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July 18th 2001 |
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tony heyes
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1. Introduction
2.The Labour Party mission
3. A Local User and Carer View
4. A National User and Carer View
5. Stigma Poverty and Unemployment
6. Conclusion
The session on Mental Health we are having today arose from a general discussion on policy at an earlier branch meeting. We discussed the need to know our own mind on important matters and agreed to resume policy discussions from time to time. I was asked to kick off the series with my personal views on mental health, since a number of members felt that there were many issues surrounding mental health and the NHS that were not often aired.
I noted then that the 1997 general election manifesto contained no references to mental health. At the time the imminent 2001 election had not been called but two ministers speaking at a mental health conference had told me that they did not know whether mental health would appear in our manifesto.
The 2001 manifesto did in fact refer to mental health, but only very briefly, so there is obviously a good deal of room for interpretation and development by even the most loyal Labour Members as to what should be the priorities over the next four years, and in the session my colleague Andrew Hughes and I want to make some suggestions.
Andrew's session is very important, for he speaks as a service user with some considerable personal experience of the problems at the grass roots, and his talk is intended to generate most of the interest, especially in the people side. What I want to do (you would expect it of a treasurer!) is to tackle the priority issue using numbers, and I have selected a number of Labour party references, and some national and local questionnaires, as a starting point.
What is conspicuous here by its absence is a treatment of the massive amount of reorganisation work going on in the NHS. The view I am taking today is that there are perhaps enough people involved in this and that we should point our eyes not on re-organisation but on the actual mental health issues that seem to be important. In due course it would be important to show how (or whether) these issues are dealt with in the hundreds of detailed NHS strategy, structural and implementation documents such as the National Service Framework for Mental Health, but this can not be done today.
2.The Labour Party mission
2.1 The 1995 Co-operative Labour Party manifesto
It is possible to encapsulate a philosophy or tangible intention in eight words. The Cooperative Party Agenda for Labour was produced in 1995 to influence Labour Party policy for the 1997 election. Their suggestion was eight words:
"restoration of the rights of the mentally ill"
Now there's a vision worth spending time on!
2.2 The 1997 manifesto contained no references to mental health
It is not possible to encapsulate a policy in zero words!
2.3 The 1999 National Policy Forum Health paper
This was agreed at Conference in 1999 and listed Mental Health as one of five priority areas for development. It contained the following (kindly supplied to me by Ann Black of the NEC):
"At any one time around 1 in 6 adults have a mental health problem such as anxiety or depression, although less than one per cent of the population suffers from severe mental illness. Suicide is now the second most common cause of death in those under the age of 35 years. Although with staff dedication and commitment the policy of care in the community benefited many, there were too many failures caused by:
"An effective mental health strategy depends on a range of NHS,
local authority and other agents working co-operatively. Nationally
the government has published proposals to modernise mental
health services by providing safe, sound and supportive services,
underpinned by £700 million of new investment over three years.
"Specific measures include
We will consult widely about proposals to change the Mental
Health Act."
2.4 The 2001 manifesto contained three short phrases
Page 20 "Mixed sex wards will be abolished, and mental health
wards will be modernised.."
Page 21 "...we will tackle the long-standing causes of ill-health and health inequality by".. tough targets to close the health gap to cut deaths in poorer communities and among poorer children improving mental health services"
(nb, they didn't proof-read the last line, but let's keep those two themes together anyway!)
Page 26 "...where people are homeless or suffer drug or mental health problems we will offer specialist support."
Now this is hardly strategic material but these individual points are important. I have no information as to why the more strategic 1999 policy document did not get into the manifesto.
Let's look now at what the people outside the Health Service and Government think is important....
The 2001 Priorities Questionnaire
Last year the Bracknell Forest Mental Health Forum responded positively to Government (Labour!) led initiatives aimed at increasing user and carer involvement at all levels. In the past (in and out of Bracknell) such involvement has been mainly tokenistic because users and carers were not given access to important meetings and were not involved in a way which enable them to prepare their views in advance (the established word for this tokenistic involvement is "consultation"). However on this occasion in addition to places on the Forum for any group, four places were allocated to users and carers on the higher level steering group. Although these places carried no votes they did enable access to a further layer of decision makers. To make the most of these places we pressed for more formal working methods at the Forum and for identification of key priorities which would be reviewed in depth.
