NORTHERN IRELAND ASSEMBLY

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT

(Hansard)

The Bamford Review of Mental Health and Learning Disability (Northern Ireland)

Thursday 24 May 2007

Members present for all or part of the proceedings:
The Acting Chairperson (Rev Dr Robert Coulter)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Carál Ní Chuilín

Witnesses:
Professor Roy McClelland (Chairperson, Bamford Review of Mental Health and Learning Disability [ Northern Ireland])
Professor Roy McConkey (Professor of Learning Disability, University of Ulster)
Mrs Marie Crossin (Chief Executive, Carers and Users Support Enterprise [CAUSE])

The Acting Chairperson (Rev Dr Robert Coulter):
Thank you for coming to today’s meeting. The first item of business is a briefing from Professor McClelland on the Bamford Review of Mental Health and Learning Disability (Northern Ireland). I refer Members to the briefing paper prepared by Research Services and to the briefing paper from the Bamford Review team.

It is my happy duty to welcome Professor Roy McClelland, Professor Roy McConkey and Mrs Marie Crossin. We are delighted to have you here today.

I invite Professor McClelland to make a short presentation of up to 15 minutes, which will be followed by questions from members.

Professor Roy McClelland (Bamford Review of Mental Health and Learning Disability [Northern Ireland]):
Thank you, Chairman. On behalf of the Bamford Review, I wish to say that we appreciate having such early access to the Committee and we wish the Committee well in the future; challenging work lies ahead for it.

As the Chairperson noted, I am flanked by Professor McConkey and Mrs Crossin. I expect that the Committee will find it more interesting if I utilise their expertise in my presentation. I will make a few introductory remarks, and we can interweave as we go along.

We have given the Committee our briefing paper, and I intend to follow the main thrust of the paper, as it provides an overview of the review’s work over the past four years. This review of mental health and learning disability has been the largest of its kind on these islands. Some Committee members have been involved with some of the review’s work, while others are probably less familiar with it. However, for the purposes of this presentation, I will take it that we are all on a level playing field, and I will try to orient the Committee on the basics of the review.

The Government asked us, as an independent group, to review policy, law and services with regard to mental health and learning disability. The review has been such a large piece of work that the Ministers of the day advised us that it would be wise to phase the work, which we duly did. Some of the early outputs of the review are about learning disability and adult mental health. The review consists of no fewer than 10 distinct reviews that interface and interdigitate. It is an enormous piece of work, and responding to such a broad review presents an enormous challenge to Government. I will deal with that issue further when I discuss prioritisation.

Two important, interacting factors emerged from the review’s evidence base in the early stages of its deliberations. The first is the high level of mental-health and learning-disability need in Northern Ireland. There may be reasons for that. We know that, in England, levels of mental-health illness follow socio-economic variables. In areas that experience high socio-economic difficulty, higher levels of mental-health morbidity are to be expected.

The other important observation is that Northern Ireland’s mental-health and learning-disability services have been chronically underfunded for many years. That lack of funding, coupled with a high level of morbidity, has created a double whammy. We can discuss the detail of that situation in our discussion, but that is our overall view.

We felt that a new vision for mental-health and learning-disability provision was needed. The recognition of the value of people with mental-health or learning-disability needs, as citizens, must be at the centre of that vision. Their needs must be met responsively by services across Government. However, that vision should also encompass the view that mental health is of concern to everyone in Northern Ireland, because there is no health without mental health. There should be a broader agenda for the promotion of mental well-being.

The 10 sets of recommendations made by the Bamford Review provide a detailed road map for reform and modernisation, which we believe will take at least 10 to 15 years to achieve. The problem with that, as I mentioned earlier, is that it is a rather daunting task. As it moved along its trajectory, therefore, the review began to form a set of priorities. As a result, we have presented a priorities report to the Department of Health, Social Services and Public Safety. That report takes a cross-section of the work of the 10 reviews and sets out what must happen in the next three to five years.

