Examination of witnesses (Questions 540
- 554)
THURSDAY 11 MAY 2000
MR M WARD,
DR M SHOOTER,
MR D JOANNIDES,
MRS P GUINAN,
MRS L COHEN
and MRS C CRAIK
540. Continual.
(Mr Ward) Yes.
(Mr Joannides) May I just introduce a perspective
which has not been introduced this morning and that is the role
of best value within local authorities? The duty of best value
does require us to challenge the way we do things, does require
us to consult with service users and no Director of Social Services
worth his or her salt would hope to undertake best value review
of mental illness services without doing that in conjunction with
their health colleagues. That really is a very useful lever for
evidencing the extent to which users and carers are involved.
The whole essence of a best value review is, just as the joint
audit commission SSI reviews, assessing just how much the users
and carers are involved. Information about treatment options,
about services, participation and care planning, consultation
meetings about wider service development, are all becoming much
more routine. The more routine they become, the more real they
will become if the outcomes from that are demonstrably being influenced
by the views and comments we are getting back.
541. When you say "routine" ...?
(Mr Joannides) "Routine" meant integral,
it meant an essential
542. "Routine" can mean lip service.
(Mr Joannides) No, that is why I qualified it afterwards.
It meant regular and very much integral.
(Mrs Guinan) Thankfully users are doing it for themselves
in the sense that they are now teaching us how to do it better.
I have seen some very useful and very thought-provoking checklists
which users are now producing in Scotland to tell us how in their
experience it has been very difficult to work in our systems and
that we ought to be subjecting ourselves to the following checklist
to make sure that we are making it possible for them to engage
them properly. Very encouraging.
Mr Burns
543. Due to a range of factors, probably the
most important being fear, ignorance, prejudice, mental health
historically and still today suffers from being stigmatised in
a way that no other form of health care, except possibly HIV/AIDS
is stigmatised. Briefly, how do you think one can seek comprehensively
and realistically to tackle this?
(Dr Shooter) I was going to start by saying that the
Royal College of Psychiatrists in combination with many other
organisations has started a five-year campaign trying to tackle
that issue.
544. How?
(Dr Shooter) In a number of ways. May I say first
of all that it is not just a five-year campaign, it is a lifetime's
campaign and beyond? A five-year campaign is seeking impetus for
various projects but we have to carry on looking at this for the
rest of our professional lives and beyond. It is a matter of particular
projects, funded projects, looking at ways in which that stigma
has practical influence on very basic areas of our clients' lives.
The members of the users and carers group in the college, for
example, have said to me when they have listened to the philosophy
of a campaign like that, that it is very laudable but in the end
it will not help unless they can get insurance, unless they can
get a job, unless they can get a mortgage without running up against
the sort of institutionalised stigma we were talking about before.
Any campaign against stigma has not just to be about trying to
persuade the newspapers and television and radio not to use stigmatising
words and not to use stereotypical images in their programmes
and to pedal mythologies and so on, which is very, very important,
but it has to be about the basic stuff of people's working lives.
We have to persuade employers that people with a mental illness
should have exactly the same sort of rights as other people.
545. With respect, is that not scratching at
the surface, however important it is? Surely the greatest prejudice
which is facing people suffering from mental illness is from their
neighbours and the general public. Where and how are we going
to educate those people to get out of these extraordinary views
they have towards people with mental disabilities?
(Dr Shooter) One of the ways of course is to start
with children in schools. Children are not born with those prejudices
inside them. They pick them up very early on in life because they
are bombarded with mythology from the earliest days. That is where
we need to start.
546. Have you?
(Dr Shooter) Of course; the children's project is
very central to the campaign which we are running at the moment.
Happily it is also the best funded because people recognise that
is where we should be starting. But it is not just with other
Members of the public; we are members of the public. All of us
are frightened of mental illness, all of us are frightened of
our own vulnerability to mental illness. We have to start with
ourselves.
547. Right, but presumably a lot of people are
frightened of getting pneumonia or jaundice or whatever, but it
does not seem then to lead to everyone wanting to cross over to
the other side of the street because someone they know has got
that. They get sympathy. People will ring up to enquire about
their general health, whereas with mental health everyone, including
a lot of the family members and the person themselves, wants to
hide what is wrong with them because they are terrified of the
reaction of others.
(Dr Shooter) Because we do not understand mental illness
and because it has a history which involved full moons and werewolves
and horrendous images. That is there lurking inside all of us.
We are terrified of it.
Chairman
548. Do I get the picture this is changing,
from what you said about your experience in Nottingham, what Mrs
Guinan said about the number of applicants for psychology courses?
I am very struck by that. I have teenage children and for their
peers it is either marine biology or psychology. As someone who
was put off psychology by Freud 30 years ago, it is a bit of a
mystery. Maybe I misunderstood psychology. Is it changing? Do
we have a new generational view on this?
(Mrs Guinan) I think it is changing and I hope it
is changing and people are wishing to engage with psychology and
are looking for a different understanding. It is not helpful to
think of it in terms of pneumonia because it is not like pneumonia
in the sense that it is not a specific illness, it is human distress,
it is human fear. To engage with a different way of looking at
that is very helpful. Most of us are concerned to understand how
we are put together, how we tick.
(Mr Ward) May I say that there is a parallel here?
