Select Committee on Health Fourth Report



67. The National Service Framework was launched in September 1999, setting out for the first time seven standards of care which mental health services across the country should aim to achieve (see above paragraph 18). The initial response to the Framework has been overwhelmingly positive. The NHS Confederation, for example particularly welcomed the Framework's "style and tone", in setting standards across the full range of mental health services, from mental health promotion to services for the severely mentally ill.[145] The value of having national benchmarks against which local services could measure their development was emphasised by the Confederation and others.[146]

68. Clearly, standards set out in frameworks will only be of value to users of services if the

services themselves are actually able to deliver those standards. We were concerned to find out from our witnesses how realistic they felt the standards set out in the Framework were, and what obstacles there might be to delivering them. Department of Health officials told us that the standards did not simply reflect a wish-list: "they are to be achieved".[147] At the same time they emphasised the need to "be realistic" and to "give people the time to reshape their services locally".[148] The Department's memorandum described in some detail the implementation and monitoring arrangements which are being developed. Local Implementation Teams (comprising representatives from service users, carers, local authority departments, Primary Care Groups, NHS Trusts and Health Authorities) have been set up in every health and social care community and required to produce draft implementation plans; a baseline survey of current service provision will be undertaken; and authorities are being asked to produce a "gap analysis" identifying the progress needed to achieve the standards in the Framework. By autumn 2000, implementation teams are expected to produce both ten-year strategic plans and more detailed rolling three year plans which will feed into the local Health Improvement Programme.[149] In oral evidence, officials also highlighted the role that the Social Services Inspectorate and the performance management arrangements in NHS Regional Offices and social care regions would be playing in monitoring how progress is being made.[150] Other witnesses emphasised the importance of principles and standards being translated into operational targets, and emphasised the need for a flexible approach to implementation to reflect the realities of "where services are at present and what staff are like".[151] The NHS Confederation suggested that it would have been helpful to have had more guidance in the Framework itself as to which element of the strategy should be given the highest priority, given that many areas will not have the resources to improve services immediately across the board.[152]

69. We were impressed with the arrangements described by the Department of Health for the implementation of the National Service Framework at local level and in particular with the requirement to produce detailed gap analyses so that there is clear information on where services need to be improved. We urge the Department to ensure that this information is made publicly available, at both local and national level. We would also emphasise the need for regular monitoring of progress within the Framework. If a need for more specific guidance on prioritisation emerges from that monitoring, then such guidance should be provided at national level.

70. There were two main anxieties expressed by witnesses who will be responsible for delivering the Framework: funding and staffing. The NHS Confederation response on funding was typical:

    "The investment of £700 million over 3 years from the modernisation fund is welcome although this is unlikely to meet the total needs within the mental health services."[153]

More sceptically, the Royal College of Psychiatrists argued that "before we get carried away with the beneficence of the £700 million we have to remember that we are starting from a very low base,"[154] while SANE put forward the view that "monies being proposed will hardly meet the current need, let alone reduce the strain on a system crumbling under pressure".[155] Other witnesses such as Lionel Joyce of Newcastle City Health NHS Trust highlighted the fact that the Modernisation Fund money, although high profile, was of far less significance to mental health services than their annual financial agreements with their local Health Authorities:

    "The real deal for us is how are the contract negotiations going to go, the SAFF [Service and Financial Framework] negotiations. At the moment they are going better than I could have ever hoped."[156]

The need for "significant and sustained growth in funding" was made by the Sainsbury Centre for Mental Health, who pointed out that:

    "Money cannot be released from the hospital sector unless effective community alternatives are in place first. Even then, most parts of the acute sector require substantial investment to bring the environment up to acceptable standards."[157]

The Centre estimated that the total resources required to achieve this "may be between 20-30% of the current total mental health budget (equivalent to perhaps £0.5bn per annum)".[158] The South London and Maudsley NHS Trust also pointed out that the amounts Health Authorities spend per capita differed enormously, with five-fold variation throughout the country.[159]

The Secretary of State, drew our attention to the importance of streams of funding other than the well-publicised £700 million, commenting that mental health services account for around 12% of the total hospital and community health services budget.[160] Mr. Milburn went on to confess that he was "always slightly nervous, it is my Treasury inheritance, about second-guessing ten years' time" but that "it would be surprising if mental health did not get a reasonable level of investment."[161] On the next three year's funding, announced in this year's Budget, he was more forthcoming, stating that "we have got to make sure that mental health services get their fair slice of those extra resources".[162]

71. While the Modernisation Fund money is clearly welcome, we believe that it is the overall level of funding going to mental health services via Health Authority allocations that will be more significant in ensuring that the National Service Framework becomes a reality and not merely an aspiration. We urge the Secretary of State to ensure that mental health services do indeed get their "fair slice of the cake". We also recommend that the Department should monitor the very disparate levels of spending on mental health services between Health Authorities, and where necessary draw Authorities' attention to spending which falls well below the national average.

