Select Committee on Health Written Evidence

75. Evidence submitted by the Oxfordshire Locality Group of the Mental Health (Oxon and Bucks) PPI Forum (PPI 71)

  I write to submit evidence to the Health Committee on behalf of the Oxfordshire Locality Group of the Patient and Public Involvement Forum (PPIF) for Mental Health (Oxon and Bucks).

  From the inception of the Forum system until May 2006, this group was an independent Forum but was reorganized to be part of the Oxon and Bucks Forum following the bringing together, for reasons of efficiency, of the Oxfordshire and Buckinghamshire Mental Health Trusts in April 2006.  This joint Trust is now applying for Foundation Trust status. Because of underlying diversity of locality, policy and performance, including financial, much of the work of the matching Forum is still organized on a county basis. The basis of our evidence is therefore three years of visits, discussions, and attendance at meetings with an ever-growing number of groups, institutions and NHS, social services and local political organizations such as the Overview and Scrutiny Committees of both Oxford City and Oxfordshire.

  Within our own specific responsibilities, we have already developed ways of working comparable with those suggested as necessary to the new LINks on a more general basis. Our main contention is that from our experience, mental health is unlikely to be adequately served within the admittedly sketchy outlines of the LINks. We can provide details of our programmes and findings, if these would be of interest and we would be prepared to give oral evidence if this would be of use.

  1.  This paper seeks to draw the attention of the Committee to various reasons for considering the particular needs of mental health as something of a special case when setting up the new LINks arrangements. Although as a PPIF we have sought to work with the Primary Care Trusts for Oxfordshire—previously five but now only one—we do not consider that this co-operative approach has been able to produce adequate evidence from patients, carers and public about the needs of mental health as a whole. The Mental Health Trusts are concerned only with the most acute needs of the mentally ill, both in hospital and in the community. Particularly now that orthodoxy increasingly requires treatment in the community, more and more provision falls to be made by the Primary Care Trusts, where mental health competes with the full range of medical needs for the limited funds available. Patients moving out of the care of the Mental Health Trusts can become much less visible as they move into this less well-informed highly competitive primary care environment. In addition they may find themselves disadvantaged in their claim on social services budgets for housing and other provision, such as in day centres or further education. Largely unseen, carers are being expected to shoulder increasing burdens. The NHS care of such patients can be too little or too late, leading to their early return to the care of the acute services. The funding of patient paths for the mentally ill has been no-one's overall concern. Technically the LINks should provide a better environment for this but attitudes are going to have to change so much for mental health to get its fair share that we think it is essential that under the new dispensation there is the equivalent of a single PPIF which will embrace the whole range of mental health care, wherever provided, its standards and financing.

  2.  A particular difficulty for the care of mentally ill patients in Oxfordshire is that the top of the pyramid is the joint Oxfordshire and Buckinghamshire Mental Health Trust, which is dependent for the commissioning of its services and for the parallel provisions, in Primary Care and Local Authority Social and Community Services, on two very different county providers. On present showing, the availability of funding from Buckinghamshire cannot be counted upon, and attitudes also differ. In any case, despite the Government's having identified mental health as a priority, neither county has been in much of a position to honour this. For the joint Trust's future efficiency and parity in its provision, it needs to be negotiating with a single body.

  3.  Certainly in Oxfordshire, the Mental Health Trust has been discriminated against in so far as it was required, mid year, to make substantial cuts in its budget so as to help less well performing parts of the local health economy, despite having broken even for the last three years and having a unit cost below the national average. When the PPIF attempted to discuss the implications of this for patients and carers with the relevant PCT and the Commissioners, we were told that the demonstrable needs of mental health patients could not stand against the claims of patients, say, with varicose veins—for whom there was an unmet target—or of those waiting for cochlear implants. There seemed to be no appreciation of the potential waste of life—in any sense of the term—associated with inadequate care for the mentally ill, many of whom—if one has to talk in such crude terms—have a great deal to offer both the community and the economy. And, of course, for the increasing number of patients over the age of 65, that economic argument cannot be invoked and, despite the new rules against ageism, their claims on available funding become vulnerable.

