Examination of Witnesses (Questions 500
- 517)
THURSDAY 23 APRIL 1998
MR DAVID
PERYER, MS
LIZ SAYCE,
MR PETER
WILSON AND
MS DINAH
MORLEY
500. So what change would you hope this Committee
would recommend to bring about the improvements you seek? You
clearly would not like us to suggest joint authorities. What would
you like to see us recommend, because at the end of the day it
is going to be our job to make some recommendations?
(Mr Peryer) I would like to see a recommendation,
first and foremost, for minimum standards defined nationally;
a national quality framework. In other words, we support the announcement
last week that mental health is going to be one of the first two
new initiatives there. We need that framework. We need from the
centre a requirement to achieve effective relationships. All the
things I have just said—effective working relationships
which relate to outcome and are tested externally by the Social
Services Inspectorate, Audit Commission, joint reviews; a whole
set of processes which are tested externally in a robust way against
targets and expectations. We want to see that in place. We clearly
want to see some of the other issues about the links with social
security addressed; the points that Liz has made. We think that
the way is open now, particularly now with the emphasis there
is on performance and best value, to say, "The experience
is there, it can be done." If I may come back to child protection,
the experience is that it has taken a long time but now I would
say in most parts of the country there are reasonably robust arrangements.
They still hinge on commitment at the top and trust, there are
still the problems of the Government's arrangements on the two
sides being different, and I accept that, but we need local authorities
to leave their senior officers free to negotiate and take good
decisions, we have to address the whole issue of the committee
structure on the local authority side and how it works and how,
from the health point of view, it can delay things. A series of
practical problems but none seem to me insurmountable in the present
climate. So we would favour robust progress on a joint approach
with very specific requirements as to achievements.
501. Can Young Minds tell us whether they would
respond similarly to the same question?
(Ms Morley) I think the issue of a mental health trust
is not the issue for us, because what we have said in our submission
is that we feel children's mental health services ought to be
located with children's services.
502. So the division you would want to see is
a different one?
(Ms Morley) I think you can make a fairly robust argument
either way, but on balance we feel that children's mental health
services sit better with the whole range of children's services.
If you think about the critical links with education which we
have spoken about, that is where children's mental health services
ought to be. There will always be issues of transition when children
become adults and how you manage those boundaries, you have to
deal with those in any case. Although I personally feel quite
committed to the idea of a mental health trust, because I have
seen the beginnings of that work so well where I have been working
before and very positive outcomes which have been properly audited,
for children's mental health services it is different. We have
to locate them firmly within the children's services' structures
in health, social services and education.
(Mr Wilson) The two points I would like to make are
that I do not think structural change is as important as finding
other ways in which to improve communication between the two.
I emphasise in particular training as a key factor. I think in
the field of child mental health there is an uneven spread of
knowledge and information about children's mental health which
gets in the way of effective communication. In most parts of the
country, social service workers are less knowledgeable now about
children's mental health than they once were, and I think this
creates all kinds of problems about communicating. If you attended
to that as your priority, it would be more important than a structural
change.
Chairman
503. Why is that? Why are they less knowledgeable?
(Mr Wilson) Because they have a relatively short training,
two years, in which they have to pack in the enormous amount of
information about statutory responsibilities which have advanced
considerably over the last ten or 20 years. The emphasis placed
on child development, on child mental health problems, has been
squeezed out in that process. I think many feel very ill-equipped
to deal with it. They do have to deal with the very hard end of
children's mental health problems—children who have been
abused, whose behaviour is chaotic, whose family circumstances
are unsupported, one thing and another, and these are very deeply
entrenched problems. I do not think they have got sufficient training
by and large—not everywhere—to (a) equip themselves
to adequately deal with this and (b) communicate with the health
services in that respect. The other point I would make is that
one can do so much through setting up joint meetings. In the child
and adolescent mental health field now there are requirements
on health authorities and on local authorities to ensure there
are strategic plans in place for child and adolescent mental health
services to cross the various agencies. I was in Manchester on
Monday and they have now agreed across agencies on service specification
for child and adolescent mental health services, the gist of which
is that with extra money, which they have in Manchester, there
is a requirement that new services should undertake to work with
at least one or two other major agencies and it should be based
in the community. So there is a financial incentive, a service
specification which is owned and agreed by the various agencies.
