Examination of Witness (Questins 169-179)
Ms Camilla Parker
30 NOVEMBER 2006
Q169Chairman: Ms Parker, it is very good of
you to come and give us the benefit of your wisdom on this rather
complicated matter. I have been looking at your CV and the things
that you are interested in, and you seem to be perfectly located
in what you do in helping us through this rather special way of
looking at mental health from the point of view of what the European
Commission and the European Union can do, which is not quite the
same thing as what Member State governments can do obviously.
Thank you very much for being with us. We want to focus our inquiry
on the strategy set out by the Commission's Green Paper so it
makes a constructive contribution to dealing with these issues
at EU level. You know Professor Martin Knapp and he is assisting
us in our inquiry. Obviously the human rights aspects of mental
health are a major element in the European Union approach to this
because human rights is so much part of the European Union locus
and they have a real right to operate in that area. Thank you
very much also for the tables that you sent us. I do not think
I have quite absorbed every bit of them, but I think they are
going to be extremely useful to us as a kind of check-list to
make sure that we have covered as many of the angles and as many
of the aspects of this rather difficult question as we possibly
can. If you want to refer to those, we do have them before us.
Before we start, I need to do a bit of housekeeping. This is an
open public session of this Committee and it will be recorded
for broadcasting and webcasting. A verbatim transcript will also
be taken and this will be published on the parliamentary website
and it will also be published in the annex to the report once
we have published it. You will be sent a copy of that transcript
in a few days' time. If you wish to correct it, please do. We
do not wish to misquote you or assign the wrong opinions to you
because we have not heard quite correctly, but please advise us
of those corrections as soon as possible. We would be delighted
if we do not get to the end of questions or if there are wider
issues than we can manage within our hour, which I think there
might be, for you to submit supplementary evidence by letter if
you are able to do that. Could you start for the record by stating
your name and your professional title and if you wish to do so
you can make an opening statement at that point. Thank you once
again for being with us.
Ms Parker: Thank you. My name is Camilla Parker
and I am a legal and policy consultant working in the field of
mental health disability and human rights. I am hoping that I
will be able to cover all the points I want to make within the
questions you ask.
Q170 Chairman: I am going to start now
on the human rights background to all of this. Of course we understand
how it is that the European Union has come to make this initiative.
Could you describe how you think the issue of human rights should
be recognised in the development of the proposed European strategy
for mental health?
Ms Parker: First of all, I would like to make
a general point which is that human rights instruments, both internationally
and within the European area, are universal and apply to everyone.
That was really why I thought it might be useful just to give
a few examples of human rights instruments in one of the tables
(marked Human Rights Instruments) to really give a flavour of
the range of human rights, and really emphasise that all of those
will apply to people with mental health problems, so that is the
first point. Therefore it will not, I am sure, come as a surprise
to you when I say that human rights are integral to the mental
health strategy that the European Commission has put forward in
the Green Paper, and hopefully will develop. First of all, I think
it is important that we recognise that people with mental health
problems face widespread human rights abuses, ranging from unjustified
institutionalisation, particularly in parts of Europe, to unfair
discrimination, which I think is worldwide. The second point is
that it is important to recognise that all activities described
within the strategy should be planned and implemented within the
human rights context, for example, ensuring that the strategy
enhances respect for the individual, promotes equality and social
inclusion, and ensuring that people with mental health problems
are able to participate in the planning and implementation of
mental health policies. The third point is it is important to
recognise that human rights are not just about ensuring that states
refrain from arbitrary interference with people's rights. There
are circumstances where states are expected to do much more than
that and actually take positive action to ensure that their citizens'
rights are protected. Within the mental health context we are
very clear that in mental health legislation we need to ensure
that the decisions on the circumstances in which people may be
subject to involuntary admission and/or compulsory treatment are
made within a human rights context and are respecting those individuals'
rights. Also looking at this from a human rights context, it is
very important to ensure that we have anti-discrimination legislation
which includes people with mental health problems. I would argue
when looking at the strategy, that the human rights context takes
us yet further, in terms of thinking about how, for example, states
should develop community-based alternatives to institutions. That
is something which I think is very key when you are looking at
the issues from a European-wide context rather than just looking
at the United Kingdom, where we see in parts of Europe people
are still placed in institutions, often for life.
