Examination of Witnesses (Questions 1
- 19)
THURSDAY 23 MARCH 2000
DR SHEILA
ADAM, MS
DENISE PLATT,
MR JOHN
MAHONEY, DR
BOB JEZZARD,
MR JULIAN
OLIVER, MR
SAVAS HADJIPAVLOU
AND DR
GILLIAN FAIRFIELD
Chairman
1. Good morning. Can I welcome you to the Committee's
first session on mental health and I particularly welcome our
witnesses this morning. We appreciate your very helpful written
evidence and your willingness to come before us today. Could I
begin by asking each of you to briefly introduce yourselves to
the Committee, starting with you, Dr Jezzard?
(Dr Jezzard) I am Dr Bob Jezzard. I work in the Health
Services Directorate, the NHS Executive, with responsibilities
for child mental health policy.
(Mr Oliver) I am Julian Oliver. I head the section
in the Mental Health Legislation Branch in the NHS Executive,
which is taking forward the reform of the Mental Health Act.
(Mr Mahoney) John Mahoney, seconded from the NHS and
joint head of the Mental Health Branch and also support to the
National Oversight Group for High Secure Hospitals.
(Dr Adam) I am Sheila Adam, Health Services Director
in the NHS Executive, with overall responsibility for mental health
services.
(Ms Platt) I am Denise Platt, Chief Inspector of the
Social Services Inspectorate.
(Mr Hadjipavlou) I am Savas Hadjipavlou. I am Branch
Head in the Prison Health Policy Unit.
(Dr Fairfield) I am Gillian Fairfield. I am Deputy
Head of the Prison Healthcare Task Force.
2. Who is in charge of the overall planning?
You have all described where you slot in and I start off totally
baffled as to who drives policy forward in a coherent way. Let
me explain why I ask this question. I am either fortunate or unfortunate
in having quite a mixed bag of mental health provision in my own
constituency, in my own local area, two prisons, a women's prison
and Wakefield top security men's prison, a regional secure unit
in the Wakefield area and a psychiatric unit. What concerns me,
looking at the way people are contained in each of these units,
is that whenever I visit them I find people who should not be
there. They should be somewhere else. When I visit the special
hospitals, I find people in there who really ought to be somewhere
else. Wherever I go in the mental health system, I meet people
who should not be where they are. Who is responsible for that
position?
(Dr Adam) The NHS Executive has the overall
lead on mental health policy in the Department of Health, obviously
working very closely with colleagues in the social care group,
represented today by Denise. We have recently, following the report
on prison healthcare services, integrated into the NHS Executive
the Prison Health Policy Unit and the Prison Healthcare Task Force,
two bodies derived from the Directorate of Healthcare which was
previously in the Prison Service. This reflects a very important
shift of responsibility in central government, to say that the
Department of Health now has the lead on policy for prison healthcare.
Through the Task Force, we will be working closely at a local
level with partnerships between the NHS and Prison Services to
make change happen on the ground. What you have here are people
reflecting different elements of the work within the Department
of Health. For working age adults, I think the way forward is
now set out in the national service framework. Bob can talk in
more detail about the plans for child and adolescent mental health
services. For older people we will be publishing a national service
framework towards the end of the year. That will encompass both
mental health and physical health needs of older people.
3. While I accept your evidence that there is
a great deal of change that is about to occur, why are we in a
situation where our key mental health services appear to be occupied
frequently by people quite wrongly and often quite expensively?
I see people in special hospitals who do not need to be there,
who need to be in regional units, and people in regional units
who need to be in low secure units; people who cannot get places
in acute psychiatric hospitals in my area, who have to go to the
private sector, paid for by the NHS, because there are insufficient
beds. Why have we got ourselves into this situation? What are
the reasons for the current provision apparently being such a
mess?
