Examination of Witness (Questions 195-199)
Dr Matt Muijen
7 DECEMBER 2006
Q195Chairman: Good morning, Dr Muijen. Thank
you very much for coming to help us. You are extremely welcome
here. Obviously, from your perspective as European WHO representative
you are just the person we need to fit this all into the international
strategy. I have a number of points that I need to make before
we start this session. We are sorry that we had to rearrange the
date. I hope that has not inconvenienced you too much but it is
one of these things which happen occasionally. We have heard from
a number of very helpful witnesses about the issues raised by
the Commission's Green Paper. Indeed, I think we have had an exceptional
set of witnesses so far to this inquiry and I am sure you are
going to be just such another one and we are keen to explore how
all this fits into a more international approach to this whole
matter of mental health and its costs and the stigma attached
to it. You may already know Professor Martin Knapp. He is here
to help us write a good report and I am going to say in public
what I said to him in private at our last session, that if he
does wish to intervene or ask a further question he should not
hesitate. We have some housekeeping points. The acoustic in this
room is abominable. If you could speak with your head up that
would help us all. It is what opera singers call singing out.
I am sorry about that but it can be quite difficult. A verbatim
transcript will be taken of your evidence and this will be published
on the parliamentary website and also in an annex to the report.
You may have seen House of Lords reports already. A few days after
this session you will be sent a copy of your evidence. Do please
correct it if you feel you have been misrepresented. Also, if
you wish on reflection to submit additional evidence when you
return home, or if we did not manage to cover all the topics in
the hour which we allow ourselves, your supplementary evidence
will be extremely welcome to the Committee. Could you start by
stating your name and your professional title for the record,
and if you wish to make a statement about how you see the interaction
between the Commission work and the World Health Organisation
work we would be very happy to listen to that. I should say that
there will be a small number of Officers of the Kenyan Parliament
who are in the House today. Over to you now, Dr Muijen.
Dr Muijen: Thank you. Let me start by saying
that I am Dr Matt Muijen, Regional Adviser for Mental Health at
the European Region of the World Health Organisation. Previously
I worked for many years in England and it is very nice to have
the opportunity to report back to the country that has been my
home for so many years. Let me make a short statement to explain
the different roles of the World Health Organisation and the European
Commission in their dealings with health and specifically mental
health in Europe. First of all, there is an important difference
in geography. The European Region of the World Health Organization
addresses the health needs of 53 countries, including the Central
Asian Republics, so in some ways one could simplify it by saying
the new EU plus all the countries of the former Eastern Europe
and Soviet Union. The EU is essentially responsible for its own
Member States. Also, the role of the EC is more diverse. We have
a role to work with the ministries of health of our Member States
to optimise health according to our mandate as set out in 1948.
The EC acts on behalf of its citizens, according to a number of
treaties, and is responsible within those treaties for public
health but not for health services, which are explicitly excluded.
It has a broad mandate which will, of course, make an impact on
health via human rights and issues that are related to the productivity
of the citizens, whereas we have a straight mandate to deal with
health, including health services. There is at times a very confusing
differentiation of responsibilities towards Members States resulting
from our different remits, which no doubt will come out in the
discussion and has great relevance to discussing the role of both
the Helsinki Declaration and the EC Green Paper.
Q196 Chairman: Thank you. That was a
useful opening statement. The Declaration of the Conference held
in Helsinki in January 2005 has been very influential in setting
the agenda for the debate in Europe about the future direction
of mental health policy, but how confident are you that developments
since the Helsinki conference have been positive in building momentum
towards actions for improvements in mental health care in Europe?
Dr Muijen: I can say that I have been positively
surprised by the impact it has made so far. I was very concerned
that, following the very successful ministerial conference in
Helsinki, this would have been perceived as a piece of paper that
was non-binding, and Member States moving on to other priorities.
That has not at all been the case. Instead there have been a large
number of countries which have compared their existing policies
and legislation with the Declaration they endorsed in Helsinki
and there has also been a tremendous amount of policy and legislation
work across the whole of Europe. Countries such as Romania and
Bulgaria have been very active in working with us, but also countries
such as Spain used the Helsinki Declaration to look at their existing
sets of policies. Much work has been happening, particularly in
the poorer Member States, and it has retained its momentum. At
the moment we are undertaking a benchmark study across the whole
of the EU, to which countries again have been remarkably committed,
so mental health has remained high on the agenda. It has not become
a marginalised, stigmatised area to which governments are not
showing any real commitment, not at all.
Chairman: Thank you. That is a rather
reassuring reply.
Q197 Baroness Morgan of Huyton: Obviously,
you have a lot of experience of mental health strategy and programmes
in Britain, having worked here for a while. We are interested,
because of your experience, in what you think in a sense we do
well here and what other parts of the EU could learn from us,
but also what we could learn from other parts of the EU. What
are the best practice areas around that we could share more effectively?
