Examination of Witnesses (Questions 140
- 158)
THURSDAY 30 MARCH 2000
MS SUE
BROWN, MR
PAUL FARMER,
MS MARGARET
EDWARDS AND
MR PETER
WILSON
140. But that surely they can take to a tribunal
and say, "I am just hanging about here and nobody is doing
anything"?
(Ms Brown) But if the law allows that to happen, which
is the implication of removing the treatability, you then define
someone as untreatable and you can detain them because there is
no requirement to detain and treat.
141. That is very clear. This is very valuable
for us to push this a little bit. Do you take the same line on
that?
(Mr Farmer) We have fewer concerns about the removal
of the treatability criteria within the legislation on a very
strong proviso that there are very clear safeguards in place in
order to cover those issues that Sue has mentioned, because the
great concern is that people will simply be compulsorily admitted
and either given inappropriate treatment or no treatment at all.
They would have no recall to, for example, access to an independent
second opinion, access to advocacy to enable them to articulate
their own concerns and their own needs, and no right of appeal
to a higher body in terms of recognising their need for support
and care, so that is where we would see it.
142. You would accept not having treatability
provided there were safeguards and reciprocity is strong enough?
(Mr Farmer) There need to be very strong safeguards
in place to ensure that the system is not abused.
(Mr Wilson) May I just make a point from the point
of view of children and adolescents? Sectioning or compulsory
orders are not made often for children and young people, so it
is a different sort of thing. Child psychiatrists very rarely
use them although I gather there has been some moderate increase
over the last 10 years.
143. They tend to be more anarchic, I think.
(Mr Wilson) Possibly, yes. To come back to your question
of resources, we are talking about personality disorder in adults
but the evidence is very clear that with adults you can see it
coming a mile off from pre-school days. The continuity now for
conduct disorder through a personality disorder is enormously
convincing. The service provision for adolescents with conduct
disorders is extremely inadequate partly because of this issue
that we are talking about. Psychiatrists tend not to see conduct
disorders as a mental illness. Therefore it is not something for
them to treat and anyway they think they are untreatable, so they
pass them over to the social service departments who think that
the children are very disturbed and need something that they do
not have and they fall into an enormous hole. There are serious
implications for resources for adolescents who, unless they are
treated in the broad sense of the word, are very likely to become
established personality disorders later on in life.
(Ms Edwards) My quick response on the law itself we
have already indicated, that we actually wish the treatability
test to be dropped so that people with personality disorders are
treated in the same way and what is being proposed effectively
is that they are treated in the same way as everyone else considered
to have a mental disorder. What goes with that is that that group
would have exactly the same and the fullest possible safeguards
against being detained in the first place and being detained for
no longer than is considered necessary. There is also the whole
issue that has already been touched on of preventing people needing
detention by tackling it very early on. We have, through our Research
Centre and a lot of work that has been done there, increasing
evidence, as has just been said, that you can start to see a pattern
building up quite early on and so the whole thrust as well as
the law should be on services and, as Paul Farmer said, to have
community based services as well [being] there as part of the
prevention package so that you are constantly trying to help people
rather than just ignoring them.
Mr Austin
144. I wanted to pick up on Mr Wilson's comments
because I want to raise this issue of the black hole he referred
to in the evidence. Clearly there is this problem with young people.
I am wondering whether YoungMinds have thought of any positive
ways in which this might be resolved? The other issue I want to
raise is to paint a parallel with special educational needs. Years
ago when children were defined as having special educational needs
that was a stigma and having your child statemented was stigmatising.
It now seems that it is reversed somewhat, in that many parents
are demanding statements for their children because it unlocks
the door to resources. When we come to mental illness or mental
disorder with young people it is not until there is a diagnosis
that they are mentally or mentally disordered that the services
are unlocked. How are going to get over this Catch-22 so that
they can get the services they need?
(Mr Wilson) I agree that there is a dilemma that a
stigma attaches to these labels. People need labels in order to
get treatment or help. You have to remember that conduct disorder
is the most common cause for referral to child mental health services.