  4.  There is, in fact, a double problem in the commissioning of provision for mental health: firstly, because many people misunderstand its nature and rather write off those who are mentally ill, it cannot compete on equal terms with the more familiar illnesses with recognized prognoses; and secondly, in a group of commissioners and expert advisers there may be only one—or sometimes not even that—to speak up for the great range of conditions counting as mental illness, compared with those representing other strongly defined medical interests. When our PPIF suggested to the lead PCT that the funding might become more equitable if there were more specific targets for mental health, we were told that would never do because it might mean reduction in more `popular' targets. If the new LINks specifically concentrate on commissioning, this problem is bound to be looked at, but it will be vital that the many but coherent claims of mental health are strongly established and properly supported. It is hard to see the necessary expertise being widely available in practice-based commissioning and it is not clear that special groups interested in mental health but drawn from such general bodies as the new LINks could really be the answer.

  5.  It is important to stress at this stage that Oxfordshire, as one might expect, has never been short of articulate voices making the claims for mental health as for any other medical condition. Furthermore the Mental Health Trust tries, within the limits of financial and procedural constraints, to keep itself informed of local opinion, both in general and in the context of any specific proposals. The Trust has standing committees of users and carers but a reading of the minutes shows how limited and almost ritual the exchanges are. It also meets regularly with a Task Force formed from the main Voluntary Bodies but again the minutes show that, however productive, these meetings do not constitute anything like the rosy picture envisaged in the LINks proposals. And there are many more voluntary bodies and lobbies, not least those concerned with ethnic minority groups, which are not part of this rather stage army. Our PPIF would be the first to admit that we cannot hear and listen to as many voices as we should. This is going to be a massive problem for the LINks in general but, when one thinks what is likely to be the limited representation of mental health issues, it is hard to see that the mental health voice will be any stronger or more reliable.

  6.  It is vital that the patient and public voice that is heard is based on absolutely up-to-date evidence from as wide a range of all those concerned as possible. We understand that, contrary to the original proposal, LINks will retain the right of direct scrutiny provided by visits. In addition it is said that they will arrange for surveys and the like. Surveys take time to organize and process, and the necessary skills to design them so that they get to the full facts are not in great supply. The use of open questions is understandably rare. It is often difficult to achieve a reasonable return or to have any understanding of the position of those who do not respond. We have looked at questionnaires used both locally and nationally and have to say that in some cases, on the evidence of our visits, the questions asked are not the right ones—though admittedly they make box-ticking easy. We also recognize that getting patients, carers or staff within the mental health system to answer honestly is difficult. Patients and carers often lack the confidence to record their real perceptions, more so than the average NHS user. Facts and views collected on visits, though they risk having been solicited by leading questions or being the result of over strong personal conditions, can provide a much fuller view of reality.

  7.  Certainly our very wide programme of visits has shown that under the pressures of `reconfiguration', the Trust's admirable policy statements cannot always be implemented on the ground and that big financial efficiencies are obscuring the loss of some small services which make such a difference to patients' recovery. We are clear that improving the provision for mental health patients is not only a case of improving funding arrangements but also of ensuring the best possible day to day environment for patients within existing expenditure. This requires a great deal of training for staff and the release of professional time to improve the interface between professional and patient. How the LINks will be able to deal with this is difficult to see, but deal with this they must.

  8.  There are other points we could make where mental health very obviously shares problems common to a great deal of NHS provision. Transport and protected housing are examples. There is a whole new world to be explored in terms of local authority budgeting, including the relationship with the Treasury. But the importance of both to the successful care of vulnerable mentally ill patients cannot be sufficiently stressed. The problem is again how to secure enough provision for mental health in the general world of bargaining and compromise within restricted financial resources and centralized policies.

  9.  We do not at this stage wish to comment on the suggested need for LINks to form up into some national opinion making body. In our view the lessons of dealing with the unavoidable complexities of the situation are best learnt thoroughly at the local level.

Ben Lloyd-Shogbesan

Co-chair, PPI Forum for Mental Health (Oxon & Bucks)

8 January 2007

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