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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