72. The recruitment, retention and morale of the mental health workforce is clearly going to be central to the success of the National Service Framework. This is reflected in the Department's decision to set up a Workforce Action Team to look at workforce planning, recruitment and retention, education and training, and developing and supporting leadership.[163] We were told that the Department has received the Action Team's interim report, but that the final report is not due until April 2001.[164]

73. We received ample evidence, both from the Department and from the professions, to demonstrate that there are significant shortages of key professions. Dr. Mike Shooter of the Royal College of Psychiatrists estimated that "we have an average of something like 15 per cent consultant psychiatric vacancy across the country" and commented that the recent creation of more training posts for psychiatric specialist registrars and hence the expansion of consultant posts, was both "good news" and "potentially embarrassing news" if qualified individuals could not be found to fill those posts.[165] Dr. Shooter recommended a two-pronged approach: an active recruitment drive among sixth-formers choosing medicine as a career in order to encourage them from very early on to consider psychiatry as a possible specialty; and action to improve morale and stop practising psychiatrists from leaving the profession early.[166] He particularly highlighted the role of the compulsory public inquiries which take place after homicides have been committed by individuals in touch with mental health services, stating that "the college for example has appealed for a long time now for the abolition of mandatory homicide inquiries ...They are increasing The Sun headlines and the climate of blame we are talking about".[167] Similar points on the homicide inquiries were made by the Institute of Psychiatry and the management of South West London and St.George's NHS Trust. The Institute told us that they were planning research on the health consequences for psychiatrists of mandatory homicide inquiries, and argued that the "blame culture" which these inquiries encouraged was the most important deterrent to recruitment.[168] On our visit to South West London and St. George's NHS Trust similar points were made to us, with particular reference to the fact that the teams serving on homicide inquiries tended to participate in only one or two inquiries, thus preventing expertise from building up or meaningful comparisons to be made between cases.[169]

74. Lionel Joyce of Newcastle City Health NHS Trust, made the provocative suggestion to us that experienced GPs could be trained to be psychiatrists within two years.[170] While Dr. Christopher Mayer, a psychiatrist from Suffolk, disagreed with this idea, he conceded that "a lot of what any of us do does not have to be done by us".[171] This theme was taken up by a number of other witnesses. David Joannides of the ADSS commented on the possibility of using competent staff trained to NVQ levels 2 and 3 "who can give people with mental illness the time they need, who can be the alerts to when more specialised help is needed, who can keep in touch with people".[172] Mike Shooter of the Royal College of Psychiatrists highlighted work currently being carried out by the Department on including some "core skills" courses across all professional training,[173] and also told us of the possible development of a diploma in psychiatry which might interest committed GPs.[174]

75. On nursing shortages, Martin Ward of the Royal College of Nursing drew our attention to the age of the nursing workforce, noting that one third of all nurses in the country would reach retirement age within the next five years.[175] While describing recent campaigns to encourage nurses back into the profession as "beneficial", Mr. Ward argued that because mental health had traditionally attracted "a more mature student" the situation with the mental health workforce was likely to be particularly acute. As an example of the effect of localised shortages, he highlighted a survey carried out in in-patient services in inner London in 1997 which showed that one third of nurses servicing 506 beds, and half of all night staff on those wards, were from agencies. He emphasised the importance of recruitment, and suggested that recent changes being made to nurses' training, such as provision for mental health placements very early on in training, would be helpful.[176]

76. The position for clinical psychologists and occupational therapists is rather different: both the British Psychological Society and the College of Occupational Therapists told us that they had no problem recruiting people into their professions, but the difficulty lay in the very limited number of training places. The British Psychological Society, for example, told us that "we have only just got over the stage where we take more than 300 people a year into training".[177]

