Select Committee on European Union Minutes of Evidence

Examination of Witnesses (Quesitons 40-59)

Professor Graham Thornicroft and Mr David McDaid

20 JULY 2006

  Q40  Chairman: Given that the WHO has got this plan for the 52 countries with a much broader and bigger Europe, is there a danger of duplication? In a sense, why should it be under the umbrella of the European Union?

  Professor Thornicroft: I think two main reasons. First of all, the World Health Organisation European region, as you know, covers 52 nations spreading from Iceland to Vladivostok and necessarily their focus is on the most deprived and economically underdeveloped countries, which would be the Soviet Union and Central Asian republics. That means even within some of the recent EU10, you might say the Czech Republic, Estonia and the Baltic States, they have relatively little contribution because their small resources are focused elsewhere. The first issue is one of focus, it cannot be the case that the WHO can simply assist all of those Member States in the same way because of the spread of countries and because their focus is on the most deprived countries which are outside the European Union. The second is the question of resource. If you think about the resource, in fact in the Mental Health Office of the WHO European region there is a small number, a handful, of people. They simply do not have the capacity to render material assistance to all of those countries simultaneously whereas the budgets of the Directorates-General of the European Union have many millions of euros to be able to render assistance where required, especially for the new accession countries through infrastructural support. That can be vital, for example, in de-institutionalising. That has been fundamental in changing the structure of services in Portugal, Spain and Greece and is already making a contribution in many Eastern European countries.

  Q41  Chairman: Those were two very interesting answers. Mr McDaid, I saw you nodding. Do you want to do a little introduction and then respond to that first question?

  Mr McDaid: Yes. Thank you. In terms of my background, I am a health economist and health policy analyst based at the London School of Economics where I work in the Health and Social Care unit. I also work as a Research Fellow at the European Observatory on Health Systems and Policies looking at broader European health system issues. Another relevant part of background is that I edit a journal called EuroHealth Journal which looks at European health policy issues. Just a very brief opening statement, which echoes much of what Graham has said, to highlight the fact that mental health has long been the Cinderella in terms of issues related to health. In many countries in Europe it is grossly under-funded if you compare that to the relative burden that poor mental health contributes to the overall disease burden. It is almost unique in these issues around stigma and discrimination which tend to mean that it remains at the bottom of the pile, so to speak. There is less focus on mental health perhaps than might be the case in other areas because it is not seen as a sexy area, for want of a better term. In terms of your first question, I would emphasise that I believe the European Commission's approach should not be seen as an alternative but as complementary and part of the Commission's response to the Action Plan declaration by the WHO. It is important to recognise the level of resources within WHO Europe. They are limited both financially and in terms of capacity where they are dealing with 52 countries. It must also be remembered that their primary focus is to respond directly to the needs of individual Member States, so if an individual Member State approaches them with a specific issue they have to respond to that. It means that they have less time perhaps to look at over-arching issues across all European countries. It is reasonable to say as well that a lot of their focus will be on those Member States further East, for want of a better term, because the issues there are more obvious and more profound. Another important reason for EC involvement in this approach is that, unlike the WHO, the EU crosses across a number of different areas, so we are not just talking here about the health care system, and I think that is very important. There are important issues about ways and means of integrating individuals back into the community, issues around promoting good health in the workplace and also protecting the health of vulnerable people returning to the workplace, issues around access to housing, issues around discrimination, issues around education and support for carers. Many of these issues' remits go beyond health and there are questions, perhaps, as to the extent that the WHO can influence sectors other than health. I think the European Union can have a very positive role to play in that respect. It is probably reasonable to say if progress is made within the European Union it will have some influence on accession countries and neighbouring states as well.

  Q42  Chairman: I find those two sets of answers very helpful indeed in answering the question about the added value. What advice would you give about ensuring that we do not cross wires with the WHO, the Commission and what is done in Member States? How can you help us there?

  Professor Thornicroft: Perhaps if I could first add one item of detail that Mr McDaid mentioned. In terms of expenditure, I have information that may help the Committee on the proportion of healthcare expenditure on mental health in different European countries.

  Q43  Chairman: Are there other items that you will be handing in?

  Professor Thornicroft: We have got a few items to help you.

  Q44  Chairman: If you give them to us as a package we will circulate them to the Committee.

  Professor Thornicroft: The main point is this: if we start with the question what proportion of all disability in Europe is attributable to mental illness, the answer is about 12 per cent. If we then ask is it true that 12 per cent of the health budgets as a whole of European countries are spent on mental illness, the answer is no, it is about three or four per cent. I would see this as a material example of how there is systemic, some might say institutional, neglect and discrimination against the category of people who have mental illness in all European countries.

  Q45  Chairman: Thank you. Do you want to add anything, Mr McDaid?

