Examination of witnesses (Questions 465
- 479)
THURSDAY 11 MAY 2000
MR M WARD,
DR M SHOOTER,
MR D JOANNIDES,
MRS P GUINAN,
MRS L COHEN
and MRS C CRAIK
Chairman
465. May I welcome you to this session of the
Committee's mental health inquiry and particularly thank our witnesses
for coming before us today? For those of you who have submitted
written evidence, it has been very helpful and we are grateful
to you. May I ask you each of you to introduce yourself briefly
to the Committee and say whom you represent?
(Mr Ward) I am Martin Ward. I am Director of Mental
Health for the Royal College of Nursing.
(Dr Shooter) Mike Shooter. I am the Registrar of the
Royal College of Psychiatrists.
(Mr Joannides) I am David Joannides. I represent the
Association of Directors of Social Services, although I am actually
Director of Social Services in Dorset County Council.
(Mrs Cohen) I am Lesley Cohen, former Chair of the
Division of Clinical Psychology of The British Psychological Society.
(Mrs Craik) I am Christine Craik from the College
of Occupational Therapists. I work at Brunel University in the
Undergraduate programme for occupational therapists there.
466. I should like to begin by putting a fairly
general question to you all about what you see to be currently
the key elements driving mental health policy overall. What are
the key determinants which you see at the present time which will
have a bearing on where over the next few years the service moves
forward to? I was particularly struck by the Royal College of
Psychiatrists' comment in their evidence, "So bewildering
has been the rate at which mental health services have been passed
backwards and forwards between hospital, community and primary
care trusts as they have merged and unmerged over the last few
years, that it has been difficult for them to establish integrated
patterns of care with outside, Local Authority agencies ...".
I thought that was a very important point.
(Dr Shooter) I recognise that quote; I wrote it. I
think it is very true. I am a practising psychiatrist myself and
my service has been through three changes, three different configurations
in the last few years. We have survived that and we have prospered
but it has made developing long-term strategies extremely difficult.
My guess is that all our colleagues at this table would say exactly
the same thing. If there were an overall philosophical plea, it
would be for a settled period in which now we can look at the
issues contained in important documents like the National Service
Framework (NSF) and so on, look at the extra resources which are
being granted to us and work out long-term strategies which can
benefit our clients. Settled existence is what we need at the
moment.
467. Picking up the point you have made, it
certainly rings true from my point of view when I look at my own
area. Only last week I was meeting with staff in the local mental
health trust who are not clear who will be employing them in a
year's time. I suspect if there were a Government Minister here,
their argument would be that they are allowing a good deal of
local determination as to the most appropriate direction of mental
health strategies, taking account of individual specific circumstances.
Is that a reasonable response from Government or do you feel that
is a bit of a cop out?
(Dr Shooter) Both. The reasonable bit of that is of
course that local services should be allowed the freedom to decide
what is best for them and what works for them. I do not think
it is particular configurations which necessarily work, it is
the personal relationships within them. Locally, if people are
allowed to sort out how things work best and how different disciplines
can work most closely together, then that of course has to be
a good thing. On a larger scale, that is one of the supreme advantages
of devolution. A problem for an organisation like the Royal College
of Psychiatrists in the not too distant future is that we might
have five different ways of doing things within our remit in England,
Scotland, Wales Northern Ireland and southern Ireland, five different
relationships with primary care groups, for example, five different
potential sets of legislation. That is an opportunity to learn
from each other, work out what sort of things work best and apply
them elsewhere. That is the reasonable bit. Having said that,
it has sometimes felt over the last few years as though we were
into change for change's sake. I have yet to see really clear
evidence on each occasion that merging with this or that part
of another trust is going to save money or be more efficient or
benefit our patients more greatly. It has been an exercise sometimes.
468. Let me be provocative. I can say this perhaps
in a more objective frame than my two colleagues who are GPs but
some people would suggest that your position is based on threats
to your long-standing hospital dominance in this area and the
moves towards primary care are rather threatening to your previous
position and empire, so to speak. That might be unfair to you
but what are your views on the debate currently around movements
towards mental health being placed in certain areas within the
primary care setting?