For the review to become a reality, and for much-needed reforms and modernisation to take place, it must cohere with the comprehensive spending review cycle. In effect, that cuts our work into four streams. The first stream relates to the issue of mental health in Northern Ireland as a whole. The second stream addresses the needs of people with a learning disability. The third is the need for reform and modernisation of mental-health services, and the fourth stream concerns the need for reform and modernisation of mental-health legislation.

Our priorities are contained in those streams, and they are manageable. There are implications for the way in which they are addressed, given that there are four streams, but before we explore that issue, I shall ask Mrs Crossin and Professor McConkey to comment on the relevant parts of those four tasks. Professor McConkey contributed so much to the ‘Equal Lives’ report, which is a cornerstone of the proposals for the reform and modernisation of services for people with a learning disability.

Professor McConkey (University of Ulster):
Thank you, Mr Chairman, and members of the Committee, for this opportunity to speak to you. ‘Equal Lives: Review of Policy and Services for People with a Learning Disability in Northern Ireland’, published in September 2005, specifically focused on people with a learning disability. In the past, those people were described as being “mentally handicapped” children or adults. The term “learning disability” is a more modern description.

The subject is of particular interest in Northern Ireland, because, compared to other parts of these islands, we have the highest proportion of people with a learning disability known to services. We also have a growing population, because those individuals are living longer, and children are being born with more severe disabilities than would have been possible in the past, due to improvements in medical care. We have a large and growing population of people with a learning disability. As Professor McClelland has said, that is partly due to socio-economic conditions.

Investment in services, certainly in the recent past, has not kept pace with changing needs and aspirations. Compared to Great Britain and the Republic of Ireland, our services are underfunded. There is a marked shortage of supported-living accommodation for people who can no longer live with their families, with 50% fewer places available compared to the Republic of Ireland or GB. That is because health and social services have not invested in those services to the necessary degree. Family carers have had to continue caring long beyond what can be reasonably expected. More than one third of the carers in Northern Ireland are single-parent carers aged 65 years and over. A crisis is looming: there will be an increase in the number of people who need to find alternative accommodation because they are without a family to care for them.

Moreover, the aspirations of people with a learning disability have changed remarkably in recent years. Some 20 years ago, the responsibility for children with a learning disability transferred from the then Department of Health and Social Services (DHSS) to the Department of Education. That brought about a big investment in new schools and better educational facilities. We are reaping the benefits of that now, in the sense that the young people in question are more independent, and have more employment and further-education aspirations. They are being failed, however, because our other education and employment systems have been unable to respond to that level of aspiration. The ‘Equal Lives’ report is not simply for the Department of Health, Social Services and Public Safety (DHSSPS) but for the Government, and for all the Departments of Government. It suggests ways in which the Government could really make a difference to the lives of people with a learning disability, and to their families’ lives.

The report contains practical recommendations. I have been involved with similar reviews in the Republic of Ireland and in Scotland, but what struck me about the Northern Irish review was the level of engagement and commitment that carers, and people with a learning disability, were prepared to put into the report. It is now over two years since that process began and people had the opportunity to comment. Those who were involved are now beginning to ask for the pay-off, the return and the changes that they were told were needed.

Those changes are documented in the Bamford Review. We have presented detailed plans to DHSSPS that explain how they could be implemented, and we look forward to the Committee and the Minister of Heath, Social Services and Public Safety making those changes a reality.

Professor McClelland:
We have drawn attention to the need for improvements in the area of mental health and well-being in Northern Ireland. Professor McConkey’s point that cross-departmental work is necessary is a logical one. Although mental health is an important issue for the health workforce, it is largely a matter to be dealt with by other Departments. It must also be acted on in schools and the workplace. Those with responsibility for housing must consider it, and it is also a leisure and lifestyle issue.

It may seem trite, but substantial evidence exists that good mental health is an important prerequisite to having a healthy community. Mental-health provision is an important resource, and major economic consequences will result from a failure to address mental-health problems. Tackling poor mental health is an important challenge: in Scotland, the mental-health promotion agenda was taken right to the heart of Government, who distinguished it as a separate strand of work. The Bamford Review must be protected, and it must be promoted separately.

