Examination of Witness (Questions 120-136)
Mr John Bowis
2 NOVEMBER 2006
Q120 Baroness Neuberger: You have
obviously been very strongly involved in the World Health Organisation
and in the Helsinki Declaration itself. I suppose what we are
interested in is both your view personally and the view—as
much as you can say it is—of MEPs more generally on how
the Commission and WHO Europe can actually work together and add
value separately and jointly in developing this strategy and,
indeed, you then pushing for new legislation?
Mr Bowis: It is something that I very much support.
When I started in 1999 in the Parliament there was a stand-off
between WHO Europe and the EU which was very jealous of its competencies
and so on. I thought that was ridiculous and because I had had
that link I tried to use it and bring people together in a variety
of ways, and I think it is now accepted. I am also on the Development
Committee and I have brought WHO into a lot of their discussions
as well as on European health. When it came to my report I had
a hearing in the European Parliament and one of the people I asked
to come and speak was Matt Muijen who is the Adviser on Mental
Health to WHO Europe. We worked with another member from Geneva
on their report on violence and health to see how that has links
to mental health. I think that has to be good and it also extends
the scope of our horizons in some areas. WHO Europe obviously
covers the whole of Europe and a bit more and so they are looking
at our new neighbours in a way that we cannot, although we have
tried to work with them under the Neighbourhood Policy of the
European Union. For example, one of the areas I have been quite
involved with personally is the Geneva Initiative—Global
Initiative as it is now called—on Psychiatry initially to
campaign against the abuse of psychiatry in the old Soviet bloc
and then to help them to introduce reforms in that area. Certainly
three of those countries are now in the European Union (the Baltic
trio) and others within the new European Union—or just about
to be—were very much influenced by Soviet psychiatry. That
is an area where we can work together to overcome that policy
on the whole aspect of looking after people who do not fit into
society—which is essentially where it was being abused—but
then moving on to helping them to de-institutionalise because
that is very, very slow in most of the new Member States. I have
been quite involved with Slovenia and even there, where it is
a very progressive country—they spend more per capita on
health than many current Member States which is very unusual in
that new group of in-coming countries—there I pushed and
pushed for them to close a castle which was where they tucked
their patients away, those with severe illness, and eventually
they invited me to come to the closure ceremony. So we do get
there bit by bit.
Q121 Baroness Gale: The European
Parliament resolution "Considers that the gender dimension
has not been duly taken into account in the Green Paper"
and it calls "for this dimension to be systematically considered."
That is one aspect. Then Professor Knapp has said that this issue
gets much more attention than he would have expected but on the
mental health debate in the UK we are, he says, rightly exercised
by ethnicity and mental health which does not get a mention. In
what particular ways would you expect the MEPs to think about
the priority of distinguishing the separate issues relating to
mental health for women and men? What would be their views about
the relative priority of gender issues and the mental health issues
relating to the different groups in the population from different
ethnic backgrounds?
Mr Bowis: I would hesitate to challenge the
statement that there is no reference; it is there but I agree
it is a very small reference in paragraph 14 where it specifies
ethnic and other minority groups. You are right in both respects.
There are bits in here which are not mine, I have to say. I am
not ducking the challenge because it is my report and I accept
responsibility for the whole, but I was under considerable pressure
from other colleagues to include aspects of the gender differences
and in the end I agreed to include some of them. I remember a
Greek colleague was very strongly of the belief that we should
recognise the difference in the brain between men and women. He
said that is scientifically proven. I said that I did not want
that.
Q122 Baroness Gale: What did it prove,
I wonder?
