Examination of Witnesses (Questions 20
- 39)
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
20. It strikes me that while we have moved away
from command and control we seem to have swung radically in the
other direction. There is a degree of uncertainty, to put it mildly,
as to what will be available and what models will be used. Maybe
I look at it from the point of view of somebody who has worked
within some of those models. If I were a professional, I would
be saying, "Where will I be in five years? Who will I be
working for?" If I were a user, I would be completely baffled
as to who will be responsible for the services that I would be
receiving in years to come. That is the concern that I have.
(Dr Adam) I take the point that change is always worrying
for people. Most of us do not like change and would prefer things
to stay as they are.
21. Usually, when there is change, we know where
we are changing to. I am not criticising you because you are implementing
government policy or lack of government policy, as the case may
be, but the change that we are moving towards seems to be so uncertain
and fragmented as to not give me any clear picture of what kind
of provision I can expect to see in my own back yard or wherever.
(Dr Adam) What we are trying to do is describe the
service more in terms of what people can expect from it, rather
than set out organisational blueprints, which is what we have
traditionally done here. We have said so many beds and so many
members of different types of staff groups. Through the standards
in the national service framework, we are beginning to say that
these are the seven standards that we expect to see applying across
the country. Not everybody is going to achieve all of those standards
very quickly, but these are where we want people to be. For example,
if I go to my GP, I can expect to be properly assessed; I can
expect to have access to effective services for whatever my problem
is; I can expect to be able to make contact with people out of
hours; I can expect to be able to phone NHS Direct and, if I have
a slightly more complicated problem, to be put through to a specialist
mental health helpline. I hope what we are trying to do for people
who use mental health services is to be clear about how those
services will be for them, what their experience of the service
will be, but to be realistically flexible about how, given all
the very different geographical and demographic situations around
the country, services are going to best be able to meet those
standards. To safeguard the fact that standards can be a bit vague,
we are putting in a performance assessment framework across social
services and the NHS. We will be monitoring people tightly. We
have a national implementation group which is overseeing this
process. We have regional offices, both social care regions and
NHS Executive regions, closely tied into the process. This combination
of things—clear standards, development of service models
but not blueprints and clear performance monitoring and management—should
begin to set out for people what they can expect of services and
ensure that they do begin to get that.
22. Can I be specific? In your framework, standard
five includes as an objective that each service user who is assessed
as requiring a period of care away from their home should have—and
it mentions in the provision "as close to home as possible".
That is the framework. While accepting the point that you are
making about not having a national blueprint, to me, for that
to mean anything, I need to be looking at how the service is organised
in terms of the model of provision at local level, because, if
you have a PCT organised on the basis of 100,000 that limits the
ability to provide for certain people as close to home as possible.
Yet, if you have, in my case, a west Yorkshire-wide mental health
purchaser, that could enable you to provide services of a specialised
nature within that particular area. The models that you offer
organisationally would surely relate to your objectives and how
you deliver those objectives. That is why I am unclear about how
this framework fits into the rather confused picture I am gaining
as to where we will be in a few years' time on who actually provides
what in mental health.
(Mr Mahoney) In a few years' time the vast majority
of mental health provision will be provided by trusts and there
will be a variety of trusts, including the existing trusts. There
is quite a mixture of community and mental health trusts, stand-alone
mental health trusts and in some places— if you take Manchester—there
are four trusts providing mental health services in that city,
including an acute trust. Manchester's view is that is not the
best model for providing mental health care. There will be development
over time of primary care groups into primary care trusts. There
may be mergers of primary care trusts or one primary care trust
will take responsibility for developing and managing mental health
services. I think that is going to take time. Allow the PCGs to
develop for the wide range of services that they need the scale
of change is such that I do not think they will be ready in the
short term. Some areas will. Hereford is very different from Lambeth.
For now, particularly for the cities, it seems that there are
attempts to try and make sense of mental health services and create
mental health trusts and reconfigure them. I think it is far more
balanced and organised than it sounds.
Chairman: I hope it is.
Dr Brand: Chairman, I think your question rather
betrays your political roots. The fact that there may be some
national uncertainty over structure does not mean that you cannot
have certainty locally as to what direction we are moving in.
Chairman: This is a liberal talking to a socialist.
Dr Brand
23. Small is beautiful. In the smaller units
that the Chairman asked about, do you think there are greater
opportunities for integrating the social care and social services
element of the mental health provision through lead agencies and
that sort of thing?
(Ms Platt) Yes. We are seeing a lot of integrated
services being proposed using the new partnership flexibilities
which come into formal arrangements on 1 April. We found, before
Christmas, when we went to look at how services were being established,
that over 200 new community mental health teams were in the process
of being established, which do involve a variety of professionals,
including social services. That is a very encouraging way forward.
We have seen an experiment in Somerset of a joint health and social
care trust which we are evaluating very carefully.