(Dr Adam) We would acknowledge that there is an imbalance
of services and the National Beds Inquiry which reported earlier
this year included a chapter on mental health and made precisely
that point. In inner cities particularly, we have pressures on
acute hospital beds. Generally, we have difficulty in finding
places in medium secure services. We also have a significant shortfall
in supported accommodation in the community and specifically in
24 hour staffed care. We know that we have not got the right services
in the right places and that, by implication, means that people
are not able to access the services which they need. Through the
government programme, we have really now got a threefold approach
to this. Additional money through the Comprehensive Spending Review—we
are just coming towards the end of the first year of significant
new investment in mental health services—the national service
framework, setting out the style of services to be developed with
clear national standards, balancing short term deliverables against
long term sustainable change and the reform of the legislative
framework to reflect modern mental health services. The other
needs which we are now beginning to address, but it is early days,
are the needs of people in prisons, where we have known for a
long time it has not always been possible to get people who need
treatment under the Mental Health Act into a hospital bed and
they remain in prison for longer than is desirable. We acknowledge
there is a problem. I think we are beginning to put in place the
mechanisms that are needed to change that and we can demonstrate
some early progress on that. For example, we have already seen
a significant increase this year in medium secure places which
will begin to help; also a significant increase in low secure
places, because we know that some of the pressure on medium security
is because we have not got a lower level of security available.
We are beginning to make progress. The signs are in the right
direction but there is a long way to go. We see this as a ten
year programme.
4. Would you reflect why you feel we have the
current difficulties? I accept that over the last 20 years we
have seen some very radical changes in the direction of care in
the community. Obviously, this Committee is looking forward, looking
at future policy, but sometimes it is useful to learn lessons
from past policy mistakes. In accepting, as you have done, the
current problems I have described—I think it is a fair description
of what I see and what other people see—where do you feel
we went wrong in the process of developing services during the
radical change in the last 20 years or more, resulting in the
problems that we have at the present time? What lessons can we
learn from where policy went wrong over the last couple of decades
and more?
(Dr Adam) If there was one thing that I would point
to, it would be our difficulty in understanding the complexity
of the needs of people with severe mental illness, needs not just
for health and social care but for education, employment, housing
and income, the range of support to allow them to be full citizens
and members of our communities. We probably saw too many parallels
with the situation for people with learning disabilities, where
resettlement from the long-stay hospitals proved on the whole
to be a rather more straightforward process. We were better at
understanding and meeting their needs, although not universally
so, but we really did not understand, as we now do, the needs
of those people with severe and enduring mental illness, the episodic
nature of their needs, the fact that they do not get ill at convenient
times and that we have not always been able to put in place the
services which they need.
(Mr Mahoney) The old psychiatric hospitals, however
bad they were, at least provided a home and occupation and friendship
as well as mental health support. In reproviding that, some of
the key things were missed around the housing, occupation and
social integration. Many people with mental illness are very lonely.
That is the nature of the drive now. As regards the high secure
hospitals, one of the key reasons that so many people are stuck
there is it has been a free good. Nobody has had to pay for it
in that sense. That is changing now. Perhaps we will come to that
later. There is much more incentive in the system now to move
people on, as well as developing local secure beds. Hopefully,
we will start to address that mismatch of the various types of
beds. It seems to be low secure where there is the big gap.
5. On the question of the Department of Health
now being the lead agency in respect of mental health, I took
close notice of a debate last Thursday, led by my colleague, Mike
Wood, who is the Member for Batley and Spen, who had a particular
problem with somebody who had mental illness and who died. I will
not go into the detail, but it came down ultimately to the relationship
between the Benefits Agency and local social services. I wonder
how your lead role in this can ensure a much more sympathetic
view of mental health problems from other agencies. I have mentioned
the Benefits Agency. I could also mention the perception of the
police on occasions. I do not want to generalise at all but certainly
I have witnessed somewhat insensitive handling by the police of
mental health issues over the years. How can you influence the
specific policies of other government departments in the role
that you now have as the lead government department?
(Mr Mahoney) The big prize for so many people with
mental illness is employment and getting people off benefits.
Huge numbers of people with mental illness do not work. One of
the priorities might be to look at working jointly with the Benefits
Agency and social security to look at ways of creating incentives
for people to work, because most people with mental illness actually
want to work. With regard to the police, I think there are a lot
of examples now of court diversion schemes and crisis teams that
can go into police cells. The key people in all of this really
are the sergeants. If you can influence the sergeants, they will
influence the others. By more exposure with mental health professionals,
particularly in local police stations, that is showing some great
dividends. Educating the police—clearly the police, like
most members of the general public, have misconceived views about
people with mental illness. Over time, by working closer together
and educating people about the nature of mental illness, and by
providing timely support to the police, it will lead to increased
knowledge and better relationships between health services and
the police.
