Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 8 - Evidence - May 6, 2004
OTTAWA, Thursday, May 6, 2004
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:00 a.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: I believe we have a quorum. We shall get started on our continuing study on issues arising from and develop during our health care study. As everyone knows, we are authorized by the Senate of Canada to examine issues concerning mental health and mental illness.
This morning we have a witness by video conferencing, Anne Richardson, Head of the Mental Health Policy Branch, Department of Health, in the United Kingdom. In half an hour, her colleague, Adrian Sieff, Head of the Mental Health Legislation Branch, will join her.
Welcome, Ms. Richardson. Thank you very much for giving us your time today on this very important issue that I hope we can raise to a new level of awareness in this country. We are looking forward to hearing what you have done in the United Kingdom to advance this important health issue.
If you would proceed with your statement and then my colleagues will have questions for you.
Ms. Anne Richardson, Head of the Mental Health Policy Branch, Department of Health, Government of the United Kingdom: I will give you an overarching summary of where I think we are on mental health reform in England. It has been a very significant period of change for us, really since the government changed in 1997. I will set out some of the highlights of the progress that we have made with mental health reform since that time. I am sure you will want to pick up on questions about particular details as we go through.
When the Labour government came into office in this country in 1997, it made mental health a priority for reform. In 1998, we published a white paper called ``Modernizing Mental Health Services,'' which set out an agenda for probably the most radical reform since the 1960s, when it became clear that it was appropriate to think about closing the large traditional Victorian psychiatric hospitals.
We made a start with our white paper, which set out three components of reform. First, there was modernization of the legislation. Second, there were changes to the investment in mental health services and the development of new models of care. Third, there was reform of ``care processes,'' or the means by which mental health care is delivered.
That white paper was followed in 1999 by the publication of the National Service Framework for Mental Health. Since that time we have published a series of national service frameworks on various issues such as coronary heart disease and cancer. We are about to publish one on children's and women's services. However, the one on mental health was the first.
The national service framework contains seven standards for improvements in services. Standard one is concerned with mental health promotion — that is all the action that is needed to help us take action against the stigma that there is surrounding mental ill health and the risks, to reduce risks of people developing mental ill health. Standards two and three were about mental health in primary care, which addressed the action that was needed to improve access to services by people with so-called common mental disorders.
Standards four and five were about people with severe mental ill health — the relatively small proportion of the total group of people with mental health problems — who nonetheless carry the biggest risk in relation to death by suicide and other causes, and who also carry the highest levels of morbidity. I am thinking of people with a diagnosis of schizophrenia or bipolar disorder or very severe depression.
Standard six concerned the action that was needed to improve services and supports for caregivers. Standard seven focused on all that we needed to do across the spectrum of mental health and social care services to reduce the risk of death by suicide.
Those seven standards were broadly evidence based. We wrote the national service framework on the basis of advice from an external reference group. We established a group of stakeholders and players in the mental health service picture and we asked that external reference group, which was chaired for us by a leading psychiatrist in England, to give us advice about the things that would really make the most difference for service users and caregivers and that would make the most difference to the quality of care provided.
Many of you will be familiar with the national service frameworks that have been published in Australia. We visited Australia in 1998 and that visit helped us enormously in the thinking that we did about what our national service framework should look like.
In 2000, a year after we published the National Service Framework for Mental Health, we published something called the National Health Services, NHS, plan. While it covered the spectrum of health and social care services, it did contain a specific section on mental health and it was backed by a promise of additional investment of over £300 million extra over and above baseline in order to ``fast-forward'' the mental health national service framework. In 2002, we published a document entitled, ``Priorities and Planning Guidance,'' which set out local targets for services on which to spend that extra money.
I should like to say something about how our health care and social care system is structured in England. In 2001, we undertook to reorganize the National Health Service. This is an important point for you to understand, because it meant that as local services were examining what they needed to do to implement the national service framework, they were also facing major service reorganization at the same time.
Since 2001, we have had three tiers in the National Health Service. I will start at the Department of Health, which is now a relatively small, relatively strategic department, staffed by civil servants, people like myself. I have a professional background, as do people in the civil service. I am a psychologist by training. The Department of Health exists to develop policy as well as the systems and structures needed to deliver services. However, it does not actually implement that change directly. We support ministers; we develop the policy; and we develop and support the systems needed. I am speaking now just about England. We have 28 strategic health authorities, SHAs, that are responsible for managing the performance of local services. They vary in size from 20 to 30 staff per location. They are responsible for as many as 30 Primary Care Trusts, which I will speak to in a minute. They help local services to design a plan to meet national service framework targets for their population.
The next tier is Primary Care Trusts, PCTs, of which there are 302 across England. Again, like the SHAs, they vary in size and some are urban and some are rural. The average population size for each PCT is approximately 100,000. They are responsible for commissioning services for their population. They have the job of looking at national standards and targets, balancing those against the needs of their local population and interpreting national standards for their local population. As you can see, there will be quite a difference between an inner urban area and a more rural area, where the population is thinly spread.
I will speak briefly to our national service framework and our priorities and planning framework targets, of which there is a large number. In the priorities and planning framework, the overarching objectives were: to improve health and social care outcomes for everyone; to improve life outcomes of adults and children with mental health problems through year-on-year improvements to access in crisis and child and adolescent mental health services; and to reduce mortality rate from suicide and undetermined injury by at least 20 per cent by 2010. We have a broad target that reaches across all of the local targets to reduce the rate of death from suicide and increase access for people in crisis.
