In Focus news analysis

In Focus news analysis pieces from Community

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(See below for news analysis on further evidence adding
weight to the campaign to increase the availability of new and
relatively expensive drugs for the treatment of psychosis) 

Public services take centre stage in new

As New Labour wins a mandate for another term, many are left
wondering what the new administration has up its sleeve for social
and public services. Linda Steele takes a look at who the potential
winners and losers might be in the plethora of promised and
forthcoming legislation in the fields of mental health, learning
difficulties and adoption.

Public services have finally made it to centre stage in a
general election. Schools, hospitals, transport, crime and welfare
through work will be key for Prime Minister Tony Blair’
newly-elected government. But what do the coming months hold for
social care?

First, the ever closer integration of social care and health –
known to some as the health takeover – will continue apace. Care
trusts got the go-ahead in the Health and Social Care Act just
before the election. “We’re worried that local, democratic control,
provided by social services and local government, is not
sufficiently valued by this government,” said Unison’s social
services officer, Owen Davies. “Joined-up services are a good thing
but our concern is that care
trusts could become the normal or preferred model of

Julian Le Grand, social policy professor at the London School of
Economics, thinks the writing is on the wall. “Will we see child
care go to education and care of the elderly go to the NHS [in care
trusts]? Yes, we will,” he said. “It’s fairly clear that the day of
the generic social worker is over.

“But that’s further down the line. More immediately, the
newly-appointed ministers – or reappointed, in the case of health
secretary Alan Milburn – will get together with the whips to decide
what will make it into the Queen’s Speech on June 20.

This will be the moment when the government sets the tone for the
kind of administration it wants to be. Competition to get bills in
will be immense – where it’s not a foregone conclusion.

The widely applauded learning difficulties white paper, Valuing
People, could be an early victim. Mencap will be campaigning hard
to get learning difficulties onto the agenda. Richard Kramer, the
charity’s head of campaigns, says they will be “seeking an
effective framework for decision-making for adults who do not have
the capacity to communicate their wishes themselves….[and]
the introduction of a new ‘abuse of trust’ law to outlaw sexual
relationships between care staff and those they are caring

As in 1997, New Labour’s first session of parliament is likely to
be a long one – 18 months – with between 12 and 18 bills. It will
be a showpiece session, so anything that’s not a top priority could
wait till November 2002.

There’s a chance that the reform of the Mental Health Act 1983
could be delayed, but campaigners are fairly optimistic that a bill
(which is probably already being drafted) will appear in November.
Although one expert has voiced concern that the plans for detention
of those “dangerous people” with antisocial personality disorders
could go ahead separately from the wider reform, this seems
unlikely. Uncoupling personality disorders and generic mental
health services, brought together in the white paper Reforming the
Mental Health Act, would require much reworking, administration and
extra legislation.

But the bill, however and whenever it appears, will not get through
unchallenged by lobbyists. “There’s no legal right to an assessment
and services. This legislation is a fantastic opportunity to
introduce that,” says Mind’s campaigns manager, Sue Brown. And the
personality disorder proposals and plans for compulsory treatment
in the community will be opposed. But the bill is unlikely to be
the government’s biggest hurdle in mental health.

New Labour has acknowledged that services must be expanded and
improved dramatically – currently around one person in three with a
serious mental health problem doesn’t get help when they seek it.
Andrew McCulloch, head of policy for the mental health charity the
Sainsbury Centre, says: “The Sainsbury Centre estimates that 8,000
new staff will be needed in mental health services alone to
implement modernisation plans. And, without a radical skill mix and
working smarter, it’s hard to see where people will come from,
given staff shortages.”

In fact, implementation across the board will create
difficulties for second-term New Labour. Crippling staff shortages
exist in social care, and elsewhere in the public sector. Without
another look at salaries and an overt commitment to valuing workers
and the public service ethos, it’s hard to see this huge problem
melting away.

While the new delivery unit in the Cabinet Office may succeed in
chivvying up the civil servants in the big spending departments,
there’s no magic formula for delivering on the ground if staff are
demoralised and in short supply.

Another problem will be the disparities in long-term care with the
Scottish executive’s promise to introduce both free personal and
nursing care. The government is sticking to its position of
means-tested personal care in England, despite the tensions the
stance will inevitably create.

