Examination of witnesses (Questions 338
- 359)
THURSDAY 13 APRIL
MR LIONEL
JOYCE, PROFESSOR
FINLAY GRAHAM,
DR SURYA
BHATE, MR
SEAN BRANNIGAN
and MR STUART
ALLISON
Chairman
338. Colleagues, can I welcome you to this morning's
session of the Committee. We welcome our witnesses. We are very
grateful for your co-operation on this inquiry. Could you briefly
introduce yourselves to the Committee.
(Mr Brannigan) I am Sean Brannigan, clinical co-ordinator/senior
nurse for the forensic community mental health team. My background
is obviously in nursing. I have worked with Newcastle now for
about ten years and previously assisted in the commissioning of
Newton Lodge. I do that half time. The other half time of my job
I am a newly appointed case manager working with the Northern
Region's commissioning team looking at people who need high, medium
and low secure services.
(Professor Graham) Finlay Graham. I am a Consultant
psychologist, head of the adolescent forensic psychiatrist services
in Newcastle. I have been a psychologist for 27 years. I have
worked in the police, prison service and social services. I have
worked in general adolescent psychiatric health service and I
have been in forensic adolescent psychiatric health service for
the last few years. I am a visiting professor at the University
of Northumberland.
(Mr Joyce) I am Lionel Joyce. I am the Chief Executive
of the Trust. I have been working as a Chief Executive running
mental health services first in Nottingham and then in Newcastle
for about 17 years. The team I have brought with me has a preponderance
of interest in adolescents and in prison and forensic services
because that was what we were deducing was an area of interest
of yours. We cover a large range of services, all the regional
specialties, and we will attempt to answer your questions. Can
I add one other thing which is that I am a user of services. I
spent nearly a year as a patient in a psychiatric hospital earlier
in my life in my mid-twenties and recently have been a user of
our own services when I suffered from severe depression and was
off work for six months.
(Dr Bhate) I am Surya Bhate. I am a child and adolescent
psychiatrist. I have worked for 25 years as a consultant with
the older age group of children and for the last seven years with
Finlay Graham I established the third specialist adolescent forensic
service.
(Mr Allison) My name is Stuart Allison and I am a
social worker based at the forensic community mental health team
at St Nicholas' Hospital in Newcastle. My experience dates back
to 1990 when I started doing voluntary work in South London. I
progressed through local authority children's homes systems, working
with young offenders and then went to work with the Inner London
Probation Service prior to moving back up north to take up my
present post.
339. Obviously we are going to cover a wide
range of areas including areas where you have got specialist expertise.
I am concerned that there is a second session, as you are aware,
so we will try and keep our questions brief (says he) and I hope
your answers can be reasonably brief as well. Can I begin, Mr
Joyce, by asking a general question. Could you briefly describe
your local structure and arrangements, in particular things like
the population served by your trust and a brief history of the
local mental health service bearing on where you are now and where
you are going, the hospitals providing psychiatric services and
the other specialist provisions that some of you relate to and
where you are at on PCGs and PCTs and co-terminosity with social
services. These are the general areas. Give us a broad picture
so when we are asking questions we have a rough idea of where
you are at on such issues.
(Mr Joyce) Thank you, Chairman. We are fortunate to
serve the finest city with the best football team in England.
340. I am a Rugby League man myself
(Mr Joyce) In Newcastle we serve a population of 270,000.
We also serve the population of North Tyneside and that is slightly
unusual because we serve that population because the local authority
approached our trust and asked if we would go in and provide mental
health services because they were so dissatisfied with the NHS
at that time. Because we are a teaching trust we employ a number
of professors and researchers. We operate a range of different
services. We quite set out to operate different services. So at
North Tyneside we have a very standard district general hospital
serving three-quarters of the population of North Tyneside. Community
mental health teams are based in those catchment populations.
