Examination of Witnesses (Questions 160-168)
Dr Marcus Roberts, Mr David Stone, Mrs Alexandra
Burner and Mr Paul Corry
23 NOVEMBER 2006
Q160 Chairman: So you want better statistics,
more comprehensive, but also particularly with a focus on carers
and users, as an origin, as an originator of data?
Mrs Burner: Yes.
Dr Roberts: We would entirely endorse that.
The only thing briefly to add is that there might be room for
something along the lines of the European Monitoring Centre for
Drugs and Drug Addiction, which was set up to monitor the progress
on the European drug strategy. One of the helpful things about
the EMCDDA is that it has also improved data collection within
the Member States. So, in the UK, to take one example, we currently
have no nationally collected and published data on waiting times
for talking therapy, so it would help to improve that.
Chairman: Yes, there are great gaps,
are there not, in the information right across the European Union;
there is different information in different countries, which is
not there. Lady Neuberger.
Q161 Baroness Neuberger: I really wanted
to ask you a question that I suppose is fairly obvious. We have
some figures quoted about better mental health services in the
UK, and you have actually raised some of that and said that, although
you can be very critical, in fact compared with caged beds that
we have seen in Romania and the Czech Republic and so on it is
very much better. But if you look at that and you say, "Okay,
we are maybe extremely critical of some of the proposals in the
Bill but the service provision here is better," what is there
about the UK mental health services that you think a European
mental health strategy could make even better, could stimulate
even further, and is there a way, do you think, that something
at a European level could push are government to doing better
still?
Dr Roberts: I think the first thing to say is
just a note on the facts about how well we are doing. It is based
on not a huge amount of data, but, for example, we know that the
UK is near the top of the league for investment in mental health
provision and we know that it is near the bottom of the league
for suicides, so those sorts of quite rough figures are indicative.
Also it is quite low in terms of use of compulsory hospitalisation
compared with some other countries like Germany or France. So
what I think we could export is that we may be slightly further
down the road in providing more effective care in the community
than some of our European partners. I think in terms of what the
European Union can do to drive up performance here, we have a
lot to learn from other countries. Just one quick example, I was
reading about some really good service user involvement work that
was going on in Estonia, which was engaging with local communities,
where they showed the film of Beautiful Mind in a local
cinema. So all across Europe there are things we can learn from—green
care farms that I mentioned earlier. We really do not know all
that much; there is not all that much evidence and research there
about what is going on. The final thing is that although we have
taken an important step over the last 30 or 40 years towards deinstitutionalisation
there is now a sense that we are back-pedalling again, and although
we are near the bottom compared with Germany or France in our
reliance on institutions, we are starting to climb back up and
we need to look at that.
Mr Corry: Rethink would endorse those points.
I do not want to sound too miserable about this because that is
what the voluntary sector often does, but in comparing our mental
health services with those across Europe, yes, I think we can
be proud of some of the services that we have developed, but there
are two warnings on that. One is that the information we are getting
back from the comprehensive spending review at the moment is that,
"Come 2008 that is it—you have had your day."
If you look at the evidence from the mental health tsar, Louis
Appleby, in his review of the first five years of reform, all
the evidence is that the job is very much only half done, and
if we were to take our foot off the accelerator of investment
and reform in the future we would have missed a golden opportunity
to do what the government set out to do in the Wittchen Report,
which was to have a gold standard, world standard mental health
service in the future. So that is the first warning—that
the job is only half done. Secondly, I think it is also important
that we compare the experience of using the mental health services
in this country to the experience of using physical health services
in this country, and there is still a large gap there. If you
look at evidence from the Healthcare Commission, patient surveys
of different kinds, it is a consistently lower positive response
rate than people using mental health services. So, yes, we are
a long way ahead of many countries but we are not where we should
be.
Q162 Baroness Howarth of Breckland: We
have talked a lot about the need to ensure that people with mental
health problems can get employment and retain employment, but
in your evidence you also talk about those people who are dependent
upon benefits. One quote that struck us was that, "Care must
be taken to ensure that people with mental health problems are
not coerced into work." It is often a very difficult balance
to achieve and we wondered how the best balance can be found in
the UK between those two things and how the European Mental health
strategy would help in that area.
Dr Roberts: I think the first thing to say is
that there will be a group of people with mental health problems
who cannot work and are not ready for work at that particular
time, and it is important that we have benefits for that group
to enable them not only to live but to participate in the things
that we know contribute to quality of life and help to improve
mental well being. I think for the group of people who could get
into work with the right support and help and the right job, the
question is: what is the best balance of things to get them into
the workplace? We have done a lot of campaigning on the Welfare
Reform Bill domestically. There simply is not a problem in relation
to fraud in relation to incapacity benefit—there is not.
Fraud rates are about 0.05 per cent; fraud is not a significant
issue. Actually the OECD has said that we have some of the toughest
gateways to disability benefits in the world. The question then
is the balance between sanction and support, carrot and stick.
