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 | You and Yours - Transcript BBC Radio 4 |
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| TX: 12.10.05 - Mental Health PRESENTER: STUART FLINDERS |
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| Downloaded from www.bbc.co.uk/radio4 THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY. FLINDERS It's an age-old dilemma in mental health care - which comes first - the patient's fundamental right to choose whether to be treated or the doctor's right to overrule the patient if he or she is a potential risk to themselves or others? The argument has been brought into sharp focus by the government's new Mental Health Bill, which starts its journey through Parliament this autumn. Compulsory treatment orders would mean some patients being forced to take their medication, even if they're living at home. But how would you compel a patient who's not in 24-hour care to be treated and when is it acceptable to override a patient's wishes? The government's national director for mental health is Professor Lewis Appleby: APPLEBY There is a group of patients who when they're ill they're very ill and when they are very ill they can be a risk to themselves or sometimes to somebody else. And the current situation is that those patients come into hospital, very often under the Mental Health Act, they're treated, they get better and then you reach the point of discharge back home and of course their families are worried that they're going to get ill again, they perhaps are not going to take their medication. They themselves are going to be a risk if they relapse and the clinicians who want to keep the person well, they're pretty helpless once the person's been discharged. And so the new power will allow that treatment to carry on once somebody has gone home. FLINDERS There is a practical problem: how do you go about forcing a patient living at home to take their medication? Professor Appleby again: APPLEBY We've made a commitment to patients, because of representation by patient groups, that if that happens and that really you do reach the final point where no persuasion is working and people have to be treated then they will be taken to a clinical setting before that treatment will be given, it isn't a question of treating people in their own homes forcibly, which is obviously an undignified happen. People will go to a clinical setting - either a clinic or a hospital ward - and get their treatment there. Now it's an unpalatable part of keeping somebody well that sometimes you have to treat them against their well, it's not something we want to see a lot of but it is a reality in mental health services and we intend that that will happen in the most humane and dignified way. And we have to make sure that the act is properly empowered, if you like, to support good mental health services to back up good clinical care. Now some of the benefits of that are public safety benefits - patients who could pose a risk to the public will be required to take their medication. So that will help them and it will help the people in their environment, it will help society more broadly and it will help the image of mental illness in society. FLINDERS I'm joined now by Simon Lawton-Smith from the King's Fund, which researches health issues. The government believes no more than one and a half thousand people would be subjected to these orders, your own research suggests the number might be far greater. LAWTON-SMITH Yes, that's absolutely right. We started work on this last year because we wanted a report that estimated the number of people who may be placed on community based treatment orders in the future. At the time that the government first mooted this idea I think nobody had any idea how many people might live in the community under such an order. So we looked at the international evidence, broadly across Australia and New Zealand, the United States, Canada and Israel, this is where community based treatment orders have been in place for some years. What we found was enormous variations in the level of use, from around two per hundred thousand population generally in Canada, to around 50 per hundred thousand population generally in Australia and New Zealand. And using that data we then tried to find out where England and Wales might fit under the new Mental Health Bill. FLINDERS So what's your estimate of the figures ... LAWTON-SMITH Well the estimates came up with, having done our analysis of the international data and looked at the position in England and Wales, was we thought that over time - and this is very important, we are talking about over time, maybe over the next 10 or 15 years - the numbers might reach between 7,800 and 13,000 people. I think the one thing I'd quickly say on that is that doesn't necessarily say these are people who are new to compulsion, they may be people who currently would be detained in hospital because they've been in crisis. So we're not necessarily saying there will be an increase in overall numbers of people under compulsion. FLINDERS Does it matter if the government's got those figures wrong? LAWTON-SMITH It matters in terms of planning for services. What the people who provide community mental health services at the moment are expecting - well they don't quite know what to expect - the government is suggesting there'll be relatively few numbers of these revolving door patients who they will have to provide services for, what we're suggesting is the government has actually underestimated that number, certainly over the next 10 or 15 years and services are going to have to think very hard how they provide an effective service to these people who are very difficult to engage, maybe non-compliant with their treatment and pose all sorts of problems to front-line services. FLINDERS And it could work out more expensive than the government thinks it's going to be, is that the point? LAWTON-SMITH We didn't actually look at the expense. The theory is that the fewer hospital admissions there are then you tend to save money because treatment in the community is less costly than treatment in hospital. We don't actually know though what will happen to hospital bed numbers, there might be an assumption that if you treat more people in the community the bed numbers will drop and you'll save money but in fact another scenario, and a perfectly reasonable one, is you will start treating people in the community under these orders but the bed numbers will stay exactly the same because there's