The flash point could, however, be public-private partnerships,
with public sector unions already promising to oppose further
incursions by the private sector. A report from Downing Street’s
favourite think-tank, the Institute for Public Policy Research
(IPPR) which is due out in a fortnight, is likely to suggest that
private contractors should be allowed to run many more publicly
owned services.

The recommendations may not touch directly upon social care, about
half of which is already delivered by the independent sector, but
will cover organisations that social services work closely with,
such as primary care groups.

“Blair will be told by the IPPR that privatising public services is
the key to winning a third term. But it’s a policy certain to
create a backlash from a public that wants better services – not
the costly failure privatisation will inevitable turn out to be,”
said Malcolm Wing, Unison’s head of local government Le Grand, who
sat on the commission that drew up the report, disagrees: “it’s not
going to be an unequivocal cheerleader for the private sector –
it’ll be quite critical of PFI [private finance initiative], for
example. I think it will present a balanced view.”

But not everything will be controversial. Campaigners are happy
about the likely reintroduction of the Adoption and Children Bill,
which ran out of time before the election. Felicity Collier, chief
executive of British Agencies for Adoption and Fostering, said: “I
think adoption will have a high profile and I’m very pleased.” But,
alluding to the fact that some felt that consultation and the
drafting of the bill were rushed, she says: “There must be adequate
time for debate in the legislative programme. It’s desperately
important that we get it right.”

While Labour’s manifesto only promised consultation on extending
the role of the national children’s rights director, there is
speculation that a children’s commissioner may be announced in the
autumn. In the meantime, children’s charities will be lobbying
politicians. “The children’s commissioner is an achievable goal if
the political will is there,” says Michelle Mitchell, the NSPCC’s
parliamentary adviser.

And the ambitious pledge to end child poverty by 2010 will remain a
high priority. “One of the implications of the size of its majority
is that the government will now be able to think over a much longer
term and develop a radical programme,” says Stephen Burke, Daycare
Trust director. “But it takes a long time to turn around services.
The comprehensive spending review in 2000 promised 900 new
neighbourhood nurseries, but they won’t be visible till 2004.”And
delivery of high quality social care and other services is crucial
to New Labour this time around. Blair knows that voters will judge
his government on whether public services improve, and are seen to

Tougher regime ahead
One of the first tasks facing new home secretary David Blunkett
will be to choose between the options outlined in a sentencing
review by civil servant John Halliday. It’s likely that shorter
sentences could be divided between prison and probation, with
inmates being electronically tagged, a scheme dubbed “custody

But there’s a feeling abroad that, whatever Blunkett goes for, it
won’t be a more lenient regime. One criminal justice expert says:
“Blunkett has put it about that he will make Straw [the previous
home secretary] look like a screaming girl’s blouse.”

Cracking down on persistent offenders will be the big target, and
as many as 9,500 extra prison places could be on the cards.

“But he will bring a background in education and there will be an
emphasis on the redemptive power of education and work,” says a
spokesperson for Nacro, the crime reduction charity. Skills
training and education will be seen as important, both in prison
and in the community.

The Youth Justice Board is likely to take over responsibility for
18-21-year-olds in jail. For the under-18s, there will be a bigger
emphasis on restorative justice and community reparation, with
young offenders atoning for their crimes through activities such as
cleaning graffiti. And there will be a greater use of intensive
supervision and surveillance programmes for young offenders. Under
these programmes, organised by youth offending teams, young
offenders have a strictly monitored timetable of activity, such as
life skills training, visiting mentors and college.

Joyce Moseley, chief executive of RPS Rainer children’s charity and
Youth Justice Board member, says the programmes were “a means of
getting appropriate help to young offenders to stop them
reoffending, giving them the potential to move on – and keeping
them out of custody”.


