Select Committee on Health Fourth Report



The need for a joined-up approach

36. We were very determined, from early on in this inquiry, to ensure that we heard the views of users of mental health services, both through the large representative organisations and through smaller grass-roots groups. We were aware that it is very easy for inquiries of this kind to concentrate on the perspective of the service provider and professionals working in the field, and we felt that it was particularly important for our inquiry to be shaped by the experiences of those who actually use the system.

37. It was made abundantly clear to us throughout this inquiry that the provision of services by the NHS and by social services is only a relatively small factor in the lives of people suffering from mental disorder. The Manic Depression Fellowship put the wider picture to us in no uncertain terms:

The importance of an adequate income, secure accommodation, social interaction and meaningful day-time activity occurred time and time again in both the oral and written evidence we received, from users and carers, from professional bodies and from research-based organisations.[57] While it may seem self-evident that good quality health and social care services will only be effective if the user of those services has enough money to live on, somewhere safe to live and something constructive to do during the day, the truth is that the professionals delivering "mental health" services have not traditionally seen it as their role, or been in a position, to do a great deal about these factors. David Joannides of the Association of Directors of Social Services, who gave oral evidence at the same time as representatives of other health and social care professions, made the point:

    "If you ask someone with mental illness what are the four or five factors which influence most their quality of life, they will come up with issues which the professions along this table may have limited ability to influence ... issues about employment, about life-long learning, about the quality of their environment."[58]

38. This emphasis on individuals leading an "ordinary life", rather than being viewed as the passive recipient of services, is central when considering claims that care in the community has "failed".[59] We were not surprised to find that users of services were vigorous in their support for the policy, while keen to highlight particular areas or cases where poor implementation had led to individuals being let down. Karen Campbell of the Manic Depression Fellowship told us:

    "You have to think of what came before. I myself had four or five years in my early adult life in the old asylum care. Community care is about a liberation ... it's unbelievably much better."[60]

Lionel Joyce, the chief executive of Newcastle City Health NHS Trust was equally forceful:

    "From personal experience I would say that anyone who has spent time on a hospital ward would go hell for leather for that [care in the community]."[61]

Ms Campbell also highlighted the highly disruptive nature of hospital admission:

    "If you have been in a psychiatric hospital it turns your life upside down. You lose your network of friends, you lose respect in the community, people shun you. It is a horrible stigma. Nobody is there to pay your rent. Who is going to explain how you behave at work?"[62]

Similar points were made by a range of other witnesses.[63]

39. We also heard many examples of problems with the implementation of care in the community: factors such as the tardiness with which community-based services are being developed,[64] inadequate funding[65] and the lack of good liaison between agencies, particularly in the area of discharge.[66] We will return to these factors later in our Report, but we feel the general picture was well summed up by David Joannides of the ADSS:

    "Community care has not failed, it has failed some people."[67]

There have been undeniable failures in service since the policy of care in the community was first launched. But we feel that it is both misleading and unhelpful to state that the policy of care in the community has failed, as the Government has done on a number of occasions. We urge the Government to make clear in the language it uses (as indeed it has already done in the policies it has embraced), that care in the community is a positive policy and one which it supports.

40. The question of employment is clearly key in ensuring users of mental health services are integrated in their communities: adequately paid work is the simplest and most obvious way of addressing the needs for income, secure housing and social interaction emphasised above. The British Psychological Society told us that "getting back to work has a greater positive impact than any other single factor" on the outcome of mental illness,[68] and this point was reiterated to us by many other witnesses.[69] The Centre for Mental Health Services Development highlighted two areas where they felt that progress could be made. Firstly, they argued that employers could do much more to help maintain people in employment in the first place, through being much more proactive in implementing the Disability Discrimination Act 1995, keeping jobs open when employees are on sick-leave and providing support and help to individuals to ease their way back into work. Secondly, they suggested that health services should be prepared to take on a much more active role in helping their users maintain employment, including working more closely with employers (with users' consent), assisting users in finding work and supporting users who are still in work but experiencing distress.[70]

