Sir: I agree with Rooth's (Psychiatric Bulletin, January 2001, 25, 8-9) comments on the future of the medical member of a mental health review tribunal (MHRT) and in support would add:

1. (a) The purpose of a MHRT is to combine legal and medical opinion in a decision that is in the best interests of the patient.

2. (b) The clinical component of the medical contribution must be based on sound medical practice, which includes access to the case notes and a clinically appropriate and private interview with the patient concerned. The medical member's contribution is not just about theory, it is about a person. It is not about, for example, schizophrenia, but about a particular person who suffers from that malady, who lives in his or her own particular family and social context. Anything less than a full clinical assessment, which cannot be made during the course of the formal MHRT proceedings, will diminish the mental member's clinical judgement and will detract from the quality of the final decision.

3. (c) The clinical contribution, no less than the legal and lay, must be made before and within the MHRT and within the subsequent decision-making. When the decision includes both legal and clinical components, both should be fully represented at all stages.

4. (d) Like Rooth, and many other MHRT colleagues of all persuasions, I do not fully understand the concern expressed about the current practice of a preliminary examination followed by medical participation in the MHRT's decision. In my opinion the desired balance noted in (a) can only be optimised via (b) and (c).

5. (e) All must respect the letter of the law, but I suggest that the process by which a hearing is conducted is a separate issue. When the nature of the hearing, and of a decision, requires that legal and clinical considerations be balanced, I suggest that equal respect has to be shown to both legal and clinical processes. When it comes to process, clinicians operate in a very different way to lawyers. That difference should be respected and reflected in the processes of a MHRT. The White Paper's proposals (Department of Health, 2000) will distort the clinical perspective.

6. (f) If the fear of the present medical member's role is that evidence from the preliminary hearing may be communicated in private and is therefore not subject to scrutiny in the MHRT, this can be overcome. The patient can be told at the preliminary hearing that it is what is said at the MHRT that counts, with the rider that anything then talked about may have to be repeated at the MHRT. Any discovery by the medical member that is not in the reports can be reported, either by the President or the medical member, as the MHRT starts. Alternatively, the medical member may elicit the information by asking questions of the appropriate ‘witnesses’ before him/her and not by giving it himself/herself as evidence. Medical members need not themselves give evidence.

7. (g) The patient's representative will have seen the patient before the hearing and increasingly often has gained access to the case notes, thus further diminishing the likelihood of information being concealed. Furthermore, he or she can call for his or her own independent psychiatric assessment, although, since the revision of legal aid regulations, these seem to be sought much less frequently.

In Rooth's view the medical member's “insider perspective is irreplaceable”. I would prefer ‘integrated’ to ‘insider’, but agree with him wholeheartedly, for the reasons given above, that it is ‘irreplaceable’.