 Good morning, and welcome to the 26th meeting in 2014 of the Health and Sport Committee. First of all, can I integrate apologies for Richard Lyle and Dennis Robertson, SNP sub, is here again with us today. Welcome, Dennis. I would ask everyone at this point to switch off mobile phones as they have a risk of interfering with the proceedings, although I should also point out that you will see some committee members and indeed those who support us using tablet devices instead of that hard papers. Firstly, the first item on our agenda today is a decision on whether to take item 3, which is our draft report on health inequalities in private. The committee agreed. Thank you. Then we will proceed now to a normal format for a round table session. I introduce myself as Duncan McNeill, convener of the Health and Sport Committee. I'm Colin Fraser. I'm a mental health officer from Glasgow City Council and I'm here as a member of the METU forum for Glasgow social work. Bob Doris, MSP for Glasgow and deputy commander of the health and sport committee. Beth Hall, I'm part of the health and social care team with the convention of Scottish local authorities. Good morning, I'm Dennis Robertson, MSP for Aberdeenshire West, and I'm a substitute for the Health and Sport Committee. Good morning, I'm John Gillis. I'm chair of the Royal College of GPs in Scotland. Good morning, I'm Gil Phaterson. I'm the local member for Clydeback Mogae. Good morning, I'm Ruth Stox and I'm representing the British Psychological Society. Good morning, I'm Colin Keir, I represent Edinburgh Western constituency. Aileen McLeod representing the south of Scotland. I'm John Crichton. I'm representing the Royal College of Psychiatrists. Richard Simpson, MSP Mid Scotland and Fife. Can I just clear my declaration chair when I'm at it as fellow of the Royal Colleges of Psychiatry and of general practice and also honorary chair of psychology at University of Stirling? Hi, I'm Derek Marnas, associate nurse director for mental health services in NHS Acernau. I'm here as chair of the mental health nurse forum Scotland. Annette Mill, MSP for North East Scotland. Good morning, I'm Karen Campbell, principal mental health officer at Highland Council, and I'm here as the chair of Social Work Scotland on mental health. Rhoda Grant, Highlands and Islands, MSP. Thank you all for that. I should point you to this stage, as the committee members will know well, the format that we have here to listen to you and there will be less questions. Well, we need the first question from MSP, but I will get things going and remind MSPs that the preference will always be to the panel member throughout this process. Richard Simpson. Can I have nothing? I'm just saying that one of the questions that concerned us originally was the fact that not all elements of the bill were being reviewed in the McManus review, and I wonder if anyone has any particular comments about emissions from the bill, as it now stands, regarding it being important. Dr Cain. Yes. There was a general feeling, particularly from my own faculty of forensic psychiatry, that there was a wee bit of an opportunity missed and that it would have been welcome to have had an opportunity to look more fundamentally at all the aspects of the act, including those forensic aspects of the act, which, because of various other pressures, have found their way into the bill without quite the same root of consultation and scrutiny. Any other comments? Dr Sox? Yes. The British Psychological Society is disappointed that the bill doesn't go far enough. In relation to the McManus report, it's felt that the comments about the care plan and the need for a more detailed care plan would help with the need for a shift in emphasis in mental health care, away from what is a traditional medical model towards a far more biopsychosocial approach to the care of mental health. If there was a detailed care plan, this would direct practitioners to pay far more attention to the broad range of psychological and social therapies that are required in the treatment of mental health. Thank you. Any other comments? Richard Crichton? On forensic, it was chaired with your permission, and I will perhaps not go into detail today, but I think that Dr Crichton is probably referring to the no-rattle case, which, in fact, was the first one that I was involved in in the Parliament, which was the first bill passed by our Parliament in 1999, which was a gentleman who was let out from the state hospital, had a personality disorder, I think, and there was then a hurried, rushed bill emergency legislation that ensured that another five or six who were about to depart on the same basis were then contained, but it was then put into the 2003 act. With your permission, chair, I will come back to that at a later stage. The other issue that I might raise for general discussion is the question of the extension of the short-term order to the additional time allowed for the tribunals to sit. As convenable remember, we had evidence the other week saying that the numbers involved in this, where there was a stress, was substantially reduced by improved administration. I know that some of our witnesses attending today for the round table have concerns on both sides about the extension of the time beyond the 28 days in which the tribunal can sit, so I wonder if people would like to make comments on the record on that. It was certainly the position of Glasgow City Council when it was discussed that they had concerns about the extension and the idea of adding or deducting time at the other end was almost like treating it like it was a prison sentence or something. The point of being detained is for treatment. We felt that there had been improvements and there would be a risk that people would work to the wire and always go up to the last minute without there being real purpose. It is important that detentions are as short as possible and that sometimes longer periods of time are required to complete assessments thoroughly. Certainly, in the case of psychological assessments, sometimes that cannot be done in short periods of time. Therefore, occasionally it is necessary to have the assessment done properly for the period to be extended. Does anyone else have a question? Just an observation about how we are dealing with an evolving pattern with the tribunals. The tribunals are working much more efficiently, particularly under the current president in the last few years than they were when they were starting off and finding their feet. Therefore, when we are looking at those time limits, it is probably worthwhile to reflect on where we are at now and not where we were at some time ago in that what a sensible time limit is now may have changed even over the last couple of years. Does anyone else want to respond to that? I will come back to that briefly. At the moment, it is 28 days and there is a five-day extension, but the proposal is to make it 10 or 14 days. I wonder whether, with the comments about the wire, which I think are pertinent, it would be practical to shift the short-term detention order back to 24 days and then have the longer extension, which would mean that people would—the total time would not be any longer, but the wire, as it were earlier, would mean that, in those cases where an assessment was possible at an early stage, it would actually happen. I just do not know whether that is clinically practical or not. Can we have someone to respond to that? I think that, Bob, you want to ask some questions on that as well. Interesting proposal. I think that, in many cases, a decision can be made in 24 days. I think that Dr Scott's observation about complex psychological treatments, even with the two-week extension, might not be resolved in many cases. I do not think that any of the time limits that we are discussing today would particularly answer that point. I think that Dr Simpson's proposal is one that is worthy of further reflection. I have nothing to add to that. You have no response to the general point. If psychological assessments are requested early enough, then there should generally be enough time to do it. It is occasionally the case that sometimes a longer time might be required than is originally envisaged. However, I take Dr Triton's point that sometimes those assessments are lengthy, regardless of when you start them, but the earlier they can be instructed, the better. Again, that goes back to the initial point about if this was much more of a priority in terms of people's care, then consideration for psychological assessment would be more in everyone's minds. I suppose that moving to the general rule that everyone could end up longer rather than addressing the initial point of getting this done properly and quickly. That is a nub of it, is it not? Mr Fraser, are you going to come in there and help me out? No, but I take on the point from my psychology colleague about the need for psychological assessment. I was just a bit concerned with how the proposal was originally drafted. The tone of it is that you compensate somehow by taking a wee bit off at the end, when, in fact, the point of it is for assessment and treatment rather than being some kind of balancing up in terms of the justice of it. I am not sure that that was the right way of thinking about it. I do think that the natural tendency is for people to work to the wire, if you extend it. I think that it is almost inevitable that that will happen. Bob Doris, you are going to test some of the evidence that we got last week because we had the mental health tribunal for Scotland and the mental welfare commission last week, and I asked specifically about why it was 28 days and could that, in theory, be reduced. Both witnesses had broad agreement that you are talking about getting between three to four weeks to get all the relevant reports ready and prepared to make an informed assessment and that the number had not been plucked out a thin air. On balance, I have been trying to know whether people think that 28 days is about right. Just to follow up on some of the evidence that we got from last week as well, the figure was given 70 to 80 per cent of all tribunals now are made within that 28-day or 5-day extension period and would not be needed for that additional 5 days. The argument was put to us. I suppose that this comes to the crux of it. There is always a balance with those