In Focus news analysis

In Focus news analysis pieces from Community Care magazine:

(It may be advisable to print this page because it is long).

(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

"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

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

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

"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

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

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

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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