Mental-health services must be reformed and modernised, and the Bamford Review has produced no fewer than five reports on the need for that. Those reports cover areas such as the needs of children and young people, which is a black hole of service development; adult mental health; our aging population, which includes an increased prevalence of mental-health need, including dementia; and people in the criminal justice system. In fact, the Department has this month assumed responsibility for the in-reach needs of people being treated by the Health Service in the criminal justice system.

The input of users and carers is something that has characterised the Bamford Review. Their input to the review has allowed us to speak with such a degree of authority. I am grateful that Marie Crossin has accompanied us today, not only in her role as chief executive of CAUSE, which is an important organisation for Northern Ireland’s carers, but as someone who has been with the review from the beginning. It is from that perspective that Marie will comment on the challenges that we face to modernise and reform mental-health services.

Mrs Marie Crossin (CAUSE):
Thank you for giving me the opportunity to address you today. The organisation that I work for, CAUSE, is peer led. All the staff have family members who have been diagnosed with a serious mental-health problem. My brother has been diagnosed with bipolar disorder, and he is currently in hospital. Unfortunately, I have experienced the paucity of mental-health services in our community at close hand. My brother suffered a crisis recently, even though I work in the system and have access to those at the heart of the beast. One reason that more cannot be done in such situations is that the services provided are crisis oriented; we wait until something dreadful happens and then try to put out the fire. Crisis-response and home-treatment teams are being developed. Some hospitals, however, are in a very poor state and are not fit for modern-day patients or anyone from our community. Hospitals and medication are needed, but the services must be developed to encourage and support people so that they can have the same quality of life that we would expect for ourselves and to prevent them from reaching crisis point.

Not long ago, the Eastern Health and Social Services Board carried out an audit of admissions to hospitals in its area. The statistics show a picture of social exclusion: people who are admitted to hospital with mental-health problems often live alone and have few friends, and their only relationship may be with their mental-health worker. Mental-health problems are hard on relationships. Families and carers can find themselves in deep water, and they are often unable to provide as much support as they would like. The support networks must be held together to allow them to provide that. My GP says that the services that the Health Service provides are crisis oriented. If investment is put upstream, not as much will be needed at the crisis point.

A recent statistic states that when people go into hospital, their coping capacity is reduced by one third. If people are taken out of their social environment and are admitted to hospital for six weeks or three months, they go though a readjustment period and their coping skills decline.

I participated in a carers’ reference group, which was made up of some 14 carers who were ordinary members of the public who had the experience of having a family member with a mental-health problem. We came together to give the benefit of our expertise to the Bamford Review, to comment on the work as it progressed and to contribute to the review’s committees. Those carers volunteered their time to participate in workshops on discussion papers; we started off by working nine Saturdays in a row to get up to speed, and we subsequently gave up one Saturday a month for three years. The group met the conveners of the various committees; we discussed issues and gave our points of view. We are content that we were given more access than we would normally receive to that type of endeavour.

Finally, we are aware that there are always financial pressures on the Health Service, but mental health has been a soft touch for years. When other pressures have come along it has been much too easy to remove money from mental health to relieve them. Part of the reason for that was because we, as users and carers, have not been a vociferous group; now we are beginning to find our voice, and, though we do not expect more favourable treatment than any other group, we do expect equal treatment.

Professor McClelland:
The other strand is the reform of mental-health legislation. We are proposing quite a strong reform process. We propose moving from having several different strands of legislation to having one for incapacity — an issue Northern Ireland will have to consider — and a separate one for mental health, with a single framework of legislation for subsequent decision-making. Legislation should not discriminate between different types of need; whether they concern mental health, physical health, welfare or finance should be irrelevant. Legislation should be principles-based, and people should be assumed to have the capacity to act for themselves unless there is evidence that they cannot. That is a fundamental shift and it reflects the importance of human-rights legislation and the need to be human-rights-orientated in our approach.

