Examination of Witnesses (Questions 180
- 199)
THURSDAY 30 MARCH 2000
MISS ANGIE
SCHRAM, MR
TONY RUSSELL,
MRS PAULINE
ABBOTT-BUTTLER,
MR LEVI
FERGUSON AND
MS KAREN
CAMPBELL
180. Are you worried that it is not just care
and treatment that is going to be imposed, it is a particular
treatment that is going to be imposed, like largactic for the
masses?
(Ms Campbell) If you look at it and study it, it is
very, very prescriptive, where you shall live, what you shall
do. There is whole raft of things attached to this principle of
compulsion in the community.
181. You are not convinced from your experience
of the services so far that the safeguards that might be built-in
would be helpful?
(Ms Campbell) They are not there. They are not there.
The proposals in the original scoping document were fairly extensive
and recognised that it was a breach of autonomy, choice and therapeutic
relationship. They proposed originally a whole set of independent
legal advocacy systems to help make the system work. That has
all been dropped now. One proposal, Model 3, is one lawyer. That
is not a safeguard, that is a non-event, one lawyer looking at
paper, the safeguards are not there at the moment.
Chairman
182. You made a fairly important and profound
statement a moment ago, your belief that to get access to a bed
in areas like London people need to be sectioned.
(Ms Campbell) You would not get in otherwise.
183. That is a very important matter. They need
to be sectioned on the basis of accessing a bed, on the basis
that they meet the criteria of the Mental Health Act, that is
the only way to get a bed. Can you substantiate that?
(Ms Campbell) There was a Report published by the
Kings Fund two years ago which showed in Hackney alone they had
a bed occupancy rate of 140 per cent. What that means is you are
actually bed-hopping, people are being sent home at weekends so
somebody else can come. The level of need in crisis and distress
is so great that whereas fifteen years ago perhaps in an area
like the Isle of Wight or Cornwall you would be able to walk in
and say, "I think I need help, I need a break, a rest from
the kids", and get some psychiatric care, now people have
to be beside themselves and in a state of great pain and emotional
anguish before they are considered for sectioning. They might
not get a bed, it just will not be there. It is an incredibly
pressured system. From recent work that the Royal College of Psychiatrists
have done, and there is a report being commissioned on all this,
the Mental Health Act, and they looked at the current rate of
sectioning and its usage and it is incredibly high in city areas
like London. I do not have the papers to hand but they have just
done that and it has just been published.
Mr Gunnell
184. Looking at the problems from a different
point of view, if you have a patient or a person who feels they
have a problem, how much information can they get in the system
as to what possible services and treatment options they have?
(Ms Campbell) I can answer that briefly, from our
members experience, very little or none, usually. Certainly not
written, certainly not accessible. Most people on entering psychiatric
care are not given a range of options, they are just left to sit
there and maybe see a doctor. There is not a lot of written information
about it. Obviously there is good practice and there are some
pioneering trusts that we do know about who put together packages.
That is usually where they have been working with well established
user and carer groups and they are following good practice. It
is good practice to give a little information pack saying, "This
is about the hospital. This is where the shops are, this is the
phone." Treatment options are rarely covered in writing.
185. Mr Ferguson's experience was that he was
obviously completely put off because his evidence at the start
suggested he got nowhere, even trying to find out what options
and what treatment were available. Are there any other contributions?
