Examination of Witnesses (Questions 660
- 679)
WEDNESDAY 24 MAY 2000
THE RT
HON ALAN
MILBURN MP, MR
JOHN HUTTON
MP AND THE
RT HON
PAUL BOATENG
MP
660. Can I move on to the question of the current
system of mandatory homicide inquiries because many people would
argue, probably correctly, that this system which is in place
contributes to a public belief that the tragedies have increased
under care in the community when, in fact, the statistics suggest
that the opposite is the reality. Do you think that the time has
come to stop this system?
(Mr Hutton) Certainly we are looking very seriously
at all of those issues at the moment. As you will probably be
aware, Mr Burns, the Chief Medical Officer has set up a group
to look at adverse incidents across the NHS. Louis Appleby, who
chairs the confidential inquiries into homicides and suicides,
has also made some recommendations in his Safer Services Report
which we are looking at too. The National Institute of Clinical
Excellence is looking at the funding and the arrangements in general
terms that relate to those confidential inquiry systems that we
operate. I think the most important thing here is that we have
a system that works effectively in future that is able to disseminate
effective messages across the service about what is good, what
is bad or where we need to improve. In the main I think the homicide
inquiries have served a useful purpose in that respect. Louis
Appleby's work has been particularly important in giving us, if
you like, an overview of the range of issues that those inquiries
have reported on in the past. I think we are pretty well placed
now to make some forward progress on that. I do not think there
are any great arguments or secrets about where we think we need
to improve. Louis Appleby's work in particular, which I am sure
the Committee has had an opportunity look at, has drawn attention
to a number of these issues where in the past it has been service
failures that have contributed to these terrible, terrible tragedies.
Of course, it is our prime responsibility to make sure that the
service does not let down the patients or the public. We are beginning
to get a very strong steer about the future of this and, hopefully
shortly, we will be able to make some announcement about how we
want to see the system improved and informed in the future.
(Mr Milburn) It might be worth saying that hitherto
we have had about 64 inquiries and there is a very, very common
pattern, as the Committee will be aware, of lack of co-ordination,
lack of communication, sometimes a lack of compliance with treatment
which raises some very, very difficult issues indeed, but they
are issues that we have got to get to grips with. It is very,
very important when these things happen that we learn from them.
The most important thing is that we learn from them. We have had
some of these very, very clear systemic failures. I know it is
the staff who get blamed and sometimes it involves people who
have done things wrong but there are actually deep structural
systems failures and it is that that we have got to put right
and learn from what goes wrong. We have got a lot of evidence
under our belts now. The evidence, as John was saying, has helped
inform the programme of change that we have got going on now which,
indeed, the Committee has just been questioning us about: co-ordination;
how you can get the appropriate range of services in the right
place; how you can improve co-ordination and communication between
the different services. Those are very key things. We are looking
very, very carefully indeed at how we can make progress in the
future as far as this system of inquiries is concerned. Indeed,
Louis Appleby's report on the confidential inquiry specifically
asked the Government to review whether or not we should continue
with the system of individual inquiries that has taken place hitherto.
We have not made a final decision about that. Clearly there is
a lot of work going on, not just to learn from mental health incidents
when they have gone wrong but, as John quite rightly said, the
Chief Medical Officer is doing a major piece of work for us on
learning from adverse incidents more generally within the NHS.
661. Do you know when you are likely to reach
a definitive decision?
(Mr Hutton) Hopefully in the very near future. I hope
we will be able to make the position a bit clearer.
662. Just as a matter of interest, if you were
to decide that the existing system, maybe with some fine tuning
or what are considered to be improvements, the basic principles
of the existing system after an incident are going to be continued
by you, how do you think, if you think it could happen at all,
that you can strip away from it the blame culture that has grown
up because of the series of inquiries in effect that the current
system puts in place after an incident?
(Mr Milburn) I think we all have a responsibility
in that regard. We do a variety of mental health promotion work,
as you know, we lend support to a variety of clinicians and so
on and so forth. I think this is a job not just for Government,
it is a job for all of us. We have got to keep repeating the message
whether as employers, the Government, voluntary organisations,
Members of Parliament, local authorities or whatever, that a lot
of people have a mental health problem, a huge number of people
do, and in the vast majority of cases that is a problem for them
but it is not going to be a problem for everybody else. We have
got to keep working on that continually. We also have a responsibility
when something goes wrong, and sometimes things do, that we find
out what went wrong and we learn the lessons from it. We cannot
abrogate our responsibility in that regard either.