Dr Brand
6. A practicality: housing benefit verification.
I wrote to the Minister of Health on this and it was referred
out of his power because he did not feel it was his particular
pigeon. I am very concerned that, where someone with mental illness
is placed through a CPN or a psychiatric social worker in supportive
accommodation, the landlord will not be paid until the housing
benefit officer has had the chance to verify that that person
is actually there. It is extremely difficult sometimes to get
hold of people with mental illness. They do not open the door
to people they do not know; they may be out all day. We are somehow
not flexible enough to make sure that the people who are willing
to support the mentally vulnerable in the community do their job.
It strikes me as quite ridiculous that the Minister felt that
was not a problem he should be addressing. Do you have discussions?
Obviously, you talk to social security officers but housing is
a very important aspect of care in the community. We quite often
fail there.
(Mr Mahoney) We will be working with the DETR on issues
such as this and housing generally but obviously housing is a
key feature of care.
Dr Brand: It is very disappointing that the
systems that have been set up do not recognise that not all the
clients that we are setting out to help are in a frame of mind
to cooperate with what seems a sensible verification system but
actually works against their interests.
Mrs Gordon
7. To take up the holistic approach to someone
with mental illness, you mentioned the episodic nature of someone
with mental illness. I find that people can be in and out of work.
They can be okay for a while and then they cannot cope. What I
find in my own case work is that there is no joined-up thinking
between the employment service and the Benefits Agency. It is
beginning to develop but for so long a person who is perhaps ready
for work but obviously is still vulnerable and is fit for some
kind of work or whatever, then falls through this hole of the
bureaucracy. The Benefits Agency is giving them loads of forms,
the employment service, and really that is the kind of stress
that they do not need. I wondered if you had any ideas about how
to simplify that person's care within that system.
(Ms Platt) The first point relates to what Dr Brand
has said. It is very sad that you have to raise nationally an
issue which should be resolvable within local government.
Dr Brand
8. With respect, Ms Platt, the regulations do
not allow it to be resolved.
(Ms Platt) If I could just finish, what we are working
towards between health and local authorities is joint planning
around mental health services and around these very particular
issues. I do know what the regulations say but there can be a
more human approach adopted locally to some of these circumstances,
with the housing benefits officer and a social worker who knows
the person operating together. We would encourage very local solutions
where there are people with particular difficulties, because you
have to respond to people on the basis of individual needs and
their requirements. We are in discussion with the Welfare to Work
One Organisation and contributing to their consideration of how
welfare to work might be developed. They are very, very conscious
of some of the difficulties of people who do need support into
work in a very particular way and where their ability to work
in the first instance may be very episodic and you may have to
support people for an extended period before they can become settled
in work. What we are hoping to do over the next year, health and
social care together, is to look at how we can improve our contribution
from health and social care to welfare to work, to give people
who have particular issues that we know about extra special support
into that process. I do not think we have the answers but we have
some strategies at local level for where we might find our way
through.
Mrs Gordon
9. The duty of partnership now between the NHS
and local authorities requires NHS trusts and health authorities
to work closely with local partners. To me, this is a great step
forward, a complete change of culture, where everybody was in
their own group. I welcome it. How do you intend to monitor how
all these new requirements will work in practice? How will it
work on the ground and how will you check that it is working?
Have you any plans to monitor it from the users' perspective as
well? How do you have this overview of what is happening?
(Dr Adam) Obviously, the health improvement programme
is the local mechanism for bringing the Health Service and its
partner agencies together. Mental health will be one of the priorities
to be covered within the health improvement programme. Joint investment
plans will then also map the resources that are going to be deployed
and for the first time will give us a better view of exactly what
is being spent on mental health by whom. We are also going to
be doing a more extensive joint mapping exercise over the next
few months, to look specifically at mental health services across
the country, to give us some baseline data as people begin to
implement the national service framework. Finally, we are setting
some short term deliverables. One of the problems with ambitious
plans and programmes is they tend to have very long term goals.
