Examination of witnesses (Questions 520
- 539)
THURSDAY 11 MAY 2000
MR M WARD,
DR M SHOOTER,
MR D JOANNIDES,
MRS P GUINAN,
MRS L COHEN
and MRS C CRAIK
Dr Brand
520. This is very interesting. I think you have
quite an educational job to do with some of your members in my
experience. May I pick up the issue of treatability because again
it depends which discipline you come from? I think the psychologists
or the psychiatrists with a more psychological bent would say
that most people can be treated no matter what their personality
disorder if the resources are there and the time is there. I have
a worry about the definition being used in resource allocation
and you can almost design outcome by the resources you put in.
(Dr Shooter) We do not have a clear answer to that
and we would share the feelings of the Home Affairs Select Committee
on this. May I very quickly pick this issue apart a bit because
it is important that we do not conflate levels? We know a lot
about personality disorder per se. There are some differences
between classification systems in DSM and ICD and so on but broadly
speaking we would agree with categories of personality disorder
and with many of the sorts of treatment which might be available
to them. It is bread and butter to most mental health services.
That is a spectrum, so we also know quite a lot about people at
the severe end of the personality disorder spectrum. I would suggest
that amongst all health professionals and probably politicians
too there begins to become less agreement on how people should
be treated at the severer end and in particular some of the specialised
treatments which are necessary. The step which has been taken
from there to dangerous severe personality disorder is a very
difficult one and fraught with disaster. The link between severe
personality disorder and dangerousness is extremely tenuous and
poorly researched. We will find that most people with a severe
personality disorder are not dangerous and most people who are
dangerous in the Government sense will not have a severe personality
disorder. I am alarmed and I think the College is alarmed at the
rate at which DSPD has become common currency, as though it existed
as a valid diagnosis and it does not. On the back of that, we
have some extraordinarily expensive proposals being looked at
as though the research will prove—back to front if you like—a
very tenuous philosophy which has been put forward. We need to
look at that very carefully.
Dr Brand: This was certainly something which
came up in discussion during our visit to Broadmoor.
Mr Hesford
521. In terms of compulsory community treatment
orders, the relationship between the professionals and patients,
how is that going to play out? Does anybody have any comments
on that?
(Mr Ward) There is a belief amongst a great many community
mental health nurses that this is going to place them not just
in a relationship difficulty but legal difficulty as well. It
is a rather invidious situation to imagine that as a community
psychiatric nurse whose risk taking is probably higher than any
other community psychiatric nurse. The clinical risk taking undertaken
by community staff is around the notion of whether or not an individual
can be left, is being assessed properly, is being treated properly
over time and with limited amount of clinical contact. You have
to take more risks, and that is with any community staff, than
you do when you have the resources of an institution acting on
your behalf. To also then place yourself in a situation where
you have to develop a relationship with that individual over time,
to work with him either as an outreach worker as a case manager
or as a CPN there is an element of trust which goes on between
the two individuals. A lot of our CPNs feel that if they are now
placed in a situation where they say to an individual that this
is a relationship based on trust, they are equal partners in that
relationship, the degree of equanimity between the two is equal,
however, if the individual does not do as they say then they are
either going to have them removed to a place of safety and into
a hospital, or they are going to force medication on them against
their wishes, that is something which they are finding very difficult
to come to terms with. It may well be that on some occasions,
and I know of a lot of instances where clinicians will argue this,
actually a patient is quite happy knowing that a person has responsibility
over them and can take responsibility for clinical actions, it
gives them a sense of security. However, the vast majority of
individuals receiving care and support from community psychiatric
nurses are disadvantaged by the nature of their condition anyway,
have difficulties associating themselves with society, do not
necessarily make contact with traditional health services in a
way we want them to, so it is already a complicated and complex
relationship which is being developed. I might add that I have
yet to hear a CPN say yes, compulsory treatment would be a really
good thing and I have to say that most of the clinicians are against
it. The argument that they are putting forward is that they are
concerned they are going to be used as storm troopers for the
social risk agenda and also that it is another way of getting
round a lack of beds within the inpatient facilities; if this
person needs to be treated that badly they should be in hospital,
not left in the community, is their argument. If you do add an
extra complication like the compulsory treatments which are being
suggested at the moment then you are misusing the facilities and
resources we do have by placing emphasis on community staff who
are already taking clinical risks and who are going to have to
walk away from that patient once the treatment has been given
with no method of monitoring or assessing its impact. There are
lots of issues here, not just about whether or not we should increase
our ability to provide compulsory treatment to people in different
environments. It is about how that is going to be used, who is
going to enforce it, how it is going to be seen and in terms of
stigma and risk and lots of other things which have been discussed
here today, it has dramatic implications for all of those.