663. Is that not the problem, that a tremendous
amount of excellent work is done by Ministers, members of Parliament,
the professionals, social services, health and everyone else you
have mentioned to basically de-stigmatise the whole area of mental
health, but however much good work is done, however much money
your Department or the Government might spend on pushing that
agenda forward, and rightly so, every time one of these inquiries
is set up and reports you undermine far more the good work?
(Mr Milburn) With respect, what undermines the good
work is the systems failure, it is not the inquiry, it is when
something goes wrong. We can argue until we are blue in the face
about the number of homicides and the number of suicides but the
truth is regardless of whether the figures are moving up or down
that is incidental because there are many too many suicides and
there are too many homicides and too often there have been real
systems failures and we have got to learn from them. My view,
and I feel very, very strongly about this, is that the patient's
safety and public's safety comes first.
664. Absolutely.
(Mr Milburn) We have got to learn the lessons from
what went wrong. There is a debate about inquiries—
665. You do not necessarily have to learn the
lessons through that system.
(Mr Milburn) Equally there would be concern from members
of the public, and indeed sometimes from the families affected,
if people felt there was a cover-up. That would be a terrible
thing and we must not have that either. We have got to try to
get the balance right. Your phrase was about "blame culture"
and that is right, we have not got to have a blame culture but,
boy, have we got to learn the lessons. You and I could probably
write a pro forma for reports into these incidents right now.
Every time it is the same set of factors. The question that has
to be asked is if we know that it is poor co-ordination, if we
know that it is poor communication, if we know that it is lack
of compliance with treatment, then is it not time that we did
something about all of those things? The answer to that is yes,
and that is precisely what we are doing.
666. Can I ask you another question which I
was not planning to but in the light of what you have just said
I think I will. Another thing that we have been told on numerous
occasions is that the findings of many of these inquiries are
by and large repetitive, and you have basically confirmed that,
but then people have gone on to say that the lessons never seem
to have been learned even though the findings are repetitive.
Would you reject that?
(Mr Milburn) Yes, I would now because regardless of
what has happened in the past what concerns me is what is happening
now and what is going to happen in the future. For me, mental
health services are a priority along with cancer and coronary
heart disease, they are the services where we have got to see
most development, most improvement, most modernisation now and
in the future. For the first time we have a set of standards that
are laid down, standards that have got to be applied everywhere.
We are plugging the gaps in service delivery and, sure, that takes
time but we are getting the beds and the staff in place. We are
backing that with significant resources, big investments going
into these areas, and we want to underpin it too with major legislative
change that allows us to learn the lessons in legal terms from
what has gone wrong in the past.
Chairman
667. I know John Austin wants to come back on
the staffing issue but before we move on to this can I briefly
reinforce the point that Simon has made. This has come over as
a very major issue among many of the staff we have met. Can I
put to you the message that we have got from a number of people
that in the work we are doing with seriously mentally ill people
inevitably risks have to be taken, and presumably you accept that
risks have to be taken. If we do not take risks then everybody
who has a serious mental illness may end up locked away for life,
which did happen in the past and no-one would defend that system.
One of the themes that we have picked up in our evidence is that
there does not appear to be any kind of guidance on risk emanating
from your Department. Is that an area that you have looked at
or do you think it is appropriate to leave that entirely in the
hands of professionals at the local level? Having done both mental
health and child protection work, and I was in child protection
work at the time of Maria Colwell, as somebody who has been a
social worker I know there is a very, very difficult tightrope
you are on. When in somebody's eyes you take the wrong decision
the worse thing is when you get it wrong the Government kicks
seven bells out of you. Having been the subject of an SSI Inquiry
I speak with some feeling on this issue. What guidance do you
offer on risk taking in such circumstances?
(Mr Milburn) As you say, Chairman, we have not got
to allow professionals, whether in the social care world or in
the health care world, out there on their own to flounder, if
that is what is happening. They have got to be supported, they
have got to be given the appropriate help. I think that is the
right thing to do and—
668. If they get it wrong what do you do? This
is the worry that we have picked up, and we were talking yesterday
to somebody who is a fairly experienced psychiatrist who was talking
about colleagues who were excellent professionals with super careers
but one thing went wrong and it finished them. Is that right?