77. The Secretary of State agreed that there were shortages in nurses, psychiatrists "and other specialist staff", but noted that the picture varied at both local and regional level and that the figure for nursing vacancies in mental health nursing (2.1%) was actually below the general nursing figure (2.6%).[178] He pointed to action that the Department had taken, including approving more training posts for psychiatrists and recruiting more nurses, but emphasised his belief that one of the significant problems in retention had been that "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". He was therefore hopeful that factors such as increases in intensive care beds and secure beds would "begin to make a difference to people".[179] On the question of homicide inquiries, the Minister of State responsible for mental health services, John Hutton MP, told us that there would be an announcement "shortly" on how the system could be improved;[180] the Secretary of State however warned us that "there would be concern from members of the public, and indeed sometimes from the families affected, if people felt there was a cover-up".[181]

78. It was clear from the evidence we received both that there are considerable shortages in key mental health professions, and that the National Service Framework is unlikely to become a reality unless these shortages are addressed. We realise that the NSF Workforce Action Team is actively considering these issues, and urge it to take on board the evidence submitted to this inquiry. We would particularly draw attention to the evidence we received on the limited numbers of training places for occupational therapists and clinical psychologists, the importance of providing early placement in mental health services for nurses in training, and the desirability of developing "core-skills" training across professions. We would also urge active consideration of the development of appropriate training and recognition for workers to be the "eyes and ears" of professionals, as described by David Joannides and others (see paragraph 74 above).

79. The question of the mandatory homicide inquiries is a very sensitive one. Like the Secretary of State we are anxious that there should never be any question of a "cover-up" if a member of the public has been killed by an individual in touch with mental health services. At the same time, it is clear to us that the effect of these inquiries on the professions, especially psychiatrists, is deeply counter-productive, with the ensuing danger that inquiries set up with the aim of improving services may have the opposite effect by driving away competent staff. We would recommend that there should continue to be public inquiries into such events, but that they should be carried out on a systematic, national basis, for example by a specialised division within the Commission for Health Improvement, with the outcomes published in an annual report on the lines of that produced by the Health Service Commissioner. This would allow a body of expertise to be built up, and for lessons learned from inquiries to be more effectively disseminated.

Gaps in general mental health services

80. We referred early to the "gap analyses" which all health and social care communities are carrying out in order to identify where their services are currently falling short of the standards in the National Service Framework (see paragraph 68). Many of our witnesses highlighted areas where they felt that services were currently inadequate, and some very clear themes emerged. The first was the lack of "talking treatments", such as psychotherapy and cognitive therapy on the NHS.[182] We were struck by the fact that this point was raised emphatically with us by both user and professional representatives: there appeared to be consensus on all sides that such services were beneficial. The point was also made that the role of such therapies is not limited to the "softer" end of mental health services: the Manic Depression Fellowship told us that recent research had demonstrated that a combination of medication and talking therapies was the most effective treatment for manic depression[183] while Lionel Joyce of Newcastle City Health NHS Trust and the Royal College of Psychiatrists highlighted the role of cognitive therapy and psychotherapy in the treatment of schizophrenia.[184]

81. We find it very disturbing that there is clearly such a shortage of psychologically-based treatments in the NHS, given the general consensus as to their value for many patients. The evidence we received did not enable us to judge whether the rarity of such treatments is primarily due to the shortage of professionals able to deliver them, lack of awareness among those responsible for purchasing mental health services as to their benefits, or cost. We therefore urge the Department of Health to undertake further research in this area and, if appropriate, to feed the results of that research into the work of the Workforce Action Team.

82. The variable availability of the new "atypical" drugs for schizophrenia was raised with us by a number of witnesses.[185] We have been struck throughout our inquiry by the emphasis many users (not only those suffering from schizophrenia) placed on the detrimental side-effects often experienced from psychiatric medication.[186] Given the current emphasis on compliance with drug treatments, it seemed to us self-evident that if, as the research suggests, these drugs have reduced levels of distressing side-effects, then they should be made more generally available. We are aware that the National Institute for Clinical Excellence (NICE) is currently considering guidelines on the management of schizophrenia, which are likely to include recommendations as to whether or not the more expensive atypical drugs should be the first-line treatment. We will not attempt to anticipate the work of NICE, but we would urge those carrying out the evaluation of atypical drugs to give serious consideration to the outcomes of treatment from the user's perspective, including the benefits of making compliance with drug treatment less onerous.