The national service framework does have long term goals but it
also has some short term deliverables. We are already beginning
to be able to monitor progress, for example, on 24 hour staffed
places, on secure provision, and we are beginning to look at prescribing—rather
tentative data at the moment, but we have some short term measures
that we will be able to look at. From the user and carer perspective,
as you know, we are going to be doing a national survey of users
and carers covering mental health services. We have done the first
of the surveys which looked at general practice experience and
there are another couple in the pipeline, but we will be following
those on mental health which again will give us some good baseline
data for those who are implementing the national service framework.
At the same time, we will be encouraging people locally to systematically
work with users and carers to look at how services are perceived
by them, how they are involved in the development and planning
of services and how we can get things better.
(Ms Platt) We will also, through the SSI social care
regions, be working with the NHS regional offices to monitor how
local authorities are putting the new plans into place. We have
during the last year introduced a new performance assessment framework
for social services departments and are introducing a new appraisal
review with social services as to how they are implementing the
national priorities guidance, of which mental health is a very
key issue. You may be interested to know that when we talked with
all social services departments before Christmas over 90 per cent
of them had already mapped their services for mental health service
users and had identified the gaps in local services and were trying
to look at how they might address the priorities for new service
development. We were concerned that only a quarter of authorities
that we talked to had actually made progress in integrating the
new care programme approach proposals in the national service
framework, but we had confidence that they would be addressing
that through the remainder of the year and that all authorities
were actively talking with health services about 24 hour care
and assertive outreach. A quarter already had it in place. There
are signs of real movement here in the direction in which we would
want our policy to go. We are also planning an inspection of social
services mental health services and we will obviously involve
health colleagues in that—to see how services are being
put in place and whether they are safe and sound. We always use
lay people in our inspections and we always start from talking
to the users of the service.
10. In your view, do they have the resources
to do this properly? In the past, I always felt that one of the
problems with care in the community was that it was a good idea
but have they got the resources? Will they actually have the money
to do all this?
(Ms Platt) Others can talk about the detail of the
resources that have been set aside for mental health services
but from our inspection and joint review activity we do not find
a lot of correlation often between the level of resources and
the quality of services. That is not to say that resources are
not an issue in some places, but some people with quite a low
level of resource that you might think were struggling are energised
and providing a really good service. Some places with a lot of
money are not making the best effect in the use of those resources.
Part of what we would be hoping to do jointly, social care and
the NHS working together, is to get the most effective use of
those resources across the country.
Mr Austin
11. On the subject of partnership and joined-up
thinking and the importance of employment, the government has
made a number of new announcements about the future of the careers
service, new connections and the youth service. What input has
there been from a mental health perspective from the Department
of Health into those plans and considerations?
(Dr Jezzard) There has been input from the Department
of Health in the development of the connexions strategy. One of
the issues that is quite challenging for us is the age range.
I think the connexions services, when they are off the ground,
are going to be looking at 13-19 year olds. At the moment, that
will involve child and adolescent mental health services playing
their part as well as adult mental health services for some of
the older young people. There is a difficulty for child and adolescent
mental health services at the moment .Ten years ago they had very
little profile at all terms of policy and development. Now of
course they have a very high profile and the expectations are
very high. We are terribly pleased with the developments but we
have to be cautious about our capacity to respond in the way people
hope. They are exciting developments and I am sure many child
and adolescent mental health services will want to play their
part in working with after these initiatives, particularly for
young people in that age group who at the moment probably do not
get a good deal.
12. I am reassured that there have been some
sort of discussions at policy level. What is being done or will
be done to ensure that things work at a local level and that there
is that input and cooperation?
(Dr Jezzard) Just yesterday we were looking at an
audit tool which the connexions service will be developing in
order to map out services locally. We have had some input into
thinking about how they can ask the right sort of questions about
mental health service input. One of the other positive things
that we hope will come out of this is that the work with young
people may well offer help and support at an earlier point so
that they then are less likely to develop severe problems later;
and also will in some ways actually support the specialist services
in providing a range of support, advice and counselling to young
people. We hope that connexions will work well together with mental
health services and be an addition to the whole spectrum of care
and not something separate.