(Mr Milburn) We have got a whole set of proposals
and we have got a whole strategy in place to deal with precisely
that. That applies not just to mental health but to clinical practice
more generally. The view hitherto has been that by and large you
allow clinicians to get on with it and if something goes wrong
then somebody somewhere comes down on them like a ton of bricks
but that is not appropriate it seems to me. That is why, for example,
the Chief Medical Officer in his proposals, Supporting Doctors,
Protecting Patients, advocated that we should move to a system
of annual appraisal. The General Medical Council have now proposed
a system of revalidation so that we do not assume that once a
clinician qualifies that is it, they can do the job for life,
if you like they have got to prove that year on year they have
kept up to date as far as clinical practice is concerned. We have
imposed a duty of quality on NHS organisations. There are clinical
governance arrangements now in place in the NHS being developed
right now to assure quality systems in all parts of the service,
whether that is in primary care, mental health or, indeed, in
the acute sector. For the first time we have an independent inspectorate,
a Commission for Health Improvement. If anybody had said three
or four years ago "we are going to have annual appraisal
and an independent inspectorate and we are going to require revalidation
for doctors" people would have said "you are not going
to achieve that because there will be so many obstacles and so
much obstruction". But it has happened and it has happened
precisely because, in my view, out there in the service and in
the clinical community there is a desire to get things right,
to learn the lessons and to apply good practice. You have seen
what happens in mental health and elsewhere, but also to assure
the public that what happens in the NHS and the people who work
within it are accountable for the work that they undertake and
that is a big change.
669. You have talked a great deal about the
quality measures and we all accept that those are having an impact
because we have seen that directly but what I asked you about
specifically was risk and where risk is taken, and it is appropriate
risk that is taken, and it goes wrong, does the Government not
have a duty to think through the fact that we have to take risks
and if we do not take risks then we will have a very strange mental
health system?
(Mr Milburn) One of the things I always say to doctors
and to others, to members of the public, is "look, medicine
is an imperfect science, it just is and sometimes things go wrong".
Dr Brand
670. Hear! Hear!
(Mr Milburn) It is a difficult area. This is a difficult
area above all else, particularly dealing with people who have
severe mental health problems. We recognise that. The issue is
how do we set the national standards to help people so that their
clinical practice is informed by the best clinical evidence about
what works and what does not. How do we ensure that we have systems
in place of clinical governance, annual appraisal and an independent
inspectorate that deal with these problems before they arise?
I think we have got a good set of quality measures in place, not
just for mental health but more generally for the NHS, that should,
over time, allow us to nip the problems in the bud. The CMO is
working right now on what I think will be a very, very important
set of proposals and documents about how we do learn from adverse
incidents in the NHS. There are a lot of adverse incidents, the
key thing is how we learn lessons from them.
Mr Austin
671. Just to go back on the figures of 2.1 and
2.6 per cent vacancies, which seem to me to be lower than I would
have expected, I do not expect an immediate response necessarily
but—
(Mr Milburn) It is nice to bring some good news.
672. Maybe you could provide us with some details
of how those vacancy rates are calculated. Do they make assumptions
about shortfall, are they budgeted staffing, are they targeted
staffing, are they by local authority?
(Mr Milburn) We can certainly provide the data for
you but they are based on the annual survey that we undertake.
673. Are they applied standardly authority by
authority?
(Mr Milburn) Yes.
674. And available authority by authority?
(Mr Milburn) I do not know the answer to that but
we can probably find out. We will let you have whatever data we
have got.
Mr Burns
675. Are they of actual figures or funded because
we have just discovered—?
(Mr Milburn) Those are two very good questions to
which I am sure there is an answer but I have not got it.
Mr Burns: Will you find out because it is crucial.
It has only just emerged about police officer vacancies.
Mrs Gordon
676. Secretary of State, earlier you said that
mental illness can be episodic and quite often that is the case.
One of the things that became clear to us talking to users and
carers was that the things that concern them most when they are
going through an episode of mental illness are issues like money,
jobs and housing, the fact that they are often in and out of work
and this is obviously very disruptive to their everyday lives.