We are talking about a lot of children, almost nine per cent in
urban areas. They are difficult in that they do not come under
a convenient label. Conduct disorder is really just a descriptive
label that does to describe a combination of behaviours. It does
not have the same order of diagnostic value as, say, schizophrenia
or clinical depression. It is a very broad based definition, so
it is very difficult to define. You are asking for our view about
what we positively think should be done. First of all the problem
needs to be recognised much more fully than it is at the moment.
What we are talking about really are children and adolescents
whose background has been characterised by treatments of different
kinds almost without exception. Harsh, inconsistent parenting
comes up time and time again when you look at the backgrounds,
so they are aggressive, they are frightened, they are mistrustful.
They are frightening for people and it is very difficult to treat
these people, to help these people or deal with these young people
unless you are fully aware of what has gone on in their lives
and how it affects their lives in the present. We feel very strongly
that we need to talk very openly about this problem. We have to
acknowledge that you do need very particular skills to deal with
it, and we need to look very broadly at what the range of provisions
are for child and adolescent mental health services across the
community because I do not think this is simply something that
inpatient care could deal with. For the more severely disturbed
I think you clearly need special residential or day facilities
such as therapeutic communities, day centres and centres of that
kind. You need a much more active contribution being given to
teachers in mainstream schools where many of these children present
initially through their disruptive behaviour, through their potential
to be excluded. You need much more professional input into EBD
schools where they also come up. My response is that we have to
look very critically at this wide range of children. They vary
in the degree of their severity, their disturbance. They do require
particular skills, they are not straightforward to treat. Drugs
for the most part have absolutely no impact whatsoever. Psychiatrists
I believe should back off from them where they cannot treat them
in a customary medical way but they can give important support
and understanding to those working with them. It is a community
issue. We argue strongly for comprehensive delivery of adolescent
mental health services including patient day centres, good child
and adolescent mental health services and good tier two and tier
one services. Unless one takes that very holistic approach to
this problem nobody will own them. We have the most shocking conditions
at the moment where psychiatrists will not deal with them, social
workers are at a loss what to do with them, and very often we
are spending an inordinate amount of money putting them into single
accommodation somewhere with a number of key workers around them
costing hundreds of thousands of pounds. It does pose a critical
problem and I do not think we are spending anywhere near as much
resource on this problem as we should. There is evidence to suggest—and
this comes from the mental health field and the juvenile justice
field and comes from what we know now from community care—that
if you do do various behaviour interventions and personal skills
training within a supportive relationship you really do reduce
certainly crime and you reduce the degree of distress in these
young people.
145. I do not want to name names here but we
all have our own examples of where the system has failed. I am
wondering if YoungMinds can in correspondence point us in the
direction of examples where the education and social services
and child and adolescent mental health services are working in
models that you would like to see.
(Mr Wilson) Yes, it is developing in certain parts
of the country and we could provide that evidence to you.
Mr Burns
146. Can I move on to the question of compulsory
treatment and basically ask Ms Brown in that you have stated in
a survey of your members that a majority would be prepared to
support compulsory treatment as a last resort. Could you just
elaborate on what you see as a "last resort" and what
sort of safeguards would you like to see embedded in such a system
if it were to happen?
(Ms Brown) There are two things here. First of all,
all the issues that we have already raised around capacity would
need to be taken into account. In terms of last resort, I think
a really serious attempt to deliver effective services without
the use of compulsion needs to be made and that is also about
discussing with people what they want. Rather than starting from
a decision, "This is what we think you need", we should
ask, "What do you feel you need and how would you best like
to be helped and what services do you need?" Those kind of
interventions are necessary before you even begin to talk about
compulsory interventions. The safeguards we would like to see
are that capacity is taken into account and also we are very much
supportive of the idea around having a medical tribunal at an
early stage so that compulsory treatment is not happening long
term without some kind of independent hearing. But it is crucial
that we get those criteria right because as the "without
capacity" model stands in the Green Paper that will result
in a huge increase in the number of people subject to compulsion
and the tribunal is no protection. The tribunal's job is to check
that the criteria are met. If the criteria are too wide the tribunal
is no protection at all. The tribunal is a protection for people
who do not fall within the criteria being subject to compulsion.