41. It is clear that some mental health services do take employment issues very seriously. We were very impressed when we visited South West London and St. George's NHS Trust to hear about their user employment programme which provides both a "supported employment" programme within the trust and assistance with finding work with external employers.[71] We were told that in 1997 the Trust adopted a Charter for the employment of people who have experienced mental health problems which stated that the trust would actively seek to recruit people currently under-represented in the workforce, which would include people who have experienced mental health problems. The success of the Charter and the initiatives supporting it seems clear: 20% of the people recruited by the Trust in 1999 had personal experience of mental health problems. These employees were recruited into existing clinical and non-clinical roles and were employed on the same terms and conditions as anyone else. The sickness absence of the "supported" employees is actually lower than average.[72] Rachel Perkins, the programme co-ordinator, also emphasised to us that many users of mental health services do not necessarily need "support" in the workplace, but simply need employers willing to take them on. As well as its work within the trust, the employment programme therefore also builds bridges between mental health services and the Employment Service and maintains directories of work and educational opportunities in the local area.

42. Work is clearly of real importance to the many people with mental health problems who want to regain power over their own lives. Help with training, education and finding work is crucial, as is the provision of information to employers to encourage them to support and retain people with mental health problems in employment. We believe that the employment service provided by South West London and St. George's NHS Trust provides an invaluable route back to "ordinary life" for people who have experienced mental health problems. We were pleased to hear that several other NHS trusts are developing similar schemes, and recommend that all trusts providing mental health services should consider how they can provide similar services to their users.

43. After employment issues, the aspect of everyday living which appeared to cause most concern to users of mental health services was the benefits system, including Housing Benefit. Two main points stood out in the evidence we received: that the actual process of claiming and dealing with the necessary bureaucracy is highly stressful and time-consuming;[73] and that the benefits system is not well designed to cope with the episodic nature of much mental illness.[74] This situation is exacerbated if liaison with other bodies, such as housing authorities, is necessary: Levi Ferguson, a carer from Sheffield, described a constant trail from one statutory agency to another in order to get the help his family needed, with agencies apparently unable, or unwilling, to share information with each other.[75] Karen Campbell from the Manic Depression Fellowship highlighted the practical difficulties generated by the range of bodies individuals in mental distress have to deal with:

    "People do not understand what sheer hell life can be, as Mr. Ferguson has described, when you are going round the houses, going down to one end of town and then the other end of town, then you have not got the right books, then you have to come back on the right day, and then you have spent all your bus fare and you cannot eat for three days, it is absolutely dreadful."[76]

Tony Russell from Breakthrough argued that "what we need is really, in a sense, a new kind of worker to deal with that. It is like a one stop shop and there is a missing link. If you are ill you do not want to go into five different departments, what you want is one person".[77] This same proposal was put forward by Lionel Joyce of Newcastle City Health NHS Trust, who told us that he had submitted to the idea to the Workforce Action Team set up by the Department of Health to look at the staffing issues of the National Service Framework.[78] The Minister of State responsible for mental health services, John Hutton MP, confirmed to us that the Workforce Action Team was looking at the issue of skill mix in teams of workers and that "the idea of generic qualified workers and people who can cross those professional demarcations is a very interesting one".[79] He also told us that the Department of Health and the Department for the Environment, Transport and the Regions would soon be issuing guidance on housing support and other services for people with mental health problems, which would aim to address areas which currently cut across a number of different agencies. Pat Holman and Claire Gregor from Local Health Partnerships NHS Trust sounded a note of caution about "generic" workers who are "good at a thousand things in a very tiny way" and emphasised the importance of increasing the flexibility of workers without losing specific skills.[80]