(Dr Shooter) I should be foolish to pretend that there
has not been a feeling of threat in that somewhere and no doubt
some of my colleagues would still feel that threat because they
have to have it proved to them that new configurations will work
better than the configurations they are in at the moment. The
evidence is not so far extant. Having said that, I personally
and the vast majority of people in the College, would welcome
mental health services being far more closely allied with primary
care. After all, primary care is where the greater portion of
mental health problems is seen and treated. One quarter of GP
seen patients are patients with mental health problems. Very few
of those are passed on to secondary and tertiary mental health
specialist services. They are treated by GPs. Of course we need
to be much closer together in our general liaison, in supporting
primary care services and in administrative structures. I might
say that where I have been personally involved in that sort of
level of working, it has worked extremely well. As it happens
I come from South Wales and, as you will know, in Wales we put
all our eggs in one, the local health group, basket. That means
different disciplines, always under the chairmanship of an important
local GP working extremely closely together, pooling resources
in the pursuit of helping our common clients with whatever problems
they have and the local flavour of their problems. That works
extremely well and we want to see more of that.
469. Does anyone want to pick up the general
point about the overall direction, the uncertainty the Royal College
has raised?
(Mr Ward) To a certain degree I would agree. Certainly
the Royal College of Nursing's position on some of those issues
is cognizant of that of the Royal College of Psychiatrists but
we do have concerns about the absence of strategic thinking. Obviously
the National Service Framework has changed that balance to a certain
degree.
470. Where should that strategic thinking come
from? I think you are implying that it should come from Government.
(Mr Ward) To a certain degree, yes, but it should
be led by people who have the opportunity to undertake the work,
those individuals and clinicians who are responsible for delivering
services and who have as their main responsibility the burden
and the responsibility of care. Those are the people who meet
with patients, the needs of the patients should be met by the
service and what has happened in the past isthat they have been
squeezed into a system which is polemic in that you are either
in the community or you are in a hospital. The gap in between
those two has not been filled by a variety of different kinds
of services which have met the specific needs of the client group.
There has been a misunderstanding about what those needs are and
it has been determined by people who do not come into contact
with them. Certainly the NSF will alter that balance, the necessity
to give people choice and the increase in the advocacy services
and the user movements is going to have a big part to play in
that. There should have been major consultation much further back
than two or three years ago about the strategic thinking itself
and probably as a consequence of that we finished up losing an
enormous amount of inpatient facility because it was assumed,
without any research to show there was any benefit to going down
the community route, that we could go to a totally community orientated
service and that patently is not the case. We have now run into
a situation where we have hard-pressed inpatient services who
will now become almost the Cinderella of the service and they
are seen as something separate to community, whereas in fact community
and the inpatient services are on the same continuum: they are
all part of a service. A patient gets put into a part of the service
which is appropriate to their needs but it is still seen as inpatient,
community and things in the middle, which is ridiculous.
471. You are presumably not defending the move
away from the old institutions, you are just attacking the manner
in which it was done. As you know, I have a background in social
work, so I have a background in mental health work, although in
the early days of the move to community care. Some of us were
surprised to hear that the Department of Health officials appeared
to be implying that community care as a policy had failed. From
a practical point of view, from the work I did, admittedly some
years ago now, I would have some questions to raise about that
because I think a lot of people have actually benefited from the
process of community care. I do not know whether you feel community
care has failed.
(Mr Ward) Certainly I do not feel that community care
has failed because I do not think we have really started it properly
yet. It is early days. What I do know is that the mental health
members in the Royal College of Nursing were extremely upset when
it was implied that they were unable to deliver the service that
they were hard pushed to do. They felt under-resourced and that
is really the issue. It is not about the fact that community care
failed, it was more a question that the resourcing of those individuals
working in the community and the fact that community resources
themselves were not instituted before the organisation had the
opportunity to close down the beds and that there was no continuity
between the closure of beds and the development of community services.