such a current pressure on mental health services for people who need inpatient care. FLINDERS And you've looked at what's happened abroad, in general terms how workable has this policy been elsewhere? LAWTON-SMITH It's very interesting that, some jurisdictions have only recently started introducing community based treatment but in Australia and New Zealand, for example, they've had it for about 15, 20 years and there's some really interesting messages there about how it seems now to be embedded in the system and almost part of the furniture of mental health care. And in terms of patients' perceptions of community based treatment orders while there are some patients who clearly do not like having their liberties impinged upon in the community, some of the research that has come out recently suggests that many patients, in fact a majority, with hindsight after the particular episodes say that they're actually grateful that they were on a community based treatment order because they got the care and service that otherwise they wouldn't have got. FLINDERS Well we'll come back to you in a moment but let's hear now from Eliza Johnston who has in the past been sectioned for manic depression. She abandoned her medication against the advice of her doctor. JOHNSTON I'd got to the point of utter desperation. Ten years of various medication, six sectionings and three voluntary admissions. I came off the medication secretly and over the course of a year because I just knew that I was not getting anywhere, after 10 years of believing that if I took my drugs I would be okay. It just didn't happen, after 10 years. FLINDERS What happened to you once you stopped taking that medication? JOHNSTON Well my mind started clearing, I actually started to get my personality back. Instead of sitting in front of the TV for 12 hours a day and sleeping for 12 hours a day, which I was quite literally doing for months on end, year after year, I actually started to realise there was a world outside my front door. And I came to my GP and said look I've been off this medication for a year and could I please go and see a homeopath. And she referred me to the Royal London Homeopathic Hospital. FLINDERS What do you think would have happened if you'd been forced to take that medication? JOHNSTON Well I'd still be trapped in the same cycle of endless psychosis and depression because there was nothing doing - nothing was changing in my life other than the changes I was making. FLINDERS Do you accept though that some patients should be forced to take their medication because they're either not in a position to make that judgement for themselves or they could be a harm to themselves or to others? JOHNSTON Well look I'm not a doctor, you know, it's only doctors who have the right to make those decisions about individuals and every person is an individual. FLINDERS But you're saying that you as an individual should have the right to make that decision yourself. JOHNSTON Absolutely and people even in the deepest psychosis do have a capacity to make decisions if they are led carefully and gently through the process. FLINDERS Eliza Johnston. Simon Lawton-Smith is still with us and joining us now are Dr Tony Zigmond, the vice-president of the Royal College of Psychiatrists and Tony Maiden, the professor of forensic psychiatry at Imperial College, London. Tony Maiden, Eliza Johnston says she was better off when she ended her medication, isn't there a danger that the new law could compel some patients to have treatment that does them more harm than good? MAIDEN There is that danger and that's why there are a lot of safeguards built into the bill, in particular the review of treatment plans, compulsory treatment plans, by tribunals. And the new bill will actually increase the safeguards against the possibility that someone is forced to take inappropriate treatment. FLINDERS But the difficulty with mental illness, it's not like cancer, there's more room for disagreement about the treatment isn't there. MAIDEN There is room for disagreement about treatment, just as there is in any field of medicine, but the difference is that in most fields of medicine it really is just up to the doctors. In mental health, when we start talking about compulsory treatment, then quite rightly there are tribunals, effectively courts of law, to keep on eye on doctors debating those questions. I would disagree, by the way, that it is only doctors who should have the right to decide that patients should take their medication against their will, I disagree fundamentally ... FLINDERS Meaning who else? MAIDEN A court of law or a tribunal should have that power. That's not the case at the moment, doctors do have that power. Under the new bill the power will reside quite properly with a tribunal, which is effectively a court of law. FLINDERS But does this law inevitably move the balance towards compulsion and away from the patient's consent? MAIDEN I think not, I mean the particular aspect of law we're talking about emphatically shifts the balance away from treatment in hospital, compulsory treatment in hospital, to treatment in the community. So it's really catching up with the reality of psychiatric care over the last 50 years, where we've been moving away from hospital toward the community, we'll now have compulsory treatment catching up with that reality. FLINDERS Tony Zigmond, it's the ethics that concern you isn't it. ZIGMOND It is, but it's a whole range of things, I want to ... FLINDERS Well let's start with the ethics first of all. ZIGMOND Well I want to sleep safely in my bed at night, along with everybody else, and there's a series of issues. The first is that in order to reduce risk to all of us we do much better if we can get people when they're - when they're early in their illness and the earlier that people will come forward and seek help the more likely we are to be able to treat them effectively and reduce risk both to themselves and everybody else. So it's rather - it incorporates the ethics but if one drives people away by fear, and that's what's happening with the proposals in this bill, then that's quite damaging. FLINDERS But just to be clear, are you against forcing patients to take their medication when they're not in a hospital? ZIGMOND I'm not against. First of all, those patients who are so poorly that they can't make decisions for themselves, that's the first thing, of course such people should be required to have medication, as they are in any branch of medicine, that's not just in psychiatry and