I think it is possible to set in motion those kind of processes
within the existing structures.
Mr Austin
504. I think all witnesses have come out against
major structural change, and you have talked about mechanisms
for making collaboration and co-operation easier. Section 28(a)
of the NHS Act was specifically designed to assist that process
of joint collaboration, joint financing and use of resources,
do you think there are still within that some barriers and some
changes which need to be made in that arena to make that more
flexible and easier?
(Ms Morley) I think on the whole the joint financial
pot tends to be very small, and it is seen as being able to be
used for jointly agreed projects but they do not impact necessarily
on the total service, and they do not necessarily have the result
of bringing services closer together. They just develop another
bit in the jigsaw, which is useful and helpful but it does not
actually bring things together in the way I think that Section
28(a) was supposed to do. From my own perspective I would say
that maybe more money has to go into the pot which is called joint
finance so that it starts to draw the core services together,
so you can have this blurring of roles between social workers
and CPNs. So that pot of money could buy a social worker in one
area and a CPN somewhere else, a community worker or a psychiatrist
somewhere else, in order to be able to flexibly meet the needs.
So I think that has not worked terribly well and it is worth having
a look at it again to see if it could not be much more of a carrot
and really make some changes.
505. Where would the impetus for change come
from? What effects that change which you want to see?
(Ms Morley) I have to go back and say that until you
can get people together in a proper joint planning process, so
they do develop a shared purpose or vision and then decide where
the priorities for spend are, you cannot really move forward very
productively. I think the joint planning processes are what should
underpin any kind of change. What we have said in our submission,
and it is obviously up for a lot of discussion and debate, is
that the children services planning process—and I am talking
about children's mental health services—is quite developed,
it is now a requirement on local authorities for this plan to
be produced, all agencies are expected to contribute to that plan,
that plan is very wide potentially, and that process could be
beefed up to be the lead process in children's mental health across
the agencies, and maybe health has to feel more ownership for
that process, and education similarly although I think that is
probably happening. From there, people would be able to see locally
where the priorities were. They would be able to make some joint
needs assessment. Needs assessments tend to be terribly patchy—health
does one and then social services might or might not do them—and
they need to be shared so people can see whether the resources
are in the right place and where the gaps are. Then you might
be able to have a look at how funding might be reorganised. I
think a larger pot of joint finance with some real requirements
to look at core services being jointly managed has not been the
way it has been used, and it may be interesting to explore that.
Dr Brand
506. I think we have just heard a very good
case for a combined authority really. It is very interesting that
you are talking about national standards but nobody has answered
the sort of rubber duck question, who is actually responsible
for delivering what part of the national standard, other than
joint working to make sure the national standard package is delivered.
We are in danger of developing a system where local authorities
pick up large responsibilities in one part of the country as opposed
to health, and vice-versa. I am very impressed by the emphasis
we have had on reducing social isolation and support for vulnerable
and recovering people, whether that is in sheltered housing or
day centres, the exciting thing you were talking about of supporting
people in the community proper rather than in isolation, and of
course support for parents. Personally I think those things do
more to help mental health than clinicians ever do, yet it is
a sort of add-on, an extra, which you can get if you are lucky
if you have an innovative local authority. You were saying you
are rather against any idea of change but of course we are going
to have change, and this is where I come back to the question
which I am asked to ask you. The White Paper suggests the setting
up of a special mental health trust, so it is not an integrated
part of either primary care or indeed has a closer relationship
with primary care and social services. Do you think that is a
mechanism which is helpful for integrating responsibilities or
do you think it may stand in the way?
