Select Committee on European Union Fourteenth Report

CHAPTER 9: Setting minimum standards or promoting principles

Variations

281.  As earlier chapters of this Report relate, it was made very clear to us at many points during our inquiry that there are wide variations in mental health policy, practice and experience across the EU.

282.  Annex 6 of the Green Paper itself illustrates that funding for mental health (as a proportion of total health expenditure) varies markedly between Member States. It is difficult to be sure, however, that reported funding indicates the same thing from one country to another. There are differences in accounting methods, and indeed in what constitutes a mental health service, but the variation is nevertheless substantial. This implies that there are cross-country variations in staffing levels, availability of therapies, what is provided in community care systems, and investments in new services.

283.  This suggests, in turn, that different Member States vary in their ability to alleviate the symptoms and to address the needs of people with mental health problems, and hence in their ability to promote quality of life. But even in the higher spending countries of Europe—and the UK is one of the Member States that for some years has devoted a relatively high proportion of its health budget to mental health services—it became clear during the inquiry that large numbers of people with mental health problems are not getting any, or adequate, treatment or support.

284.  There are also marked differences in relation to attitudes to mental health problems, among the general public, employers, politicians and other key decision makers in health and related systems. Patterns of discrimination, although hard to substantiate, would therefore be likely to show differences between, as well as within, countries. The emphasis given to promotion and prevention is also not the same across Europe. There are even countries in Europe without an explicit mental health policy framework, other countries where the policy has not been revised for decades, and some where agreed policies are simply disregarded. At a finer level of detail, and despite the high suicide rates in some countries, there are still few national strategies for suicide prevention.

285.  Most obviously and, as some witnesses suggested, also most shockingly, there are enormous differences between countries in their intentions to close poor quality institutions and to replace them with well-resourced community-based models of care. Good residential provision has an important place in community-oriented systems of care. Indeed, more fundamentally, there are enormous differences in the degree of protection afforded to individual rights of vulnerable and marginalised people.

286.  In this inquiry we did not set out to document the differences between Member States, something that would be a substantial research project in its own right and which the Commission might want to consider supporting in the future (see Chapter 10). Some of the reasons for those variations should be appreciated.

287.  One source of variation is a country's underlying commitment of resources to health care in general. A society's attitudes to mental illness will then have a bearing on what proportion is allocated to mental health services. Similarly, these attitudes could influence the level of investment in social housing, criminal justice diversion schemes, support for employers offering workplace mental well-being programmes, respite for carers of people with dementia, and other "non-health" inputs to a mental health system broadly defined.

288.  Some, perhaps much, of the observed variation in funding, patterns of services and levels of activity between Member States is legitimate and entirely appropriate, but one of the concerns that led the Commission to set out to develop a European strategy for mental health, and to publish its Green Paper, was that at least part of the variation was neither appropriate nor acceptable in the 21st Century. As we have summarised in previous chapters, many of the individuals and organisations submitting evidence to or appearing as witnesses before the Sub-Committee shared that concern.

Minimum standards or guiding principles?

289.  Our witnesses suggested two principal means of addressing these inter-country differences; in particular to help eradicate unacceptable policies and practices:

(a)  a set of minimum standards that each Member State would be required to achieve; and

(b)  a set of guiding principles which each Member State would be asked to agree.

Under a), the Commission's role would be to regulate; under b), the role would be to advise, guide and occasionally to monitor.

290.  Mr Jurgen Scheftlein of the Commission explained the thinking behind the drafting of the Green Paper. One idea was to use a vehicle such as the Fundamental Rights Agency as a means to collect information about conditions in institutions for people with mental health problems in all Member States (and not just new Member States) on the premise that there could be a need for action across the whole of Europe. He was unsure whether Member States would be ready to accept such an approach. He was equally unsure about whether it made sense to set minimum standards on human rights in mental health care. His preference was to encourage the emergence of harmonised but not legally binding standards (Q 33).

291.  Officials from the Department of Health indicated to us their broad support for the principles set out in the Green Paper, which were of course very similar to those in the WHO Helsinki Declaration, and not antagonistic to the standards set out in the 1999 National Service Framework for Mental Health in England. The feeling was that Member States might feel that they know their local situation best, but that they would and should be willing to learn from good practice examples from elsewhere. Mr Fowles, one of the DH officials, commented that it was difficult to come up with a one-size-fits-all solution (QQ 75, 92).

