Examination of Witnesses (Questions 60
- 79)
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
Audrey Wise
60. We want them to be helpful to you as well
because it is very difficult to understand how the Department
can develop strategies without certain basic information. Strategies
about where to treat kids do seem to depend a lot on knowing where
kids are treated currently. If it is the wrong place, why? I wonder
if you would like, not off the top of your head, to go away and
think about this and what kind of helpful suggestion this Committee
could make to the Department about changing the methods or whatever
of the statistics that are collected. I think there are very competent
statisticians who would very much like to remedy and fill up these
great holes but unless somebody arranges that they can do that
then they will go on being frustrated, as I am sure they are,
and MPs will go on being frustrated, as I know we are, at not
collected centrally or not collected in this form or whatever.
So what sort of things should we be saying? If you would like
to go away and then drop us a note about this then there will
be at least one Member of the Committee who will be very grateful.
(Dr Jezzard) I would be very happy to do that. Can
I just say that we have already in mind that in the collection
of data for the services and financial frameworks, given that
we are giving additional money this year specifically for the
development of inpatient care, it is necessary for us to get better
data. So we are looking at the way we could get this data more
usefully. It is important to us as well as to Committee Members,
there is no question about that.
61. I am sure.
(Dr Jezzard) I think also that our research project
hopefully will throw up even more detailed information. It is
essential for good planning and I would certainly agree with you
there. We will be happy to get back to you.
62. Are there any steps being taken, and if
so what, to examine potential differences between the treatment
of children under child care legislation and their treatment under
mental health legislation? Who is responsible, especially locally,
for trying to get liaison amongst and between the various agencies
involved? In relation to local authorities I have a particularly
despairing feeling, because in this sort of field the local authority
is often used almost as a synonym for social services department
but, of course, education is also a local authority service. When
we did our children inquiry we found lack of liaison between education
and the health service and education and social services, even
when in exactly the same authorities, to be a cause of real hair
tearing. I do feel, and I know from my consistency work, that
there seems to be a chasm between services under the education
authority, which bear in some way on the mental health of kids,
or on how the kids are handled when problems show up, and the
National Health Service, including the mental health service.
This drives me to want to throw things but I am not quite sure
who I should throw the things at. Can you help in this? Can you
suggest a target for me?
(Dr Jezzard) I hope it is not me. I think the services
vary considerably around the country. I have had experience, certainly,
of very co-operative relationships between education and mental
health services and social services, so it is not a picture that
is easy to generalise about but we are very conscious also that
there are some places where people do not appear to be talking
to each other effectively. I think there are a number of approaches
that are helping to address this problem, such as the Children
Service Planning Process, the Health Improvement Programmes and
Behaviour Support Plans, all of which are seeking to bring everybody
into discussion over what are the very same children that they
should all be concerned about. I think there are quite a number
of changes taking place. Certainly I have been quite impressed,
if you like, by the way social services, for instance, around
the country have taken on board child mental health issues over
the last five years which previously they perhaps had not. In
terms of education, I think I can say at Government level, between
Departments, we have now established a good linkage within the
advisory group for children with special educational needs, particularly
emotional and behavioral difficulties. The Department for Education
and Employment, for instance, have decided to bring in somebody,
within the context of their work in that area, with child mental
health expertise. We have a better linkage. I think if people
see a better linkage and more joined up policy development centrally
then that does give the message in the field. The other thing
that I think helps provide some reassurance is projects which
were funded—in 1998 the funding first started for 24 projects
around the country under what was then the Mental Illness Specific
Grant now the Mental Health Grant—specifically to establish
joint enterprises, and if you look at the list of projects around
the country they are covering a range of activities, including
work with schools, work with looked after children with a mental
health perspective. So there is a range of initiatives around
the country. But it is none the less encouraging what has happened
in the way of co-operative relationships.
63. There used to be a fearful shortage of educational
psychologists, is that still the case?
(Dr Jezzard) I do not think I can answer that question.
We would have to go to the Department for Education and Employment
to answer that. Certainly, educational psychologists are no longer
regularly part of child and adolescent mental health teams but
I do not know what the position is nationally. If you would like
us to contact the Department for Education we will do so.
Audrey Wise: Yes please.