(Mrs Guinan) My professional group would support that
view very strongly indeed. I did the Society's response to the
Green Paper and collated a lot of people's views on this. That
particular view, in terms of the practicalities of the people
who will actually have to do that work, came over very strongly.
Treatment is being used in a very narrow way here. It tends to
imply medication. It is important to remember that some users
have been very vocal in saying that they would consider that to
be free of the unwanted side effects of medication in hospital
is actually a preferable and less restrictive alternative than
being indefinitely medicated in the community. A number of vocal
users, some of whom were involved in the external reference group,
pointed out that they stopped medication against medical advice
and that they were able to maintain their recovery. We are concerned—this
is not an anti-medication plea—that people should not be
in a situation where compulsory treatment in the community is
used as a first option because it is an easy option and that people
should remain medicated indefinitely.
(Mrs Craik) I would support the views of my colleagues.
We would all realise the difficulties it places on frontline professionals.
(Mr Joannides) May I reflect a different perspective?
Contrary to my colleagues' views, our Association has not picked
up a strong body of concern amongst approved social workers. We
talked earlier about the core competencies and moving towards
more integrated workers. One of the strengths of ASWs is that
they have been able to look objectively within community teams
at issues about rights and responsibilities. We are taking a slightly
different perspective, we are saying that with much greater improvements
in care coordination, in discharge planning, with an NSF which
is resulting in much stronger community support services, we believe
there is a place for the use of compulsory assessment and treatment
although we have said in our response to Government on the Green
Paper proposals that we do believe there does need to be greater
safeguards in line with the scoping group's recommendations. We
would say that used properly, and there is potential for abuses
of power, we believe that care and control are indivisible. Social
workers probably live with this with children's services more
frequently where they have to balance issues of care and control.
I have not picked up through the Association any strength of feeling
amongst ASWs, as probably the people who would be most likely
to be applicants in situations like that, that there would be
a very strong resistance.
(Dr Shooter) I never thought I would be heard saying
this: may I add a word in support of CTOs as well because it has
to be said? We were not against the idea of community treatment
orders as a College from the outset; that was a mythology. We
were against the idea of community treatment orders being seen
in isolation. When reforms to the Mental Health Act were proposed,
what we said was that we needed a reform of 1959 proportions not
of a tinkering nature of 1983 proportions. We were very much against
community treatment orders being bolted on in some sort of way
as an afterthought. Community treatment orders need to be seen
within the whole panoply of the mental health system. I cannot
believe that community treatment orders per se are a bad
thing. Our Scottish members would say they had been working very
well in principle in Scotland for a long, long time. The philosophy
behind them has to be right that people should be treated as close
to their homes as possible and that at every point in the system
we should be asking ourselves whether this person, albeit under
compulsion, is better treated in the community or better treated
in the hospital. One cannot argue with that and therefore cannot
argue with a philosophy of having a treatment order to allow that
to happen. You can see certain sub-specialties in child psychiatry,
in old age psychiatry and so on where that is particularly important.
What we worry about is the potential proliferation of treatment
orders, for the reasons we have already talked about, because
if community treatment teams are being bowed down with a massive
increase in CTOs, of course it is going to affect their therapeutic
relationships; how can you give proper care in the community to
people when you are running around from one house to another all
over the place. The same thing applies to the acute wards too.
