All Party Parliamentary Group on Mental Health

7th March 2006

MEETING TO DISCUSS INCAPACITY BENEFIT REFORM

Vicky Pearlman, Citizens Advice

Ms Pearlman began by saying that the Citizens Advice report What the Doctor Ordered, focuses on medical assessments which will continue to play a key role in the benefits system under the new welfare reforms proposed in the Green Paper. She noted that these assessments are often conducted in an unsatisfactory way and that her colleague would expand on this.

In terms of the general picture of Incapacity Benefit (IB), Ms Pearlman noted that many recipients do want to work but that it is hard to get off the benefit once you are on it. She also noted that 40% of IB claimants have mental health problems and that the Government wants to reduce the total number of people on IB by 1 million. The biggest change in the Green Paper is the abolition of the existing IB system which is being replaced by the new Employment and Support Allowance, work-focused interviews will be introduced for claimants across the country  as Pathways to Work is extended and the age and dependents additions will be abolished. Many people struggle to make ends meet under the current system and it remains to be seen whether claimants will really be any better off under the new proposals.

Pathways has been a largely successful pilot with a package of support and condition management. The personal advisors who worked on Pathways enjoyed working intensively with claimants and found the work more rewarding than their usual Job Centre Plus work. Citizens Advice are concerned whether Job Centre Plus will be able to deliver this service nationally though especially for people with mental health problems who may need extra support. The Government has committed £360m to this but the IPPR has predicted that the true cost could be nearer £500m if Pathways are rolled out fully. Existing problems at Job Centre Plus concerning unsatisfactory systems and job losses do not bode well for the future.

An element of compulsion has been proposed in the Green Paper to force claimants to attend work focused interviewed and subscribe to action plans or face sanctions. This could have a very negative impact on people with mental health problems. The voluntary and private sectors will become involved in delivering services but voluntary organisations would have no appetite for getting involved in penalising claimants.

Ms Pearlman suggested that improvements in occupational health and the system for statutory sick pay would be more helpful as well as changes to the Personal Capability Assessment (PCA) to better identify claimants’ needs. A high proportion of IB claims which go to appeal are over-turned showing that the current system is not working properly in the first place.

In summary Citizens Advice welcome reform but oppose the introduction of sanctions and compulsion. They are pessimistic about the implementation of Pathways and are concerned that junior Job Centre Plus staff will pressure people into taking unsuitable jobs to meet targets.

What the Doctor Ordered is available online at: http://www.citizensadvice.org.uk/what_the_doctor_ordered_(medical_assessments)_feb_06.pdf

Alan Barton, Citizens Advice

Mr Barton elaborated on the What the Doctor Ordered report saying that it was based on the experiences of CAB clients. The report looks beyond the Green Paper to consider other disability benefits also. He reported that too many bad decisions were being made by clinicians and as over four million people are on disability benefits, many people are affected by this. Many people lose the benefit because they don’t pass the PCA including a lot of people with mental health problems and learning disabilities. These bad decisions add to people’s stress and financial hardship.

The appeal process is extremely stressful and many people are put off pursuing an appeal because of this. There is a six to nine month delay before the appeal is heard and during this time the claimant will be on no or reduced benefits, and though benefits can be backdated if the appeal is successful, the financial damage may be severe. One client lived on £45 per week for two years.

Citizens Advice’s recommendations include that disability benefits should be reviewed in consultation with stakeholders. They would also like to see the reform of the mental health component of the PCA including the forms which claimants complete. Doctors can be rushed or inattentive during the medical assessment and Citizens Advice would like to see better administration of this system to make it less formulaic and more sensitive to individual circumstances for example not penalising people when they miss a medical. Claimants should also be given advance warning before a benefit is stopped or reduced.

Mr Barton also noted that given the high proportion of people with mental health problems facing difficulties with benefits, this should be a real focus for Government attention. He recommended that the Government appoint a mental health champion to the DWP to work on this.

Dr Jed Boardman, Royal College of Psychiatrists

Dr Boardman said that his key concern was that the Green Paper should create a fair system with a level playing field for those with mental and physical disabilities, which does not discriminate against those with mental health problems.

PCA – the Citizens Advice report presents a clear picture of the problems with the current system and how claimants with mental health problems fare particularly badly. The system is archaic and presents an old fashioned view of disabled people and their needs. Many people in the medical system have been complicit in this poor system. There needs to be a clear and well timed and executed process, delivered by well trained and competent people. The review needs to look at content, circumstances and timing of the PCA.  The review of the PCA interview and ratings could learn from the literature on research interviews which may help the reliability of the process and the quality of the interview.