In March 2001 we sent a priorities questionnaire to all groups attending the Forum. This offered our own short list of 23 topics from a much longer list. Seven voluntary sector groups (predominately users and carers) and 10 statutory sector groups responded. The results were most interesting.
Taking both sectors together the top five choices were:
1
employment
2
increasing user involvement in policy
28 points
3
24-hour services
28 points
4
User/Carer consultation
24 points
5
Primary Care
23 points
The next three topics scored 21, 15, 13 points and the lowest scored 2 points.
Together the two (entirely different) user-related items would come top, but as an individual item Employment came out a clear winner reflecting perhaps that after several years of discussion, no significant employment scheme or support for people with mental health problems is as yet up and running in Bracknell. It is not a priority either of Health or Social Services and taking just the statutory sector votes, employment came only 7th with 22 points against the statutory (and important) favourite 24 hour services with 22 points. This reflects the slow introduction of joined-up thinking in the Borough, and led the Forum to accept (reluctantly) that the only practicable approach might be to support the efforts of Mind in Bracknell (a statutorily-funded but voluntary-sector-managed enterprise) in forming a consortium to raise funds outside the Borough. This will be a difficult project to get right.
The diversity between statutory sector and voluntary sector votes is quite noticeable. The statutory sector was cool about Mental Health Promotion, giving it only two votes, even though it is one of the 7 standards in the Government's own National Service Framework for mental health. However it came second for the voluntary sector, which perhaps reflects their greater awareness of the consequences of stigmatising those with mental health problems and of the opportunities for prevention rather than after-the-event clinical treatment. The Forum took the user view here and Mental Health Promotion was selected as the Forum's next "hit"
No-one expressed much interest in discussing the National Service Framework. The voluntary sector gave it no points and the statutory sector only 2.
The 1999 Questionnaire
The Bracknell questionnaire was small, and it may be interesting to compare its conclusions with those of an older questionnaire which I put in 1999 to 250 user and carer groups, members of the UK Federation of Smaller Mental Health Agencies, of which I was then chair. The 250 members claimed to represent 150,000 service users and the 50 actually replying claimed to represent 47,000 service users.
For that 30 topic questionnaire I analysed the responses into nine groups, which came out as follows:
1
User Involvement
1850 points
2
Provision for Minorities
1840 points
3
Preventive and alternative treatment
1582 points
4
Increased funding for community care
1017 points
5
Better statutory coordination
768 points
6
Drug and treatment safety
540 points
7
Employment and benefits
468 points
8
Legal reform
258 points
9
Housing
240 points
These results were little different from the questionnaire we did for Federation members in 1996. However they are different from the Bracknell survey in many ways. Some of this is obviously local difference, for example Bracknell does not share the UK's range and scale of ethnic minorities. The low 1999 score in employment may reflect the substantial increase of attention to employment matters devoted in recent years by national mental health groups and Government .
But as with every survey I have seen of this type, User Involvement in its various forms comes top or close to it! This is not just the effect of campaigns by brain damaged individuals for control, improvement and perhaps abandonment of electroconvulsive and grossly addictive tranquilliser treatments, but also a demand for user empowerment at the very heart of the NHS. To some extent this is reflected in the words of recent NHS and Government documents; as a matter of local implementation there is a long way to go.
Coming top of a list does not necessarily mean something should be done about it. But have no doubt, the situation is bad. Here are a few quotes on topics underlying those which came highest and which are close to Labour's social justice agenda.
Stigma
Surveys show little reduction in scare-mongering headlines. If it's not the Suinday tabloids with their "mad axeman", it's Frank Dobson (1998) saying Community Care has failed.
But....
