Examination of Witnesses (Questions 40
- 59)
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
40. You have a feeling that people working towards
the aims that you have there, that they are working at a different
pace. Would you be confident, say, in three years' time, that
you will have got a good way along the way?
(Dr Adam) I think we will have made good progress
in three years. I also think that we will need to keep the National
Service Framework under review because as we get better knowledge
about what works and how to make things work better, we do not
want this cast in concrete. We want to be able to go back and
revisit bits of it, so it will be a living document. But, yes,
I feel confident that in three years' time it will be well on
the way.
41. It is a positive step to have a framework
in place which shows where you are going. Would you say that redress
is likely to be available for individuals who feel that for them
the framework is not being met? We mentioned earlier people who
had to go for facilities which were a good way away from their
home. In one of our earlier visits we went to a psychiatric hospital
in York where we found they had a very big range of intake: people
from east London and, at the same time, a very huge intake of
people from the Newcastle area, but they were not geographically
convenient for either. Would patients who were in that position
have some means of bringing it to your attention and asking for
some sort of redress?
(Dr Adam) We will certainly want to know where that
is happening and where that continues to happen. We have obviously
got to give people the time to reshape their services locally.
Again, the evidence is that this is beginning to happen. We can
give you some examples from London particularly, if that would
be helpful. We have obviously got to be realistic about how long
that will take, particularly bearing in mind the points made about
staffing, and particular difficulties of recruiting and retaining
staff to inner city areas. So we must be realistic, but we will
be wanting people to work with their service users and carers,
and positively seek their concerns about how they think services
are delivering for them. We will be bench marking. We will be
performance managing. If we find that some services are really
struggling in certain areas we will help them. One of the things
that has been mentioned already were the Nye Bevan Awards and
the Beacon Scheme. We selected a number of mental health services
which we feel have learning that can be shared with other people.
A lot of this is showing people that things can be done differently
and better and then supporting them in doing that; but, as I say,
being realistic about the time that some of these things are going
to take.
42. In this particular case, it was during our
study of the private health care system, a private facility which
was in use. To what extent are you thinking that you will use
all the facilities which are available in the country to ensure
that the whole area can be covered? Is that going to be fairly
typical, that you will continue to use a good number of private
facilities?
(Dr Adam) Certainly we have talked, in the National
Service Framework and in many other cases, about partnership with
the independent sector. I would envisage that the independent
sector will continue to provide an important range of services
for people with mental health problems. What I would also envisage
is that where people are managed at a distance from home, simply
because there is not an appropriate more local facility, that
that issue will be addressed. But I think there are some specialist
resources in the independent sector which will continue to be
important for us.
43. You would certainly regard 200 miles as
too far from home?
(Dr Adam) Unless there is a very, very special need
that that service is meeting; not least because it is very inefficient.
It is not a good way of providing services, even if you look at
it just from a clinical perspective.
44. If we take a very different sort of problem,
where there are possible inequalities, are you taking any steps
to ensure that patients have equal access to what we might describe
as atypical drugs? Health authorities have obviously got very
variable policies as to what they will provide. Are you trying
to ensure that you can get equal provision from health authorities?
(Dr Adam) What we have asked health authorities to
do is to ensure that the prescribing of all anti-psychotic drugs
is reviewed within their own local audit programme. So that is
the first step for people to see where they are and how they compare
with similar parts of the country. We have not actually set a
level or a national norm or anything like that, but what we have
said is that the evidence supports the use of these drugs in certain
circumstances. First of all, we want people to look at what they
are doing locally. At the same time, through the National Institute
for Clinical Excellence, we have commissioned guidelines on the
management of schizophrenia, which will include prescribing among
the other components of treatment. That is in progress, at the
moment, and we will look not only at the clinical effectiveness
literature and the cost effectiveness, but also look at it from
a user point of view because obviously that is an important issue
in determining which drugs somebody receives.
45. So that is another area where you would
expect progress and where particularly you would give some specific
assistance?
(Dr Adam) Yes.
46. If I talk about funding—and you have
said already that you have 700 million within which you have,
in a sense, to manage your first three years—presumably
that will not be sufficient to make the National Service Framework
a reality all over the place. I presume you are looking at the
next Comprehensive Spending Review to see what additional funds
are likely to be needed to bring the matter some further years
forward. Have you any specific ballpark figure within which you
talk about? A further tranche of funding as the Comprehensive
Spending Review moves forward?
(Dr Adam) As you know, on Tuesday, the National Health
Service was told what its overall resource picture for the next
three years. We do not have the same understanding yet for social
services. We also are not yet in discussion about exactly how
the additional money for the NHS will be allocated, but obviously
mental health will be one of the topics which will be considered
in that.
47. Clearly your 700 million is a ceiling within
which you have to manage your first three years. Is that correct?
