COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health & Social Care Reform (Mental Health Commission)
3 July 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mrs Carmel Hanna
Mr John McCallister
Ms Sue Ramsey
Mr Paul McBrearty )
Dr Brian Fleming ) Mental Health Commission
Mr Noel McKenna )
Ms Clare Quigley )
The Chairperson (Mrs I Robinson):
I welcome Mr Paul McBrearty, chief executive, Mr Noel McKenna, chairperson, Ms Clare Quigley, social-work member, and Dr Brian Fleming, consultant psychiatrist and medical member, from the Mental Health Commission. I apologise that the Committee had to deal with other business before the evidence session could begin. I invite you to make a brief presentation, after which members will ask questions. When you have finished your presentation, I will allow up to one hour for the question-and-answer session. You are very welcome.
Mr Noel McKenna (Mental Health Commission):
As chairperson of the Mental Health Commission, I thank the Committee for receiving us. Paul McBrearty will deliver the substantive presentation. I want simply to record our thanks to the Committee before he starts. Clare, Brian and I — and, indeed, Paul — will answer any questions that arise from the presentation.
Mr Paul McBrearty (Mental Health Commission):
Thank you, Madam Chairperson. I understand that members have possession of our briefing paper. We will deal substantially with most of its points.
The Mental Health Commission is an independent, non-departmental public body — probably the smallest in Northern Ireland. Our budget is in the region of £600,000. We are comprised of a chairman and 16 sessional commissioners, who carry out a range of activities. Although those activities have been listed in our briefing paper, it is important that I highlight what they are and what they mean for the commission.
Commission members are drawn from a range of professions: psychiatrists, psychologists, nurses, social workers and other individuals — lay members — who bring their expertise to our work. We create teams that are required to visit any individual who is detained in hospital under the Mental Health (Northern Ireland) Order 1986. We also visit any individual who has a mental-health problem and is being treated under the legislation. That leads us to people who have difficulties that are associated with learning disability. Multi-disciplinary teams visit individuals in hospital and community facilities to check on the services that are being provided and, specifically, to meet and talk to those people and their relatives about their experiences while they are receiving treatment from health and personal social services.
That is a very important starting point because that means that we focus on the individual. We do not focus on the generalities of the service, but how the service has been delivered to specific individuals, how they are dealing with it and the sorts of issues that emerge. Within the statutory requirements, we can bring to the Department, the health trusts and any other body — this Committee included — any important issues that have arisen from the findings of our visits and discussions with those individuals. For example, we have expressed concern to the Minister in the past about under-18s being admitted to adult wards in mental-health facilities, and we are tracking progress on that regularly. We also have issues about the unavailability of acute psychiatric admission beds. Again, the commission has raised that issue in the past.
If we feel that it is necessary, we can refer a particular case to the Mental Health Review Tribunal so that it can review it with regard to, for example, issues of detention or guardianship. Very specifically, the commission has the power to gain access to any facilities, and, if required, it can medically examine an individual in private, whether it be in a hospital or a community facility. We have access to their medical notes to assure ourselves that the treatment that they are receiving is appropriate to their illness and that it is required. Last week, two of our commissioners travelled to Enniskillen to visit a learning-disabled individual in his own home to check that the guardianship was appropriate to his circumstances, as an issue had been raised with the commission about whether it was appropriate. We had to assure ourselves that that arrangement was appropriate for this individual. Again, I must emphasis that we focus on the individual, not on general services, although those general services are important to us.
The commission will appoint doctors who, at the end of the Mental Health (Northern Ireland) Order 1986 assessment process, can detain an individual — that is the "part II" appointment, as we call it. We also appoint doctors under part IV of the Order, which enables a doctor to get a second opinion if a patient has to undergo, for example, electroconvulsive therapy (ECT).
We review all legal documentation in relation to any formal detention, which is a very important function. The removal of anyone’s liberty is an extremely serious issue. The commission has to ensure that trusts that apply the legislation do so correctly. Not only do we check that the legislation is being applied appropriately, but we consider whether the clinical reasons for the detention are appropriate. That is an important function of the commission.