Beneath that overarching target we have a number of capacity assumptions and, in particular, local targets: 335 crisis resolution teams by December 2004; 50 additional assertive outreach teams to make 220, due at the end of last year; 50 new early intervention teams for people developing the early signs of a psychosis, because we know that young people are vulnerable to death by suicide. In England, death by suicide is the commonest cause of death for men under the age of 35, which is a compelling statistic. Young men are more likely to kill themselves by their own hand than they are to die of a motorbike accident.
We have targets to improve the provision for those who are dangerous and have severe personality disorder. We have targets for those who are in prison, where mental health problems are really extremely prevalent. For instance, we have set a target to develop 140 new secure places for people with personality disorder who are dangerous, and to increase the number of nurses and staff working in prisons. There are targets across the board such that we have specific targets for psychiatrists, psychologists, nurses, and so on. We also have targets to develop new staff and new ways of working. We know that our existing recruitment and retention capability is limited. New staff and new ways of working are crucial to enable us to deliver this.
We have been making good progress in some areas. The priorities and planning framework was published in 2002. We have already hit our target to develop new assertive outreach teams. However, our targets to develop 335 crisis resolution home treatment teams have been much slower to be realized. The same applies to our targets for early intervention, although that one is a bit better. That is because working in that way represents a challenge to existing services. It is difficult for services to work in new ways and, at the same time, face the NHS reorganization that they were required to implement in 2001. We have asked our NHS and social care staff to do a difficult thing. Their progress has been incredibly impressive.
Over the last two years, we have been trying to improve our data capture systems. I guess it is as true for us as it is with other countries that our information on services in this field is relatively limited. That is not the least because the services are provided by numbers of different agencies. There is NHS care; social care, which is provided by local government provision; independent private sector care; and charitable and voluntary sector care, which is an increasingly significant component of our provision.
Information is a challenge. We have worked in partnership with local services to develop a self-rated system for assessing progress called our ``autumn assessments.'' Each fall since 2001, we have asked our local services to assess their proximity to target across a whole range of dimensions. They submit that information to a database that enables us to map the relationship between new teams and local measures of need, and spending, et cetera. We are not quite there yet.
We are assisted in that task of gathering information and in supporting local services to deliver on their targets by a range of arm's-length bodies. I described the structure comprising the Department of Health, the Strategic Health Authority and the Primary Care Trusts. One of the arm's-length bodies is the Modernization Agency, part of which is the National Institute for Mental Health in England. That is our implementation arm and has a series of eight regional development centres spread across England. Their job is to specifically help local services improve their closeness to targets. They set out models of best practice, visit local services and employ champions to raise the profile of the new service model and of the needs of people with mental illness. There are about 26 programs of work led through the National Institute for Mental Health, all of which have central funding. These programs are designed to support reform. Just an example: We have a Black and minority ethnic mental health program, currently funded to the tune of £2.5 million over the period to 2006. That will employ new community development staff and pump-prime about 80 community development projects, which will help us to do something about the fact that service users with mental health problems who come from Black and minority ethnic groups are better served by our mental health services. We know, at the moment, they are more likely to be detained under sections of the Mental Health Act, less likely to access services and less likely to find services acceptable to their needs. That program is designed particularly for them.
We also have a program targeting women's mental health, a program targeting violence and abuse. We know, for instance, domestic violence is a very big issue for mental health. We have programs targeting community teams' development, and research programs as well, so it is an enormous endeavour.
I think should stop there, because it will be more meaningful to you if you ask me questions and I try to elaborate on the bits that you are interested in hearing about.
The Deputy Chairman: Thank you very much. You did a very good job of outlining a huge endeavour you have taken on with some great success.
I was interested when you talked about Australia, because we had a teleconference meeting with Australia two or three weeks ago. We are now looking at Australia as our guidepost. They are having great success.
I will now turn to my colleagues.
Senator Morin: I have a number of questions. In Canada, we do not have — and we are obviously thinking about — a national mental health plan, which I think is important. I was very much impressed by the plan you have, which I think is called the National Service Framework for Mental Health. This is a very impressive document. I am impressed, for example, that the patient is given a copy of his or her written care plan, which includes the action to be taken in crisis and access to 24 hours. This is really impressive.
I have two questions dealing with this matter. The first one: How much of it has been implemented? I see it is quite detailed. There are really good indicators of what should be. It is very practical and easy to see whether you have obtained that or not. What has really been implemented?
My second question: I realize this applies to England, but what about Scotland? Are there any links? I ask because in Canada, of course, the provinces have the responsibility of the actual service delivery of mental health and of health care generally. Our role, at the federal level, is to assure some coordination between the various provinces. Is there a similar coordination role somewhere between England, Scotland and Wales, or are these completely independent as far as health care is concerned?
Ms. Richardson: Let me take your first question first, about the Care Programme Approach, CPA. The guidance on Care Programme Approach has been operational now for quite some time. It has been rolled out to all of those who are in contact with specialized mental health services, which represents around 630,000 people in England.
Each local mental health trust has a system for capturing data about the CPA. They have to make routine returns to us at the centre about the numbers of people with a care plan. We ask them to give us feedback about the numbers of people who are given a copy of their care plans, as well as the number of caregivers, because we have extended our CPA guidance since the framework was published to include a requirement that the needs of carers are also assessed.
As far as contact with specialized mental health services is concerned, that is working quite well. Where we have a question mark is whether CPA should be extended into primary care. Of course, it is much more difficult there, because people in contact with general medical practitioners quite commonly do not have a formal diagnosis. It is a requirement on CPA that you get a diagnosis, that your needs are assessed. That is an expert's endeavour.