Conditionality – Dr Boardman welcomed the Green Paper’s focus on work and the many benefits work can bring to people’s lives. However he noted that moving people off benefits into work can be a long process and the emphasis should be participative and on providing people with opportunities and hope rather than on compulsion which may be detrimental and counterproductive. Claimants with mental health problems are a diverse group with a variety of needs and have many additional disadvantages.  He presented three arguments against conditionality:

• Moving people onto a lower level of benefits because they fail to achieve a target is wrong in principle,
• There could be a negative effect on claimants with mental health problems causing them distress and to take up unsuitable jobs which they subsequently loose.
• There is no evidence that compulsion works.  But the levels of conditionality used in the pathways to work pilots are sufficient to get people moving and at the same time are perceived as supportive.

He said that we have more to learn from the literature on therapy, motivation and engagement than from the world of compulsion.

Long-term benefits – Dr Boardman said he was concerned about the proposal to introduce two levels of benefit which would see some claimants written off as unemployable and they will face the same, or greater, disincentives as current IB claimants. He said that in the right circumstances, with the right support, that virtually everyone who wants to work is employable.  The goal for people with mental health problems should not be just open employment, but work and meaningful occupation should be considered as of importance.  He stressed that there was insufficient emphasis placed on rehabilitation in mental health services in the UK and that vocational rehabilitation schemes were poor and patchily distributed.  There needs to be give a spectrum of opportunity and work orientated schemes, more research should be commissioned into evaluating work schemes and heath service staff should understand the value of occupation.  Employers also need to place more emphasis on employing disabled people and could have conditionality imposed on them.

He finished by saying that firm policy initiatives are required to aid the process of inclusion of people with disabilities and mental health problems into mainstream aspects of society and with the rights and respect given to others.

Q&A

Lynne Jones MP introduced Dr Moira Henderson (Principal Medical Advisor) and Alan Davidson (Policy) from the Department for Work and Pensions who joined the discussion. She noted that at the MHAPPG’s benefits seminar in 2003, the Social Exclusion Unit and DWP had agreed that a different approach was needed towards claimants with mental health problems and that staff in Job Centres needed to be better trained and motivated and it was a shame that these changes were taking so long.

Tim Boswell MP said he was not opposed to the concept of the Green Paper but was concerned about the assessment process, particularly for those who have two disabilities also those with fluctuating conditions. He also expressed concern about sanctions and whether the resources will be in place to support people adequately. He noted that the New Deal for Lone Parents did use work-focused interviews and that there can be helpful.

Baroness Murphy thanked the speakers and noted that medical assessors needed a much better training in mental health issues. A Mind survey showed that around one third of employers wouldn’t consider someone with mental health problems for a job.

Dr Moira Henderson said that she had found the presentations very interesting and hoped that the Green Paper consultation would be an opportunity for mental health groups and professionals to engage in dialogue with the DWP. She noted that it is recognised that a culture change is needed in the welfare system and that this will be difficult.

Philip Dixon-Phillips stated that the Green Paper says that GPs will assess a person for the PCA but that it might be better if the person was assessed by their therapist or psychiatrist as the claimant would be less intimidated and concerned about giving personal information about themselves to a stranger. Also there should be more sensitivity about the timing of assessments in case the individual cannot attend in the mornings due to irregular sleeping patterns. He also suggested that other forms of communication are used to target employers with information such as the internet. At the Starfish project he had been involved at looking at the process and it is hard to juggle the forms involved and people need a lot of support.

In response to a question from Lynne Jones about job losses at Job Centre, Dr Henderson said that Job Centre staff need to refocus on what matters and that efficiency savings should free up their time to do this. The current process for appealing must be improved to speed it up and make it more effective.

Tony Haynes said that the problems associated with the welfare system have gone on for a long time and that more needed to be done than simply changing the culture in Job Centres.

Jane Harris noted that some efficiency savings such as phone and web based services have alienated groups such as those with schizophrenia who may be unable to use the phone. Dr Henderson promised to take this issue back to the DWP. Ms Pearlman added that people who are in hospital also have problems accessing the phone or internet and paper forms are hard to obtain.