44. The British Psychological Society submitted additional written evidence to us on the way that the benefits system is not designed to cope with the reality of living with mental illness.[81] In particular, they highlighted problems with the "therapeutic earnings" rule which allows people claiming Incapacity Benefit or Severe Disablement Allowance to work up to 16 hours a week, as long as the earnings received are less than £58.50 a week and the work is undertaken for therapeutic purposes, on the advice of a doctor. While the principle of the scheme is precisely to encourage therapeutic employment, the very fact that the individual is working may trigger the Benefits Agency to consider whether the claimant is now capable of full-time work - and hence no longer eligible for Incapacity Benefit. Moreover, the scheme is based on negative incentives: that is, the claimant is required to demonstrate inability to work full-time, instead of being encouraged to focus on what they can achieve. While the rules apply equally to those with physical and mental disabilities, it is argued that an individual with mental health problems may need a longer rehabilitative period than that usually allowed by the therapeutic work option. The Society suggested that a better approach might be to widen the scope of the Disabled Person's Tax Credit, which is the only in-work benefit specifically geared at disabled people. Currently the credit is limited to those working over 16 hours a week; this threshold could be removed to include people who need a more part-time entry back into the labour market.

45. The Society also expressed concern about the way the "personal capacity assessment", used to judge entitlement to Incapacity Benefit, operates, arguing that it is difficult for medical assessors to make a judgement on a claimant's mental state in 40-45 minutes on one particular day. They argued that "pre-medical reports" by professionals who know about a claimant's mental health history would provide a fairer assessment of their needs. Similarly, they felt that the claim forms for Disability Living Allowance are "very physically focused" and do not encourage claimants to give a full picture of their mental health problems. We are aware that our colleagues in the Social Security Committee have recently addressed some of these issues in their report on the Benefits Agency Medical Services and recommended that the doctors undertaking assessments for disability benefits should receive better training on mental health issues with specialists available for dealing with more complex cases.[82]

46. While the British Psychological Society evidence concentrated on difficulties experienced in claiming disability benefits, our attention was also drawn to the problems caused by the rules governing income-related benefits. The Mood Swings Network commented on the rules whereby benefits are reduced if an individual is hospitalised for more than six weeks, and argued that the stress caused by delays in reinstating benefit on discharge can hinder recovery and even cause further hospitalisation.[83] They suggested that the system could be much improved if benefit claims were just suspended during long hospital stays, allowing for their immediate reinstatement as soon as the patient was discharged. Similar points have been made in the past about the problems experienced by people with mental health problems who want to start working but are worried about the loss of their benefits if they find later they are unable to cope with the job.[84] We are aware the Department of Social Security has made, or is soon to make, a number of changes to make it easier for people moving in and out of work: for example since October 1998 people who are on Incapacity Benefit or receive a "disability premium" as part of their Income Support or Job Seeker's Allowance have been able to return to the same level of benefits within a year of taking up the job,[85] and from April 2002, IS and JSA claims will be "suspended" for 12 weeks rather than being instantly closed when people leave benefit, to streamline the process of re-claiming if a job falls through during that period.[86]

47. It is clear to us that a far more "joined-up" response is necessary from statutory agencies if users of mental health services are to be properly supported in the community. We do not believe it is acceptable or realistic to expect vulnerable individuals to deal with complex systems without support, especially where it is clear that these systems are ill-equipped to deal with fluctuating illness. We would encourage the Department to give particular attention to the idea of a dedicated worker, who would be responsible for liaising between the various statutory agencies and ensuring that users of mental health services, living in the community, have access to the benefits and other services to which they are entitled. We recommend that the Disabled Person's Tax Credit should be extended to those working fewer than 16 hours per week and that the period for which benefit claims may be suspended, rather than closed, when individuals leave benefit to go into work, should be extended to a year. We also endorse the recommendations of our colleagues on the Social Security Committee, that the doctors undertaking assessments for disability benefits should receive better training on mental health issues with specialists available for dealing with more complex cases.