We have some reservations about extending CPA into primary care, even though it is the case that a significant number of people with severe mental health problems are only in contact with their GP, and only receiving support from primary care services. People on CPA actually represent the tip of the mental health iceberg, if I can put it that way. There are many more people with quite disabling conditions who are not on CPA.
Another issue we have with CPA — and we would strongly recommend this system — is that it is also a system that is being thought about for extension into care with older adults and other people with long-term conditions. If you do adopt such a system, it is well worth trying to find a way of helping local services with the information infrastructure. At the moment, we have a system where many trusts are using very different ways to capture that information. Commonly, the reporting back to us is still on paper rather than electronically. I would advise implementing an electronic system at the outset.
In respect of your question regarding Scotland, my colleague Adrian Sieff will talk to you about the arrangements that exist for working in partnership with Scotland, Wales and Northern Ireland in relation to the legislative framework. However, when it came to writing the national service framework, we was ensured that we had representatives from Wales and Scotland and Northern Ireland involved in our planning.
The National Service Framework for Mental Health for England is a framework for England. It does not apply to Scotland and it does not apply to Wales. Although there are systems in place following devolution to ensure that the legislative and other governmental decisions are discussed in Scotland and Wales, it is by no means automatic that the reforms extend there.
Senator Morin: Therefore, in fact, the reforms may not apply to Scotland at all. If the reforms are necessary — and I believe they are — nobody is ensuring that they should be applied to other parts of the U.K. Am I right in saying that?
Ms. Richardson: You are. Let us not forget that the national service framework qua framework is best practice guidance.
The parts of our reform program that really have teeth — if I can put it that way — are the priorities and planning framework, the local targets that are set through the public service agreement with the treasury. In developing our best practice guidance, which is what the framework is, we work in partnership with the other administrations. Then it is for them to set local targets as they see fit, building on what that best practice guidance says or not.
Senator Morin: Could I address now the issue of resources? I address this because there is an argument that a plan, without resources, may not be worth doing.
According to the Sainsbury Centre and the King's Fund and the Royal College of Nurses, there have been issues with the resources affected to mental health or mental disease. For example, the growth of resources in the mental health field has been half the rate of growth in other parts of the health care delivery system.
The Sainsbury Centre concluded that there is a widening gap between promise and performance in the delivery of mental health services. You are as familiar as I am with the figures here. Not only was there not an increase in resources when you brought up this national plan, but as compared with inflation and so forth, there has been a decrease in resources.
I realize that 75 per cent of resources in the health field are now devoted to the Primary Care Trusts. There has been major criticism of the commissioning of mental health care by these Primary Care Trusts. They have neither the time nor the expertise to do this. What we call the ``tyranny of the acute'' has taken over the resources that would have been normally devoted to the local implementation teams.
This is important for us. If there are increased resources allocated, we should go ahead. We heard from New Zealand where they had a very ambitious plan whereby they had an increase of 173 per cent of funds allocated to mental health. According to them, without an increase in resources, there is little point in carrying on a plan.
I see you have done the opposite. You have a plan and not only did you not have an increase it resources, you had a decrease. Do you think it is still worth carrying on with this plan without having the increase in resources?
Ms. Richardson: First, I think I have to challenge robustly the perception that there has not been an increase in resources for mental health in association with the national service framework. As I think I said earlier, the NHS plan set out how an additional £330 million over and above baseline would be invested in the NHS in order to fast-forward the national service framework by 2003-04.
Our evidence supports the fact that that money did go into mental health services. We know that up to April last year an additional £262 million was spent on mental health over and above the baseline figure for 2001. Therefore, we did spend extra money was spent on mental health. I am very familiar with the Sainsbury Centre for Mental Health report and the allegations that funds are insufficient. We respect the fact that local services commonly tell us that their resources are stretched. It is not enough, but we do know that extra allocations did go into mental health services and we know it has been being spent on mental health services. That is the first point I want to make.
Second, I think it is important to say, and you will respect this too, that additional investment is not the only answer. In shifting the balance of power and devolving the decision making and commissioning down to the primary care level, we have tried to ensure that the commissioning for local services most closely matches local population need. We have tried to measure performance in terms of outcome rather than expenditure.
I also have to acknowledge that our information about spending on health and social care services for people with mental health problems is extremely difficult to calculate. The Sainsbury Centre report made an estimate of the amounts of money spent by social care and on incapacity benefits for people who could not work because they have a mental health problem, and so on. We, in England, are about to introduce program budgeting across the health service that would enable us to know much more about where the money has gone and what has been spent.
In summary, I will make three important points. One, we did invest more. Two, we do have good evidence that more has been spent. Three, we did want to shift the balance of power and give local services much more control over how they spent money for their local population. You make the valid point that mental health is often the ``Cinderella'' of the NHS. It is true that local service managers can become preoccupied with waiting times targets in other areas of health care. It has been quite challenging to keep mental health chief executives' and trusts' minds focused on mental health, which still is seriously stigmatized in this country. Our ministers have had a tough job to keep the profile high.
We have not done a bad job. It remains as a priority. I would strongly recommend that if you are going make a similar level of reforms, it is absolutely essential that that profile is kept high.
Senator Morin: I will put my question another way. If the figure is not right, please correct it. If I understand correctly, in England the resources allocated to mental health would be 12 per cent of the total health care expenditure. Do you think that is a sufficient number? Have you thought about this? Should we have a target that it should be 15 or 20 per cent? Is that a way to approach it?
Furthermore, I am still interested in Scotland because as you realize we are a federation, and we are at the federal level. Does Scotland have the same resources for mental health? Do they get it as a total budget? If so, are they at complete liberty of doing what they want with the money in allocating it to mental health?