We then have a fourth quarter of North Tyneside where we experimented
with an entirely different approach to mental health services
and we took an acute ward and based it in the centre of Long Benton
and we turned it into an in-patient unit, a partial hospitalisation
unit, a community mental health team and a walk-in walk-out 24-hour
service for that particular population. We then cross the boundary
to Newcastle and have three distinct services there. We have north
of Newcastle where we operate acute beds on an old asylum site
but we have just recently rebuilt them with a separate women's
section where the community mental health team is based in the
same premises as the acute in-patient team. We then have the east
of the city which is a fairly deprived area. That is served by
beds in the Royal Victoria Infirmary, a classic old infirmary,
now brand new teaching hospital. Then we have the west end of
the city which is the other very poor area where we have three
community mental health teams working an in-patient unit as a
separate unit on the site of an old general hospital. Those models
are changing even as we speak because we believe there are better
ways of doing some of our services currently being demonstrated
in Melbourne and therefore we are looking to bring some of that
back. In fact, we have bought some of that learning over from
New Zealand into our trust and we are trying to change some of
those services. We are doing it in two patches. What we have is
a continually evolving set of services. We do not believe it is
our job to arrive at a single model but to continually be pushing
the boundaries out because that is what teaching trusts exist
for. We are moving on from all the models that were set out to
try to find better ways of doing things. In addition to the general
adult psychiatry we provide forensic services for adults. We set
up forensic services for adolescents and that came about because
we took on adolescent psychiatry—and I would like to pay
tribute to Dr Bhate—when it was a five-day-a-week school-refusing
service. Surya turned it into a seven-day-a-week really ill kids
service and then he came to me and said, "I have just been
to Lower Newton remand prison and I have seen the way they are
looking after some of those adolescents. It is disgraceful. You
will do something about it." We agreed to jointly do something
about it and we went off and recruited Finlay and I hope we will
have an 18-bed in-patient unit doing that sort of work. We also
do children as a separate unit. We do child psychiatry and we
are changing the way we do that because it all used to be rather
precious and remote. It needs to be out there working with GPs
and working with school nurses. So we are changing that model.
We have got some wonderful old age psychiatry services but I will
not talk about those. We do drugs and alcohol and I think they
have had enormous problems in the last ten years. As a result
of the introduction of contracting drugs and alcohol services
have dramatically changed their shape not because of what was
needed professionally but because of the way the money went. We
do cognitive therapy. We integrated that and psychotherapy and
transferred some of our psychotherapy into borderline personality
disorder work. I think that has been quite a useful development
for psychotherapy. The other aspect of psychotherapy is that it
is used for supporting our medical staff, a private support service
to all the medical staff in the northern region. We were the first
unit in the country to bring cognitive therapy over from Philadelphia.
We are now doing some astonishing work, I find it astonishing
work, where we use cognitive therapy with schizophrenia and what
we are finding is if you can get that to work with people with
resistant schizophrenia you can improve their symptoms quite dramatically.
So we do that range of therapies. I am sure I have missed another
service out but I cannot remember it at the moment.
341. That is a very comprehensive answer you
have given us. Clearly we have been exploring different models
in the inquiry so far and different areas of different models
and you have got different models within your area.
(Mr Joyce) Absolutely.
342. What conclusions have you drawn of how
appropriate those models are? Where do you see the service going
in the future? Are there difficulties for example in one trust
having different models? Clearly you represent different communities
within Yorkshire, I appreciate that, but I am certainly concerned—and
Mr Brannigan presumably knows my area of Newton Lodge—if
I am looking five years hence from where we are now I cannot predict
where my service will be in Wakefield. That slightly worries me
even though I am happy to listen to the explanation of different
models. I wonder how it all fits together and the way you see
it going over the next few years?
(Mr Joyce) We do not, unfortunately, see any golden
or silver bullet arriving to deal with mental illness. The range
of responses we currently have will need to continue. Effectively,
they are the same range of responses where we have psychiatrists
working with drug therapy, we have psychologists working with
psychological therapies and the two of the them should be working
absolutely intimately. We have mental nurses providing a range
of therapies and direct care. We have social workers trying to
make the rest of the world work for patients. That is a real problem
for us because as soon as the patient get out of our closed system
they do not get decent incomes, they do not get jobs, they do
not get proper housing and the whole of the rest of society does
not help us to do our work. So we expect our services to continue.