I should like to pick up the interesting point Mr Ward made about
the actual quality of the relationship between a mental health
professional and their client and how the mere fact of being involved
in the compulsory sectioning process may affect that or not. When
we were devising our response to the Richardson committee, we
took very careful cognizance of members' feelings about this.
It was very clear that many of them, most of them, resented the
position of being gaoler and treater at the same time. The majority
of them said to us that it would be better if the responsibility
for applying longer term assessment and treatment orders was lifted
from our shoulders and given back to some quasi judicial body.
There were other people, older people in the College, who said
that we had fought for a century to wrest this process from lawyers
and this was ratting on that. I think times have changed, we heeded
the new thinking and that is what we actually went for. We supported
the tribunal system. However, there are people, and I appreciate
their point, who say that actually the business of living with
your client through the compulsory sectioning process is the stuff
of your relationship. To hand that on to some outside body actually
negatively affects your relationship rather than helps it. It
is an argument we have to listen to.
Chairman
522. It is useful from our point of view to
see these distinctions between you because it is an area which
is a matter of great debate in here as you can imagine. May I
just press you briefly, particularly the ADSS and the Royal College
of Psychiatrists, on where guardianship fits in this whole debate?
I recall being involved when the community supervision order proposals
went through Parliament and making the point that I could not
see a real distinction from what the then Government was proposing
with what I had seen used in terms of guardianship many years
ago very successfully. Is guardianship still alive and well or
is it something which is only remembered by people like myself
who are knocking on a bit? Is it still used?
(Mr Joannides) It is used, but the extent to which
it is used is probably lower than the Government had hoped.
523. Why? Do people understand it?
(Mr Joannides) People will give you varying arguments.
When you look at the figures, there are quite significant variations
between some authorities where there is little or nil and some
where it is much more prominent. Some would say that if you are
working well, then the need for guardianship is limited because
you do not have the power to convey, you only have the power to
require to reside. That in itself has limiting factors. The Association's
view on this is that probably the whole issue of guardianship
and supervised discharge and CTOs should come together in a single
framework of a requirement on discharge to be supported and treated
and cared for in the community.
(Dr Shooter) I would agree with that and the college
would agree with it. The role of guardianship in specific instances
is something which has to be negotiated within the framework of
possible Mental Health Act reforms and also within the frameworks
of other pieces of legislation too. We do not know what influence
for example might come out of the document Making Decisions from
the Lord Chancellor's Department on people without capacity and
that is going to have a big influence in this area.
Mr Hesford
524. Is capacity a matter for professional judgement
or should it be in a new Act?
(Dr Shooter) Capacity is a fascinating issue. When
we were all being asked for submissions to the Richardson committee,
we were asked specifically about capacity and indeed we were asked
whether we would be in favour, rather than having a separate Mental
Health Act, of having an overall umbrella incapacity Act. The
longer we thought about that, the more attractive that became.
It was attractive because it would lower the sense of stigma,
which we have been very worried about this morning. Why is it
that people with one form of disability, a mental health disability,
should have a whole area of legislation to themselves? It would
also erode the barriers which are now artificial in many cases
between physical illness and mental health problems. But it had
some major problems attached to it too.
525. Is that just liberal discussion eyewash?
(Dr Shooter) No.
526. Or is it realistic?
(Dr Shooter) I think it is realistic. The problem
is that we were asked to give a snapshot view and feelings are
videos, they change over time. If we were asked the same question
now, we would be seriously considering an overall incapacity Act.
What we had in the Richardson proposals was a Mental Health Act
with capacity tests built into it. What we have in the Green Paper
is a Mental Health Act with no sieve tests at all based on capacity
or otherwise. We have to ask ourselves whether we should still
be asking for capacity tests and whether they are attractive or
not. They are attractive but there are some problems. First of
all, they are novel. Not many people in the mental health field
are experienced in looking at capacity. Capacity is an enduring
concept where most mental health problems fluctuate over time.
It is an all or nothing idea and most mental health problems are
spectrums, degrees of disorder. One wonders how the idea of risk
and protection against risk and so on would bolt on with incapacity
legislation. There are problems in the application of such tests
for mental health professionals which is where your question started.
