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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