things. The argument is put to us that the main reason for the extension from 5 to 10 days would be for those 20 to 30 per cent of cases that do not meet the current targets, that it would avoid or reduce repeat tribunals and that it would give more time for relevant family members to make statements and representations as well. We are looking at whether there is a balance to be struck in relation to the rights of the individual under those detentions or not. So 28 days, there was agreement last week that that seemed to be about right. There seemed to be agreement last week that this was not for people to work to the wire, but it was to reduce multiple repeat tribunals and give family members more time to have a say. So that was the evidence that we got last week. I am just wondering whether the professionals here today concur with that or not, because we have to make a judgment call as a committee. Colt O'Claeter. I would broadly concur with that. I read the evidence from the commission and the present of the tribunals to you. We are talking broadly about similar timeframes here. It is very difficult to say what precisely is the correct timeframe that we should look to when we are talking one week or either side. We are trying to strike a reasonable balance. In striking that reasonable balance, ultimately, we need to suck it and see and review how we go with that. Clearly, there have been some issues. Those issues have come to their conclusion in the proposal that is before us in the bill. The only observation that I would make is that I wonder whether some of those conclusions have been borne out by experience when the tribunals were settling in and not working as efficiently as they are at the minute. However, if the tribunal is coming back to us and the commission is coming back to us and saying that particular groups are being disadvantaged in the current timeframes, I do not think that there will be strong views from the professionals about one week, one side or another. I will say again that we would be concerned that, if there was a deadline that responsible Anare Mo felt could not be met if a more specialist assessment such as the psychological assessment was instructed, it would not be instructed because of the fear that the deadline would be missed. I appreciate that there is a difficulty in deciding exactly how long that period of time should be. However, my concern is that, if there is already some pressure that is felt and that this is when psychological reports are not routinely instructed, then perhaps this is making it less likely that we will be in future. No other response. I should have said that I am here in the half of the Royal College of Nursing as well, just for the record. I asked some of my colleagues across Scotland to relate to this from a nursing perspective, and they were not convinced that the extension from the five days would actually make a significant difference on the basis that a lot of the extensions are because solicitors are asking for a second opinion, so it is a bit about that point. However, they did absolutely acknowledge what Bob Doris said that it may allow the named person or relatives to gather more information so that there was an unbalance. They were not convinced but recognised the argument of better access. I think that it is an area that will need to be examined thoroughly in the future to see if it has made any difference. There seems to be some questions about whether it will address the issue. Would there be a benefit in putting into the legislation a time limit, say, five days that the patient was informed of the tribunal so that they had the extra five days to pull together second opinions and reports? You are not shortening the time for the tribunal, you are extending the time for the patient, rather than going to a tribunal and then getting an extension to come back to a tribunal. Is there any merit in changing the length of time and saying what proportion is available to whom? Does that make sense? I am not understanding what I am saying. I am looking at blank faces. Rather than a patient going to a tribunal and asking for an extension because they need extra time to pull together the reports that they require to represent themselves properly, they will be allowed to do that sooner so that the tribunal needs to present them with the paperwork within the five days, as currently happens, but that they can then ask for the tribunal to rather than go to a tribunal and ask for an extension that they can ask for that extension to pull back their papers without having to go to two tribunals? It may have been a better question for last week in those who run the tribunal, I suppose. There is an attempt here to reduce appearances and all the stress that that involves. The question is, instinctively, if you feel that in life experience, if you extend the time, you do not actually change that problem at all. If you work within those limits, there is no pressure, if you like, to increase to 70 per cent who are going through successfully at this point to 80 per cent or 90 per cent. Of course that will go up because the time frame that they are working on will go up. That will look pretty good, but what are the consequences of that for the individual who is caught up in that procedure? Dr Creighton? I think that there are issues of access to appropriate specialists to give independent reports for patients who are seeking them, but often folk will know very early on in terms of a 28-day admission that longer detention powers are being under consideration and the ball can be started rolling. Perhaps the conversation has been about the provision of timely reports, but actually the length of time is also about response to treatment and observing the person in a specialist environment to try and get clarity about diagnosis and the other questions that we have to address in terms of compulsory measures. I think that that is worth thinking about as well. Sometimes the time limits that we have do not allow us as much time in every case to do that sort of assessment to see whether longer detention is the correct way forward. That is particularly the case in section 52, on which we may come on to later. Given that this is obviously a difficult decision, a number of people have mentioned that it would be interesting to know who the group that is not meeting the 28 days consists of and whether there is any pattern to that. If Mr Barron suggested that it is often because a second opinion is being requested, then those are generally the more complex cases and it may be that it is a subset of people who actually do require additional specialist assessments, a more thorough look at their situation that needs this additional time and that the vast majority of cases can be dealt with in the shorter time period. It may be worthwhile to examine whether there is some detail around those for the committee about those groups or individuals that this particularly applies to, so we could maybe check that out and ask for some more information. Certainly, one of the issues that was related to this was the role of the mental health officer and the capacity there. Indeed, the importance of that role within the system. Does anyone want to speak to that or comment on that? I seek to associate myself with the statements made in the Mental Welfare Commission's written response to the committee. I think that there are quite serious implications for MHO resourcing. I think that what has been proposed involves some significant extra work for mental health officers that certainly was a concern to us in the forum and when it was discussed in a group at Glasgow City level. In particular, the proposals that a named person has to sign up to be named person. I am not clear if there has been any further developments in thinking about who the prescribed person would be. I think that our assumption is that that would fall to MHOs in large part. Quite often, we have named persons who live in different cities. Quite often, our out-of-hours standby service might give consent to detention at 2 o'clock in the morning or something like that. There is no way that you are going to access a named person in those circumstances. The idea that we may have to actually, it will certainly involve an extra visit. I would have thought that, in terms of the concern that I have at a national level, we are having problems retaining MHOs. The numbers are going down and it is an ageing population that we have nationally of MHOs. In Glasgow, we had 120 MHOs in 2011. We have 94 in 2013. That is at a point when their workload has dramatically increased, particularly in relation to adults with incapacity requirements. The number of adults with incapacity applications in which the older population has been increasing steadily over the past few years has increased dramatically in relation to people with learning disabilities. Some of that is to do with the self-directed support agenda. If not unanticipated, I think that the impact of that has been underestimated possibly. At a point when, if anything, our MHO workforce is in a slight decline, we are already having significant increases in our workload. We need to be very careful with some of the proposals in the bill, because there is no doubt that it is going to add significantly to workload. I would also wonder if the proposal, the requirement that MHOs produce a report at review stage, whether it would be scoped for instead of that being a report that the forms are amended so instead of just being a signature, there is a statement of the MHOs opinion put in at that stage, that would go some way to addressing some of the concerns that you may have. Without requiring the significant extra work that would be involved in producing a separate report. As a number of concerns that I would have, I think that there is quite significant workload implications on what has been proposed for MHOs. Beth Hall. I think that maybe just to echo some of what Colin has said in terms of the work that we have done with our members around existing pressures on MHOs in terms of the shrinking workforce that Colin has already mentioned, but I think that we are also looking forward. Those are only projected to continue to rise in terms of the adults within capacity, in terms of the existing duties there, for example, around guardianships. I think that there is some information being