Examination of witnesses (Questions 380
- 392)
THURSDAY 13 APRIL
MR LIONEL
JOYCE, PROFESSOR
FINLAY GRAHAM,
DR SURYA
BHATE, MR
SEAN BRANNIGAN
and MR STUART
ALLISON
380. The National Service Framework does not
cover children and adolescents. Do you think this would make it
more difficult to plan for continuity of care between adolescent
and adult services?
(Professor Graham) I think it would.
381. Also would you welcome a National Service
Framework for children and adolescent services?
(Professor Graham) Absolutely. I think the principles
are almost impossible to disagree with. Certainly within our trust
we are applying it to our youngsters anyway. So we are meeting
with adult colleagues and trying to approach the thing in the
same way. I think children and adolescent services are running
on entirely different principles. Inevitably that will have a
negative impact on the transfer. I think there should be continuity
of service on similar grounds. You need to modify it if you want
to get into the detail. I think it is a pretty easy transfer.
Dr Stoate
382. I would like to follow on straight from
that. What impact do you think the NSF will have on mental health
services?
(Professor Graham) I think the challenge for us in
clinical services is to translate the NSF principles into performance
criteria type targets and make them practical, achievable targets
within the organisations that we run. It is a management challenge.
If we take it up properly it will provide better services for
patients.
383. Do you think it is realistic? Are you in
favour of the concept?
(Professor Graham) I am in favour of the concept.
I find some of the principles and standards very aspirational
and within services if we do not translate that into more clear
operational targets I think it will fail and we will just be playing
with words.
384. How are you going to do that?
(Professor Graham) We have set ourselves a set of
performance targets, for example on the one in relation to gender
we have set specific targets about how we are going to achieve
a more female friendly environment. We have been trying to do
that with other standards as well. I think management have to
monitor to see we have achieved that. I think the other thing
within the health services is that there has to be some reward
for those who embrace change and some punishment for those who
do not. You are not going to get change on some altruistic basis.
We sometimes ignore the basic laws of human behaviour. Movement
down the route of change must bring some sort of benefit and services'
resistance would have to be dealt with in a different way. And
I think we need to think about how you could provide the push
to achieve the change. You cannot just expect us to fall on our
swords and do it.
(Mr Joyce) Just to broaden it to the rest of our services,
the NSF has been extremely well received and the aspirational
bits have also been very well received—what can we do about
mental health promotion and those sorts of targets. It has actually
gone down extremely well. The way government works if you get
a document like that, introduced with widespread consultation
and with widespread credibility and then you move to implementation
and they say, "Where it used to be model A, this is what
we want you to do now, model B. Could you get on with it please
and tell us when you have done it." Or, "Please complete
a plan," which you send back. If we are trying to achieve
major change in our trust we do not write a plan down to our units
and say, "Please now do this." We get some people who
really understand how to do it, some people who know how to do
change management and put them together and say let's discuss
this because it is not going to be a single model on how we change
this. I think the Committee might be interested to observe what
happened in the state of Victoria, Australia where they not only
identified the same sort of policy they went a bit further and
said what is the best model. They then took the clinicians and
they went to each service and said, "This is the model that
we think works. How would you change it to fit your patch?"
They might say, "We have got a Finlay and a Surya, we will
change it and do it like this." Someone else would say, "We
have got a Stuart and he is a bit of problem so what we will have
to do is change the model." It becomes a very interactive
process. It is nice to allocate it down to us but if we want to
comprehensively introduce it across the country one might think
how do you do that in a million person organisation?
385. How do you involve patients and carers
to involve them in the planning of care? What process do you go
through?
(Mr Joyce) Could I ask clinicians to respond about
the individual patients with the individual clinicians. Do we
have a group of users advising the whole service and do we have
a group of carers happily responding to the care areas? Carers
set us another set of problems because we sometimes have carers
in conflict with patients and in the way the law works at the
moment we run into problems when the next of kin rules operate
but the patient's prime relationship is not with the next of kin.
If there is a quick chance to change the law on that we would
be eternally grateful to you. If you have a person for example
in a same sex relationship but their next of kin is deeply opposed
to that sexual mode of life, you find one minute when they are
ill and the next of kin rules operate we are being told this is
what must happen and the moment the next of kin rules stop operating
they say, "Don't you ever talk to my mother again",
and we say, "Right you are, we will talk to your partner."
Carers do give us a problem because that mother needs support,
but the patient says you must not talk to her. That does not mean
as a mother I am not going to be deeply concerned about my daughter.
