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