published that shows that it has been increasing around 10 to 12 per annum since it was introduced. We can see that there is a trajectory against the decline in the workforce that Colin has mentioned. Just last week, the Scottish Law Commission published a report that I believe is proposing a new scheme around the restriction of liberty, which would place additional pressures again on MHOs. Against that backdrop, looking at the bill that would introduce additional duties on MHOs, we would concur with the mental welfare commission's call for a national strategy on MHO workload and capacity on recruitment and retention. I think that we would want to see that go further and also look at projected future demand, what that means for the capacity requirements and also how that would be resourced going forward in terms of some of the specific proposals within the bill. We had other concerns where we weren't able to reconcile what was being said in the bill explanatory notes with the financial memorandum. It looked as though the financial memorandum estimates were based on a narrower interpretation of the duties that were appearing in the bill. The mental health tribunal for Scotland also picked up on that. It was very clear that it shared the view that MHO reports would be triggered in far more circumstances than the financial memorandum anticipates. If we can come on later, I could give a bit more detail around that in terms of what we think the likely requirement would be, but, certainly overall, we would be wanting to think very carefully about any new duties within that context until a proper review is undertaken. I thank you. I will get Mr Barron and then Dr Crichton. Not my year of expertise, so I asked some of my colleagues in North Ayrshire Council. I am the lead nurse there as well. They concur with exactly what Colin Beath has said about the workload issue and the resourcing issue as it is going up. To put it into the bill, would it cause great difficulty just in terms of workload? For us, in terms of the workload, would it cause great difficulty in implementing the bill, as it is intended? I suppose that is the question for the committee. Change is always not intended to dismiss or reduce the anxiety that we have had here, but in most cases, if changes are proposed, people will be worried about that. However, in terms of the bill and the implementation and objectives of the bill, we would still be able to go ahead with the bill. Beth Hall? I think that the difficulty is that, within the financial memorandum, it gives some estimates of the number of additional reports that would be required by measures within the bill, specifically section 2 of the bill that relates to section 101 hearings. The financial memorandum estimates that that is requiring an additional 20 reports per annum. However, if you look at what the financial memorandum actually bases that on, it is different circumstances—it is narrower circumstances—than are contained within the bill itself. I think that both the Mental Welfare Commission and the Mental Health Tribunal for Scotland have also picked up on the same discrepancy, so looking at what it actually says in the bill around just section 101 reports and taking mental health tribunal for Scotland figures, it would not be 20 additional reports, it would be 493, around 500. There is the same issue with section 41 of the bill, discrepancy with the financial memorandum. It is a significant difference, and I think that it is significant enough that it would be a big problem. Dr Clayton. We would, of course, welcome the input from mental health officers in a wider range of circumstances, but we had some real concerns that that might cause delays in various different areas regarding appropriate treatment. For example, transfer for treatment directions, where we have some national prisons, where the MHO will be called upon from various parts in the country to provide reports, sometimes in urgent circumstances. As a general comment—and I would not take away at all from the comments from our social work experts in the room—it has struck me as a curious thing that, for psychiatrists, the approved medical practitioner training is really quite modest, an online module and a day's course, and that compares, rather starkly, with the very comprehensive training of mental health officers. I just wonder whether we have got the balance there right and also the balance of expectation in terms of the mental health social workers generally, or being expected to be mental health officers, as we would expect all psychiatrists to be approved medical practitioners. I would just concur with what is being said about the extra duties on MHOs and from the social work Scotland mental health subgroup. We have also raised the concerns about the additional workplace on MHOs, and it is significant. It is important to look at why those reports are being required. They are seen to be best practised, and it is important not to dismiss that we need to remember what the act is about. Although we require to do more work, we need to look at how we are going to be able to do that and what support we need to be able to do that, rather than not do it. The bill, as it has been presented, is specifically to support people who are mentally unwell and have mental disorders and are needing the legislation for their protection and well-being. When it comes to training for MHOs, I think that that is another issue that you mentioned. It is important to look at it. It is very comprehensive training, and it is for a workforce that is ageing and how to make MHO training attractive to people. Currently, we have a lot of mental health officers in Scotland that are in the next 10 years not going to be around and are going to retire, so we need to focus on how we encourage people to undertake the training and become MHOs. I think that Karen Campbell has hit the nail on the head here. First of all, I would like to say that, of course, the committee will explore the numbers that were outlined, whether they are 20 reports or 493 reports and the pressures and the workforce planning and recruitment and retention. Of course, as a matter of course, we will be asking those questions to the relevant people in the Government and elsewhere. The bigger picture is whether those reports are required, are they essential, are they highly desirable or are they just a slight advance in the way things are just now? I have not really heard from people how desirable those reports would be. I would like to make a judgment on whether it is the right thing to do, and then I would like to make a judgment on how we resource and enable that to happen. I feel that the discussion that we have had so far has been around whether we can resource and enable that to happen. We will look at those figures as a committee, and we will make a well-rounded decision on that, I am sure, in due course, but we have not heard enough, apart from Ms Campbell, really, about whether it is desirable or not. For myself, I would like some information about how desirable or otherwise that is. Dr Clayton. I think we would say that they were highly desirable, but we are responding from our real world experience of how sometimes we can have difficulties even now, and we would certainly need to have some urgent measures whereby in those circumstances where we could not achieve the report, we could still achieve the urgent treatment required, for example, in transfer for treatment erections. Dr Stocks. I think that, in the code of practice, mental health officers recommended that they seek advice from other practitioners who might be involved in a person's care. To that extent, we would feel that the reports are highly desirable. They are desirable anyway, but I think that it is often the case that wider input does not happen possibly because of the resourcing issue. We would feel that it is extremely important to continue having the reports, but there needs to be contribution from other professionals into those reports. Dennis Robertson. I wonder what the role of the general practitioner is in that. I think that the pathway for a lot of patients in the initial stages is through general practitioners. I just want the pressure on the general practitioners themselves from making that initial judgment to refer patients on for the specialist pathway of treatment. I think that's your cue, Dr Gillies. Thank you. Am I audible? Yes. Thank you for raising the point, Dennis. These events in general practice occur. They are not rare, but they are unusual and they are not part of the day-to-day work. When they do happen, they are often complex and require a lot of time and attention and can often be disruptive to the more routine parts of a GP's day. GPs do not take the decision to refer on for a psychiatric opinion and for a mental health officer's opinion lightly. My understanding and my experience is that when they do happen, they are dealt with by GPs in a reasonably timious manner. As far as I can understand from the bill, I don't see a large implication for an increased workload for GPs from this, as far as I can see in that the oldest force is largely on mental health officers rather than on the general practitioner. There are one or two points about general practice that I would raise later on, but does that address your concerns? I think that what I'm really trying to get at is GPs that are under significant pressure to make these initial judgment calls. As you say, general practitioners are general practitioners and they don't have a generic knowledge, but rather a specialist knowledge. I'm just wondering whether there are enough specialists within practices in various parts, where there may be a high incidence of what people require referrals on. Is that covered adequately within general practice and medical centres? You call on your colleagues, thank you. I think the point of view of the general practitioner is that of an expert clinical generalist. That means an understanding of both the kind of biomedical aspects of care and that means both physical illness and mental health or psychiatric illness, but we also have a knowledge of what we would describe as the biographical aspects of care, which is an understanding of that person within the context of her family, her community, her culture and ethnicity. Those are the core skills of general practice and it's on the