Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 518 - 538)

THURSDAY 23 APRIL 1998

DR MATT MUIJEN AND DR ANDREW MCCULLOCH

Chairman

  518. I welcome our witnesses from the Sainsbury Centre. We are most grateful for your detailed written evidence and for your willingness to come along today. Could I begin by asking you a similar question to the question I posed to our first group of witnesses which relates to this perception of the Berlin Wall? Is that your perception? Is it something that you recognise as a problem? If so, can you offer any definition as to the division between the two areas of service, health and social services?

  (Dr Muijen) We certainly perceive a problem with the interface between health and social services and very much welcome the attention being given to it. We do not think that the Berlin Wall is necessarily the best analogy—it is very structural and there is a sense of danger about crossing the boundaries, which are not the reality. The reality is that it is more like the European Union—well, maybe that is not a well-chosen one—a group of different cultures, different languages, who find it very difficult to work together even if they try so very hard. The problem between health and social services is not purely structural but about different accountabilities, different legal frameworks, finance which differs, boundary issues which are very important, and different training issues. It is two cultures rather than a wall in between.
  (Dr McCulloch) I have not got much to add to that but I think if you speak to a social worker about mental health issues you will get a different model and a different view of those issues than if you speak to a psychiatrist or a community psychiatric nurse. Those differences are pretty fundamental. They start off when people do their basic training, and they are reinforced in the working environment on a day-to-day basis. Neither of those models are wrong but they are different.

  519. Forgive me, I did not ask you to introduce yourselves and give some idea of your backgrounds, so perhaps you could do that in answering the next question. In your evidence you are not asking for major changes in agency responsibility, but you are actually supporting joint planning mechanisms. Do you have comments on the existing joint planning arrangements and, if so, how would you see them being improved?
  (Dr Muijen) I am Matt Muijen, Director of the Sainsbury Centre for Mental Health. You are quite right, we would consider that any change in responsibility is purely cosmetic and would shift existing boundaries rather than resolve problems. The model we would be in favour of is a joint planning agency, a joint mental health agency, which is at a commissioning level and would combine the executive power of the health authority and the social services department but below the level of the health authority and social services department, with a chief executive officer responsible for commissioning the money and as such requiring a pooled budget which would be spent through this body.
  (Dr McCulloch) I am Andrew McCulloch, Senior Policy Adviser for the Sainsbury Centre. I think the way things work at a planning level at the moment is very hit or miss. You do have many locations where people work well together, where they produce a joint plan and they go away to deliver it. You have other locations where there is great difficulty because of the different models, the different accountabilities. We do not think major structural change is necessary but we do think some kind of primary legislation is necessary to bring existing authorities together and to ensure there is a minimum standard of joint planning across the country.

  520. You do feel there is some legislation needed?
  (Dr McCulloch) There is legislation needed but not to create a new bureaucracy. I think it must build on what we have now.

Mr Austin

  521. You specifically said in your evidence there are legal barriers which prevent joint commissioning, joint financing and pooling of budgets. Would you like to specify what those precise legal barriers are?
  (Dr McCulloch) They are specified in some detail in the report which I believe is available to the Committee although it has not been published yet. We are not lawyers but the analysis in this report shows how the existing mechanisms, such as Section 28(a), are useful, very useful indeed and are being well-used but they do have gaps. They are not designed to deliver modern, mental health services within the context of modern health and social care policy. They were designed many years ago in relation to issues like the closure of the asylums and resettlement of people in the community. So there are a number of gaps and omissions within the current legislation which are detailed in here. For example, authorities can get together to spend money but they cannot actually physically pool those budgets, which means that there are difficulties over efficiencies and perverse incentives. So there are areas where primary legislation is needed, but it needs a careful detailed and measured approach. We are not in favour of some kind of big bang, structural reform which throws everything up in the air and achieves nothing for service users.

Mr Gunnell

  522. You have made it clear to us you do not favour any major structural change, so you would not favour a joint mental health and social services agency because of the disruption you would see the setting up would cause. But you accept there is a relationship between mental health and community health, so how would you ensure that that is an effective relationship if you are not going to bring about structural change?
  (Dr Muijen) At the moment legislation and also regulation is running behind what the field is trying to do. There are large numbers of examples in the field where health and social services work together, sometimes very much on the edge of what is permissible. What we are keen on is in effect to enhance this kind of joint working. What the field is asking for—and I am always impressed by the consensus in the field at the moment—is this kind of joint agency which will allow the two parties to work together and commission services together. I think at provider level it is a bit simpler because at most services it is required there, but it is the joint commissioning which will allow integration at provider level. Again, this is happening in a lot of places de facto but in a rather artificial manner.