83. The third theme to emerge from the evidence submitted to us was the urgent need for more "bridging" facilities between in-patient care and care in the community. The Sainsbury Centre for Mental Health listed a range of supported accommodation options which could theoretically fill the gap between no support at all and admission to an acute bed: these ranged from ordinary housing with intensive support through sheltered accommodation, group homes, low support hostels, care homes and high support accommodation to 24 hour nursed accommodation.[187] It is clear that such a range of services is far from universally available: a number of witnesses argued for an increase in the availability of 24 hour nursed accommodation[188] while others commented that the gap between 24 hour care and low intensity support in the community was too great, with the implication that in many areas little was available in between.[189] We noted a link here with the issue discussed earlier of the importance of meaningful day-time activity. Written evidence from Victims' Voice[190] highlighted the need for purposeful day-time occupation for those living in hostels, and this need was brought home very clearly to us in our visit to Belmarsh Prison where a remand prisoner told us of his relapse in the community after discharge from a medium secure unit: he was living in a hostel with nothing to do all day and rapidly joined drunks on park benches and succumbed to his previous abuse of alcohol.

84. We believe that particular attention should be given to the development of a range of accommodation with suitable support arrangements, including long-term supervised hostel accommodation which is adequate to support people with high-level needs, such as those discharged from medium secure units and those with histories of drug and alcohol abuse. There is an additional need for appropriate provision of ordinary high quality housing in the community that can be made available to people with mental health problems who may need support and specialist services from time to time, but who enjoy full rights as tenants. This will require close partnership working by health and social care with housing authorities and local housing providers. We are aware that the Government is currently working on the details of a new single funding stream for housing support services, to replace the current arrangements through Housing Benefit from April 2003,[191] and urge that the needs of people with mental health problems be taken fully into account in the development of the new system.

How and where services should be delivered

85. The evidence we received and the visits we undertook as part of this inquiry confirmed our initial impression that mental health services are presently a "patchwork quilt", with enormous variations in both standards of service and methods of service delivery around the country. While the very rationale of the National Service Framework is to bring standards up to national benchmarks, there is no consensus on whether a national approach to organisational matters is desirable. Both NHS trusts who gave oral evidence to us argued that different populations and circumstances demand different methods of service delivery: Lionel Joyce from Newcastle told us that "we quite set out to operate different services" in the various parts of their catchment area[192] while Pat Holman from Suffolk told us that "Birmingham's [service] will work well in Birmingham, it will not necessarily in Suffolk".[193]

86. The area where the debate on service delivery appeared to us to be most acute is the question of which NHS organisations will, in future, be responsible for delivering mental health services. At present, mental health services may be provided by stand-alone mental health trusts, by trusts combining mental health services with a range of other community services, or by combined acute and community trusts which provide mental health services as part of a general district hospital service. In April 2000, the first wave of Primary Care Trusts (PCTs) came into existence and these will potentially be able to take over the provision of mental health services.

We felt that there were two issues of considerable importance here: firstly the significant disruption for management and staff (and hence almost certainly also for patients) of major organisational upheaval; and secondly the implications (both positive and negative) of specialist mental health services moving closer to primary care.

87. Several witnesses drew our attention to the significant upheaval caused by trust mergers and re-organisations: Dr. Shooter of the Royal College of Psychiatrists, for example, told us:

    "My service has been through three changes, three different configurations in the last few years. We have survived that and we have prospered but it has made developing long-term strategies extremely difficult."[194]

The Centre for Mental Health Services Development at King's College London stated that there is "no robust evidence to link specific service configurations with specific outcomes for service users", and argued that services should be given a year to make any changes deemed desirable and then a three-year moratorium on further change should be declared, albeit it with provision for pilot projects involving PCTs.[195] The NHS Confederation emphasised that service reconfiguration is inevitably a distraction from the "key issue" of managing services and urged that any such changes should be taken consciously, and not by default as a result of other policy initiatives. The Confederation suggested the following check-list of criteria should be met before a significant reconfiguration of services takes place:

    "The proposed reconfiguration [must] clearly demonstrate service improvements; advantages of economy of scale and scope, for example staff groups of sufficient size to achieve an optimal mix of skills; management capacity and capability with a senior manager focused on the mental health agenda, and seamless management of in patient and community components; ability to recruit and retain staff in all professional groups and provide access to staff training and education; clear clinical governance pathways with appropriate expert clinical leadership; clear managerial and clinical lines of accountability."[196]

88. The question of the relationship between primary care and the specialist mental health services is clearly a highly complex one. The users and carers who gave oral evidence to us (representatives of Breakthrough, FOOTPRINTS and MDF) were unanimous in supporting the idea of psychiatrists being much more generally available in primary care, for reasons such as ease of access and the fact that primary care services are seen as ordinary and non-stigmatising.[197] We ourselves were very impressed with the description we were given in Northern Birmingham of a pilot project covering one of the trust's localities, where the psychiatrist saw all his patients in their own general practice and wrote directly into their GP medical notes.[198] At the same time, witnesses were concerned about low standards of knowledge about mental health in some GP practices; Karen Campbell of MDF, for example, commented that "there is a whole raft of people out there who go to their GP because they are not feeling very well and never get the help they need".[199] Pauline Abbott-Buttler of FOOTPRINTS made much the same point.[200] While the provision by psychiatrists of services in primary care is a distinct issue from the interest in mental health shown by individual GPs, it seems unlikely that specialist services could develop successfully in primary care without the enthusiastic involvement of the GPs concerned.

