Examination of Witnesses (Questions 140-159)
Dr Marcus Roberts, Mr David Stone, Mrs Alexandra
Burner and Mr Paul Corry
23 NOVEMBER 2006
Q140 Chairman: One of the mechanisms
that the Commission is talking about is the well-worn mechanisms
that they use quite a lot, of bringing various sorts of organisations
together, both those involved in delivering services and those,
like you, working from civil society. I do not think this question
is on our list but would you consider that applying that methodology
to the whole question of mental health would in fact be quite
valuable? I think they tend to discuss a relatively limited agenda
so you might meet four times a year or twice a year and concentrate
once on stigma and once on some aspect of treatment—different
things each time. Do you think that would be something that would
enliven and enable you all to get in better touch with what is
going on across the Channel in continental Europe?
Mr Corry: Certainly from our perspective, absolutely.
We hosted the annual general meeting of EUFAMI two years ago and
we brought organisations from around Europe together and it was
fantastic to be able to be in the same room together for a day
sharing experiences.
Dr Roberts: We are a member of an organisation
called Mental Health Europe, which is an umbrella organisation
for voluntary sector provider and service user organisations across
Europe and acts as an information hub. It does very good work
but it is not particularly well resourced. So it may be that there
is no need to invent a new platform level but that investing in
that platform would be better. The other thing is that bringing
people together to discuss issues is important but there has to
be some clear agendas and some clear purposes.
Q141 Chairman: I think that these meetings
can be, as it were, clerked by the Commission, is that not correct?
That is my impression. So that might give them that kind of continuity
and also reduce the expenditure from the point of view of the
organisations involved if that was the way it was going to function,
but I think that is a question we might address in our report
because it is obviously a very important aspect of the work. I
have gone outside my remit, so we will get back to the proper
questions now. Mind in particular gave us evidence of the importance
of prevention and the large numbers who are involved, and you
have repeated that again in your statement today. So what measures
would you regard as the most important for preventing against
the impact of the factors in modern life which can lead to mental
health; and how would you see a European Union health strategy
helping with these measures?
Dr Roberts: I think that is a very good question.
When you look at the World Health Organisation's list of some
of the causes and contexts of people developing mental health
problems it is about addressing some really very big and difficult
problems—problems about inequality and poverty, problems
about isolation and lack of community and integration, and of
course things like war and conflict, and all those are contributors
to people's mental health, and the question of how much and in
what ways the European Union can impact on those as part of the
mental health strategy is something that needs thinking about
in practical terms. I would suggest that there are two or three
things that spring to mind. I think the first thing, just as a
note, is that it is interesting that the European Union has become
more interested in mental health exactly at the time when we become
more aware of its social and economic causes and the way it is
bound up with all these things, because of course the EU does
not actually have competence about this area of policy—that
lies with the Member States. But once mental health is seen as
a mainstream public policy issue that has enormous implications
for citizens across Europe, it creates the space for Europe to
become involved, and the question then is what sort of things
it could do? It could be approached all those other policy areas
in a way that reflected considerations about mental health. For
example, it may be that European legislation, reports, etc, across
a certain spectrum could be "mental health-proofed"
so that legislation and reports would be checked and there would
be some sort of reporting about their likely impact on mental
well being as part of the process of debate right across the range
of policy areas the EU is concerned with. Another question is
whether a set amount of funds available for European regeneration,
could be directed at projects that have a clear mental health
component. So when the European Union is investing in measures
to tackle social exclusion, integrate communities, it would actually
be required to devote some of that resource always to projects
that are about mental health and well being. The final thing is
that I think there are various obvious areas of existing European
policy where there are more direct ways that it can help tackle
causes of mental health problems and promote mental well being.
Two obvious examples: I do not think the European Union drugs
strategy has much to say about mental health at the moment—its
drug and alcohol strategies are much more fixated on crime and
physical health, blood-borne illness and so on—but the mental
health issues around substance misuse are enormous. The second
example is the EU's responsibility for employment and health and
safety at work, and the possibility that the European Union can
play a role in mainstream mental health as a core health and safety
issue again would help to tackle a lot of those causal issues
around the workplace stress and so on. There will be other examples,
as well.