While only 6% of psychiatrists might think of someone with schizophrenia being dangerous to others, 71% of the general public thought that way. (Royal College of Psychiatrists 2001)
More than three times as many perpetrators of known homicides had symptoms of mental illness at the time of the offence, compared with those who kill a stranger (RCP 2001)
There was little fluctuation in numbers of people with a mental illness committing criminal homicide over the 38 years studied (1957 to 1995). In the ten years 1970-79 there were 106 such homicides, but in the ten years 1986-95 the annual figure dropped to 78. On the other hand homicides from other causes increased from 310 per year in 1970-79 to 444 in 1986-95. (Taylor and Gunn, RCP, 1999)
At the same time Mental Hospital Populations have decreased (from 150,000 in 1955 to less than 50,000 in 1992). So the newspapers' anxiety is grossly misplaced.
In many high profile cases of personality disorders (Michael Stone 1999, Barry George 2001) it appears that treatment has been with-held. While 91% of psychiatrists thought personality disordered patients would improve if given treatment, only 51% of the public felt that way (RCP 2001). Hence perhaps, the disappointing Government emphasis on new custodial measures.
There are no votes in mental health, especially at this end of the spectrum. That should concern us as Labour Party members with a social justice agenda.
A 1999 survey of 556 service users by FOCUS showed that people with mental health problems are doubly disadvantaged, both by their illness and their poverty. I quote:
"They see significant hurdles in trying to escape from poverty by returning to employment, with many anticipating discrimination and ignorance. Expectations are low. Eight out of ten expect to have a low income. Only 15% of our respondents were employed, and of this small group 57% regard their income as low.
"Significantly, one in four stated they had been unable to get help from mental health services through an inability to pay for transport or childcare, for example. Access to health care should be based on clinical need, but here is evidence that poverty is perceived as frustrating one of the fundamental rights of our citizens, one that is so essential to their well-being.
"Asked how they would spend an extra £10 a week, 74% responded by saying it would go on food and other basics, items that most of us take for granted. Respondents had practical ideas about what they need: an accessible and flexible benefits system that helps their return to work, and more access to education and support.
"Without positive national and local action to provide specific and sustained help for people with mental health problems, poverty will continue to isolate and ensnare many of the most vulnerable people in our society."
Unemployment
These national results were confirmed locally in October 2000 by a Mind in Bracknell survey of 100 service users of whom:
97% had worked in the past
24% were currently working
97% want to find or stay in employment
93% want training (21% wanted IT training)
69% had attended specialist training, but only 9% found existing training helpful to seeking work
The users thought employers resisted taking people with mental health problems mainly because of:
59%: employers fear of people with MH problems
62%: disbelief in users' ability to apply themselves
59%: lack of knowledge among employers
59%: lack of flexible working
3%: physical appearance
They thought their own main difficulties were:
48%: lack of confidence
38%: managing stress
35%: difficulties with benefits
31%: lack of good advice
17%: lack of understanding among employers
The situation is grave, but it is being picked at and improved from all sides, by user and carers themselves, by charitable agencies, and by the better parts of the NHS. Some leadership is now being given by the Government, though this is often a case of three steps forwards, two backwards. It is because of this slow progress that the demands for user involvement, especially in monitoring and development of services, are building up, largely un-met. In preparing this article I drew freely on the work of colleagues and others, to whom I am extremely grateful. They include:
More needs to be done (now, where did I hear that?) and perhaps there is scope for the Labour Party itself to take a lead. This is actually not a party issue, except that almost by definition we can expect Labour Party members to be more sympathetic to the social exclusion problems than our right wing opponents (in all parties!). But in an election context Mental Health is clearly not a banner that is attractive to party managers. Perhaps some people will be motivated to look into why this is and how to address it?
Acknowledgements
Mind in Bracknell
National Mind
Focus Group on Mental Health
UK Federation of Smaller Mental Health Agencies
The Royal College of Psychiatrists
ECT Anonymous
Ceredigion Advocacy Network
Campaign for Involuntary Tranquilliser Addiction
The Co-operative Labour Party
The unofficial NEC web-site
The Labour Party manifestos
The Bracknell Forest Mental Health Forum
The Mental Health Employment Network
Psychexam.co.uk