The Pharmaceutical Journal
Vol 269 No 7227 p809
7 December 2002

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The draft Mental Health Bill — is it time to rush to the barricades?

By author

Taking up cudgels and rushing to the barricades or taking on the government publicly has never been our style as a profession. The usual response to a controversial piece of legislation has been to give the government cautious support and hope that, by ingratiating ourselves with the powers that be, we will somehow be rewarded at some later stage. Other professions have been more defiant.

A case in point is the recent response to the draft Mental Health Bill. In the period immediately following the publication of the Bill the Royal College of Psychiatrists and the Law Society made a joint statement: "The Law Society and the Royal College of Psychiatrists unequivocally reject the Government's current proposals for the reform of the Mental Health Act 1983. In our opinion the proposals are fundamentally flawed."

In addition the Mental Health Alliance, made up of more than 50 mental health groups, has accused the Government of not listening to the concerns which had been fed through the previous rounds of consultation.

So what are they all getting so steamed up about? Is it something that we pharmacists should get steamed up about too?

The Secretary of State for Health presented the draft Mental Health Bill to Parliament in June 2002. In addition to the draft Bill were documents providing explanatory notes and requesting further consultation.

This draft Bill is a further stage of the programme to reform the Mental Health Act 1983, a process which began in 1998. The stages to date have involved establishing an independent expert committee, the publication of a systematic review of the literature relevant to the Mental Health Act 1983, publication of the report of the expert committee, publication of a Green Paper for consultation and publication of a White Paper for further consultation.

Unfortunately there are so many problems with the draft Bill that it is difficult to grasp one single issue but those that have grabbed the headlines are as follows. The first is the redefinition of mental illness so that dangerous people with personality disorders can be detained using the Mental Health Act. The second is the proposal to enforce treatments in the community (called community injection orders by many mental health organisations).

There are so many organisations opposing these two that adding the pharmacists voice might seem pointless. Have no fear. The proposals relating to drug treatment provide more than enough additional concerns to keep us busy. Throughout the process of the review of the Mental Health Act 1983, the UK Psychiatric Pharmacy Group (UKPPG), together with the College of Mental Health Pharmacists has participated in every stage of the consultation, making proposals to provide greater safeguards for patients.

Underpinning these proposals is the knowledge that best use of medicines in mental health is achieved by well-trained specialist mental health pharmacists working in close collaboration with users, carers, psychiatrists and other professionals. Unfortunately, the draft Bill ignores the potential contribution of specialist mental health pharmacists.

Of particular concern is the redefinition of treatment. In the past, treatment mostly applied to electroconvulsive therapy, medicines and, rarely, psychological therapies. Now the definition is much broader and includes nursing care, education, training in work and social and independent living skills and rehabilitation. In other words almost everything that is done to the person or by the person. Such a broad definition of treatment is unhelpful.

Another is the process by which compulsory treatment will be authorised. Currently if a patient is admitted to hospital for compulsory treatment the responsible medical officer can treat the person with the medicines they think appropriate. Understandably, there are those who believe that such decisions should be subject to the safeguard of expert scrutiny by an appropriately qualified person, and the UKPPG has suggested the best person to do that is a specialist mental health pharmacist. The proposed safeguard in the draft Bill is wholly inadequate: there is no mention of pharmacists. All long-term treatments can be authorised only by the "tribunal" — an independent judicial body. The tribunal will seek advice from an expert (another psychiatrist) before agreeing to the proposed treatment. This proposed treatment must be presented in the form of a care plan. There are obvious advantages to there being a care plan for drug treatment: it ensures that all the staff are aware of a plan and facilitates easier discussion and provision of information to carers, relatives and the patient. It could also be argued that slowing the rate of drug changes might have advantages in some cases because it avoids multiple changes before allowing time to achieve a therapeutic response. On the other hand it bureaucratises the process of prescribing to such an extent that it may result in delays to treatments or reluctance to embark on treatments. It also increases the requirement for the involvement of psychiatrists.

The need to complete a raft of forms for every treatment and to seek agreement of others before treatment is inevitably time-consuming and will provide a deterrent to prescribers. It has been estimated that between 400 and 800 additional psychiatrists will be required for England and Wales. It is somewhat ironic that one of the overarching concerns of mental health services is a major shortage of psychiatrists. Many mental health trusts are seeking to re-engineer roles in order to reduce the need for key professionals to undertake tasks that can be done by others. The draft Bill not only increases the demand for psychiatrists thus reducing the pool available for mental health services but imposes such restrictions on their ability to prescribe treatments that there is a risk that patients will not receive treatments that may be of benefit.

The consultation phase of the draft Mental Health Bill has just ended. Although the draft Bill was surprisingly omitted from the Queen's speech on 13 November, the Secretary of State for Health has vowed that the Bill will be reintroduced in the current session of Parliament following further consideration of the responses received to the consultation. Then the fun will really start. Perhaps we should don our hats and coats and man the barricades alongside the psychiatrists, lawyers, and patients.