If that is too wide that is no protection.
Chairman
147. Mr Farmer, would you like to say something?
(Mr Farmer) There are two points. First of all, the
survey that we did of 2,300 users and carers found something like
something one in three people have been turned away from care
when they have asked for it. People are being told, "You
are not ill enough yet. Come back when you are worse." Only
in mental health does this subsequent power exist and it needs
not to be used simply as an excuse for not treating somebody earlier.
We end up potentially falling into the same trap you alluded to
earlier in the context of people with special needs wanting to
get access to the treatment and there is something wrong there,
surely. In the context of last resort for community treatment
orders there are a number of questions that need to be asked.
First of all, what other treatment routes have been tried first?
CTO should never be the first line of treatment, surely. Has the
person been offered new and up-to-date treatments? Have those
treatments been given some sort of time to work? Have they been
offered an independent second opinion? Have they been offered
any form of psycho-social intervention at all? Are they well supported
within the community at present? If you had a community treatment
order and that person was not well supported in the community
it would not make any effect. There is also a question around
the number of times that person has already been in contact with
mental health services through the Mental Health Act. How many
times have they been sectioned to date? If those questions are
being asked the corollary comes back to the point we was making
earlier and Sue were making earlier about safeguards, things like
close monitoring and accountability, with the involvement of the
user in that process and reciprocal rights for people who are
on compulsion so that CTOs do not become a cheap option to the
neglect of good treatment and care. There is some real concern
about what a community treatment order might mean in practice
in terms of the type of medication administered and so on and
forth. Perhaps the final point on this is around the involvement
of family and family members in the approach towards the questions
that need to be asked. Have they been involved in the process
so far?
Mr Burns
148. Can I ask you, Ms Edwards, a slightly different
question but it will give you an opportunity to answer because
of time being pressing and that is in your written evidence you
support the recommendations of the scope of new Mental Health
Act but again you say that compulsion should only be an issue
of last resort. You have also highlighted a whole series of areas
where you believe that a whole series of improvements can and
should be made, for example more psychiatric beds, more 24-hour
nursed units. Are you suggesting you would only support the Green
Paper on the basis of the provision of these improvements that
you have mentioned and there is a balanced entitlement to support?
(Ms Edwards) I am not saying that we would only support
the new legislation on the lines proposed if there are those beds,
no, but we see the two absolutely going together and we see the
lack of beds, and not just acute beds in hospitals but 24-hour
nursed units, community based provision, supported housing, the
whole range of community based provision, as being absolutely
crucial to providing modern mental health services and preventing
the need for deterioration of people who [do] have a mental health
problem, particularly those with serious mental illness, and certainly
preventing the need for detention. When it comes to extending
the existing compulsion powers, we see compulsion being just as
much a last resort whether in hospital or in the community and
if there is to be compulsory treatment in the community we would
only wish to see the treatment actually carried out in a clinical
setting equivalent to a hospital, which could of course be a 24-hour
nursed unit or some kind of clinical environment where it can
be administered properly with proper monitoring and so on. We
share very much the concerns expressed by Paul Farmer about the
reality—and there is some evidence that this has happened
in Australia—of extending compulsion into a community setting
which could mean that it is a cheaper option and that the patients
are not given the new anti-psychotic drugs which could benefit
those with schizophrenia. We would also very much want family
and carers to be fully involved in the process, as indeed with
hospital compulsion. Yes, it would be a step [forward] which has
not been there before and we would need the fullest possible safeguards
but we keep coming back to the need for the proper services in
the right place at the right time so that compulsion can truly
be a last resort.
Mr Burns: Thank you very much.
Chairman
149. Could I ask, Ms Edwards, you said earlier
on that there is an acute shortage of beds. Some people would
disagree with the emphasis you are placing on returning in a sense
to a hospital-based system. Assuming that we have better community
care services along the lines that you describe and more imaginative
provision in the community, what percentage increase in beds would
you envisage being needed, bearing in mind certainly in my experience
a lot of people are in hospital beds who would not need them if
they were properly cared for in the community.