Mr Lansley

  523. Our previous witnesses from Mind were talking about a joint health and social care body. Do you see the kind of body they were talking about as being similar to your own conclusion about the potential for the creation of a joint statutory committee? If so, when you talk about the changes in the law required in order to pool the budgets or enable the reciprocal delegation of authority to local authorities, health and service staff, would you see that being tied to the creation of such a statutory committee and the establishment of plans through such a body?
  (Dr McCulloch) Yes, we would. I think they have to go together. I think the whole system is interdependent. If you are going to have proper accountability for this pooled money, the authorities have to agree a plan first. I think that plan has to be quality controlled by the regional offices of the SSI and of the NHS Executive. You have to have a whole system which meshes together—people have to talk to each other more often, they have to have more joint and shared training. I do not think even the small structural change we are suggesting is a panacea at all or an end in itself, you have to have better communications, you have to have better joint training, people have to be working with clearer leadership to a clear plan which the local community and which patients and staff have access to. If you do not put all those things together in place then you always stumble over the thing you are not put in place; it is always the barrier which creates the problem rather than the other opportunities which may be there. So I think we need a systematic approach to joint working which ticks off the different issues and addresses them.
  (Dr Muijen) To add to that, of course many of the opportunities are already suggested in the recent NHS White Paper, but I think the health improvement plan is the kind of strategic framework which has to be signed up to by health and social services and would allow this kind of joint commissioning.

  524. Earlier evidence we received, particularly from Department of Health officials, acknowledged that insofar as two bodies like health and social services or health and local authorities were seeking to arrive at joint planning, not only the differences in the planning cycles but, perhaps more importantly, the differences in the degree of certainty each was able to attach to their future funding were considerable impediments to the agreement and pursuit of joint planning. What evidence have you had of those difficulties and how might they be overcome?
  (Dr Muijen) They are being overcome. If the goodwill is there, people can achieve it. What I find very interesting is the areas which have made most progress, which are on the whole the rural areas where people know each other and have worked together for a relatively long time and trust each other. They have already moved down this road and clearly these are obstacles which can be overcome if the will is there. On the other hand, there are other areas where the trust is far less and often agreements are broken up and sometimes a statutory framework will be required. These are not barriers which are written in stone.
  (Dr McCulloch) This reinforces the point I made earlier about bringing all the factors together. People are making the system work and you can make the system work as it is now, the problem is that is not consistent across the country and so that results in inequality. Also, there are often problems in areas which have great mental health needs where it is vitally important that people do work together. That is why we think a statutory framework, with the money tied to that, will encourage those who have made less good progress come up to the standard of those who have already made good progress. But we are certainly not saying it cannot be done now. It can be, people have proved that.

Dr Brand

  525. You have just touched on the White Paper, do you think the White Paper is going to be helpful to achieve what you are looking for in relation to what is the role of the primary care groups as opposed to mental health trusts? You are clear in your evidence where the strategic overview should be, but where should the actual purchasing be happening or the commissioning and where should the providing be going on?
  (Dr Muijen) We think the present White Paper is very helpful because much of the local purchasing can be delegated from this kind of joint body to primary care groups who should also include, and will include, a strong social services involvement. As such, around the primary care groups, one could build joint commissioning by them, supervised and with accountability, towards the joint or mental health agency designing the HIP (Health Improvement Programme). So at present, the proposed framework with possibly some strengthening on the social services side might indeed facilitate this kind of joint commissioning leading to integrated provision.

  526. So you see the primary care group as being the commissioning group and you accept the suggestion that there needs to be a special mental health trust?
  (Dr Muijen) I do not think I said that.

  527. Well, you said the White Paper was helpful, and the White Paper actually excludes mental health from primary care by setting up a specialist trust, which I found a very bizarre idea personally but I am biased.
  (Dr Muijen) It is a preferred option rather than being prescribed, I think. I was talking about commissioning. What I think the White Paper suggests is a variety of mental health provisions which indeed we do welcome. On the different question you are now posing, which is really our opinion about a specialist mental health trust, I think it can be helpful in some areas but unhelpful in others. Let me be more specific about that, I visited North Lakeside recently, which has a population of about 300,000 people and is clearly very isolated and might be too small for a single mental health trust. On the other hand, a combination with the community trust might be very relevant and might well work jointly with primary care groups; some kind of sensible working together could be feasible. There are other parts of the country which are far larger geographically where a specialist mental health trust might be indicated. It is horses for courses. A single solution is never sensible and certainly not a single structural conclusion. So one has to separate between the commissioning model and the provision model, which can easily sit side-by-side.
  (Dr McCulloch) It is the framework within the White Paper we are particularly attracted to. There are dangers in that sentence in the White Paper you are referring to, and I think it would be counter-productive if everybody thought they had to rush off and reconfigure into a specialist mental health trust. I myself am quite interested in models like community trusts and also using primary care groups, possibly experimentally, to place some mental health services in those. I think these models have to be evaluated. The evidence that we have to proceed everywhere down the road of specialist mental health trusts is not strong, and I do not think there is much appetite for everybody to reconfigure into that particular configuration, but it does work in some areas.