The problems that they highlighted included dealing with agencies,
dealing with housing benefit, employment issues, in fact the whole
gamut of government agencies. What plans do you have to ensure
that the benefits system and employment services remove barriers
to full social integration of mentally ill people? I agree with
joined-up government but is it working in this area and, if not,
what can we do about it because it is a real problem?
(Mr Hutton) You are absolutely right, this is a hugely
important area for us to be concerned with. We have to start from
a very simple starting point which is the NHS has a major contribution
to make in providing better services but we cannot guarantee good
mental health on our own. Good mental health is going to be conditional
upon a range of other services and support mechanisms including
housing support, jobs, benefits and so on and we have accepted
that. We are trying to do some work in that area. Let me give
you an indication of how we are trying to tackle that and we are
trying to do it in a joined-up way right across government departments.
One of the exciting areas where we are beginning to address these
concerns is in the health action zones. There are 26 of them across
the country in some of the most deprived parts of England with
some very high needs in terms of mental health services. We are
looking at putting together schemes to make those connections
between care workers in the NHS and other key agencies. There
is a very good scheme in Lambeth, Lewisham and Southwark looking
at doing exactly that with young people with mental health problems
and the early signs of that are looking very encouraging. The
health improvement programme approach is going to help us in this
area because what we are doing there is linking up all local authority
functions with the NHS so we are looking at social services, the
contribution they can make, but housing and benefits advisory
services too. There is an opportunity through Health Improvement
Plans (HimPs) for local authorities to work with health authorities
to put those services together. We have issued some new guidance
in relation to the Care Programme Approach which stresses the
need for exactly that kind of on-going support for those sorts
of services so NHS staff know what to do in those circumstances.
The New Deal for Disabled People is breaking some ground in this
area and there are some early signs too that progress there looks
quite encouraging. We are doing a lot of work around the needs
of mental health patients. And the Department of Health and the
Department of the Environment, Transport and Regions very soon
will be issuing some joint guidance about housing support and
other services for people with mental health problems. It is a
problem. We have got a lot to do, to be perfectly honest, to get
that approach right. We are approaching it from a number of different
angles working across government to try and get the answer but
the question in the short term is absolutely right; it is a very,
very serious area where the system has not worked effectively
in the past and people slip through the net and their condition
has deteriorated and we get this revolving door syndrome. We cannot
support them effectively out in the community and they come back
in, sometimes as a detained patient, under the Mental Health Act.
That is a totally unacceptable state of affairs. We have got to
be much better in all these areas. In some of those areas we have
indicated we are trying to cross the lines, get rid of some of
the organisational boundaries that impede effective support for
people with mental health problems. We firstly recognise that
as an issue and we are trying to put mechanisms in place to deal
with that. In doing that we are, as you said, breaking some new
ground in trying to see mental health services in that more holistic
sense. It is not just what the NHS can bring to the table or what
social services can bring, it is a whole service response going
right across the range of local authorities as well.
677. At the moment when people are at their
most vulnerable they are hitting their heads against a brick wall
going from one agency to another with no co-ordination or understanding
really. One of the suggestions from our witnesses is the need
for a new kind of worker, a generic mental health professional
who would do this job, prioritise aspects like benefits and housing
as well as social and health care. Has it been looked at in the
health action zones as a possibility or would you be willing to
do some research on whether that is viable?
(Mr Hutton) This is a primary area where the workforce
action team will begin to develop some more specific proposals
for us. They have only started to get their work on line. An interim
report has come out and one of the issues in relation to Mr Burns'
questions was the idea of a skills mix in teams of workers. Do
we have the right people there with the right range of skills
and expertise to open some of these doors up? In a time of crisis
in a person's life sometimes it does take someone else to open
those doors. Yes, absolutely, we have got to look at that and
we have got some quite challenging issues to address as we try
and equip the mental health workforce for some of those new challenges
in the new century. We have got a lot to do and the idea of generic
qualified workers and people who can cross those professional
demarcations is a very interesting one and we are looking at that,
I can assure you.