That was where the problem lay and we spent the rest of the next
ten years in a catch-up process. If it is possible to come back
to your primary care issue, we have major concerns about the nature
of the delivery of health care services in primary health care
and the relationship betweenprimary and secondary and tertiary
specialist care. Some recent work has been done, commissioned
by the United Kingdom Central Council for Nurses, which shows
that most nurses working in a primary care setting, in particular
the district nurses, health visitors, school nurses, paediatric
nurses, spend up to 60 per cent of their time dealing with issues
in relation to mental health, yet the organisations in which they
work do not recognise this as core business, so they are not in
a position to support or invest in the training and education
for those staff to do this work. The only supportive links which
those individuals now have are informal with colleagues on the
ground working in mental health with supervision and mentorship.
Our major concern is that with the NSF putting great emphasis
on primary care organisations having to set and refer on, in fact
we are going to be left in a situation where a great many of our
members and nurses generally are in a position where they are
asked to do something for which they have not been trained. It
is causing a great deal of professional stress.
(Mrs Cohen) On the question of whether community care
has failed, I wanted to advance something in general terms and
the philosophy and the philosophy of this Government really in
terms of its attitudes towards mental health. Sometimes very conflicting
messages come across and that is unhelpful in so far as people
are actually working very hard to provide services.
472. Can you be explicit about what you mean
by philosophy?
(Mrs Cohen) I shall be explicit. The mixed messages
are that first of all there is an emphasis on destigmatising mental
health and people with mental health problems, particularly when
Mr Frank Dobson came out publicly with the statement that community
care has failed. Even if that was later qualified in relation
to a number of very key cases, the media message was well across.
I can understand, those of us who are trying to provide services
can well understand, that there is a balance of risks and benefits
and the different players; there are users' needs as opposed to
the requirement to protect the public. The Government has very
clearly given confused messages and sometimes the ones which come
across most powerfully are the ones which frighten people most.
The evidence on community care would indicate that homicide by
people with mental health problems has actually gone down within
the period within which community care has been implemented. The
very thing on which the Government were actually giving the message
that community care has failed in fact has been a success rather
than a failure. It is absolutely right in the National Service
Framework and in modernising mental health services that those
key issues are very clearly addressed, that care is taken in terms
of how that is expressed. No matter what we can do in terms of
health promotion for a mental health service, if key Government
agencies give scaremongering messages, we are up against it. The
other thing is to say that people with serious mental health problems,
very severe and enduring mental health problems, do live most
of their lives in the community and there is still a problem in
terms of how resources aremanaged within. The different commissioning
arrangements are actually going to be very helpful in those terms.
I agree with my colleague here about the confusion. I have lived
through a number of mergers and counter mergers and I would agree
with the point that commissioning services differently does not
necessarily result in better services. It is important that those
services which are commissioned and perform a whole actually adopt
processes and protocols which are in common so that the care which
is provided between the different services and indeed the different
agencies can be better planned and resourced and resources can
be pooled together.
473. You have made some very telling points.
May I ask for the ADSS perspective at this stage? Clearly we have
had some interesting points and mixed messages from Government,
lack of lead from Government. Would you concur with those points?
(Mr Joannides) It is correct that the emphasis must
be on developing more integrated services. We owe it to the public
to ensure that we have single referral points, common assessment
formats. The extent to which we need structural change to achieve
that depends on how well services are performing. I actually believe
the Government is right to give local health communities and local
authorities the right to determine that what matters most is what
works best. There are cases where the maintenance of specialist
trusts, particularly in inner city and urban areas where there
are very significant problems to be addressed, would be correct.
But there are other areas where integrated social and health care
organisations, for instance in Somerset and Wiltshire, are developing
with minimal turbulence, building on already quite strong foundations.
Subject to the Secretary of State's approval later this year,
we shall see the first convergence of community trusts and primary
care trusts to try to address this vexed issue of 85 per cent
of mental health being in primary care and yet GPs and their colleagues
in primary care getting the message that it is not their problem.