Chairman
64. Can I just take one specific point in relation
to Audrey Wise's question. I would be interested in the difference
between child care legislation and mental health legislation as
it relates to children and young people. We have got here a group
of civil servants who reflect different camps within the different
activities of the Department of Health. The Prime Minister is
going on about the relationship between health and social services
and it strikes me that we have got the Children Act which has
as its central principle the welfare of the child which informs
any decision made on the child under the Children Act. If that
welfare principle was applied in respect of children and adolescents
in mental health services, what are the implications in looking
at how children and young people will be treated compared with
how they are treated now?
(Dr Jezzard) This is a timely question because at
this point where the Mental Health Act itself is under review.
We had a meeting just yesterday to look at the interface between
the Children Act and the Mental Health Act and to look and consider
what read across there should be within the Mental Health Act.
To meet just the points you have made the Mental Health Act, while
applying to children, has tended to be focused on looking at the
needs of adults in hospitals. We had a very interesting and useful
discussion bringing a lot of people together with ideas about
how there could be a better read across. What I would say in relation
to the Children Act is while it statutorily relates primarily
to the work of social services, many services around the country
in child and adolescent mental health setting see the principles
enshrined in the Children Act as principles which should inform
their work. That may not be universally the case but certainly
I do not think that you will find people shunning the principles
of the Children Act simply because they see it as a local authority
issue.
65. There is a tie-up in relation to the dialogue
around the new legislation and it is informing thoughts about
the provision.
(Dr Jezzard) Yes. I do not know whether Julian wants
to comment?
(Mr Oliver) Certainly, as Bob said, we had a meeting
with interested parties in the field yesterday at the start of
the process on ensuring that the reformed Mental Health Act, the
new Mental Health Act, will take full account of what you describe
as the interface issues between the two pieces of legislation.
This is a dialogue in which we will continue to see what scope
there is for making special provision, possibly, within the new
Mental Health Act in the way that the current Mental Health Act
does not.
66. We have not forgotten you, Mr Oliver, we
will come on to your area later.
(Mr Oliver) Delighted.
Audrey Wise
67. I happened to be talking to a little class
of girls on Monday this week who had various problems which had
led to them being out of mainstream education and being dealt
with separately, getting two hours a day in this little class.
I had some conversation with the teacher who said she could not
believe that the Government could not realise the damage it was
doing to youngsters and schools by the constant going on about
GCSEs and the use of the league tables. I have observed already
the really detrimental effect of the use of raw league tables
in my area and the polarisation this leads to so that schools
which have problems find their problems exacerbated and they are
unable adequately to defend themselves. The teacher told me that
the girls to whom I had been talking had mostly been put in by
the schools for ten GCSEs, they were under enormous stress and
could not cope. Several were pregnant, one had a nine week old
baby, one was due to have a baby in a couple of weeks. They had
problems in relation to this. The one with the nine week old was
suffering severe sleep deprivation and lots and lots of problems.
The teacher had been trying to get the two hours lengthened to
two and a half, but without success. In this conversation I expressed
my agreement with what the teacher was saying and also I expressed
the view that we would find ourselves in the position of Japan
where the suicide rate amongst kids and young people is just awful.
I was then told that of the eight girls to whom I had been speaking,
who were all aged about 16, three had already attempted suicide,
two with overdoses and one with slashed wrists. Now I know that
attempted suicide is not the same as really failed suicide, it
can be a different manifestation and it may be that those girls
who have survived their suicide attempts will be more competent
in future but, on the other hand, it may be that whatever their
underlying purpose in their heads is served by failed attempts,
I do not know. It was very disquieting because I had just finished
a discussion with girls who seemed to me to be perfectly nice,
reasonable, ordinary girls and to find that three out of eight
of them had either taken overdoses or slashed their wrists was
upsetting to say the least. What is your view of that little picture?
Would you say it is quite a common picture? What do you think
can be done?
(Dr Jezzard) The issue of self-harm, young people's
self-harm, is very important. Certainly it has a higher prevalence
among young girls than boys.
68. Yes.
(Dr Jezzard) I think to specialists working in child
and adolescent mental health services, it is a familiar picture.