In response to a question from Sue Christoforou, Dr Henderson said that the review of the PCA should be completed by September and that a panel of experts had been established. She would check whether Dr Boardman had been invited to sit on the panel. External groups will also be consulted.

Sheree Parfoot noted that there is a difficult period between benefits stopping and the first pay cheque in work which puts financial pressure on the claimant.

Lynne Jones summed up by saying that Pathways should be applauded and she hopes it won’t be watered down when it is rolled out. She felt that compulsion was not necessary but if it was included in the final proposals it should be executed sensitively. She noted that targets for staff in Job Centres could be a useful motivator but they must be properly trained. Lynne Jones thanked the speakers for their presentations and said that a note of the meeting would be sent to John Hutton.

Members:

Lynne Jones MP

Baroness Murphy

Lord Mayhew

Earl Howe

Tim Boswell MP

Laura Moffatt MP

Baroness Wilkins

Lord Carter

Observers:

Sue Christoforou – Mind

David Stone – Mind

Aileen McWey - Mind

Jane Harris – Rethink

Andy Bell – SCMH

Philip Dixon-Phillips – Social Exclusion Reference Group

Tony Heyes – UK Federation of Smaller Mental Health Agencies

Caroline Hawkings – Turning Point

Sue Silk – Janssen-Cilag Ltd

Sheree Parfoot – CAPITAL

John Wheatley – Citizens Advice

Kim Maynard – Citizens Advice

Eric Lynch – Sanofi-Aventis

Caroline Hawkings – Turning Point

Agnes Wheatcroft – Royal College of Psychiatrists

Dr Ian Hall – Royal College of Psychiatrists

Mental Health

All Party Parliamentary Group on Mental Health

Joint Chairs: Dr Lynne Jones MP, Rt Hon Virginia Bottomley MP, Sandra Gidley MP

Secretary: Lord Alderdice

ANNUAL REPORT: 2004

Mental health services faced another mixed year in 2004. In February the service reached a new low with the publication of the Rocky Bennett Inquiry Report, which highlighted institutional racism and bad practice in the health service. The lessons of this tragedy must but be forgotten. The Social Exclusion Unit published its Report on Mental Health in June and its recommendations are now being implemented. In June, Maca (the Mental After Care Association) celebrated its 125th anniversary, it is the oldest mental health charity in the UK and the Group hopes that it will continuing working as long as its services are needed. In September the Department of Health published the long-awaited Revised Draft Mental Health Bill. Parliament has established a Joint Committee to scrutinise the legislation and the Group welcomes this move.

March

At the first meeting of the year, the Group discussed Therapeutic Communities and possible treatments for Personality Disorder. Dr Kingsley Norton (Consultant and Director of Henderson Hospital) and Dr Rex Haigh (Chair Association of Therapeutic Communities) presented their findings. Dr Norton outlined the difficulties surrounding the diagnosis of personality disorder, particularly the stigma attached to it, including prejudice held by the medical profession. The diagnosis is also sometimes used to exclude people from receiving treatment.

Dr Haigh addressed the issue of whether PD can be treated, explaining that therapeutic communities have been treating PD since the Second World War when group therapy experiments began with soldiers. There is evidence that these communities provide a very effective treatment as well as being cost-effective. Research is currently being collated for future publication. The Royal College of Psychiatrists’ Research Unit hosts the Community of Communities project which aims to improve the regulation of therapeutic communities and share best practice.

April

In April the Group asked ‘Are Mental Health Services Improving?’ Professor Louis Appleby, National Director for Mental Health, outlined the achievements of NHS mental health provision since the National Service Framework (1999). He talked through the expenditure on mental health services and the indicators, showing that the investment is having some success. He also presented detailed statistics on the number of beds, admissions, discharges, consultants, nurses, NHS plan teams, prescribing patterns of anti-psychotic drugs, and mortality rates.

Dr Andrew McCulloch, Chief Executive of the Mental Health Foundation, focused on the premise that mental health provision is primarily about protecting human rights. He criticised the Government for not listening to the sector and noted that the draft Mental Health Bill has united the sector in opposition. He commented that the draft bill is wrong in both principle and practice. Dr David Taylor, Chief Pharmacist at the Maudsley Hospital detailed the NHS expenditure on services for schizophrenia and the response to treatment, which have shown a 40% improvement. He detailed the potential adverse effects of antipsychotic drugs and noted that in atypical anti-psychotics, the level of adverse effects was markedly improved. Dr Jacqueline Atkinson from Glasgow University reported on the progress made in Scotland since the creation of their new Mental Health Act.  She stated that it has been a year since the Mental Health (Care and Treatment) (Scotland) Act received Royal Assent, despite the fact that the whole process starting after the reform south of the border.