Ms. Richardson: In respect of your second question, I honestly cannot answer you about Scotland. You would need to talk to Scotland.
Spending on mental health services in this country made up 13 per cent of the hospital and community health services expenditure in 2001-02. That is from our evidence to our public expenditure inquiry. However, I repeat that hospital and community health service expenditure is only a portion of the money that is spent on mental health. We also have social care spending, which goes down a separate route to local government for social services, education services and the like.
I do not have that figure here but I will be pleased to send you details on how much money is spent by local government services on personal social services. A significant proportion of that is for people with mental health problems. The figure of 13 per cent represents an underestimate if you are trying get a picture of total spending.
Senator Morin: Have you heard of a target? Should we aim at more, or is that not a way to go at it?
Ms. Richardson: The way to go is to match local spending to local need. I guess it is the same for you as it is for us. Levels of mental ill health are much higher in the inner city urban areas than in some rural areas. The inner cities' average expenditure on mental health in some local services is as high as 18 per cent. In other parts of the country, it is much lower. As I said, there is not a direct correlation between allocation and outcome. We want to monitor spending carefully, but we would like to perform its management on the basis of outcomes.
Senator Morin: Thank you.
Ms. Richardson: I would like to introduce Adrian Sieff, my colleague who is head of the mental health legislation branch. He could elaborate a little bit on the relationship between England and Scotland, at least as far as the legislative framework is concerned.
The Deputy Chairman: Before we move to the next question, I would like to welcome Mr. Sieff. Would you please tell us how you, as the head of mental health legislation branch, interface with the system you have there now? There were some questions about how England and Scotland and Wales and Ireland connect. I will turn it over to you for brief comments.
Mr. Adrian Sieff, Head of the Mental Health Legislation Branch, Government of the United Kingdom: In respect of the relationship between England and the other countries in the United Kingdom, we are bringing forward new legislation for mental health in England, which covers England and Wales. This is primary legislation, since devolution covers England and Wales. Scotland sets out its own legislation. Scotland passed a new Mental Health Act last year, which applies Scotland only. The Mental Health Act in England and Wales applies to England and Wales. There are separate powers made under regulation for Northern Ireland.
The primary legislation applies to both England and Wales, but it is devolved to Wales to secondary regulations, secondary statutory instruments which set out some of the detail of the law, and it can also provides its own code of practice. There will be a code of practice for Wales and a code of practice for England under the same primary legislation. Likewise, there will be regulations for Wales and regulations for England under the same primary legislation.
There are interfaces, for example, if someone is detained under mental health legislation in England and transferred to Scotland or vice versa, then there are transfer arrangements that take place, but the individual is always made liable to whichever legislation of the territory in which they are at that time. I do not know if that answers your questions.
Senator Morin: We were told that England was the most centralized country in the world in respect of its health care delivery, but the U.K. is really the most decentralized system, as if it were different countries. Here in Canada, the provinces have the responsibility of health care delivery, but the federal government is responsible for coordination and for ensuring that certain minimal standards are kept. The system is quite similar from one province to the other and the federal government plays a role through financial arrangements.
Now, whichever body has that responsibility in the U.K. could have the same power, unless taxation is completely different, because I expect that there is some funding that flows from the centre to Scotland for example. It seems there is no role here for whatever government is responsible for the total of the U.K. I still cannot understand clearly — and this is extremely important to mental health because as you have stated, there is the tendency for it to be the ``Cinderella'' of the system.
Ms. Richardson: To provide answers to your questions, Mr. Sieff and I will have to go back to colleagues because it falls outside our remit. I do not really know how it works in an overarching way. I honestly do not know how resources get allocated to Scotland, Wales, and Ireland.
Mr. Sieff: I do not know in respect of Scotland. There is a formula in respect of expenditure between England and Wales and I think it is called the Barnett Formula. Under this formula, money is allocated to England, then a calculation is made for allocations to Wales on a population and various other bases. Certainly, when any new policy is developed in England, then Wales needs to be ensured that since that policy may apply to England and Wales, the funding is being made available for it.
The Deputy Chairman: Honourable senators and witnesses, we have lost our video communication link. We will proceed without video until it can be re-established.
Senator Keon: Ms. Richardson, I know a little bit about your system because my daughter is a doctor there. I am fascinated by the integration of your mental health strategy and your primary care system. We do not have such a capacity in Canada at this time, although we are groping to find one. We have to design a primary care system before we can deal with it.
I understand that your Primary Care Trusts deal with a panacea of mental health — including the decriminalization element — across the system. Could you expand on how this works? You have a complex system of programs and then you have the Primary Care Trusts and the primary care system. How do you interface all of these programs and standards into the Primary Care Trusts? Could you expand on that?
Ms. Richardson: Yes, if I can. It is necessary to have a perspective of the history of primary care in this country in order to understand where we are right now. Traditionally, mental health care has been the preserve of those working in specialized services — that is, not primary care. Traditionally, those with an identified mental health problem would have been referred to a psychiatrist or to another specialist in secondary care services. Although that was the perception, it is nonetheless true that a very significant majority of people with mental health problems — as I think I said earlier — are managed only in primary care or are managed only with the support of family and friends and local community services.
In a sense, by default, primary care services have provided a huge amount of the support for people with mental health needs. Perhaps it just has not always been seen in quite that way. That has been generally thought to be a great strength of primary care, not least because of the stigma that is attached to mental ill health. As a person with a stress- related condition or someone with a long-term depression, it has perhaps been easier for the patient, for the person with the mental health problem to get contact, to get help through his or her GP.