They will see many young people who do harm themselves. I think
one of the difficulties often is disentangling all the various
risk factors and the elements that have come together to create
this level of distress in the young person. It is not easy to
put your finger on any one factor. You raised the issue around
the demands for education, educational attainment. Some people
will say also that some young people have suffered because there
were no expectations at all for them. I think there is a balance
to be struct. Certainly some young people will be more vulnerable
to the pressure to succeed, which may also come from their families
as well as from the educational system. Some will be vulnerable
because nobody has any expectations of them at all. I think they
can be factors. For many of these young people they will have
had many other experiences which will have set the scene. In terms
of how we tackle this, ideally we try and prevent children getting
to this point. Part of the solution is obviously about providing
services that respond when young people are in difficulty but
there are also initiatives like the Healthy Schools Programme
in which the Department of Health and Department for Education
and Employment have put money together to try and address the
issue of health promotion in schools and that includes mental
health promotion. I think that is early days but it is a very
good sign because we have not in the past taken seriously the
notion of what can be done in schools which will alert not only
teachers but also children and young people themselves to mental
health issues and what they can do about it. There have been a
number of interesting conferences around strategies to promote
mental health in schools. One that I participated in was a European
conference bringing people from around Europe looking at it. There
is a new interest in what can be done to prevent it. The problem
is, that in the case of prevention of suicide, there are a lot
of initiatives, a lot of people, a lot of ideas, but it is not
very easy to tease out exactly what approaches work. Certainly
research in the States has not demonstrated that there is a simple
fix to that. You probably need to think about a range of initiatives
which are not always mental health initiatives but a range of
initiatives to reduce inequalities, etc., and the effects of social
exclusion etc may all have their impact.
Chairman
69. Could I throw in one point here to suggest
something which would help. My perception—I have two youngsters
in the secondary school system—is children and young people
are under more pressure in the schools than ever they have been.
In my view it is a real worry, the pressure we put on the young
people. It is the league table pressure on teachers, that is an
area we need to look at carefully. It is something which worries
me as a parent and many other parents I have talked to.
(Dr Jezzard) I think it would be inappropriate of
me to comment on DfEE policy.
Chairman: I am conscious it is a huge area.
We have looked at it only briefly but we have many other areas
to cover before we conclude.
Mr Gunnell
70. I will kick off on an area which raises
acute care in the community but it also raises the Government
Green Paper on Mental Health. I want to ask if there is a difference
between the way in which we regard physical illness and mental
illness? Given that we have had some publicised cases where people
who are regarded as physically ill can refuse any treatment, even
if it leads to their own death, it is somewhat curious that the
Government takes the view in the Green Paper that the concept
of capacity is largely irrelevant when it comes to making decisions
about compulsory treatment and it is the degree of risk and not
the person's capacity which should be the determining factor in
compulsion. I wonder whether it is a somewhat dangerous route
which we are going down when we say that a person's capacity to
make decisions is not relevant to whether or not they can refuse
treatment?
(Mr Oliver) Thank you. I think it is important to
state at the outset that the Green Paper does not reject the notion
of capacity. We accepted a large number of the recommendations
from the Expert Committee which was appointed to scope new mental
health legislation and the Expert Committee plainly favoured a
set of criteria which involved a tester capacity. We had some
concerns, I think, about the practicalities of capacity and there
were issues also around whether or not the tester capacity of
itself would greatly influence whether or not a patient was going
to be subject to compulsory care and treatment or not. What the
Government has done in the Green Paper is to simply offer an alternative
model but there is no decision yet taken on whether or not there
would be a capacity test on the face of new legislation, and we
await the outcome of the consultation we have had on the Green
Paper.
Mrs Gordon
71. Part of this debate which is ongoing is
I am very worried about the public perception of mental health
problems. As we have heard, most people with mental health problems
are helped by the GPs, and also a lot of it is the stress and
strain of modern life. We know that something like one in four
people are vulnerable to a mental health problem at some time
in their lives. What worries me is that the public perception
is more based on the very rare, the tiny minority of cases that
we hear about where, unfortunately, homicides are committed within
the community, and of course they are very tragic. Given recent
evidence that homicides by the mentally ill have not actually
increased during the era of community care, I would like to know
if the Department could challenge the misrepresentation, the headline
news about mental health, if you like, and actually put forward,
educate if you will, the public to the gap between the perception
and reality of mental health problems within our society?
(Dr Adam) If I could answer that in two ways. I think,
first of all, it is important that we recognise how people do
perceive people with mental health problems and, as you say, in
the very rare cases of homicide, the impact that has on perception.
I think it is important, also, to recognise that not only are
these cases tragic as homicides but they are tragedies for the
people who perpetrate the homicides. When we look back at the
care that they have received, almost always there are real problems
in the standards of care that is being provided: poor communication,
staff not working in partnership, service users not receiving
the level of support that they require and, therefore, failing
to continue to take their treatments. All of these things recur
in each of the inquiries. I think it is essential that we take
that very seriously and do what we can to reduce the risk of homicide.