(Mr Peryer) I think it may stand in the way. I do
not think it has been thought through quite honestly. I have looked
hard at the White Paper, I have looked at the Scotland White Paper,
and I have not understood the difference of approach. I do not
see quite where the thinking is coming from. I do think a mental
health trust on its own will raise a whole heap of questions about
who is actually going to pay for the services, whether the primary
care groups will have total spending power, if not they will have
a very big interest in shifting responsibility across to the mental
health trust. There is the possibility that mental health specialist
services will then, in a sense, take the resource, and the very
things you are talking about will be lost. The moment you talk
mental health trust, a whole series of issues are raised like
what primary care groups do, where community health trusts are
going to be if at all, and there is a lot of unfinished business
there. But as it stands the notion of a mental health trust does
not appeal to me at all, and I do not think it appeals to Mind.
When you say that we are not asking for change, we are asking
for change. We are asking for very substantial change. If I may
say, the present situation is profoundly unsatisfactory—
507. I agree with you.
(Mr Peryer) There is no equity across the country,
there is no equity for different users within a local area, what
happens to you depends very much on the luck of the draw or who
answers the phone, who is on duty, there is a whole series of
issues to be addressed. There is the whole dangerous list agenda.
What is driving, what needs to drive this, is concern for the
dangerous list and actually to learn the lessons from that. The
history of child protection is that the tragedies do lead to results
eventually and we have to pick up the public concern about dangerousness,
and that is about effectiveness, and about dealing with all these
practical things. If you look at the history of those inquiries,
it is about a whole heap of things, clinical decisions but an
awful lot more about communications, objectives, shared objectives,
are there shared objectives. So I am talking about enormous change,
a change of values, a change in culture, a change in ways of working,
a change in performance expectations. It is about defining standards
but it is then expecting local arrangements and holding people
accountable for them, not standing still. If I may, it seems to
me to look at the structural change from the top without looking
at the size of the problem which needs to be addressed, which
I think will miss the point.
508. I always start from the bottom.
(Mr Wilson) I would very much support that, Mr Chairman.
It seems to me there is an issue of resources which we are not
here to discuss but there is an enormous problem out there, much
larger than I think people imagine or are comfortable to accept.
Certainly that is the case if one looks at prevalence rates of
child's mental health problems in the community. So that is an
issue. There is a great deal of change going on, certainly in
our field over the last two, three, four years. I take the point
that clinicians have a part to play in this broad field of mental
health, but there are many non-clinicians who have a key part
to play and I think this has been well embraced by the initiatives
I have already referred to which do, it seems to me, have an opportunity
to progress. There is a lot of scope too, if I may say so, for
more circumscribed local initiatives bringing the various agencies
together. For example, in the proposed health action zones and
in education action zones, or indeed in the youth offender teams.
These are all new initiatives which seem to me to be pointing
in the direction of change where, in a more circumscribed way
around specific communities, there is going to be more and more
of a requirement for different agencies to come together to deal
with specific problems. This seems to me to be manageable, feasible,
better-targeted.
509. Can I ask Young Minds, would you see services
for the people you are concerned with sitting with the primary
care groups, with acute trusts, community trusts, combined trusts,
or special mental health trusts?
(Ms Morley) What we would say is not specialist mental
health trusts because they sit more appropriately with children's
services. There is a real debate to be had about how the specialist
services which relate to children's mental health link to the
generic services which are so critically important at tier one.
I think that is more about how those services are commissioned
than any structure, although I think the structural changes need
to be debated.
510. But the commissioning depends on your structure,
because your structure determines who has the money.