There are difficulties with that, too, because one of the things we know historically to be true is that GPs do not have the specialized training. That is both their strength and a weakness of the system. They are generalists so they see everyone. They do not necessarily put a diagnostic label on a person. That is something that happens very much more in secondary care. That is good from the patient's point of view or service user's point of view because it is less stigmatizing.
On the other hand, the absence of specialized training means that we also, like other countries, face a difficulty with delivering effective care to people, for instance, with depression, where we know that GPs tend not to prescribe in doses that accord with the recommended guidelines, and they miss cases of depression because they have not enough time to spend seeing the service user.
When you say that you are impressed with the integration, that is good that you should perceive it that way, but we have to acknowledge that we have a long way to go to achieve what we would really like to achieve for people with mental health problems.
That is why we set two standards in the National Service Framework for Primary Care. They are mainly about access to services, which is why we set the specific targets through our priorities and planning framework to supplement the expertise that there is in primary care by providing new workers, who will be trained specifically to help people with so-called common mental disorders.
You mentioned the criminal justice system. Traditionally, the responsibility for provision of effective care has been and continues to be with the home office. However, we have been trying very hard to integrate the mental health care for those people in order that the standard of care they get in prison is better than it has been in the past. We have set up a program of prison in-reach and a program of general health care including health care in prison so that people can get an assessment of their needs more quickly and can get access to the help they need, which was not happening in many cases.
We have implemented a number of programs that help primary care and I will mention two that might be of particular interest to you. One is the NHS plan target to develop 1,000 new graduate primary care mental health workers by December 2004, to help GPs manage and treat people of all ages with common mental health problems. The second is a target to recruit 500 ``gateway workers'' who will help GPs to signpost service users and carers to the right part of the system to help them get help more quickly.
The graduate worker is a new breed of worker. I am not aware if they exist in other countries but here we were faced with a problem that I touched on earlier. We were not able to recruit enough nurses. We were taking steps to increase the number of GP trainees. We were taking steps to increase the number of psychiatric trainees and psychologists and other groups. However, that was not going to deliver for us quickly enough because it takes so long to train those professionals.
Therefore, we looked at the evidence and we saw that two things were true. One is we had a group of able graduates in our system who wanted to work in the NHS who could be trained, so the evidence suggested, to deliver brief, effective evidence-based treatments in primary care for people with common disorders. We set that target and we set up 12 new programs of education and training across England to provide them with one year of post-graduate certificate level training offered on a day-release basis. We are halfway through that; we have about 400 of those workers in place right now, and local plans to recruit the rest by the end of this year. Gateway workers are in fact qualified nurses, community psychiatric nurses, whose jobs are being reconfigured to help them focus more on what primary care staff need to help signpost them through the system.
That is about service redesign. However, you can see 1,000 do not go very far among 300 PCTs. It is obviously not sufficient to meet all the needs that there are but we hoped by highlighting the importance of this to trigger an interest in primary care mental health and promote the development of similar such workers on a wider scale.
Senator Cordy: You talk about the 28 strategic health authorities that manage performance services. I am from the province of Nova Scotia. We have regional health authorities in my province, but they have a great deal of difficulty because they spend a tremendous amount of time negotiating with the government for budgets. Is this the same in the United Kingdom, specifically to mental health? When regional health authorities or the strategic health authorities receive funding, is the funding targeted specifically for mental health or more broadly, or are they just given budgets?
Ms. Richardson: Strategic health authorities here have a performance management responsibility as PCTs but they are not holders of the bulk of the money. They obviously have small budgets of their own that they use to recruit staff and they have a budget that is capped to certain work.
Seventy-five per cent of the money spent on the NHS is devolved to PCTs. It is not ring fenced or badged. This was really the essence of the health service reorganization that took place in 2001. We touched on it earlier, in answer to the first set of questions, which were much about Scotland. There is a difficulty or a challenge there for local primary care commissioners to divide up their allocation of the NHS resources among the competing demands of mental health, cancer care, coronary and heart disease and so on.
Senator Cordy: You spoke about assertive outreach teams. Specifically what is the role of an assertive outreach team? What do they do?
Ms. Richardson: It is a small multidisciplinary team consisting of anywhere between 9 to 15 staff. Their aim is to focus particularly on the estimated 1,500 people who are in the mental health service system with a severe mental illness and who are at particular risk of falling out of contact with services or of disengaging with their key workers. This particular group of service users is among the most challenging with which to work. They usually have long-term histories, severe mental illness, schizophrenia and so on. They are quite often transient or not living in fixed places.
The assertive outreach team would start its work after a period of admission. Let us say, typically, a service user would have an admission to a psychiatric hospital, have a period of treatment and get a care plan. The assertive outreach team would follow up, as the name suggests, quite assertively. They would visit the person at home; if the person missed an appointment, they would chase it up. They might see the service user, the patient, in the place of his or her choosing. We know assertive outreach teams that work in the local launderette, and they will be trying to help ensure that the service user sticks with the care plan and does not fall out of contact.
This approach, which has its origins also in Australia and in some of the work of Stein and Test in the U.S., demonstrates to be an effective way of working with that client group — providing you configure the teams properly. It is not everyone's cup of tea, if I can put it that way. You need careful training for your staff. It is a rewarding job but not an easy job for staff.
Senator Cordy: There are a number of patient advocacy groups in Canada. I am wondering how they would react to an outreach team meeting someone in a laundromat, for example. Has that been a problem at all?