skills that we would draw to make a decision. Obviously, we specialists and generalists, which we are, work closely together, need specialists, need generalists and generalists need specialists. I would suggest the right starting point to still the general practitioner and then he can make a decision about involvement. As far as I know, that system has worked reasonably well. I'm grateful for any discussion from specialist or psychological colleagues on that. Dr Crane? I would support those comments. I think we were talking about why 28 days and this has been a tried and tested time frame. Another tried and tested observation is that the combination of specialist and general practitioner in decisions about compulsory treatment is something that historically has worked very well. Colleagues who are regularly making these decisions with their general practice colleagues give very positive feedback about that input, particularly that broader appreciation of families and communities that general practitioners bring to these decisions. It's actually in those areas where somebody isn't registered with a general practitioner that we have difficulties and we usually have to scratch around to find an AMP from an independent area to come and assist us in second medical recommendations. I've often thought in those circumstances it would be nicer to try and get an independent GP from some place, but of course GPs are under tremendous pressure and we're very grateful to all the contribution they do bring to those decisions. Anyone at the S? Dr Stalk? That more holistic view of individuals is being very important in decisions about their management. I would just reiterate my point that there are times where specialist input is also required. There are a number of ways to do that. Psychologists are one of the range of professionals who might be contributing and perhaps more often the views of those people could be taken into account. Dr Gillas. Thank you. Not to prolong the discussion too much, convener, but we're certainly on record at RCGP in supporting an increased provision of psychological services for people with mental health disorders. There is some evidence that the biomedical model of dealing with mental health, which has been the predominant one for the last 30 years, has had great strengths and great successes, but the paradigm is now changing and I think we are often frustrated in general practice by an inability to access, timiously, psychological support. There certainly have been improvements in that area in recent years, but there is still some way to go on this. Beth, do you want to say anything more on that? In 1614, the bill makes provision for certain nurses to detain, as we have touched on a lot of areas here. Does anyone want to speak on that in terms of certain nurses' power to retain, which the Mental Welfare Commission are concerned about? Mr Barron. As I said the last time I was at the committee, we are concerned about that and don't see that as a proper extension of the nurses' role. The nurse to be able to do that has to diagnose and nurses don't diagnose. An element of nurses being able to prescribe, and we've got very few nurses that can prescribe, we have some, so it's not something that we support at all in terms of nurses to be able to detain in those circumstances. The only detainment that we would say for a nurse is in section 299, which is part of consideration, which I presume we're coming to as well. Dr Stocks and then Dr Crichton. Yes, certainly. I'm extremely pleased to hear that there is a recognition of the need for this shift in emphasis from the traditional medical model towards a more biopsychosocial approach. Can I just say that we're not as psychologists presenting anything that is a challenge to what other people do. It's about seeing mental healthcare as requiring a number of components with various interventions, but that in addition to the more traditional forms of treatment, such as medicine and mental state monitoring, a range of psychological and social therapies are required. It seems to me that the shift, although it may be recognised by the clinical professions, also needs to be made aware amongst the general public and users and carers of services. We would recommend that the language of mental health legislation has changed. Currently there is reference to medical treatment, although listed under that are a range of different types of intervention, including psychological interventions. In practice, those are not given the due recognition. It seems to me that only by more fundamental changes in the legislation will there be a more progressive approach to mental healthcare, which I think was envisaged in the existing legislation but has not been realised in practice or certainly not to the extent that users of services require. The social work mental health subgroup, we felt that to extend it to three hours, nurses' holding power to extend it to three hours was something that we viewed positively because it would enable their nurses to contact both the MHO and the RMO. I think that there are a number of local authorities in Scotland where hospitals are not necessarily right where the MHO happens to be, so it allowed that extra bit of time. As a result, people would be more likely to be detained on an STDC rather than an EDC, which would be a better practice for them. See, Mr Bam wants back in on that. Last year, 2013-14, there were 177 uses of the nurses' power to detain. Only 74 per cent of them went on to actually have a detention. Of that, 40 per cent were emergency and 34 were short-term detention, and another 23 per cent actually stood on in the hospital without use of detention. The code of practice, as is currently sent out by the Main to Welfare Commission earlier this year, in terms of the step of processes, the nurse tells the individual, I'm going to use section 299 of the nurses' holding powers and I've got a form to fill out, and they inform the doctor. The doctor has to be there within two hours. Only once the doctor has said, yes, I'm going to do that, do the call the MHO. To actually impact on the three hours, you'd have to call the MHO at the beginning of the process. If you called the MHO at the beginning of the process, bear in mind the workload issue that we've already heard from the MHOs. In 44 cases, you'd have called the MHO for no purpose whatsoever because the person either decided to stay in hospital or were not then detained. We're using our MHO resource going from somewhere remote to a hospital for no purpose whatsoever, so there's no advantage of that. My other issue is about reciprocity for the individual. We're placing on them and saying we're not going to allow you to leave for two hours. I think that places on us in service equal response that we must do as soon as. So there's no evidence to say that the extension of two to three hours would have any impact whatsoever. Ayrshire and Arran, we only used nurse's power to detain nine times last year. Even in Greater Glasgow and Clyde, we only used it 27 times in the entire year, so I'm not sure why the push of where that and I've got the stats which will come out from the commission later this week, I think, to say there is no evidence that there's going to be an advantage to this, nor is there any evidence that increasing the length of time is going to impact whatsoever other than the person who our duty is to protect their human rights, not to make it easier for our workload. Just going with the panel, I've got a couple of bits from Dr Creighton. I think that one of the possible areas where this may be coming from is concerns from rural and remote, but I wonder whether there are other solutions that can be looked into. We are expanding our use of video technology and that type of assessment where there can be Terry Meddson from a practitioner's home computer into the clinical workspace with appropriate safeguards and security. I wonder whether there may be other ways to crack that down. I'll try to clarify a couple of things. Mr Barnett, I have no idea if this extension is the right thing to do or not. That's why I have no preconceived views on this, but just for clarity, I wasn't sure whether you were saying we shouldn't extend it because the Mental Welfare Commission said we probably shouldn't extend it because they don't think that it will lead to any greater involvement from the RMOs rather than the fact that it was necessarily a bad thing to extend in itself that it wouldn't have the intended consequence. In your evidence, are you suggesting—I might just have picked you up wrong—that the current power to detain shouldn't exist? I was getting a sentiment that you were saying that maybe it's not a positive thing in the first place, and just some clarity around that. Secondly, just in terms of the views of nurses, it's not only some nurses, but it's mental health nurses and it's learning disability nurses that can do that. Have they, themselves, raised concerns specifically—have they, across Scotland, taken a view on this and raised concerns specifically about the current to our detention, because if they had done that, this committee would obviously want to know about it? The first part of that question is a positive thing. Yes, it's a positive thing. It's not used as well as we would like, and when the commission published their guidance, their updated guidance, earlier this year and we're going to do additional training, we would like far more nurses to use the power to detain because with it brings the protection of the act to the individual. We probably feel there are some detentions, de facto detentions, going on without the provision of the act, which I think is unfair on the individual. That's the first part of that. There is no concern from mental health nurse leaders across Scotland in relation to the two hours. Our concern is extending it further. We don't see any need to do that, and I don't think that's within the ethos of the act or our approach to human rights, because we don't see it will give any advantage whatsoever and yet you're placing a restriction that you maybe don't need to. I'll digest that. I'm generally not trying to walk with it. I wasn't clear what the point you were making was, I suppose, the only other thing I would ask is, you gave an initially, what's in 74% of the cases or something, did an initial, when the RMO got