  Mr McDaid: Just a small caveat in terms of funding, and that is always to be aware that there is funding outside the health system, particularly in social care systems, that often does not get reported when we look at funding statements. It is just to be a little careful about that.

  Q46  Baroness Howarth of Breckland: I will tell you a bit more about who I am when I come to my proper question. I know that we are going to have a lot of discussion about definitions but in terms of funding and coming to a conclusion about the proportion of funds that go to mental health, one of the difficulties is the spectrum of mental illness/mental health and what other budgets contribute to mental well-being that therefore contribute to mental health. Is that not a complexity that is difficult to come to and, therefore, a straightforward 12 per cent/3 per cent is really an inappropriate sort of response? I do not know how to put that kindly.

  Professor Thornicroft: This is a fair point. In terms of the mandate of the EC here, part of the difficulty the Committee may be grappling with is by virtue of the delegation to Member States on issues regarding treatment and services, so there is an open question about what issues may be taken at the pan-European level. This is usually restricted to promotion, prevention and those issues within the realm of public health, but also they will address questions of access to healthcare and human rights and social exclusion, for example in the workplace. I think we can see it in the broader realm, as Mr McDaid mentioned, not just in pure health terms. With respect to definition, I can take that now or later when we come to that item.

  Q47  Baroness Greengross: As you were talking about other ways of dealing with this problem, I just wondered about the budget which might be very helpful in something like this, which is the social exclusion budget, and whether that is something we could look at.

  Mr McDaid: I can come back on that. Certainly I think it is important to try to capture all the elements of funding, including social exclusion, but it is extremely difficult to do. Just to illustrate with one simple example: the WHO in Geneva produce an atlas on mental health of all the countries in the world and it is very helpful. If you turn to the section on Norway and look at the funding of mental health in Norway you will see that they spend 0.1 of 1 per cent on mental health in Norway. Clearly that is not true, they spend a lot more, but because it is not specifically earmarked for mental health it is very difficult to identify. That is just looking at funding within the health care system. It is an incredibly challenging issue and I do think it is something where the European Union, because it works across different sectors, can try and improve our understanding and knowledge of total funding for mental in other sectors, but it is difficult to do and there are no easy answers to that.

  Chairman: I saw Lord Moser's head nodding when you were talking about the difficulty of comparing like with like. Let us move on to definitions.

  Q48  Lord Trefgarne: You have described at some length the difficulties of definition of funding and Professor Thornicroft explained how large numbers of people suffer from mental ill-health, but would you not agree that the numbers of people are wholly dependent upon the definition of what is mental ill-health. The Green Paper quotes the WHO definitions of mental health and mental ill-health, which are exceedingly broad, and if you make it broader I think you could include almost every member of the population. Are you happy with the definitions that the WHO, and hence the EU, are relying upon? I cannot resist quoting from Katherine Mansfield, who was an author from the 1920s, who wrote about health rather than ill-health: "By health I mean the power to live a full, adult, living, breathing life in close contact with what I love. I want to be all that I am capable of becoming". That is a wonderful definition of health, I wonder if you could produce such an elegant one for mental ill-health.

  Professor Thornicroft: Thank you very much. As a humble researcher I could not compete with the lyricism of that quotation. I think what I would say is this: clearly the frequency of mental illness wholly depends upon how widely or narrowly you define those particular definitions. Nevertheless, we now have an international consensus on what forms of suffering should be included within the broad remit of mental illnesses and when you apply those criteria to any populations in the world you find very consistent findings. You find roughly between 25-30 per cent of people have such problems which are serious enough to affect work, social relations or everyday functioning within any year. If you say how many people in their lifetimes suffer from these problems, the answer is half. They are both remarkably common and do have impacts on people's everybody lives. A paradox—we will come later to the stigmatisation—is why it is that we should have such adverse reactions when these are so common. If you ask in general population surveys, "Do you know someone directly who has been affected by mental illness (including yourself)" the answer is 75 per cent. The large majority of people have direct family experience of these problems, so I am afraid the plain fact is they are that common.

  Mr McDaid: The only thing I would add is that the Green Paper deliberately takes a broad definition to emphasise the importance of promoting mental well-being. I am not a psychiatrist but I do know that is a more difficult concept to measure. There is no doubt about that, but it does reflect partly the political reality of the Commission having competence over public health and health promotion but not so much, other than what Professor Thornicroft has already said, in terms of looking at treatments. There is a philosophy within the Commission, in my view, which is partly about dealing with mental ill-health but also about trying to promote good mental well-being, which is more challenging.

  Q49  Lord Trefgarne: We all know what hypochondria means. It means I want every kind of pill I can find. Is there such a thing as mental health hypochondria?