Having said that, I think it is important also to recognise that
we have a series of strands of work which are really, at the other
end of the spectrum, tackling issues of stigma and discrimination
against people with mental illness. That is represented in standard
one of the National Service Framework where we specifically highlight
the need to reduce stigma and discrimination. We work closely
with a range of external bodies in doing that. World Mental Health
Day has 5,000 local co-ordinators now, that happens each autumn,
working closely, for example, with the Royal College of Psychiatrists
and professional bodies on anti-stigma campaigns. We have done
a series of pieces of work with the media—there is a group
called Mental Health Media—we work with them to see how
we can support them in presenting rather different images of mental
illness and mental health problems. I very much take your concerns
about public perception. I think we have to work on a number of
levels to do what we can to combat that and the very adverse effects
that can have on people with mental illness.
Mr Burns
72. Dr Adam, would you confirm that, as Mrs
Gordon said in her question, the number of deaths under care in
the community is in fact relatively lower than those when people
are suffering from mental illness and are kept in long stay hospitals?
The trouble is that because there is far more publicity and a
far higher profile of these crimes, the public are far more aware
of them which creates a vicious circle in which whatever good
work is being done to seek to remove the stigma of mental illness
is undone by the few very high profile and sadly very horrific
crimes. Do you think—if you will confirm that is a broadly
correct assessment of the situation—that one of the ways
in which one could seek to reduce the damage of this high profile
is if one is to stop the practice, whenever any of these crimes
are committed, of setting up an inquiry which, with the actual
incident of the crime, causes a great deal of publicity and then
when the report is published there is then another wave of publicity,
sometimes a year, two years, three years later on? Would it not
be in the interests of everyone if that inquiry process was stopped?
Certainly learning from where there may have been a breakdown
in the provision of service, learning where improvements can be
made, but not doing it in such a high profile way, it undermines
all the work that everyone else is trying to do?
(Dr Adam) Certainly I recognise the problem that you
are putting and the fact that we can go through two or, sometimes,
three episodes of media coverage of one tragedy. I am not sure
that we have got reliable comparative data to go back to homicide
rates when people were in long stay hospital. Certainly I would
accept that there has not been a recent increase. We are looking
at fairly steady levels of homicide committed by people with mental
illness and also, of course, that rate is very much lower than
the rate of suicides among the same group. I think it is important
that we keep the situation under careful review. Now we have the
National Confidential Inquiry well established in Manchester reviewing
all of these cases, homicides and suicides. I think it is beginning
to generate extremely helpful reports which by grouping incidents
and by grouping the learning that comes from them it is probably
going to be more effective in helping us to put the lessons into
practice. Also, we have now the Commission for Health Improvement
almost up and running. One of their responsibilities will be to
conduct inquiries at the request of Ministers. We do have some
new opportunities to look at the problems which you are raising.
I think it will be important obviously for us to keep the situation
under review, recognising the extent of the problem that you have
raised.
73. Can I raise another fairly contentious issue
which is the proposal for compulsory treatment orders as set out
in the Green Paper. There is a view that they run the risk of
alienating both sides of the situation, both the patient's because
some patients may be hesitant to seek help and treatment because
they feel they may be subjected to a compulsory regime, and also
the medical practitioners may be unhappy because they may morally
or ethically disagree with such a policy or because they are reluctant
to provide a service under those conditions. What are your views
on these fears and the policy proposal?
(Mr Oliver) I think the basis for the proposals in
the Green Paper to introduce compulsory treatment in the community
is about greater freedoms for the clinical team to prescribe something
or to describe a course of treatment for somebody on an individual
basis which will work better for the patient. The current Act
is very inflexible in this way. There is a group of patients,
it may be small, I do not know, for whom the therapeutic environment
of an inpatient psychiatric ward is not the best therapeutic environment
available to them. There is quite a strong feeling I think that
modern legislation should reflect the move that there has been,
particularly since the 1970s and 1980s, to treatment for people
with mental illness in the community that the law should reflect
this.
74. Can I move on to special hospitals. As you
are more than aware, the three special hospitals are large but
in the case of Ashworth and Rampton in particular they are physically
isolated. They have been the subject of numerous inquiries over
the years and, in the long term, do you believe that smaller units
near to local medium secure units would be a more effective way
of providing the services that they provide or do you think, notwithstanding
their past history, and the lessons that we have learnt from the
various reports, that maybe there is still a role and a need for
large special hospitals?