Mr Corry: We would agree with that approach.
Chairman: Thank you. Lady Morgan.
Q142 Baroness Morgan of Huyton: I want
to ask you about quality of life issues. You have both put in
evidence that has covered quality of life. Our anxiety as a Committee
is to try and work out where is the value added of European action
on a whole range of issues, but particularly it seems to strike
me on the quality of life, as distinct from action by national
governments on quality of life. Can you pin down in any way how
you think European mental health strategy could seek to promote
improvements in quality of life, which could help with mental
health wellbeing?
Dr Roberts: I think that certainly in this country
the issues about the quality of life—issues about mental
well being, the benefits of good food, of green space, of access
to nature, of physical exercise there is more and more awareness
of those issues and we are certainly doing a lot of work to encourage
and to see active participation in nature as a core mental well
being issue. I think there are a couple of other ways that the
EU could add value. Firstly, one of the things that I do know
about the European Union is that it has a lot to do with agricultural
matters—and working time directives—those are areas
of European policy, that spring to mind! What I think is interesting
about promoting green exercise activity as a source of mental
well being and quality of life is actually that it is also quite
a useful way of regenerating rural economies so that people who
are going out into the countryside to do all these things are
also helping regeneration, and I would have thought that was something
that could be integrated into European policy in that area. I
think the other obvious thing is that Europe could do a lot to
support the emerging evidence base and, as Paul said earlier,
to help to invest in research and good practice sharing across
the Union about the quality of life initiatives. A good example,
I think, is the development of green care farms in lots of European
countries which are actually mainstreamed into health and social
care provision, and are places where people go where it is nice
to be and where they get involved in various activities with therapeutic
value—conservation work and so on. The European Union could
potentially play a useful role in looking at how effective they
are in funding the research and also disseminating it.
Mr Corry: If I could just add something completely
different to the mix. Rethink works with a membership charity
that works with people mostly with severe mental illness—schizophrenia,
bi-polar disorder and severe personality disorder—and the
quality of life issue that people come back to us with time and
time again is the side effects of the medications they use, and
I think there is an interesting tension that exists at the moment
between some of the European regulatory measures around the use
of medicines and our own regulatory system inside the UK, and
I know that Rethink, unlike Mind, works with the pharmaceutical
industry in terms of some of these issues. I know that from talking
to some of the pharmaceutical companies they certainly look to
Europe or the UK to see whether they may get most advantage before
introducing new medicines and putting through different regulatory
processes, and for us, Rethink, there is a definite need to get
common standards across the European Union and the UK and for
a greater concentration on governments to work with the pharmaceutical
industry to minimise the side effects of the medication that people
use.
Chairman: That is very interesting. Baroness
Neuberger.
Q143 Baroness Neuberger: You have already
answered to some extent the question about the stigma and what
you think the European mental health strategy could do and Lady
Thomas asked you the question about possibly bringing together
groups from the UK and around Europe for some kind of summit.
Do you feel that there is more that the European Union could do?
If you had a blank sheet of paper—and you are not very aware
about how the EU works or indeed you can influence it—is
there something that you would like to happen at a European level,
a statement, whatever, that you could see making a difference
to stigma, which you have both written about and given a lot of
evidence about, both here and in the past?
Mr Corry: One thing in a dream world is hard
to pick on. It sounds simplistic to say this but I think it is
about creating that public space; it is about making sure that
governments across the piece recognise that stigma and discrimination
is a huge issue for people with mental health problems, and if
there was one thing that any government or indeed any European
institution could do it would be to enforce some of the very good
practice that we have around discrimination issues in the disability
field, and to enforce those in the mental health field. I think
that is the one thing I would pick up.
Q144 Baroness Neuberger: So that is bringing,
as has happened to some extent in this country, mental health
or mental illness into the frame of disability?
