Examination of Witnesses (Questions 638
- 659)
WEDNESDAY 24 MAY 2000
THE RT
HON ALAN
MILBURN MP, MR
JOHN HUTTON
MP AND THE
RT HON
PAUL BOATENG
MP
Chairman
638. Can I welcome you to this session of the
Committee. Can I particularly welcome our witnesses and express
our thanks to you for being here today and also to your officials
for the helpful evidence we have received during this inquiry.
Can I ask you briefly to introduce yourselves?
(Mr Milburn) Alan Milburn, Secretary of State for
Health.
(Mr Hutton) John Hutton, Minister of State for Health.
(Mr Boateng) Paul Boateng, Minister of State at the
Home Office.
639. Can I particularly welcome you, Mr Boateng,
back by popular demand I would say.
(Mr Milburn) It is just like old times, is it not?
640. Can I begin by saying that obviously this
is the last formal session of this inquiry. It has been an interesting
inquiry and we have picked up a series of what I would say are
key messages, many of which are positive. Firstly, that the National
Service Framework has been very well received and has informed
the debate around the quality of the mental health services in
a very positive way. The other area I must mention, and this is
a personal perspective, is that we have been to special hospitals,
regional secure units, prison units, community mental health services,
we have had a range of different visits, and I think it is fair
to say that we have all been extremely impressed by some very
dedicated people who are doing a first class job in a difficult
environment. I think that needs placing on the record and I speak
for all my colleagues who have been with me on these visits. If
we develop a dialogue on a negative front, I think it is worth
making those provisos first of all. What I want to say from a
personal perspective is that one of the concerns that has been
expressed to us by many of the professionals is while they are
attempting to do their best, and certainly the National Service
Framework is informing debate at local level about quality, what
they appear to be lacking is a clear steer on the organisational
framework within which mental health will be placed over the next
few years. There is a lot of uncertainty about the direction of
travel. I met my local community mental health trust and met staff
who in a year's time are not quite sure who will be employing
them. They are uncertain about their future employer and users
and carers are uncertain about where the services will be placed.
So we have got a picture of a developing pattern—some people
describe it as a patchwork quilt—of different service provision
evolving in different areas. I am not being negative about that
because we have seen some excellent work being done with different
models being applied. What came over loud and clear from many
of the people we have spoken to is the lack of a clear message
as to the direction of travel from Government. That is the point
I want to put to you. What do you see as being the direction of
travel for the mental health strategy at a local level in the
next few years?
(Mr Milburn) First of all, can I reiterate what you
said, Mr Hinchliffe, about the work that goes on in mental health
services because every word you have said is absolutely true.
By and large we have first rate people doing a very, very good
job indeed, sometimes in very difficult circumstances. Certainly
what we have tried to do, and have been trying to do over the
last few years, is to bring some order to what I think most people
would regard—leaving aside the party politics—as what
was a pretty chaotic system. Certainly when I became Secretary
of State I was pretty clear that mental health services were important.
They are important because so many people rely on them. It is
worth recalling that for all of the concentration that inevitably
there will be in the media and elsewhere about those with a severe
mental illness, the vast majority of people who have mental health
problems are no threat to anybody, no threat to themselves and
no threat to others. Indeed, it is also worth remembering that
one in six members of the public at any one time will have a mental
health problem of some sort. The range of services that we have
to provide, therefore, are complex because the number of problems
and the range of problems we have to deal with are complex too
ranging from mild depression to very acute psychosis and in some
cases very, very severe illness indeed. What we have sought to
do is to bring some order out of chaos. I think the National Service
Framework is very, very important and it is a landmark as far
as mental health services are concerned because for the first
time it sets out the sorts of national standards that should apply
not just in some places but everywhere. That has been widely welcomed
in the mental health field, in the NHS, in social care and more
generally. It provides the framework, if you like, for a long-term
programme of change and development. I want to reiterate that
message too, because to get these things right is going to take
time. I think actually we have got a good story to tell but there
is a long way to go. I will come back to services in a moment
or two, perhaps in answer to further questions. As far as structures
are concerned, and I understand the point that is being made,
and in particular, as you know, and as Members of the Committee
will have picked up, there is a big debate going on out there
about crudely whether we are going to see a move towards more
specialist mental health work housed in Primary Care Trusts as
they come on line, or whether we are going to see mental health
services being the preserve of Specialist Mental Health NHS Trusts.