292.  Mr John Bowis MEP told us that he could see some arguments for favouring an approach based on minimum standards in some areas, and certainly, as he said, in the areas of employment law and human rights. He suggested that there were plenty of examples of good practice across Europe, and the challenge was to find them and share them. Overall, Mr Bowis favoured describing, rather than prescribing, good practice in order to put pressure to raise standards on Member States via their citizens, their media and their professionals who have come to learn what was possible and what had been achieved in other Member States (Q 113).

293.  Mind and Rethink gave some support for minimum standards. Dr Marcus Roberts of Mind suggested that the EU could play a role in ensuring that certain minimum standards were upheld, against the background of Europe's long-term commitment to human rights. He also argued that the Commission could ensure that mental health policy was based on evidence and that it could be a bastion and informer of evidence-based practice. He illustrated the point by questioning the principles underlying the proposals in the Mental Health Bill[61] (Q 158).

294.  Ms Camilla Parker (a legal and policy consultant working in the field of mental health disability and human rights) saw the attractions of minimum standards, but warned of the danger that countries that had already achieved higher standards might feel that they did not need to try quite so hard to progress (QQ 173-174). In Table 2, reproduced following chapter 5, Ms Parker set out some of the human rights principles that she suggested might be adopted as guiding principles to provide an alternative approach to setting minimum standards.

295.  Dr Matt Muijen (Regional Adviser for the European Region of the WHO) also expressed reservations about minimum standards. He was unsure how these could be phrased in such a way as to have meaning, and how they could be monitored or enforced. His preference would be for a system based on both minimum standards and guiding principles (QQ 200-201). Dr Muijen discussed the National Service Framework for mental health services in England, one of the strengths of which was that it was based on principles reinforced by standards, but not minimum standards. He recommended that well-meaning principles needed to be followed by quite hard-hitting policies and legislation supported by funding. Neither the EU nor the WHO has a mandate to set binding principles or standards, so that any initiative would at best be advisory. He was worried that principles could refer to attractive ideas about human rights and other aspects of care, but must not be seen as a substitute for the real thing. A second worry was that principles could have different interpretations in different countries, so that they should perhaps be translated into quite specific statements of what was required. He did not oppose principles, but on their own he felt they could be worthy but meaningless (QQ 200-201).

296.  The Minister, Ms Rosie Winterton MP, did not feel that setting minimum standards would be particularly helpful. She supported the general approach to health service matters within the EU, which was to try to keep responsibility with individual Member States, not least because of the substantial differences between them. She argued that mental health provision in the UK was already at quite a high standard, and she was not sure that European legislation would necessarily alter the standard of provision already available in the UK (QQ 247-248).

297.  We find it helpful to recall that the mental health spectrum is wide, and there is a need to make some distinctions. For people with severe, enduring and highly distressing symptoms, institutional care remains the mainstay of provision in some countries. Some arguments were made to us that to set minimum standards might be a helpful way to convey the strength of feeling about the inappropriateness of such provision, particularly during negotiations with candidate Member States. However, the diversity of circumstances and provision across countries to which we have just referred, especially with regard to the identification and treatment of less severe mental health problems, was seen by many witnesses as probably ruling out the use of minimum standards.

Sharing good practice

298.  The processes through which changes might be achieved in Europe's mental health systems were discussed by witnesses at various points during the inquiry. Framework directives, minimum standards, principles and other mechanisms were discussed. There was universal agreement that the sharing of experiences, both good and bad, would provide very valuable material to inform efforts to improve the identification and treatment of mental health problems.

299.  This approach was advocated by the Commission itself in the Green Paper.[62] They recognise that there are significant inequalities between (and also within) Member States' so that, given the diversity between Member States, it is not possible to draw simple conclusions or to propose uniform solutions. They take the view, however, that there is scope for exchange and cooperation between Member States and for opportunities for them to learn from each other.[63]

300.  We recognise the diversity of circumstances and provision across Member States, especially with regard to the identification and treatment of less severe mental health problems and we do not, therefore, support the imposition of minimum standards for mental health provision across the European Union.

301.  We do, however, support the development of a set of principles to guide mental health policy and practice in Member States. These principles could cover the locus of care (and particularly the use of institutional services), compulsory treatment, access to evidence-based treatments, protection of human rights, efforts to combat negative attitudes, stigma and discrimination, and structures to empower individuals.

302.  We recommend that the European Commission and the World Health Organization draw up, in consultation with national governments, a set of such principles. We also recommend that the Commission and the WHO introduce mechanisms designed to facilitate the effective operation of these principles.

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61   A Bill to "Amend the Mental Health Act 1983 and the Mental Capacity Act 2005 in relation to mentally disordered persons; and for connected purposes". Back

62   op. cit. p. 6 Back

63   op. cit. p. 7 Back