Our position is that we actually suppport the Government's tolerance
in allowing local communities to resolve that within an agreed
framework. In answer to your earlier question about the anxiety
that causes staff, it is down to issues of leadership. If leaders
help staff understand that people's needs change, organisation
structures need to change, to address that and if we are going
to engage primary care, we are going to engage local authorities
as a whole, then sometimes we have to effect changes to support
that. Community care has not failed, it has failed some people.
If you look for instance at the social services inspectorate's
evidence of how local authorities have used the mental health
grant and how we have supported resettlement programmes in a very
constructive way from long-stay hospitals, there is no doubt that
there are many thousands of people today enjoying a quality of
life which was previously denied them.
(Mrs Craik) I suppose the answer is that community
care has not failed but it has not yet totally succeeded. We are
at a transitional stage and some of the proposals in the National
Service Framework are a combination of the top up, having a national
view, but allowing local services todevelop, having the potential
to help things improve. The difficulty which my colleague has
mentioned is the cynicism of the workers on the shopfloor that
there have been yet more changes and the concerns they have about
whether this will really improve things. Certainly good leadership
is important but many of the leaders have moved on and there is
not necessarily consistency of leadership and that can also be
a major problem.
Mr Burns
474. We have skirted round and alluded to the
National Service Framework but now we have this Framework which
is meant to be a blueprint for the way we move forward, may I
ask all of you—because I know there are slightly differing
views amongst you on this—whether you are confident that
it will actually become a reality over time rather than just an
aspiration? In particular do you think the necessary funding will
be available to make sure that it does actually work and achieve
what it sets out to do?
(Mrs Guinan) In answer to your first question, the
right response is: confident, no; hopeful, yes. I have been happy
enough to have been involved in both ends of this because I was
a member of the external reference group and I am now a member
of two local implementation teams. The importance is that we now
have a message that every key player understands and that is not
the vague hope that mental health will be a priority but an actual
agenda being set for us that we will all work towards. It is certainly
proving to be a balancing act and one in which other key players
are being recognised. We are no longer in a situation where the
acute tail wags a much larger dog. One of the interesting things
recently has been to see the argument between primary care stakeholders
and carers with the acute sector about how money is going to be
used. I think that is very healthy and very appropriate. It is
helpful because it gives us examples of service models and we
all look forward to receiving the kind of guidelines and protocols
that will inform grassroots practitioners about what they are
working towards, even if they are starting from a very poor base,
which some places are, particularly in my neck of the woods. In
terms of funding I was there when Paul Boateng launched the external
reference group and I actually wrote down what he said, which
was "You will see increased funding the like of which you
have never seen in your professional lives before". You can
imagine I took that down very quickly. That seems to have changed
a little, but it is interesting to be in a position where all
the key players are now putting the cards on the table so that
we are all in the game of being involved in talking about what
increased resources available will come on stream. That is very
useful. We do need some central funding to push the workforce
problems ahead and one or two other matters to do with training.
Hopeful, yes; confident, no.
(Dr Shooter) I should also like to give a hopeful,
yes, which I hope does not sound mealy-mouthed, because it is
not supposed to do. There is a lot of confidence at the moment
and if I could couple thatvery briefly with the questions about
community care earlier, one has to contrast some of the despair
which was felt just 18 months ago in the wake of Frank Dobson's
comment with the very bullish and confident feel about the Royal
College document on community care, the chair of which working
party is sitting not too far behind you. All of us are confident
in the principle of community care and the principles in the National
Service Framework. It has to be right to treat the bulk of people
as close to their home in the least restrictive environment possible.
The seven principles of National Service Framework are incontestable
and offer a framework for jointly putting those into practice.
I have to say though that the devil of course is going to be in
the detailed implementation over the next five, 10, 20 years.
Traditionally we have been rather poor in all the services, perhaps
in Government as well, at monitoring how detailed large-scale
strategies work in practice in local communities and that is going
to be very, very important.
