Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 489 - 499)




  489. Good morning. I welcome our witnesses and thank you, first of all, for your written submissions to the Committee and also for agreeing to come along today to give oral evidence. I should, first of all, warn everyone that there may be a fire drill around 11 o'clock, so we may have to suspend the Committee for a short time, but I hope you will bear with us. Could I ask each of our witnesses to briefly introduce themselves to the Committee?
  (Mr Peryer) David Peryer. I chair Mind, the National Association for Mental Health. In a previous incarnation I was Director of Social Services in Humberside and therefore I have that background knowledge. I was also involved as adviser to the Association of District Councils on local government reorganisation, very much looking at the issues of small and large authorities and the interface.

  (Ms Sayce) Liz Sayce. I am policy director of Mind. I recently studied in America, looking at ways of addressing social exclusion for people with mental health problems.
  (Ms Morley) I am Dinah Morley, I am professional services manager for Young Minds. My previous work was as assistant director of a London borough, responsible variously for mental health services and children's services and the development of family support. Prior to that, I ran a multidisciplinary mental health team, and before that I taught. I have had an on-going involvement with the Health Service as a member of a health authority throughout that time.
  (Mr Wilson) Good morning, I am Peter Wilson, director of Young Minds, which is the National Association of Child Mental Health. I have been director for the last six years. By profession I am a child psycho-therapist, was a social worker many years ago, and have worked in the field of child and adolescent mental health at the Maudsley Hospital and at various child guidance clinics in London and New York.

  490. Thank you very much. Can I begin by asking both organisations before us whether you agree with the term "the Berlin Wall" between health and social services and if this is your perception in dealing with users of services? If there is this division, can you define from the point of view of your own organisations, where the dividing line is, where you see social services ending and health beginning in the context of the work you do?
  (Mr Peryer) Thank you, and thank you for the opportunity to come and give evidence. From Mind's point of view there is not a Berlin Wall but there are a series of hazards. I have written down that there are a series of hedges and ditches and fences to be crossed, hazards to be tackled. I say that because our experience is that there is no single obstacle, therefore no single solution. That would be our starting point. But there clearly are issues. The divide is not just between health and social services though, there is an issue about whether we are talking social services or local government, in the sense of housing, education and other responsibilities, and there is another set of issues on the divide from social security and the welfare state in that sense. So there are a series of issues about boundaries, a series of obstacles, a series of hazards. I would be happy to suggest what we see from our experience as those hazards being if that would be helpful?

  491. That would be helpful.
  (Mr Peryer) Really four things. One is inadequate structural arrangements, and that is in a sense the question. The second, from our experience, would be insufficient work on processes and pathways and defining pathways. Third, would be the reluctance to manage performance. The fourth would be resources. I put resources last because in a sense it is always the most important and in a sense it is the least important, it is what you do with them. As to adequate structural arrangements, we would see the need to bring mental health provision together as a whole, clearly remembering the wide range of issues—loneliness, housing problems, neighbour abuse, the need for a fresh start, new learning, work opportunities as well as clinical symptoms. That is the heart of the problem.

  492. Specifically on the structural arrangements, clearly you have a background in social services, were you around in any capacity before 1974 with the previous structure with local government health departments which, of course, included mental health provision? Do you have any knowledge of them?
  (Mr Peryer) No, I actually came in in 1977, in the fall-out from that. Perhaps I need to say that my hard experience of inter-agency work and these problems is in relation to child protection, because I went to work in East Sussex shortly after the Maria Colewell case, and therefore was in the middle of that, working out how to make things work on that front. I say that because some of that experience is relevant. It is about structure but it is not just about structure, it is about a lot of other things.

