Mental health service users may find themselves facing a harsh new treatment regime under green paper proposals now out for consultation. Laura Donnelly reports

The soundbites were flowing thick and fast as health secretary Alan Milburn launched the government's green paper to overhaul the Mental Health Act.

Proposals for forcible treatment of community patients who break care programmes will end a 'culture of abandonment' which left them locked in asylums or floundering under a policy of 'couldn't care less in the community'.

Radical change will ensure mental health services which are 'fast and fair' as well as 'safe and sound', he promised.

But not 'supportive'. The third element of the government's mental health strategy - the sop to those concerned by its public safety focus - is missing.

An oversight? Or an indication that the hard man of health is determined to push through even tougher legal reform than that outlined in the review the government ordered?

The concept of community treatment orders (CTOs) met with outrage from civil rights campaigners, service users and charities when the review began in September 1998. But resistance weakened following reassuring noises suggesting that tough laws would be supported by a focus on patients' rights.

The green paper is based on the report of an expert review committee - chaired by Professor Genevra Richardson, dean of the faculty of law at Queen Mary and Westfield College, London University - which made plain that balance.

Published alongside the green paper, its recommendations include advocacy rights, advance patient directives defining acceptable treatments, and a principle of reciprocity under which the service users and the service would be bound to comply with care plans.

But policy experts believe the government's response has 'lost the balance' by 'cherry-picking' the harshest elements of the expert review rather than 'taking on the package as a whole'.

Both the green paper and review outline a very broad definition of mental disorder, which would include personality disorder and under which treatability - one of the central tenets of current mental health law - would no longer be a key factor.

It would include any condition which causes impairment or disturbance of mental functioning - whether temporary or permanent.

The expert review put forward extensive legal checks, including a seven-day review following the use of compulsory powers, and a tribunal hearing at 28 days.

But the green paper flags up the 'significant practical implications' of having both checks in place, and questions the 'real need' for a review of CTOs at seven days.

'The balance has tipped, ' says Dr Matt Muijen, director of the Sainsbury Centre for Mental Health. 'The tone of the government paper is pretty tough.

But an awful lot of the key decisions are yet to be made.

'I would like to think that leaves some room for democratic decision making and consultation. But the tone is very tough.'

Although the 'principle' of reciprocity is in the green paper, patients would not get any legal entitlement to services.

Health minister John Hutton insisted he could not 'envisage' a situation in which health or social services failed to meet their side of the bargain.

In that case, says Dr Bob Grove, director of the Centre for Mental Health Services Development's employment support unit, service users aren't likely to be offered much of a deal to sign up to. 'I would worry that service users will end up accepting care plans which are inadequate to their needs.'

He also criticises as 'short-sighted' the green paper's focus on the 'practical implications' of reviewing CTO applications at seven days. 'Twenty eight days is an awful long time. . . if they are thinking about cost implications perhaps they ought to look at the cost of detaining people without a hearing.'

There are concerns over what level of discretion would be given to those charged with stepping in when patients fail to adhere to care plans.

Dr Muijen says: 'I think it would be really unjust to put perfectly healthy people in hospital because of a rational decision to stop taking medication.'

Ray Rowden, visiting professor of nursing and clinical management at York University, describes the proposals as 'completely wrong-headed', with too strong an emphasis on medication, and likely to damage therapeutic relationships by 'using mental health services as society's policemen'.

'Politicians are perpetuating a delusion. They are trying to persuade middle England that they can have a risk-free mental health service. Well, they can't.'

Charities and service user groups variously describe the green paper as 'a load of unworkable bollocks' (Reclaim Bedlam); 'a gross invasion of civil rights' (UK Advocacy Network) 'a missed opportunity' (National Schizophrenia Fellowship); and 'in danger of seriously backfiring' (Mind).

Like them, the Mental Health Foundation is calling on the government to reconsider its proposals. The Manic Depression Fellowship reports members saying 'the fear of being treated against their will would deter them from seeking help'.

Cliff Prior, chief executive of NSF, hopes that consultation - which runs until 31 March 2000 - will result in a return to 'the more thorough and considered approach' of the Richardson review.

Even Sane - a staunch supporter of the reforms - warns that the increased resources promised by Mr Milburn 'will not be sufficient to meet the new powers'.

But the Zito Trust - set up by the widow of a man killed by mental health patient Christopher Clunis - urged the government not to 'water down' its proposals.

Reform of the Mental Health Act 1983: proposals for consultation.

Review of the Mental Health Act: report of the expert committee.

www.doh.gov.uk/dho.htm Lock and key: how the green paper puts the emphasis on detention Application to detain patient made by 'trained professional', backed by a doctor with specialist psychiatric training. A third professional may be involved. 'Emergency holding powers' - under which a nurse can detain a patient - would be cut from 72 to 24 hours under the Richardson proposals. The green paper questions whether this allows enough time for assessment.

Possible review at seven days - the green paper questions the 'real need' for this.

Tribunal at 28 days: a care plan attached to the compulsory treatment order is agreed. Tribunal cannot determine content of care plan but can veto it. Patient can call for an earlier tribunal to challenge the process. CTO stipulates consequences of noncompliance. CTO can last up to three months. Options in the green paper for tribunal to have between one and four members.

Patient fails to comply: can be recalled to a clinical setting or treated in the community. Local protocols laid out in CTO should determine course of action.

The cost of change: Milburn 'ups the ante' Health secretary Alan Milburn vowed to 'up the ante' in modernising mental health services, increasing numbers of secure beds by an extra 500 by 2001, giving a further£53m of modernisation funding and mental health grant next year and establishing three times the number of assertive outreach teams, taking the total to 170 by April 2001.

But critics warned against 'draining resources from other equally valid parts of the system'.

Sainsbury Centre for Mental Health director Dr Matt Muijen said: 'I welcome the teams - as long as the money is there to support them.

'But of course the question is at what cost to other elements of the service? And will they be any good? Will people be properly trained?'

Bob Quick, project manager of the Community Mental Health Team Management Association, points to the 'diminishing pool' of nurses from which mental health services can recruit.

Last week the association wrote to Mr Milburn and Professor Keith Wilson, head of the government's mental health workforce implementation team, demanding more staff involvement in its work.