89. There are clearly strong arguments for strengthening the primary care involvement in the provision of services to people who are suffering mental ill-health. As Lionel Joyce of Newcastle City Health NHS Trust pointed out to us, there is no "simple division between 'you are a primary care mental illness' and 'you are a secondary care mental illness' because mental illnesses, as you know, swing in severity from one to the other".[201] People with mental health problems also, like everyone else, have physical health needs and are likely to visit their GPs regularly; moreover primary care services have the great advantage of being seen as non-threatening and non-stigmatising. The current emphasis on the development first of Primary Care Groups and then Primary Care Trusts is very much based on the premise that services, wherever possible, should be delivered as close to the patient's home as possible, and on the belief that this will be achieved by giving power over service development to primary care professionals.

90. The arguments for keeping specialist mental health services as distinct entities are, however, also powerful. We have already touched on concerns about the varying levels of knowledge of mental health issues in primary care (see above paragraph 88), and we certainly feel that it is crucial for the prime movers in organisations responsible for commissioning or providing mental health services to be both interested in and knowledgeable about mental health services. The Sainsbury Centre for Mental Health, for example, argued that the complexity of mental health services means that the commissioning of them is likely to be beyond the ability of most PCGs or PCTs,[202] while Tony Russell of Breakthrough told us that "PCG people are crying out for guidance themselves".[203] Given that PCTs are likely to cover far smaller catchment areas than stand-alone mental health trusts do at present, there are also issues such as whether they would be large enough to provide the "critical mass" necessary to support their staff, especially if they are working over dispersed sites.[204] On the question of the commissioning, as opposed to the providing, of mental health services, however, the Department of Health drew our attention to the outcomes of "total purchasing" pilot schemes (where GP practices were delegated the entire healthcare budget for their population), suggesting that these resulted in improvements in mental health services.[205]

91. Given the reality of PCT development, Department of Health officials expressed doubts about the practicalities of instituting a moratorium on institutional change, as suggested by the Centre for Mental Health Services Development.[206] However, the Secretary of State pointed out that, if PCTs were to "take over" the direct provision of mental health services, this would be not a take-over, but a merger with the organisation currently providing those services:

    "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."[207]

The Secretary of State also emphasised that, as set out in the National Service Framework, PCTs would have to meet key criteria, before they would be permitted to take control of mental health services.[208]

92. We accept that, although organisational change can be immensely disruptive, in particular circumstances it may be appropriate for Primary Care Trusts to take on the provision of specialist mental health services, for example in areas of the country where there is already successful provision of specialist mental health services in primary care settings. However, we strongly believe that this should only take place if the PCT has been able to demonstrate clearly that the new system will provide significantly better services to local users. We would suggest that the Department give consideration to those PCTs that are able to progress early on this front becoming pilot sites, sharing their learning and expertise with others. We also urge the Department to consult with users when setting out the criteria which PCTs will have to meet before being permitted to provide mental health services.

93. Even if a number of Primary Care Trusts do take on responsibility for mental health services, there seems little doubt that the issue of the relationship between individual GP surgeries and the specialist services will continue to be of great importance. The two NHS trusts from whom we took oral evidence both gave us examples of how they were seeking to forge closer links between themselves and primary care. Lionel Joyce of Newcastle City Health NHS Trust described how some of his consultants visited GP practices fortnightly, reviewing cases in a way that seemed similar to the model adopted in Birmingham (see paragraph 88 above).[209] Pat Holman of Local Health Partnerships NHS Trust in Suffolk told us that each of their community mental health teams had a link worker, usually a nurse, who was responsible for liaising with primary care.[210]

94. The Disability Partnership is currently looking at ways of improving the liaison between general practice and secondary care, and their proposals include:

  • educating and orienting primary care staff on mental health issues
  • developing some services, such as counselling, anxiety management and understanding psychosis, at general practice level
  • creating and refining care pathways into secondary care
  • obtaining user-input into training primary care staff, user representation on PCG boards and user involvement in service evaluation.[211]

We endorse these proposals which we believe would do much to improve the relationship between general practice and specialist mental health services.