My view about this is the key thing is to make sure that whatever
the mechanism is that it works. The truth is that there will probably
be different requirements for different areas.
641. Who is going to take those decisions because
some people are pointing to you as abrogating your responsibility,
Secretary of State, by leaving it all down to local determination?
(Mr Milburn) It is a funny old job this because I
get accused of being a control freak if I attempt to stipulate
the way that services should be organised—that is sometimes
levelled against me by people who should know better—and
then one gets accused of abrogating responsibility if you do not
stipulate. We are at a very early stage of development here, we
do not have Primary Care Trusts up and running across the country
yet. We have got a few in the pipeline and there will be more
to come, I have got no doubt whatsoever about that, because I
think GPs and others will see that makes sense. As we have laid
down in the National Service Framework, if we are going to see
a move towards more specialist mental health services being housed
in Primary Care Trusts then there are a number of key criteria
which we will judge against the bids that are made by Primary
Care Trusts to take over control of mental health services. Crucial
to those is the preservation of capacity and capability in any
organisation that is responsible for mental health services. Specialist
Mental Health Trusts obviously have that, they have built that
up amongst the clinicians and the managers, and if we are going
to see a move towards the merger, if you like, of Specialist Mental
Health NHS Trusts into the Primary Care Trusts then I have got
to be assured, and there will be clear criteria laid down, that
if that move does take place then it preserves the capacity and
capability that we will need in order to deliver first class modern
mental health services.
642. So if that criteria is met you are perfectly
happy to see a system evolving at a local level that would be
markedly different from area to area within the criteria? So we
could have some Primary Care Trusts, we could have a continuation
of local Specialist Mental Health Trusts, we could have, as is
being discussed in my area, a county-wide Mental Health Trust
broadening out the area, The problem with that, as I see it, and
what has struck me very strongly in this inquiry, is the relationship
between what is happening in the local communities in relation
to the quality and range of provision and what is happening right
down the other end of the system, say in specialised units. We
have clear evidence from visiting Ashworth where we were told
25 per cent of patients at Ashworth could be contained, could
be supported, in managed units in the community and we were in
Broadmoor and were told that 60 per cent of the women in the women's
unit could be supported in the community under assertive outreach.
What worries me about the models that you are putting forward
is how can you develop that kind of coherent response to those
problems right down the line when you have got such a patchwork
quilt of local community provision that will evolve from what
you are suggesting?
(Mr Milburn) I think the question, with respect, sometimes
presupposes there is a perfect model and a perfect answer and
there is not. The range of problems that we have to deal with
in mental health services is complex and varied and inevitably
wherever you draw the organisational and structural line there
will always be the need to ensure co-ordination as well as integration
between services. I think that is a fact of life in the health
and social care field. However, what we do have to do, as you
quite rightly have said, is ensure that the services that are
provided are appropriate and right. What is all too clear in the
mental health field, as it is clear across the National Health
Service generally, is that all too often we have got the wrong
patient in the wrong place at the wrong time. Our programme of
change and reform is about getting the right patient in the right
place at the right time. That means you need the right number
of beds in the right places as well. You are quite right to raise
the point about the high security hospitals. It is perfectly evident,
as we already know from the work that we have undertaken and the
evidence that you will have heard, that there are people in those
institutions who can probably be outside of them, a lot of them
are women, and we have not hitherto had the resources, we have
not had the infrastructure if you like, to move people out from
an inappropriate setting into a more appropriate setting, but
we are addressing that.