Mr Corry: Yes.
Q145 Baroness Neuberger: And that would
be a European-led statement?
Mr Corry: Yes.
Q146 Baroness Neuberger: Thank you very
much, that is very helpful. Is there anything you want to add
Dr Roberts?
Dr Roberts: I have. I will say it very briefly.
I think the crucial thing is, exactly as Paul said, the mainstream
of good mental health is a core disability rights issue. I think
people are sceptical about changes in language, but I think it
would be quite helpful if mental health was not just assimilated
within "disability" as a legal term, because I think
if people are told that the policy is about disability they naturally
think about physical disabilities. I also think there is a role
for the European Union in funding a really good pan-European anti-stigma
campaign. There is a campaign called SHIFT in the UK, which is
something you might know about, but it is only funded to around
£873,000.
Q147 Baroness Morgan of Huyton: When
you say "funding", do you mean European money going
to national governments to run campaigns that work in individual
countries, or do you mean some European-wide campaign?
Dr Roberts: I think the answer to that would
be whichever one seems to be the most effective way to get the
message across actually—both of those models could work.
We know from the experience of, for example, New Zealand, that
if you invest real serious money in anti-stigma work it significantly
changes attitude.
Q148 Baroness Neuberger: I know about
this, as you probably know—I think you gave me the evidence.
Could you tell the rest of the Committee about that because I
think that is important, about how much they invested and how
it worked?
Dr Roberts: I know it was 20 times as much as
we did.
Mr Corry: I can remember off the top of my heads
the figures that I carry around with me that made the biggest
impact with me. In New Zealand it is a government-funded five-year
campaign. So the first important thing about it is that it is
sustainable over a long period of time; in England it is from
year to year and we have already had two different incarnations,
one called "Mind Out for Mental Health" and now the
SHIFT one, with a year gap between the two. So that is the first
point to make. In Scotland they have a campaign that is called
"See Me", which, interestingly, is funded through the
Scottish Executive, but it is funded by monies that they raised
through tobacco levy. I think that is an interesting thing about
mental health as well; I think we are guilty in the mental health
world of living in a bit of a ghetto sometimes, when we do not
look for some of those other opportunities that are out there
which present themselves to look for other areas. There is a distinct
link between smoking and mental health anyway, and I think that
a legitimate use of a tax on tobacco would be to use it in the
discrimination world. But the figures that made the impact on
me are that in New Zealand they spend the equivalent of 34 pence
per head of population on their anti-discrimination work; in Scotland
it is about 13 pence per head; and in England, shockingly, it
is 1.44 pence per head. So the scale of difference is tremendous.
The other factor that I would put on the table is when you talk
about the European Union perhaps giving money to governments to
do this, what works in New Zealand and what works in Scotland
is the longevity of the funding, but the actual programmes are
delivered by coalitions of the voluntary sector and I think that
is an important element.
Q149 Baroness Neuberger: That is something
that you would like us to say to you.
Mr Corry: Absolutely.
Dr Roberts: Could I add one quick thing? I think
one of the important things about stigma is that it sometimes
seems quite soft in terms of policy, but it is not at all because
so many of the concrete costs associated with mental health are
rooted with stigma; it is stigma that keeps people out of work,
it is stigma that stops them approaching services when they need
help, and it is stigma that keeps people isolated because they
do not integrate into their community, and therefore it perpetuates—in
a vicious circle—those wider causes of mental health we
were talking about earlier. So I think it is important to make
out that there is a hard, practical case for stigma work for tackling
economic, social and human costs, well as changing attitude as
an inherently desirable thing to do.
Chairman: Lady Gale's question was about
stigma in the workplace.
Q150 Baroness Gale: When Mind gave evidence
to our Committee you did speak about the stigma of mental illness
in the workplace and that employers are reluctant and avoid people
who they know suffer mental illness. So what do you feel are the
most serious issues faced by mentally ill people in the workplace
and how could these be effectively addressed? Are there particular
problems for small businesses, which need to be considered?
