A voice of sanity in ministers' ears

January 9, 2004

Fears that civil liberties might be eroded by proposed mental health legislation caused alarm, but the government's mental health tsar is trying to help get the balance right, writes Adam James

He may be a distinguished researcher, but Louis Appleby's diplomatic skills are more important to him these days. One of the most pressing duties facing the University of Manchester professor of psychiatry and national director for mental health - or so-called mental health tsar - is to reassure vociferous critics of government plans to change Britain's mental health legislation.

A draft mental health bill published by the Department of Health and the Home Office in 2002 outlined new conditions for the compulsory treatment of mentally ill people. It was condemned by both mental health professionals and service users. The proposals would be "unworkable" and "regressive", argued the Mental Health Alliance, a coalition of 50 mental health and lawyer groups.

The alliance accepts that the draft bill has some merit, such as a proposed tribunal system that would go some way to protecting the rights of detained patients. But its key objection is that the bill would lead to more people being taken into hospital by force.

Under present law, an individual's mental illness must be treatable in order for him or her to be detained. Not so in the draft bill. Moreover, the definition of mental disorder has been extended. Critics point out that this broad definition - even taking into account other criteria that would need to be met - might allow forcible detention of, for example, a young man diagnosed with schizophrenia who gets "lippy" with the police when they arrest him for an offence he claims he did not commit. The same fate might befall a young woman with learning disabilities who has no sense of sexual inhibition and whose mother wants her removed from harm's way.

Ministers, perhaps also wary of creating a law that might be susceptible to challenge under the Human Rights Act, were so taken aback by the critical response to their plans that they put on the brakes. Twice they left a mental health bill out of the Queen's speech. Instead, they announced in November that a revised draft mental health bill would be "scrutinised" by a parliamentary committee that would report to government.

Speaking to The THES , Appleby hints that the conditions required for compulsory detention - that the person must be a danger to themselves or others - are to be tightened in the revised draft. He says: "My position is that we should specify in more detail the conditions under which compulsion can be used. The problem is not with a broad definition, it is with the combination of the definition and the conditions."

He has also indicated that clinicians are likely to be granted ultimate discretion to decide who should be compulsorily detained, a point that was not in the draft bill. "There is every intention to leave the use of the bill in the hands of sensible clinicians," he says.

Appleby will not disclose specific changes to the revised draft. But last year he promised that any new law would, ultimately, have to meet the approval of all mental health professionals. His credibility hangs on this pledge. As the government's chief adviser on mental health, he has had more than a year to get used to dissent over the draft bill among his professional colleagues.

The Royal College of Psychiatrists was so alarmed by what it envisaged would be a further erosion of patients' civil liberties and poorer mental health care as a result of the draft bill that it demanded the government return to the drawing board.

Some mental health professionals and service users took to the streets in protest. The Mental Health Alliance accused the government of ignoring the views of experts in an attempt to appease public fears and to find a legal mechanism by which to detain people diagnosed with "dangerous and severe personality disorder" who many psychiatrists believe are untreatable.

Appleby has taken a lot of the flak, largely because he spends much time seemingly defending the draft bill. While some seem to be grateful to have someone of his status to convey their concerns to ministers, others suspect his true allegiance is to the government. Appleby, however, insists his role is one of "brokerage" between interested parties and the government.

"It is my job to listen to what they (the critics) have to say and to help civil servants, departmental officials and ministers understand where those criticisms are coming from," he explains. "I am not the voice of the government. I communicate the voice of professionals and patients to the government."

The rise to his government role has been steady. After qualifying, Appleby worked in psychiatric wards in Edinburgh and London in the 1980s.

But he was always an academic at heart. In 1987, the British Medical Journal published the first of many co-authored papers. He has one book to his name, and he was a columnist for the BMJ in 1988-90, writing on subjects as diverse as health in the Outer Hebrides and space medicine.

Moreover, since 1991 he has pulled in more than £3 million of external funding for research bodies he has worked for.

But suicide prevention is Appleby's research specialism. Thirty-four of his 81 peer-reviewed journal articles relate to the subject. It was this expertise that was likely to have been key in endearing him to the Blair government, which, as part of the 1997 Saving Lives: Our Healthier Nation report, outlined plans to reduce suicide by one-fifth.

Appleby served on a string of DoH advisory groups in the late-1990s. In 1996, the government made him director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Ministers were obviously pleased with his performance because four years later they made him national director for mental health. "I guess I was in the right place at the right time," Appleby says. "I do not think you can plan to do a job such as this - certainly it was not in my mind."

Away from the heat surrounding the bill, he has, through the National Institute for Mental Health, helped spearhead a drive for mental health service provision to be "evidence based". He can also take professional pleasure in the fact that his work has helped reduce the national suicide rate to the lowest level ever recorded. The number of people taking their own lives fell from 9.2 per 100,000 people between 1995 and 1997 to 8.9 per 100,000 between 2000 and 2002.

Small but effective changes have been made nationally. The size of aspirin and paracetamol packs has, for example, been reduced. This makes it harder for people to overdose. Not that Appleby is complacent. "The fact that the suicide rate is the lowest this year does not mean it will not be slightly higher next year," he says. "There are still things to be concerned about."

Both Appleby and the government have emphasised how keen they are to work in partnership with service users, who are held up as being experts in their own right.

In December, three consultant psychiatrists, including RCP president Michael Shooter, "came out" as former service users. So it seems fair enough to ask whether Appleby has ever experienced mental health problems or been spurred on by friends and family who have been affected.

"No," he says, evidently surprised by the question. "I have no experience any other psychiatrist would not also have had. But it should not be thought that (if you have not experienced mental health problems) you cannot empathise with those who have."

Appleby has proved so far to be level-headed and assured in his handling of the mental health debate. To date he has, from the government's point of view, not put a foot wrong. But, in the eyes of mental health users and professionals, he is still treading dangerous waters.

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