(Mr Ferguson) I can just add to what I was saying
and pick up on that point. To be honest, over the last three years
I have had to see local councillors, the MP, the Citizens' Advice
Bureau just to get access to information. You tend to find that
if you are even trying to access information on behalf of the
people you are caring, for one agency, ie the benefit section,
will not share information with housing, housing will not share
information with the benefit section. For two to three years I
was being sent from pillar to post. I was being told that I needed
to have access to this information before I could get access to
another set of information. It was even to the point where the
local councillors and local officials even had problems themselves
trying to get to the bottom of my case. Basically what was happening
was one Government department did not have the information to
show what benefits were being received by certain individuals
so thereby the Housing Department would then impose full rent
when certain people were in receipt of benefit. At one stage I
went to see my mother to try to explain to her why she was getting
letters saying she was thousands of pounds in rent arrears, because
her sick son was living back at home now, who himself was on benefits,
and at one stage my mum said she might as well be dead because
even though I was her son who was given the authority to look
after her affairs, I myself was being so confused and being made
to feel as if I was begging for something. I was appalled to know
that I was an able-bodied person who was reduced to running round
having to seek help from councillors and local politicians just
to get access to benefits. It took three years and various complaints
and having a lot of doors and shutters shut in my face and then
eventually the benefits system, the housing department realised
that really when you are dealing with people suffering from mental
illness and you send them papers to fill in and they do not fill
them in and you should not turn around and say, "If you do
not fill in these papers you will lose benefits." How can
you send papers to somebody to fill in who has a learning disability
which even a lawyer would have problems filling and then as a
result of them not filling in these papers you deny them benefits,
further giving them hardship? I have seen, some years ago, where
by somebody not getting their money on time it made them kick-off,
they got angry. When you are suffering from mental illness and
you are used to that regular money or you get into a routine and
when that routine is broken your whole world falls apart. Sometimes
the system itself actually creates a situation that makes living
with mental health actually worse and more problematic.
186. In the revision of the Mental Health Act
do you think we ought to give people the right to information
so they do not have to go around? I recognise that when you get
constituents coming to see you who really want information which
should have been available to them—I think it may need us
to say there is a right to information for people who come under
the Mental Health Act or they have that right as to what service
is available and to what treatment options are available for them.
(Mr Ferguson) Can I finally mention, the use of language
within that information? Sometimes even when you look at a lot
of the papers written by Government people it tends to be in a
language full of jargon that goes above the heads of the people
supposed to be using the information. If you are a person who
works within the legal framework, you probably have no problem
understanding the language. You do not seem to address who this
information is going to. If you are a teacher working in a primary
school you would not write an essay so that other teachers can
understand it, you would write it so that kids can understand
it. Similarly, if you are going to write information for patients,
carers and users, you have to write it in a language they can
understand.
187. I agree.
(Miss Schram) This is one of the areas that comes
up time and time again and I would like to see things go further
about making a requirement for people under the Mental Health
Act to have information. Anybody who has contact with mental health
services, particularly in-patient services, should have that right.
There are trusts out there who are making a wonderful job of information,
let us see that disseminated, let us see other people picking
up on that and taking that information forward, particularly on
talking therapy, cold therapy. It is impossible unless you know
your way around the mental health system, unless you have any
information. I would like to see that go further, even if there
is something built into the NHS targets, so that people have to
provide quality information.
188. I think we have that message pretty strongly.
(Ms Campbell) Can I make a point that has not been
made? There is a huge stumbling block as to why people do not
easily get written information available on the service and treatment
options. There are not many options around and doctors are very
protective about their clinical freedoms. It is a big job to say,
"You come to us and you can have this, that and the other,
here it is, here is all about it", when there is not a lot
available in medication. There is ECT. If you are looking for
counselling somewhere somebody might tell you about it and that
it costs you £30 a session, that is another reason.
Mrs Gordon
189. Can I say, I totally agree with you on
this information matter. There are good practices within the voluntary
sector. In Romford we have a very good MIND scheme advocacy and
directory so that people know where to get people. There is Clearer
Head, an advocacy service and it helps people back into employment
throughout the country but there is no standard sort of care.
I really wanted to ask about primary care and the role you see
for primary care? You are talking about where you have to get
sectioned to get any help. Usually first contact with somebody
who is not feeling well is their GP. I would just like your opinion
on how you feel primary care actually copes with this and what
can be done to improve the service—I can see by your face
what you are going to say—and whether PCTs will make a difference
with the GPs having to work together?
(Mr Russell) I think primary care groups need to have
access to mental health professionals and easy access to mental
health professionals. I never understood why it is not possible
to second mental health professionals on to PCTs so they can make
informed decisions. It seems to me our first point of access is
our GP. He is rushed off his feet and it would be in the interest
of the GP and in the interest of the patient if they can get quick
and easy access to somebody who understands mental health problems.