The way you deliver those services is something we are still learning
about. That is true of every bit of medicine whether it is heart
disease or diabetes. How do you reach someone who is about to
suffer from schizophrenia? Is there a way you could predict an
on set of psychosis in an 18 or 19-year-old. Five years ago people
would have said, "We don't really think so." Now we
are thinking may be there is. The fact we might be able to predict
it earlier and reach the patient earlier is good news but I do
not think we will need any less of those services. We have to
find better ways to reach those patients and retain them. A big
new problem for us (and you) is drugs. Most of our patients have
dual diagnosis. They come to us and they are not only suffering
from psychosis but also taking numbers of drugs in various forms.
How do we manage that? Do we need a special service that reaches
young men, for example, and allows them to go out clubbing and
acknowledges that they are going to take drugs and still has an
environment they can come back to and be cared for because on
a general ward that is really very difficult where you have other
people with other conditions who do not want young men out of
their heads on wards. So we have to think about how do we reach
the patients, keep in touch with them and help them get better.
That is not going to go away.
343. As you may be aware, several members of
the Committee spent part of this week in Birmingham looking at
some of the stuff in the North Birmingham Trust where they are
looking quite radically at separate services with respect to assertive
outreach and providing centres at a local level and linked in
a very interesting way with primary care. Do you have separate
services within your local arrangements in your area? You mentioned
the community based teams that you have got.
(Mr Joyce) We have got community mental health teams
and they are fairly comprehensive but we have also got an assertive
outreach team and that will try to capture those patients with
severe and enduring—
344. That is separate?
(Mr Joyce) Yes. We are also developing what is known
as a crisis outreach teams (CATs) so that the first contact that
someone will have is not with one of the community mental health
teams and not the psychiatrist for that patch, it will be with
the crisis outreach team. We are taking this experience from the
same part of the world as North Birmingham took its experience
from, John Hoult and all that home treatment stuff. What they
are doing in Auckland, and probably doing it better in Auckland,
is when you get that first contact and you are doing that assessment,
the first desire is to keep people at home but that may be undesirable
for the family or for the individual. The second thing is what
is the minimum support they need. We do not do this in the United
Kingdom but why do we not rent a hotel room? So they negotiate
with the local hoteliers because quite often someone needs simply
that, withdrawal from an environment and then support from a team
going in. So they are looking at that. Admission to an in-patient
ward will be a position of last resort. We expect 12 months from
now to see that as being very successful, reducing the number
of in-patient beds and then we will start releasing resources
from those beds to roll that model out across our whole patch,
but it has to prove itself.
Chairman: One of the things we looked at yesterday
was the relationship with GPs and primary care groups and I know
Peter wanted to briefly explore that area.
Dr Brand
345. I am interested in two trends going on.
One is to have more psychiatric intervention and support based
on a practice model but at the same time we seem to be developing
all sorts of geographically based specialist teams. You have already
used the example of your crisis intervention team working in parallel
with your community psychiatric team. How in practice do these
two trends work together?
(Mr Joyce) I do not think we have really resolved
how that is going to fall out. We have quite close relationships
with some practices with particular consultants so that a consultant
will go into the practice and review cases on a fortnightly basis
for instance is one thing that goes on. Where we have got a CAT
team the GP, who is often the first person phoned, will call the
CAT team and hopefully they will then work out a plan of care
together and that will be a mutual plan of care, particularly
if someone is staying at home. What I would not want us to under-estimate
is the sheer quantity of mental illness. What we deal with largely
is very severe and enduring mental illness. What GPs have huge
numbers of is other less severe forms of mental illness. A lot
of GPs struggle with that as it is because, after all, their training
might have included no psychiatry. There is no requirement for
them to do a psychiatric attachment and we are talking to them
about whether we need specialist general practitioners with additional
support around mental health and we have had a few sessions currently
linked to one of our academic departments to explore that. We
are going to be actively talking to a primary care group about
whether we should be creating a new consultant, a consultant of
primary mental health who is actually a GP we have given additional
training to because we do not think there is a simple answer to
it or a simple division between "you are a primary care mental
illness" and "you are a secondary care mental illness"
because mental illnesses, as you know, swing in severity from
one to the other Some GPs are really excellent at handling quite
severe forms of mental illness and others have little knowledge
and little interest. We need to accept that those differences
are going to continue and try and arrive at population-wide solutions.