Dr Brand
13. It has been suggested , and I do not necessarily
agree with this, that organisational upheaval such as trust mergers
is very disruptive and that it might be helpful to set a cut-off
point of April 2001, to put in place what seems to be the best
possible configuration before that time and then declare a three
year moratorium on organisational change. Do you have any views
on that suggestion?
(Dr Adam) Our view on that would be that the important
thing is that services are not destabilised for those who use
them and that the clinicians and practitioners who are providing
services are able to get on and do that while organisational change
may happen around them. We thought very carefully about this when
we were working on and discussing with people the national service
framework because clearly configurations are a significant issue.
We had quite good evidence that, where mental health services
were combined with acute services in a single trust, they did
tend to be overlooked. They were very much the minor player; and
similarly evidence that, where mental health services were focused
in larger either single mental health trusts or mental health
and community trusts, there seemed to be a better focus on what
people needed from services and how to support staff in delivering
those services. That is why we recommended that people should
consider single mental health trusts, particularly in the inner
cities and in the larger conurbations. To respond to your "could
we stop there" point, we do need to take account of the development
of primary care trusts. Again, there is evidence that where mental
health and primary care are working closely together there is
very considerable benefit from that. The approach that we have
taken—and we are going to be developing this in further
guidance—is to say that primary care trusts need to demonstrate
their capacity and capability to take on responsibility for mental
health services and in a sense the burden of proof is with them.
We will be giving more detail on how we think that should happen
and the criteria that we will be using, but we will clearly be
looking at their capacity as providers, as commissioners and as
promoters of public health. We will not be happy for them to take
on responsibility for mental health services until they have reached
those thresholds. I would see this as being an evolving process
over the coming years. Because of, firstly, wanting to bring mental
health services together into a critical mass and, secondly, not
wanting to lose the potential of closer alignment with primary
care, we would favour a gradual, evolutionary process rather than
let's try to get everybody over the line by one point and then
stop.
14. That is a very helpful answer. Are you doing
anything at the moment to make sure that PCGs and PCTs develop
the expertise for commissioning mental health care?
(Dr Adam) We are obviously working through regional
offices closely with PCGs as they develop and as they put in their
proposals to become primary care trusts. One of the things that
we have done with the mental health branch is work closely with
Barbara Kennedy, the NHS chief executive in north-west Anglia,
who has been responsible for some of the earliest first wave primary
care trusts that will come into being on 1 April. She has been
working closely with us about the implications for mental health
services and how we can take people up the learning curve, explore
what the potential pitfalls might be and make sure that we do
it in a way which is safe and takes service development forward.
Mrs Gordon
15. This does worry me. With great respect to
Dr Brand, GPs do not have this expertise. They are not specialists
in mental health. It does worry me that we are potentially giving
the PCTs responsibility for commissioning this service. You talk
about waiting until they are ready but is this going to be another
gap in time? Is this going to be another change? You say that
you do not want patients to be affected, but I do not see how
you can have this massive change in responsibility without upheaval.
(Dr Adam) One of the important things to remember
is that most people with mental health problems are seen and looked
after by their general practitioner. They do not go anywhere near
specialist mental health services. In fact, we are already depending
on primary care to provide the vast majority of mental health
services within the NHS. There are some good experiences in some
of the GP commissioning pilots and the total purchasing pilots,
where we did move more mental health into primary care. We began
to get much better working relationships between the GPs and their
colleagues in the practice and specialist services, better protocols
developing for referral and people beginning to look at the envelope
of resources that they had and how they could use those for the
total patient group rather than a bit of the pass the parcel that
can happen when people are just referring backwards and forwards.
One of the other points that I am keen to explore is the sense
that specialist mental health services are there to support primary
care. They may not take over clinical responsibility for a patient
or a service user, but they can provide advice; they can offer
an assessment. They can work with the primary care team and again
we did see this happening in some of the pilot projects. They
are the sorts of ideas that we would be looking to PCTs to think
through locally and demonstrate how they would put that into practice
and how there would be benefit for services users.
16. Have you done a report on those pilots?
(Dr Adam) We certainly have some information which
we could let the Committee have.