Mr Bowis: There are clearly differences such
as the obvious one of pre- and post-natal depression which is
a woman's issue. There is clear evidence, I think, that if we
can promote good mental health among mothers then their children
are more likely to grow up without some of the difficulties that
otherwise ensue. I well recall, when I had responsibility for
the high security hospitals, coming away very uneasy that we were
putting women into this very intensive security and you only had
to look at their arms for the cigarette burns and the stabbings
to see that self-harm is very much a woman's issue (not entirely
but very much so). It is not just women, there are men's differences
too. I was speaking recently in the Parliament on breast cancer
and where 88,000 women in Europe die each year from breast cancer,
so do a thousand men. Nobody knows that but if you are one of
those thousand and you are diagnosed and you have to go home and
try to tell your family that you have breast cancer or down to
the pub to tell your mates, that puts enormous pressure on men
and I know of cases where suicide has been the solution. That
is a men's problem because we do not screen men, we do not give
them the counselling after such a diagnosis that they need, so
there are areas where we could do much more to link into mental
health to ensure that they can cope. That is what mental wellbeing
is all about being able to cope with stress in crises. I think
we need to do a lot more.
Q123 Baroness Gale: Could I just
follow that up, the difference between men and women and their
attitudes to health? We see now that women are quite willing now
to talk quite openly about breast cancer and other cancers whereas
men are still very reluctant to discuss these issues because of
embarrassment and so on. There is a lot of effort being put into
this now, for men to talk much more openly about it; there are
a lot of promotions going on to make them come forward, as it
were, and go to their doctors to seek help and advice. How do
you think this strategy could be brought about to get rid of this
sort of stigma?
Mr Bowis: It is a stigma, and part of that is
ensuring they all have access to the services, that men in that
case have the same access to the counselling and cancer screening
services that women expect to have. I think we have to look for
good practice in some of the areas affecting women to see how
we can share that in all parts of Europe to make a difference.
Asian women have very specific health problems, including mental
health problems, and we need to look at those. That links into
the ethnic minority issue where I am convinced we need to do a
lot more. It may be that we understand that better in this country
than in most. I remember one of the first initiatives I had in
the Department of Health was to establish and receive a report
on black mental health and the fact that black males in particular
were more likely to be diagnosed with schizophrenia and more likely
to be in custody or compulsory care and more likely to receive
high dosages of medication and so forth. The question was whether
that was because they needed that or because society was in some
way labelling them as needing that. There was an institutionalised
stigmatisation with or without racial connotation that we needed
to look at. Those are certainly areas we need to develop and I
think that Britain can actually send quite a helpful message to
other countries—perhaps France—which are beginning
to look in these areas. Certainly when I go to speak at European
conferences on these sorts of issues I am impressed at how often
it is a British speaker who has come as the expert.
Q124 Baroness Howarth of Breckland:
I would like to go to the question of definitions, which is a
difficult one. In paragraph nine of the European Resolution there
is a stress about the need to be careful in the use of various
terms: "Mental Ill Health", "Mental Health Disorders",
"Severe Mental Illness" and "Personality Disorder".
We have had some concern in our evidence that mental ill health
embracing as a wide group as 25 per cent of the population might
not be helpful. The concern we have developed is this recommendation
to include people with learning disabilities on the basis that
in the UK these people are treated very differently. Indeed, the
organisations that deal with people with learning disabilities
and the users themselves do not see themselves as mentally ill;
this is a condition they have had from birth, they have come to
live with it and many of them live very successful, mentally ill
free lives. We just wondered what views the Parliament members
have about the need to distinguish elements of mental health strategies
specifically applying to the cases of "Mental Ill Health",
"Mental Health Disorders" and "Severe Mental Illness"
as well as "Personality Disorders" (one that foxes most
of us who are working in these fields), and what arguments are
there for including people with learning disabilities within the
strategy when the users particularly themselves may have a very
different view?