(Ms Edwards) It is difficult to put an exact percentage
on them because there are so many variables. Certainly we would
like to see a big extension of 24-hour nursed care in a community
base so that if people need that, probably for only a short time—they
have deteriorated, they have relapsed, they need more intensive
clinical input—that would be the first port of call, if
you like, but until there are better treatments and managements
for people with severe mental illness there are going to be times
when voluntary access, ready access to an acute bed is needed.
Certainly, as we have said, the external evidence, the National
Beds Inquiry produced in February—and we could send in the
facts and figures to people afterwards in correspondence—does
say that there are still major shortfalls in acute beds—particularly
in inner cities and medium secure beds. Back to your question,
I cannot put a figure on it but it is much worse in inner cities.
This is the whole bed-blocking scenario. People who certainly
do not need to be in acute units stay there because there are
not the community-based facilities, including supported housing
and the whole array. Certainly people who ought to be in medium
secure provision are not and they are themselves blocking acute
beds. Quite a few looks have been taken at provision, high secure,
medium secure and acute beds, which the beds survey did. I think
it is timely for someone to look at these things together. It
would be helpful if this Committee did that. It is difficult to
put figures on it because it depends what the mix is in the locality
and what they have got already.
(Mr Wilson) I want to come in here on the issue of
actual numbers and just highlight from my perspective of children
and adolescents that there really is an appalling lack of data
about, for example, how many children are detained under the Mental
Health Act, how many children are in in-patient units, how many
children are first admissions or repeat admissions. From a child
and adolescent mental health point of view we have woefully inadequate
data and therefore it is extremely difficult to get any sense
of what kind of services we should provide. I think it is incomprehensible
that we do not have a National Service Framework for children.
You have set all this up for adults. The clear message I want
to convey to this Committee is that many of the problems you are
talking about and all of these issues of compulsion are crucial,
but you can do much to prevent or ameliorate people's lives if
you invest in children. The fact is that child and adolescent
mental health services are underfunded in comparison with services
for adults. This seems to me to be unacceptable now with the knowledge
we have. We do have very important knowledge about the continuities
that exist between childhood disturbance and adult disturbance
and the two gaps I wanted to raise here are clearly the gap we
have already talked about in relationship to conduct disorders
but the gap that exists between child and adult mental health
services. It is a no man's land, particularly for the 16 to 18-year-olds.
Unless we have better data and unless we have a National Service
Framework for children we are never going to grapple with that
and you are not going to attend to the matter that matters the
most which is how much you can prevent the adult problems developing
in the first place.
Mr Gunnell
150. A question to Mr Farmer. You express concern
in your evidence about the way in which patients you describe
as having a dual diagnosis, schizophrenia and substance abuse,
or schizophrenia and personality disorder, are treated. How would
you want to see them treated? What sort of improvements would
you like to see and does this relate to the use of compulsion?
(Mr Farmer) This is a major problem particularly in
the inner cities. A study by Professor Graham Thornicroft in the
inner cities suggested that there is a dual diagnosis of around
46 per cent of patients with severe mental illness and either
drugs or alcohol abuse as well. It seems very well-catalogued
in inquiries, the great concerns at the problem of treating somebody
with both substance abuse and severe mental illness. Unfortunately
what happens quite often is that people are unsupported on either
side. They are deemed to be too "mad" to go into an
alcohol or drugs unit or too "high" to go into a mental
health service and it does mean that people often end up falling
through the net. I think initial research indicates that there
are two possible routes to go down. One is to have clearly defined
dual diagnosis services for people with mental illness within
the community, and the other is simply to have much more effective
collaboration between the various agencies in addressing and treating
the needs of the individual. If you look at it, it goes back to
the chart we put forward within our submission around treating
the needs of the whole individual and in a sense the substance
abuse issue is the tip of a bigger iceberg around the way in which
the physical health needs of people with mental health needs are
addressed. Very often physical health needs are put to one side
and mental health needs are prioritised. I think that is particularly
the case within the substance abuse field.