I want to point out that in bringing the review to its conclusion we have not created a wish list that we expect the Government, somehow or other, to fund. We have tried to address the key infrastructure issues, and one of those was illustrated perfectly by Marie Crossin’s presentation. That showed that the practical outworking of reform and modernisation requires a representative user voice and carer voice to be present at every stage of decision-making, from implementation at departmental level through to carer level when a person’s plan for care is discussed. It is a key infrastructure issue that can be addressed and will cost very little.

Another key issue is reform of the workforce. We are not suggesting more of the same, but new ways of working. This is challenging to the workforce: it is about putting a new value on the relationship between the service user and the professional carer and involves a shift of attitude and values and gaining new skills.

Northern Ireland’s mental-health service is very good at prescribing medication, but our skill base with psychological interventions is weak. That requires resources, which brings me to the last point. There is a resource aspect to the review. It is about doing things differently, but we must also address the shortfall in resources in order to make community-orientated, community-based services a reality. I will stop there because I am sure that some of those themes will be developed through the questions.

The Acting Chairperson:
I am sure that you could talk for much longer on this matter. From my experience of sharing research with you in the past, I know that you have undertaken a huge problem following the untimely death of Professor Bamford.

May I say on behalf of the Committee and its Chairperson, Mrs Robinson, whom I have not spoken to on this point but whom I know will agree, that we appreciate the amount of work that you and your team have put into this matter. We are pleased that you have come along to give us an insight into it. Please keep on with the good work.

In making recommendations, the review will have looked at best practice. How far has availability of resources been a factor in shaping the recommendations? Has there been any compromise between the ideal and what would be possible given the resources available? For example, what are your recommendations for people reaching the age of 19 when there does not seem to be much else available for them?

Professor McClelland:
The resource issue is a major challenge. The review considered the current evidence base for effective care in the mental-health and learning-disability spheres. Unlike previous attempts to devise mental-health and learning-disability policies, there is now a much stronger evidence base of what does, and does not, work. The review team also listened to the users and carers in the system. Therefore, both qualitative and quantitative evidence greatly informed our insights.

We produced proposals that seek to address what can work and make a difference. Aware that the proposals had a cost implication, the review team established a needs and resources group that costed the proposals during the review. A detailed map of those costs is summarised in the last appendix of the priorities report that was given to Government.

To bring Northern Ireland up to a par with standards in England, allowing for our increased morbidity differences and historical underfunding, a 60% increase in resourcing is required. The Sainsbury Centre for Mental Health has already outlined what is required in England in order to reach the ambitions for the national service frameworks. We are trying to achieve the same frameworks for mental health and learning disabilities in Northern Ireland. To achieve the goal by 2012, from the position in England in 1999, a 40% increase in investment has been identified. Combining that with the present analysis of what is needed for Northern Ireland to catch up with England, investment in mental health and learning disability would need to be doubled to address the priorities of the review. That is largely a workforce issue.

Mr Easton:
My questions will not take too long to answer. How much is your budget in comparison with the overall health budget? We do not have figures on that. We discussed prevention, which is a good way of trying to solve problems early on. As local GPs are usually the first port of call, will they be given any extra training to try to identify problems early on? If so, what extra community support will be put in place to help to achieve that?

Finally, I am concerned that a director of mental-health services has not been recruited and that a committee will be established instead. That extra layer of bureaucracy will only slow the process. Would it not be better to widen the pool of candidates for the position instead?

Professor McClelland:
That is quite an array of questions. In relation to prevention, we highlighted the key role that primary care, including GP services, can play. The role of GPs in the mental-health and learning-disability fields must be considered, and Roy will develop that point. The review recognises that a tiered approach is required to address modernisation and reform. Most people’s mental-health needs need to be addressed at primary-care level, which presents a major skills challenge.