Mr Bowis: You are right, we included both those
references. One is what I would call the Norman Sartorious school
of thought which is that there is a lot of muddled thinking over
definitions and therefore we should try to find common definitions,
at least throughout Europe, on what is a mental disorder and what
is a mental illness and so forth. I think he would probably put
under the disorder category the diagnosed and treatable conditions
as opposed to the ability to cope with stresses and challenges
of life which, if you are not able to cope, then you have an illness
but not necessarily a disorder. I think the issue of personality
disorder is something we have wrestled with since the Reid reports—there
was a sequence of them—in the early 1990s and it was how
we should care for people who have different types of disorder
for which it was questioned whether there was a treatment programme
and therefore within the Mental Health Act whether you could detain
them for treatment and so forth, whether or not there was some
perceived risk of self-harm or harm to others. That has been a
difficult one. I met a lot of those people again in high security
institutions and they are clearly different from the average severely
ill user of those services. I think nobody has yet found the solution
as to how we manage people. Personally I am certain we do not
manage them by just locking them up and if I have any advice it
would be to try to make sure that it is the Health Department
which manages such people and not the Home Office, but that is
a personal belief which I actually gave in evidence to Lord Carlile's
investigation in that area. That is one of the areas where we
need a lot more research and we can learn from each other. The
definition of who comes into that category, perhaps at the back
of my mind is again Soviet psychiatry and meeting psychiatrists
who have said to me, "What do you about people with sluggish
schizophrenia?" and I said that I did not think we had a
definition called sluggish schizophrenia. They said, "You
must have, otherwise what do you do with those terrorists in Northern
Ireland?" It dawned on me that actually these were society's
problems all being labelled in this way and it might well be a
personality disorder. I met another young man in the Ukraine who
had absconded from the then Red Army with his weapons and so,
perfectly correctly should have been taken to court under the
laws of the land and put in prison to be punished. But he was
not because it was deemed that no sane person could have absconded
from the glorious Red Army so therefore they put him in a hospital,
pumped him full of drugs and not surprisingly he became a zombie
and certainly very ill. There is an argument to say that learning
disability is very different; it has a definition problem too.
There is a term used in many parts of Europe other than learning
disability (mental difficulty in some places; mental handicap
it used to be called). My experience of that is that there are
different degrees of disability and very often there is a dual
diagnosis of having that learning disability but also having a
mental health problem. If we are going to try to separate them,
then where goes your policy on dual diagnosis and treatment?
Q125 Baroness Howarth of Breckland:
It does not necessarily follow, does it?
Mr Bowis: No, but if you ask people like the
Open Society who deal a lot with the new Member States, they will
tell you that it is normal practice for them all to be institutionalised
in the same institution and that in a way we are trying to introduce
the more humane services, the ability to be cared for in the community
and to give a degree of independence, dignity and respect which
applies to both. I think it is close enough for us to say, in
this Green Paper at least, that we think you must not forget that
side of this world.
Q126 Baroness Howarth of Breckland:
You were saying that this was much more a European perspective
because in the UK I think we have sorted this pretty well—although
not perfectly—and presumably there is something that one
could say about what the UK could demonstrate in terms of having
clearly separated this issue and how you therefore treat across
the spectrum because there are people with learning difficulties
who are never going to be mentally ill.
Mr Bowis: Yes, and there are people who are
alcoholic or drug addicts who do not need some aspects of the
mental health services, but there are many mentally ill people
who do need addiction services. I do think that is maybe something
where the UK can help to spread better practice but always remembering
that in no case that I am aware of do we really have that respect
for the individuals and that involvement of the individual in
his own case and in the primary services, for example, which applies
to both. We must be very careful that we do not assume that people
with learning disabilities cannot think, cannot express themselves
and cannot have a say just as we must make sure that people with
severe mental illness have rights—within limits maybe—to
choose how they live, where they live, have some say in their
treatment and medication, their therapies and so forth. In all
countries in both those areas I think we are woefully behind best
practice.
Q127 Lord Colwyn: The Green Paper
recognises that people with mental ill health or disability or
this dual diagnosis you have just been talking about meet fear
and prejudice and they can suffer discrimination in many ways.
This is fuelled by a lack of public information and mis-information
in the media. When you said the main problem is stigma and that
can lead to suicide, how do you see a European strategy helping
existing efforts of the Member States and do you think they really
are going to be able to work together bearing in mind the different
ways they deal with this matter?
Mr Bowis: I think stigma is an added burden
to an illness which is wholly unnecessary and therefore we must
tackle it as a human rights abuse. That implies both that we should
give people some legal protections in terms of access to work,
to play, to services and so forth; that is part of it. I think
the more we are able to help the public to understand what a mental
illness really is, I find that the public are remarkably tolerant
of people living in their midst who have a mental health problem
so long as they know what that person needs, so long as they know
that the services are available in the community to care for those
needs and so long as they know who to turn to if there is a crisis.