It does worry me and it seems to me, as we look around the country,
that people are making it up as they go along. There is no consistency
anywhere. Some people are making a good job of it, because they
are led by people with an interest in mental health, but they
are in the minority unfortunately. Again, it is about sharing
information.
Chairman
190. Can I press you on that? I am very struck
by what you said, people are making it up as they go along. You
obviously were not present for last week's session. I was concerned
about rapidly moving towards great inconsistencies in the organisational
models for mental health provisions from one area to the next,
even within the space of five to six miles. I would be interested
in your thoughts on the role of primary care in relation to mental
health. There has been a big debate that primary care groups should
be given responsibility for mental health services. The current
arrangement in some areas, like my own in Wakefield, is that separate
mental health trusts work better than where mental services are
within an acute trust. Do you feel that in areas like Mr Ferguson's,
in South Yorkshire and West Yorkshire, South Yorkshire ought to
have a South Yorkshire-wide trust that is suggested in West Yorkshire?
These are issues the Department of Health is saying there is no
blueprint for and your perspective is that people are making it
up as they go along. That is an interesting point and it is the
picture I have gained so far. (Mr Russell) I think it is
no coincidence that some of the best mental health services are
the stand alone mental health trusts, Northumberland being an
ideal example of that. The bottom line, as a service user, is
that I do not care what they call themselves, as long as I can
get quick and efficient access to the treatment that I need. I
do worry about the trusts getting bigger and bigger as the re-configurations
and the trusts' mergers get bigger and bigger and, again, I do
not think it is a coincidence that when we go around the country
assessing services some of the worst services that we see are
those run by big acute trusts.
191. Can I press you on that point? One of the
problems that you have with the current arrangement is that there
are certain specialist provisions that exist that are not provided
within many trusts because the requirements for their use are
few and far between, so people then end up having to travel far
and wide to access services that are not in their own area. The
argument is that if you had a bigger trust the more likely you
are to be able to access them. I am not saying that I agree with
that, that is one argument in the wider county-wide perception
of trusts.
(Mr Russell) I was with a room full of PCG people
yesterday and I think the problem is that, firstly, they are getting
inundated in the National Service Framework with all kinds of
things and all of them have to be implemented straightaway and
I do have some sympathy with them when they say they just cannot
cope with it all in one go, but I am worried that it is led by
personalities, not procedures. That is the fact of the matter.
If a personality has an interest in mental health services, we
will get good services. If he does not, we will not. I go back
to needing mental health professionals attached to whoever it
is that is providing the service.
192. You have given me a very clear message
that you, or your organisation, has a view that separate mental
health trusts have offered better services. The picture in some
areas, including my own, is that where we have separate mental
health trusts, they will actually disappear as mental health functions
move in the direction of primary care groups. Would you be worried
about that?
(Mr Russell) I would, because PCG people are crying
out for guidance themselves. It gets back to the access of information.
We need to also develop an information pack for your average GP
so that he knows exactly what services are available and where
they are. It is a big issue.
Chairman
193. You have met Dr Brand before, obviously.
(Mr Russell) I ought to just say that I have very
good experience of West Yorkshire Mental Health Service, having
been hospitalised in Wakefield myself.
(Ms Campbell) Having acknowledged that there are some
good mental health trusts around that stand alone, I think that
is historic and a result of specialisation and protected funding
more than a matter of principle. My own experience is that what
people want is quick accessible care, and the way to do that is
to phone up and see your GP. I would like to see psychiatrists
come out in the community and be part of primary care set-ups.
They are not there yet, not as a matter of course. Some GPs appreciate
the importance of mental health issues and have counselling people
attached where you get six weeks, but GPs themselves have no specific
mental health training. The Royal College of Psychiatrists has
acknowledged that only about 50 per cent of people with mental
health problems that present with a problem get picked up anyway,
and of those 50 per cent only about a third of those get effective
treatment and help. There is a whole raft of people out there
who go to their GP because they are not feeling very well and
never get the help they need.