The review team has made clear recommendations as to how that approach can be put into practice in adult mental health, for example. The main issues are skills training and additional resources, but the relationship between community mental-health teams is also important. Good examples are being piloted in Northern Ireland. For example, a project in Limavady has a full-time mental-health worker working in a community primary-care setting whose role includes advice, support and education. That makes a big difference to triage, prioritisation and early intervention.

Most people want their mental-health needs to be met at primary-care level. One of the major problems is that much mental-health need has not been recognised by general hospitals. For example, perinatal mental health is a big challenge; it must be supported by better screening and with better training for those who work in that area.

Roy McConkey will illustrate similar examples that exist in the learning-disability services.

Professor McConkey:
The proportion of spend is roughly 8% for mental-health services and 7% for learning-disability services. Northern Ireland is unique in that that money has to cover all health and social services. In Great Britain, a separate stream of money goes to social services.

We must also compete with the acute sector for our budget. I have sat in many meetings in which it has been agreed to top-slice money from community-care moneys in order to subvent the acute sector. Therefore, it would be useful if the Committee were to keep an eye on how much of the increased spending goes to the different health and social care areas. The direction of the spending would indicate the level of commitment to fulfilling the strategies.

Prevention is more about reducing the impact that impairment can have on a person’s life. Education and training programmes have shown us that it is possible to help people to do more for themselves, thereby reducing the amount that we need to spend on, for example, care staff. People who can do more for themselves are perhaps able to travel around by themselves. Therefore, our transport companies could do more to encourage people to become independent travellers. The further education system could do more to promote people’s learning competence.

However, the Government often introduce policies — for example, in further education — that force colleges to focus on work-related courses and on getting people into employment. That means that courses that those colleges might have taught to help with overall skill development and with lessening the impact of disabilities will no longer be funded. It is easy, therefore, for Government to create a prevention strategy in one document, while, simultaneously, making it more difficult for another Department to act on that.

The recommendations of the learning disability review for the director’s post have always caused a difficulty for us. Learning disabilities and mental-health problems are two different matters. The services to deal with both have different starting points, and although the conditions have something in common, the issues and challenges that they face are different.

The ‘Equal Lives’ report recommended the establishment of an interdepartmental board that would bring together some of the planning. The chair of that board could have been the director of mental health and learning disability, but we felt the need for a specific group to consider learning disability and another to examine mental health, because, for example, problems that carers face do not easily transfer. The Department will have to attend to that matter quickly. What is its strategy for implementing the report’s recommendations? It is chasing its tail at the moment, if I may make that off-the-record-type comment.

We have yet to see any evidence of a coherent strategy, and matters are not being helped by the incoming health and social care authority: we cannot get clarity on the distinction between its roles and those of the Department.

Ms Ní Chuilín:
First, I would like to tell Marie Crossin that I work with carers, and I feel passionately about people’s mental health and well-being. It is a breach of human rights that mental-health care has not been protected and resourced equitably in comparison with other health areas. I would like to put that on the record.

Mental health and learning difficulties must also be discussed in the context of 30 years of conflict. We must resource that area, as the Bamford Review made clear. Unless we examine and resource it seriously, we will pass on trauma from one generation on to another, as we have seen happen.

I am also concerned that we have been unable to secure a mental-health tsar or commissioner — or whatever the term is — and that that appointment will be in the gift of a committee of the new authority. As Mr Easton pointed out, that means more bureaucracy and is not a good example of how to champion mental health. There is a champion for human rights, another for equality and a third for children. We need one for mental health.

How will future work in Northern Ireland dovetail with the South’s ‘Reach Out: National Strategy for Action on Suicide Prevention 2005 – 2014’, particularly with respect to the care of children and adolescents? The situation is most worrying. Proportionately, there are more mentally ill children here than in England. The Bamford Report states that prevalence of mental illness is estimated to be 27% or 28% higher in Northern Ireland than in England. However, the resources deployed are not comparable, even though our children, and our people generally, have come through more traumatic experiences than those in England.