(Dr Adam) That was the three years that we were allocated
through the Comprehensive Spending Review. That position has changed
a bit with the announcements in the Budget on Tuesday. I do not
think I can comment any further than that.
Mr Gunnell: Thank you. That probably deals with
the questions on the Framework for the moment.
Chairman
48. May I press you further on the point John
was talking about in respect of patients who were placed away
from their home areas, and the aspirations or requirements of
the National Service Framework: going back to the point we talked
about, the requirement to be as close to home as possible. I got
the impression from your answer that where we have a specific
problem—we picked up, as John says, on the people from London
placed 200 miles away in York, and it is bad enough, Londoners
being up in Yorkshire, but I have a Yorkshireman in Lancashire
and that is totally unacceptable as far as I am concerned!—but
the serious point is that it just costs money. It strikes me,
certainly what we looked at in respect of the private sector,
that the money which was being paid there could have been more
usefully utilised by the National Health Service in providing
specific provision in the London area. The cost of it was very
high. It seemed a very short-sighted policy. Do I get the impression
that in looking at the Framework you will be evaluating where
this process is taking place, not just from the Framework point
of view but the cost effectiveness point of view. How soon can
we expect that to happen?
(Mr Mahoney) The big exporter of people is London.
They estimate that there are at least 100 people from London in
medium secure or secure beds who would not be there if a place
had been available locally within London. London has some plans
to increase the level of medium and low secure provision quite
substantially. There is talk about another 60-odd this year; 113
next year; then a further 260 places over the next four years.
The plan is to stop that exodus of people from London up to other
facilities.
(Dr Adam) As you realise, that adds up to more than
the people we think are currently inappropriately. It also takes
account of people in high secure hospitals who could probably
transfer to medium secure provision locally, subject to the work
that is being done at the Institute of Psychiatry to assess the
need. It also makes an estimate of the number of people who we
think may be in prisons who could return to a London medium secure
unit. So that is really very substantial progress over the next
four years.
Mrs Gordon
49. Of those 260 places over the next four years,
what is the proportion? Are they all medium secure places or how
does it work out?
(Mr Mahoney) About a hundred are listed as being medium
secure. About 60 long-term secure, which I think will be what
we call low secure. I do not have a break-down for one of the
major developments, but there are another 70 beds. There will
be a mixture of long-stay, low or medium secure.
Mr Gunnell
50. In terms of the proposals for support for
carers, how are you dealing with getting that in place? That will
be very diverse and variable. What sort of proportion of your
700 million do you imagine will be spent on carers?
(Dr Adam) I do not think we have a proportion of the
700 million. What we were trying to do in standard 6 was to reflect
the very important role which carers can play; a role which has
been underestimated in people with severe mental illness. It has
been hard sometimes for carers to be recognised for the role they
play because often the people do not have any obvious disability.
This is just beginning to say that following the review of carers
and the strategy document that was published last year, we should
reflect those recommendations for services that we provide for
families with people with severe mental illness. They should at
least have their own care assessment. They should be seen on a
regular basis and given the support they want. Obviously not all
carers want support. We can give information off the network.
Some people just want to be left to get on with it. However, others
do need more support than we are currently giving and they need
their role recognised. We are at quite early stages again on this
one and obviously building on the experience of social services
departments in implementing work on caring. This is a slightly
new territory for us because there has not been a major focus
for the work on carers so far.
51. Certainly recognising some of the cases
we have picked up in the constituency, that the people who care
tend to do so on a full-time basis, on an unpaid basis, it obviously
can be subject to personal degrees of stress.
(Ms Platt) There is a small grant within social services
this year and the next two to provide respite care for carers
in those circumstances. You know of a Private Member's Bill which
gives carers an entitlement to services in their own right.
Mr Gunnell: Yes.
Audrey Wise
52. I am very concerned about the issues around
children and adolescents. I am very conscious that the National
Service Framework really does not cover children and adolescents.
When it was in the course of being formulated and we had Ministers
and officials here I specifically asked: would it include children?
with a quite clear implication on my part that it jolly well should,
but the answer was very firmly no, it was about adults. Do you
know why this is so? My immediate reaction is: here we go again.
Children and young people are a very large percentage of the population
and yet they are usually, in my view, at the bottom of everybody's
lists. There is a lot of quite specific problems which arise.
One thing is that when we talk about the Child and Adolescent
Mental Health Service, there is an implication there of something
reasonably unified. Yet we have had evidence which talks of a
widespread lack of liaison within that service between the child
bit and the adolescent aspect. Now if you have a lack of liaison
within what is apparently wrapped up in one bundle, it is not
very encouraging since lack of liaison and fragmentation of services
is a problem which comes up again and again. Whatever inquiry
we are doing, this comes up as a serious problem: fragmentation
and a lack of liaison. The Government, I know, and the previous
Secretary of State himself, was extremely concerned about it,
perhaps particularly the disjoint between social services and
the health service. Of course, the fact that the pots of funding
are totally different and the mechanisms of accountability are
totally different, in so far as they exist at all, none of that
helps. Now what can we do in relation to children and adolescents?