June

In June the Group joined forces with the Drugs Misuse All Party Group to discuss whether enough is being done for people with complex needs. Lord Victor Adebowale, Chief Executive of Turning Point said that his organisation provides substance misuse services and also provides services for people with mental health problems and learning disability. Many of their clients have complex needs. Many of the people who Turning Point work with are homeless and many are from BME backgrounds. Using the term ‘dual-diagnosis’ can be helpful as a medical diagnosis of concurrent problems but it may also cause people to be excluded from services, which fail to provide joined-up care.

Eloise Cooper, Complex Needs Service Co-ordinator and Cognitive Behavioural Therapist, at Turning Point’s Drug link Hammersmith and Fulham spoke about the people she works with, many of whom have severe and enduring mental health problems, complicated by substance misuse, physical and/or learning disabilities. These people were very affected by stigma and exclusion and many faced exploitation by drug dealers. Liz Garrod, Director of the London and East of England Regional Office of Maca spoke about their work, which offers a range of services incorporating people with dial diagnosis and complex needs. Maca provides residential services, personal development and forensic workers in probation services.

October

The Group held the first of a series of meetings on the Revised Draft Mental Health Bill by looking at Workforce Issues with a talk by Dr Mike Shooter, President of the Royal College of Psychiatrists.

Dr Shooter began by explaining that there are workforce shortages across mental health including psychiatrists, psychologists, CPNs and social workers. He noted that the stigma which is attached to mental illness also affects the workforce and people are often put off entering psychiatry because of prejudice within medicine. The College is working with the Department of Health and other bodies to address the recruitment and retention problems as well as training issues. There is also a NIMHE strategy to develop new ways of working for senior psychiatric personnel.

On the Revised Draft Mental Health Bill, Dr Shooter noted that the proposals were likely to lead to a huge increase in workload due to the extension of the use of compulsion. The Bill, as it stands, would also be detrimental to the relationship between psychiatrists and service users as more people would fear compulsion and be scared to give their psychiatrist the full details of their illness.

November & Annual General Meeting

The Group held its AGM on 9^th November followed by a discussion on the Revised Draft Mental Health Bill which contributions from Rosie Winterton, Minister of State, Professor Louis Appleby, National Director for Mental Health and Paul Farmer, Chair of the Mental Health Alliance. This was the best attended meeting of the year and a provided a good opportunity for Group members to find out more about the proposed legislation. The Group’s officers were re-elected for another year.

1. The Group welcomes the establishment of the Joint Committee on the Draft Mental Health Bill and hopes that its report will provide a balanced perspective on this controversial piece of legislation. The Group will invite the Chair of the Joint Committee to present the findings of his report to the Group.

2.       The Group is worried that mental health services are currently understaffed and that the proposals in the Revised Draft Mental Health Bill will further exacerbate this problem.

3. The Group is very concerned about the lack of provision for people with dual-diagnosis. These people with complex needs are often neglected by services, which are too rigidly divided into one area of care or another.

4.       The publication of the Rocky Bennett Inquiry Report presented a shocking picture of institutional racism in the NHS. The Group hopes that the Inquiry’s recommendations will be implemented swiftly and effectively.

5.       The Social Exclusion Unit published its Report on Mental Health and Social Exclusion in June. The Group warmly welcomed this Report and it is hoped that it will be implemented across government departments.

Details of future meetings will be circulated later this year. Topics are likely to include further meetings on the Revised Draft Mental Health Bill including particular aspects such as advocacy; a presentation of the findings of the Joint Committee on the Draft Mental Health Bill; a meeting on mental health and cannabis and the findings of the Health Select Committee Inquiry into the Pharmaceutical Industry.

The All Party Parliamentary Group on Mental Health aims to enable Members of both Houses of Parliament and other interested groups to become better informed about mental health issues. The Royal College of Psychiatrists provides the secretarial support for the All Party Group. If you would like further details please contact:

Agnes Wheatcroft, Parliamentary and Policy Officer, The Royal College of Psychiatrists

17 Belgrave Square, London SW1X 8PG

Tel: 020 7235 2351 x149

Email:  awheatcroft@rcpsych.ac.uk