643. Some would argue that the Tilt money could
have been spent in a different direction. We will come on to that
later, some of my colleagues want to raise that.
(Mr Milburn) There is a variety of Tilt money, quite
a lot of money, going into improving security, which I think is
absolutely the right thing to do, but I will come back to that
in a moment. Remember £25 million of it is being used to
speed more appropriate care and treatment for people who are currently
in the three hospitals who could be elsewhere. We will be able
to provide with that money around 200 secure places. What I can
tell the Committee today is that our priority for discharge and
movement out of the hospitals will be for women patients who have
been identified as probably not requiring the sort of intensity
and security of treatment that the three hospitals provide. However,
what we have been doing more generally across the piece is providing
the right beds in the right places. So over these two or three
years we will be dramatically increasing the number of secure
beds, for example. There will be 500 more secure beds by around
2001/02. As a result of the Tilt money there will be a further
200 secure beds on top of that. We will be providing around 320
24 hour staffed accommodation places for people who might be in
high secure prisons, might be in high secure hospitals, might
be in acute hospital beds at the moment who need not necessarily
be there. All of that has been informed by the National Beds Inquiry
that, as you will remember, we published in February and its conclusions
were pretty stark. As you will remember it said that a lot of
our acute sector provision in mental health hospital care was
under severe pressure, particularly in the inner cities. That
is true and any psychiatrist, any clinician, working there will
bear that out. Largely that is a consequence of the fact that
we do not have appropriate move-on accommodation and it is that
that we are putting in place. Those gaps in provision have bedeviled
the provision of mental health services, particularly for those
with a severe mental illness. We are putting that right and you
will see the fruits of that in the secure beds, the secure places,
the outreach teams that you have described, all coming on line.
Our priority when we got into office was to ensure that we got
the right number of beds in place. Indeed, one of the first things
that Paul did when he was covering John's job was to place a moratorium
on any further closures of hospitals to ensure that we could be
assured, and patients and local communities could be assured,
that we had the right number of beds. We are building up the number
of beds. There is a good story to tell. Of course it takes time
to get there but increasingly what people will see is that we
are able to get the right patient in the right place.
644. Before I bring Peter Brand in, as the National
Service Framework is implemented do you envisage a shift in the
balance of expenditure between community provision right across
the board, local authority health provision, as opposed to acute?
Is that balance going to shift and, if so, in what way do you
envisage it shifting?
(Mr Milburn) I think it is difficult to second guess
ten years down the line and, remember, the NSF is a ten year programme,
we make no bones about that.
645. Would you want it to shift?
(Mr Milburn) I think the important thing is that we
get the balance of service provision right. Clearly from the evidence
that you have, and all the data that we have, we know the balance
is not right and it has got to be put right.
646. Are you implying that the balance is too
much in terms of the acute beds sector?
(Mr Milburn) No, I do not think that. I mean that
we do not have the right people in the right place. For example,
we have got people who are occupying beds in hospitals now who
could well be accommodated and provided for and more appropriately
treated in a less intensive environment. Similarly, in the high
secure hospitals we have got probably quite a large number of
people who could be accommodated and treated in a more medium
secure or low secure setting. It is that provision that we are
putting in place. Our first priority was to deal with these issues
of public safety to make sure that both the patient's safety,
the staff's safety and the public's safety is properly taken into
account, hence the investment in secure provision. Our priority
now that we have done that, as you were indicating earlier, is
to move on and provide the range of community services that we
think have got a proven track record, and I suspect the Committee
thinks have got a proven track record, outreach teams, crisis
teams, that will enable the pressure that is currently on acute
sector provision to be lessened.
Dr Brand
647. Can I explore that a bit further, Secretary
of State, because I think there is a terminological confusion
sometimes between the primary care and community. Primary care
delivery is presumably based on general practice and PCGs, as
it is at the moment, whereas there is a lot of community treatment
being developed, treatment and support, which is really secondary
in nature, the assertive outreach work and that sort of thing.