  Professor Thornicroft: Yes, there is, but I do not think it would be at all helpful to the Committee's considerations to think that out of that 25 per cent of the population a proportion of those are malingering or suffering from hypochondria in any way.

  Q50  Lord Trefgarne: None at all?

  Professor Thornicroft: Not of those people. These are people who meet diagnostic criteria, in the technical jargon. To expand upon your point: if we consider not the broad range of people mostly suffering anxiety or depression, or both, but the much smaller proportion who have what we would call severe mental illnesses, essentially psychotic disorders such as schizophrenia or bipolar disorder, that would probably come to about 1 per cent of the whole population in European countries. Although the care of those is properly the remit of the Member States there are aspects of the wider social participation of those people which are clearly within the remit of the EC. One example is work. Recently I conducted a study in several European countries and one of the questions was simply among people with schizophrenia, typical people with schizophrenia in five European countries, how many are working, and the largest proportion was in Italy with 23 per cent. The smallest proportion was in London with 5 per cent.

  Q51  Chairman: In London?

  Professor Thornicroft: In London it was 5 per cent. I can pass this information to the Committee. These were otherwise remarkably similar people. It is not true that it is somehow inherent that such people should be excluded from the workforce. It is true there are huge variations between countries and it appears to be true that in this country we are the best at excluding such people from the general workforce and all that that implies.

  Q52  Chairman: Without asking you why that discrepancy is the case, that would typify why it is useful perhaps to embark upon the research that we are doing in this report because when you compare those kinds of statistics it begins to ask why that is the case.

  Professor Thornicroft: It then leads us into anti-discrimination laws, disability laws, and arrangements to make the necessary adjustments in accommodation for disabled people to enter and stay in the workforce, which we might come on to subsequently.

  Chairman: I am going to invite Lord Moser to put his question on information-gathering and dissemination but I know that he was interested in the question of definition.

  Q53  Lord Moser: First of all, to declare an interest: I have various links with the Alzheimer's Society. My field is statistics. I note in your joint paper you stress that from the point of the view of the EU strategy improving the information base, the evidence base, improving the data would be an important element. I was pleased to see that but slightly puzzled. The Commission has said that although they have spent a lot of money on improving information, data, there are many gaps. From my own experience—I used to be in charge of statistics in this country, I was on Eurostat, UN statistics, the WHO, et cetera—I remember endless concern about improving health statistics, including mental health statistics. I am also aware that in ONS, as it is now called—I was looking up the statistics yesterday—there is a lot of information on mental health, including age differentials, social class differentials, regional differentials, so it does not seem to me, as a statistician, to be a field that is lacking in information. But clearly you experts think that there are big gaps, so it would be very helpful to us to get your assessment on the state of play on the information and what should and could be done.

  Mr McDaid: In terms of what we understand about the prevalence of mental health problems in Europe, there was a very interesting report produced by the European Brain Council recently. I think you have seen the figure quoted of one-quarter of people having mental health problems at any point in their lifetime. That came from a survey of surveys looking across Europe and the interesting thing was in 12 of the 28 countries that were covered there is no information at all. I agree, the UK is a good example and we have good information, relatively speaking, but there are parts of Europe where the information base is very limited.

  Q54  Lord Moser: You are not referring to the accession countries?

  Mr McDaid: I am referring to the accession countries, but not exclusively. If my recollection is correct, Ireland and Portugal were two of the countries where no information was available. I do know in Ireland, for instance, there is quite a lot of information on use of beds and so forth, but not in terms of other things. There are clear issues around the spread and access to information across Europe. In terms of what the Commission can provide I think we have to be pragmatic about that. I do not think it is possible for the EU to try to impose on all countries a common system of data collection using the same standard. I think that is going to be very difficult to do, but what they can do, and are doing now through Eurostat, is they are trying to increase the amount of information on mental health they do collect, and that is a process that I believe is ongoing at the moment. I am sure Eurostat can provide more information on that. There is also a role for trying to collect, or even fund, specific surveys and perhaps long-term studies looking at trends over smaller timescales across a number of different countries. As we have seen here in the UK, if you follow children, for instance, over a very long period of time that can provide very powerful evidence on the consequences of poor mental health. That may be a more targeted way of doing things rather than trying to do everything that national statistics agencies should be doing. It is a question of working with them but there are things on which the European Union can help and also the sharing of good practice about data collection and perhaps coming to more comparable measuring methods.

  Q55  Lord Moser: If I can go on for one more minute, and welcome to you from the LSE, in your reply were you thinking specifically of incidence or also care?

  Mr McDaid: I think it is important to have information on the utilisation of services, access to services, the availability of services, as well as the incidence and prevalence of poor mental health across Europe. These surveys could look at populations that have been identified as having mental health problems, to what extent they do come into contact with services and not just emphasise healthcare services necessarily but also broader services that may be appropriate as well.