Dr Brand
475. Ten or 15 years ago when mission statements
started to become fashionable, I used to be bombarded with mission
statements and job descriptions by the various agencies now trying
to struggle with the National Service Framework. If you actually
read what the CPNs had on offer and what the OTs had on offer,
the psychologists had on offer and the social workers had on offer,
they covered almost exactly the same spectrum. One of the real
problems—and there has been comment here about leadership—is
that an incredible number of turf wars were being fought on a
very local level. Do you think that the new frameworks we are
now talking about are going to help to resolve that further? A
lot of improvement has been made in the last five years; it just
had to be made because we had such a nonsense.
(Dr Shooter) I hope very much so. If there are twin
problems in the way of implementing something like the principles
of the National Service Framework, they are first of all resources
and before we get carried away with the beneficence of the £700
million we have to remember that we are starting from a very low
base. The reason why one version of community care failed was
because it was trying to work with poor facilities, overstretched
people and all the risks which are attendant on that. We are starting
from a low base and I am yet to be convinced that the £700
million extra is going to be enough. Secondly, you are quite right
in saying the other thing which potentially could stand in the
way of proper implementation is the old turf wars. We should be
stupid not to admit that has happened. We have in the past in
the various bits of various caring professions spent our time
carping at each other from the top of rival ivory towers and that
has to stop. Mental health care is about multidisciplinary coordination
from national down to very local level and we have to make it
work jointly. That means joint strategies. It might in the end
mean joint pooling of budgets, though that of course is a long
stride down the road.
Mr Burns
476. I should be interested to hear the RCN
view on the original question.
(Mr Ward) I would echo what has already been said
in relation to hopefulness. From a nursing perspective we are
just pleased that the NSF has raised the profile of mental health
within the clinical agenda and in the public eye. Our major concern,
if it is a concern, is that the expectations and aspirations of
the NSF are not met and that it falls on the shoulders of clinicians,
not just nurses but right across the board, to accept responsibility
for not being able to meet those expectations. I should also reiterate
what has been said that many clinicians are working at absolute
maximum; they cannot do any more. They are looking for good leadership
to be able to make sure that they convert all that good will,
all those skills, all that expertise, into something positive
which makes a difference. Our major concern is that if we get
to the end of four or five years and the NSF has not been able
to deliver this, people will have invested a lot of time and effort
into it, they just will not know where to go and we shall see
people leaving the Health Service in droves because they will
feel disenfranchised by the whole system. That brings me to my
final point which is that we do need to set in place some mechanism
to evaluate the performance of the implementation of the NSF.
If we do not do that, if we do not know whether what we have now
and what we have in three years' time is any different or any
better, then we could be accused of doing exactly what we did
10 or 15 years ago when we started closing the beds down without
really checking that we were making a difference.
477. What sort of mechanisms would you like
to see that you think would relevantly address the point you are
making?
(Mr Ward) There is no one single answer, it is a multidimensional
response for that. It is essential that we have local evaluative
mechanisms in terms of practice development, evaluating longitudinal
studies, both research and audit processes which establish some
benchmarking around what we have at the moment and what we develop
onto over the next couple of years. It does demand that we link
the research agenda with the clinical agenda in perhaps a more
creative way than we have done in the past. It is also about trust,
being aware of the way the money is being spent and having a feedback
loop into central government to monitor that process.
(Dr Shooter) That monitoring process, the evaluation
process, must be multinational too. We are talking here about
a National Service Framework for England, but there will be a
separate one for Wales and Scotland and so on. They will each
have their different national inflection to them and it is vital
that we compare those and work out what has worked better in some
areas than others.
478. As you will know, mental health services
have been described as the Cinderella service of the NHS; it has
almost become a cliche. Certainly over the last decade successive
governments have sought to strip away that problem in different
approaches. Given that the emphasis of this Government like the
tail-end of the last Government is to prioritise mental health,
because, rightly, it is correct to say that sadly mental health
has suffered from neglect over far too many years both in resources
and prioritisation, to what extent do you think we are actually
going to be able to strip away that description of mental health
within the Health Service and see it at the forefront of health
care in the way that other forms of health care are prioritised?
