College Briefing for the Second Reading of the Health Bill

Tuesday, November 29, 2005

Response to: Health Bill

Applies to: England, Wales

The Royal College of Psychiatrists welcomes the smoking elements of the Health Bill, agreeing with the general principles outlined in it.

However, we are concerned that the proposal to allow full exemption for residential premises may not be in the best interests of patients or carers. At the moment the Bill states (part 1 section 3, 2(a)) that one of the grounds for exemption will be:

premises where a person has his home, or is living whether permanently or temporarily (including hotels, care homes and prisons and other places where a person may be detained),

This means that many institutions and homes in which people are detained will be exempt from the smoking ban.

Patients resident in psychiatric hospitals and units exhibit increased rates of mortality and morbidity in comparison with the general population.  People with learning disabilities, in particular, show higher rates of cardio-vascular and respiratory disorders than the general population.  As part of the promotion of health and offering healthy choices it is appropriate to encourage a reduction in smoking habits.

However, a balance needs to be held between promoting physical and mental health: enforced and unsupported cessation of smoking may cause emotional and behavioural problems, which are harmful to mental health.  There is also a balance of risk to be considered between the risks from smoking (whether active or passive) and possible increased risks to staff and other patients from increased disturbance and patient distress if people are not allowed to smoke. 

The provision of limited, appropriately designated, properly ventilated and maintained smoking areas, combined with a positive programme to support cessation, would perhaps be more helpful than either a blanket ban or exemption and could perhaps be made part of the Care Standards.  This would help to protect staff and patients from passive smoke caused by other people on the ward.  As individuals become more aware of the detrimental effect of passive smoking, their willingness to remain within smoking environments is likely to reduce. Part of the support for smoking cessation programmes should include the provision of therapeutic and recreational activities which provide former smokers with alternative perceived benefits and pleasures to smoking; boredom is a key factor in heavy smoking.

We have particular concern about people who are not able to choose their environment.  This would include prisoners, people detained under the Mental Health legislation, long-stay patients, and those in residential homes (of whatever size) who are not able, for whatever reason, to move to a different environment.  In residential homes, bedrooms may be the only private space, but smoking is not usually allowed there for good safety reasons.  There may be no other spaces available indoors; the only area which could be designated for smoking may be the garden.

The situation of individuals requiring care or supervision within what is in effect their home environment presents a potential conflict between the right of the individual to smoke in their home against the right of the professional to refuse to work in an environment which would expose them to smoke. 

There are a number of issues about the care of people with learning disabilities.  The residential environment of individuals with learning disability is complex.  They may live alone, in family units or in some form of shared accommodation.  The degree of autonomy over whether they themselves smoke or remain in environments in which other individuals are smoking may vary significantly.  Their ability to understand the implications of the risks associated with smoking will vary.  For many individuals with more severe intellectual impairment or for those where neuropsychological or physical problems dictate their place of residence, there will be less opportunity to influence and if necessary absent themselves from their designated home environment. 

Individuals with a learning disability will sometimes lack the capacity to make an informed decision on their actions in circumstances such as these.  This means that consideration must be given to effective communication with individuals with a learning disability such that they could understand both the nature of and reason for prohibition and the likely consequences of non-compliance.  Similarly, they must be aware of and be able to successfully negotiate the mechanisms for reporting non-compliance.  Clearly some more able individuals will be able to understand the full implications of smoking.  In contrast, many individuals with more impaired intellectual function smoke despite being unable to adequately understand and weigh the risks and benefits of this action.  The need to take decisions in a person’s best interest where they lack capacity should be addressed by the Capacity Act.

Whilst we acknowledge the reasons for exempting areas where people are living or detained, we feel that more needs to be done to help people give up smoking in these environments and that greater investment is needed to ensure that people are not simply smoking through boredom. The staff and patients in psychiatric facilities deserve the same access to a smoke-free environment and smoking cessation help that people in other parts of the NHS will receive and we hope that this can be achieved over time.

For more information please contact:

Agnes Wheatcroft

Parliamentary & Policy Officer

RoyalCollegeof Psychiatrists

tel: 020 7235 2351

E-mail: awheatcroft@rcpsych.ac.uk