If an individual has been detained for more than three months, we are required to see the drug-treatment plan for that individual, and I know that the Committee is interested in drug-treatment regimes. Our medical panel, which is made up of the medical members of the commission, will review each and every drug-treatment plan for that individual and assure itself that the treatment plan is appropriate to the patient’s needs. We will obviously appoint individuals to give second opinions.
On 23 June, the Minister announced that, as part of the Health and Social Care (Reform) Bill, he intended to transfer the Mental Health Order functions from the commission to the Regulation and Quality Improvement Authority (RQIA). The commission welcomed the opportunity to make its views on that proposal known in the consultation process. In essence, the commission believes that it should be retained and its members made a submission to the Minister to indicate why it believes that that should happen. The commission felt that the fact that it is an independent body is important — that is especially important for those who access mental-health and learning-disability services. As we are a stand-alone body that is separate from the health and social services bodies, we are able to question the care and treatment that is being provided. We have indicated that we believe that that facility will be lost with the transfer of functions to RQIA because those functions will be only a small part of that overall body’s work. We are concerned about that, and I will address that issue in more detail shortly.
People with learning disabilities and mental-health needs are vulnerable and require an element of independence. As I said, we focus on the individual. The body that will take responsibility for that field is, in the main, focused on measurable standards, such as the regulation of various organisations and quality improvement. Although that is an important issue, the focus is different from that of the commission — we focus on the individual, rather than the wider body.
As I said, the commission is made up of professionals and lay members, which has been very important. The lay members challenge the professionals, and many have experience as either a service user or a carer for someone with mental-health requirements or a learning disability. That challenge is an important element of the discussion in the commission and is important to the way in which we carry out our visits. We are concerned that that level of service and client-user involvement would be lost if the commissions functions were transferred.
In recognition of the Minister’s indication that there will be a transfer of functions, the commission considered how to respond. We said that if our functions transfer to the RQIA, we would prefer a stand-alone unit in the RQIA to maintain the pseudo independence of the commission and to ensure that the mental-health and learning-disability element of the Mental Health Order is visible to anyone who wants to access our services. Part of our argument against the transfer is that the title "RQIA" does not reflect any aspect of the Mental Health (Northern Ireland) Order 1986. In contrast, the title "Mental Health Commission" conveys a clear message — if someone is unsure about who to contact for help, he or she will find the Mental Health Commission in the phone book or on the Internet and, if we cannot help that person, we will send him or her to the correct organisation. That is an important element that should not be lost if there is a transfer of functions. We are not sure whether a stand-alone unit can be established under the RQIA’s constitution, but we want it to be considered.
The functions of the commission include visiting patients and scrutinising legal documentation. Another important element of our work is the examination of serious incidents by the commission’s multi-disciplinary teams — those teams that are notified of any serious incidents that happen to people involved with mental-health services. Such incidents include suicide, other serious self-harm and violent incidents in hospitals or in the community, such as abuse from staff — which, sadly, sometimes happens — or abuse from another patient. The commission is notified of all serious incidents and intensely scrutinises the issues that arise from them. We talk to the trusts about their responses after their investigations and refer any issues that arise to our visiting panel so that, when they visit the facilities in question, they can ask what has been done to address the problems. We document the issues that are raised and how they are addressed.
Lay involvement is not as significant in RQIA’s format as it should be. Also, some of the professional representation for the Mental Health Order is not what it should be. Those are issues of concern, and we raise them as such with the Committee.
The commission made several recommendations to the Minister in the event of the functions being transferred, which is why we have come to give evidence to the Committee. Certain actions will reassure the commission about the future delivery of the Mental Health Order functions and that the interests of the vulnerable groups that I have mentioned — those who have a mental illness or a learning disability — will be protected.
Therefore, we made a number of suggestions. Firstly, the commission has a small budget, which it believes should be given to RQIA in its entirety. Given that that funding is a small proportion of the overall budget of RQIA, the commission feels that it should be protected for a period of years, enabling the functions to become embedded in the organisation. If efficiencies are produced as a result of economies of scale, the commission wants those additional moneys reinvested in the operations of the Order. That would allow the development of, for example, links with user-care organisations, enabling RQIA to become more familiar with the general public. The commission wants the Committee to be particularly aware of that issue.