(Mrs Craik) Picking up a point made earlier about
education and training and workforce issues, we clearly do not
have enough mental health professionals from whatever profession
they come. We do need to do something about recruiting people
and retaining people within the service because that has not necessarily
happened. My colleague in nursing has talked about people moving
out of the profession if things do not improve within the next
four or five years. The problem with the training and education
agenda is that it takes that length of time to bring new people
into the service and that is going to be a major issue both for
recruitment and retention. It is particularly important with occupational
therapy where there is a national shortfall. Also, given the recent
recruitment drive in nursing, while that has been very necessary
and very helpful, it perhaps has left other professions with not
as much to deploy as one might like.
(Dr Shooter) Recruitment is very important and it
may be something which we are going to go into in greater detail
later on. The aim which you outline is dependent on many factors
but three very important ones. One clearly is the political will
and, if we are to believe Ministers at the moment, that is there,
plus the resources which go with the political will and remembering
that we are starting from a very low base. Cinderella is not necessarily
being offered a silver slipper but at least some shoes. That will
be no good if we do not have the skilled workforce to use the
new facilities and the new resources. It is small wonder that
over the last two or three decades our recruitment has become
a problem. I can speak clearly for psychiatrists but my guess
is that I should also be speaking for acute ward mental health
nurses for example. It is becoming very difficult to recruit good
quality mental health personnel. Some people would say facetiously
that you would have to be crazy to want to work in an acute inner
city ward at the moment with the sort of headline-in-The-Sun opprobrium
which surrounds them. We have to address that and that is partly
a political issue, but it is also partly a matter of public education.
All of us know in our heart of hearts and I hope in our heads,
that mental health problems are part of all our lives and addressing
that has to be part of all our responsibilities. As long as we
are still surrounded by the stigma felt by clients, mental health
services and ourselves, that will not happen.
479. I am glad you raised stigma but I do not
want to jump the gun because we shall be coming back to that later.
(Mr Joannides) May I pick up the point from the Association's
point of view and that of local authorities in general? There
is no doubt that governments can and do influence the way that
local authorities invest in services. Despite the fact that we
are not accountable to the Secretary of State, there are mechanisms
in place and sometimes local authorities are actually better at
complying with what the Government want than our colleagues in
the Health Service where at times there seems to be a greater
degree of discretion. We would point to Quality Protects and the
extent to which that has climbed the local authorities' agenda
because of the messages which Ministers have given. There is no
reason why mental health cannot be the same. There is a very strong
performance assessment framework with clear indicators, some of
them interface indicators with the Health Service, about suicide,
about psychiatric re-admission rates, which give us all the evidence
we need to pinpoint areas in which we are not delivering services.
There are resourcing issues, as long as the expectations and resources
are in proper alignment and as long as we can address the critical
problems on workforce planning. Because in the past it has not
been politically popular to invest in issues like training or
in strategic planning for workforce planning, they have not been
frontline investments which members in local authorities have
wanted. The message politically now is that is all right. In fact
you cannot invest in more services without investing in the workforce
structure to deliver on that. What I would say is that I come
back to the point about leadership. It is within my gift as a
Director of Social Services and my colleague chief executives
in trusts and in health authorities equally to ensure that we
give mental health a profile in our budget planning and in our
questioning of whether the proportion of funding within our authorities
on mental health sits in relative balance with our comparator
authorities in a way we can justify to the public that we are
giving mental health a priority that the Government and the public
would want us to give. We can exercise much more influence over
that than we have in the past.
(Mr Ward) To come back to the Royal College of Psychiatrists'
point about the international aspect, I do not think it is just
within the UK, I think mental health has been raised as a primary
part of the health care agenda by everybody. The EU, the European
section of WHO have now identified it, albeit belatedly, as a
priority and recently somebody asked me where I worked and I said
I worked in mental health and they said that must be really good.
It has now become fashionable almost to be in mental health whereas
a few years ago it was something you admitted to eventually.
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