Drugs debate intensifies

Mental health campaigners are demanding that quality of life
considerations should prevail over issues of cost in the debate
about who should get new anti-psychotic drugs. Sarah Wellard

New evidence submitted last week to the National Institute for
Clinical Excellence (Nice) adds further weight to the campaign to
increase the availability of new and relatively expensive drugs for
treating psychosis.
A survey carried out by the Mental After Care Association looked at
the treatment regimes of 189 people, and included the observations
of both service users and staff about the effectiveness of
treatment. It found that the new atypical anti-psychotic drugs are
associated with improvements in people’s quality of life and mental
health, and with reduced side-effects.
Maca also found evidence that older people are being discriminated
against within the mental health system. The research found that
older people, often from long-stay hospitals, are more likely to be
prescribed cheaper conventional anti-psychotic medications than
young people.
Gil Hitchon, chief executive of Maca, says the finding reflects the
tendency of psychiatrists to stick with what they know. “If a
person has remained apparently well there’s less incentive for a
review of their medication unless it is specifically requested. For
an elderly person who has a history of problems, or who has come
out a long-stay institution, there’s a tendency not to ask whether
there is scope for improving the quality of their mental
Campaigners are hoping that Nice will recommend that the new drugs
should be the first line treatment of choice for people diagnosed
with schizophrenia. The institute is presently collating evidence
from drug companies, user organisations and professionals as part
of an appraisal of atypical anti-psychotics, and will be publishing
guidance on their use at the end of the year.
The medical world remains divided on the issue. Research published
in the British Medical Journal in December recommended that
conventional drugs should be considered first, and atypicals used
only if a patient failed to respond. This study, based on clinical
trials with more than 12,500 patients, found that although atypical
drugs caused fewer side-effects, the improvement in symptoms was
very similar.
Stephen Hirsch is professor of psychiatry at Imperial College
School of Medicine in London and a spokesperson for the Royal
College of Psychiatry. He is not convinced that the new drugs are
necessarily better than the older type.
He says: ” The best reviews of the evidence suggest that if you use
lower doses of standard drugs you get lower side-effects and
similar benefits. But it does depend on the patient.” He points out
that for some people atypicals can also have unpleasant
side-effects, including massive weight gain. But, he concedes: “If
you want to reduce the risk of losing a patient’s confidence
because of the side-effects you would start with atypicals.”
Some experts believe it is too simplistic to draw a “new drugs
good, old drugs bad” dichotomy. David Taylor, a pharmacist based at
the Maudsley Hospital in London and chairperson of the UK
psychiatric pharmacists group, explains: “It’s important to
separate out the new drugs. It’s very clear that Clozaprine is more
effective than the rest. It works with people with resistant
schizophrenia who don’t respond to anything else.”
The Maca findings reinforce those from another much larger survey
of users’ experience, conducted by the National Schizophrenia
Fellowship, Mind and the Manic Depression Fellowship. This survey
found that people diagnosed with schizophrenia or manic depression
overwhelmingly preferred the new atypicals and reported fewer
Gary Hogman, head of policy and campaigns at NSF, says: “For some
people, atypicals have worse side-effects than the typicals. But
they are a minority. A lot of people with mental illness don’t want
to leave their older drug because they feel comfortable with it.
It’s not necessarily the best and most efficient, but they don’t
want to change.”
The NSF/Mind survey also found that people using the older typical
anti-psychotics were significantly more likely to have stopped
taking their medication than those on atypicals. In the context of
Nice’s emphasis on cost-effectiveness, this finding is particularly
important because it puts people at risk of breakdown, of missing
work or ending up in hospital. Most worryingly, non-compliance is a
major risk factor for suicide. The official confidential inquiry
into suicide and homicide found that one in five people known to
mental health services who committed suicide was not taking their
medication at the time of death.
Hitchon believes that the relatively high cost of the atypicals
means that health authorities and trusts are reluctant to make them
more widely available. The new drugs cost around £40 a week
per patient – up to 10 times as much as conventional
anti-psychotics. However, Nice says that affordability is not a
consideration in its deliberations. A spokesperson explains: “We
look at cost-effectiveness, not affordability. The process does
allow for the Department of Health to comment on affordability, but
so far this hasn’t happened.”
Hirsch agrees that cost is a significant factor influencing
psychiatrists’ prescribing practice. He points out people will be
taking drugs for 30 years or more. “An oncologist may be treating a
patient with cancer drugs costing £50,000 but they aren’t on
them for life,” he says.
Ultimately, it is up to psychiatrists to determine which drugs are
best for individual patients. But when Nice draws up its
recommendations, let’s hope that the views of users will be
uppermost in their minds. Two thousand pounds a year seems a small
price to pay for enhancing or saving someone’s life.

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