I do not want to get involved in history, but if we go back a
long way leprosy was the original mental illness which was superseded
by mental illness. One of the reasons that leprosy is no longer
regarded in the same way it is and you were talking about people
crossing the street, I am not sure they cross the street because
they know you have mental illness, they cross the street because
they are frightened of what you are going to do to them, because
you look strange or are even behaving in a very aggressive way
or your social skills are different. Certainly the reason people
go out of the way of people with leprosy is (a) because they thought
they were going to get it and (b) it was just an awful thing to
see. The leper colonies became psychiatric hospitals; that is
a long transition but that is where it went to. That is what happened
not just in mythology but in reality. We learnt how to cure leprosy
and it was superseded by something else. You could argue that
if we get better at what we are doing in terms of the provision
of services and we are able to provide good community facilities
for people, then in a sense we are curing it; you do not cure
psychiatric illness in that sense. Something else will then come
along and at that point, it is only at that point, we shall be
in a position to say the stigmatisation process has diminished.
(Mr Joannides) We have to come at it from a number
of angles. Some of the new curriculum issues, personal and social
development in schools, community service in years 9, 10, 11,
12, are all helping. We also have a solution in our own hands.
Mention was made earlier about the low level of public confidence.
The more we can get the basics right, the more we can reduce the
number of causes for the media to highlight cases. If we can for
instance adopt the child protection procedures on reporting on
serious incidents and homicides, that will get a much more measured
approach. We also have a job in working with the media because
they would actually welcome feature articles on success stories.
I know that our community units with people with a mental illness
are in areas that the public pass every day of the year without
realising it.
Mr Burns
549. Do we not have a problem in that you may
well have feature writers on newspapers and particularly tabloid
newspapers who would welcome working with you to have intelligent,
sensible articles, but they have no control and do not even seem
to be able to influence the newsroom which on the front page will
have "Barking mad" or whatever?
(Mr Joannides) You live in a world where the national
press is paramount. As far as local services are concerned, our
allies are our local press. The national press owe no allegiance
to me, the local press does because they are dependent on me to
get responses and reaction to stories that happen. We work very
hard. Every head of service in public services works exceptionally
hard with the local media to be able to try to get better more
balanced responsible journalism. It is much more difficult with
The Sun and the Daily Mail and the broadsheets because they have
no allegiance to us. We are here today and gone tomorrow. As far
as the local media is concerned, local BBC, ITV stations, they
rely on us.
550. I find it slightly unusual for you to say
that they rely on you; it is actually probably the other way round,
it certainly is in politics. The fact is this. I accept the point
you are making that local newspapers are far more balanced and
probably have a more intelligent approach, but it does not matter
how many local features or stories there are in papers, you just
need one horror story on the front page of a tabloid newspaper
to undo years of work with the local media.
(Dr Shooter) This works the other way round too. I
have mixed feelings about this because I am an ex journalist myself.
551. Then you have a vested interest.
(Dr Shooter) No, I do not have a vested interest.
The college spends four per cent of its income from its members
on public relations activities and public education activities.
You are quite right in saying that one disastrous headline in
The Sun demolishes the campaign against stigma, but similarly
one really good upfront portrayal does more for anti-stigma than
anything we can do in a five-year college campaign and we should
not be elitist about this. Undoubtedly the thing which has affected
children's, adolescents' views of mental illness more powerfully
than anything else in the last decade was the portrayal of Joe
in East Enders. We should not be elitist about this, we should
go very hard for that sort of end of the media and work with them.
552. Yes, but that is television, that is not
the written national newspapers.
(Dr Shooter) Adolescents look at television.
Mr Burns: I know they do, but if you are going
to talk about Joe, I am sure it did a tremendous amount of good
at the time, but I imagine now he is forgotten to many of those
people and will have been overtaken since his last appearance
on East Enders by other stories in newspapers which, if children
have not seen them, their parents certainly have, which has reinforced
their parents' prejudices and views.
Dr Brand
553. I think the media actually reinforce people's
existing prejudices, which is why they are clever. I am very surprised
on that issue that the Royal College of Psychiatrists came out
recently saying that they were still advocating the traditional
first-line treatments for schizophrenia for instance. I can tell
when somebody is on lots of largactil, so can my neighbours.
(Dr Shooter) May I answer this because that is not
actually what we said.
554. There are two issues: there is a quality
of life issue for the patient, but it is also the way they are
perceived. If we are just keeping people quiet in the community,
that is not having quality of life in the community. So you can
give a complete answer to my unreasonable question, the other
part is that there is a danger, if this is the perception of the
public that that is what you are advocating, that compulsory treatment
orders may then involve compulsory treatment with the cheaper
drugs rather than the best drugs.
(Dr Shooter) Very quick answer to that. First of all,
it was not a college document, it was commissioned from the College
Research Unit along with other organisations to produce for outside
people. It was not a College endorsed document in that sense.
Secondly, my reading of that document in detail was not as your
reading of it has been. What I think that document was saying
was that there was no overriding reason why the first-line use
of anti-psychotic medication should not be with the more traditional
and, as it happens, cheaper drugs. But, if the individual clinician
and the individual patient sitting down and working out what was
best for them, decided that one of the atypical anti-psychotics
was what would work best for them, was what they preferred and
which had fewer side effects, then there was an obligation to
move to that atypical anti-psychotic. In fact, that gave power
to clinicians who want to prescribe more atypical anti-psychotics
and have actually been prevented from doing so by their management
who are worried about the cost. Actually it was in support of
them, not against.
Dr Brand: I am glad you managed to put that
on the record but it does not do away with the problem though
that many patients do not have the opportunity of experiencing
the atypical anti-psychotics because they get doped into submission
and that is where they are.
Chairman: Do any of the witnesses wish to make
any brief final points on issues which we have not covered before
we conclude? If not, may I thank you all for your very helpful
evidence? It has been a very useful session and we appreciate
your participation. Thank you very much.
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