24. Much comment has been made about the expertise
of GPs. Primary care teams are not equivalent to GPs. GPs are
generalists. Some of them may have more experience in mental health
but primary care teams certainly should have people with expertise
in mental health. I hope that that will moderate some of the current
barriers we have within mental health services themselves. Have
you done any work on how effective the interaction is between,
say, psychiatrists, psychologists and psychoanalysts, because
from my own experience and stories from round the country it is
very easy to talk to any one of those groups, but you never get
the three of them to talk together.
(Dr Adam) There is quite a lot of literature on some
of the interprofessional issues within mental health services
but I do not pretend to be an expert on it.
25. Who is going to break down some of those
barriers? Is it going to be left to the commissioning team or
are we going to see some national initiative on that?
(Dr Adam) My sense is that the barriers are breaking
down. Denise has just given the example of greater integration
across health and social care professional staff, which is another
of the traditional barriers.
26. That is working well. It is the interprofessional
bits in the health side that are difficult.
(Dr Adam) On the health side, the piece that will
really drive that will be the evidence base and the sense that,
if you actually get teams working around individual people and
their needs and the best way to meet those needs you really do
shift the focus of the interactions and the discussion. My sense
is that, yes, I am sure you could go to places and still find
some of the debates that you are talking about but, as people
become increasingly focused on what are these services for, on
who are we serving, how well are we doing, I do think you will
pull people back from some of that and move the world on a bit.
I think there are encouraging signs of all sorts of boundaries
beginning to look much less like walls and becoming permeable
in some places.
Dr Brand: I like your sense of optimism.
Mrs Gordon
27. Small may be beautiful and I am sure there
are some fantastic examples of work locally but we are talking
about national standards and that is what worries me. Someone
with a mental health problem in the north of England, in Cornwall
or wherever actually gets the same standard of treatment, whoever
provides it. I am just concerned that national standards are obviously
crucial. How will you monitor them? Are you going to have regular
reports? How is that going to work?
(Mr Mahoney) We have established a mental health implementation
group nationally which involves social care regions and the health
regions. There are two aspects to the work of that group. One
is to monitor what is going on at local level with every health
and social community and identify problems early. We have established
a mental health implementation team that, where there are problems,
will help develop services around the common standards. You are
absolutely right. People should have good access wherever they
live. There is quite a drive, a major investment of our time in
terms of implementing the national service framework right down
to the local health and social care community level.
(Dr Adam) One of the things we have tried to do is
to set some quite specific short term measures so we will know
whether people are on course or not. For example, have people
integrated CPA and care management? Have service users an integrated
care plan that they have a copy of that names their key worker,
says how they contact services, including out of hours? We are
setting some measures that will be quite easy to assess whether
people are delivering or not, because these are national standards,
as you say, and at the moment we know that we do not provide the
same quality of service across the country. It is not necessarily
dependent on resources or the level of local needs. There are
all sorts of issues bundled up in that. A combination of some
specific measurables that will show up early in that process,
together with a much more systematic approach to bench marking
than we have previously had, is going to give us the performance
data that local people will be able to work with and say, "Why
are we not doing so well on this? What do we need to do? How can
we learn from other people to begin to do it better?"
(Ms Platt) What we are hearing now is the implementation
and development phase. What will also happen is that, when the
Commission for Health Improvement has found its feet together
with the social services inspectorate, we will inspect that the
standards are actually being met.
Mr Austin
28. Sorry to lower the tone of the discussion
but I want to talk about money. You have referred to the 700 million
additional funding over three years announced in the Comprehensive
Spending Review. There has been some criticism that these global
figures are announced but sometimes the purpose for which they
are going to be spent is announced and the government is accused
of under-funding. You have referred to the £148 million,
128 million for adult and 20 million for child services. Can you
confirm that that is within the 700 million that was announced
in the CSR?
(Mr Mahoney) Yes.
29. Of that additional 700 million, can you
confirm that it is additional to the spending that was otherwise
there? Would it be more appropriate to say that it is ring fenced
funding within the allocation of funding to the NHS?
(Dr Adam) It is additional money from the Comprehensive
Spending Review. It is covering the three years from April 1999.
30. But it is essentially ring fenced money
and can only be used on mental health services?
(Mr Mahoney) There is a mixture of ways the money
has been allocated. Some has been ring fenced. Some has gone in
what we call unified allocations to local health authorities.
The mental health grant has gone to local authorities and I think
you could regard that as being ring fenced. It is basically a
mixture, although at the same time we have issued the national
priorities guidance, which is very specific about what should
be delivered within that money. We are expecting health and social
care communities to use that money to develop services beyond
what they currently have.
31. The additional money which is going to be
for mental health services is, when allocated to the mental health
authorities, ring fenced?