Dr Roberts: This is a really important issue
for us and I think there are three issues about mental health
and well being and employment. The first is the issue of stigma.
The Social Exclusion Unit report that only four in 10 employers
would be willing to employ someone with a mental health problem—this
is frankly a shocking figure. Second there are issues about access
to employment and employers duties under the Disability Discrimination
Act to facilitate access for people with disabilities. A lot of
employers see that, as I said, in terms of wheelchair ramps and
so on; they are not so clear on what their responsibilities are
to facilitate access for people with mental health problems, which
may be about staged return to work; it may be about providing
facilities and opportunities where people can leave their desks,
those sorts of things. I do not think it is just about stigma
with employers, I think a lot of it is about support, information
and advice to know how to handle mental health as an issue. The
third thing is bad working practices as a source of stress and
mental health problems and what we do about them. On what we could
do I have three things to say. I wonder if there is a room for
a European Directive, or something along those lines, which would
actually require all businesses above a certain size to have proper
mental health policies. Secondly, in the UK the Department of
Work and Pensions runs a scheme called Access to Work, which helps
to provide funding to make adjustments in the workplace to help
people with disabilities, including mental health problems, back
into the workplace, so, in theory, financial issues should not
be a barrier to people getting into work because they can apply
to that fund, and that will speak to the issue about small businesses
as well. Perhaps something similar could be done at European level.
I think on small businesses there are obviously issues about size
and resources. If you are a three-person business then it can
be hard to be as flexible as a bigger organisation. I think it
is about the public purse stepping in to give some support, but
also I think potentially as well social enterprise models are
very good models for reintegrating people into work. So support
for mental health service users to set up their own businesses
and to make those businesses work is another thing that we would
want to support and encourage.
Mr Corry: I do think there is a particular issue
with small employers and I think the first thing to do is to get
a couple of facts across to small employers about the productivity
rates of people who have a history of mental health problems,
that when they are actually in work their productivity rates tend
to be higher than the general workforce anyway; their motivation
rates are higher, so there is a good reason for employing somebody
with mental health problems. In terms of when they are in the
workplace, the fear on the part of the employer would be: what
is the sickness rate going to be like? Different schemes have
been tried, even with the voluntary sector or in limited ways
through the statutory sector, of having replacement workers that
can go in and fill the place for somebody at short notice. They
have tended to prove to be quite expensive and they are not particularly
popular with service users either because it makes them feel that
there is always someone standing behind them ready to take over,
although they seem to work very well on the West End stage! So
there is a kind of model there that perhaps could be tested further.
There are issues but there are not issues that are insurmountable.
Q151 Baroness Gale: This access, especially
to small businesses, do you know how effective that has been?
And is there anything going on between employers and trade unions
in working together to tackle this problem of the stigma of getting
people back into work when they have suffered mental illness?
Dr Roberts: I think on the Access to Work scheme
and how that is being used—I would have to check this—my
understanding is that there is an issue about how aware employers
are about that scheme and how to get the money, and I think it
tends to have been used more for people with physical disabilities
and those sorts of adjustments than mental health, is my understanding.
Q152 Baroness Greengross: Just a quick
supplementary, if I may? How widespread is the practice with people
who suffer, for example, from depressive illness, in flexible
working and having a set of goals which need to be done in a month,
for example, which give people that sort of flexibility? Does
that seem sensible because within an organisation there are jobs
like that to be done, and people cannot always say they will be
in from nine to five but can take on a certain amount of tasks
to be done in a month? Is that widespread?
Mr Corry: Just to use the example of Rethink;
Rethink employs 1,400 people and 20 per cent of those have a declared
mental health problem. We like to think of ourselves as quite
a successful organisation in terms of the services that we provide,
and so on, so in terms of a business model it works and you can
employ large numbers of people with mental health problems and
still be successful, and I think one of the keys to it is flexibility
in working practices, and I think it is good working practice
anyway to have flexible hours and, as you describe it, workloads
that can be spread over a day, a week, a month, and different
targets that are set. It is also good management practice to use
systems, which certainly Rethink use, around monthly supervision
sessions, one-to-one sessions to check back on work and workloads.