  Q56  Lord Moser: My final point on this: obviously from our point of view the key question is, is the Commission, and that really means Eurostat, in your joint professional view well-equipped to do what we are talking about, in other words fill the gap both on incidence and care throughout the European Union?

  Professor Thornicroft: I cannot answer that directly because I am not very familiar with the workings of Eurostat and perhaps that says a lot about the extent to which their information reaches the research community.

  Mr McDaid: I would echo that. One thing which is relevant to all of these discussions is communication within the Commission. Although there are good links between some of the DGs there are always ways in which communication can be improved, and perhaps communication between public health and Eurostat, and indeed between researchers and what Eurostat is doing, is an interesting area to look at. I cannot directly answer that question, I do not have the competence.

  Professor Thornicroft: I think there is a lot of information collected within Europe but much of it is not very informative. A lot of it is about inputs, for example investments, or processes, for example the numbers of beds, and I have got material here that may help the Committee on these things, but you will have seen this. Relatively little is on helpful processes such as the extent to which these are services delivered in ways that are acceptable to the patients they are intended to benefit and very little useful information on the outcomes of care, including the extent to which the needs of people with mental illnesses are met in their own judgment, for example.

  Lord Moser: I am left with the conclusion our experts feel that not only in what is available there are major gaps but also it does not reach the researchers, et cetera. I think that is something for us to talk about, but not now.

  Chairman: My comment was going to be that this Committee is learning a lot which is very useful this morning. I am going to pass on to Baroness Neuberger to talk about research.

  Q57  Baroness Neuberger: Good morning, Graham, it is very nice to see you. I ought to declare an interest: I am an adviser to Trustees to the Sainsbury's Centre for Mental Health, as you well know, Graham, and also a newly elected Honorary Fellow of the Royal College of Psychiatrists. I think in a sense you have answered part of the question about the priorities that you would like to see for using the EU research budget to make a positive contribution to the EU Mental Health Strategy because part of that is clearly about pulling together some of the data that you have been talking about that is not properly available. I suppose the question I would like to ask is have you got a view between you on doing more than that and more than drilling down into what already exists and some fairly basic primary research that needs to be done that could make a positive contribution to the strategy?

  Professor Thornicroft: If I could start with a slightly broader statement and then focus down on the detail. It seems to me that what the EC can contribute here more generally are three domains: namely, ethics, evidence and experience. What I mean by "ethics" is making it clear to all concerned throughout Europe what already their obligations are under various treaties and covenants in relation to human rights of people with mental illness. By "evidence", I mean gathering and then using research to the best effect. By "experience" I mean trading examples of best practice between nations but particularly carefully assembling information from people with mental illnesses, from their experience, what helps them the best. I come on to the research point in particular. Most of the important questions we simply do not know the answers to within the wider Europe. We have some detailed information about the occurrence of mental illness but, the second point, the extent to which such people are treated at all we do not know, then the extent to which those people are receiving anything resembling effective care we do not know. We do have some worrying background information in, again, the Kessler paper that I will pass to you that in some, perhaps many, countries, of those people who are treated within the mental health system up to half do not have a mental illness. They are not necessarily malingering, or whatever we may call it, but perhaps they have recovered and no longer need active treatment. The coverage of our mental health systems in Europe we know will miss at least two-thirds of people with mental illness. In terms of the targeting it suggests that up to half of the people who are actually treated do not or no longer require treatment, so we are actually misusing the scarce resources that we have. More particularly, it is clear to me that I would like the Committee to consider carefully the extent to which the general framework FP7 focuses on mental illness. In the current FP6 programme, the two core themes are genomics and the information society and it was essentially very difficult to find any category under which one could bid for mental health or mental illness related research despite the clear public health impact of these disorders. I think it would be very helpful if you were to recommend that FP7 should have a clear commitment to mental illness and mental health research within its forward remit.

  Q58  Chairman: Is FP forward planning?

  Mr McDaid: The Framework Programme.

  Professor Thornicroft: It is the five year funding spend for research throughout the European Commission.

  Q59  Baroness Neuberger: Can I just follow that up? You said a lot about looking at who is actually receiving treatment who do not need it and people who do need it not getting their treatment. Clearly you can deal with part of that under access and the question of human rights, but is there an area around the public health and promotion area which you think also requires research? Is that an area that is as urgent given how widely the Green Paper is drafted?

  Professor Thornicroft: I would interpret this in relation to the access question, therefore the need to pass on clear information to all of the publics throughout the European Union about what are the features of mental illness, if you may have such a condition, or somebody within your family may have such symptoms or signs, what do you do, where do you go for help, are these conditions treatable, should we be less embarrassed and not ashamed to seek contact at all. I would frame it in terms of the access question primarily.

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