  493. Would you have any views about whether that structure was a more effective structure in addressing the problems you have identified than the current arrangements? This is an option organisationally, among a number of others.
  (Mr Peryer) I think the short answer is no, but mental health needs and problems as then defined were very different from mental health needs and problems as now defined. The whole regime of treatment has changed and the speed at which people move is different. In a sense that was a public health system which built on the Poor Laws, built on the workhouses and built on the outdoor relief, which said, "We need people called mental welfare officers who will service that system." We no longer have those long-stay institutions, we no longer have that kind of stability, we have huge fluidity and speed of change. That is right, people should not be in hospital and in clinical settings longer than need be. But that, I think, is a different set of issues. I am not saying it worked badly at that time, I am saying it worked for a different set of questions. What we are saying is that there is a need in structural terms clearly for all stakeholders to define common goals and strategies, and that I take for granted and I am sure you do. There is a need to commit resources, in a sense to commit what resources they are going to put into the pot; to make plans to improve performance but also—the point I made at the beginning—to establish machinery to review effectiveness. From our point of view, part of what is missing is the relationship between what is set up and what is planned and what the outcomes are. There is a need for arrangements which actually define the pathways, define the expectations, set targets and then, with users, look at the outcomes and feed that back into the process of planning. The history of joint planning from my own experience is of endless documents which one has to write and other people have to read, but which do not necessarily add very much to the fund of common knowledge because they never get related back to outcomes. That would be our starting point in terms of structure.
  (Ms Sayce) Could I give you a couple of examples of the sorts of problems which service users bring to us and maybe some of the kinds of solutions which have been tried? First of all, people do call our information and advice lines with specific problems relating to the boundaries of health and social services. A typical example might be somebody who has long-term mental health problems, recognises their condition is deteriorating, they see the signs, they ring up perhaps their social worker, the social worker says, "Contact the CPN", they try to contact the CPN, the CPN is not available because of a huge caseload and has not got time to see people unless there is a life or death crisis, and the result is that the deterioration continues and eventually they are admitted to hospital. Whilst that is typical there are also disjunctions, as David mentioned, between health care and social care and other areas which come to our attention just as much. Just to give a couple of examples of that, we often get calls from people who say, "I was discharged from hospital, I have a monthly depot injection, the CPN visits me every two weeks, they suggest I go to the day centre but what they do in the day centre is very boring, people just sit round and smoke, or you can do crafts but I am not interested in crafts. I have no friends, I am sitting at home on my own and life is very bleak." To contrast with that, there are multi-agency approaches in Britain, one example being Community Connections in Nottingham, where they have dis-invested, to some extent, in the day centres and instead they have invested in link workers and have, for example, succeeded in obtaining over 100 places in open, mainstream adult education by providing clinical supervision or workers in the education service—so stopping being precious about these boundaries—and they have gone out and trained people in volunteer bureaux, they have got people to volunteer and into work, and colleges are now taking on mental health issues, training all their staff. So you begin to open up opportunities which actually safeguard people's mental health and protect them and give them something to live for. David mentioned social security. It is obviously a key aim of Government policy and a priority for mental health services to ensure that people with serious and long-term mental problems do not slip through the net, that they are successfully engaged in services. There are a couple of things which can deter people, sort of perverse incentives, one being that if you live in a 24-hour registered residential or nursing home or in a hospital hostel run by an NHS trust, the money you have available as an individual to spend is £14.45 a week. If, however, you are seriously disabled by mental health problems and you live in your own home or a low key support housing project, if you are eligible for a range of disability benefits, as well you might be, you could have as much as £100 a week. This means that people do not want to go into 24 hour staffed housing, and indeed they refuse to go into it and one can well understand it. So while there may need to be a difference between those two levels, the difference is far too great.

  494. Can I take you back to the second part of the question, which was in relation to whether you can define the boundaries? You gave an example of people ringing up and talking about the social worker and the CPN, can you define where the division is between the role of the social worker working with a service user in the community and the role of the CPN? Is it clear-cut from your point of view? Is it clear-cut from the user's point of view?
  (Ms Sayce) No, it is not clear-cut and some users do not even know from which professional background their key worker comes. I think different professionals have undergone different post-qualified training and have different skills. Also there is a very close inter-relationship because there is a clear health gain from addressing people's social care needs, and actually it is a joint enterprise, which is why we would favour pooling of budgets, joint accountability, jointly agreed strategies and links into health improvement plans and so on which are owned by social service departments and health but which also link up with primary care, with education, housing, urban regeneration and so on. It is a wider picture.