Someone needs to respond to the mother in a quite separate way,
then there is the partner and then there is the patient. I will
leave the clinicians to talk about the patient relationship.
(Dr Bhate) With children and young people it is even
more complicated. With young children it is normally reasonable
to assume that you work with adoptive or natural parents but a
proportion of those children may in fact be brought to our attention
because of concern about evidence of abuse or whatever and the
Children Act quite clearly identifies that the needs of the child
must be paramount in whatever one does for the child. Clearly
it makes logical sense to work with parents. With adolescents
there are additional problems because some are Gillick competent
for example, some aspects of their difficulties they may wish
not to be divulged, other aspects you would wish to divulge but
in their presence and given the state of marriage and the society
that we are in, you have an added complication of one biological
parent, the other one is estranged and part of newly constituted
families. The question that you asked about the user and the carer
involvement, with children the carers can (apart from parents)
be local authorities because of the law, and the partnership needs
to be there, so it can be with the schools, headmasters phoning
you about aspects of those behaviours, the probation services
and sometimes the courts. And I think even though other people
are involved, and other agencies are involved the parents must
be part of the consultation unless there is evidence that they
have been harmful to that child or child's interest. In psychiatry
it is slightly more difficult because under the Children Act you
can have a court order barring a parent from continuing the contact
but under the Mental Health Act we do not have a legal right to
stop it, although I think we use innovative ways. I have said
to a parent, "I must talk to you to be satisfied that you
are a safe person to be allowed in the unit", because he
was accused of having abused his daughter who was my patient.
He had demanded the right to visit and I cannot stop him coming
in under the Mental Health Act but I said I need to be satisfied
and he said, "What would it involve?" and I said, "Telling
me the whole story of your life." Obviously he has never
spoken to me again. There are those kinds of practical difficulties.
I think we do our best to protect. I think that is true throughout
the United Kingdom because I think professionals who work with
children are very zealous about their obligations to those children.
That is one endearing feature about child services.
Mr Amess
386. Mr Joyce, when you first introduced yourself
and explained your circumstances certainly you took my breath
away, not permanently but you were very open and honest with the
Committee, whether that is because you are overworked and underpaid,
I do not know, but I simply want to explore your staffing arrangements
at the moment. The Committee has had evidence, for instance, from
the Sainsbury Mental Health Centre that there are considerable
staff shortages and I wonder what your difficulties are in attracting
staff and then retaining them across all the different professions?
(Mr Joyce) If I start with medicine. Historically,
the great advantage of being a teaching organisation, having university
posts, was that you could normally fill them much easier than
surrounding organisations. That has been true for us for most
of the time. The downside of it is we are an inner city area.
If you come and work for us you have to work really hard, you
have to work with unpleasant patients, frequently in unpleasant
areas. The competition is Northumberland, the Lake District, County
Durham, so for the first time we are running into real problems
and we are having to rethink what we are going to do about medical
consultant vacancies which originally I had hoped to solve by
attracting a high flying academic who would bring people that
he has trained. I have failed on that front and now we have to
completely rethink that. We have a problem there with medical
staff. Psychologists, we keep offering everyone to be a professor
so they come for that. We are doing some very cutting edge psychological
work and we have grown quite a lot of people because we have a
course locally. At the moment we have some vacancies, certainly
in general adult psychiatry we have some vacancies, but I think
we are still rich in clinical psychologists compared with most
people. Nursing, again because we are in the North East, it is
probably the best part of the world, people do not want to leave
or if they leave they want to come back and be able to get to
see good football. We have not had a major problem with nursing,
although we have ended up having to use the nurse bank, you know
where you buy people, more than we would like to. We are shifting
that around. It has not been an overwhelming problem for us and
we are fairly fortunate compared with, for instance, some of the
problems they have had in London at different times.
387. Thank you for that. I have to say, Mr Joyce,
my team, West Ham, beat your team with just a minute to go, one
shot served us well. Obviously you have pointed out that your's
is a challenging area so it is not quite so attractive. Are you
able to give the Committee any indication roughly of the percentage
of vacancies that you have across the levels? Is it getting worse?
Is it about the same?
(Mr Joyce) Consultancy is worse than it has been for
as long as I can remember. It has been a particularly bad patch
and we have four vacancies at the moment but it will go up to
six out of about 30, so that is rising towards 20 per cent and
that is unacceptably high. We are going to have to move very decisively
to resolve that. Clinical psychologists, the vacancies, we have
four vacancies out of 15.