First of all it is a cognitive test. So many of our clients are
emotionally disturbed and one wonders how one assesses their cognitive
capacity in the middle of an emotional disturbance. Secondly,
deciding on somebody's incapacity is almost like deciding on their
role as a decision maker per se. Going back to the compulsory
detention process and the arbitration which goes on between a
mental health professional and their client during that process,
it is very much one of together looking at alternatives, looking
at levels of insight, degrees of risk and so on, in which the
client, however much they may feel a junior partner, is involved.
If you are deciding on somebody's capacity, you are deciding on
whether they can take any role in this at all in an all or nothing
basis and that is perhaps undermining their autonomy rather than
supporting it. Of course there are various situations like "threatened
self-harm" where capacity becomes a very difficult concept,
and indeed the Richardson committee admitted this, whereas under
current legislation one does not have to decide on capacity, one
just has to look at the level of risk to themselves or other people
and so on. Capacity is a difficult issue for mental health practitioners
in a philosophical way and also in a practical way. I still believe,
the College still believes and we supported the Richardson committee
in believing, that in the future it will turn out to be a very
valuable concept. We should look very carefully at it again and
whether there should be an incapacity test within any future reform
of the Mental Health Act.
Mr Gunnell
527. Based on our visits to Ashworth and Broadmoor
recently and other evidence we have received, patients are inappropriately
placed in medium and high secure care because of a lack of other
provision. Likewise, other individuals in need of high secure
psychiatric care, such as those in prisons, are unable to access
services. What do you think needs to be done to break what seems
to us to be a log jam? Do you think the new commissioning arrangements
will be sufficient on their own or are other incentives necessary?
(Mr Joannides) I should be happy to kick off by saying
that one of the difficulties for local authorities, who are often
consulted about their ability to support people on discharge from
secure hospitals, is that we have not had a system of care management.
The patient's admission to hospital allows them to become detached
from what has happened before. If you think of some of the difficulties
in getting care coordination in local hospitals, it is not surprising
that we have really become disengaged from the secure hospitals
in working towards the transition to medium, low and ultimately
independent accommodation. As a result of that, there is a log
jam going the other way, that people are being supported in less
secure accommodation who probably need higher security. I think
you have had evidence from the Department of Health that they
are interested in looking at a care management approach of assessing
individual patients. What we actually need is an injection of
some short-term funding to act as a catalyst in getting some discharges
and placement arrangements in order to oil the wheels for this
to move. Certainly there needs to be a much greater movement and
greater levels of support through medium secure and low secure
in order to help people, staff and the patients themselves, manage
the transition towards taking greater responsibility for their
actions.
528. Would you say there was a shortage of suitable
places in each category of accommodation?
(Mr Joannides) There is indeed. That is why I think
some of the additional funding in the National Service Framework
on increasing bed capacity may help but unless and until there
is actually some money attached to the patients so that we can
not just deal with the movement towards medium and low secure
but actually fund their transition into the community because
they will need some fairly intensive support services in the initial
stages ...
529. In a sense we shall obviously come on to
question whether £700 million will be anything like enough
if we have to include a good measure of additional capacity in
hospitals.
(Dr Shooter) I should like to add my support to what
was said there. What we are looking at here is an historical process.
You can see it through the Butler committee, and the Reed committee
and the Fallon committee and the appeal for a network of facilities
at every level of security, high security, medium security, low
security, special care facilities within ordinary mental health
hospitals and above all community facilities and unless every
region has the range of facilities available, as the Fallon committee
says, we shall constantly get blockages at one point in the system
or another. Along with that also goes an attitude of mind. General
psychiatrists have to be persuaded that they can look after some
people with some very difficult problems with offending records
as well as mental health problems. In a current climate of blame
and criticism, that is going to be very difficult. Unless people
are more generally willing to take on in the community as part
of general psychiatric and mental health systems some of the people
who have gone through that panoply of care and out into the community,
that is where we shall get the real blockage.