(Mr Mahoney) I think the Government's response in
relation to the Fallon Report proposals for Ashworth is a very
robust one. These hospitals do develop an expertise and help which
has developed over time. It is difficult obviously to find that
expertise in staffing three sites. I think the worry is it might
be even more difficult, and significantly more expensive if it
was split into a number of regional sites. The conditions of security
are such that it would be extremely difficult to foresee a time
when such facilities could be built around the country. I think
it is highly unlikely in that the three high secure hospitals,
clearly they have got a job to do and will remain for quite some
time.
Chairman
75. Could I put a question, I know Simon wants
to pursue a few more issues but probably this is a question that
he could not ask, having been a Minister with some responsibility
for this area. Is it fair to say—it probably is not fair
to ask you but I will pursue it anyway—that we have had
report after report after report that has made recommendations
about the special hospital sector, fairly consistent recommendations
along the lines discussed about breaking up and moving more towards
regional secure unit models. We had the Ashworth report last year
which again reinforced certain proposals in respect of that establishment
which this Government, in my view wrongly, rejected. Is not the
simple fact of life that as long as we have politicians who are
faced with the problem of where do you allocate regional secure
units to, and, knowing the kind of response of MPs about "We
do not want it in our back yard, thank you" but I have got
one in my back yard, is that not a problem which will obstruct
any firm movement on the special hospitals improving what I think
can still in some respects be described as bins?
(Mr Mahoney) The absolute key is that the people who
should not be there, should not be there. People who require high
security should be a grave and immediate danger to the public.
I think that is one of the features that we are waiting for in
the report of Sir Richard Tilt, the former Director-General of
the Prison Service, to see what that says. One of the key features
of the development and around the development in this area will
be to develop alternative services, alternative services for women,
for example. I think everybody will recognise that services will
be developed which will change the style of the special hospital
slightly. There are still a large number of people in prisons
who need to be in high secure hospitals. It is really getting
people into the right level of security that is the key to all
this.
Mr Burns
76. As you are aware, successive Secretaries
of State, including certainly, if I remember correctly, the last
one and so I assume the current one as well, have said that they
have and will continue to allocate more funds, plus some reorganisation
in the light of the Fallon Inquiry into these special hospitals.
Part of the reorganisation is going to result in closer functional
and administrative integration of the high security hospitals
and the NHS. It will still leave us with the three hospitals.
What are the long and short term plans for those hospitals at
the moment?
(Mr Mahoney) I will come back perhaps to performance
management in a moment. As far as I know there are no plans for
anything other than Ashworth, Broadmoor and Rampton providing
services for people who require high security. Organisationally
Broadmoor has gone out to consultation in terms of merging with
Ealing, Hammersmith and Fulham Mental Health Trust to create a
new organisation. I think Rampton either has or is about to go
out to consultation around a reconfiguration of trusts in Nottinghamshire.
Ashworth will be following. The view is that what has caused many
of the problems in these hospitals has been their very isolation
from the NHS. That is seen as one of the solutions in terms of
their future. Also, there has been a tremendous amount of work
around safety and security directions, child visiting and so on,
and tight performance measures have now been introduced where
accountability lines for all hospitals are now very clear and
each host region has appointed a performance manager for their
particular hospital. Things are changing. You mentioned money,
there is also some significant money being invested in all three.
This year it is focused on Broadmoor and Rampton because, believe
it or not, staffing levels are far worse at those two hospitals
than Ashworth. They have recruited a significant number of staff
so it is looking quite good for once. In terms of organisational
structure I think all the features are resolved, certainly for
Rampton and Broadmoor. In terms of organisation I think the Ashworth
merger at the moment is suggested between themselves and the mental
health services of Salford.
77. Something occurred to me as you were speaking.
If one is to sort out with these three hospitals and with the
Prison Service as well in that clearly there are a number of people
in prison who should not be in prison, they should be in secure
units, and I would assume that there must be a relatively small
number of people in the three special hospitals who arguably should
not be there but, if you jig this all around so that the right
people are in the right place, presumably there would not be enough
places in the three hospitals for all the people who should be
in those hospitals? If the answer to that question is in the affirmative,
would you expect the building of any more special hospitals?
(Mr Mahoney) In fact, it is the other way round. I
think there are far more people in high secure hospitals who should
not be there.
78. If you take them out, and presumably take
from the Prison Service prisoners who should not be in the prisons
but should be in a high secure hospital—
(Mr Mahoney) That number is lower.
79. It is lower than the numbers who should
not be there?
(Mr Mahoney) Yes.
|