How will we learn from one another? If we fail to learn, why is that? How will we make progress using the contrasts and comparisons? How can we make progress and share the learning experience? When experience is not shared, what steps can we take to rectify that? It is particularly important that carers and people experiencing mental illness are helped to help themselves. Self-help is therapeutic, but it must be resourced and supported. I have asked many questions.

The Acting Chairperson:
Thank you, Carál. Other Members also have questions.

Mrs Crossin:
I take a simpler view of life; some might say it is a simplistic or naive view. We can effect change and bring it about through relatively simple steps. Improving mental health is not about purchasing expensive machinery; it is about employing people with a range of skills. Therefore, we do not need myriad psychiatrists — forgive me, Roy —

Professor McClelland:
I certainly do not.

Mrs Crossin:
— or an endless number of occupational therapists. We need a range of those skills, or a certain number of each of those specialists. Earlier, Professor McClelland made the point that we need new skills: that is, a workforce with a set of skills different to that which the current workforce has. Users, carers and others can be skilled-up to contribute more than they currently do to promote mental health.

We do not examine the issues and problems in the community systematically. We are afraid of unearthing something that we will be unable to handle and, therefore, we do not honestly face up to problems. If we could do that, and start to document unmet needs, we could begin to come to terms with the scale of support that is required and must be provided.

To address an earlier point, it is much more expensive to deal with a crisis than with prevention. It would help if we could put some money upstream. It costs £1,500 to keep someone in hospital for a week, or £5,000 per week to keep someone in the medium-secure unit at Shannon Clinic.

If we could invest that money in early intervention, we would be spending it better. However, we need resources to bring about that change. I am not saying that all we need to do is rearrange the finances. It is not that simple. However, we could save a lot of money if we took the early intervention approach, examined unmet needs and faced problems squarely.

The Acting Chairperson:
Time is running out, so I ask that questions and answers be as short as possible. I am not criticising anyone; it is just that time is not on our side.

Dr Deeny:
Your concern shows the Committee the importance of the issue. As a GP for over 20 years, I agree that Northern Ireland’s mental-health needs are huge. They have been underestimated for a long time and, subsequently, are chronically underfunded.

GPs tend to deal with people with mental-health problems in only one way — writing prescriptions. I cannot agree more with the points that Mrs Crossin and Professor McClelland raised. There is a wonderful service, but GPs cannot access treatments such as cognitive behavioural therapy. They have no choice but to write prescriptions. Mental health is the Cinderella of the Health Service. GPs have literally been negligent in respect of patients with mental illness and have not dealt with the issue properly.

In all areas of health, prevention is everything, and mental health is no different. Yesterday, I heard a very disturbing case about a gentleman with bipolar illness. Sometimes I do not see my mental-health patients until they become very ill. I come from Downpatrick and now live near Omagh. I have been in the Health Service long enough to remember Omagh having two major psychiatric hospitals. The situation changed, and hundreds of patients were moved into community care without the necessary support.

The Acting Chairperson:
Kieran, do you have a question?

Dr Deeny:
Yes. The situation now is that GPs can see the patients who are fit to come to their surgeries, but some patients are not able. My question concerns funding. The situation is new to us, with the establishment of the new health and social care authority and the local commissioning groups. How do you propose health needs in all areas can be met? How would funding be broken down? We are all hopeful that the review of public administration will release some funds for front-line health services. That is my question.

Professor McClelland:
I urge the Committee to utilise its position to make the Department focus on a couple of key issues. The first issue relates to the overarching implementation arrangements. The steering group of the Review of Mental Health and Learning Disability has done quite a good job with its output, if that is a test of integrity. I commend the group’s work to the Committee. The Department could do worse than appoint a group of people, such as those who participated in the review, to the health and social care authority, along with key Department personnel. That would create a highly energised and highly motivated body that would ensure that the Minister was called to account.

Northern Ireland has the intellectual capacity, resource, energy and vision required to deal with the situation, and those qualities have been captured in the Bamford Review process. It is a matter of unlocking those qualities. There is a lot of expertise, and the expertise of users and carers is a tremendous resource.