there, was there any additional detention given, and quite often that was a short-term one, but it was given. I suppose the question I would ask is, what would happen if the nurse didn't have that power to detain, and then in the medium term, the minority of cases where that detention would have been required for the safety of that individual, what the consequence of that being? Again, I'm talking to get behind this. I totally accept that the more power of detention you give, the more you infringe the rights and freedoms of individuals within society, but that has to be commensured and balanced because you're also seeking to protect vulnerable individuals at the same time. Is there any benefit at all from extending from two to three hours? I'm just trying to tease that out. My personal view and that of my colleagues across nursing, associate nurse directors in the main to health, et cetera, there is no advantage of extending it. We don't see any advantage at all. It may be workload related to some area. We don't even know where it came from, because it certainly didn't come from nursing to suggest that we should do this. In actual fact, we would prefer going back and doing more work with our nursing workforce in terms of using the actual powers to detain. I suppose that it's okay just to briefly. There's no reason for asking this other than I'm just interested to know that when you talk about taking the views of senior nurses about what the views are across Scotland, has the RCN done a deep survey of those nurses on the co-face and learning disability and in mental health? Those on the ward and mental health units, for example, when those day-to-day hands-on at the co-face with learning disabilities, is this a grass-roots view or is that a senior clinician view that you're bringing? Possibly it's both, and that's fine, but it's just starting to get a flavour of where the view is coming from. It's both because we obviously engage with our staff. A certain from my area, we've got a main to health nursing advisory committee, which is main to health and learning disability nurses on it. Whether that's a brand new staff nurse on a ward or a community team or somebody more experienced on that, we get the feelings from them as well. I certainly speak on behalf of senior staff who are the ones who are responsible to monitor and accountable for it. We don't see any advantage. Not one single nurse has come to me and said, do you know if we'd had a three-hour period, things are going better? That's really helpful. Thank you for that. Any different talk to me on that? There's a comment about another part of the act, if we want to move on next time. It's on sections 21 and 22 advanced statements where the bill seeks to place a duty on health boards to ensure that a copy of an individual's advanced statement is placed in the medical records and a copy is sent to the mental welfare commission. That seems like sensible practice. Health boards and, presumably, hospitals have their own records. General practice has separate records, and good practice would obviously be that this advanced statement is shared with the patient's GP as well as with the hospital record. We know from practice that that doesn't always happen, and I wondered if there could be some way of ensuring that the duty was not for health boards to ensure that both GPs and specialists and other clinicians who had an input into a patient's care were made aware of the advanced statement. Frequently, the advanced statement comes through the general practitioner, but that's not always the case. It's just to make sure that everyone is kept informed, because those are very significant statements when they're made and they must be carefully looked at in the context of, say, a recurrence of a serious mental illness. Dr Cleane? One place where the advanced statement should reside is the emergency care summary. As that rolls out and becomes more available to emergency mental health services, I think that there'll be greater awareness of what is used within mental health, but I think that it's essentially a matter for the code of practice and professional development rather than a statute. I would agree with that. It was just to raise it as an important issue. The emergency care summary has been hugely useful, but it includes just very basic data about drugs and allergies and intolerances. The key information summary, which is currently being rolled out electronically across Scotland, might be the best place for this to sit. If it sat there, it would have the explicit consent of the patient involved. I would agree that that would be the way forward. I was going to suggest the key information summary. I think that we should pursue that. There will be technical difficulties in how we actually do it, but that shouldn't preclude us from trying to do it. Not everyone can access either the emergency care summary or the key information summary. The emergency care summary is only available for out-of-hours practitioners, so it's not broadly across mental health, and it's not currently available in our awards, which is where you need to have access to. Neither is the key information summary, so I'm not saying that we shouldn't do that because I think that you're right, and it's one central place to do it. I think that we might have technical difficulties in how we do it, so when we introduce it, we need to be concise into that. Anyone else wish to make a comment on that? I think that it's really important. The point that Dr Gillis makes is essential, because patients in terms of their follow-up care will probably sit with a general practitioner in a lot of cases, and not just for that patient but maybe for the patient's extended family or carers. I take his point that it doesn't always happen, and I'm just wondering to some extent how often doesn't it happen, because I am aware of issues where it hasn't. It has, unfortunately, meant that a patient doesn't have the required follow-up care, and the GP is basically in the dark of the treatment or recommendations from psychiatry or psychological services. It should be in the code of practice, but it needs to be something that is acted on. It can't just sit there and be nice words. It's something that is to the benefit of the patient, and we need to ensure that it's something that is followed up. We mentioned in our written response that there is a need to take account of the fact that, often, service users change their minds. Although we recognise that there might be a benefit in having a central register, there also needs to be some way of ensuring that the advanced statement is kept up-to-date. Another point to make is that there is not always a good understanding among staff working with service users about how to create an advanced statement. It would be useful to have some guidance in the code of practice. However, as we've learned from previous experience, the attention is not always paid to the code of practice. It might be that some training is required for staff working in mental health services across the board in how advanced statements can be created and kept up-to-date. Is there a role for advocacy in all of this in terms of making people aware that they can and possibly should have advanced statements to influence difficult circumstances? How common is it for a patient to have that advanced statement and that information anywhere? Colin Fraser and Derek Barham. My experience is relatively rare. It's been an aspect of the legislation that really didn't take off as much as people had hoped and anticipated. It's always a bit of a treat when you actually do come across an advanced statement, but we are often asked to try being nervous if there's an advanced statement. The answer is more often than not, no. I think that it is an area of work that perhaps merits revisiting in terms of guidance training, and I agree with Dr Stox's comment that for the advanced statements that do exist, people do change their minds. If there's a mechanism for recording that, there needs to be a mechanism for reviewing that and making sure that the information is up-to-date. Mr Barham. I think that the answer to your question is the role for advocates. Yes, there is, but there's a much greater role, for example, for community nurses who are engaged with people when they're at a less ill stage, because the advanced statement is about when I become ill, this is what I want to happen. We need to be careful that the practitioner is not the one who's generating this. I agree with Colin that they're rare, and some of them are not very good in terms of just saying things that are just not doable. A good advance statement, because one of the suggestions from what it was actually the social work of the mental health subgroup said about a pro-former. I think that a pro-former, we've asked the commission, the mental welfare commission, to think about doing a pro-former so that we can have that, but we have a lot of people who choose not to have advanced statements, and we have to be cognisant of that as well. I have a huge concern about us having a central repository for it. The NHS in general has not got a fabulous track record of having massive centralised systems at work, and we can access it in terms of who's allowed to access it and when we can access it. Unless it's available 24-7, it's pointless, because you need to be able to access it when the person is becoming unwell or is going to be admitted. You want the advanced statement to say, so what is it, what's your desire, what is it that you want us to do, and we're listening to that. Not all boards across Scotland have electronic systems that could do that, and then we're with the central point to go and get all these Bs, and then as Dr Stalk says, if he changed your mind, how do you make sure that it's updated on a regular basis from the minute you change your mind to do things? I suppose we don't need to worry about any of that, because it's a rare occurrence if a patient presents with one of those advanced statements, despite the fact that we all agree that they at least could be helpful to that person. We need to turn that upside down a wee bit. I mean, these problems will present, but if we recognise that it's a good thing, if somebody wants to opt into that, we should maybe help make it happen and overcome some of these difficulties. We can do it in Ayrshire now