Do you need to sanction people into work or is about supporting
people and encouraging people? There is no evidence that sanctions
work and what sanctions do, if you are required to attend a work-focused
interview, or whatever, for a lot of the people we work with,
this is a very worrying experience; people become panicked and
they often take unsuitable jobs. They do not need sanctions, they
are ready to work; what they need is support, condition management,
and so on, to get them back in the workplace, and a lot of that
is already provided in the voluntary sector. Mind in particular
has some excellent services. It is not only providing support
and encouragement and training and building self-esteem to get
people back into the workplace, but also stopping people dropping
out of the workplace in the first place. I was at Croydon local
Mind association the other week and they have a very close relationship
with their local GP surgery, and when people are developing problems
they can help to ensure that they retain their jobs and do not
fall out of their job in the first place. So there are lots of
things you can do. What is the right balance between coercion
and support? You do not need any coercion apart from the obvious
laws about fraud and proper benefit administration. What you need
is condition management and help and less stigma.
Q163 Baroness Howarth of Breckland: How
do you think that the EU Strategy could help?
Dr Roberts: I think that the European Parliament's
disability integration, its disability action plan could be looking
at employment as an issue. I think its anti-stigma campaign that
we earlier talked about, the potential for that could make attitudes
among employers a key target. I think that there is a whole range
of work the European Union could do across its responsibilities—across
the areas where it has competencies—which would help to
make inroads into that—health and safety at work responsibilities,
for example, should include mental health as a core issue.
Mr Corry: We would endorse that again and just
add perhaps one point to that, which is the whole work focus,
employment focus. It is also proving a challenge to the voluntary
sector as well. Historically—and I do not think this is
true of Mind, and I would not ask them to associate themselves
with the following comment—certainly for Rethink we were
founded by family members of people who were coming out of long-stay
psychiatric hospitals and moving back into the community, and
I still think that for us there is a challenge about the relationship
that we have with people using our services and how much of that
is a dependency culture in which we say, yes, we want to encourage
people back into work but that there are risks involved and we
are perhaps a little conservative—with a small "c"—in
encouraging people to engage with that. However, I would also
make the point that as a membership charity we have to listen
carefully to our members and one of the big issues for our members
is—do not force us back into work if we are not capable
or we are not willing or we are not ready to go back into work.
Offer a gradation of choices between a life on benefits and a
life of full-time work; everything from the therapeutic benefit
that exists at the moment where people can go to work for periods
of time and earn a certain amount of money, to when you move back
into the workplace to protect your position in the benefits ladder
in case the work does not work out and you have to go back onto
benefits. So it is quite a complex area with different tensions.
Dr Roberts: Can I mention one point that we
would like to put on the record? You may be aware of Lord Layard's
work, which makes a strong economic case for investment in cognitive
behaviour therapy and notes that we lose about £20 billion
a year in lost output and benefits by not providing talking treatments
that we know are a factor in getting people back into work. So
we would also say that better access to psychological therapies
is a key part of solving the employment issue, but also that this
is not just an employment issue, and not just about cognitive
behaviour therapy. We recognise that there are very powerful arguments
about work, but, as Paul said, there is too much emphasis on employment—it
is also about elderly people, about young people and so on; it
is about access for all to evidence-based therapies that we know
can be effective.
Chairman: Strictly speaking we only have
five minutes left of your hour. We have two questions from Lady
Greengross and then another two that we have not covered. What
tends to happen, unfortunately, is that the Membership begins
slipping away as the hour approaches because they have other things
they need to get on to. We may be able to maintain a quorum, but
if there is any danger that we do not maintain a quorum—which
is only three essentially—perhaps you could respond to our
questions by letter or whatever. Having made that proviso, Lady
Greengross, your question on vulnerable populations, please.
Q164 Baroness Greengross: Dr Roberts
what you have just said in your last sentence, most European Union
countries now are very diverse in their population and do you
think that there is a role for Europe in identifying particularly
vulnerable groups—and you mentioned two—and particularly
ethnic minority differences—and we know there are significant
differences—in the type of mental health problems from which
different groups suffer. How could Europe help with the mental
health strategy to do something like that?
Dr Roberts: It feels to me, particularly in
terms of ethnic diversity, that Europe should have a core role
to play because the European Union is partly about people moving
between countries and the problems and issues they confront in
new societies. The point to make is that there are two general
issues. One is an issue about access people have to appropriate
cultural services, which might be about language, but it also
might be about wanting to talk to someone who shares your cultural
presuppositions. There is also the problem about the shocking
over-representation of some minority groups among those who are
in the mental health system under forceful detention in secure
units and so on. I think there is an issue there which is about
stigma, but I also think that it might be a core European Union
work stream to look at the mental health issues that arise given
the movement of population between different countries, and to
provide financial and other support for developing culturally
appropriate services and, quite simple practical things like the
availability of talking treatments in a range of languages, or
of mental health resources more generally in languages that are
appropriate in what are often very diverse communities.