A woman in Battersea once told me that she worried rather when
the lady who lived underneath her flat went out and left the gas
cooker burning. I think she had a point when she said, "Who
do I ring because I think she's wandered off and I can smell burning?"
She was not saying, "Take this woman away, lock her up".
She was saying, "Tell me who I turn to when there's a crisis."
I think we can do more in that field to reassure the public and
reassure them that the policy is possible. The media also has
a responsibility in this. Every time we had a problem like one
man in the lion's den at London Zoo or the Christopher Clunis
case on the London Underground and a number other cases like that,
they were reported three times in the press—once when the
incident took place, secondly when the court report was made and
thirdly when the Inquiry conclusions were published—and
the public thought there were three of them every time. That is
not helpful. Of course it is right to identify and change the
procedures that have gone wrong and so forth. Of course it is
right to make sure we have the care services in place in the community
and of course it is right that we ensure that the agencies work
together. It is one of my criticisms that getting doctors and
social workers to work together is difficult: "It is not
my responsibility; I am not trained to share information on my
patients with X, Y or Z". We could get housing officers to
be aware that actually the housing environment in which you place
somebody who has come out from a period of hospitalisation is
fundamental in helping that person to recover. That is important.
The employment services, the training services, the social security
services, all these need to work together which is why I have
often advocated a one-stop-shop so that one person purchases all
the care needs and the providers can be from a variety of places
but if somebody, like a good key worker (beyond just health and
social care) is looking after the individual, that I think would
help to defeat stigma. Then I think we have to recognise that
this stigma is in all of us; it is in the health service. The
attitude "I'm a doctor and I know best" (with apologies
to doctors present) is there in the health service and it is certainly
there in government and in Parliament who respond to the tabloid
headlines leading to letters coming in from frightened or worried
constituents. We have to do more to undermine that ignorance.
Q128 Lord Colwyn: You are describing
a situation here but is it possible that all Member States can
think along those lines?
Mr Bowis: I think so. Italy, as I said, has
moved further than we have I think in some of these areas. Denmark
is a good example of where things are going; Slovenia is moving
in that direction; Finland has some good practice; some of the
French practice is moving that way. I think there is a willingness
to try to overcome this. It was the Greek Presidency which launched
an initiative on defeating stigma. I think it is there but it
will be much more difficult when we come to the Czech Republic,
Hungary, Slovakia and those countries.
Q129 Chairman: Yes, because of the
Soviet background where, if you oppose the state, you must be
mad. You had a mental illness if you were, in any sense, an opponent
of anything that was run by the state so you were sent to a mental
institution. Then of course you did become mentally ill naturally;
you lost your own sense of reality at that point. I am sure many
of them did become mentally disturbed or mentally ill but their
sin was that they opposed something or disagreed with something
or whatever it was. That was a terrible method of punishing anybody;
I cannot think of anything worse actually.
Mr Bowis: That is absolutely right. That was
the state diagnosis and then the state with its authoritarian
solutions and that combination was disastrous.
Q130 Lord Harrison: I would like
to turn to Mental Health at Work policies now and I have three
questions. First of all, how would you fit those in with the Lisbon
Agenda which you mentioned right at the beginning in your opening
statement which I regard as an extremely important aspect of this
issue? Secondly, could you help the Committee understand how operating
at an EU level would add value other than simply Member States
doing these things by themselves? The third question relates to
small businesses. You mentioned an interesting idea of asking
employers perhaps to report on their mental health at work policies
as a way of reminding them, nudging them and encouraging them
to have such policies. I think it was small business and the added
bureaucracy that they might say was the outcome of making that
kind of requirement so how can we constructively help small businesses
to engage in policies of the kind that you describe that would
work and operate at EU level to the benefit of employees, employers
and ultimately for the European Union and its prosperity and competitiveness?
