Examination of Witnesses (Quesitons 60-72)
Professor Graham Thornicroft and Mr David McDaid
20 JULY 2006
Q60 Chairman: Mr McDaid, do you want
to add to that?
Mr McDaid: Yes. I think there are important
areas within public health and health promotion that research
could focus on. Let us be honest, it may be one of the few sources
of funding for public health and health promotion in later research.
As Professor Thornicroft has indicated, the evidence base in this
area is not as good as it could be. But there is a lot of evidence
in the United States in several areas: issues around early interventions
for children in school and also in the workplace and promoting
mental health within the workplace. One modest research agenda
might be to look at to what extent that research could be applicable
within a European context. I say it is modest because I talked
about funding but within certain streams of funding in the European
Union, the public health programme, that is limited, the Seventh
Framework is where there is more scope. The second thing that
might be important is going back to this point about the longitudinal
studies, cohort studies, following people over a period of time.
If we could fund that, that would be very valuable, but the challenge
is we are talking about time-limited funding for research programmes.
If there is a way that is possible to think beyond two or three
years and think about a longer term approach to actually generating
the evidence, so that instead of saying we do not know what the
answers are to questions we can come up with some answers, that
would be helpful, but it is a difficult thing to do. Certainly
I would have thought the European Commission may have more scope
to do that than perhaps national governments can.
Professor Thornicroft: One more detailed point
in relation to promotion, which is promoting the physical health
of people with mental illnesses. We know that death rates are
much higher than for the general population. We know that people
with schizophrenia on average die eight years younger than their
otherwise equivalent counterparts and we know that rates of smoking
and diabetes are higher, essentially across the board, are higher
and we see poorer physical health and poorer physical healthcare
for people with mental illness. There is strong evidence of discrimination
against people with mental illnesses when they seek investigation
or treatment for physical problems, essentially it is ascribed
to being all in the mind. These are issues fairly and squarely
within the health promotion domain.
Chairman: I am anxious to use our final
15 minutes as well as we might. Lord Colwyn, I think we have partly
moved into the area that you were going to talk about. Would you
like to just put the question.
Q61 Lord Colwyn: I think everything you
are saying is enormously useful but it is making me realise the
vast task we have got and what a wide subject it is. When we saw
Mr Scheftlein from the Commission he talked about promotion and
prevention as being very important goals and we are hearing from
you of vast numbers who have mental health problems, vast numbers
not knowing they have got it, and now vast numbers who have got
it and are not being treated, and yet infants, children, young
people and older people are particularly at risk from social,
psychological, biological and environmental factors. I am getting
a bit lost here. What does it mean in practice and what should
the practice be? Can you help us?
Professor Thornicroft: We will try to be helpful,
I am sure. It is true that this is a vast domain and one has to
try very hard not to become lost because of the magnitude of the
task. It would be helpful if the Committee wished to focus on
very specific recommendations, for example the extent to which
the mental health of the workforce may be promoted and protected.
We know that in all European countries there are two main issues.
One is access to the workforce for those people who have, or have
had, mental illness. The second is re-entry into the workforce
of people who are on sick leave by virtue of mental illnesses.
Both issues are dealt with badly everywhere that we have got evidence
about. We could make specific recommendations with respect, for
example, to identifying people who are becoming stressed or depressed
or anxious at any early stage; with respect to employers employing
good practice for psychological treatments for people who have
developed, for example, anxiety and depression; and for good practice
in flexible arrangements in re-entry to work, return to work,
for people who have had a period of sick leave by virtue of anxiety
or depression, for example.
Q62 Lord Colwyn: Should we be trying
to identify the causes of mental illness?
Professor Thornicroft: Certainly. There is a
very large amount of research, including from my own Institute,
on that, but at present relatively little is clearly understood
about the causes and, therefore, it is difficult to be precise
about whether the current evidence allows us primary prevention,
if you like, to stop mental disorders developing in the first
place.
Chairman: Because of what Professor Thornicroft
has said about mental health in the workplace, I am going to invite
Lady Greengross to put her question because I think it is particularly
relevant to Mr McDaid's work.
