Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 500 - 517)



  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.


  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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