Mr Bowis: I think those points and your concerns
are correct, so is your reference to the Lisbon Agenda. I think
when we look at our development of policies for Africa or wherever
we clearly understand that if you do not have a healthy people
then you cannot have a healthy economy and so health becomes a
priority within our development strategy. When it comes to Europe
I think we are learning that again and two of the pillars of Lisbon
are a healthy people and a healthy environment and both are actually
ingredients in a healthy economy. In fact I would say they are
a prerequisite to it. It avoids some of the costs, obviously,
to the community if you can have a healthier people and it gives
great potential benefits not just to the country but to the firms
that are involved. Just as there is a market out there that America
is beginning to understand that we are ahead of the game on having
a cleaner environment in our policy making including our product
design, so I think they will come to learn that if we are showing
the way in terms of ensuring we have healthy people at work then
that will give us something of a competitive advantage in the
market place. I think one should do it where possible by encouragement
and carrots rather than sticks not least because of the small
firm issue which is why my specific suggestion was that we should
require firms to report as they do on their attitude to the environment
and their workforce in general, the community and so forth. Why
not on this? I was a judge some months ago in the national Health
and Safety at Work awards and I sat for a day listening to multi-nationals
and small firms all coming up and telling me how few accidents
they had had. We were able to cross-question them and say, "That's
fine, we understand the safety bit, now what about the health
bit?" A lot of them had not really understood what that meant
and when somebody did show that they understood what it meant
I said, "Well, what about the mental health bit?" and
they looked blank. That is why we need to educate employers and
unions to work more in this direction. If, for example, you have
a non-threatening counselling service within a firm—I am
talking about a bigger firm now—so that if somebody feels
they have a problem or they have had a problem and are returning
to work and they feel a bit of a crisis coming on, they can go
and talk to somebody without feeling that it is line management
and it is going to be put on the employee's record. Then I think
that helps both to give opportunities to the individual but also
helps the firm to manage the risk that is there. The same goes
if you are a carer. If you are trying to look after somebody maybe
with learning disabilities, maybe with an eating disorder at home
and your firm is inflexible, you are going to find it very tough
going both at home and at work. If a firm is flexible in terms
perhaps of working hours and it makes sure that the person is
not having unnecessary worries on top of the job responsibilities,
then you can help the employee be both a better employee—and
therefore help make the company more productive—and a better
carer at home and therefore maybe avoiding society having to step
in and provide that care. That is the sort of thing I want to
see and if we can require people to publish what their policies
are then of course somebody—maybe the Health and Safety
Executive—should come up with some guidelines of the sorts
of things they might include. I do recall when I was in the Department
of Health going to some awards for firms that do well in this
area. I remember going down to Marks and Spencer's headquarters
at Baker Street to make these awards and before I went I asked
our permanent secretary if I could have a look at the Department
of Health's Mental Health at Work policy and he said, "I
think it is just being finalised". I do not know whether
it is there now. Public service has to set an example and not
just require everything to come from the private sector. In terms
of the small firms it is very different. Some of the pressures
of working in a big firm will not be there; you will be more part
of a team and have a better relationship with the managers and
so on. However, even in a small firm there should be opportunities
for people who have had mental health problems to come and work
there in an appropriate capacity, and people who work there and
develop such problems should be looked after, given appropriate
leave and helped back to full working life. It is more difficult
and they may need more help particularly if it is a key worker
whom the firm cannot operate without. We know there are difficulties
but I do not think that is an excuse for saying that small firms
should not be included in this, although the requirements on publishing
your company policy each year is restricted at the moment to the
larger firms rather than the small partnerships.
Q131 Lord Trefgarne: Could I just
ask whether you think that the Human Rights Protection which will
be in place—particularly as it applies to what we would
regard as the less careful nations in this regard—is adequate?
Am I right in thinking that not only do we have the benefit of
the Universal Declaration of Human Rights but also the European
Convention on Human Rights?
Mr Bowis: Yes, although the European Convention
on Human Rights is not the responsibility of the European Union,
it comes under the Council of Europe. The Council of Europe, let
me stress, has a role in this as well to ensure human rights.