194. Are you saying that the location of psychiatrists
is wrong?
(Ms Campbell) Accessibility.
195. You are talking about locating psychiatrists
within primary care? (Ms Campbell) Yes.
196. So the entire emphasis will be completely
turned on its head, it would be in the community rather than the
hospital?
(Ms Campbell) Absolutely.
197. Is that something you all agree with?
(Mr Russell) Yes.
(Ms Campbell) Yes.
(Miss Schram) Yes.
(Mr Ferguson) Yes.
(Mrs Abbott-Buttler) Yes. Can I briefly add that,
of course, primary care is a welcomed provision, but I think in
terms of the black community, especially young black men, clearly
primary care is not meeting their needs. If you look at all the
research evidence in terms of findings, you will find that a disproportionate
number of them are not able to access primary care but are sectioned
instead. The thing you mentioned about training of GPs, it is
very, very poor. I, as a carer, recall when I sought advice and
made an appointment for my son to see my GP. He went to see the
GP but the GP's response was, "There is nothing wrong with
your son." Within a couple of weeks I had to call the police
so that he could be sectioned in the interest of his own safety
and others. I think there is a lot of work that needs to be done
with GPs. The final thing that I need to say is that GPs need
to be more culturally aware of their patients. We know that racism
exists within society and, therefore, I would say also that racism
is reflected amongst GPs and they need to take on board that they
have a role to play in terms of making sure that the black community
is treated fairly.
Dr Brand
198. I should have declared an interest. I spent
some years as clinical assistant in psychiatry, so I am as guilty
as the next doctor. I was interested in the discussion about PCTs.
I would like to change it slightly and talk about primary care
as opposed to primary care groups at a practice level. There was
a trend, and I think somebody alluded to it, in fund holding where
some of the practices started employing their CPNs and counsellors
and bringing the secondary care work into a primary care setting.
In the last two years the fashion has changed to having crisis
intervention teams visiting the community but being firmly based
on institution in secondary care. Do you have any views as to
which model is more appropriate, because certainly, in my experience,
if you have a good crisis intervention team, they deal with the
problem so well that primary care themselves becomes totally divorced
from the day-to-day treatment of psychiatric illness?
(Ms Campbell) I think there is room for both and there
should be both, because they are not mutually exclusive. I know
that the preferred model that is indicated in a lot of surveys
is to be able to receive their support and their care in a primary
care setting. The big problem that we have not mentioned is the
gap. If you go to primary care and you are deemed in need of support
in crisis, it could be ten weeks before you see a psychiatrist,
by which time you could be climbing the wall. So the gap is there
and the two models do not exclude themselves. You sould be able
to have your CPN appointment in your local surgery, but if things
get really bad and you have gone beyond the out-patient appointment
stage, then you bring in the crisis intervention team. We are
talking about seamless care. There is room for both I think.
(Mr Russell) It is a difficult problem, is it not,
because it is a geographical problem? I live in the Wear Valley
in Durham, out in the middle of nowhere. Having all singing, all
dancing teams in the hospital 40 miles away from me, where I have
to get three buses to reach it, is not any good to me. It is about
quick and easy access, and if my GP practice happens to have a
mental health team attached to it, that would be ideal in my view.
(Miss Schram) Can I just take what you were saying
about the crisis intervention idea slightly further? We were talking
to a group of service users last week in our region and somebody
came up with a really nice phrase, they said that it is lovely
that people come and intervene when they have a crisis and it
is lovely that they have rapid response, but not-a-crisis-resolution
team would be nice, where people could actually come in and really
do something to help, not just come in and hold the fort for a
few hours, but come in and actually get that person on a programme
to get them feeling better.
199. The really behind my question is that the
more the treatment of chronic mental illness, in this case, is
dealt with by a specialist team, the less preventative work is
done by the primary care team.
(Mr Russell) That is dangerous, is it not?
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