Chairman

  528. You do not have a fear that if there is not specialist provision for mental health, that resources may well move elsewhere to, say, more fashionable parts of acute provision?
  (Dr Muijen) Anything might happen in any configuration. Equally, there is a risk that if one has specialist mental health trusts they might not get the added funding they might get at the moment from combined trusts. There is tremendous variation around the country, sometimes for the best reasons and sometimes for the worst reasons. Let me give another example, Andover, a very small, cohesive community, at the moment provided by a combined community and mental health trust and they intend to move towards primary care trusts, level four, but they do not quite know what to do with the mental health component which on its own is actually not feasible. It is quite clear one has to be pragmatic there, which indeed they are, but if they went for a purely structural solution it might lead to disasters for the mental health trust.

Ann Keen

  529. Following on from that, you mention in your report the unitary system of care management which you favour and how that works. Could you give some examples of how that works and where it is working?
  (Dr Muijen) If there is anything in mental health which is varied it is the attempted integration between the CPA and care management—CPA of course on the health side and care management on the social services side. There are various levels of integration. I think one could come up with four or five levels—single access to health and social services, combined assessment, single line management of nurses and social workers mainly to a team manager, integrated IT, which is remarkably rare, and the final stage is a delegated budget to individual team members. Each of these stages is becoming more and more common. There are examples in this country—the well-known one in Northumberland, but Kirklees and especially at the moment Scarborough—which are moving all the way and everyone is making attempts. It is quite clear at the moment there is an awareness that joint health and social service working is a good thing and everyone is trying to get around the present legislation at different speeds. The very final integration of budgetary responsibility and particularly residential care money is at the moment very rare, because of ownership issues and because of perverse incentives, but there are many examples of good working.

  530. What sort of training and development would you think would be required for this to be spread around the country?
  (Dr Muijen) It is first of all about managers willing to take the risk of integrating the services. The second stage is indeed the training, but at the moment neither nurses are really able to input through the care management assessments, as required by social services, because of the budgetary responsibilities which they are not used to, and nor are social services necessarily used to working with the mentally ill in multidisciplinary teams. So there are at least two levels of training required. There is the specific, skill training required for joint working but there is also at a higher level a far greater need for training in community care of all disciplines involved, without which this whole issue of care management is rather irrelevant.

  531. In view of what you have just said, how long do you think it could take us to develop this system? What would be a reasonable timescale for that?
  (Dr Muijen) It depends, of course, which step in the system you are thinking about. The legislative framework is your expertise and you are better at that than I am. At practice level, people are ready to run. If the opportunity is there, people will be very keen to move towards it and are already doing so often, as I said earlier, at the margins of legislative appropriateness. The training agenda is a big one. It is not only that people have to be trained, you also do not necessarily have the trainers in this country because we are moving towards a new model of care. I would put a five year agenda on that one. It does not mean this system cannot work in the meantime, but for it to work optimally one has to take a long-term vision.

  532. So you are saying that we need to train the trainers?
  (Dr Muijen) Yes.

  533. There is evidence there is a gap in this area?
  (Dr Muijen) I would say we need to train everyone in the system. This is beyond what we are discussing at the moment but that is one of the major issues in the whole of community care. We have shifted the system to community care without providing appropriate training.
  (Dr McCulloch) You have to think in terms of the lifespan of the workforce. The mental health system which was there when the people who are working now were trained could have been 20 or 30 years ago. When you couple that with the fact that education agendas and educational bodies, good though they may be, are often quite slow in terms of keeping up with the pace of policy change and community development, you have a big time lag and a big gap between the training which people have had and the services and the communities which they are now expected to work in and the clients they are expected to work with. So we really advocate a strategic approach to training, asking questions like, what are the competences needed in the community now, how do you develop those, and that is why it will take time to put that in place.