The second key issue is that the system depends on a workforce strategy. That strategy is not about recruiting more psychiatrists, as Marie rightly suggested. Rather, it is about providing more and alternative resources. It is about using the potential of users and carers, empowering them and shifting the balance from where patients see themselves in one place and professionals see themselves in another. That has a tremendous enabling effect, but it is also a learning curve for professionals. There is a serious skills issue, and more recruitment is needed.

I urge that the Government be pressurised as much as possible about the workforce strategy — not a nursing strategy, but the workforce strategy that was envisioned by the Bamford Review.

Mr Gallagher:
Thank you for your presentation, at a time when new health structures are being put in place.

It is clear from what has been said, and from what I have learned from constituents, that the structures that we had in place did not provide anything like an adequate service for people with mental-health problems or learning disabilities. The Committee may have to give detailed consideration to the legislation for the new health authority. Indeed, reforming the legislation has been mentioned already.

What are your views on the legislation that the new health structures will work under? From the voices that I am hearing around the table, I expect that there will be a duty to consult users, but will the legislation be strong enough to ensure that the key users are consulted?

Mrs Crossin:
The user and carer movement is in its infancy, but we are working hard and pulling ourselves up by our bootstraps. As a member of a user and carer forum, I have a seat on the mental-health commissioning team of the Eastern Board, as does a user representative. Those are small beginnings, and more such steps will have to be taken with the new authority.

Public participation and user and carer participation will be important elements in the Health Service. There are problems to overcome, but the contributions of the public and of users and carers to debates on structures and services will be repaid in spades. It will be important that people such as myself and other carers who work with me in the Health Service can feed back into the system to allow it to right itself. However, it is early days for the new structures and we do not yet know what will happen.

Professor McConkey:
Legislation can help, but often it is custom and practice that determine what happens. In Northern Ireland, there has been a deficit in the involvement of users and carers and our accountability to them. However, we can see the seeds of change: the new structures will offer a strong voice to users and carers, and it will not cost a lot of money to do so. There is a wider political will that goes beyond the money that is spent on learning disabilities or mental-health problems, and the wider community acknowledges that we have a responsibility towards such client groups.

Mrs Hanna:
I want to start by welcoming the witnesses. Your presence shows that mental health is at the top of the agenda, and I am glad about that. We need a bit of fresh, twenty-first century thinking to get the issue out in the open. We all have friends and relatives with mental-health problems. When people have physical problems, they might complain about waiting lists but they will get the offending organ removed or get whatever treatment they require. However, it is different when people have mental-health problems, when there seems to be a feeling of powerlessness.

There seem to be parallel strategies, and we need better promotion of mental-health issues to empower people and their carers. Marie Crossin spoke about simple steps to be taken, and I know that there is much to be done. Some of the more serious illnesses seem to be very challenging to deal with over the longer term. Marie spoke about reform of the workforce. It seems to me that we have to improve people’s skills and bring the services out of the hospital setting and into the community. How much planning has there been on who will take the leadership roles? We need those people to be in place so that we can bring others along. We have to change culture and attitudes.

With physical ill health, I get frustrated about the simple things that we are not doing but could be doing. Therefore, on mental-ill health, are there things that we could do? You have spoken about milestones. How could we start to achieve a win-win situation in some simple areas to get us off the ground?

Professor McClelland:
The size of the challenge is potentially overwhelming. However, the review involved not only writing papers, it was a process of engagement, and there has been a tremendous groundswell of willingness to move forward. People who are involved have a great deal of energy, and that costs nothing.

Morale must be boosted. A lead strategy, energised by the Committee, as part of the Administration, would do a great deal for the esteem in which the process is held. You can get an awful lot back for your buck by doing that. Giving a lead is crucial, and some acknowledgment of the user and carer communities would give them a greater sense of presence.