Does that alter the answer you gave to the Chairman's question
on whether this secondary treatment in the community should be
provided by the PCT or would they be buying it in almost as a
sub-contractor? Do you not see there might be a conflict within
the PCT as being both the provider and contractor for those secondary
services?
(Mr Milburn) In truth, I am less bothered about the
structural arrangements than about the service provision. I think
the structural arrangements might take a variety of forms in different
areas. For example, it is perfectly clear to all of us that the
needs of rural communities and the needs of inner cities as far
as mental health services are concerned are probably markedly
different for a whole variety of reasons. In the inner cities
it will probably be the case for many years to come that Specialist
Mental Health Trusts will continue to be the provider of mental
health services. However, I do not rule out the PCTs, where they
meet the criteria and where they can jump over the hurdles we
have set for them, taking over some specialist mental health services.
I say that because we have evidence already from the time before
we were in office, when the previous Government was in office,
of some of the successes that have resulted from the integration
of primary care mental health services with more specialist mental
health services. I am thinking of the Berkshire Health Purchasing
Project, for example, which is a success story.
648. Would that extend to PCTs taking over the
inpatient facilities as well, other than the regional specialists?
(Mr Milburn) I think in some cases that might be feasible.
That is already happening in some places. For example, when the
Committee went to Birmingham you would have been aware that what
you saw there was a primary care team working hand in glove with
the secondary care team to provide outreach and crisis services
in the community and that works. There will be a variety of structures
by which that is delivered. In the end, and I know there is some
big debate about this and I know there will be some uncertainty
about it, from my point of view what I am more interested in is
the end product, the end result rather than getting hung up on
defining right now when PCTs have only just begun their life.
I am less hung up about the end structural arrangements that we
will see. We have got an opportunity now as the PCTs develop and
as we set the right criteria for them to test out there what works.
649. You think that the PCTs, through the health
improvement process, will be able to integrate more successfully
perhaps than some of the mental health trusts have been able to
with local authority provision?
(Mr Milburn) I think that is potentially the case,
yes. All of the inquiries and surveys that have been undertaken
over recent years demonstrate that one of the key failings, particularly
when something goes seriously wrong, is the failure of co-ordination.
It is not just a failure of co-ordination between primary and
secondary care within the NHS, it is also a failure of co-ordination
between the National Health Service and the other statutory agencies
which are responsible for providing care and treatment to people
who are very, very vulnerable indeed. PCTs provide us with an
opportunity and a vehicle to overcome some of those barriers and
obstacles to a better co-ordination of services.
650. Can I ask the Minister for the Home Department
whether the Probation Service is going to take part in this process?
There is a tremendous spectrum. Would they be happy to work with
a PCT as opposed to the traditional links at the moment which
are very much the super-specialist links with secondary care?
(Mr Boateng) Dr Brand, I very much hope so. One of
the reasons why we are reorganising the Probation Service and
giving it now local—
651. Can I say how much I would welcome you
changing your mind on the naming of this.
(Mr Boateng) Yet another ringing endorsement from
this Committee. That is always welcome. One of the reasons why
we are reorganising the Probation Service, but not renaming it,
is so that the national structure has a sound local base and on
the local boards I would want to see health interests represented
alongside the voluntary sector because everything we know from
the good work that has already been done at the very heavy end
around public protection and risk assessment shows that the Probation
Service, the Prison Service and the Police are working quite effectively
with forensic psychiatrists and other health interests in that
area. So there is plenty of scope for good joint working between
health and probation.
652. That might prevent some of the confusion
presently created by your Department sponsoring with seed money
essential services without making arrangements for Mr Milburn's
Department to pick them up, for instance in support of people
with drug problems?
(Mr Boateng) I think we now have a very effectively
co-ordinated drugs strategy.