The commission has suggested that the RQIA organisation should have full-time staff. That departs from the commission’s current practice of part-time sessional commissioners, but there was always an aspiration to bring in full-time professionals at some point. The commission believes that that approach is essential in delivering the function and in ensuring that it is delivered in a proper manner.
I have already referenced the name and logo of the RQIA. However, the commission would again ask that consideration is given to the inclusion of a reference to the Mental Health Order somewhere within that name or logo. It is not about the commission, but the Order, and it is important that it is reflected in some way so that users of the service and carers can find their way to that particular service.
The commission also suggests that the board of the RQIA should reflect the functions that it delivers, particularly in relation to the Mental Health (Northern Ireland) Order 1986. The commission may be being a little cheeky in that respect, but we have raised and discussed that with RQIA, and I know that it is giving it due consideration. It is fundamental that whoever is involved in the strategic direction-setting of the organisation running the Mental Health Order, has knowledge of the Order, mental-health and disability services. Furthermore, the commission feels that there should be someone with that knowledge at a very senior level in the new organisation. The commission has suggested appointing a new deputy or vice-chairperson, but that would be very aspirational in relation to what it wants to see.
As referenced at point 4·7, the commission is working with RQIA on a model of delivery. If a clearly identifiable and visual stand-alone unit cannot be created, the commission will work closely with RQIA between now and March 2009 to develop that model. That will satisfy the commission that delivery through RQIA will be appropriate to our beliefs and ethos, with respect to focusing on the individual. It is fundamental that a clear model of delivery is determined prior to the transfer.
It is also important that service users and the client groups are made fully aware of RQIA. The commission feels that that is important and that it should be actioned through the external-relations function. Preferably, there should be user or carer representation at a significant level within the RQIA organisation to represent mental-health and any disability functions.
Thank you, Paul, for that interesting presentation. I would also like to congratulate you all for the sterling work that you have done up to now. I hope that the Minister will listen to those calls for the commission to have representation on RQIA, so that that sterling work does not get lost in the ether.
I am a great believer that if something is working, it should remain the way that it is. In my opinion, the commission does not need fixed or changed.
Has the commission had direct meetings with the Minister about RQIA and is the Minister sympathetic to the commission? Furthermore, what can the Committee do to influence the Minister in the right direction?
Finally, how many people in Northern Ireland are held under the Mental Health Order?
I will answer some of those questions, and, perhaps, Paul will provide the statistical information. The commission did not have a personal, direct engagement with the Minister, but during a consultation meeting in a local hotel, I, along with Paul and some other colleagues, did have an opportunity to make a verbal representation to him, which we followed up with a substantive letter. He was well-disposed to listening to what we had to say. He told us that the purpose of transferring the functions of the commission to RQIA was to strengthen the work that will be done on mental-health and learning-disability services. If that materialises, I would be truly delighted.
I accept that there were deficiencies in the commission. Given its size, being a small organisation, the commission is vulnerable when it loses one or two key members of staff. There are certain benefits in economies of scale and a larger resource. If money was not a major factor, I could prescribe exactly what is needed for an independent commission. However, we live in the real world and acknowledge that money is a factor. We in the commission would be very concerned if the budget allocation for mental-health and learning-disability services was cut, and there were moves to economise, because those affected by such issues are a vulnerable section of the community.
I have a son with Asperger’s syndrome, and, when I meet psychiatrists and mental-health professionals, they tell me that they do not have the resources to do much for him. I will stay at the Committee meeting after this session to hear Lord Maginnis’s presentation on autism.
The commission would love to continue to carry out its functions, but we are not reactionary; if the democratic decision is to transfer those functions to RQIA, we are merely keen to ensure that the baby is not thrown out with the bath water. The challenge is there for RQIA, and we will do our level best to ensure that, when the functions of the commission are transferred, RQIA will deliver those functions in a competent and, indeed, an enhanced manner. We are confident that that will be the case
Had the commission remained in being, there were plans to appoint two or three full-time commissioners; to create a more expansive role for users and carers; to establish strong external communication links; and to provide some mental-health education. Hopefully, those things can still be done when RQIA assumes control of the functions. I was reassured when you told me on Monday, Madam Chairperson, that, as a watchdog body, the Committee will be monitoring very closely what happens when the functions transfer.