  495. Does Young Minds want to say something?
  (Mr Wilson) To start with just emphasising the importance of children's mental health and make a distinction in our thinking between children's mental health and adult mental health. Clearly there are similarities and continuities, but when we are thinking about children's mental health we are really thinking of a much broader area of concern. Certainly we are concerned about children who have psychiatric disorders and require psychiatric treatment, but we are also concerned with promoting mental health which is actually creating conditions in which children can become mentally healthy, or ensure they are mentally healthy, and prevent mental health problems when they arise. There is a lot of evidence to suggest you can really significantly reduce the incidence of later mental illness in adolescence and in adult life, and the more you put into prevention and promotion the chances are you will reduce costs in the judiciary system and social services later on. So clearly we have much in common but our emphasis is on prevention and on promotion of mental health, on early intervention and so forth. I think it is important to make this point. When you think about children and families, you are thinking of a wide range of agencies. I think the NSPCC in a commission they carried out last year came up with eight major agencies which would be of relevance to the emotional well-being and welfare of children and their families. So we have a much broader canvas we must keep in mind. The Select Committee here on child mental health services last year very much endorsed a model of provision which was a tiered model, which conceived of children's mental health services not solely in terms of child psychiatric services but in terms of a service which included a wide range of agencies at different levels, at different tiers. Tier four, which is at one end, would have been the specialist child mental health professionals, the psychiatrist, the psychologist, and tier one would be very much to do with teachers, nursery school teachers, GPs, health visitors, midwives, a whole range of people who would not ordinarily see themselves as predominantly concerned with mental health but nevertheless have a significant part to play in the promotion of mental health and prevention of problems. So our canvas is very broad. Clearly health and social services have a key role to play in all this, and indeed education is of crucial importance in all of this, which is another part of the local authority function, and the youth services. So the first thing I would like to say is that it is a very broad area we are trying to bring together. The whole point of a comprehensive service was to try and create a vision and a model of service that would bring together these various agencies in different ways, for children of different ages, for the under-5s, for the school age and that would predominantly concern education a great deal, and for what in our evidence we made very clear, the importance of the 16 to 25 age group, which is an age group which has traditionally fallen through the net, and we feel very much that age group needs to be seen as a whole area, something again that was strongly recommended by the Health Advisory Committee's Report called Together We Stand a couple of years ago. I would like to make that as our setting. Where that brings us to your original question about the Berlin Wall, I do not see there is a Berlin Wall, I think there are problems, and I think social services have a particular role to play in relation to family break-down, in relation to problems according to the criteria of the Children's Act and child protection, and they have clear responsibilities there—education clearly is a responsibility for education in its wisest sense and health covers the rest, if you like. Our experience is that the Berlin Wall does not pervade the country, it is very variable according to different kinds of arrangements, different kinds of personalities, different kinds of innovations, different kinds of readinesses to enter into small specific pieces of work.

  496. From your knowledge of the different arrangements in different parts of the country and some areas which work better than others, are financial factors a feature in where there are particular difficulties—disputes over boundaries in terms of resourcing services? Is that a factor you have picked up?
  (Mr Wilson) Financial constraints?