653. There is seed funding for a year or two
years and then it dies because there is no other body, other than
a public body, that can pick it up.
(Mr Boateng) Much of that initial funding was so that
we could get a secure evidence base for subsequently mainstreaming
the work, for instance around drug treatment and testing orders.
That has now been done and, in fact, there are some very good
examples of Health money, Home Office money, voluntary sector
money, Police money, being used effectively on the ground to provide
drug and alcohol, substance abuse programmes. I was at one this
morning as it happens, ADACTION in Brent, which is helping us
there deliver the drug referral interventions in a very effective
way.
654. So we can be sure that where there is an
effective service that between you you will sort out the continued
funding?
(Mr Boateng) Yes, and we have got the structures in
place now to enable that to happen.
Chairman
655. Before I bring Mr Burns in can I just ask
a question on the back of Peter's earlier question which probably
he did not feel appropriate to mention being a GP himself. One
of the worries I have about the placement of mental health within
PCTs is the competence of some GPs in this area. As someone who
worked, as you know, many years ago very closely with GPs, their
capacity to address mental health issues was very variable. I
do not want to denigrate some excellent GPs who do their work
really very well. How do you envisage ensuring that wherever there
is a move towards a PCT taking on competencies for the mental
health provision that they are in a position to give the quality
of provision, the expertise, that is required? How would that
be evaluated from your point of view?
(Mr Milburn) I think there are two answers to that.
First of all, remember that although this is being posited as
a primary care takeover, if it happens, Primary Care Trusts taking
on a greater role as far as the provision of specialist mental
health services is concerned, it is not. It is about the fusion
of two sensible organisations, primary care and community services.
Therefore, that fusion will bring with it, if you like, a transfer
of expertise from within the Community NHS Trust setting into
the primary care field. That can only be beneficial for the organisation
of PCTs and for those working in them and, most importantly, for
those patients who are receiving the care. So, if you like, we
will import both clinical and managerial expertise into the Primary
Care Trust from the specialist mental health world. The second
thing to remember about all of these discussions is that for the
overwhelming majority of people who have a mental health problem
they get their care treatment right now from GPs.
656. Or do not as the case may be.
(Mr Milburn) By and large they do and by and large
they get good service because it is an appropriate service. Remember,
one in four GP consultations right now are taken up with mental
health problems. There are around nine million GP consultations
a year that are about mental health problems. It is about locating
the right level of expertise in the right place to get the right
patient the right treatment and care. Of course, there will be
a requirement for a small minority of patients to have more specialist
mental health services made available to them and, of course,
people's care sometimes is episodic just as their condition is
episodic. People with schizophrenia, for example, can be perfectly
stable and well and living life in the community independently
going to a position where actually they need more specialist help
and support, sometimes in a hospital setting. It seems to me self-evident
and obvious that what we have got to try to do as far as possible
is to get the service provision properly balanced to match those
changing requirements and those different requirements between
individuals and, where it is feasible to do so, to reflect that
in the structures. The key thing is the service provision.
Chairman: The case for the defence from Dr Stoate.
Dr Stoate
657. Just for the record, Secretary of State,
in fact there are 200 million GP consultations a year of which
50 million are people with mental health problems. The order of
magnitude is staggering. I want to agree with you that 90 per
cent of mental health consultations are carried out by GPs very
satisfactorily. When I meet GPs what they really want is more
services in the community that they have much more input into,
as do their primary care teams, their nurses and so on. What I
am looking for from you in a way is how are you going to make
sure that those really do integrate into the primary care set-up
so that GPs and other primary care workers actually have got more
input into mental health services?
