Executive summary

1    This White Paper sets out the Government's proposals for improving and modernising services for people with mental health problems. This will be achieved through new legislative powers, new resources and new national standards for care and treatment in the Mental Health National Service Framework. The vast majority of these people pose no threat to others and, in many cases, are among the most vulnerable in society. But in a minority of cases, people with mental health problems may pose a serious threat to the safety of others.

2    Public protection is one of the Government's highest priorities. Public protection and the modernisation of mental health powers and services are complementary aims. New, more transparent powers, clearer pathways and processes, and more resources for specialist services will both provide greater protection to the public and improve the quality of services for the individuals themselves. Part One of this White paper sets out the Government's proposals for change to the Mental Health Act. This part of the White Paper shows how these changes will operate for the high risk group within the context of extra resources for improved specialist services.

Patients who pose a significant risk of serious harm to others

3    The vast majority of people treated under mental health legislation are treated in their own best interests, in many cases to protect them from self-harm. By contrast, there are a smaller number of people with mental disorder who are characterised by the risk that they present to others. This group includes a very small number of people detained under civil powers, and others who are remanded or convicted offenders.

4    Within this wider group are a number of individuals whose risk is as a result of a severe personality disorder. A narrow interpretation of the definition of the 'treatability' provision in the 1983 Act, together with a lack of dedicated provision within existing services, means that current arrangements for this group are inadequate both to protect the public and to provide the individuals themselves with the high quality services they need.

The criteria

5    New criteria for compulsory treatment under the Act will form a key part of these changes. These criteria will provide clear authority for the detention for assessment and treatment of all those who pose a significant risk of serious harm to others as a result of a mental disorder. The criteria will achieve this by dealing separately with those who need treatment primarily in their own best interests and those who need treatment because of the risk that they pose to others. In high risk cases, the use of compulsory powers will be linked to the availability of a treatment plan needed either to treat the underlying mental disorder or to manage behaviours arising from the disorder.

Assessment

6    Legislation must also respond to the various ways in which such individuals come to the notice of statutory agencies. The White Paper sets out the processes for initial and more detailed assessment for such high risk individuals in the community. In some cases, these people will already be under the supervision of the probation service. Others may be known to mental health or social services or may come to the notice of the police in the course of their work. Powers in the Criminal Justice and Court Services Act 2000, expected to be implemented in April 2001, will mean that the police and probation services will be under a new statutory duty to assess and manage relevant sexual or violent offenders. Under new mental health legislation, the relevant statutory agencies will be able to refer the individual for an initial assessment and, if the initial criteria are satisfied, apply for a 28 day period of compulsory care and treatment to allow for more detailed assessment. Beyond 28 days, compulsory care must be authorised by a new independent decision making body ­ the Mental Health Tribunal ­ which will obtain advice from independent experts as well as taking evidence from the clinical team, the patient and his or her representatives, and other agencies, where appropriate.

7    These arrangements will be sufficiently flexible both to provide for the immediate healthcare needs of individuals and to ensure that they are kept in the appropriate degree of security. In addition to existing facilities, specialist assessment facilities for those who are dangerous and severely personality disordered (DSPD) are being established for the in-depth assessment needed for this group.

8    Arrangements for the assessment of those already serving prison sentences will also be improved by the creation of a new power for the Home Secretary to direct such individuals for assessment. In the case of those who may be DSPD, these assessments could be carried out in specialist facilities in either the Prison Service or the NHS.

9    For those before the Courts for an offence, there will be a new single power for the Court to remand for assessment and treatment.

Treatment

10    Under new legislation, the Tribunal ­ or the Court in the case of mentally disordered offenders ­ will be able to make a care and treatment order which will authorise the care and treatment specified in a care plan recommended by the clinical team. This must be designed to give therapeutic benefit to the patient or to manage behaviour associated with mental disorder that might lead to serious harm to other people. The first two orders will be for up to 6 months each; subsequent orders may be for periods of up to 12 months. Where treatment is authorised under the legislation, individuals will be transferred to appropriate NHS facilities taking account of any security risks that they pose. Wherever possible, treatment will be specifically aimed at addressing the underlying mental disorder. But in all high risk cases, treatment will be designed both to manage the consequences of a mental disorder as well as to enable the individuals themselves to work towards successful re-integration into the community.

Safeguards and oversight

11    The Government is committed to ensuring that any new arrangements are fully compliant with the Human Rights Act 1998. The White Paper sets out safeguards and protections for those to be detained under the Act. These will apply equally to this high risk group. The introduction of a requirement that all longer-term care and treatment orders are authorised by a body independent of the clinical team is a key way in which the new legislation will protect patient rights. But all those detained under compulsory powers will also have the right to:

• free legal representation;

• access to independent specialist advocacy services; and,

• provisions to cover the use of certain specified treatments for mental disorder and all long-term treatment without consent.

12    The White Paper also sets out new arrangements for the oversight of the new legislation and for the provision of annual reports through the creation of a new Commission for Mental Health.

Developing services for those who are DSPD

13    However, in the case of those who are dangerous as a result of a severe personality disorder, legislative changes alone are not enough. New powers must be backed up by a programme of service development that will begin to provide the capacity and specialist approaches to treatment and assessment that this group needs. Resources allocated within the recent Spending Review across the Department of Health, Home Office and Prison Service include an additional £126m over the next three years for the development of new specialist services for those who are high risk as a result of a severe personality disorder.

14    The Government recognises the importance of building a secure evidence-base for these services and is therefore committed to a series of pilot projects to test out new approaches. The assessment process is already being piloted in both NHS and Prison Service high security settings and the first treatment pilots will begin in 2001. These pilot projects will be rigorously and independently evaluated as part of a comprehensive research agenda.

15    Capacity for the pilots will be created through a programme of refurbishing existing accommodation and new builds. Over the next three years this will provide:

• 320 additional specialist places across the Prison Service and the NHS; and,

• 75 hostel places.

    The pilots will also inform subsequent decisions on the nature, scale and pace of any further expansion of services beyond this first phase.

Sharing information

16    Improved public protection also relies on the effective co-operation of the various statutory agencies. The Criminal Justice and Court Services Act 2000 has already placed a new statutory duty on police and probation services to establish arrangements for assessing and managing the risks posed by relevant sexual and violent dangerous offenders. In respect of those who are mentally disordered, new mental health legislation will build on this approach by introducing a new duty covering the disclosure of information about patients suffering from mental disorder between health and social services agencies and other agencies, for example housing agencies or criminal justice agencies.

17    We will also introduce new arrangements for the provision of information to victims of mentally disordered offenders who have committed serious violent or sexual offences and who have been given a care and treatment order by the Courts rather than a prison sentence.