We accept that the decision has been made, but welcome the fact that the Committee will be monitoring the transfer of functions very closely. If the Committee can use its good offices to influence the Minister and the Department, perhaps some of the recommendations that have been suggested — which I think are valid recommendations — can be implemented under the governance of RQIA. The transfer of functions is going to happen, whether I like it or not — we are democrats, and accept the decision of the Government. All we are keen to do — and this is our bottom line — is to ensure that a good service is provided to our stakeholders; primarily, users and carers.
Thank you. Will you provide statistics on the number of people who have been sectioned under the Mental Health Order?
Dr Brian Fleming (Mental Health Commission):
On average, around 1,500 people per annum are compulsorily admitted to hospital by their general practitioners, and usually an approved social worker or member of the family. That period of admission is for, in the first instance, a week, then two weeks, and, thereafter, they may be detained for treatment for up to six months. Of the 1,500 people admitted per year, just over half of those remain detained for treatment. In others words, half are regraded as voluntary admissions or they are discharged from hospital before they require that detention.
Ms Clare Quigley (Mental Health Commission):
To clarify, the role of the Mental Health Commission is also to monitor the care and treatment of the great number of voluntary patients in hospitals, in the community and with learning disabilities. Primarily, the voluntary patients with whom we deal have mental-health problems, but others may have learning disabilities.
Clare made an important point to which I want to add. As more and more vulnerable people with learning disabilities or mental-health problems are being decanted out of hospitals and into the community, they will need a watchdog body to represent and speak up for them. At least when those patients were in hospital they were sure of a visit from the commission, when it was in existence. My son lives in the community, so I am involved in the care movement. Community groups, with which I am in contact, are crying out for a watchdog body to represent them.
I want the programme for mental-health and learning-disability services to offer more user and care representation, which can deliver improvements to the service
Thank you for your input.
Thank you, Chairperson. Good afternoon. Thank you for your presentation; it was very good. I do not have a specific question, but I understand where you are coming from.
I share your concerns about the role of an independent watchdog following the transfer. It is important that an additional mental-health role is clearly defined; at times, it is inclined to be an add-on. The presence of user groups is essential. As the Chairperson said, we will continue to monitor what happens following the transfer, because it is vital that there continues to be a specific role for the inclusion of your recommendations.
In future, there may be an opportunity for that when the new mental-health legislation is considered. It may be that, in the course of your monitoring, you are not satisfied with the level of specific individual attention that can be paid to mental-health issues within the transferred functions. You may want to look for a body under the proposed future legislation. That is worth keeping in mind, because we, as a commission, will not be around to make that plea.
We are keen that the good work undertaken by the commission is not lost or swallowed up in RQIA and forgotten about. Will you develop your point about the external-relations function; do you see some of that feeding into this Committee? How is that function being progressed? Is it effective? Where must we direct our focus to ensure that that continues to work?
Everyone in the room agrees that we must do more for the groups that you identified and with which you have been working. They are some of the most vulnerable people in society, so we want to be rock solid that we do everything that we can. Will the external-relations function help to build on that by not only promoting your work in the community, but by assisting all elected office bearers to communicate any problems arising from your duties back to the Committee and Assembly?
It is fair to say that the commission expects a much broader discussion to take place with a wide range of groups about the operation of the Mental Health (Northern Ireland) Order 1986.
The commission has a limited life-span. We have only nine months left in which to work closely with RQIA on those issues. I hope that two developments take place before 1 April 2009.
First, the Committee will be keeping a close watching brief on the application of the Mental Health (Northern Ireland) Order 1986. However, RQIA, with its own statutory responsibilities, will be in a position to address the Committee or make reports to it, through whatever mechanisms are in place.
Secondly, we want RQIA to become actively involved with voluntary organisations and other user and care organisations. Without fear of contradiction, I can state that we have a good relationship with RQIA. We work very closely with it in order to develop everything that we have flagged up.
We cannot make RQIA do what we want, but we can try to influence its approach — in the same manner that, through talking with members, we hope that the Committee will seek to exert its influence to secure reassurance on issues that it regards as important.
RQIA seeks to develop external communications and to actively involve users and carers as part of a total remit, not just in regard to areas such as mental health and learning disability. RQIA must address the Committee about its plans on those issues. However, I would be remiss if failed to state that we are working closely with RQIA in order to share what we do and how we do it.