Engagement is not rocket science. Over the past few years, many health trusts have been majoring in much of the material that we reviewed. We are simply asking where the central drive and leadership lies. The trusts are ready for the push. I have met the chief executives of all the new trusts, and they are well versed in the Bamford Review and are well aware of mental-health issues. Most have appointed directors, who will include those who will deal with mental-health and learning-disability services. They only need the green light to move on the required implementation of the review and to mirror its plans at local level through the five trusts.

Mrs Hanna:
Champions should be put in place to implement the review.

Mr Buchanan:
You mentioned the complete change in the workforce that is required. Do you agree that the number of consultants per head of population for adult patients in Northern Ireland is wholly inadequate?

There is also a serious lack of beds in child inpatient psychology services. The difficulty has been that 16 to 18 year olds have fallen between two stools. Funding is the key issue, and we have heard how money has been sifted away over the years when other Departments faced pressures. Will you be proposing that a certain proportion of the money coming into the Health Service should be ring-fenced solely for mental-health services?

Professor McClelland:
Absolutely. I do not want to leave the table suggesting that everything can be achieved if everyone simply does things differently. Of course, that must happen, but there must also be additional resources. For example, at the moment, community mental-health teams, which are the cornerstone of community-service development and reform, are staffed at half the level per capita compared to England. At the moment, teams are staffed on an average of 25 members for each 100,000 people. We need to move towards doubling that figure to 50 for each 100,000. The priority for mental-health services, using that standard of developing community-based services, dictates that over the next five years the figure must rise to over 30. By edging towards that, our final goal can eventually be reached.

Other kinds of workforce must be considered, thus bringing in users and carers. Support workers, graduates in other fields, and non-graduates can contribute. There are examples elsewhere, such as in south Stockholm, where front-line staff hold outpatient clinics, not in hospital rooms, but in cafes and patients’ homes. Those people may have a degree in forensic health but no proper nursing degree. However, they are supervised and supported. That is an example of how to create a new workforce infrastructure. New ways of working are required.

The Acting Chairperson:
Thank you. We have a couple of minutes left. Carál, a couple of your questions were not answered.

Ms Ní Chuilín:
I asked about the South’s ‘Reach Out: National Strategy for Action on Suicide Prevention 2005 – 2006’ and the comparisons that have been made with it. Perhaps you will elaborate.

Professor McClelland:
There is a tremendous opportunity for the Republic and us to learn from one another. For example, John Owens, the chairman of the Mental Health Commission, which is involved with the ‘Reach Out’ strategy in the South, is a member of the adult mental-health review group. He is regarded as one of our external experts. There are opportunities for shared training, but the legislation in both jurisdictions must be compatible. We have much to learn from one another on an all-Ireland basis; that applies to public health generally.

The Acting Chairperson:
There are two minutes left. Will you say a final few words please, Professor McClelland?

Professor McClelland:
We are grateful for the opportunity to meet with the Committee. This is an important forum in which to raise the profile of mental health and learning disability. The timing is excellent, as the meeting comes just as the review has ended. By inviting us so early, you have given us a head start.

We urge the Committee to strive to ensure that the right implementation arrangements are in place: we do not want another level of bureaucracy. However, there is a knowledge base and a resource base that could work quickly with the Department. The four streams of work must be protected, and a human resource workforce strategy must underpin that.

Professor McConkey:
We have built up a large evidence base of data, information and evaluations of services that is at the Committee’s disposal or at that of any member who wants to contact us.

The Acting Chairperson:
I was about to suggest that a direct line of contact between you and the Committee be established because the subject is so wide that an hour is not sufficient to deal with it. A direct line of communication would make a great difference to the Committee in its work and decisions.

Professor McClelland:
We have benefited from there being a mental-health special-interest group of MLAs and their policy advisers. We met the group on 18 May to discuss workforce issues. That conduit of expertise is a ready source that can feed the Committee with much finer-grain information than we can provide this afternoon.

The Acting Chairperson:
That is good news. I want to ensure a direct line of communication with you. It is not only helpful to the Committee, but to MLAs as well, to be on top of the subject. Thank you very much; the Committee appreciates your presence.