Mr Corry: Particularly in the field of severe
mental illness it is crucially important that as the labour market
opens up across Europe that this issue is taken on board. All
the evidence suggests that the incidents of prevalence of severe
mental illness are much higher in what you might describe as second
generation groups in society. It does not matter where their first
generation comes from—Africa, Caribbean, Eastern Europe,
Ireland or faith communities—there is no doubt that the
second generation experiences significantly higher rates of severe
mental illness. I do not think it is fully understood why that
is the case; a lot of it has to do with living in two cultures
and the tensions and stresses that are involved in that, but I
do not think that is the whole picture, but as we get very large
population movements across Europe to different work places it
is going to be very important for those groups who settle that
services are in place for their children.
Q165 Baroness Greengross: I think we
have talked about this to some extent, but in terms of human rights
and institutionalisation, that is not really the Commission's
job, human rights, as such, is it, it is wider? But is there a
role for the Commission to do something about that, in your view?
Dr Roberts: I think there is a role for the
Commission in upholding the principle of proper human rights protection
and safeguards within the mental health system. In broader European
Union terms there are issues about the application of the European
Convention on Human Rights within the mental health system. It
is extremely difficult to pursue cases within the ECHR framework.
The most obviously relevant Article would be Article 3—inhuman
and degrading treatment. What happens to people in the mental
health system in any other context would qualify as inhuman—being
pinned down and injected with drugs, for example. But there is
an issue about medical necessity. My understanding from our lawyers
at Mind is that what cases have been brought, however extreme
the treatment has seemed, none of them have been successful because
there has always been a defence of medical necessity.
Q166 Baroness Greengross: My main question
was, was that the Commission's role as opposed to the lawyers
at Mind's role?
Dr Roberts: Yes, absolutely.
Chairman: Except that sometimes you can
get a course in the European Court and of course that then sets
a precedent. Talking about the legal cases as far as the Court
is concerned and what happened to them when they did get there,
if there were a different attitude and there were a couple of
good cases, which were good from your point of view, that would
of course have a knock-on effect, certainly throughout the British
legal system because we take the decisions of the Court extremely
seriously, and I am sure we will continue to do so. I cannot speak
for other legal systems but I know that we do take that very seriously,
so it is an interesting point.
Q167 Baroness Howarth of Breckland: I
can compact the last two questions very quickly. We have talked
a bit about the platform anyway, and really what I want to know
is what would be most useful to users and services in terms of
a platform across Europe. And whilst you are answering that, also
to say a bit about what could be done across Europe in terms of
the needs of carers and the kind of support that families and
other members would have in caring for people with mental illness.
Dr Roberts: The first thing to say is we would
like to see mental health services at the very heart of the development
of the European Strategy, and it is not clear from this document
that that is really there yet, and there is a lot to be done.
There are existing pan-European service user networks—there
is a network called Users, Ex-Users and Survivors of Psychiatry,
so I think the European Union as part of this process should be
identifying and engaging with existing networks. There is also
something about sharing good practice on user involvement across
the European Union; there is something about providing support
information to enable service users to participate in a meaningful
way where they are supported and paid properly for their services
and their expenses are paid promptly—quite simple practical
things. I think there is also something about potential for consultancy
style support across the Union in developing service user involvement.
I think this is, an area where the UK can play a part because
the work of organisations like Mind and Rethink is quite well
down the road and we have good practice we could be sharing with
other people, and we can be learning from them too. I think it
is important that service users are not presented with documents
that have largely been worked out by other people to say yeah
or nay to; it is about proper service user involvement in strategic
decision-making, in planning, in design and in monitoring the
delivery of services, and that should be absolutely at the core
of European work.
Mrs Burner: I would agree that everything Dr
Roberts has said basically applies to carers as well. Carers'
organisations do exist, such as EUFAMI. We spoke about these pan-European
umbrella organisations however what is often ignored is that the
fact that they are very, very small and they have very limited
funding. I think the necessity of having this platform, as Dr
Roberts said, is to create a space for research and funding, it
would be very important to have a single point of access to information
about service users and carers and from service users and carers
as well.
Q168 Chairman: Would that be a website
type single source of information? Is that the way you would go?
That is a natural thing to do at a European level is it not?
Mrs Burner: Yes, I think that would be a good
potential source. There already exists the EU Portal on health,
which is a good source but then there are issues around people's
access to the internet and use of computers and technology. But
that would be a good foundation.
Mr Corry: My Lord Chairman, we are coming back
to visit you again in slightly larger numbers next Tuesday as
part of our work around the Mental Health Bill, so if any of you
wanted to come and speak to service users and carers about any
of the issues that are in front of you at the moment or any other
issues, we will be in and around Parliament on Tuesday from one
o'clock.
Chairman: On behalf of the Sub-Committee
I would like to thank you very much indeed for your very interesting
contribution. As I say, if there is anything that you wish you
had said but did not, we would be delighted to receive it. Look
carefully at the record to make sure that you have not been misquoted
in any way and thank you very much for your examination in this
inquiry.
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