because we have an electronic health record for mental health, so all of our advanced statements are available 24-7. In fact, I could access one, obviously I wouldn't, right here just now, so that you have to have that ability to do that, but again you're right that we spend a lot of time doing that for something that people are not opting into doing. Dr Gillis and then Dr Stox. Thank you. It's been a really interesting discussion. I agree with Colin Fraser that advanced statements are really pretty rare, and I was hoping that we would see many more of them when they became available, because when they have been available with a patient, they've often been hugely helpful for guiding professionals and how to deal with the patient. On Derek Barron's point about the Mental Welfare Commission, I assumed that the Mental Welfare Commission were sent a copy so that they were aware of the data and statistics around advanced statements rather than for them to be used in the day-to-day care of the patient, and I still think that it would be useful to have some hard data on advanced statements, and I would agree that it would be really useful to encourage them. I would be concerned about advanced statements going into the electronic care summary, because that will become more widely available over time, I think that's the point of it, but I think often patients would be rather concerned if an advanced statement were made available in that way, and I think the place for them would be a key information summary, which should, to answer Dr Stox's point, be regularly updated in conjunction with the patient. I note that, in previous evidence given to the committee, someone from one of the third sector organisations spoke about how their research showed that people, service users, were not producing advanced statements because they believed that they would not be paid attention to and that there seemed no point in doing that. It seems to me that that's very worrying, and worrying for us as a society, and that, with any opportunity to influence the legislation, we need to make sure that it is promoting collaborative care for people who suffer from mental health problems, and that we're doing everything that we can to make sure that people feel empowered, that having a view when they're well about how they would like to be treated when they're unwell is going to be paid attention to. I think that's very important. There are some examples of good practice in this area. Those patients who are within forensic mental health services are subject to the care programme approach, and we are rolling out innovations in the care programme approach to make it more patient-centred, but within that process of regular review, the advanced statement is revisited on a periodic basis. That information is shared with primary care and other forums, and also on to electronic databases in those health boards that have these things up and running and accessible to on-call and emergency services. I think that we can make the advanced statements work a lot better. That, of course, works for the severe and enduring those subject to practices like the care programme approach or equivalence. I think that it becomes more problematic with less serious conditions. I go back to your question. Should advocacy have a role to play with advanced statements? I think that we think that they should. There is clearly something that advocacy could pick up on there. From another point, and this is on the point of being based in the Highland myself, that the Highland user group is a very proactive user group, and they have spent a lot of time with their members. As the arc came into force in 2003 and implemented in 2005, they did a lot of work with their members about advanced statements. I do not know if it has been reduced, if there is less uptake now than it was then, but I know that it was viewed as a very positive thing, especially for people who had severe and enduring mental illness and who required treatment on more than one occasion. It is something that user groups could become involved with because they would be able to support members to do the advanced statements and understand the benefit of having that. I agree with that entirely. I was here when the member of the third sector said that people do not believe that their statements are going to be listened to. That does not make it evidence that that was one person's view or a few people's view, and I am not sure that is entirely accurate. If we take the Highland user group, for example, their previous chair stood at a conference and actively promoted the use of advanced statements and said the really good things, but I do not have one. He actively chose not to have one, and we must retain that right. I have just come back to Dr Gillis's point about the main to welfare commission. We send advanced statements to the commission who are the protectors of human rights. If, in a board, we do not follow what is in someone's advanced statements, we have a duty to inform the commission and then the commission will look into it specifically. It is there and it goes to them as a protective factor because they are the protector of human rights. There will be occasions when we do not follow an advanced statement and we have to answer for that. That is the purpose of it. I would like to reiterate the point that I think that rather than recognising the low uptake of advanced statements and organising around that, the priority should be to ensure the increased uptake of the facility for using advanced statements. I think that it is a really important part of legislation. I think that it is really unfortunate that the making use of that availability is being so poor. It would be interesting research to try and get behind why so few people make use of advanced statements. I agree with Derek. It is voluntary and nobody is forcing people to use advanced statements, but it is striking how low the numbers are. It requires attention to at least know why. Richard Simpson. Mr Fraser made the point that I wanted to make. Do we know if there is any research on whether that is a myth that advanced statements are not followed? The protective mechanism was written into the original act. The purpose was that if an advanced statement the MWC knew about it and could then determine whether the treatment that you received was in conformity with your advanced statement, and if it was, why not? It is disappointing to hear that there is some view out there that those statements are not worth the paper that they have written on. It would be interesting to go back to the MWC and say, has this been properly analysed? How often has it been a problem? The other thing is, convener, that you raised the question of advocacy. If I could just move that on a bit, at the moment there is a qualified right to independent advocacy, if practicable. One of the questions that has been raised is, should it not be an absolute right to have independent advocacy? That might help us in terms of the advanced statement issue as well. I wonder if witnesses have any comments on that, whether it should be a right rather than if practicable, a much firmer statement in the law. Anyone? Beth, thank you. I mean, certainly we are aware that there have been issues with availability of advocacy services across the piece. I think that across Scotland a number of reports now have indicated that provision can be patchy. However, in taking a decision to move to legislation and go down a legislative route to try to solve that problem, we have to be very careful and be very clear that additional duties will actually solve that problem. We need to get a better understanding of what the issues are and what are leading to those problems. I am just not sure that we quite have that as yet. It is a question back around whether we have a good understanding of what is happening here. Is the issue not more about making sure that local authorities and health boards fund the provision of advocacy services? It seems to be well recognised that provision is patchy, but in some areas it seems to work very well. We gave a response in relation to that as well, and I have to confess that that is based on knowledge that I have from my clinical job, which is a clinical psychologist working in Greater Glasgow and Clyde. The example that we have is of an advocacy service that is fully funded by the health board. I am not sure if there is a contribution from the local authority as well, but the advocates are very embedded in the work of the health services, and every patient within the forensic services where I work has access to an advocate. The advocates also become a part of the culture, the environment, so they learn about how mental health services work. They get to know the professionals that they will be sitting beside it, care programme approach meetings, and with that, in those circumstances, it is much easier to advocate for someone. There are probably many other examples of good practice across the country that we could learn from, but it seems to me that the key point is about making sure that the financing is there to be able to employ advocates. Beth, do you want to come back to that? Maybe just to agree with those points and add to it a little bit in terms of work that local authorities are having to do—it is actually a duty under the self-directed support act to look at the marketplace of services within their area and think about how they can develop that to make sure that it is sufficient to meet need. That includes looking at funding for those types of services and looking at the balance between resource that is invested in direct service provision to the individual, if you like, through things such as self-directed support and personal budgets, and then having some resource available to fund universal services or specialist advocacy provisions. I agree that there is an issue about funding there. However, that begs some bigger questions that I am just not sure would be solved by creating a stronger duty. Advocacy has exceeded expectations. In those areas that have well resourced advocacy, they very much become part of the mix that promotes patient welfare and patient rights. If we are a little bit disappointed in the take-up of advanced statements, we are not disappointed in the use of advocacy where it is available. As for strengthening it, I guess I would