Q63 Baroness Greengross: Exactly, and
I know Mr McDaid because of that. I should just declare an interest
as co-Chair of the Alliance for Health in the Future which works
across Europe. I am also involved in two organisations which promote
health in the workplace, including mental health, but it is people
with disabilities of all sorts. I was going to focus on the economic
aspects of mental ill-health and ask particularly Mr McDaid, but
both of you if you will, to tell us more about the work that is
being done in collaboration with the Commission and how the hard
work that the data and economic analysis can provide us in looking
at how better mental health in the workplace and more employability
and retention of people with mental illness in the workplace could
help the European Union regarding the Lisbon Agenda particularly,
hard economic data?
Mr McDaid: There is a challenge with hard economic
data, I have to say. I should say I co-ordinate with colleagues
at the London School of Economics on the Mental Health Economics
European Network, which is a 31-country network funded by the
Commission and it is on its second phase of funding, which is
quite unusual by Commission standards. We have extended the number
of countries involved. One of our key areas of work is looking
at the economics of prevention and promotion in the area of mental
health and there we are focusing on two areas specifically, one
in terms of early childhood interventions, the other in terms
of the workplace. We are hostages to fortune in the sense that
most of the evidence of effectiveness is US-based evidence so
we are looking at two things: the potential for using interventions
that have been shown to work within a US context within the European
context, and these include things like employee assistance programmes
and also some of the things that Professor Thornicroft mentioned
around flexible working arrangements, et cetera, for people in
the workplace as well. We are trying to combine that with evidence
on the extent to which mental health problems impact on absenteeism,
early retirement from the workforce, and something called presenteeism,
where you are at work but you are not productive. We are trying
to put an economic cost on that loss of productivity, for want
of a better term. We are also looking at the potential requirement
for disability benefits and so forth to be paid out earlier, looking
at the costs of delivering interventions to promote mental health
in the workplace and then to try to have some crude, but hopefully
quite helpful, figures in terms of the potential benefits of investing
more in promotion of mental health within the workplace. We are
constructing models for various countries around Europe. We cannot
do it for all of them but we are trying to think of different
contexts to show the potential benefits of doing this. I have
to say it is interesting that many of the interventions in this
area may not necessarily be funded by public money. They may be
funded by companies and enterprises, which is another stakeholder
we have to think about in this equation. There are some interesting
issues there but, hopefully, at the end of the day we can say
something about the potential costs and benefits of actually investing
in workplace health promotion and other areas as well.
Q64 Baroness Greengross: Could I just
follow that up very quickly by saying I was at a breakfast meeting
this morning with somebody from the Royal Mail, and this was regarding
disability including mental illness and mental health, who was
saying that one million invested got them a return of five million,
and that was very impressive. Would you agree that is the right
sort of calculation? That would include all disability.
Mr McDaid: The one thing I will say is despite
being an economist, of course, we should not make decisions just
on the basis of whether it is value for money.
Q65 Baroness Neuberger: Gosh!
Mr McDaid: That is terrible, is it not?
Q66 Lord Moser: Very brave!
Mr McDaid: I do think it is terribly important
to emphasise the benefits of having a healthy workforce. There
are some people who argue you can replace people by others who
are unemployed and so forth, but in fact you can take that argument
apart to a large extent. There are strong economic benefits in
having good mental health in the workforce if the US evidence
is to be believed. There is good evidence from the Boeing company,
for example, of a long-standing programme, not just for mental
health promotion but physical health promotion as well within
the company.
Baroness Greengross: This data I am quoting
from was on physical health but it was one to five and this was
a big pilot that they had done.
Q67 Chairman: Professor Thornicroft,
do you have anything to add to that?
Professor Thornicroft: Not on that point, no.
Q68 Chairman: So it is not outlandish
to say when the Commission talk about the Lisbon Strategy it is
not as fanciful as it might at first seem?
Mr McDaid: No, it is not. The Lisbon Strategy
did originally talk about social inclusion much more than it does
now and, of course, there is an important element of integrating
people into the workforce or other activities.
Q69 Lord Moser: Is Richard Layard's recent
stuff on the cost of depression to the economy part of your—
Mr McDaid: It is not part of our unit's work
although my colleague, Professor Martin Knapp, has been working
with Lord Layard on that. That is an interesting and important
area because he is looking at broader issues in terms of income
levels and some of these macroeconomic determinants which are
very important.