with mental health problems. Secondly, there are a very small group of people who do come into hospital, get well, present real dangers - and we know they present real dangers because they've been convicted of serious offences - and they should be required to continue with their treatment and the law, as it stands, enables that... FLINDERS But isn't that all that the law - isn't that all that the change in the law would do? ZIGMOND No, what the change in the law does is to massively expand the number of people who will fall within this group, so ... FLINDERS Well Tony Maiden says it just means - it's the difference between treating people in a hospital and treating them at home - and that's the real difference. ZIGMOND No, no, as I said, at the moment one can treat people at home. But if I give you - this is a sort of scatter gun approach, which is to say well if we're not very good at predicting who these relapsing patients are let's force everybody to have it and as I said that drives people away, it increases dangers. Tony Maiden, for example, mentions the safeguards, but we can only have safeguards and we can only have this tribunal if we significantly limit the number of people subject to it, there just isn't the workforce to provide the tribunal. FLINDERS Tony Maiden. MAIDEN I think we have to be a bit cautious about the numbers, I mean Simon Lawton-Smith there was saying possibly in 10 years we may see 13,000 people, that's presumably the top estimate. At the moment psychiatrists in this country detain 50,000 people a year. And so if in 10 years time 13,000 of those detentions are actually in the community that on the whole would be progress. Nobody likes going into hospital and in that context of 50,000 detentions a year I don't think the possibility that ... FLINDERS So you're not too worried that the government figures are wrong - you're not too worried by that? MAIDEN I'm not because I think this will be a measure that's popular with doctors, it will be popular with patients as well because nobody likes going to hospital and there's nothing worse than that scenario of a very unwell patient being compelled to come to hospital, it's often necessary to involve the police, an awful traumatic incident and we hope to avoid that by keeping people well. And every mental health team in this country will be able to reliably identify patients who come back again and again, the so-called revolving door patients, and this legislation will, for the first time, allow those mental health teams to avoid that repeated trauma of waiting until someone gets ill and then detaining them in hospital. ZIGMOND ... come back here with one or two figures. The government's own figures, even assuming no increase in numbers of people subject to detention, say that we will need four times as many tribunals as we have now in order to make sure that the tribunal is there as a proper safeguard. Now we don't have the workforce to provide four times as many tribunals, the government has acknowledged that and it's talking about not giving people this safeguard. So one doesn't need me for that. In terms of the will it be welcomed by the medical and indeed other caring professionals - every single organisation involved in mental health care, everyone, including doctors, nurses, managers, psychologists, social workers, nurses and so on, has said very clearly, has joined the Mental Health Alliance, to say no we don't any part of this because it is not only against people's civil liberties but it is so damaging to health and safety. And the Royal College of Psychiatrists is firmly against it. So again I'm afraid Tony Maiden's just ill-informed or being misleading. FLINDERS Well let me bring in - I just want to bring in Simon Lawton-Smith because I want to know, from your research, whether there's any evidence that health professionals would want to use these orders perhaps more than they should, simply because it's a good way of getting things done? LAWTON-SMITH I mean the picture isn't absolutely clear. As I mentioned earlier where community based treatment orders have been embedded in the system for some years they tend to be popular with psychiatrists and the recent evidence suggests that quite a lot of service users themselves appear to be content to be on them. What we weren't able to look at is whether people are overusing them, I think the key issue for the draft Mental Health Bill in this country is will they be abused, will they be overused. The truth is probably going to be somewhere between concerns that there will be a massive increase in compulsion and people saying no, no it'll only be a tiny number of people. I suspect the truth is somewhere in between. What we need in the draft Mental Health Bill are just some changes to the conditions and this is the key point - there are certain conditions in the draft Mental Health Bill that have to be met before compulsion can be imposed. At the moment these are drafted rather broadly, we would like to make sure that either in the bill or in the regulations that come along with the bill that people who can be treated under community treatment orders are very, very tightly defined as that revolving door patient that Professor Appleby was talking about. Currently that tightness of definition isn't there. FLINDERS I just want to talk finally about how in practice you carry this out. Tony Maiden, if somebody doesn't want to be treated do you end up with a situation where you've got burly security men dragging people out of their homes to take them to a medical centre? MAIDEN Well the current situation is that if a patient doesn't want to take medication in the community whilst that patient is well there is nothing at all that can be done about it. And so the mental health teams sit and wait until the patient becomes ill enough to be detained in hospital under the Mental Health Act and at that point yes they send in either the - well not burly security men but usually the police. And it's a frustrating situation for the team and it's humiliating for the patient, it's no good for their mental health and the vast majority of psychiatrists support the principle of a community treatment order which would allow us to keep patients well - keep them at home, keep them well. FLINDERS There we must leave it. Dr Tony Zigmond, Tony Maiden and Simon Lawton-Smith, thank you all very much for joining us. Back to the You and Yours homepage The BBC is not responsible for external websites |
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