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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