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
    term

    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
    provision.”

    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
    for.”

    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
    improve.

    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
    plus”.

    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
    reports.

    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
    health.”
    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
    side-effects.
    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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