(Professor Graham) Fifty.
(Mr Joyce) Is it 50? 50. That is significant.
388. I think you have answered my question,
you are obviously all of you under quite a bit of stress because
of the vacancies.
(Mr Joyce) Yes.
389. It must mean that you are disappointed
at the sort of service you can offer because of the staff shortages.
Moving on then quickly to funding. The Government has announced—I
say they have announced, I do not know how many times it has been
announced but we will say they have announced—£700
million additional funding up to 2002. How much of this money
have you had and, if you have had some of this additional funding,
what is it being spent on, presumably not staffing at the moment?
(Mr Joyce) I cannot tell you which source the money
has come from, which bit of the pot. Certainly we have had an
additional million pounds this year to develop our Assertive Outreach
Team and our CATT team in General Adult Psychiatry. We have had
an additional million pounds, also, to introduce a number of low
secure beds. The real deal for us is how are the contract negotiations
going to go, the SAFF negotiations. AT the moment they are going
better than I could have ever hoped, I think we are going to sign
off with a smile on our faces and on their faces. Quite where
those pots have come from, I do not know. In terms of having more
money that would not solve my psychiatrist problem unless we start
to behave in ways I would not allow, which is offering serious
overpayments or recruiting from places like South Africa. There
is actually a national shortage of psychiatrists. What I would
press the Department to do, and indeed they did ask this five
years ago, is to allow many more senior registrar posts to be
banged through or, the alternative is, to tell the Royal College
that we do not need 25 years to become a psychiatrist and if you
took an experienced general practitioner who had been dealing
with these issues and is interested in these issues, I think they
could be converted into a very good psychiatrist in under two
years and I would be happy to pay their full salary during that
time.
Chairman: This is explosive stuff.
Dr Stoate: I am listening carefully here, Chairman.
Chairman
390. Dr Bhate just fell off his chair.
(Dr Bhate) I do not think general practitioners would
give up their lifestyle for the money Mr Joyce offers. I think
there is a serious shortage of general psychiatrists but I think
what is not often reported is a much worse shortage of child and
adolescent psychiatrists. We have no vacancy in Newcastle but
in the North East there are six consultant jobs which are vacant
and you cannot recruit them for love nor money and the same with
Scotland and Middlesbrough where I work part of my time. That
is a great shortage, I think, particularly as we are talking about
working with other agencies collaboratively and seeing those children
in children's homes and everywhere else. Hopefully the situation
will change but it will take longer than the Government anticipates
I think.
(Mr Joyce) Could I add to that because what the current
research is showing is that the incidence of mental illness in
the adolescent age group, for example, talking between 10 and
20, is the same as it is in the adults. We have never set out
to have a service to deal with that. We have always assumed that
with difficult adolescents that is where you have hormones and
you can grow out of it, to suddenly discover that actually there
is real depression, real mental illness that is not being diagnosed
and is not being treated and is resulting in loss of school years
and in opportunities and what have you, I think it is something
that as a society we need to address very quickly and as a service
we need to find ways to reach those patients, identify them within
schools, get them treated and get them functioning again.
391. I am conscious that we are well over the
time we had allowed. Do any of my colleagues have any quick final
points? Can I ask one last question to you, Mr Joyce, hoping you
will reflect your team in your brief answer. If there was just
one central message that you would like to come out of our inquiry
in terms of recommendations to Government, what would that message
be?
(Mr Joyce) You are already going to say joined up
health and social services.
392. We have said it before.
(Mr Joyce) At the moment we are in an extraordinary
position where we have a Secretary of State who understands mental
health services better than any other Secretary of State, we have
a minister who is really well briefed, we have a head of the civil
service, Sheila Adman, who understands it and two cracking leads.
Our problem is if any two of those go the leadership of mental
health suddenly vanishes, so a system that continues to give us
real leadership. Within the National health Service—a special
plea here I am afraid—people like me do not stay in mental
health because if you want to be a successful Chief Executive
you go and find a big teaching acute trust. I am here because
of my personal agendas, which I have shared. I have resisted the
offers of much larger salaries to move across. My job is much
more difficult than their job because I am working multi-agency
and, you can tell, with these difficult people here all the time.
If we could somehow address the issues of management within the
NHS to give mental health services the same status and importance
that the rest of the population feel it has when they are ill,
I think we could make a big difference.
Chairman: Can I thank you all for what has been
an extremely interesting session.
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