Chairman
530. A moment or two ago you nodded when one
of your colleagues made the point about a need for increasing
capacity overall, particularly in the acute sector. One of the
concerns I have had in recent weeks with the visits we have made
is the extent to which, certainly in the special ones, we have
been given very clear evidence of a significant number of people
who are in those establishments who do not need to be in those
establishments. The figure I remember at Ashworth was 25 per cent
of the people currently being treated at Ashworth could actually
be managed within the community in an appropriate setting. That
is a fairly sizeable proportion of the people they are dealing
with at Ashworth. I was certainly very struck by one of the senior
managers dealing with women's services at Broadmoor two days ago
who told us from her own experiences that she felt 60 per cent
of the women in Broadmoor could have been dealt with in the community
on the basis of assertive outreach provision. I was quite struck
by the extent to which they were saying very strongly, hang on
a minute there are people here who do not need to be here. Your
argument is that we shall actually increase capacity. My point
to you would be, do we need to or is it not a matter of how we
manage the existing capacity and perhaps reduce that capacity?
(Dr Shooter) Both. One of the peculiar problems you
are picking up in that process is that the people who do the assessments
for entry into somewhere like Ashworth are not necessarily people
who are then going to be looking after them, either when they
are in Ashworth or when they come out again. What we lack there
is a long-term strategic view of how this person's risk will be
managed over time including coming back.
531. Are you familiar with the recent changes
in the funding arrangements which came in earlier this year and
the point which was made a moment or two ago from the ADSS was
in fact that the money side of it is a problem and the management
side of it. Clearly now there has been a move, a change in the
funding arrangements. Will that change impact in a positive way?
It seems, to be fair to the Government, that they have responded
to the criticism of people being locked into the system by virtue
of their local health authorities in a sense losing touch with
them financially. Now it is back to a regional funding arrangement
will that improve the system in the longer term, do you think?
(Mr Joannides) The new commissioning arrangements
will certainly give those responsible for the patients greater
knowledge and awareness about the way the system operates. If
the home health and local authorities are still disengaged from
that, because in my case people who live in Dorset are in Rampton
or in Broadmoor, it is not going to help. There actually has to
be an ownership so that once somebody is admitted to secure accommodation
it is not time to close the book, which is what has happened in
the past. That is why the care management approach needs to apply.
The home authorities retain a responsibility for continuing to
manage and assess the degree of risk associated with the patient's
care.
Mr Gunnell
532. A question which has not been raised and
ought to be raised is the position for young people in particular.
A number of organisations have suggested that there should be
a youth service for young people between about 16 to 25 because
of the great difficulty in moving between child/adolescent services
and adult services. There are particular problems there in the
transitions between acute care and medium secure care.
(Dr Shooter) This idea has had a fairly long history
and I well remember my late colleague William Parry Jones trying
to force this up the political agenda to the day he died. I think
it is a supremely attractive idea and as a child psychiatrist
and adolescent psychiatrist I think it makes sense. It makes sense
because although there is of course a developmental cut-off somewhere
within the group you are suggesting, the 16-to-25-year bracket
is also the age at which adultlike mental health problems are
going to be emerging. To hand on from one service, a child and
adolescent orientated service, to an adult orientated service,
right slap in the middle of that, seems to me to make no clinical
sense whatsoever. I think the day of youth psychiatric services
is just round the corner. It does however have some practical
and attitudinal problems attached to it. One is of course that
what we are talking about here is massive transfer of resources.
We are talking about combining the flower of two different sub-disciplines.
Some people will not give that up without a fight and it will
necessitate a lot of attitudinal change on the part of people
who have been used to dealing with just this or just that. There
are some developmental issues too. One has to think very carefully
about binding somebody into service just at the point at which
hopefully they ought to be developmentally breaking away. I think
that argument is outweighed by the clinical argument for continuity
of service.
(Mr Ward) There is also an issue about 16 to 25 which
seems to be chronologically an arbitrary decision. Sixteen to
25 does not actually make a great deal of sense. I would not,
as a twenty-four-year-old, want to be put into a youth service.