(Ms Morley) What I was going to say was that what
we see at the moment is that health authorities will commission
a child and adolescent mental health service for specialist services,
what is not necessarily commissioned within that is the ability
of those specialist services to support the people at tier one,
support the GPs, the teachers, the social workers, et cetera,
so you find that a lot of really quite troubled children are being
managed at the tier one level by people who desperately need specialist
support which they cannot access. What you find when you pick
into it is that the specialists do not have the time and nothing
has been purchased by the health authority which gives them the
time. I think that is something which needs to be recognised.
There will never be, in my view, the way I see it at the moment,
a possibility of sweeping all those tier one services and the
children's specialist mental health services into one trust, the
way things are structured at the moment because it would not be
appropriate, but there has to be a much better link between the
special tier and the front-line workers so that the front-line
workers know what they are looking at. It comes back to Peter's
point about the importance of training, so they know what they
are looking at, they know what services there are to support the
various very troubled children they are dealing with, and that
those services are there in sufficient quantity to be able to
respond.
Julia Drown
511. I wonder if Young Minds could clarify?
Is what you are recommending that there is not any need for structural
change but that there is a need for a bigger emphasis on communication,
education, services and health authorities are all taking a wider
responsibility for all groups of children and mental health is
a particular group for concern within that?
(Ms Morley) I think that would be our broad position
but I do think it is worth looking at the development of a more
co-ordinated and preferably singly-line managed specialist service.
For example, social workers who are seconded into the Child and
Family Consultation Service, any other staff from education who
might be seconded on, need to be more clearly seen as part of
that team as opposed to part of social services or education.
512. As part of the health team?
(Ms Morley) Yes. Well, it could be a health-led team.
Some people will argue it should be a social services-led team
and there is a room for a huge debate about that. But to get that
kind of cohesive child and adolescent mental health specialist
team is important and it needs to work as a team because otherwise
you have the possibility of people overlapping on cases and some
cases being ignored, you just have so many inefficiencies built
in. So I think we need to look at that.
(Mr Wilson) It is a key responsibility of that team
then to be outwardly directed to the community and people working
in that community. That was what I was referring to earlier on
in Manchester where there is going to be a requirement in the
service specification of the specialist child and adolescent mental
health team that they work with agencies in the community and
collaborate. I think it is endemic to the whole of our thrust
in child and adolescent mental health field that educationalists
see they have a key part to play in the mental health of children,
in the broad sense of the term. Not mental illness of children,
mental health. Indeed social services are laden with severe problems
in mental health by virtue of the clientele they have. It is trying
to get people to see that dimension which would then serve as
a vision for it to come together in these various ways. I think
it is more of a cultural, training, communication, information
issue rather than a structural issue.
513. You said in your evidence that you thought
one authority should be given the lead responsibility for bringing
it together. Other witnesses have said that that allows other
people to say, "It is not our responsibility" and that
everybody should be given the responsibility for co-ordination
and bringing it together. Would you like to comment on that?
(Ms Morley) If everybody is given the responsibility
then nobody needs take it. So whichever way you look at it, it
has its down side. Emphasising what Mind colleagues have said,
if proper standards and responsibilities are set and located and
monitored, you can deal with that. What is important from day-to-day,
if you are out there in the field, is to know very clearly where
your line management is and for the service to know it can properly
and efficiently and effectively allocate the work across a range
of professionals who are working as a team. The Government could
very usefully locate responsibilities very clearly somewhere and
I think what we see at the moment in child and adolescent mental
health is that that is not anywhere, and you have some workers
in one trust here and another trust and a community trust there,
all part of the service but nobody being responsible to say, "A
good child and adolescent mental health service should contain
this and this and should be doing that in this locality."
That is the issue.
Mr Walter
514. So that we do not forget that it is the
users actually that this is all directed towards, I wanted to
pick up on some of the evidence we had from Mind—but I would
like answers from both groups—which is really with regard
to user involvement. Mind talked in its evidence about that one
should include an active partnership with service users and seek
to engage users with services which are acceptable and helpful
to them in terms of the planning and service delivery. Would you
like to talk about what kind of organisational framework you think
would encourage involvement of users and carers in planning delivery
of services, and how you think those sort of plans could be developed?