(Mr Milburn) The idea of the generic health social
care worker, whatever the proposal is, let us have a look at it,
but there is more general issue too and that is if we are going
to do what we want to do and ensure that support for people with
mental health problems is not confined and ghetto-ised to the
National Health Service and social services we have to have the
appropriate training in the housing system and the benefits system
and elsewhere. That is going to take some time but that is what
we need to do because otherwise we will not be able to deal with
the range of problems those agencies have to confront as well
as the problems that the NHS and social carers have to confront
day in day out. So there are some very big training recognition
issues we have to get to grips with across government, not just
in the Department of Health but elsewhere as well.
(Mr Hutton) I would also say the issues were fully
flagged up in the National Service Framework too, identifying
those areas where we need to improve the range of services currently
on offer to people with mental health problems.
Dr Brand
678. Can I probe you a little bit on housing
benefit verification where people with mental health problems
are placed with supported landlords either by a social worker
or a CPN and that landlord does not get paid until that verification
gets made by somebody in the housing revenue department and that
could take weeks and we are losing social landlords because they
are not getting paid. This is a real problem. I have written to
you and to the DETR. I am told that joint working is possible
on the ground but if you ask the individuals on the ground they
say, "No, they have got to see the person in their home before
any money is paid." That is notoriously difficult if you
have got somebody on the street most the time or who does not
answer their door. It is these frustrating things that are not
only difficult for the patient but totally time-consuming and
frustrating for the people actually working. That is not lack
of goodwill at local level, that is government regulation getting
in the way.
(Mr Hutton) This is something that the joint Department
of Health/DETR guidance is going to address. What we want local
authorities to be able to do in conjunction with health authorities
and social services is to provide an effective range of housing
support services for people with mental health problems. That
is what we are trying to do in the guidance and I will want to
keep the Committee fully informed on how that is moving on but,
yes, there are problems and I think we recognise that and we are
trying to address those in some of the work I have outlined particularly
looking at the guidance we intend to issue to local authorities.
Dr Brand: I look forward to seeing it.
Mr Austin
679. I want to follow up on Eileen Gordon's
point and raise a note of caution about generic workers because
whilst I think there is some immediate attraction in the concept
as she put it, I think there is also a very real danger of devaluing
the very real skills that particular professionals bring to a
job. A health trust not a million miles away from this building
who sought to get rid of all art therapy workers and replace them
with generic mental health workers was a denial of the real skill
the art therapy workers had. On the question of the welfare rights
issue, I think it is very difficult for people to keep up to date
and on track with a very complex area. I know that government
is trying to simplify matters but in the very complex area of
welfare rights, would you not agree that what is required is a
resource available to whoever it is, social worker, OT or other
therapist, to have access to a very skilled and up-to-date welfare
rights service which can provide the advice and information?
(Mr Milburn) Probably, yes, we do need to make sure
that information is accessible to people and understandable to
people. That must be the case. On the first point about the generic
workers, in some senses it is rather like the argument about PCTs
versus specialist mental health trusts. We are terribly hung up
about the structures, but actually what counts is making sure
the patient, whoever he or she is, is getting the right access
to the right level of skills. There are two or three things we
have got to do there, one is expand the capacity of the workforce
in mental health and elsewhere to make sure there are more doctors,
more GPs, there are more specialist registrars, there are more
CPNs and social workers able to do the job. Secondly, we have
got to make sure, with this business about the majority of people
with mental health problems getting very good care from general
practice, that there are no barriers to patients getting access
to the right level of skills that is necessary for their condition
and for their treatment. It will be very important, in my view,
that the NHS takes a very hard look at the skills that are available
within the workforce to make sure that we are maximising the potential
of nurses and physiotherapists and others and we do not assume
that every clinical task is a medical task. That will be an important
thing we need to do. A third thing we will need to do is self-evidently
we will need to take a good look at proposals for merging the
functions between different members of staff where that is the
right thing to do because in the end what counts is not the staff
label on the uniform, what counts is the services and skills that
are being provided for the individual patient. If there are proposals
around let's have a look at them by all means, but the key thing
in all of these things is to make sure the patient is getting
the right level of skill commensurate with the problem.
(Mr Hutton) We are not deskilling the workforce. That
is a hugely important point for the Committee to understand. If
we are going to go down the road of looking at more generically
qualified workers, there is no suggestion, and no one should read
into it any intention on our part, to somehow produce a workforce
with lesser skills or lesser qualifications. We are talking about
re-skilling workers and there is a very important difference between
those two things.
|