Chairman: You have really covered both
the first and the second question. I think it would be more sensible
to leave this matter at this point because I suspect we will come
back to it again as we go through the rest of the paper. I am
going to ask Lady Howarth to get down to some of the nitty-gritty
and talk about the European Commission's platform approach.
Q171 Baroness Howarth of Breckland: Before
I do that can I ask a follow-up which may not be where I am normally
coming from. Because you are talking about rights, what about
the rights of people to be protected from those who are dangerous?
It is an issue that has become a great cause of debate at the
moment. It would be useful if you took a moment to expand on that
balance between the rights of people who have mental illness and
the right of the community to be protected.
Ms Parker: Thank you very much for asking that
question because clearly it is a very important one, particularly
at the moment when we are looking at a new Mental Health Bill
for England and Wales. It clearly is a matter of great importance
and I think that is where, looking at human rights, what is helpful
is recognising that what needs to happen is a balance between
individual rights and the interests of the community. I think
it would be wrong to suggest that there are clear answers on that,
but what the human rights framework can do is offer a mechanism
for really engaging in very, very difficult and complex matters
and trying to weigh up the interests of the individual against
the interests of the community. It is a process of doing that
in a way that one is respecting the individuals' rights, for example
the right to liberty, the right to private and family life, which
within the European Convention context includes personal autonomy
and integrity and would include issues such as compulsory treatment.
So it is engaging in those very difficult areas and trying to
ensure that the process balances those two aspects; the individual
rights and the rights of the community. I do not know whether
that has answered your question, but I cannot give an answer in
terms of what is right and wrong because it would very much be
in terms of looking at the individual circumstances. What human
rights can offer is a mechanism for going through that process
and making sure that the ultimate decision did respect those two
interests and balance them and come to a decision that can be
seen to be fair and reasonable and there are good grounds for
making whichever decision it is.
Q172 Baroness Howarth of Breckland: That
leads me neatly to the problem we have which is what is it that
the EU mental health strategy is going to add to the general debate?
As you know, the Commission has seen the strategy having a platform
where there can be some of these discussions across the whole
of the Union. How effective do you think the concept of the platform
for discussion will be in taking this forward?
Ms Parker: I think it will be a huge challenge
and one that I think is needed to be engaged with, but thinking
about how to include all the relevant stakeholders, particularly
people who use mental health services and their families, and
ensuring that all of those with an interest in developing a strategy
can meet and discuss and everyone has their voices heard, ensuring
that those discussions are focused and then can conclude with
some concrete action, and ensuring that that then can be taken
forward. I think it is a very welcome step, but I think it would
be wrong to pretend that it will be easy.
Q173 Baroness Howarth of Breckland: Which
takes me again nicely into the next problem which is that standards
across Europe vary so hugely, and we understand that you have
a lot of experience across Europe. How realistic do you think
would be the aim of achieving minimum standards in mental health
across the European Union and how could the platform approach
achieve that aim? We are particularly concerned that there might
be a whole range of legal instruments, Directives and Regulations.
How useful do you think that might be?
Ms Parker: Again, I think that that is a very
difficult question to answer. My first point would be the issue
about minimum standards, and I think we would need to be very
clear about what we are looking at because there is a very broad
range of issues that the strategy covers. I think while yes, in
theory, having minimum standards is a good idea, there is clearly
a danger that those countries that are providing services which
are of a higher standard may feel that they do not need to try
quite so hard to progress, and I think that is something that
would need to be very clearly stated; that these are minimum standards
and the goal is that much further than those minimum standards
would suggest. So that would be my first point. Secondly, coming
with some experience of looking at what is happening in Eastern
and Central Europe, my view is the first thing we would really
need to do is to have a commitment across Europe to ensure that
governments work with the stakeholders within their countries
to close institutions and develop alternative community-based
services. That for me would be the key thing to come out of this
strategy, which I think is not expressed strongly enough. While
there is some reference to institutions and how that has a contribution
to stigma, my view is that it is far worse than that. If we continue
to have institutions where people are placed for long periods,
as I said, often for life, that is going to perpetrate the social
exclusion of people with mental health problems, and it is going
to perpetrate the fear and ignorance which then leads to stigma
and discrimination. If we are serious about trying to do something
to promote mental health that has to be, for me, the first step
in a European-wide strategy; to make that commitment and make
it very clear that there must be work to ensure that the long-stay
institutions are closed and community-based services are developed,
with the involvement of service users, to ensure that people can
live in the community and can be supported within the community
and have respect for their human rights. So that would be for
me the first step. I think it would be interesting to engage then
in terms of minimum standards of how we take that forward, but
that would be the first and foremost point that I would want to
see.