We think that primary care groups and maybe primary care trusts
could give us the opportunity to shape a service around a whole
group of practices. That might be more economical and more satisfactory
for most of the GPs and patients.
346. Do you see primary care trusts taking over
the management of the whole gamut of mental health other than
the regional specialisms presumably brought in by multiple trusts?
(Mr Joyce) The consensus I have picked up from my
colleagues is that about five years from now that will probably
have happened and if primary care trusts develop the sort of strengths
and expertise everyone hopes they will, that will happen. What
would frighten us all is if there were any attempt to do it now
when the PCT and the organisations have not acquired any maturity.
The view of what is needed in secondary services has not got across
to what is needed in primary care, yet primary care has large
quantities of its own demand but frequently does not see what
the demands are on our services because the numbers that come
through every GP are not large enough.
347. You have so far talked about relationships
between primary care and your own services but in practice there
are so many other agencies involved, government initiatives funded
for two or three years and then disappear, use of the voluntary
sector and certainly in my own home patch consultants will refer
to voluntary sector organisations yet not be prepared to take
on any responsibility for what happens after that referral in
the voluntary sector. Some work there is absolutely excellent
but there is very little evidence available to know whether that
organisation is actually doing the job that we hope it might be
especially in things like drugs, alcohol, and some of the counselling
services.
(Mr Joyce) Some things have gone wrong, I am afraid,
as a result of the creation of trusts and one of them is our relationship
with voluntary organisations because when I used to work just
in a health authority I was the health authority person on mental
health and my job, as I saw it, was to make sure that all the
voluntary sector was robust and successful. If they got into trouble
they would phone me up and I could get a cheque in a car and go
across and say, "Here is the money. Keep going because we
cannot afford for you to break down." When I became a trust
they said, "You are not allowed to be friendly with the voluntary
organisations, they are your competitors. You are not going to
be allowed to give them any money. We do not want any of your
staff on their boards." MIND which was a superb provision
for patients in Newcastle went bankrupt and collapsed leaving
100 patients without care.
Chairman
348. How recently are you talking about?
(Mr Joyce) About 1993. We were a trust from 1989-90
even though I have to say we opposed trusts and felt they were
damaging to mental illness and could produce evidence to support
that. Then they got harder and harder about trusts and voluntary
organisations being in competition and those rules have not been
changed so that nonsense still exists. I still cannot fund voluntary
organisations. I would normally be saying to Finlay, "Why
aren't you on those adolescent charities?" I want to know
that every one of those charities is working well. I think that
is my job. I am on the Workforce Action Team for the implementation
of the NSF and I do not want in any way to prejudge its outcome
but the evidence I have given to them is we need a different type
of worker. We need a worker who can address the whole issues about
an individual in the community. There are issues about income
because if you try to get income out of social security that is
a nightmare if you have got an illness of variation; housing,
which sometimes gets well done and sometimes does not; employment,
which never gets well done and if you are not going to be employed
what do you do during the day? Not my problem, not social services
problem, so who is going to take that responsibility? I think
we need another type of worker to give that much more holistic
care.
Dr Brand
349. But not a completely different department?
You want to have them integrated within what you do?
(Mr Joyce) It is in some ways another department because
you have got the other government departments who are all following
different agendas and so often mental illness drops off everyone's
agenda.
Chairman
350. You would like to be a purchaser as well
as a provider and also much more comprehensive enabling you to
cover all the services that you describe? You would therefore
share the view that we should integrate health and social services
formally in some way?
(Mr Joyce) Yes.
351. Your colleagues agree with you on that?
(Professor Graham) Absolutely.