  497. Yes.
  (Mr Wilson) Very much so.

  498. Would Mind share that view?
  (Mr Peryer) Yes. Financial constraints and the difficulties of getting a commitment to put in resources. It is partly a legal point, although that may be taken care of, but it is more than that, it is difficulties in getting commitments. From Mind's point of view, it is not just a beginning-of-the-year commitment to a budget, it is the commitment to make resources available when they are needed, and that is about housing management, about the management of health services and management of social services. So the commitments to resources are about access as well as the budget.
  (Ms Morley) I agree with what has been said, that the Berlin Wall exists in some places and not in others. It does seem to depend very much on personalities and whether you have people who are willing to come together and develop a shared vision and purpose for the service. Once they have that, you will find the resources will work together. In Hackney, where I have been working, we did set up joint mental health teams for adults which were line-managed into the health service, with the social worker seconded and the budgets were effectively pooled. However, because of the regulations around resources for local authorities and health you cannot actually pool them, but you can technically do it and you have to audit it carefully. That worked very well and building on that one could look at a similar framework for children's services, but the children's mental health services are that much more complex in a way because education is such a key player and education seems to be more difficult to bring on board, probably because it has a huge agenda of its own and does not necessarily see its role yet as very significant in children's emotional well-being. Everyone is beginning to see that but I am not sure that has been the case in the past. The fact that resources are short means that the authorities do tend to retrench their position and are very anxious about spending in any area they would consider to be the other authority's responsibility, and it gets a bit antagonistic. I think the differing governances of the two agencies are problematic. Health Service officers are part of the executive board, local authority officers are not in that same position. So there is a sort of inequality which is around and makes things more difficult than perhaps they might be. Mind has mentioned the difficulties around charging for different sorts of care, and that is an issue for children's services where there is always, in my experience, blood spilt over who is to pay for the child who needs a particular level of provision. That can be worked out and authorities can agree tri-partite funding arrangements for children who need specialist services, but when resources are short that is picked over in a rather unhelpful way, which means that unless you have this clear shared purpose things can go adrift.

Mr Gunnell

  499. I am going to ask about structural change and whether it would help. It sounds to me from what I have heard so far that it may be the two organisations have slightly different views on this. Would structural change help to improve collaboration between health and social services? What about the question of a joint authority? Would a joint authority, a joint health and social services authority, solve the funding problem? Would you favour that sort of creation, a rather more radical change like that? If not, why would you not favour it?
  (Ms Sayce) I think that because of the points we were making about the number of different departments in local government which are involved, and indeed agencies beyond local government, there is a risk we could go to huge trouble and time reorganising to bring health and social services together, so we break down one barrier, but we would in a sense potentially even entrench other barriers, because you would then have this agency which was cut off from education and housing potentially. So we do not think there is evidence that the benefits would justify the disruption of further major reorganisation. Having said that, we would like to see piloted creative ways of ensuring strategies really are jointly agreed from the top and that budgets are flexible and that service users can have a strong input into the standards which are agreed and into the strategy. We have a document here called The Avon Mental Health Measure which enables service users to do exactly that and assess their own needs and their own outcomes, and that feeds into the management system as to what the outcomes are. I can tell you more about that if you are interested.
  (Mr Peryer) I very much support what Liz Sayce has said. We need more robust arrangements, clearly, and Mind is not saying there is no need for change. I agree with the point that Dinah Morley made that at the end of the day what is effective depends on the degree of commitment and trust. It also, being realistic, depends on the extent to which people's performance and performance expectations are defined and performances managed. It is not just a soft, "Let's hope for some trust and goodwill", it is actually a hard, "Let's manage performance." So there is a whole set of issues on the health side about regions, regional offices, expectations of chairmen of trusts and so on. On the local authority side there is a whole lot of issues about best value, the way it is used, joint reviews, the implications of that. Taking both of those expectations of performance, as they get worked through on both sides, we would believe that if the requirement is there to put together strategies, plans, commitment to resources, committed access to resources, and the mechanisms to review performance in relation to outcomes in which users participate and share their experience, one is beginning to get something robust which does not put a boundary around health and social services and limit the scope of the exercise. I do feel very strongly that there is an enormous danger of getting locked into a series of health and social care arrangements in a joint authority which add to cost and restrict the service which in the long-run is available to the service users.

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