Memorandum of Evidence from MIND (National
Association for Mental Health)
INTRODUCTION
1. Mind is the leading mental health charity
in England and Wales. It works for a better life for people diagnosed,
labelled or treated as mentally ill and campagins for their right
to lead an active and valued life in the community. Mind is concerned
to contribute, wherever possible, to new thinking on mental health
services and to the improvement of standards in the treatment
of those with mental distress.
OPTIONS FOR
STRUCTURAL CHANGE
2. Mind recognises the importance of the
interface between health and social services in delivering well
coordinated services to people experiencing mental distress. However,
this is just one amongst many elements which need to be in place
to ensure high quality, responsive service provision. The fundamental
aim should be to deliver a package of services which address the
range of needs experienced and expressed by people with mental
distress, including health, social care, employment, housing,
leisure facilities and an adequate income. In providing services
the focus should be on working in an active partnership with service
users, and seeking to engage users with services which are acceptable
and helpful to them. The organisational framework needs to be
designed around this objective rather than vice versa.
3. It is tempting to believe that structural
change can solve problems in delivering coordinated and sensitive
services, but reorganisation is not a panacea for inadequate resources
or inappropriate service patterns. Any organisational change must
be designed to make it easier for staff to deliver sensitive services
and must remove rather than create blocks to working in partnership.
It should also avoid creating excessive bureaucracy and layers
of management as happened with the NHS changes under the previous
Government. Democratic accountability is also essential and does
not currently exist for health authorities.
4. Mind rejects major structural change
such as the creation of a new Mental Health and Social Care Authority
single authority responsibility as proposed in options one and
two of the former Administration's Green Paper—Developing
Partnerships in Mental Health. These options would damage existing
good practice and introduce another major upheaval, creating confusion
for service users and demoralising staff. There is also a grave
danger that these models could lead to a health or medically dominated
approach to service provision (unless the commissioning lead was
given to local authorities). This could result in users' wider
social needs being ignored. While health care, including physical
health care, has an important role to play in responding to service
users' needs, it is by no means the most important component of
services, nor do health based models of mental distress capture
many aspects of users' lives and needs. These options also carry
the grave danger that the authorities which lose their role in
mental health withdraw investment and commitment as soon as any
announcement is made. Mind sees many advantages in the current
diversity of services which include statutory social care services
and the voluntary sector. Any model which damages this diversity
should be rejected.
5. Mind generally favours a joint health
and social care body. Such a body would be accountable to the
local authority for the funds allocated for social care and to
the health authority (or the new primary care groups) for funds
allocated to health care. This would be a way of improving co-ordination
whilst minimising damage to existing good practice. Mind supports
the concept of a universal requirement for local joint plans for
mental health. Mind's support for such an option depends on the
following points being taken on board:—
(i) service users are fully engaged including
as members of the joint body, and that wider service user views
are considered by that body through representation, stakeholder
consultation, surveys and so on; structures need to be in place
to ensure that consultation is effective and that adequate time
for consultation is allowed;
(ii) a joint plan prepared with service user
involvement is published and disseminated locally;
(iii) the voluntary sector (whether or not
user-led) is also closely involved in planning as well as service
delivery and that it has a flat playing field in securing funding
for services and projects;
(iv) GPs are engaged in an effective way;
(v) co-ordination between providers is also
addressed in an effective way.
If these aims cannot be achieved under a new
structure, then Mind believes it would be better to try to build
on existing arrangements, perhaps with limited enabling legislation
to remove blocks to joint commissioning, than to opt for radical
change.
6. Mind believes that there should initially
be piloting of any proposed new structure. Thereafter it should
be introduced universally rather than on a voluntary basis. Otherwise
it is hard to see how the option could address poor performance.
WIDER ISSUES
7. Mind believes that consideration of structural
change only tackles a small piece of the jigsaw which needs to
be put together to provide responsive services. There is a clear
need for more resources for mental health services across the
country and for greater training, including user-led training
and inter-agency training, for staff. There is also a need to
move away from coercive styles of service towards services which
work with and alongside users.
8. Structural change can only be helpful
if it forms part of a programme of change to tackle these issues,
specifically including:
(i) developing those elements of services
which help to engage users rather than those which damage partnerships.
This means building a welcoming style of service—which has
implications for example, for staff training and the hospital
environment—and removing those measures such as supervision
registers and supervised discharge which discourage engagement;
(ii) developing services which are welcoming
to and meet the needs of people from black and ethnic minorities.
It is widely recognised that services are often very weak in this
area. There are limited numbers of senior staff from black and
ethnic minorities, while some black people are over-represented
in secure services and on Mental Health Act sections. There may
be a variety of reasons for this, but the emphasis must be on
making the full range of services more accessible to people from
black and ethnic minorities and in enabling them to have a much
greater say in the style and content of services. In many areas
people from black and ethnic minorities are already alienated
from services and considerable effort will be required to rebuild
trust;
(iii) developing services which are welcoming
to and meet the needs of women. Single sex provision for those
who want it is essential in in-patient services and in other services
such as day centres.
(iv) it is clear that the particular problems
services have in responding to people from black and ethnic minorities
reflect wider problems in addressing the needs of service users
generally. There has been a disturbing increase in the use of
the Mental Health Act and the environment of many in-patient units
remains unacceptable;
(v) it is vital that improvements in co-ordination
of services at commissioning level are reflected by improvements
in providers. In particular, much more could be done to develop
the "linkworker" concept where staff work to support
users in accessing the full range of services they need. There
should be a single assessment of users' needs across health and
social care which is formulated in partnership with the individual
affected. Mind would like to see national adoption of the assessment
model known as the Avon Mental Health measure which has the user
at its centre and in control. This measure has already been successfully
piloted in a number of health authority areas;
(vi) it is also important that partnerships
are built between all the local agencies concerned with mental
health, including housing authorities, the benefits agency, employment
services, leisure services and the voluntary sector including
user groups. This process needs to take place at national as well
as local level, with better co-ordination of policies across Government
Departments and user involvement in central policy formulation;
(vii) in driving up standards amongst providers
it is important that some national standards for mental health
care are promulgated by the Department of Health. These should
be developed in partnership with users who should also be involved
in assessing individual providers.
9. Mind would also wish to draw attention
to the current difference in charging policies between health
and social services. Health services are free at point of use
whereas social services now charge for many services including
day centres and domiciliary care. Mind opposes the introduction
of charges for mental health services and is concerned about the
impact of such charges on the take up of services by those with
mental health problems. Mind would be very concerned if one effect
of structural reorganisation was to extend such charging into
areas currently free at the point of use. Local authorities also
have the power to make direct payments to users and Mind encourages
the use of this power for mental health service users. Again Mind
would be concerned if reorganisation were to lead to the loss
of this opportunity for users of mental health services to take
more control of their lives.
12 January 1998
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