want to see the evidence of those areas that struggle to provide it. Mr Barron, I agree that I am getting old. I am not sure of the advantage of putting it into legislation and I would rather take the approach of it. Where are the people struggling just now or what areas are struggling and address that rather than taking a blanket or putting it into legislation? We do not struggle. We have advocacy, including in dementia units. We approach it as a right and a responsibility for that. I am just not clear what the advantage would be. There must be an advantage or the lies that you would not be doing it. That one has been well-earned. Is there any other questions from committee members? I am just trying to get the committee members there, John. You are fine. Did you want to come back in that, Dr Gellison? No, it was another point. It was another sub. Right, that is okay. I was just about to do that because we are probably in the last 25 minutes of this session. I know that Beth Hall and indeed Derek Barron have mentioned issues that they would hope to get to or raise. Given the opportunity now about some of the areas that are of particular concern to you, if you want to place those on record, that would be helpful to us all. If they stimulate another debate, all the better for it. On Beth Hall, you said that you were going to come back on to some issues. I will give you the floor and accept bids from our panel members about areas that they feel that they have not been urged yet, but they would want to say something about it. Just trying to be brief, it was maybe two additional points that relate to the first point that I was making about the MHL reports being triggered in a broader range of circumstances. It was to draw the committee's attention to sections 41 and 26 of the bill as well, which relate to section 41 to compulsion orders and compulsion and retention orders, and section 26 to transfer for treatment directions, which we touched on. I suppose that it is a general point about the need to consider those resource implications, and I would be happy to provide further detail in writing at a later point if that would be a better use of time. The final other point was about welcoming the extension of the victim notification scheme. I think that, certainly, many of our members had expressed some concerns about what then happens as a result of that, potentially making offenders who have, for example, learning disabilities placing them in quite a vulnerable situation. There would be a need to consider what additional measures you would want to wrap around that in those circumstances. My colleagues from the professions may want to say more about that, but I think that those were the key things that I am happy to provide for other detail, as I mentioned. Three good points and important areas. If any of the other panel members wish to say anything about that contribution, please do it, Dr Crater. As you perhaps have declared at the beginning, I am chairing a Scottish Government-sponsored group on the implementation of the victim notification scheme. We are at an early stage of deliberation, but I think that things to ponder would be that, of course, we have been involved with victim liaison for some time. This is new, but a certain provision, for example, the participation of victims at Shrevel tribunals has been rather haphazard and patchy, depending on whether people happen to know that they had the right to go to the tribunal and ask to be an interested person. I think that there is an opportunity for making a much more sensible provision for victims. The discussions that we are having at the minute to concentrate first on restricted patients is the right initial focus, and to base victim notification scheme within Scottish Government is probably the right practical way forward, at least initially, in terms of getting it right for that particular group of individuals and then seeing whether extension is appropriate to other compulsion order cases. However, using as our guide the non-mental health victim notification scheme and pegging ourselves to that. Just in respect of the victim side of things that I have just received a very recent communication from an organisation called The Hundred Families Organization, this is an organisation that deals with the victims of families associated with the victims of homicide where mental disorder has been involved. I am not sure if their figures are correct but they are suggesting that there have been 137 homicides in Scotland over the last 10 years in which mental health issues have been involved and that this is a greater proportion of the total homicides in Scotland, some 15 per cent as opposed to 10 per cent in England. More concerning, there have been only two incident reviews out of those 137, whereas in England there have been 321 reviews out of 576 homicides. I just put that on the record because I think in terms of the section of the bill, the victim notification, the victim may not be around, it may be the families as well. I just raised the issue and asked if anyone has got any initial comments on those rather stark figures because, if they are valid, they are really very stark, a difference between Scotland and England in our apparent approach to this. I am very pleased that the chair of The Hundred Families Organization is part of the expert group in contributing to that. I think that the figures that he has taken are from the national confidential inquiry into homicides and suicides, which is based in Manchester. If you are a practitioner who is unfortunate enough to have a patient who either kills somebody or commits suicide, you fill in a questionnaire which is sent to the national confidential inquiry. I am pleased to say that the apparent figure of 15 per cent is largely because of our greater problem with substances. They are including people who may be in contact with alcohol and drug services in that. If you borrow down into the data and look at the absolute rate, for example, of schizophrenia-associated homicides, we are exactly the same as England and Wales. I think that that is a really important message to get over in terms of that. In terms of victim notification, it has always been the case that close family relatives of someone who is killed is considered a victim—sometimes referred to as a secondary victim. I think that that is true of the current victim notification scheme under criminal justice and will be true under these proposals as well. I think that the particular beef of 100 families is in the inquiries that are made following a tragedy. We take a very different approach in Scotland compared to England. I think that it is timely to have a discussion about whether we have got the balance right. The new chief executive of the mental welfare commission was speaking about this very topic at a Royal College meeting two weeks ago. We were discussing then whether the balance was right in terms of their published inquiries. I think that 100 families have got a point in saying that it would be timely to have a discussion about the mental welfare commission's role in investigating those tragedies and what they put in reports. I am not sure of the mental welfare commission's role in relation to that, so I think that that is an aside. This is healthcare and problem in Scotland's role, and it is a bit scrutiny. Over the last couple of years, they have developed a very robust process where incidents of suicide or homicide within mental health services must be robustly reviewed and reported on, and we report to Healthcare Improvement Scotland in relation to that and to the commission. However, we have got to remember that the commission is there to protect the human rights healthcare improvement Scotland. They are there to scrutinise what the services have done and they work together. Although 100 families may have been true 10 years ago, it has not been true in the last couple of years where we are well scrutinised by Healthcare Improvement Scotland and have to put reports and publish them on our board websites in relation to what has happened and the action plans and the follow-up actions. The other aspect of that is that we have fatal accident inquiries as well, so the Procater Fiscal looks at what we have done and what has happened and then makes a decision along with the families based on whether we have a fatal accident inquiry as well as a boards inquiry. I am not sure what else has been required of being asked for on top of that and having been through several of those, they are quite robust. That is very helpful indeed. It really gives us a much better picture than the one I was getting, which was quite a narrow one. Maybe we should ask Healthcare Improvement Scotland to give us some further information as well. Dr Gillis, Colin Fraser. Thank you. It is on the same victim notification issue. Our members, when we consulted with them, welcomed the proposal. I can certainly think of several instances over the years where victims and families of victims have been severely distressed when offenders have been released whether or not they have mental health problems. There were two other aspects that I just wanted to raise, convener. If one looks at crimes that are short of homicide or murder, there are people with mental disorders whom one would hope to partially or completely rehabilitate following that sort of event. It would be important to ensure that the victims and families of victims were informed and that this proposal moved forward in a practical and practical way. I think that we also have to bear in mind that there are humanitarian aspects for the person with the mental disorder as well. It should be made available to them, both from the humanitarian point of view but also from the consequential point of view of avoiding repetitions of these events when they are released. I think that there is a balance to be struck here, which is actually quite a delicate one. I just wanted to raise that before the committee. Colin, you went back in. I was going to say that, as chair of the MHO forum in Glasgow, I brought the proposals in the bill before the MHO forum. That was the most hotly disputed subject. People had strong views about resource implications by the MHO role and what have you. From an ethical point of view, that was the subject that caused people most difficulties. It was the one subject on which I