The recent UN Declaration on Disabilities is going to be another
player in that, as are the children's rights and so forth. I think
rights are not perfect in any country but they are even less perfect
in the countries you referred to and that is where we have to
put pressure on politically—and we are doing so—to
get them to stop the practices which we find unacceptable. In
terms of all of us, I think the right of access to services is
a fundamental right we need to look at. Thinking back, when I
was reviewing the Mental Health Act—Louis Blom-Cooper was
very much involved in reviewing that—to see what we should
be doing about it and we were very conscious that our other legislation
covered people in institutions but not in the community. With
a service moving increasingly towards the community we had to
make sure that it was both giving them rights of access but also
giving them rights to be treated or not to be treated in the community
in the same sort of way.
Q132 Lord Trefgarne: The particular
issue is the right of compulsory detention and compulsory treatment
which we, of course, allow only very sparingly but no doubt in
some of the new countries—as you have said and others have
said—is much more widespread and we need to look to them
to modify their position on that.
Mr Bowis: Yes, and in our law we have some very
odd concepts like the constables who have the right to come and
take you to a place for assessment. The old legislation was very
good. The Mental Health Act Commission was actually seen as a
demonstration site by the WHO to show other countries how to manage
that aspect of human rights. If you are going to have more people
treated in the community and some of them treated compulsorily
in the community that is where the gaps are.
Q133 Lord Moser: I am very interested
in the research and statistical backup to all you have been talking
about. We have been told that the Parliament has talked about
the research funding and that there is a framework in place for
it. On the assumption that you can get access to that funding
is that the kind of backup that you feel you really need for your
work on mental health, coupled with, are the statistics good enough?
Mr Bowis: Certainly we have established mental
health in the FP6 and 7 policy for research under DG research's
work in a way that it probably was not before. That is good. We
also have neurology there incidentally, in the sense that the
two work together. I think in terms of the statistics our worry
is that different Member States calculate in a different numerical
language as well as linguistic and that is where we want to see
the research done in terms of having comparable data. I think
we also—it is not just the European Union—want to
have better measurements of the outcomes, particularly for mental
health promotion. I believe that we need to invest more in enabling
people to have mental wellbeing. I cannot prove that to the Treasury.
I cannot prove that if you invest in A, B or C you will produce
this outcome and thereby you will make savings in terms of the
cost or free up money which you could spend in other areas of
health. There are various ways of calculating this. We have the
DALYs (Disability Adjusted Life Years) and we need the Healthy
Life Years (the HELYs or WELLYs perhaps) to be the other side
of that coin. I think that would be extremely helpful. The other
areas really are in the areas we have talked about like personality
disorder and in suicide prevention and in the stigma that causes
and how you tackle it.
Q134 Lord Moser: In a sense the MEPs
and the Commission are in the hands of the European Statistical
Office in Luxembourg for a lot of this stuff. Everybody knows
it has been through a terrible crisis. In a word, has it recovered
from that sufficiently to help you?
Mr Bowis: Not noticeably.
Q135 Chairman: I take your point
about inter-comparability or at least inter-understandability
even if they are not strictly speaking comparable. Could you do
some of that statistical work on the basis of Member States by
a collaborative process?
Mr Bowis: You could if you could trust them
to give you an objective picture. One of the effective tools we
do have is the Health Observatory and the publications it has
on each country in the EU and outside the EU. I think it needs
the objective eye based, of course, on what governments and health
services will tell you as to how effective a policy is.
Q136 Chairman: We are all extremely
grateful to you for giving us your time and also for the very
interesting light you have shed on several aspects of this matter.
We do have some questions which I think I would have asked Professor
Knapp to ask had we had the time. I apologise, we had a difficult
morning this morning; we started late and of course as a result
we have ended late. What I would be happy to do, if you could
accept it, is to ask Professor Knapp to send a letter to you with
his questions. I think you have actually touched on most of them
so if you think there are still things you might be able to feed
into us on that particular little set of questions we would be
extremely grateful. I do not want to increase your workload; I
know that MEPs do actually work. Contrary to what most people
suppose, they do actually work quite hard. You are obviously completely
on top of this subject so while it is all fresh in your mind you
might be able to dash off a few answers that that would be very
helpful to us. If it is too much of a burden we will find out
another way.
Mr Bowis: I am happy to do that.
Chairman: On behalf of the Committee
I really would like to thank you most sincerely for your evidence
today.
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