Summary

In 1998, the Department of Health (DH, 1998a) issued a White Paper on the future of mental health services. Entitled Mental health: Safe, sound and supportive, this document was the first in a series of official publications to outline fundamental reforms of health and social care for people with mental health problems (see, for example, DH, 1999a, 2001a). Subsequent measures included the introduction of national targets for adult mental health services, a new National Institute for Mental Health in England (NIMHE), additional investment and attempts to reform mental health legislation (the 1983 Mental Health Act; see DH, 1998b, 2001b, 2001c). Such activity in an area often seen as a ‘Cinderella service’ was almost unprecedented, yet was something of a mixed blessing. While mental health had long been campaigning for greater resources and recognition, this additional policy focus also highlighted a series of significant tensions. The White Paper suggested services were to be “safe, sound and supportive” (DH, 1998a), but largely failed to recognise that these factors may be different aspirations. In other words, can services, which are perceived as ‘safe’ by the public, media and politicians, also be perceived as ‘supportive’ by service users? More recently, the notion of patient choice has become key to NHS reforms (DH, 2003). In mental health, however, patient choice poses a key challenge, not least because the evolution of services has been influenced by the stigma of mental illness and coercive practices (Lester and Glasby, 2006). Against this background, this chapter examines the contested nature of mental health provision within the context of proposed legislative changes, exploring the key ethical dilemmas that are raised.

Reform of the 1983 Mental Health Act

Frank Dobson's statement in the House of Commons on 29 July 1998 that “care in the community has failed” heralded a series of papers and consultation documents on the revision of the 1983 Mental Health Act. These papers included the Report of the Expert Committee: Review of the Mental Health Act 1983 (DH, 1999b), chaired by Genevra Richardson and a Green Paper, Reform of the Mental Health Act 1983: Proposals for consultation (DH, 1999c). The Expert Committee argued that capacity, reciprocity, statutory rights to early advocacy and advanced statements needed to be recognised in future legislation.