It has to be more than simply providing a service for people in
that age bracket. There has recently been a four-year programme
of study done in Birmingham and Edinburgh looking at a service
for 14 to 19-year-olds. The issue here is that the individuals
are in child and adolescent mental health services up until 14.
From 14 to 19 they are offered the option of going into a youth
service and then at 19 they go into an adult service. It is about
this notion of giving individuals who are going to use these services
the option as to where they are placed, which is probably more
fundamental than the service itself. Whilst I do not disagree
at all with Dr Shooter's arguments about the necessity for youth
psychiatry, which is certainly a burgeoning new discipline but
one which is really needed, it is also important to recognise
that during those developmental years, if you do not give the
element of choice to some of these individuals they will simply
rebel against whatever system they are in.
533. You should obviously be careful what label
you give it. Do you feel the label youth service would put off
many people within that range?
(Mr Ward) Yes.
(Mrs Guinan) May I caution against giving this a static
notion in any sense either in terms of absolute barriers, in terms
of age or in terms of talking about placing people within services?
We have to do some really radical thinking about this. The problem
is that we are missing lots of people who are insidiously developing
problems which are going to last the rest of their lives, if in
fact they live, because the suicide rate amongst young people
is high. I do not think it is about looking at our services and
seeing where we fit people in. It is looking at different models
of service. We have to look at where we might contact people who
are out of our reach at the moment. That might be the Brooke Advisory
Service, it might be to do with people who are in contact with
young women who get pregnant in their teenage years, it may be
to do with accident and emergency and so forth. Again it is a
sort of outreach concept rather than where do we place people
within the existing model. We have to avoid being complacent in
thinking that we have personnel around who are very well trained
to do this. We need to be really thinking very carefully about
the training implications as well as the service models.
Chairman
534. We have a number of important areas still
to cover which we may only do in a very fleeting way. I mean no
disrespect to the importance of these areas. I am going to combine
two together which it is wrong to do. This morning we are an all-male
Committee—our two women members are not here. We are also
an all-white Committee. May I combine two issues there? One is
very briefly your thoughts on provision for women in the mental
health system, particularly women in the secure special and regional
secure settings. Also I am particularly interested in your views
on the over preponderance of black people and the likelihood of
black people being sectioned. The Royal College of Psychiatrists
talk about black people being six times more likely to be sectioned
than white people. These are pretty serious concerns and certainly
we were very struck, when we looked at the private sector, by
our visit to a private hospital in York which was full of young
black men from London, 200 miles away. There is a lot to do here.
(Dr Shooter) That is the college's own research and
it is an extraordinarily valuable piece of research. I have to
say that it has confirmed what anecdotally practising clinicians
and mental health teams have always known, that if you are especially
young, black and male and live in an inner city, your chances
are very much higher than anyone else of being sectioned and it
does turn out to be six times more likely. The question is why.
One could postulate a number of factors, the most controversial
of which will be, whether there is a greater prevalence of certain
forms of mental illness amongst black and other ethnic minority
populations. That is a very controversial suggestion but it would
have to be looked at. There are different patterns of comorbid
drug misuse which can also contribute to their need for compulsory
treatment for example. Such ethnic minorities are naturally suspicious
of services which, as you quite rightly say, have not been designed
around their need. They have been made to fit in with an alien
system and that happens still all too often. Hence people from
the ethnic minorities present late to services and cooperate less.
One has to tease that apart slightly because it seems that some
ethnic minorities present earlier than others, so we need to work
out why that is. They are subject to many more social disadvantages:
unemployment, poverty, poor housing and so on. Their geographical
distribution is largely inner city based and we know what that
means. Many of them are very isolated, alienated from their parent
cultures. The College would be delighted if we have the funding
to look at that issue more clearly. I hope, I very much hope,
that the Department of Health will see this as vital as we do
and this Committee obviously does and give the College Research
Unit and others the funding to look at that. May I say that it
is also about an education process. It is not just about one ethnic
minority presenting later than others to a service because they
feel stigmatised and alienated. All people with mental health
problems present later to services than we would like them to
do. It is an education process in which we have to have a two-way
dialogue with the leaders of ethnic communities, not only about
how they can inform our service development and how they would
like us to develop more culturally acceptable services, but how
we can also persuade them that mental illness is part of their
culture too and that they need to come forward for help earlier
in the life of that illness.