For example, there seems to be a wide variation around the country
as to the age at which young people move from child services to
adult services. Do you think—and I may be looking particularly
at Dr Jezzard when I ask this—that there should be a sort
of standard age which is recognised as the age for this shift?
There again, there is an alternative view: that there should be
a youth service for 16 to 25 year-olds, which would avoid the
need for this shift; to be an overlap on both lots. Do you have
a view about that? Young people around 16, 17, 18 are extremely
vulnerable and there are lots of problems. There are differences
of views as to how accurately these can be described as actual
mental health problems and how much they are more issues of bad
behaviour, naughtiness, failure on the part of adult society to
socialise young people now into being proper members of society;
but, whatever the reason, there is a lot of difficulty. Do you
have a view about this youth service for 16 to 25 year-olds? Starting
with Dr Jezzard.
(Dr Jezzard) Defining the issue of standard age, clearly
in management terms and organisational terms it makes life very
much clearer. There are indeed confusions within some services
at the interface between child and adolescent services and adult
services. You may have noted that in the National Service Framework
we have alluded to this, and said that local services should have
protocols to ensure that that junction between services is managed
better and more efficiently. However, it is a real debate about
whether the chronological age is the best way of determining how
services should be provided. Other factors come into operation.
The level of independence and maturity of the young person. The
issues around whether they are in work or education. Also, clinical
need. Certainly my experience has been that there are some young
people (shall we say, of 18 or 19), who have psychiatric or mental
health problems are better handled within the Child and Adolescent
Mental Health Service. This is because of the particular presentation
and the context in which that young person is living. Whereas
others might be better handled, in terms of skills and resources,
in the adult service. I am not sure that chronological age is
the best way to deal with this. In relation to the idea of a youth
service I think there it has considerable merit but, once again,
you then have the point of when does the youth service start?
It is a very tricky issue. If you look at services around the
country you will find more people are becoming interested in trying
to meet the needs of this age group. I was at a conference in
the Wirral last year where the service there, which is geared
for older adolescents and young adults, had taken the initiative
to explore how many services of a similar nature coexisted around
the country and they came up with a number of services .They brought
services together and they represented different age ranges. They
were all looking at the needs of this particular age group. I
think it is very exciting and very interesting and I think we
are going to learn something more from that. However I do not
believe there is a consensus at the moment about what the age
range should be. Certainly I would like to see more of a focus
on the needs of people in this age group because they can undoubtedly
fall between services at the moment. There is a longstanding,
if you like, cultural difference between child and adolescent
mental health services and adult mental health services in terms
of focus, so we do need to try and address the interface. We have
gone some way by highlighting one or two of the points in the
national service framework to ensure that people begin to start
managing the interface better. In relation to young people who
are vulnerable as a result of difficult behaviour, I think there
is no simple solution. This is what is interesting about the development
of connexions—it is early stages, there will be pilots this
year and services developing more widely from next year—exploring
the skills from a wider resource, if you like, within the community.
For instance, psychiatrists I would suggest are not particularly
good at dealing with difficult, naughty behaviour. There will
be other people working in the youth service who may be able to
gain the trust of young people and work with them and help put
them back on track. I think there has been a change, there is
a shift to looking at the gaps in service provision for this age
group and I think mental health services will have their part
to play in co-operation with local authorities, in co-operation
with the voluntary agencies and in co-operation with these new
services, such as the connexions service. I do not know if that
satisfactorily answers your question but it is a tricky area in
terms of who is going to take responsibility for doing the work.
53. I agree with your hesitancy about fixing
an age. I too think a chronological age is very rarely a good
guide. Sometimes you have to have it so you have a pension age,
for instance.
(Dr Jezzard) Yes.
54. I am sure we all know people who do not
give the impression at all of being what one associates with being
an OAP and who would resent very strongly just being lumped in
as pensioners. The search for different terminology I think is
quite instructive, so we have got senior citizens. I think that
is all absolutely right. I think it does happen at the early end
as well. There can be huge differences between this 16 year old,
that 16 year old, the other 16 year old. So I agree, I am not
going to criticise the fact you have not said "bang, bang,
bang". The issue of children and youngsters who are inpatients,
one of the things that the NSF does touch on is that it makes
clear that children should be placed only exceptionally in adult
psychiatric wards and says a protocol should be put in place setting
out when and how these placements may be made. This reminds me
of the fact that the Department of Health policy on children who
have physical illness is that they should not be on adult wards
and yet when we looked at child health a few years ago we were
told very strongly that about half the children in hospital in
fact are in adult wards, and this for a variety of reasons, frequently
more to do with administration or with the views of particular
consultants than actual clinical desirability. I am interested
in this particular thing and I suppose protocols would be useful
in deciding what is meant by "exceptionally" but I wonder
if the Department has any estimates, whether reliable or more
of a guestimate, of how many children and young people are currently
in adult wards? Have you any idea?