(Ms Sayce) In developing a strategy for delivery of
mental health services, we have argued it has to be jointly owned
by health and social services, and has to be linked into health
improvement programmes and any local work, for example, health
action zones, central to that planning must be the service users
themselves and evidence from the service users themselves. This
Avon Mental Health Measure, which I mentioned, is basically
a tool whereby service users can look at their own lives across
a whole range of dimensions. They do not just include need for
treatment, although that is there, but it includes mental health
symptoms, it also includes food, do you have any adverse effects
from this treatment, do people discriminate against you, and this
is rooted in what service users themselves have said are the key
issues. So the service user in a sense devises their own care
plan, with support from an advocate and a professional, and we
would like to see this built into an assessment process which
did not involve two separate assessment processes, as it can do
now with a care approach in health and a care management in the
local authority, which is absurd often. You can then extrapolate
up from that. What is actually happening with this measure is
that in certain parts of the country there are local action groups
which are implementing this and the local action groups include
service users but they can draw on the information which has been
gained from a whole range of service users, so it is not just
a small number who want to get involved in the process. So the
experience of service users is directly informing the planning.
One of the reasons we think this is important is that we very
much support the emphasis on evidence based practice and effectiveness,
but we would raise questions about who decides which evidence
takes precedence. For example, a lot of clinical effectiveness
research in the health sector focuses on reduction of symptoms,
so if you hear voices, if you do not hear voices after the treatment
then it has been a success, however it might be that you are taking
a type of medication which stops the voices but also, let's say,
means you cannot concentrate at all which means you cannot work.
There is a balance there. Another outcome might be more important
to the service user, which is why we think service users should
be informing the research agenda and also the whole notion of
what is effectiveness. Users need to set the outcomes with professional
input as well and scientific input. I am not sure whether I have
answered your question about organisation. There are some real
examples of good practice around the country, and if we had a
requirement for that type of user involvement—part of the
requirements which David was talking about which would be monitored
by the Social Services Inspectorate or Commission—that could
be used as a lever to spread the good practice. At the moment
it is a bit ad hoc, some areas have very good user involvement
and some areas do not.
(Mr Wilson) In children's mental health the user involvement
is perhaps less advanced than in adults, partly because the beneficiaries
of the service are either children or parents. Children find it
difficult to have the confidence or channels to express their
views about a service, and parents are very varied, some parents
do not care, or find it difficult to demonstrate they care, or
they are ashamed and they do not come forward, so it is a more
complicated business in children's mental health. That is not
to say we should not be constantly attuned to it, and hopefully
through good professional practice you are, but there need to
be further safeguards than that. There are a number of interesting
initiatives now, particularly in the voluntary sector, trying
to engage young people's views and parents' views. Parenting groups
are now becoming more confident in expressing their views, so
in different ways we are getting feed back. I do know that in
some of the strategic planning which is going on—and I am
referring to Manchester because it is in my mind this week—the
strategic planning and the service specifications are public documents
and they are getting through to people in the process and there
is some involvement there. It is a more complicated subject I
think in children's mental health.
Mr Lansley
515. Perhaps I could direct my questions towards
Mind because they were prompted by what Mr Peryer had to say a
few moments ago? Your evidence rejected in your view the creation
of an authority, a separate mental health and social care authority,
as was discussed under the previous Green Paper. However, your
evidence goes on to say that you generally favour a joint health
and social care body. This is not, judging from what you said,
a specialist mental health trust, so could you elaborate for me
what it is that you mean by such a body which is a joint health
and social care body but which is not a trust and is not an authority?
(Mr Peryer) The joint body as we envisage it would
be a set of arrangements first and foremost at the top of each
organisation which commit in terms of policies, resources, strategies.