95. A second area where service provision appears to vary markedly around the country is in the way assertive outreach, home treatment and crisis services are delivered. The National Service Framework places considerable emphasis on the role of assertive outreach and home treatment, and the evidence we received strongly supported both approaches.[212] The Sainsbury Centre for Mental Health emphasised the importance of clarity of purpose when setting up assertive outreach teams: the aim of "assertive outreach" is to reach patients who would otherwise refuse to engage with the system and teams hence have far lower case-loads than general community mental health teams. The Sainsbury Centre argued to us that "unless teams are focused and effective, it is hard to justify creating them", and commented that their availability is still patchy.[213] The Centre for Mental Health Services Development at King's College London developed this point further, telling us that there existed enormous variations in the outcomes of different assertive outreach teams, and that this was at least partly due to inconsistencies in the client groups being targeted by teams and differences in the way assertive outreach teams fitted in with other services.[214] The Centre suggested that the "unhelpful debate about service models" could be avoided by setting standards for assertive outreach defined by the users they were designed to help.

96. Similar points were made to us about home treatment and crisis intervention services. The Sainsbury Centre argued that home treatment teams could be very effective in supporting users in their own homes during crises, hence avoiding hospital admissions.[215] However, the Centre also commented that "a number of attempts to set up effective crisis services around the country are currently failing or even increasing bed utilisation". The conclusions drawn by the Centre included the fundamental importance of providing long-term funding for such services, rather than setting them up with "soft", non-recurrent funding. They also emphasised that it was vital for home treatment schemes to be able to provide medication if necessary. The theme of the differing results of home treatment and crisis intervention work was taken up by South London and Maudsley NHS Trust, who argued that these services should be evaluated through randomised controlled trials.[216] The Royal College of Nursing went further in urging research on many of the service models advocated by the National Service Framework, including assertive outreach, home treatment and relapse prevention;[217] in oral evidence to us, Martin Ward of the RCN commented that the NSF "does demand that we link the research agenda with the clinical agenda".[218] Users certainly seemed very positive about crisis services: the National Schizophrenia Fellowship for example "strongly advocated" the use of crisis intervention schemes.[219] Angie Schram of Breakthrough highlighted the importance of such services being prepared to be as supportive and stay as long as the user needed, suggesting "it is lovely that people come and intervene when they have a crisis and it is lovely that they have rapid response, but wouldn't a crisis-resolution team be nice, where people could actually come in and really do something to help, not just come in and hold the fort for a few hours, but come in and actually get that person on a programme to get them feeling better."[220] Other witnesses drew our attention to the value of crisis cards and advance directives[221] in helping patients inform services what treatments have been successful and acceptable in helping them recover from crises in the past.[222]

97. We were very impressed with the work of the home treatment and assertive outreach teams that we saw in our visits to Northern Birmingham and South West London. We were also struck, however, by the research presented by the Centre for Mental Health Services Development on the variations in outcome achieved by assertive outreach teams, and by the similar evidence on home treatment provided by the Sainsbury Centre for Mental Health. Given the rapid development of these services at present, as part of the National Service Framework, we recommend that the Department should review current research on assertive outreach and commission further research on home treatment and other forms of crisis intervention, so that services can be developed on the basis of the best available evidence. The evidence base should incorporate the views of users and carers about the effectiveness and acceptability of services, including specific views of people from black and minority ethnic communities.

Standards in in-patient wards

98. There appears to be considerable evidence that home treatment and crisis intervention services can, in certain circumstances, achieve significant reductions in demands for acute in-patient beds, particularly by reducing patients' length of stay.[223] However, there is no doubt that there will remain a need for in-patient care; indeed both the Royal College of Nursing and the Royal College of Psychiatrists argued in their evidence that good quality community care is only possible if patients also have access to good quality in-patient care.[224] The Sainsbury Centre for Mental Health made a similar point, stating that "acute 24 hour care should be viewed as one component of a comprehensive and integrated service - a range of crisis services should be available of which hospital care is one component".[225] We therefore found it very disturbing to receive evidence from a variety of witnesses on the current low quality of much in-patient care: the Sainsbury Centre, for example, cited its recent report Acute Problems which suggested that the pressures on acute beds were so great that the environment was positively "untherapeutic", that services lacked clear goals, and links with community services were poor.[226] The Mental Health Foundation similarly suggested that the "real weakness" in the mental health service at present was to be found in acute wards,[227] while Angie Schram from Breakthrough cited improvements in in-patient care as her highest priority.[228] The need for a substantially improved environment in acute inpatient units was stressed in the Royal College of Psychiatrists' policy document Not just bricks and mortar, which proposed that all newly built facilities should provide single ensuite rooms for all patients, with general fittings equivalent to the "standard of a good quality hotel".[229] The NHS Confederation commented on the practical difficulties the NHS was experiencing in improving the support available in the community, while at the same time trying to improve the quality of in-patient care, and suggested that access to a "capital modernisation fund" would be very useful.[230]