(Dr Jezzard) Unfortunately the figures are not collected
in a form that enables us to extract that. We collect figures
under specialities. The method of collection or the questions
asked were changed about three or four years back as well. It
is actually difficult, we cannot give a figure to that question.
There is no doubt about it, and we are well aware, that some young
people do find themselves inappropriately admitted to adult wards
and that is not satisfactory. One of the things we are trying
to do at the moment is to address this problem. Of the £10
million that is on stream for this year to go into child and adolescent
mental health services, half is being directed towards so-called
tier four services which include inpatient services, to endeavour
to increase the number of beds, and also to provide alternatives
to admission. Child and adolescent mental health services do not
have, in the same way that many adult services have, much in the
way of alternative options to admission in between outpatient
care and the very much more expensive inpatient care. So we have
a lot of work to do. We are putting money specifically into this
area to try and make the likelihood of admission to adult wards
less. In addition we have funded a number of research projects
but there are three that are focusing particularly on inpatient
care around the country. We do not have a proper handle on exactly
how the inpatient beds are being used, what they should be used
for, the pathways into care and the alternatives. So we have commissioned
these projects to look at those in some detail, including issues
of costs as well, to try and monitor the pathways and look at
the effectiveness of the services. We hope that when they produce
the results that will give us a better guide to what sort of policy
development should be in the future.
Mr Austin
55. Can I just ask, during the previous inquiry
Audrey Wise raised the issue then, that even where children were
not on adult wards, they were on children's wards, very often
they were being cared for, certainly nursed by nurses who were
not paediatrically trained or trained in working with children.
I am just wondering, in the particular area of mental health and
children and adolescents, I would have thought it was even more
appropriate for those who are caring, nursing and other carers,
to be trained in working with children. I am wondering whether
much note has been taken of that and our previous recommendations
in an earlier report? What is being done to ensure that children
are being looked after by people who are trained to look after
children?
(Dr Jezzard) The survey that was commissioned by the
Department and conducted and published in 1994 on services around
the country indicated that nurses within child and adolescent
mental health services did not always have the training that was
required. Either they had child training and no mental health
training or else they had mental health training and no child
training. I think the situation may not be a great deal different
at the moment but we have commissioned a nurse tutor to help us
in terms of looking at what would be required to improve the training.
There is training out there for people, for nurses working in
child and adolescent mental health services.
Chairman
56. You say there is no training?
(Dr Jezzard) No, there is training. There are courses
but they are not always easily accessible. We need to think of
rather more flexible approaches to giving nurses the appropriate
mix of skills for working with children and for working in mental
health. There is still work to be done and the person concerned
has been consulting widely with nursing bodies, the RCN and with
people in the field and so on to try and produce an approach to
nurse training that will help us in the future. It is not yet
complete and not yet available but certainly it is something we
have taken seriously.
Mr Austin
57. Can I just follow that one up as well. On
the question of training, one of the issues that was particularly
raised by nurses in an earlier inquiry was that very often nurses
were responsible for their own training and have much less access
to funding to go on those training courses. That was something
we highlighted in our earlier report so, again, I would like to
know what has been done to redress that?
(Dr Jezzard) I am not sure that I can answer that
question.
(Dr Adam) Not specifically in terms of young people's
mental health services but obviously the continuing professional
development of staff in health services is now covered within
clinical governance. I think what we are going to see there is
probably a reducing dependence on people going off on courses
but rather people thinking more creatively about how they can
develop staff at work without needing to send them off for long
periods of time, which is a deterrent both financially but also
in terms of who does the job while they are away. CPD is very
much a core theme within clinical governance and I think we will
begin to see some change but probably not very much to show you
so far.
Audrey Wise
58. Could I go back to Dr Jezzard's answer to
my question about how many. When you said figures are not collected
in this form, I cannot be the only MP around this table to whom
those words had a sort of inevitability about them. It is so common,
either not collected in this form or they are not collected centrally
or they are collected and they might as well be put straight in
the bin because nobody ever looks at them. When you said about
speciality that rang bells as well. It is exactly the same with
physical illness. So children on an adult renal ward are not classed
as children, they are classed as kidney patients but they are
children.
(Dr Jezzard) Yes.
Audrey Wise: It is obvious from your answer
that this is the same kind of thing. The Committee has a certain
interest in encouraging the collection of suitable, useable, helpful
statistics.
Chairman
59. Helpful to us not to you probably.
(Dr Jezzard) Helpful to us too.
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