352. For the record, everyone is nodding and
saying yes. What do you see about the existing professional roles
because the logic of what you have suggested organisationally
(and when we recommended that we recognised this point) is that
you are looking at a different professional. What about the CPN
relationship with the social worker? I would be interested in
Mr Allison's views on this problem with his background. I have
a social work background but I am also very conscious of the way,
when I look at my own area, in which the work CPNs are doing and
the work social workers are doing could be combined in a more
effective way and would be if you combined the organisational
base of the operation. I do not know if you have any comments,
Mr Allison, from your point of view.
(Mr Allison) I am quite unusual in the setting I work
in in that I share an office with CPNs, occupational therapists—
353. You are employed by the local authority.
(Mr Allison) I am employed by the local authority
but my money is supplied by the local city health trust. My accommodation,
as I say, is shared with CPNs, OTs, Mr Brannigan and our admin
support. As a multi-agency team it works very well in that it
dispels some of the mythology that surrounds some of the different
professions. Having said that, we do have a slightly nonsensical
situation where because we are employed by different authorities
we have to keep separate case notes. We have got two filing cabinets
next to each other, one which is the local authority social services
case notes and the one next to it contains the medical notes.
Clearly it would make sense to amalgamate those things.
354. I am interested in Mr Joyce's point about
what you were able to do in funding voluntary organisations. We
came across in our previous inquiry a situation in Dorset, if
I recall, where the local health authority was actually buying
social care services, I think illegally. I should not say it was
Dorset, it was somewhere in the South West of England, but they
were doing it. What they were doing was excellent and was right
but what it illustrated was the barriers that were caused by means-tested
social care services addressing the needs of somebody who had
health problems. The barriers were so obvious that they got round
it by the health side purchasing care services which seemed rather
odd and illustrated the problem. Has the common budget issue with
the Health Act made a difference to that kind of problem from
your point of view?
(Mr Allison) I think this is something—
355. It is early days yet, I know.
(Mr Allison) Yes and I know for example in the National
Service Framework the amalgamation of the care programme Launching
Care Management is another facet of that. I am not sure that I
can give a clear view on that.
Chairman: Okay. Peter, have you finished?
Dr Brand: Yes.
Chairman: John? Be careful, Mr Joyce, he supports
Leeds United!
Mr Gunnell
356. I will not talk about that. It is a complex
issue at the moment but it is certainly true. In their evidence
to us about people with acute mental illness the Department of
Health stated, quite bluntly I guess, that care in the community
has failed, but other evidence we have had has taken a very different
view. The National Schizophrenia Fellowship, for example, said
where care in the community has been dealt with effectively it
has dramatically improved the quality of life of many people or
that it is a good concept ruined by under funding. How would you
assess the impact of care in the community for these patients
in your own area?
(Mr Joyce) If to take this lovely emotive phrase "care
in the community has failed" one has to ask the questions
"Whom?" and "In what way?" If I look at the
situation that patients were in 20 years ago they were housed
but they were housed in dormitories; they were fed but they were
fed on a budget of £10 a week; they were entertained but
that consisted of a very old film on a Saturday night; and their
risk of violence and committing violence was very much higher.
I think 80 per cent of those patients are in immeasurably better
domestic circumstances, financial and humanitarian circumstances.
A number are not. A number have ended up in our city in hostels
run by the criminal fraternal and our ability to reach out and
protect them is limited because I do not have the ability to influence
housing or income. I could say, "I have done this deal with
social security, they are prepared to fund this. We have done
this deal with housing and they are prepared to allow that. During
the day we could organise this for you." Not only do I not
have the power to do that, I do not have the person, I do not
have the expertise who could put that together, and that is where
it has failed. It has failed to give patients the sort of lives
that all the rest of us would expect.
357. At its best it is working very well and
has brought about dramatic improvements but there are failings
in the way it works for some patients in practice?
(Mr Joyce) Yes.
358. But what proportion of acutely mentally
ill patients do you care for in the community as opposed to in
hospital?
(Mr Joyce) It is a very tiny number that now end up
in hospital for any great length of time, what would have been
the old long stay patient. But some of them do end up in hospital
for a long time simply because we cannot put that package together
well enough for them.
359. But your aim is to care for them in the
community?
(Mr Joyce) From personal experience I would say that
of anyone who has spent time on a hospital ward would go hell
for leather for that.
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