital or if it is safe for you to be "non-resident". This is all very different from the 1983 Act. Currently you can be detained only if you have a mental illness as defined by you - the public (there are other disorders for which you might be detained if you can be helped by the detention). Secondly the disorder has to be severe enough for you to need to be in hospital.
Have you ever thought of ending it all or that you'd be better off dead? Have you ever, perhaps after a few drinks, said something along the lines of "if he does that again I'll swing for him" or "if she doesn't stop I'll murder her"? You have said such things but only in jest. Actually the reason the assessment is taking place is because the friend you told you were feeling depressed has requested the examination. Clearly the assessment must be undertaken in hospital. You tell me you would never act on your thoughts, but how do I know? My ability to determine who will kill themselves or others is poor. I know that I will need to detain, unnecessarily, at least 100 people to prevent one suicide and something between 2000 and 5000 people to prevent one homicide. Your detention is probably unnecessary and damaging to you but you meet the criteria and I have my career to think of. I will be pilloried if you harm yourself or someone else.
When I opened the newspapers the morning after the bill was introduced almost all of them had two faces staring out - Michael Stone and Christopher Clunis. Much has been written about so called "failures of care". Some patients reject the service because they believe, rightly, that it offers them nothing. When detained under the Mental Health Act they commonly become increasingly difficult to manage and may assault other patients and nursing staff. They may use illicit drugs on the ward and try to persuade others to do the same or to acquire drugs for them. This behaviour is not manageable because acute adult mental illness wards have neither the staff nor the security nor the space. The service offers neither safety nor therapy. Properly funded services, readily available and at the right level of security might obviate the need for compulsion and would certainly reduce risk. Of course with this bill if the patient presents a "substantial risk of causing serious harm" to other people their seeking admission and requesting treatment is irrelevant. They must still be made subject to detention (I wonder if that will encourage openness from patients).
Many of you may think that despite the current resources it is better for the next Stone or Clunis to be in hospital rather than in the community. I ask you to consider how you might feel, when you visit your detained daughter or son, to learn that the man who spoke to your daughter in hospital that morning is a violent paedophile (the Trust will have to arrange their assessment and admission if requested to do so) or your son has been experimenting, for the first time, with crack cocaine given to him by a visitor to a fellow patient.
Please don't think you will be able to rescue your relative. The nearest relatives' authorities to order the patient to be discharged and to object to a six month order have both been removed. Indeed after the first 28 days even I, as "Clinical Supervisor", may not have the authority to discharge the patient even though I recommended the order and the patient is detained under a civil section.
I must turn to "compulsion in the community". You may think this is a good thing as it is less restrictive than admission to hospital. There are, however, a number of difficulties. Firstly it removes one of the safety features of the current act - the need for a real test of severity (of a nature or degree which warrants detention in hospital). Secondly I don't understand how I can reduce serious risk if the patient is at large in the community. The current proposals will no more reduce admissions to hospital than community service orders have reduced use of prison. Community treatment orders will replace persuasion in the community rather than admission (based on research from Australia).
The starting point in risk reduction is encouraging patients to seek help. We have seen the impact on patients' behaviour when they believe that doctors are acting neither with their consent nor in their best interest, in relation to the body parts scandal and agreement rates for post-mortems. I struggle to believe that my acceptability to patients will be improved if they know that I will have a duty to enforce treatment on them, not only in hospital but also in the community, and not only when they are poorly but also when they are well. The image of me sending the police or community nurses to a patient's home to drag them to hospital for an injection and then letting them go is not one that will, in my opinion, enhance the likelihood of patients turning to me for help at times of distress. Patient avoidance will certainly limit my ability to intervene effectively.
Finally I must mention the workforce implications. There are currently over 450 consultant psychiatrist vacancies. There will be a considerable waste of psychiatrist time forcing treatment on those who don't want it (and are a danger to no-one), writing unnecessary reports and appearing before purposeless tribunals - not to mention serving on ever increasing numbers of tribunals and as members of the expert panel. This will lead to a deterioration in early psychiatric intervention - a real way to increase safety. It will also lead to increasing problems with recruiting young doctors into psychiatry and the early retirement of more experienced ones. Psychiatrists wish to be an arm of the medical profession not the law enforcement agencies.
The Royal College of Psychiatrists has been campaigning for mental health law reform for many years. In conjunction with many other organisations and service user groups we remain willing and able to advise further. Will the government listen?