(Mr Milburn) Partially the PCTs might provide an answer
to that but in terms of service provision what we have done thus
far with the establishment of the outreach teams, and there are
going to be around 50 outreach teams by 2001/02, providing care
and treatment for sometimes pretty difficult to engage people
in the community, many will be homeless, many will be drug and
alcohol abusers and they need a specialist level of pretty intensive
support in the community, we are going to put that provision in
place to accompany the secure beds, the intensive care beds and
the supported accommodation. There are about 20,000 people in
that difficult to engage group. The next important group for us
are the 650,000 people who are subject to the Care Programme Approach
Services which you are seeing already in places like Birmingham
and Islington—and I launched a crisis team in Newcastle
very recently indeed—are taking that approach, crisis work
in the community, out from the hospital setting into the community
precisely to reach those sorts of people who otherwise would sometimes
end up in the GP's surgery and perhaps sometimes not be able to
call on the requisite level of expertise there. So all the time
what we have got to do is get the right balance of services in
the right place. I think we are getting there but it does take
time to get it right.
Mr Burns
658. Secretary of State, one of the issues that
has arisen time and time again during the course of this inquiry
has been that of the question of the workforce allocations, of
national shortages, of problems with morale and so on. Would you
agree with those criticisms that we have been told about?
(Mr Milburn) Certainly we have got some shortages,
that is absolutely true. We have got some shortages as far as
nurses are concerned, we have got some shortages as far as psychiatrists
and other specialist staff are concerned. It is pretty variable.
There is a localised and, indeed, regionalised picture. It is
worth bearing in mind, although people always say to me on nursing
shortages "heaven's it is always worse in mental health",
actually the vacancy figure in mental health is lower than the
overall vacancy figure. Our vacancy figure for nurses generally
is around 2.6 per cent; for those working in the mental health
field it is around 2.1 per cent. We have recruited an extra 2,000
nurses over the last two or three years to work in the mental
health field. We have got 350 more consultants working in the
mental health field. We are putting more money in to undertake
more training for specialist registrars, the future generation
of consultants in elderly care, child care and general adult services
too. That means that over the course of the next few years we
should have around 230 more specialists in mental health. There
are some issues there. I think what is true is that on morale
all too often the clinicians, and I think particularly the psychiatrists,
right now feel as if they have to fight the system rather than
the system working for them. I think that is a general problem
in the NHS but it is particularly true of mental health. If you
are a psychiatrist on call and you have to spend hours finding
an acute bed for somebody then that is a pretty frustrating experience,
of course it is. It is that that we have got to put right. The
big decline in acute beds that we saw in my view is unsustainable.
The answer to that in terms of service provision generally is
to get the right provision in and that is why in the secure beds
we are going to have a very big build up. In historic terms these
are very, very large increases in provision that we will be seeing
over the course of the next two or three years. The number of
secure beds over the course of the next couple of years will increase
by around 18 or 20 per cent overall. This is a big build up. We
will get the intensive care beds in as well. That will begin to
make a difference to people. It is undeniable that right now the
people who are out there working in the field doing a damn good
job feel as if they are under pressure.
659. When your officials came before us they
told us that as part of the NSF you had set up a Workforce Action
Team and that it was going to produce its interim report last
March. Has it actually produced this interim report? Can you tell
us what the conclusions were in that report and what your thoughts
are so far?
(Mr Hutton) The group under Sue Hunt has actually
now reported to the Department, and did so in April. We are currently
looking at their recommendations. The final report is not due
until April 2001, so it was very much a first stab at some of
the quite complex issues that they went into. They are very keen
for us to do some more detailed work in a number of areas, particularly
in relation to issues to do with skill mix, issues to do with
whether we cannot make greater use of other staff in the NHS and
possibly looking particularly at the greater use of psychology
graduates who have a significant contribution to make and by and
large do not make it. The issues are being looked at very seriously.
Also, we are trying to look at it in the context too of the work
of the National Plan. Yes, there are some specific issues the
Secretary of State has referred to that are clearly apparent in
relation to mental health services but whatever recommendations
the team produce have to be consistent with our wider workforce
investigation that is taking place in the context of the National
Plan.
|