(Mr Mahoney) One year's allocation was actually ring
fenced and the regional health authority allocated the money for
specific schemes but for 2000-2001 the money has gone out, along
with the global budget for every health authority in what are
called unified allocations.
32. Can we turn to the enormous variance in
levels of spending between health authorities on mental health
which cannot be explained by differences in need? Is there not
some argument to ensure that we do have adequate mental health
services for the allocation of funding for mental health services
to be ring fenced or for there to be a greater proportion of ring
fencing?
(Mr Mahoney) There are huge variations in the level
of spend in mental health. There is no clear relationship between
quality of services and spend mainly. There were eight Nye Bevan
Award winners this year. Two were for mental health. Both could
be regarded as low spenders on mental health. There are extensive
variations. A number of authorities spend far more than they would
get in their allocation, particularly if you look at inner London,
on mental health. It is one of the issues that the mental health
implementation group that I referred to earlier will be taking
up with every health and social care community. Where there is
poor quality, we will be looking at the funding made available
by the local health authority out of its overall budget and we
will be watching that very closely, but there is no plan, as far
as I know, to ring fence mental health money throughout the NHS.
33. Could I bring Denise Platt into that as
well? We would all recognise that mental health services generally
have been the Cinderella of health both in health care and social
services. At the moment we are in a climate of expanding finance
and growth. A few years ago, we were not in that sort of climate.
You were talking earlier about the nature of some mental illness
being episodic and the need for instant services. In my area local
authority, we had what, in my view, was a very good crisis intervention
centre. Once the squeeze came on and local government cuts in
finance, that was the area that was sacrificed. Is there not an
argument, in the local authority sector—I know it is very
unpopular; I talk as an ex-councillor—to have more clear
direction to ensure that we have adequate mental health services?
(Ms Platt) Yes. As has been said, the local authority
mental health grant is ring fenced to deliver particular purposes
in mental health services. This year it is 38 million. You might
say that you might want to hypothecate a bit more on local authority
funding. I suspect you would have an argument with your former
colleagues. But Local authority services are very dependent on
that specific ring fenced money. As you have said, local authorities
have not always seen mental health services as a priority for
local government and we have been actively trying to persuade
them differently. Most people with mental health problems are
living in the community most of the time. Many will be tenants
of the local authority. They will receive social services. Their
families might be in touch with social services, even if they
are not. We have been working very closely with the local authorities
to try and get them to see that mental health issues are centre
stage to their preoccupations. We can only determine how they
spend their specific grant but we can enjoin the local authorities
into the national priorities guidance and through the public service
agreements into improvements in mental health services and we
can try and ensure that the whole of the local authority plays
a different part. Certainly as part of the health improvement
programme we will be looking to the local authorities to see mental
health as much more of a priority than they have done in the past
and make a commitment.
34. Representing an inner city area—my
Chairman has a substantial prison—can I raise the issue
of the funding formula and whether you feel the funding formula
generally takes sufficient account of inner city needs or forensic
services? As someone who comes from south-east London, I find
it wholly unacceptable that when an emergency bed is required
we may have to go as far as Oxford or Northampton to find one.
Is there any crumb of comfort for those of us who represent the
inner city areas in the review of the funding formula?
(Mr Mahoney) There is going to be a review of the
funding formula but for the moment there is a freeze on further
changes to allow some stability which will last until 2001-2002.
The Advisory Committee on Resource Allocation, which includes
NHS managers, GPs and others, is reviewing the allocation for
mental health and it is still at its very early stage. It is happening
and there is recognition that urban, inner city areas have some
greater pressures around serious mental illness than others. That
should be reflected but it is very early at the moment. The work
is at least starting.
35. I take it you accept it is not acceptable
that a Thamesmead patient has to be referred to Northampton or
Oxford for emergency admission?
(Dr Adam) I suppose there is still a question about
whether that is simply a financial resource issue, but yes, the
point is taken. Concerns have been raised over the years about
whether the funding formula does properly reflect mental health
needs. Particularly in the 10 to 15 per cent of authorities which
have the highest level of need. The review has been set up specifically
to look at the fairness of the formula and it will include issues
such as mental health for inner cities and the inner city rurality
issues as well. It should report some time in the next year.
36. Can I raise staffing and the difficulty,
particularly in inner city areas, of recruiting adequate numbers,
for example, of community psychiatric nurses, of which I believe
there is a national shortage anyway? What steps are being taken
to address that both in terms of training and resources?
(Dr Adam) One of the proposals coming from the national
service framework was that we urgently set up a workforce action
team to look at precisely these issues. There was a strong view
in our external reference group who advised on the framework that,
even with financial resources beginning to play into mental health
services to a greater extent, we would still have a whole series
of workforce issues to deal with. The group has been established
and it will deliver an interim report at the end of this month
which will look at a range of issues. What sort of workforce will
we need in the future to deliver the sorts of mental health services
that we talk about in the NSF? How do we educate and train? How
do we recruit and retain these people? How do we support them?