Q174 Baroness Howarth of Breckland: In
a word are you suggesting that there really should be a set of
principles rather than minimum standards? You were describing
the dangers of minimum standards and then what you are describing
is a set of principles. If that could be worked out through the
EU it would actually give us a way forward?
Ms Parker: Yes, and again human rights are a
good starting point for thinking about those principles. In the
second table that I gave to you I suggested some key principles
right at the top: protection against discrimination; the promotion
of equality and social inclusion, the promotion of personal autonomy
and independence; least restrictive alternative. You talked about
the issue of people who presented a danger and what action should
be taken in order to protect the community. That principle would
be picked up in there in assessing someone's risk and identifying
those risks and then thinking about how to address those risks.
Within that process you would be thinking about the least restrictive
alternative, which means how can you address those risks in a
way that is the least intrusive, so you address the risk but you
do not—the expression that is used in the European Convention—use
a sledgehammer to crack a nut. It is thinking about what is the
most appropriate action to take. I think that is a very crucial
principle within mental health. Then the provision of care on
the basis of individual needs and then, finally, I have suggested
participation in policy development for service users. Yes, that
might be the starting point which the platform could then look
at and decide what principles they think would be valuable. For
me the underlying point is that what we need to do is have a shift
from the idea that people with mental health problems and people
with learning disabilities should be placed in institutions, and
move towards providing the appropriate support within the community.
Q175 Chairman: Can I ask a question which
is perhaps not quite so straightforward from your point of view.
During the process of enlargement, the incoming states are supposed
to acquire the accumulated fruit of all treaties but they are
also supposed to show that they are on the right path as far as
human rights are concerned. That usually means the justice system
works well, the police are under control, the military does not
take too much part in public life and all that kind of thing.
There are some other major human rights issues of which this might
be one where we might want to be a little bit more fierce—not
that the British have a particularly strong platform on which
to stand in this particular respect—but the Community might
wish to be a little bit more exigent in this kind of matter. What
would you think about that?
Ms Parker: Yes, I think that would be very helpful
and extremely important. That is certainly something that people
have tried to highlight within the European Commission, the need
to look at the human rights of people with mental health problems
and intellectual disabilities (learning disabilities as we call
them in the UK). That is certainly something that does need to
be raised as an issue. Again thinking about the debate around
institutionalised care and community-based care, I think that
is something that would be important for all European Members
to discuss.
Chairman: That is why I said I do not
think we have a particularly strong platform here on which to
stand on and criticise other people, because although we are putting
people out of institutions, I am not so sure that we are supplying
the mental health care in the community that people need. I have
got two supplementaries, one from Lady Greengross and one from
Lord Trefgarne.
Q176 Baroness Greengross: It follows
on, Chairman, from what you have just said. We must learn from
history as well. I would have thought that closing down institutions
before adequate provision has been set up in the community would
be a total abuse of human rights. We know what happened in Italy,
we know what happened in some parts of the US, and even here when
one assumed there was a community care pattern which was widespread
which in fact did not exist. I just think if we are doing this
in the context of human rights it is sometimes a very slow process
and the disaster of institutionalisation could be exchanged for
something even worse, because they are totally insecure if we
chuck people out into the community when they have been institutionalised
for a long time.