  534. I am envisaging there would be many different levels of this training. What would the new recruits come in as? Would they be degree-holders?
  (Dr Muijen) It will be varied. It depends which profession one is talking about. One has to take a broad view here and one has to include psychiatrists, nurses, social workers, but also community support workers who are traditionally considered as untrained although they often have qualifications in different areas, such as teaching or anything else. Each of those has to be reviewed. If we talk about psychiatrists, the skill involved in working in community services within this kind of joint system responsible for commissioning services is very different from the traditional hospital work. If we talk about social workers with their two year training, they are only fit for work rather than fit to work, and require intensive on-the-job training. Basic nurse training at the moment in Project 2000 does not offer nurses the kind of comprehensive skills required. As was mentioned by Mind, we do not any more have the narrow, depot injection view of psychiatry, the very broad view, the very broad range of interventions required, it is just not there at the point of qualification. So we are talking about a combined review of pre-qualification training, which indeed ENB is considering, but also far broader availability of post-qualification training, both at multidisciplinary level and uni-disciplinary level for specific skills.

Chairman

  535. Can I pick up from your knowledge, because I suspect you have good knowledge of other European countries, your views on the appropriateness of the existing professional roles within the United Kingdom because I am conscious, having been to the Netherlands and other countries, that there are different approaches in relation to health care and social care, in some instances combining the two roles in one single role. You were here when I raised this question with our previous witnesses about the division between the role of the social worker and the CPN. Do you have any views on whether the existing roles are broadly appropriate or whether from your European experience there are possible arguments to be made for developing very different professional roles from those we have at the present time within the area of mental health?
  (Dr Muijen) It always astonishes me how similar many of the problems are around the world and how the split between social service and health has far more to do with statutory differences which really comes down all the way to ground level, to the role of the nurse and social worker. The one difference which is always very noticeable is the difference in the level and intensity of training between the UK and most other European countries. It is quite common for community nurses in Holland to receive training of six years. If we think about the US, social workers in the field tend to have master's degrees which require at least four years training and the same with nurses. The roles are often equally muddled or equally split but the level of training, the level of skill, is greater.

Julia Drown

  536. You described how pooled budgets would provide opportunities for the more efficient deployment of total health and social care resources. I wonder if you have an idea about the scale of inefficiency that is present there at the moment which, if budgets were pooled would be released to be spent on other services?
  (Dr Muijen) It is very hard to give it in percentage terms but let me give you a few examples which are related to duplication and overlap as well as gaps. We know of areas where there are four different services - health, social service, voluntary sector and housing—each having a team addressing the same target group and very poorly communicating and normally offering the same service. We know from another study that people with severe mental illness can be cared for either by a health team or a social care team or both and you get a distribution that seems to be largely random, it seems to be dependent on who you call first. We also know from users' experiences that they sometimes do not have any of the services available locally. We have two or three services which are fully co-ordinated. Bed occupancy shows quite consistently about 30 per cent of people on the wards should not be there but are stuck in the beds because of perverse incentives and are unable to move into residential care because of the shift of budget from health to social services, which is probably easiest to put a percentage on. It is undoubtedly true that better targeted better care could be provided by some kind of joint commissioning body if only so these silly bits of overlap of individual services could be got rid of.
  (Dr McCulloch) There are a couple of other points around that. We know from general management theory that deploying a single budget and mixing and matching within that is more efficient than having separate budgets simply because as soon as you start to separate budgets and prevent the exchange of monies across then you create perverse incentives, you create little empires. We can see that at work. I visited Sweden recently and they have been addressing this issue of the health/social care interface. They have actually placed a system of penalties on social care and charged social care when they cannot discharge someone from hospital in order to address that. I do not think that is feasible in the UK because I do not think we have the sort of resource levels that they have in Sweden. It shows you really that this is a general problem that we see wherever that financial boundary is created.

  537. But might creating a pooled budget then create the other financial boundary, that health and social services then try and limit what they are putting into the pool because they hope the other will pick it up? How do we avoid that?
  (Dr Muijen) I think that is something that can be regulated and controlled by regional offices and regional SSI. That is not our experience. The problem is the insufficient resource level to start with. Again recently when I visited the service, social services were very happy to put their resources towards a joint budget but the level of funding put towards residential care was so minimal that even a combined budget would still not be resourced heavily.

Chairman

  538. Do any of my colleagues have further questions to put to the witnesses? Do any of the witnesses have any points that they wish to add or any areas that we have not asked you about that you would wish to mention?
  (Dr Muijen) No.

  Chairman: Can I thank you once again for your co-operation. Both your written evidence and your oral evidence we are grateful for. Thank you very much.


 
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