Chairman: You said earlier that there is no
great push to be at a certain point at a particular time. Having
said that, I look at my own area where I talk to many people who
seem to feel that, as somebody who is in this place, I ought to
have an idea of where we will be in five years' time. It is very
difficult, looking at my area where, in my constituency, I have
a separate community trust dealing with mental health. We are
moving towards three primary care trusts and there is a big argument
about a west Yorkshire-wide mental health purchaser. People are
uncertain as to where we are going. While I accept that you should
not be just setting a plan for people to work to and there is
merit in exploring pilots as you have been quite clearly, there
is also a balance to be had in that people want to know the direction
we are going in. I certainly am unclear as to the direction in
my own area at the moment. How would you respond to the uncertainty
that does raise questions of the kind that Eileen has raised?
I would reinforce her point about the position of GPs. With no
disrespect to Peter, I know many GPs who I would not want sectioning
me.
Dr Brand: We normally defer to the social workers.
Chairman: That is the worry.
Dr Brand: Statutorily, we have to.
Chairman
17. I found that, as an authorised social worker,
the very limited knowledge of many GPs was extremely worrying
when they are in a position to remove somebody for 28 days, or
whatever it is. They certainly have power to take people away.
It is a worry, the expertise. My experience is somewhat limited,
I accept, and somewhat dated now but there is a worry, as Eileen
has pointed to, that if you are moving towards the emphasis being
on primary care, have we the expertise and depth of knowledge
that we need to drive forward some pretty difficult areas of provision?
(Mr Mahoney) A study by Goldberg and Huxley—it
is a bit old now—showed that for every 1,000 people who
go to their GP 250 will have a mental health problem. GPs usually
miss half of those. Of those 250, only 26 are referred to mental
health services and, of those, only about six end up in hospital.
The massive morbidity is in primary care in that sense. If you
look at the pressures on the secondary care system, that is very
much the tip of the iceberg of mental health. There have to be
ways where secondary care and primary care mental health services
have to work better together. First of all, I do not think primary
care trusts will rush to take on mental health. Over the years,
different models will be developed. The key to the model that
is developed is that, if there is a primary care trust that takes
on mental health, it must take on all of the local provision.
It cannot cherry pick nurses or psychologists. It must take on
in-patient care as well as community care and keep it as an integrated
whole within the primary care trust. Our own primary care unit
in the department is working on this now.
18. If we are talking of primary care trusts
covering populations of, what, 100,000—more perhaps—if
we use the critical mass term, is that enough population to offer?
Therefore, where does it leave them?
(Mr Mahoney) For those primary care trusts with small
populations, I would be surprised if they took on mental health.
I think mental health would be provided by another provider, another
trust, in the local area. This is what is happening mainly in
the cities. Trusts are being created which are much larger and
can provide a whole range of services. Small PCGs I do not think
will be taking on mental health, although they need to work very
closely with local trusts and the trusts need to reorganise their
services around PCGs. There are a lot of examples of that now.
Mr Austin
19. That gives the impression that people are
thinking on their feet, but it is not particularly well planned
with much foresight.
(Dr Adam) We set the principles out in the national
service framework that over time we saw some mental health services
being provided by primary care trusts but not necessarily all.
In some cases, it might be one primary care trust on behalf of
others. We sketched out what we thought some of the criteria would
be that a primary care trust would have to demonstrate before
they could be considered ready to take on responsibility for the
provision of mental health services. Also, as John said, we were
clear that it had to be the totality of local mental health services.
As primary care trusts become real, we now have some people to
work with and to have discussions with. I think we are just honestly
reflecting to you where we have got to on this. We have set some
ground rules out. Clearly we now need to develop the detail of
that with the people who might potentially be interested in taking
on these responsibilities. It now becomes a more realistic discussion.
We should sound all sorts of caveats around this. We have worked
hard but, much more importantly, people out in the field have
worked hard to build good mental health services and to focus
those services on the people who most need them. We are not about
to dismantle that by any means. We are proceeding cautiously on
this one. We will be setting very clear criteria and we will want
to be assured that there will be benefit to patients out of this.
We certainly will not want to take any risks on it.
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