Each of the organisations—health trust, health authority,
the commissioners on the health side, local authority and social
services within local authority—commit them to the provision
of mental health services which are integrated to the extent they
need to be integrated. I say that as a sort of hyphenated sentence
because there are certain things like specialist care in medium
secure units which are of a different order from the day-to-day
problems of care in the community. Those arrangements will need
to be owned and formally subscribed to by each of the commissioning
and managing authorities, and that is the sense in which we are
talking about a joint body. We are not talking about taking things
away, we are saying there will continue to be a local authority
with local authority responsibilities, continue to be health commissioning
and trust and primary care group arrangements, but we want to
see freedom to put money into the pool without hindrance so there
can be a pool of money which can be called on flexibly, and we
are quite clear about the need for that change in the law aside
from the joint finance. Secondly, we need that joint body to ensure
there are arrangements in place which are together to the extent
they need to be together, which is for the large part of the business,
and are left to the separate responsibility of those concerned
where they are actually separate and do not fall within that remit.
In other words, the problem with mental health is, on the one
side you have people with relatively low level problems, which
are important to them, the one in four, the one in four women
who at any time in life will need help with mental health problems.
Many of those are not going to enter the mental health system,
they will stay within the primary care system, so we need to acknowledge
there will be things which will be outside these arrangements.
Equally, there will be arrangements which lie outside at the other
end, the future of secure hospitals, big secure units, regional
commissioning of those. In the middle of all that our joint body,
as we envisage it, would be a set of formal arrangements committed
to by the authorities on each side at the commissioning level
and then by the providers, which would actually commit strategies,
plans, resources, arrangements and an agreement to review performance
and outcomes against targets and all the things we have been talking
about. That is the sense in which we mean a joint body, but it
is not about saying take responsibility away from here and here
and give it to somebody else, because we think the present powers
are there on both sides to make it work.
516. If I were to characterise, forgive me for
over-simplifying it, you are suggesting there should not be a
structural change, there should not be a legal change on the responsibilities
from existing bodies to a separate new body, but that in some
way each of the bodies should commit their finance structure and
legal responsibilities to some joint meeting in effect, or series
of meetings, from which derives a plan?
(Mr Peryer) The responsibility for the professional
contribution of those involved would remain with the managing
authorities—doctors would continue to work for health trusts,
specialists would continue to work for health trusts, GPs would
continue to be independent practitioners, social workers would
be accountable to the directors of social services—those
things would not change. The programmes within which they work,
leaving aside the things at the extremes—the very low level
problems and the very major problems—would be jointly owned.
The responsibility of the joint body is to their effectiveness
and outcome, recognising that people working within them have
to work together but also have their separate accountabilities,
because doctors are not going to work for a local authority and
be accountable to a social services committee. Social care is
a responsibility on local authorities and in our view needs to
stay there because it links into a whole range of other things
beyond social services. We would want to see joint housing, community
service departments and all those kind of things. So we are not
taking away the lines of accountability and the professional and
clinical responsibility of individual practitioners, we are saying
they have to work within a system where a body is accountable
for the outcome of that system and the performance of that system
and those arrangements and is answerable for it, each for its
own players.
Chairman: I am conscious that we have been an
hour with our first set of witnesses and it may well be that we
will follow up with written questions, if that is okay with our
groups of witnesses.
Mr Syms
517. Social exclusion: we started to touch a
little earlier on local authorities, how could local authorities
as a whole contribute to the social inclusion of people with mental
health problems?
(Ms Sayce) First of all, within the monitoring and
accountability which we have been discussing there needs to be
performance measures which relate to social inclusion provisions.
Chairman: I am sorry, but we have a fire alarm
and we have to vacate the building. I think at this stage it is
appropriate that I thank our witnesses from our Mind and Young
Minds. We hope it will be possible to follow up with some written
questions on areas we have not managed to cover. Once again, we
are most grateful for your co-operation in this inquiry. We will
adjourn now until the alarm is over.
The Committee suspended from 11.29 to 11.36
for a fire drill in the House
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