48. We welcome the fact that the Department of Health has spoken of "pulling all the necessary levers" to ensure that mental health services remain a priority.[87] We remain unsure, however, who is in a position to "pull the levers" when action is required across Government Departments. We were encouraged to hear that the Department of Health and the Department of the Environment, Transport and the Regions have been working together on joint guidance, although the content of that guidance has not yet been made public. We also hope the newly appointed mental health "national director" will be in a position to highlight areas of work that require a cross-departmental approach. Nevertheless, we remain concerned that more formal arrangements, such as the existence of a dedicated mental health Cabinet sub-committee, are not in place to ensure the necessary co-operation between Departments.

49. One area of "joint working" where there has been a considerable amount of movement in recent years is that of the relationship between health and social services. The Department of Health referred in their written evidence to the role of local Health Improvement Programmes in drawing together the NHS and local authority social services departments and to the fact that

"National Priorities Guidance" is now issued jointly to the NHS and social services departments.[88] The Health Act 1999 also brought in a new "duty of partnership" between the NHS and local authorities, together with the power to pool budgets for health-related projects. Much of the evidence we received was positive about these changes, while emphasising that it was important for examples of good practice to be disseminated quickly.[89] Angie Schram of Breakthrough, for example, told us:

    "There are some positive examples of joined-up working and real partnerships out there. Let us see them used and actually go out. I do not mean held up as an example and saying 'Aren't they wonderful, because they are working together?' Let us actually see some of them go out into other trusts and other social services departments who are not working together".[90]

We were particularly impressed with the close working arrangements there appeared to be between a Suffolk trust who gave oral evidence to us, Local Health Partnerships NHS Trust, and their local social services department. Staff from the trust described integrated community mental health teams, with social work members being full members of the teams,[91] social workers working in the same office as occupational therapists and community psychiatric nurses[92] and the integration of the (social services) Mental Health Grant and the (NHS) Modernisation Fund.[93]

50. However, the evidence seemed to us to be more mixed as to whether these various incentives for closer working were adequate. David Joannides of the ADSS argued that they were:

     "You do not have to manufacture major structural change to create much greater cohesion. The whole point of the flexibilities under the 1999 Health Act is to enable organisations which are already working well to achieve that."[94]

He also expressed concern that the full integration of mental health and social care services would risk these services disengaging from other parts of public service, particularly those in local government, which are increasingly being recognised as crucial to mental welfare.[95] Other witnesses emphasised the distance still to be travelled: the Sainsbury Centre for Mental Health argued that "despite the current emphasis on partnership much remains to be done to integrate services horizontally",[96] while the Royal College of Nursing suggested that while individual members of staff often work well together "bringing these agencies together at a strategic evaluation level will be crucial to move these existing relationships forward and provide a cohesive services from the service user perspective."[97] Local Health Partnerships NHS Trust from Suffolk highlighted some of the day-to-day practical difficulties inherent in working across two different organisations: the need to keep separate "medical" and "social services" notes[98] and the difficulties in having straight lines of authority across two agencies.[99]

51. We were impressed with the way NHS and social services staff have clearly responded to the challenge of working together to provide a more coherent service for the service-user. Nevertheless, we remain unconvinced that it is sensible to retain two separate organisations, each with their own hierarchical structures, when the aim is to deliver a seamless service for the public. We believe that the evidence we heard gives additional weight to the recommendation we made in an earlier inquiry, that health and social services departments should be merged into single entities.[100]

Race and culture

52. We noted in our introduction that one of the triggers to this inquiry was our visit to an independent secure unit in Yorkshire as part of an earlier inquiry, where we found many of the patients to be young black men from London. It has long been accepted that black patients of African-Caribbean background are statistically far more likely to be compulsorily treated by the mental health services than white patients, and we were keen to find out firstly to what extent this was still true, and secondly what action was being taken about it. The statistical evidence we received gave us considerable cause for concern. The British Psychological Society highlighted the tendency of ethnic minority patients to access services later, when they are more severely ill and more likely to be detained, rather than treated as informal patients.[101] The Royal College of Psychiatrists quoted research showing that black patients were in fact six times more likely to be detained than white patients,[102] while the mental health charity Mind and Sheila Foley from Rampton Special Hospital commented on the over-representation of black patients in the secure services.[103] Dr. John Reed, the Chief Medical Inspector of Prisons told us that they had "remarkably little information about health care and ethnicity" in prisons,[104] but Sir David Ramsbotham, the Chief Inspector of Prisons assured us that he would soon be doing a study of racism in the Prison Service, and that they would certainly be including the health care aspects.[105]