Dr Muijen: Let me start this off by saying how
different mental healthcare is across Europe and healthcare in
general. Certainly one has had to learn very fast how important
context is, particularly differences in health service funding
and traditions. An important factor I did not realise at the time
was the degree of centralisation in England. England is probably
the most centralised country in Europe. What I mean by that is
that policy and guidance but also standards set by the Government
are valid throughout the country and are taken seriously, and
do not underestimate the importance of this last bit. Germany
has 17 different health policies, as does Spain. Switzerland is
tremendously decentralised. Most countries in Europe have forms
of government which allow a far greater degree of freedom at the
periphery, for good and bad. Some of the strength of England follows
from that, and the national service framework was a massive achievement
in this respect. I took part in it and, if I may mention my Guardian
interview, my position was largely based on that. Only in retrospect
did I realise the achievements of this, ie to develop a visionary
strategy document supported by funding and driven through by identifying
the need for policy, legislation, workforce as well as standards.
This was unique and I do not think has happened, with the possible
exception of parts of Australia, anywhere in the world on this
scale. I do not know anywhere in the world with the number of
specialist services in each catchment area which have been introduced
in England, maybe not all perfect but at least they are there,
so in a structural way England is remarkably impressive. Also,
the workforce reform that has taken place here, the changes in
staff roles, the introduction of new professional groups in the
primary care, again I do not know of any country with such a highly
developed form of primary care related to mental health. This
is an area where England is very far ahead, with the development
of teams of primary care staff and mental health specialists working
together. There is a negative side to this, which is the potential
lack of flexibility, which is a clear problematic aspect of centralisation.
Whether rural Shropshire should have the same global outline of
services as Lambeth in London is highly debatable, and maybe at
some stage a greater degree of flexibility might be helpful. Another,
probably more important, difference is the consequences of health
service funding, and I am thinking about the element of choice
here. England, because of its central budget raised by taxes,
distributes this budget in a way which creates salaried staff
who are given specified jobs to do and on the whole are linked
to catchment areas. Patients go to a specified psychiatrist and
other staff and receive ongoing care from these staff. What does
not exist here in the public sector is the opportunity for people
to go in particular to therapists of their own choosing, receive
the care they want and decide what else they might require. What
this means in combination is that, if one suffers from a severe
mental illness requiring continuity of care possibly involving
multiple agencies, England might well be one of the best countries
to be in. However, if one suffers from more common mental disorders,
such as depression, which may need short, sharp interventions
in a one-to-one relationship, I would prefer not to be in England
because one does not have choice as one has in countries such
as Germany and France.
Q198 Baroness Uddin: The Commission's
Green Paper makes clear that the proposed European mental health
strategy has the aim of lending practical support to the implementation
of the WHO Helsinki Declaration and Action Plan. In their evidence
to our inquiry also the Commission have explained that they are
closely working with the WHO in taking forward the development
of the proposed strategy through their Platform approach. Largely
you have explained to us some of the issues that I would want
you to address, but why could not the objective of the WHO's Helsinki
Declaration and Action Plan be achieved by individual countries
working together with the WHO without the need for an EU-led mental
health strategy? Also, how effective is the Platform approach
adopted by the EU Commission likely to be in your view, given
the discrepancies in services and strategies at this current moment
in place?
Dr Muijen: In essence, of course, you are asking
a highly political question of why the European Commission requires
its own strategy, and in a way it is not quite for me to answer.
I suggest that one of the answers might be because is the issue
was there for the EC, so it needed a strategy. Obviously, my concerns
at the very beginning were indeed that we might find ourselves
in a competitive position, two strategies, two champions, so we
start competing for our Member States. That has not at all happened,
largely due to very strong personal partnerships but also because
I think the EC has made great efforts to involve us, which have
been genuinely impressive. They made a special point of inviting
us and for us to open some of the key events, in order to underline
that we work together. We also have been very closely involved
in drafting many of these papers. I have seen all the papers well
before they were published and have commented on all of them beforehand,
and our contributions were taken seriously. In reality the EC
commitment is very welcome to us because of the single fact that
it keeps mental health on the agenda. It is still constantly being
discussed by Member States who need to look at some aspects, such
as the benchmarking exercise we are currently undertaking. This
is an indicator of the importance given since it is co-funded
between the EC and the World Health Organisation. Member States
also meet at the EC Green Paper and now strategy events where
we are also represented. An important point which I have already
referred to is the different remit of the two organisations. The
EC is very strongly focused on mental health promotion and prevention,
which sits within our remit, but neither organisation has the
capacity to deal with this alone. The potential impact of the
EC is massive. On this point, we have found that we can make the
greatest impact in countries that are striving to become EU members.
We have noticed a strong difference, particularly in Romania and
Bulgaria in the last few years, because they had to work towards
meeting non-explicit EU standards, and often asked us to assist
them to do so, which has also been encouraged by the EC itself.
The partnership can work very effectively if parties choose to
do so, which, not only in mental health but also in other areas,
is on the whole working well. If we were set up against each other
it would be very difficult.
Q199 Chairman: What about the effectiveness
of the Platform approach? Do you have any experience of that?
Dr Muijen: It has yet to be demonstrated because
you they are part of the Plan as outlined in the Green Paper.
So far there have been a few discussion meetings that were helpful
towards formulating the content, particularly of the strategy,
but I think it is a plan for the future, which is very challenging
because, of course, the real concern is that it could become a
talking shop for a very limited group of people. At its best it
will create an ongoing communication and agreement on further
work.
Chairman: Certainly the voluntary associations
who have come before us, "civil society" I think is
the phrase, were very happy that these platforms allow them to
interact, and in one case interact on behalf of the sufferers
of mental health problems as well, which they obviously found
very useful.
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