535. One of the factors you did not mention
is the fact that presumably it is white psychiatrists who are
sectioning black people. The second part of my question related
to women and I have certainly seen research that raises questions
about the way in which male psychiatrists treat women from a male
perspective. Are there not some parallels here in this debate?
I have lobbed in two issues which are distinct but there are also
some crossovers here.
(Dr Shooter) Of course there are issues there which
we need to look at very, very clearly. I just remind you that
one quarter of consultant psychiatrists come from black or other
ethnic minorities and that is about four times the proportion
one would expect from population figures.
536. It would be interesting to evaluate which
those minorities are. My understanding is that it is not the minority
which is being usually.
(Mrs Guinan) I would confirm that you are absolutely
right. Where I work in Blackburn there is a serious problem about
an ethnic minority origin psychiatrist males sectioning ethnic
minority origin females. I am conscious of the time slipping away
but you might be interested in a little detail about this because
it is something which exercises service deliverers a lot. We would
probably be united in our concern about this, particularly as
concerns black and ethnic minorities. My professional group has
for some time had a special interest group in race and cultural
issues to do with mental health services. Such is their enthusiasm
that with one day's notice they have written a very short paper
for me with examples of good practice which I should like to leave
with you.
Chairman: We should be happy to look at that;
thank you very much.
Mr Hesford
537. If we are to avoid tokenism in the sense
of using care involvement, how can the services plan their proper
involvement?
(Dr Shooter) That is an issue which is facing the
Royal College of Psychiatrists right now, today, literally, in
a meeting I have to attend later on. Within the Royal College
of Psychiatrists we have, as most Royal Colleges have now, a very
powerful users and carers liaison group. It was one of the earliest
and is one of the most powerful. Users and carers from that liaison
group have representatives on all the working groups producing
college documents, on all the major college committees, including
just round the corner on its council and so on. However, the charge
always is: is that tokenism? I think that is a very valid charge.
We have to think of much more powerful ways in which users and
carers can affect training for example. We try to use the experience
of users and carers as part of the training packages for junior
psychiatrists but that does not always happen. At the moment it
has local impetus: it ought to be a central direction from bodies
like the Royal College that users and carers should be a vital
component of the training of every junior doctor. It is that sort
of issue which we need to get straight if we are to avoid the
charge of tokenism. You are absolutely right.
(Mr Ward) There is a difficulty about practicalities
of this. The issue is not about whether or not the users and carers
should be involved in a genuine therapeutic alliance, it is about
recognising that historically we have been exceptionally bad at
recognising ourselves and our own failings. The difficulty arises
in the decisionmaking process.
538. "Our" meaning the profession.
(Mr Ward) Yes, "our" meaning collective
responsibility within a profession, the mental health services
generally. We talk about patient involvement, but usually that
means patient compliance with decisions which have already been
made much further back along the decisionmaking trail than one
would expect some degree of equality to take place. This has been
compounded at the moment with the move towards evidence-based
medicine because in a sense it removes users and carers from the
agenda altogether. One classic example of this is in Oxleas where
Stephen Lawrence was murdered. They were trying and are still
trying to develop responsive community services which the evidence
told them should be A. They went to the community and the community
wanted B. So they chose B, I am very glad to say. In this particular
instance, if we had not had a particularly vociferous user group
lobbying for their rights within that particular organisation
there is a chance they would have gone for A and that would have
been inappropriate. It is about recognising where in the decisionmaking
trail you actually need to start the process of changing direction
or instituting services and it is also about involving users and
carers in the evaluative process as well and not just assuming
that we can always evaluate what we think is best for those individuals.
539. At either end.
(Mr Ward) Absolutely, and the middle.
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