53. The evidence we received also commented that it was not simply a question of black patients being more likely to be in the compulsory part of the mental health system, but also that the services offered are often "inappropriate or insensitive".[106] A number of witnesses raised the issue of the availability of counselling services and other "talking treatments" as opposed to medication.[107] Levi Ferguson, a carer for three members of his family, who had tried to get counselling for his brother, commented:

    "I do not know of any black people who seem to have had any form of counselling rather than ending up being pumped full of drugs."[108]

The staff at the North London inter-cultural counselling service Nafsiyat told us that the psychotherapy service they provide is heavily over-subscribed and that they recently had to close their waiting lists because of demand.[109]

54. The charity Turning Point drew our attention to the fact that certain ethnic groups are also under-represented in services, and that this should also be a matter of concern: women from South Asian communities, for example, make below-average use of formal mental health services and have an above-average suicide rate.[110]

55. The reasons put forward by witnesses as to why ethnic minority use of mental health services is significantly different from that of white patients fell into two broad categories: the inappropriateness of services and a failure by service providers to understand the needs of ethnic minority patients; and the psychological effects of belonging to an ethnic minority in England. Mrs. Pauline Abbott-Buttler from FOOTPRINTS, for example, emphasised the first approach:

     "What is running straight through, for me, is institutional racism ... What the black community is asking for is mutual respect, understanding of their cultural needs and cultural backgrounds, and finally to understand that they too need to be treated fairly and equally within the mental health system in terms of psychiatrists providing appropriate assessment, appropriate diagnosis and appropriate treatment. This is all we ask for, nothing less, nothing more."[111]

The British Psychological Society, on the other hand, listed a number of factors as possible explanations of why ethnic minority patients should appear more likely to develop psychological problems:

    "the psychological trauma of experiencing racism, of being a refugee/asylum seeker, conflicts of racial identity and the effects on child development, ongoing complex grief resulting from the loss of role, identity, homeland and culture."[112]

Dr. Surya Bhate from Newcastle City Health NHS Trust and Sheila Foley from Rampton Special Hospital commented on the danger of assuming that patients from ethnic minorities constitute a homogenous group.[113] Dr. Bhate, for example, told us that "needs change between first and second generation children and second and third generation", giving as an example his own son, whose Geordie accent was so strong that friends in Bombay could not understand him:

"His needs would be much different than my needs or my parents' needs if they were living here."[114]

The Royal College of Psychiatrists has called for further research on the causes underlying the very high rates of detention among the black community.[115]

56. A range of ways of improving the current situation were put to us, reflecting the different approaches taken. Mrs. Abbott-Buttler of FOOTPRINTS emphasised the need both for more doctors from ethnic minority backgrounds and for GPs to "take on board that they have a role to play in terms of making sure that the black community is treated fairly".[116] Paul Farmer from the National Schizophrenia Fellowship argued that "it is crucially around involving users and carers in planning services and black users have not been involved in identifying and planning the way in which care for them should be constructed and should be put forward",[117] an approach echoed by Levi Ferguson:

     "I personally would like to see a more effective voice from within the black community."[118]

The British Psychological Society made a number of recommendations on how services could be made more responsive, including:

  • the development of services, such as counselling, in primary care rather than in large institutions which may be associated with stigma
  • a visible commitment to non-oppressive practices for both users and workers
  • ongoing assessment of the training needs of workers, for example in areas such as the awareness of different expressions of distress across and within different communities and genders
  • the recognition that some potential users may wish to bypass the primary care system altogether and hence the provision of services in alternative locations such as drop-in centres and community projects
  • the construction of links with local communities.[119]