Ms. Richardson: No, because the service users and carers, by and large, say that they quite value having someone — a team or person or care-worker — who is prepared to put himself or herself out. Service users, particularly in this group, commonly do not like going along to the psychiatric hospital for their outpatient appointment. They do not turn up. If the team member is prepared to come out and meet them on their territory, so to speak, the relationship and the engagement is much better.
Senator Cordy: In respect of primary care, you stated earlier that you need a diagnosis to be on the Care Programme Approach. As Senator Keon was saying earlier, the first point of contact in most cases is the family doctor or the GP. You stated that the GPs do not necessarily have specialized training in giving the effective care. Is this where your gateway workers come in, helping to make initial diagnoses?
Sometimes when a person goes in to see a GP, they will go in with a variety of ailments, none of which they will claim to be related to depression or any other type of mental illness. As you stated earlier, it would take a period of time before a GP could actually make a diagnosis that it is not continuous headaches or not stomach problems or whatever, it is, in fact, a depression or something else.
Are GPs receiving training so that they can red-flag patients when they come in, or do your gateway workers play a large role in that?
Ms. Richardson: You are absolutely right, that is the role of the gateway workers as envisioned in our guidance. However, at the moment there are not very many gateway workers in post. They do not have a monopoly on that role; there are many other members of the health and social care system who help to provide support for GPs in that initial diagnosis.
For instance, many psychiatrists are now working to deliver outpatient clinics in GP surgeries. Many psychologists are also placed in GP practices. They can help GPs resolve an uncertainty about whether a particular patient should be referred on or not.
The gateway workers' job, therefore, is partly to do initial assessments, where there is not anyone else to do one, and partly to signpost through the system and help the system work as a more united whole. The gateway workers' job description — and we published some sample job descriptions in our guidance — is to help the development of local referral protocols between different elements of the service system, so that it saves patients having to be reassessed multiple numbers of times.
You can imagine what that is like. A GP is not certain whether someone should be referred to specialized services, so to be on the safe side, he or she refers to a psychiatrist and there is a wait. Perhaps the GP refers to the psychologist simultaneously, thinking that the wait might be quicker, which it often is not. Meanwhile, it will have been suggested that the patient might go to the local charitable voluntary service for some counselling to tide them over, in which case the counselling service will also do an assessment.
Those three systems are not well integrated at the moment. The gateway workers' job would be to help them work together more closely and agree what would be an appropriate format for an initial assessment, so they could accept each other's judgment more readily. That would speed things up for the patient.
Senator Fairbairn: I have been following Senator Cordy's questions. They were basically along the line that I wanted to ask. However, I would like to just follow one part.
Yesterday, we heard witnesses speak to the community part of this issue. I found it a very tough session to go through, because of the difficulty on the ground of developing ways to have people access proper care outside of hospitals. We do not have the structures that you have in Britain to do that. Also, we do have a confederation, so we have different rules and laws in various provinces.
I wanted to touch on the idea of assertive outreach. We do not have that in Canada either. As we are going away from the institutions and back into the communities to try and provide the kind of service in primary care and otherwise, we are also placing a distinct responsibility on the client, on the patient, to wish to become part of this system.
With the assertive outreach groups and individuals, what happens when the person who has been diagnosed one way or another in need of help chooses not to follow up with primary care or whatever other kind of care he or she has been getting? What if they choose not to respond, however assertive these people may be? What happens then? Is this then something that goes back to an institutional capacity?
Ms. Richardson: That is an extremely important and interesting question. In fact, it relates very closely to the work that my colleague Adrian Sieff has been doing to reform the mental health legislation. It is being reformed precisely in order to bring it up to date and in line with modern patterns of treatment and care, which, as you have pointed out, are much more likely nowadays to be provided in the community than in a hospital base. I will ask him to say something about that in a moment.
I cannot give you a general answer. In our guidance to assertive outreach teams, and crisis resolution home treatment teams and on CPA, we have stated that it is absolutely essential to take an individualized approach to each person's care. Therefore, I cannot give a general response in respect of what would happen in any one case. I can say that it would depend on that person's history and upon the care worker's judgement of the level of risk.
Let us take a specific example of someone for whom the question has been raised that they are a danger to themselves. Let us say that they have had a history of self-harm or of attempted suicide. Add to that a history of domestic violence, or a history of offending so they perhaps also have a criminal record, but they are not formally in contact at the moment with the police. In such a case, the assertive outreach team would make every effort to follow-up with that patient. If the patient were on medication, they would do their best to persuade the patient that he or she should abide by the guidance set out in the care plan. In fact, the person would have signed on to the care plan in the beginning, because our guidance makes it clear that guidelines should not be developed without the patient. It is absolutely essential that the service user is part of that work.
In the event that the member of staff or the team thought that the patient was a risk and thought that they were dropping out of treatment and/or were not taking their medication, then the Mental Health Act might become one of tools that they would need to use. If you agree, I would quite like to land over to Mr. Sieff to say something about that. Is that okay with you?
Senator Fairbairn: Absolutely. I should like to add one more element to my question. What happens if this person not only has mental difficulties, but also has an addiction? When they are back in the world, he or she does not want to drop the addiction either?
Mr. Sieff: As Ms. Richardson was saying, we are proposing to bring forward new mental health legislation. One of the key changes is to modernize the legislation in line with modern treatment and care.
As the developers of the assertive outreach teams, we want to see more consumer-based delivery of care, where appropriate, to enable people to be treated under formal powers in the community. That is not something that is possible under the current legislation, which requires that a person be detained in a hospital if they are being treated under formal powers.
If a person has a serious mental disorder and is at significant risk of a high level harm — either to themselves or others — and if there is an appropriate treatment available, that person can be sectioned under the mental health legislation for treatment, even without their consent.