Q70 Baroness Howarth of Breckland: The
Chairman wants the question on the record, so I am going to read
it in a minute. I am a social worker by training and background
with 40 years in social care, and I do not look or feel that old
but I started young. I am concerned about what progress we have
made in what time and in doing this investigation whether or not
you believe that the EU can really make some sort of step change
across the whole piece. You put it very much in terms of changing
things around stigma, ignorance, discrimination and understanding,
and those are things that may have moved somewhat but are still
fairly well engrained in this country, never mind Eastern Europe
as some of your statistics have said. So that we have got the
question on the record: we were very impressed by what you said
about overcoming stigma. Bringing mental illness out of the dark
corners where it has been consigned by fear, prejudice and ignorance
is potentially a massive long-term task requiring sustained political
determination and a sense of clear priorities, and my work in
the child-care field has shown that has not moved substantially
in paediatric mental health. In your paper you have outlined levels
of action that would be needed. Do you detect, because this is
the whole point about what we are doing, a receptive climate for
constructive progress among EU Member States? Is the level of
public awareness sufficient to generate political momentum for
change?
Professor Thornicroft: I shall be brief. I have
recently written a book on this question so I have information
about that for the Committee, but I will try to encapsulate that
in a small statement. We can see these as three related problems:
the problem of ignorance, that is a knowledge problem; the problem
of attitudes, namely prejudice against people with mental illness;
and the problem of behaviour. In my own judgment it is the behaviour
problem, namely discrimination, which is the worst and the most
urgent to tackle. I think we can look to European institutions
and the Council of Europe, but also those framing and implementing
human rights and civil liberties arrangements, to take a lead
on this. In terms of preparedness, I think we now see for the
first time signs that the European Union, European Commission
and the World Health Organisation/Europe are taking these issues
seriously and they are named amongst the five highest priorities
in the WHO/EC European Declaration and Action Plan. In answer
to your question have we made progress in these areas, no. Is
there now a receptive framework where we can make a serious and
long-term commitment, I think yes.
Chairman: That is very helpful. I wonder
whether we can take the last two questions together.
Baroness Neuberger: To a large extent
I think my question has been answered in what Professor Thornicroft
just said.
Q71 Chairman: Just on the EU Platform
on Mental Health, which is mentioned in the Green Paper, does
that mean something or is there a danger of a talking shop developing
here?
Mr McDaid: With all platforms there is always
the potential for them not to be as effective as they could be.
It will depend a lot on whether or not there are good links between
those working on the platform and those that actually influence
policy and the Member States. I do not have any knowledge on how
that is going to work. One thing I will say is that it is important
that all stakeholders do take part and there have been some practical
issues in the past with representatives from service users and
service user organisations not necessarily being able to participate
simply because of cash flow issues. It is not that there is not
funding to allow them to attend but the funding is retrospective
so they find it difficult to get there. In terms of involving
more stakeholders, that is important but it is the links that
will determine whether or not the platform is effective or not.
Professor Thornicroft: I would make two brief
points. It is meaningful if it leads to real investment decisions,
probably requiring hypothecated funds, for mental illness because
given the competition with cancer or people in wheelchairs, we
always lose out. Within that investment I think there needs to
be a clear-cut budget, again probably hypothecated, to support
patient services and consumers and family organisations to establish
themselves because at the moment they are operating on a shoestring
and with central investment they could play a much more realistic
role in the long-term.
Chairman: In concluding this session
can I invite you again just to think if there is anything you
were unable to answer in your questions because of the lack of
time or, indeed, the additional information that Professor Thornicroft
has, if that could be advanced to our officers. Can I say, Professor
Thornicroft and Mr McDaid, rarely have I had such an interesting
and informative session on a Committee like this and I believe
that I do speak for the rest of the Committee. Also, the quality
and economy of your answers were very helpful indeed for us pondering
this issue, which is a very important issue, over the summer break.
We are extremely thankful.
Q72 Lord Colwyn: How many years do you
think we need to undertake this Inquiry?
Professor Thornicroft: I believe in short reports
and long-term commitment and to change things around with respect
to discrimination in ethnicity or physical disabilities has taken
about 15 years to see real progress, and I think that is the perspective.
Thank you for your interest in this field.
Chairman: Thank you very much.
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