Dr. Bhate of Newcastle City Health NHS Trust raised the issue of "mainstream" versus "integrated" services, a topic we had also discussed when we visited Northern Birmingham Mental Health NHS Trust.[120] Both trusts were in agreement that the aim should be to create mainstream services which can meet the needs of all the patients they serve; "if you create minority services they become ghettos".[121] Dr. Bhate argued that services need "champions" from within mainstream services, to ensure that the needs of minority patients are recognised. We saw an example of this in our visit to Birmingham where the appointment of such a "champion", in the form of a development manager for services to Asian communities, has developed awareness within the trust of the needs of this ethnic group, encouraged patients to be more vocal and involved, and built links with local community groups.[122] Dr. Bhate also emphasised the need to be "innovative": while he felt it would certainly be appropriate to make positive efforts to recruit staff who speak languages common in the area served by the trust, for example, he suggested that there would always be cases where a patient's language needs could not be met directly and where it would be necessary to find an interpreter they could trust.

57. The Secretary of State in oral evidence to us endorsed many of the views put forward by earlier witnesses. On the question of services being "culturally appropriate", he emphasised the role of outreach teams and crisis services in encouraging earlier intervention.[123] On the issue of racism in the NHS, he stated categorically that "nobody should be under any doubts about the Government's commitment to tackling racism wherever it appears in the NHS": he highlighted the introduction of the requirement for all trust boards to undertake training on management of diversity issues, and the policy that "we want to see local NHS organisations in their workforce better representing the nature of the communities that they serve".[124] Department of Health officials also drew to our attention a recent series of inspections of compulsory admissions to mental health services, focusing on the experience of black and ethnic minority patients,[125] and, at our request, submitted a supplementary memorandum, giving examples of good practice in both training and service delivery in NHS trusts.[126]

58. We welcome and endorse the Secretary of State's clear statements on the need to make the NHS workforce more representative of the communities it serves. We were also impressed with some of the examples of good practice which were described to us. Nevertheless, we remain concerned that many patients from ethnic minority backgrounds clearly experience a far from adequate service, for a variety of reasons. Our concerns are heightened by the fact that these problems have been recognised for some years, but that change remains slow in coming. We note that discussions about institutional racism are current in many public services and believe that mental health services should not be excluded from these debates. Many of our recommendations below on issues such as user involvement and advocacy may be particularly relevant to ethnic minority patients. In addition, however, we would make the following specific recommendations. Firstly, the Department of Health's requirement that all NHS trust boards should undertake training on management of diversity should be expanded, so that all front-line NHS staff receive training on race awareness. Secondly, all educational bodies providing pre-qualification training to health professionals should be required to include training on cultural and racial issues as part of their core curriculum. Thirdly, all NHS trusts should designate a board member to take the lead on issues of race and culture within their trust and to ensure that active policies are in place to champion the needs of the ethnic minority groups in their area. Fourthly, the Department should ensure that trusts have access to a comprehensive network of interpreting services, if necessary providing grants to the voluntary sector to enable the necessary services to be developed. Fifthly, given that there is clear evidence that ethnic minority groups currently access services late, we recommend that priority is given to developing early intervention services, such as easy access to counselling. We believe that it is as important for trusts which do not include large minority ethnic populations in their catchment area to act on these recommendations as it is for those which do: the mobility of NHS staff means that staff trained in one part of the country may end up working in very different environments a few years later; and the vulnerability of minority populations to inappropriate services is arguably greater when they represent a tiny proportion of the local population.