There is a particular group of people that we loosely call ``revolving door patients,'' who may deteriorate in a relatively foreseeable way on occasion in their need for care and treatment. It may not be necessary, if they are well- known to services, to bring them back into a hospital, but they will need the sanction of the legislation to be treated. That legislation provides for helping people who are leaving the hospital to move into the community in such a way that it is hoped they will not continue to revolve in and out of hospital. They can be treated under sanction — that is, that certain sanctions can be placed upon their discharge into the community. For example, they would need to reside at a certain place, turn up to an outpatient's clinic at a certain point in time or to attend treatment.
As long as they comply with those conditions, they do not need to be brought into hospital. This is enabling people to be treated in the community while they are still meeting the conditions of their compulsion.
It is important to stress that, once their condition has improved and they no longer met those conditions that are set out for a serious mental disorder with a significant risk of harm, they are then discharged from treatment under the act. However, it is hoped that that support should continue in the community with either an assertive outreach team or from other areas of the community. That provides a smoother transition in their care.
Senator Léger: I was impressed by Ms. Richardson's description of the changes since 1997 and the priority for reform. The first area on which you focused was mental health. It is the contrary with us. We started with everything else; our last item is mental health. Was there a reason for this?
Ms. Richardson: I should correct a misapprehension owing to the fact that our first standard in the national service framework did indeed address mental well-being and mental health promotion rather than mental illness. I must say, however, that it would be unfair to conclude that that is where we began.
Like many other countries, we made a priority of addressing reform in those services designed for people with the most severe mental illness because that is where the highest levels of morbidity are. That is where the biggest risk of death by suicide and other causes is. We did start work simultaneously to promote mental health, but if you were to show how the resources were allocated to those different elements, it would be fair to say that we have done far more on the severe end of the spectrum than the preventive end.
Standard one is the relevant standard here. We started in March 2001 by launching a national campaign called ``Mind Out for Mental Health.'' That campaign was aimed at tackling the stigma and discrimination faced by people with mental health problems. It was designed to support their social inclusion. Although that targeted a group that was already identified as mentally ill, it was our intention to try to remove some of the stigma attached to mental illness in order to make it easier for people early in the development of a problem to seek help.
One example of the work done there is something called ``The Campaign Against Living Miserably,'' CALM, which was launched almost five years ago. It targeted young men at risk from suicide who tend not to go to GPs to discuss their problems. This program constitutes a helpline that takes about 6,000 calls a year, half of which are from men between the ages of 15 and 35 years of age.
Our aim is to raise awareness in the right places. We work in youth clubs through DJs and discotheques. We use footballers and celebrities to try to get the message across. We had a big campaign. There have been messages on buses such as ``Did you know that one in 100 is affected by severe mental illness?''
We have also taken steps to strengthen NHS Direct, our national helpline. This is a relatively recent innovation that has been running for about five years. Trained nurses staff the call centres have been training in mental health awareness. They have also been trained to use an algorithm, which is a decision tree that helps them to assess a call and then direct the caller to the right place to get help if they need it, or, to put them in touch with charitable and voluntary sector helplines that meet their particular needs.
We have in England, for example, as I am sure you do, a range of independent charitable and voluntary sector help- lines targeting particular groups. There is the Child Line, there is a rape crisis line, survivors-of-sexual-abuse line, Saneline, and there is the Bi-polar/Manic Depression Fellowship helpline. We got these together and operating to some sort of similar standard and linked them to our national helpline, so that we could divert callers their way if appropriate. That is a very important piece of work.
Finally, in 2001 we published a document entitled ``Making It Happen: A guide to Delivering Mental Health Promotion,'' which is a guide for local services to take action on mental health promotion. This guide has sections on physical activity and the relationship between exercise and depression. We have done some work to help GPs refer people with depression to local fitness centres. There is a range of good practice examples in that document.
The cabinet office of the government has a unit called the Social Exclusion Unit. In the last 18 months they have been working to develop a report on social exclusion among people with mental health problems and their report will be published in June this year. I urge you to have a look at that. It has a wealth of information about this general area of stigma and mental health promotion.
We also have a public consultation underway. This consultation has been designed to ask the public what would make a difference for them. There are two foci: First, we are asking people who do not have mental health problems what would help prevent mental health problems from arising, what would help to make them more resilient, manage transitions more effectively, deal with stress at work and so on. The second focus is what we can do for people with existing mental health problems to ensure they get the public health messages that the rest of us get, because we know people with severe mental ill health die earlier from respiratory disease, they do not get the cervical smear tests and other tests that the rest of us get, and they do not get the health checks that would provide the early warnings of other kinds of physical ill health.
Senator Léger: I am impressed with the structure of your system. For example, the Primary Care Trust designed a plan that applies to about 100,000 people, I understood, and you have differences between rural and urban applications. In other words, it is broken down into many small cells, which I find most interesting.
Ms. Richardson: That is tremendously important in order to secure engagement of local service providers with the national plan. Without that it could not possibly work.
There is one element of that organization that I did not mention. We have the National Institute for Mental Health, NIMH, of England, which is our implementation arm. None of this could have been done without NIMH and without the local buy-in that NIMH has fostered. NIMH has eight regional development centres but there is another level even beyond that. We provided some central government resources to support the development of what we called ``local implementation teams,'' LITs. There are about 196 LITs that are made up of staff working in health and social care in the mental health field, who come together to support effective commissioning and effective integration of services.
The LITs have been absolutely essential to such changes as we have been able to secure. I do not want to create a falsely positive picture because we have an enormously long way to go. We are nearly five years into this program and we have made significant change but there is a long way to go. The LITs have been essential for that and it is terribly important in thinking about the whole of the reform program to get that infrastructure right, from the beginning.