I suppose the other thing to mention is just to emphasise that
the world Rethink works in is not all soft and fluffy, we run
350 services in the community which are largely funded by the
statutory sector and they are only funded against certain outcomes
and targets on which we have to deliver. So there is pressure
on us as an organisation as well to deliver in the same way that
there would be pressure on a private sector organisation to deliver.
I am sure it is the same at Mind. I do think that we have a successful
model that is built around flexible working and close, supportive
supervision with our employees.
Dr Roberts: I think the model that you have
sketched out is eminently sensible. I think one of the questions
is how widespread is that. I do not have a figure in front of
me but my guess is that it is pretty rare from what we know about
employers' attitudes and how many businesses have proper mental
health policies. The other point I would make is the issue of
what the legal requirements are under the Disability Discrimination
Act, and whether that kind of practice would count as reasonable
adjustment, and I think there is also quite low awareness of legal
responsibility under the Disability Discrimination Act, as applied
to mental health.
Q153 Lord Trefgarne: My Lord Chairman,
our witnesses have referred to the existing legal structures in
all this, but then they went further and were talking of new European
Directives. Are you really sure that the small and medium-sized
companies are going to welcome a directive that they must employ
even more people of one kind or another? That will be deeply resented.
Dr Roberts: The proposal, when I mentioned European
Directives, was that it would be all employers above a certain
size, and the requirement would be simply that they have a mental
health policy.
Q154 Lord Trefgarne: But a directive
would be hard.
Dr Roberts: It might not be a directive; it
might be some other mechanism of achieving that end.
Lord Trefgarne: When people talk about
European Directives the alarm bells start ringing!
Chairman: Lord Dundee.
Q155 Earl of Dundee: Good morning. How
do you think that a European mental health strategy can best develop
a consistent and coherent approach for policies impacting on mental
health?
Mr Corry: For us it is about sharing good practice
across a number of countries. We would see the European Union
as being instrumental in taking best practice in one country and
being able to spread it further through a strategy for mental
health, which is what is being developed. I think from Rethink's
perspective, perhaps picking up the earlier point, we have to
recognise the real limitations of the European Union as it exists
and perhaps even the theoretical limitations of what the future
European Union may look like. I do not think we can get to a stage
where we have a national service framework for mental health,
which we have in England, which sets out certain standards for
service delivery. I could not envisage a future where we could
roll that out across the European Union. But particularly on those
large public health issues that we have talked about, mental health
and health well being in general and—I am sorry to keep
harping on about this—the stigma and discrimination question,
I think that is where the European Union could be instrumental
in spreading good practice.
Q156 Earl of Dundee: Let us take the
desirable aim of best practice. How consistent do you think the
1983 Mental Health Act is with just that?
Mr Corry: Across the European Union?
Q157 Earl of Dundee: Yes.
Mr Corry: I think it varies enormously. The
research that I referred to before that we are doing with the
Institute of Psychiatry about mental health experience across
the European Union produced—I will not go through the statistics—a
photograph from Romania of a caged bed still being used in a psychiatric
hospital. We can argue about how well the government has done
it in this country, but compare that to the new services that
we have over here around early intervention services, around getting
15 to 18 year olds before they develop serious mental health problems,
crisis services that are aimed at engaging with people in the
community to prevent them going into hospital in the first place,
there is a huge gap between the practice on the ground. In terms
of compulsion—I think I can speak for Mind when I say this
as well—we do believe that as far advanced as we think many
of the services on the ground are in England, we are about to
take a very great step in reforming the 1983 Mental Health Act—and
I believe it is coming to the House of Lords next Tuesday—and
we are stepping back into a culture of crisis and compulsion,
where in fact what we should be doing is stepping forward into
an era of recovery, hope and optimism. I think I have dodged answering
your question in detail about different legislations in each country
because I do not know in detail what the different legislations
are.