99. We were very disturbed by the evidence we received on the quality of in-patient care. We feel that the environmental standards on in-patient wards are important for two reasons: because an improved environment will increase the therapeutic value of units; and because natural justice and the principle of reciprocity demand that those who are detained on such wards without their consent should be provided with accommodation which affords reasonable privacy and dignity. We believe that a capital modernisation fund, aimed specifically at improving environmental standards on in-patient wards, could make a significant difference to the quality of life of patients staying on these wards. The views of service users should be incorporated into any local plans for ward improvements.

100. It was also put to us by Dr. P. Moodley of the South West London and St. George's Mental Health NHS Trust and Professor Ray Rowden that it was time to move away completely from the medical concept of a hospital with wards, developing instead a "core and cluster" system of mental health services in every neighbourhood.[231] Dr. Moodley and Professor Rowden suggested that such a service could include a "core" in the form of a small well-resourced residential facility to support people in crisis, with "spokes" leading out to a range of other provision, both residential (from 24-hour nursed beds to low support housing) and non-residential (including therapeutic interventions, educational services, social networks such as user-run Clubhouse schemes and employment services). Dr. Moodley and Professor Rowden went on to propose that an alternative model of this kind could be "devised, widely discussed and then piloted"; rigorous evaluation of the pilot schemes could then inform future development. The Royal College of Psychiatrists' report, Not just bricks and mortar, on the other hand, suggested that there was no easy answer to how such units could be made small enough and domestic enough in character to avoid institutional overtones while, at the same time, being large enough to ensure adequate staffing and safety and to avoid a hot-house atmosphere.[232] It argued that although a whole range of provision, such as crisis homes, acute day hospitals and home treatment were being developed, these services were "invariably in addition to an 'admission ward' rather than a substitute for it".[233] The report went on to recommend retaining the concept of wards, which should provide for between 10 and 15 patients, with units having a minimum of three and a maximum of five wards (although the maximum of five could be exceeded if the units were multi-functional).[234]

101. It is clear from the evidence we received that the environment of the traditional hospital is not the best environment for helping individuals in crisis: people suffering acute phases of mental illness may need a "safe haven" away from their own homes, and sometimes secure surroundings, but this need not be in an institutional building. Indeed, the use of such buildings appears to be based on necessity rather than on any belief that they are the best or only way of providing care to individuals in distress. We recognise the need to balance domesticity, good quality care and security which is emphasised in the Royal College of Psychiatrists' report Not just bricks and mortar. However, we do believe that further research on how these aims can best be achieved would be very valuable. We therefore urge the Department to fund pilot schemes following the "core and cluster" model described by Professor Rowden and Dr. Moodley, so that their effectiveness can be rigorously evaluated. If such pilot schemes are successful, we recommend that the Department commit itself to providing the capital expenditure necessary to expand them swiftly.

The voluntary sector

102. We have been very struck throughout this inquiry by the vital role played by the voluntary sector in providing mental health services. The chief executives of both the NHS trusts who gave evidence to us emphasised the valuable part played by the voluntary sector;[235] indeed Lionel Joyce from Newcastle City Health NHS Trust expressed great regret that, as a trust, they were not able to support voluntary groups but were, instead, expected to view them as competitors.[236] Two of the user and carer representatives giving evidence to us made clear how important "grassroots" organisations could be: Karen Campbell of the Manic Depression Fellowship suggested that "user-involvement" could only be real if users had a budget and developed services for themselves,[237] while Levi Ferguson, a carer from Sheffield, expressed great concern about the vulnerability of much of the funding of the voluntary sector:

"Why should certain workers only be in a post for three years, even when their work is valued?"[238]

103. Both the value and the vulnerability of the voluntary sector was made clear to us when we visited the North London inter-cultural therapy centre, "Nafsiyat". Nafsiyat's work is both valuable and valued: they are funded by local Health Authorities and have waiting lists of over a year. Yet their future is uncertain: the lease on their premises runs out in two years time and several of their staff members are working unpaid.[239] Nafsiyat told us that they appreciated the need to evaluate the work of the voluntary sector, and that they clearly understood that grants could not be given unconditionally. At the same time, they argued that the procedures for applying for grants were unduly onerous: fresh applications had to be made each year, even though their work had already been evaluated and endorsed; the management burden this placed on a small organisation was disproportionate; and perpetual short-term funding meant that staff never had long-term security even when grants were renewed.