I think there are real issues, particularly in the inner cities,
about the working conditions and working lives of people in mental
health services. We have asked them to look at all of that and
also issues around leadership of mental health services, recognising
that this is probably one of the most intractable problems that
local mental health services will have to address.
Chairman: I have a local grievance at the moment
because my health authority is disputing having to fund the costs
of somebody in Rampton, whose only connection with the area was
a short period of time in Wakefield Prison. It does not seem fair,
for those of us who have prisons, that our constituents currently
lose out on funding by virtue of the costs of people who have
no local connection, other than being in the prison.
Dr Brand
37. This is not just an issue of mental health;
this is an issue generally. The cost of health services to prisoners
is done on some capitation base. Our experience on the Isle of
Wight with three prisons is that that capitation does not cover
the actual cost to the NHS.
(Mr Hadjipavlou) We recognise it is a problem that
was identified in the working group report published last year.
The current rules are difficult, particularly for prisoners. We
are doing a piece of work looking at how resources should be met
to help prisoners, particularly in relation to ensuring that transfers
to secondary services are made, as well as recognising that, for
some areas which do not have a prison in them, they ought to in
some way contribute to the fact that some of their population
is in prison.
Chairman: We might get a refund in Wakefield
at some point.
Audrey Wise: Following on John Austin's question
about staffing and Dr Adam's reply about working conditions, it
is in my mind that when the Committee did its inquiry into NHS
staffing we came across a problem relating to people working in
the community, a problem of safety, and considerable resentment
about the lack of thought and equipment, particularly by way of
pagers or mobile phones for people working in the community. The
place we were at when this came up most fiercely was east London.
It is something which is not only related to mental health, but
it certainly does relate to that; it also can be midwives working
in a district, health visitors, and it did seem to the Committee
that, in these days, it is not asking too much for a nurse working
in difficult areas in particular to expect to be provided with
a mobile phone and a means of contacting colleagues or headquarters
or somebody, or the police, in case of trouble. Do you have any
views? Is that one of the sorts of things that you had in mind,
Dr Adam, when you mentioned working conditions? That was a matter
of money. At least, it was put to us as a matter of money. It
was on monetary grounds that the provision was being refused.
I thought and the staff thought that it reflected attitudes as
well as financial stringency. It was a question of how much importance
was being attached to the safety of the nurses concerned or midwives
or health visitors. We made a recommendation about this in our
report. I cannot remember whether the government replied to it
specifically or what the government said about it.
Chairman: We received quite a positive response
saying they recognised the concerns that have been expressed to
us and were looking very positively at how they could address
the recommendations we had made.
Audrey Wise
38. I think it would be legitimate for a nurse
in that situation who was afraid to say, "Find somebody else
to do this job. Either give me a mobile phone or you do it".
That would probably result in money being found.
(Dr Adam) You have obviously had the response on your
previous recommendation. I am sure we must make sure that our
staff are able to work safely and in the context of mental health
we have as one of our standards improving access to services out
of hours. Safety is obviously going to become more of an issue
for those providing services locally. I certainly take the point
that you are making.
Mr Gunnell
39. We have been talking around the national
service framework for most of the morning. I had some specific
questions I was going to ask about it. I was going to start by
asking you whether you regarded it as a compulsory set of policies
or whether it was a wish list. The impression from what I have
heard is it is a very broad outline of what you hope to achieve
in the future. It is somewhere between the two and it is in the
process of gestation at the moment. Where would you place it at
the moment? Is it just a broad guidance to you or is it something
that you are intending to reach? You want to make sure all these
policies are in place eventually and you have given yourself presumably
until 2001 to get them in place.
(Dr Adam) These are national standards which the government
is setting for mental health services across England. In that
sense, they are to be delivered. However, having said that, they
are clearly going to be delivered at a different pace in different
places and we recognise that this is a long term strategy, ten
years. This requires significant change in some places and for
that change to be sustainable it has to be developed locally;
it has to be owned by people; it has to be properly resourced
and in line with what local people say they want. These are national
standards set, as the White Paper on the NHS said they would be,
through national service frameworks. They are to be achieved.
The short term milestones are to be achieved and are reiterated
in the national priorities guidance which came out just before
Christmas, which sets some two and three year timescales for people.
In fact, the evidence as we come towards the end of the first
year is that people are beginning to achieve, whether it is additional,
assertive outreach teams, additional 24 hour staffed places or
additional secure places. People are moving in the directions
that we have set for them. My sense is that the field is taking
this very seriously. It was obviously developed with a lot of
participation from service users and those who provide services
and I think it is broadly supported although obviously people
are reasonably concerned about the extent of change that is going
to be required in some areas.
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