Anti-therapeutic community mental health lawBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7006.689 (Published 09 September 1995) Cite this as: BMJ 1995;311:689
- Nigel Eastman
EDITOR,—The defence by K C Calman, the chief medical officer, of the government's Mental Health (Patients in the Community) Bill seems to be based more on hope than on clinical argument.1 It is also contradicted by the Department of Health's internal review of legal powers on the care of mentally ill people in the community, which preceded the drafting of the bill.2 This stated that, although the department believed that wider use of guardianship might help some patients, “we cannot see guardianship offering a ready answer to the problems of the patients with whom we have been concerned.” Aftercare under supervision, however, amounts merely to “guardianship, fortified with the power to convey.”3
Neither I nor Calman can support our expectations of the clinical impact of the bill by reference to clinical trials. This contrasts with the introduction of supervision registers, for which piloting would have been possible and should have been pursued. Calman offers no clinical argument, however, that influence over patients will be enhanced by enforced conveyance to a place “for medical treatment, occupation, education or training” in the absence of the power to treat. Is setting such a weak and confusing clinical boundary likely to enhance patients' compliance with treatment?
Calman rebuts my criticism of the bill—that it fails to offer resources in exchange for further restriction of civil liberties. Clause 1(1)25A(4)(c) of the bill says, “being subject to after-care under supervision is likely to help to secure that [the patient] receives the after-care services to be so provided.” I would emphasise that adequate resources are required for this principle to be satisfied. Ordinary guardianship orders are often resisted by local authorities specifically because of their implications for resources, emphasising the frequent inadequacy of community resources. Ironically, some clinicians have suggested that the bill might allow adequate health and social service resources to be obtained by overtly showing unmet need. The doctor would simply record in the case notes, “I would have applied for aftercare under supervision for this patient, but I was unable to legally do so because the aftercare services were inadequate.”
Since forced conveyance is likely to be perceived as anti-therapeutic, and sometimes even as dangerous, aftercare under supervision will be reduced to a mechanism for encouraging proper case reviews. It must not be perceived as a means by which patients in the community can be directly controlled. There is a deep divide between legislating for care in hospital and in the community.4