104. The work of the voluntary sector in mental health services is clearly of immense value. Yet individual organisations are perpetually on the brink of collapse because of the uncertain nature of the funding system. We recommend two improvements in the current system. Firstly, the Government should provide central funding for initiatives offering administrative and practical support (such as pay-roll services) to small voluntary organisations on a local basis. Secondly, Health Authorities should apply the same principles to their voluntary sector service agreements as they are required to do in their NHS agreements: that is, that they should set up three year rolling agreements, subject to adequate review and appraisal arrangements. If this recommendation were implemented, voluntary organisations would always have the certainty of three years funding, allowing them to plan more strategically and to recruit able and committed staff.

145   Ev., p284. Back

146   eg Ev., p284; Q384. Back

147   Q39. Back

148   Q41. Back

149   Ev., p6. Back

150   Q9. Back

151   Q384. Back

152   Ev., p286. Back

153   Ev., p284. Back

154   Q475. Back

155   Ev., p66. Back

156   Q389. Back

157   Ev., p303. Back

158   Ibid. Back

159   Ev., p322. Back

160   Q681. Back

161   Q682. Back

162   Q682. Back

163   Ev., p7. Back

164   Q659. Back

165   Q483. Back

166   Q480. Back

167   Q496. Back

168   Ev., p239. Back

169   Ev., p367. Back

170   Q389. Back

171   QQ414-415. Back

172   Q480. Back

173   Q483. Back

174   Q486. Back

175   Q480. Back

176   Q482. Back

177   Q480. Back

178   Q658. The Department's subsequent memorandum (Ev., p359) clarified that these figures related to posts which were still vacant after 3 months. Back

179   Q658. Back

180   Q660. Back

181   Q665. Back

182   Q167; Ev., p72; Ev., p147; Ev., p153; Ev., p322. Back

183   Ev., p72. Back

184   Q340; Ev., p153. Back

185   eg Q177; Q554; Ev., p330. Back

186   eg Ev., p50; Ev., p64; Q177. Back

187   Ev., p301. Back

188   eg Ev., p67; Ev., p248. Back

189   Ev., p250; Ev., p310; Ev., p348. Back

190   Ev., p255. Back

191   DSS, Supporting people: a new policy and funding framework for support services, December 1998; HC Deb 31 March 1999 cc 829-830. Back

192   Q340. Back

193   Q404. Back

194   Q466. Back

195   Ev., p291. Back

196   Ev., p285. Back

197   QQ193-197. Back

198   Q411 Back

199   Q193. Back

200   Q197. Back

201   Q345. Back

202   Ev., p304. Back

203   Q192. Back

204   Ev., p285. Back

205   Ev, pp206-7. Back

206   Q13. Back

207   Q655. Back

208   Q641. Back

209   Q345. Back

210   Q411. Back

211   Ev., pp348-349. Back

212   eg Ev., p291; Ev., pp300-302; Ev., pp321-322. Back

213   Ev., p302. Back

214   Ev, pp291-292. Back

215   Ev., p300. Back

216   Ev., p322. Back

217   Ev., p145. Back

218   Q477. Back

219   Ev., p62. Back

220   Q198. Back

221   Crisis cards may name the most appropriate person to be contacted if the user is in distress or crisis, and may draw attention to particular problems and disabilities, or recommend the best way of helping the user through the crisis. Advance directives provide an opportunity for the user, when well, to make decisions as to how they would like to be treated if in the future they experience another episode of acute illness. Back

222   eg Ev., pp277-278. Back

223   Ev., p321. Back

224   Ev., p145; Ev., p151. Back

225   Ev., p300. Back

226   Ev., pp299-300. Back

227   Ev., p276. Back

228   Q217. Back

229   Royal College of Psychiatrists, Not just bricks and mortar, 1998, p28 and p43. Back

230   Ev., p286. Back

231   Ev., p358. Back

232   Royal College of Psychiatrists, Not just bricks and mortar, 1998, pp17-21. Back

233   Ibid, p16. Back

234   Ibid, p20. Back

235   Q347; Q418. Back

236   Q347. Back

237   Q214. Back

238   Q209. Back

239   Ev., pp350-351. Back

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