User involvement

59. The issue of genuine user involvement in planning services was raised repeatedly throughout our inquiry, both in the specific context of developing culturally sensitive services, and as part of the more general picture of creating a service responsive to the needs of users. We were told of a number of major initiatives to seek the views of users and carers: the Department of Health, for example, told us that one of the forthcoming national surveys of users and carers would cover mental health services[127] and emphasised the role of users and carers in developing the National Service Framework. While this acceptance of the role of users and carers represents a major and welcome shift in emphasis over previous decades, we were also warned that the reality of such consultation can often be suspect.[128] Karen Campbell of the Manic Depression Fellowship was scathing about the limited impact user involvement often has:

    "I think we have reached a stage, as people who use mental health services, of thinking you ask us to come to meetings and listen to what we say, but very, very rarely - I can count it on two fingers, does what we say make a difference. I was part of the National Service Framework, I was in the Users and Carers Outcome Sub-group with three professors of psychiatry and a colleague from another charity, and we were talking about user and carer led outcome measures. Needless to say, none of the work that we did got into the National Service Framework."[129]

Ms Campbell went on to argue that the best way of tackling the problem was for a "bottom-up" approach, helping user-groups develop their own services, rather than the more traditional "top-down" one of asking users what they think of services that are already being provided.[130]

60. David Joannides of the Association of Directors of Social Services was more positive about the possibility of genuine user-involvement, suggesting that:

     "if you actively embrace user and carer involvement in assessments and care planning and recording the needs you are meeting and not meeting, and you actually treat those as partners not as simply recipients of a service on a take it or leave it basis, then you are developing a much greater appreciation of how well you are doing as a service."[131]

He also pointed out that the policy of "best value" required social services to challenge how they did things and to consult with service users.[132] Dr. Mike Shooter of the Royal College of Psychiatrists argued that one way of addressing the danger of "tokenism" was to ensure that users were involved in the training of healthcare professionals in a much more routine way than they are at present.[133]

61. Other witnesses emphasised the importance of outcomes being defined by users, not by service providers.[134] Christine Craik of the College of Occupational Therapists, for example, pointed out that "often those outcomes will be what other people will see as very mundane things ... they may be to enable them to do the everyday tasks which people have difficulty with because of their mental health problems."[135]

62. We believe that it is crucial that users and carers are involved in all aspects of service delivery. User-involvement in setting the outcomes which services aim to achieve should be central in service planning. It is clear that such involvement can only be more than lip-service if the professionals involved are prepared to regard users and carers as equal partners, to involve them early on in the process when decisions are actually being made, and, sometimes, to hear uncomfortable views without feeling personally or professionally threatened. We appreciate that this will involve, for some, a new approach, and strongly recommend that both the pre- and post-qualification training of all health and social care professionals should include structured input from users as part of a national programme.


63. The stigma of being labelled "mentally ill" or "mentally disordered" is clearly a factor in many of the difficulties experienced by individuals with mental health problems when living in the community. This was put to us forcefully by Dr. Mike Shooter of the Royal College of Psychiatrists, when describing the anti-stigma campaign his college has started:

Witnesses suggested that the main trigger for the sort of stigma associated with mental disorder is fear: fear of one's own vulnerability to mental illness[137] and fear of difference, exhibited for example through apparently aggressive behaviour or abnormal social skills.[138] Some of our witnesses argued that the Government itself had sent out stigmatising messages, with its statement that community care had failed and its emphasis on the risk posed to the public by some mentally disordered individuals.[139]

64. Education is clearly key in combating the myths surrounding mental disorder and the fear many feel when faced with mental distress. David Joannides of the ADSS suggested that personal and social development in schools, together with community service in years 9 to 12, will help combat ignorance from an early age, while Dr. Shooter of the Royal College of Psychiatrists argued that the most powerful effect on adolescents' views of mental illness can be achieved through positive images in the popular media, with a good example being the portrayal of Joe in East Enders.[140] Department of Health officials highlighted the requirement in standard one of the National Service Framework to overcome discrimination and described initiatives such as World Mental Health Day and work with the media to encourage them to present more realistic images of mental health problems.[141]

65. On the issue of media representation of mental illness, Mr. Joannides also drew attention to the role that service providers can play in the very practical sense of improving their own services and ensuring that vulnerable individuals are not left unsupported:

    "The more we can get the basics right, the more we can reduce the number of causes for the media to highlight cases."[142]

This approach was taken up forcefully by the Secretary of State, when we raised with him the stigmatising effect of the way inquiries into homicides by people in touch with mental health services are reported:

    "With respect what undermines the good work is the systems failure, it is not the [homicide] inquiry."[143]

66. We agree that, the more mental health services are able to "get the basics right", the easier it will be to challenge the fears surrounding mental ill health. We would encourage the inclusion of discussions of mental illness in the school curriculum. But we also call upon the Government to take a more proactive approach in challenging the perceived link between mental disorder and dangerousness. We recommend that the Government should fund a high profile public education campaign on similar lines to that supported recently by the Australian government which included extensive television, cinema and outdoor advertising to educate the public about the realities of mental illness.[144] We also believe that the Government's own current emphasis on risk conveys a highly misleading message to the public. We return to the subject of risk later in this Report (see below paragraphs 125-131).

56   Ev., p72. Back

57   eg Ev., pp62-63; Ev., p149; Ev., p253; Ev., p301; Q224.  Back

58   Q499. Back

59   eg Department of Health, Modernising mental health services, December 1998, para 3.19. Back

60   Q171. Back

61   Q359. Back

62   Q172. Back

63   eg Q356; Ev., p53; Ev., p321. Back

64   eg Ev., p299. Back

65   eg Ev., p66; Ev., p321. Back

66   eg Q171; Q173. Back

67   Q473. Back

68   Ev., p148. Back

69   eg Ev., p253; Ev., p294. Back

70   Ev., p294. Back

71   A full description of the programme is given at Ev., pp351-353. Back

72   Ibid. Back

73   eg Q208. Back

74   eg Ev., p283. Back

75   Q165; Q204. Back

76   Q207. Back

77   Q204. Back

78   Q348. Back

79   Q677. Back

80   QQ406-407. Back

81   Ev., p283. Back

82   Medical services, Third Report of the Social Security Committee (HC 183, Session 1999-2000), paragraph 57. Back

83   Ev., p325. Back

84   eg Social Security Advisory Committee, Social security and mental health: report on the SSAC workshop, 1996, p51. Back

85   Social Security (Welfare to Work) Regulations SI 1998/2231. Back

86   HM Treasury, Budget 2000, HC 346 1999-2000, p75. Back

87   Ev., p6. Back

88   Ev., pp5-6. Back

89   eg Ev., p284; Ev., p297. Back

90   Q202. Back

91   Q393. Back

92   Q353. Back

93   Q404. Back

94   Q501. Back

95   Q499. Back

96   Ev., p297. Back

97   Ev., p145. Back

98   Q353. Back

99   Q402. Back

100   The relationship between health and social services, First Report of the Health Committee (HC 74-I, Session 1998-99), paragraph 68. Back

101   Ev., p279. Back

102   Ev., p153. Back

103   Ev., p58; Q623. Back

104   Q625. Back

105   Q625. Back

106   Ev., p305. Back

107   eg Ev., p279. Back

108   Q168. Back

109   Nafsiyat Business Plan 2000/2001. Back

110   Ev., p310. Back

111   Q211. Back

112   Ev., p279. Back

113   Q362; Q623. Back

114   Q362. Back

115   Ev., p153; Q534. Back

116   Q197. Back

117   Q155. Back

118   Q217. Back

119   Ev., p279. Back

120   Q362. Back

121   Q362. Back

122   Northern Birmingham Mental Health NHS Trust, Annual report and financial summary, 1998/99. Back

123   Q686. Back

124   Q686. Back

125   Q98. Back

126   Ev., pp209-210. Back

127   Q9. Back

128   eg Q538. Back

129   Q214. Back

130   Q214.  Back

131   Q497. Back

132   Q540. Back

133   Q537. Back

134   eg Ev., p277; Ev., p292. Back

135   Q507. Back

136   Q544. Back

137   Q546. Back

138   Q548. Back

139   eg Q472; Ev., p73. Back

140   Q551. Back

141   Q71. Back

142   Q548. Back

143   Q664. Back

144   National Community Awareness Program, summarised at Back

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