151. Are there any specific ways forward that
you would wish to see?
(Mr Farmer) Two things I think. One is we need to
pilot some integrated service approaches. I believe some of that
is beginning to happen particularly in inner cities. Secondly,
we want to undertake a lot more research on finding out what really
works and part of that research needs to be in conjunction with
users themselves to identify what their needs are.
152. Do you think this would involve at all
any element of compulsion?
(Mr Farmer) I would doubt it.
153. Thank you.
(Mr Farmer) I think it is about treating individuals'
needs and responding to their needs.
Chairman: I want to conclude this session in
about four minutes' time. I appreciate there are many areas we
have not covered that we would have liked to have covered. We
will obviously follow up with some written questions which I hope
you will respond to on areas we could not cover. John Austin wants
to ask a question.
Mr Austen
154. I wanted to raise the race and gender dimension
and talk about the appropriateness of provision. Mr Farmer said
earlier that people access services in different ways and I think
all the evidence suggests that far more black people access psychiatric
services through the police or criminal justice system. Black
and other ethnic minorities are twice as likely to be detained
than their white counterparts. Ten or twenty years ago people
were producing those kinds of statistics and it would appear that
nothing in that period has changed. Why do you think this continues
and what do you believe ought to be done about it?
(Mr Farmer) That is why we called our report No
Change? because nothing has changed. I think there are a number
of reasons for this. First of all, I think there remain grave
questions about the way in which the health services in general
treat people from black and ethnic minorities. It comes back to
cultural issues which we certainly have not got time to delve
into now.
155. Would you say it is just cultural issues?
(Mr Farmer) No, it is not. If we have 30 seconds to
make one central point it is crucially round involving users and
carers in planning services and black users have not been involved
in identifying and planning the way in which care for them should
be constructed and should be put forward. Again, if you like,
this is a very fine example of how their needs need to be responded
to. We have not had time to talk about the role of the National
Service Framework which is going to be crucial in laying those
foundations for supporting people and has the potential, with
its commitment to involving not just black and ethnic minority
users and carers but all users and carers, to shape services that
are culturally appropriate.
156. Would the other witnesses share your view
on that?
(Ms Edwards) Certainly we would share the view to
the extent that it is fundamental to the provision of services
that the people who use them and the people who are caring for
the users are involved in planning and the fundamental thing is
that they feel that there are services there which will help them
whatever their needs are. One thing I would like to submit perhaps
in follow-up evidence is the evidence from our helpline which
shows very starkly from all the analysis we do just how much service
users and their carers do not feel that the services are there
which will be able to respond to the range of their needs and
that is fundamental to any modern mental health service.
Chairman
157. Mr Wilson?
(Mr Wilson) I would echo that. We have a lot of information
coming into our organisation that services are not adequate and
certainly for adolescents are virtually non-existent in parts
of the country. I am talking about the 16 to 21 age group where
it is inadequate and young people are placed either in adult psychiatric
wards or paediatric wards, which is very inappropriate. This crosses
gender and crosses race. It is a general picture. I cannot really
draw out any particular distinctive remarks about that because
I think the services are so grossly inadequate across the board.
(Ms Brown) I would agree. There is a big problem with
particularly young black men seeming to be more likely to be defined
as dangerous, and more likely to be in locked wards, and so on
and so forth. I think that does come down to issues about assumptions,
about training of staff and also about recruiting a more diverse
workforce and also very much underlines the point about the need
to involve users, including black users, in saying what services
they actually want and need.
Mr Austen
158. Would you share my view that the failure
to involve and engage people does lead to the psychiatric services
being effectively institutionally racist?
(Ms Brown) Yes.
Chairman: Can I thank you for what has been
a rather short but very interesting session. We have a number
of areas we have not been able to cover which are fairly important
areas and we will write to you about them. If there are areas
you felt we might touch on that we did not that you want to come
back on or you want to expand on any points that you have made,
we would be very happy to receive them. Can I thank you on behalf
of the Committee for a very helpful session.
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