Senator Léger: There is a new breed of professionals. Do these people still have that mentality of going to the small cell or are they more specialized and separated from the reality?
Ms. Richardson: We have been extremely anxious to ensure that the training these people receive differs in a number of important ways from the traditional training that doctors and nurses get. Most importantly, the new trainings that we have established are competence-based rather than exam-based, if I can put it that way. We have developed a set of national mental health competencies, which we are promulgating through the various workforce development and training organizations and higher education establishments. It is also crucial that this education and training for these new staff is not restricted to health matters. It is also focused on social care, housing issues, occupation and the much broader spectrum of issues that are relevant to people with mental health problems.
At the same time we are trying to influence pre-registration training for doctors and nurses and our traditional staff groups by supporting the delivery of this competence framework and by extending — particularly for GPs and psychiatrists — the opportunities that they have for learning about non-drug ways of intervening. Thus, we are trying to strengthen the delivery of psychological therapies training as well.
Senator Cook: What attempts have been made to integrate mental health services with addiction treatment, given the high prevalence of concurrent disorders in mental illness and substance abuse? I am thinking about our young population in particular.
Second, do you have a national suicide-prevention strategy? In practical terms, how have mental health providers — psychiatrists, psychiatric nurses, psychologists, and in this country we have a category of nurse practitioners — been integrated into the primary care system?
Ms. Richardson: On drug treatments and the NHS, most funding for addictions services comes from public funds with only a small amount provided from the private sector. However, there is a pooled budget for drug treatments, which combines health and criminal justice funds from the government. Drug services are provided through 149 drug action teams across England. They deliver services within that pooled budget, which is held by the local Primary Care Trust, which acts as a banker for the provision of drug services. The drug action team decides what should be provided and the PCT holds the budget.
We have a National Treatment Agency, NTS, for substance misuse, which is a bit like the National Institute for Mental Health. That is an arm's-length body set up by government to set standards for treatment services and to monitor the delivery. It is fair to say — and someone commented on this earlier —that the levels of co-morbidity between mental illness and substance abuse are very high. We acknowledge that the drug services at the local level are still inadequate to meet the level of need. We have further work to do to improve working partnerships between drug action teams and mental health services. It is not always easy to have drug action teams. I would add that they mostly focus on substance abuse rather than on alcohol abuse. That is also an issue for them.
We have a National Suicide Prevention Strategy, NSSP, which is available on the Web. The first report of progress with the strategy was published last year. There are encouraging signs that the rate of death by suicide is falling. The data for the last two years show the lowest rate yet. The three-year average for 2000-2002 was the lowest rate yet compared with the baseline that we set in 1995. Currently the rate is 8.9 deaths per 100,000 population. That compares moderately favourably with the European rate, which I think was 8.8 at last count.
Most of that reduction in rate of death by suicide is attributable to a drop in the rate of death on in-patient wards. We have about 4,500 to 5,000 deaths by suicide each year. One-quarter of those are by people in contact with specialized mental health services and one-quarter of those happen in the week following discharge from hospital, which is why we have so emphasized the importance of assertive outreach, follow-up and proper care planning.
Senator, could you repeat the third question, please?
Senator Cook: In practical terms, how have you integrated mental health providers — the gamut of psychiatrists, psychologists, nurse practitioners, and psychiatric nurses — into the primary care team that you have told us about?
Ms. Richardson: That is a difficult question to answer. It is fair to say that we have not had a formal strategy for the integration of primary and secondary care. However, it has been much written about and we began to address the vision for better integration in the national service framework. Development has been more piecemeal such that we have begun to provide psychiatric outpatient clinics in primary care and to locate psychologists in primary care. We have these new workers who will help us to bridge the gap between primary and secondary care.
We have also done substantial work to support primary care commissioning through another arm's-length body, the Modernization Agency, which has a specific arm that focuses on primary care. It is called the National Primary Care Development Team, NPDT. A mental health collaborative has been started to promote more effective working between primary and secondary care.
We have had a series of initiatives but there is not a single solution because the problem is not a simple one, as you can appreciate. It is about winning hearts and minds and moving the location of care as much as it is about training staff.
Senator Cook: One of the categories that you have in place is the nurse who continues his or her education with one extra year of psychiatric training. There seems to be an emerging role in Canada for a nurse practitioner — a registered nurse with a BA or equivalent who continues with a masters' program in a chosen discipline. Am I comparing these nurses favourably in our respective countries?
Ms. Richardson: What you describe pretty much matches our community psychiatric nurses who, like yours, are registered nurses who continue their training to gain specialty expertise in mental health. In fact, community psychiatric nurses, CPNs, are more commonly attached to secondary specialized services than to primary care because they mostly focus their work on people with severe mental illness. They also work in primary care but, more typically, they are associated with secondary services.
Our graduate workers, thus far, tend to have qualifications in social sciences or psychology and are not nurses. That additional one year of post-graduate training qualifies them to deliver the kind of self-help, the information dissemination, and some of the brief effective cognitive behavioural treatments for people with common disorders. They would not be involved in prescribing. You may be aware that our legislation in respect of nurse prescribing has recently been extended to make it possible for psychiatric nurses to deliver an element of the required drug treatments.
The Deputy Chairman: On behalf of senators, I thank Ms. Richardson and Mr. Sieff for appearing before the committee today. I am sorry that one-half of the technology did not work for the last part of the meeting. Certainly, we benefited greatly from the information that you provided.
The committee adjourned.