Select Committee on Health Minutes of Evidence



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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