had to take a show of hands as to what the position of the room actually felt. The show of hands came down in favour of the broad view that, if you are a victim, you are a victim, it does not matter what route you have come down to get to that position. However, the minority position, and it was a slight minority, was concerned that there should be a more nuanced stratified approach to different types of mentally disordered offender. I think that people could see the point of transfer treatment directions. However, there are real concerns for the vulnerability of people with mental health difficulties and the risk of them being exposed post discharge, and that had to be recognised. Ethically, it was the most contentious issue and all the proposals in the bill had generated quite a lot of heat. Thank you, Beth, for raising that as one of your points. I think that we had a good discussion around the table here. Is there any other—yes? That is a different subject again. Yes, that is fine. We have already spoken about the need to promote a bi-psychosocial approach in mental health care and efforts to give greater attention to the broad range of therapies that service users would benefit from, of which psychological therapies are one. I have already mentioned that the terminology could be looked at and spoken about the need for more detailed care plans, just as was mentioned in the McManus report, and that we need to make better use of specialist expertise. We have spoken about some of the ways of doing that. I would like to add that the British Psychological Society would like to see the tribunals seeking reports from specialists more often and, for future legislation, to give consideration to extending the AMP role to other disciplines. Psychologists being one but also potentially nurses and occupational therapists, if that was considered appropriate. I am thinking about cases where the primary treatment may not be strictly medical. For psychologists, that would be particularly in relation to people who suffer from learning disabilities or other cognitive problems, people who suffer from autistic spectrum disorders and people who suffer from personality disorders. There are many psychologists who have the expertise to be able to give the information that is required when people are to be considered for compulsory measures. I do not doubt that there are other professions who might feel that they also could provide a role in that respect. We have spoken about the resource problems in relation to mental health officers, but there are also resource problems in relation to psychiatry. I know that the extension of the excessive security tribunals is going to lead to additional burden on psychiatrists. It may be that there is a real need to look at who else can contribute to the function of applying compulsory powers. Thank you for that. Dr Crater. This, of course, was a matter of great discussion in England for the 2007 Act there, and we see in England no more responsible medical officers but responsible clinicians. I think psychiatry had difficulty in articulating why we felt uncomfortable about that, because we wished to promote multi-disciplinary working and expanding the role of our colleagues. It is partly because we are sometimes a bit shy of saying what medical people bring to the table. The two things that medical people bring to the table in particular are a tradition of making a clear diagnosis. We are not the only professions to do that, but that is one thing that we bring to the table. The other is our experience of non-consensual treatment that we learn, usually first of all, in the medical receiving bay or in the casualty department with usually an unconscious patient or someone who is clearly incapable of consenting to treatment, and then we make sensible decisions accordingly. Those two professional backgrounds are something that a medical perspective brings. There is a question of equality of esteem in terms of psychosocial treatment and that contribution, but I wonder whether that can be addressed through tribunals asking for appropriate evidence from colleagues. I am not particularly convinced that changing the complement of who makes compulsory detention recommendations is what is required. As I have stated before, in nursing we are not in favour of this. At 9 o'clock on an evening in Crosshouse hospital, the doctors' toadl of home and the nurses are the only people in terms of mental health. In mental health, it is advanced nurse practitioners who are on during the night from 9 o'clock to 9 o'clock the next morning during the weekends. I am not against extending the nurses' role. The one thing that they cannot do is that they cannot diagnose and they cannot take under the act. The vast majority of nurses who are not qualified either mental health or LD nurses are qualified to make a diagnosis. In terms of being able to apply the act, you must be able to have a diagnosis and make a diagnosis of what it is, so we will reach a differential diagnosis of what is unbalanced wrong with someone and treat them. Those advanced nurse practitioners can also prescribe because they are non-married prescribers, so again it is not about not wishing to advance the role, it is about appropriateness, and so there is no support from within nursing, mental health or LD, and there is the ability to extend the amp role to nurses. Anyone else? Yes, please. I just respond to two things. First of all, I don't see this as being about parity of esteem in terms of professions. I just think that certainly psychologists could play a valuable role, and actually this is about making sure that the patients get the best assessment and that the best decisions are made based on a comprehensive understanding of their circumstances and that in some cases where the mainstay of treatment is a psychological one, surely a psychologist is well placed to be able to advise on that. The point that Dr Gillis made earlier applies here as well. Things are moving on, and in the past where it may only have been psychiatrists or medical practitioners who were able to have certain experiences that gave them certain competencies, things are changing. Lots of psychologists now have experience of working with people who are detained and certainly have the competence to diagnose patients' mental disorder. Is there any other guest on the panel today who wishes to raise an issue that they feel that might not have been covered? Dr Crichton wants it. Mr Barron, do you want to go back in on anything? No, we can. I'm just trying to assess, and Colin Fraser. Can we move on to that? It's basically a transition aspect of age-related. People may be moving from a CAMHS service onto an adult service, and I'm just wondering what difficult is that to present in the detention aspect in terms of the resourcing facilities? We've already mentioned that insufficient attention has been paid to the situation of young people under mental health legislation. I'm not able to comment on the resource issues other than to say that, as was mentioned by my colleague in the previous evidence hearing, that educational psychologists are going to become less available given that the funding for their training has been stopped. We see that as being quite a serious problem in terms of young people's mental health. Most people would agree that it's important not to stigmatise young people too early, and if their difficulties can be dealt with when they're at school by educational psychologists, it might prevent them from having to move into formal adult mental health services. I think that this is something that hasn't been given enough attention to under the current revisions and needs to be addressed. I think that I've got Colin Fraser and Dr Crichton, and I'm going to bring it up close. Forgive me if I'm a wee bit behind the curve on this, but I just wanted to raise an issue that I know is a concern for some of my colleagues, and this may have been addressed in previous hearings. It was the impression of the potential role of a second doctor in applying for compulsive treatment order that there would be some kind of transfer of responsibility of arranging that to the local authority, rather than as it currently is the RMO contacts GP. That was something that my colleagues were quite concerned about. You may have addressed this in previous hearings that may have been discussed, but I was wondering what the current thinking is and what the current position is. As it is, it can be quite challenging for consultants to get GPs in certain circumstances. The idea that the responsibility for the AMHO would be to deal with the GP is actually something that is quite difficult for us to anticipate, but it may be that thinking has moved on on that issue, and I would welcome any comments on that. I don't recall—I'm looking to my other committee members here, but I don't recall that they have been raised as yet. Is that correct? You have now raised it, Colin. That was your opportunity to raise issues that haven't been raised, and that offer is there to you all. Dr Creighton? I just wanted to return to the length of section 52. This is the remand assessment section for people before the courts. I just wanted to urge—sometimes a bit of a shorthand is taken that it's the same as a short-term detention and we should be making our mind up about treatability criteria in the similar length of time. Those can be very complex cases involving the most extreme of circumstances. Section 52 allows that period of in-patient assessment without a treatability requirement. It's the strong consensus of college members that sometimes we need a bit longer before nailing our colours to the mast and saying that somebody fulfills treatability criteria. I was involved in one case before the Court of Criminal Appeal this year, and I have one coming up next year, both of which may have gone down much less contentious routes had that section 52 being available and being available a little bit longer. Any response on any of the last two contributions? I thank you all for your attendance here this morning, the evidence provided in written form and today. I thank you all for your valuable time, and I hope that we will be able to use your evidence effectively in our ultimate report. Thank you all very much for your attendance. We previously agreed that we are now going to private session. Thank you.