Ms Parker: I completely agree with you and I
think that is why when the word "deinstitutionalisation"
is used, which for non-native English speakers is always a very
difficult word to say, but also it is a very difficult thing to
achieve. For me deinstitutionalisation is not just about closing
the institutions; it is about developing the alternatives, and
they have to go in parallel. I think that is one of the points
arising from the UK experience—and we have not got everything
right—but we can perhaps highlight the things that we have
not done so well. Looking at where countries have closed institutions,
the point is that alternatives must be developed at the same time,
and that obviously has cost implications but I do not think that
is something that governments should shirk from. It is very complex
and that for me is why we do need to address it, because it is
about sharing experience and thinking about the complexity of
shifting from institutionalised care to community-based care and
thinking how the financial, the legal and other mechanisms need
to be thought through, and it is very complex. Where perhaps other
countries that have not started that process as yet might be in
a better position than the UK was, is that there is now, a very
strongly feeling that people who are receiving services and their
families and other supporters should be very much engaged in that
process of shifting from institutional care to community-based
care. What I am concerned about is that there is not sufficient
impetus to make that change, and that is what for me really does
need to come out of a mental health strategy for Europe: to say
that we need to close the institutions but in order to do so we
need to ensure that alternatives are developed so that we are
not in a situation where people are removed from the institutions
and then have no support. That is not at all what I would argue
for.
Q177 Lord Trefgarne: May I agree very
strongly with what Baroness Greengross has been saying and our
witness has been confirming about the need for the development
of in-the-community arrangements in parallel with the closure
of the huge institutions. We seem to take it as read that the
standards of human rights observance in the Eastern European countries
and the new members of the EU are generally much worse than ours,
and on the whole I believe they are. How far, however, I am anxious
to be lectured on these matters by the European Commission is
another matter. I do not think that we would take that very kindly,
particularly as many of the Commissioners themselves come from
those Eastern European countries, and if one of them were standing
up to lecture us on some shortcomings he had seen here I would
take that rather amiss, as I dare say we all would. I was going
to ask whether you think that the overall observance of human
rights here—and charity begins at home does it not—with
regard to the human rights field is, in your view, adequate?
Ms Parker: The short answer is no. I should
really talk about England rather than other parts of the United
Kingdom. We have made the shift from the large institutions to
community-based services, but I think we still struggle with the
fact that people who develop mental health problems do face a
huge amount of stigma. In England what we see is insufficient
service provision for people. Too often we see that people have
to reach crisis point before something is done, and that then
means that they are perhaps placed in hospital under the Mental
Health Act. I think what we really do need to be looking at is
how to ensure we can provide appropriate support to people and
ensure that that is timely and is something that they are involved
in in terms of planning their own care, and also families are
involved as appropriate. I think that is for us the real challenge
to ensure that we provide mental health services in a way that
is accessible and is appropriate to people's needs.
Q178 Lord Trefgarne: Do you think that
it too easy for a family to get, say, an elderly relative who
has gone potty locked up?
Ms Parker: I would perhaps think about it in
another way, which is that people trying to get services for themselves
or for their relatives sometimes find it incredibly frustrating.
One of the challenges in this country in terms of the provision,
particularly of social care support, is that we are looking at
local authorities who say they have got very restricted budgets
so the eligibility criteria for receiving services tend to be
very high. Then there are issues around the provision of care.
I think one of the things that has caused concern for disabled
people generally is that, too often, a placement in residential
accommodation is suggested rather than providing people with support
in their own homes. That is how I would describe the scenario,
rather than families trying to put their relatives in an institution.
It is much more the frustration of not getting suitable support
for people so they can live at home, if that is what they choose
to do. Clearly people should be able to choose whether they want
to receive support in their own homes or want to go into residential
care.
Chairman: I think I am going to bring
us back to our list of questions; thank you for those interventions.
Lord Dundee on defining mental health and mental ill health.
Q179 Earl of Dundee: Within the context
of human rights how important do you think it is to clarify the
definitions of mental health and mental ill health?
Ms Parker: Again, I think it will really depend
on what context we are talking about. In terms of mental health
promotion, having some very broad concepts of mental health—and
I know you talked about issues such as emotional well-being—and
being as inclusive as possible would be good in that context,
but clearly, going back to the previous question about people
who are perceived to be dangerous and what needs to be done, what
you need to have then is some very clear criteria, which would
include an assessment that somebody does have some form of mental
illness, alongside other criteria to ensure that only in limited
circumstances do people become subject to compulsion. That is
why I am saying it depends on the circumstances.
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