Q158 Earl of Dundee: Thank you. Dr Roberts,
you made a point earlier on that while of course mental health
is a national responsibility, nevertheless building onto European
strategy is much to be welcomed, and we would all agree with that.
I wonder how you would encourage contributions within that strategy,
coming from the European Union on the one hand and from the Council
of Europe on the other.
Dr Roberts: That is an interesting question
and it may be around some of what Paul said, because I think that
traditionally the role of trans-national and international organisations
has been more the enforcement of minimum standards than achieving
consistency of practice, which would not be realistic, and I think
the EU could potentially have an important role in ensuring that
certain minimum standards are upheld within mental health systems
right across the European Union. I found out from our legal unit
earlier in the week that there already is a recommendation—No
10-2004—of the Committee of Ministers of the Council of
Europe to Member States concerning human rights and protection
of the person with mental health. That, as I understand it, does
not have legal force, it is not binding, but it has a certain
moral authority and political clout, and that sort of set of minimum
requirements might be what we should be looking for rather than
consistency. Very quickly, if you would allow me, on the Mental
Health Bill because it is such an important issue for us at the
moment, I would make three very quick points about that. The first
thing—and this is why I think it is an issue that should
be engaged by Europe—is the sheer fundamental nature of
the rights and liberties that mental health legislation is dealing
with. It is about withdrawing from people some of the most fundamental
rights of all—about bodily integrity, about freedom of movement—so
we need to be very, very careful about safeguards and rights there.
I think the second thing is that the mental health system is a
health system and hospitals are hospitals, they are not places
that you should look to for preventative detention for difficult
people. So if we are going to deprive people of their liberty
the quid pro quo for that has to be that we can give them
treatment with a demonstrable therapeutic benefit, and the government
seems reluctant to accept that as a criterion. The third and final
point I quickly make is about the European role in making sure
that policy is based on evidence, and the proposals in the Mental
Health Bill to increase compulsion in the community as a way of
stopping people relapsing after release from hospital. These proposals
have raised rights issues but they are also not evidence based;
all the evidence tells us that the way that you prevent relapse
when people leave hospital is about good after care provision,
good support services in the community, assertive outreach, and
so on. So Europe can help to ensure that minimum standards are
complied with; they can do so against a background of recognising
that this engages with the sort of fundamental rights that Europe
has traditionally championed and it can also be a bastion and
informer of evidence-based practice.
Mr Corry: Could I add one very quick point on
the evidence-based practice? We do know, in particular in relation
to the Mental Health Bill and government's present attempts to
amend the 1983 Act, that there has been a very large Department
of Health funded study done on the use of compulsory treatment
orders around the world and their effectiveness, which we would
be very interested to see published at this moment in time, as
it is an issue that is being hotly debated shortly in both Houses.
The Department of Health at the moment seems reluctant to release
it publicly, but we would be very encouraged if Members of the
Committee requested to see it in the context of what it actually
says about compulsory treatment orders and their use within the
European Union. That was probably a bit cheeky, sorry!
Baroness Neuberger: But useful.
Chairman: Lady Gale will take the next
question.
Q159 Baroness Gale: My next question
is on improving information and knowledge about mental health.
Could you expand upon the types of information about mental health
issues that you feel have been most deficient, and which you think
should be a priority for improvement in the EU knowledge base
that you envisage?
Mrs Burner: I think at the moment the mental
health arena in Europe is quite a fragmented thing, and I think
the greatest problem is finding information. Information is increasingly
available through Eurostat and the WHO, but the types of information
that are available are quite limited. I know when we came to do
our response to the Green Paper consultation that obtaining information
about what services and carers felt was important to them was
very difficult, so we had to carry out our own research report.
I think the most significant aspect is the lack of service user
and carer involvement within Europe, and I think that the EU platform
that is proposed in the consultation paper would be a useful mechanism
for giving service users and carers a voice within Europe.
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