Select Committee on European Union Minutes of Evidence

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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