RQIA may have a better way of doing things — we will be happy if that is the case — but we have told it to heed our concerns. We would like to walk away on 31 March 2009, content that we had shared all our functional knowledge, and that RQIA had satisfactory plans in place for delivering services. However, we will not know whether that is the case, because we will no longer exist. RQIA’s preparedness might not be formally assessed until a year later.
In light of the relationship that has grown up, are you hoping for as seamless a transfer of functions as possible from RQIA?
Absolutely, we are anxious to ensure that a good, smooth transfer takes place. That is our responsibility and that is what we are charged to do. We have a good working relationship. We do not agree on everything, but dialogue is about negotiating.
We are here to make representations to the Committee, Madam Chairperson, because we will be gone in fewer than nine months, whereas the Committee will still have influence and be able to continue to monitor developments.
On Monday, I was reassured by your undertaking, in a personal capacity, to meet with us again formally or — time permitting — informally, if we have concerns that things are not progressing as well as we would like them to. I am confident that progress will be made.
Madam Chairperson, the Committee’s support, if it were possible, would be a confidence boost that we could convey to the Department, with which we share a steering group. We are also represented on a project group with RQIA. Committee support will add weight to our recommendations and ensure that both groups pay serious attention to your views.
Finally — and our psychiatrist, Brian, is very keen on this issue: we must have a separate annual report on mental health and learning disabilities.
RQIA must have some form of mechanism to convey to the population of Northern Ireland exactly what is happening in the fields of mental health and learning disability. The incidence of mental-health illness is increasing, instead of decreasing. We must take every step that is possible to reassure our population that the Government are doing everything that they can through both good health education and services. The Bamford Review has been endorsed, and the Government’s response to it, which looks positive, is available.
I am grateful that the Committee has listened to us today. With its support, the minds of senior civil servants and the RQIA will be more concentrated, and they may take the view that the recommendations have a lot of validity. Although they may not necessarily agree with everything that has been said, they will try to thrash out the recommendations and see whether some consensus can be reached.
I commend the work that the commission has carried out already. I share its concerns about the transfer and hope that, during the transfer, none of that good work will be lost. We must keep a close eye on matters and scrutinise events. We do not want mental-health services to take a step backwards; we want to keep it moving forward.
I am disappointed that the Minister refused to meet with the commission during the consultation period. He should have met with it and listened to the concerns that you are now expressing to the Committee. The Minister will want to streamline services to provide a more efficient, effective service. I note that in your presentation, you said that the commission is already providing such a service.
What financial savings does the commission envisage the transfer will make, while maintaining the current level of service and building on it? We cannot stand still; we must build on the services that are provided already. If the services are being streamlined to make them more efficient financially, what will the savings be?
The question of how the RQIA was dealing with the situation was put to it in discussion with the commission a year ago. At that time, the RQIA — perhaps not having an understanding of the full remit of the functions being transferred to it — indicated that there could be savings of about £250,000 to £300,000 from the commission’s existing budget. That is a considerable sum. However, that took into account the fact that the commission has a secretariat, a building and offices that represent expenditure that would be subsumed in a much larger organisation. At that time, and as the RQIA was considering addressing the transfer of functions, that was probably a reasonable place to be initially. However, following from our more detailed discussions about what will be required, the RQIA has shifted considerably from that position. Although I am not in a position to give an exact figure, I think that the potential cash saving that would come about from a transfer of functions would be less than £100,000.
I reassure the commission that, following today’s meeting, the Committee will be making general comments to the Minister. I also reassure you that we will be scrutinising any legislation on the matter at Committee Stage, and we will ensure that the points on which you have major concerns are addressed in that legislation. However, if, before decisions are made, there is disparity between that and what the Committee sees as the continuation of effective good mental-health services, it will be mindful to ask the commission to come back and highlight those issues.
We thank you for coming before the Committee and making your presentation. I endorse what you said. It is important that we hear the voice of the user and the carer in any set-up; they represent the coalface. It is also important that that mechanism for representation is afforded to the carer or the user. It has been an interesting session; thank you very much.
On behalf of my accompanying colleagues from the Mental Health Commission — and, indeed, all commission staff and members — I thank the Chairperson and Committee members for receiving us today.