Policy Responses 2007 Bamford Review social inclusion.htm

1.1 Law Centre (NI) is a public interest law non-governmental organisation. We work to promote social justice and provide specialist legal services to advice organisations and disadvantaged individuals through our advice line and our casework services from our two regional offices in Northern Ireland. We provide a specialist legal service (advice, representation, training, information and policy comment) in five areas of law: mental health, community care, immigration, social security and employment to almost 500 member agencies. Members include local Citizen Advice Bureaux, independent advice agencies, local solicitors, trade unions, social services, probation offices, constituency associations of local political parties, libraries and other civic organisations.

1.2 The report on Promoting the Social Inclusion of People with a Mental Health Problem or a Learning Disability is of particular relevance to Law Centre (NI) as it cuts across all aspects of our work. This response has been informed by the work of our mental health, employment and social security practitioners who provide representation relating to many of the issues highlighted in the report that affect people with mental health problems or a learning disability.

1.3 We welcome the opportunity to respond to this consultation document on promoting the social inclusion of people with a mental health problem or learning disability. We do not comment specifically on the education recommendations as Law Centre (NI) does not currently work in this area. We have made some comments in response to the other specific areas and general issues raised within the Report.

The Report makes many welcome recommendations to ensure that people with a mental health problem or learning disability are valued and able to enjoy their rights to full participation in all aspects of everyday life. We have some further recommendations for the Review to consider as part of its final report. We comment in more detail on each of these recommendations within the body of the paper and have highlighted the appropriate paragraphs for ease of reference. In summary we recommend:

3.1 We welcome the recognition within the report that significant inequalities still exist in Northern Ireland for many people with mental health problems or a learning disability. Access to support and services remains a considerable barrier to full and effective equality and participation. Three key areas of general concern are identified below.

3.2.1 The Report reviews a plethora of laws and policies that refer to the need to promote equality and human rights to combat inequality for people with mental health problems or a learning disability. We particularly welcome the extension of rights for people with disabilities through the Disability Discrimination (Northern Ireland) Order 2006 (the DDO). We are encouraged by the significant changes in legislation and policy that have occurred over the last few years in Northern Ireland. There is an expectation that this momentum will continue to ensure that people with mental health problems and/or a learning disability are finally on an equal footing in all aspects of everyday life. A future review of mental health legislation in Northern Ireland will also provide an important opportunity to influence the development of the rights and recognition of people with mental health problems or learning disabilities.

3.2.2 We are concerned, however, by the omission of any reference to Section 75 of the Northern Ireland Act 1998 and the duties and obligations placed on bodies in Northern Ireland to have due regard to the need to promote equality of opportunity including between persons with a disability and persons without. The section 75 duties have a key role to play in the protection and promotion of the social inclusion of people with a mental health problem or learning disability and the Review needs to make reference to these duties, which are unique to Northern Ireland.

3.2.3 The Report also refers to the UN Convention on the Rights of Persons with Disabilities. This is the first comprehensive human rights convention adopted in the 21^st century and it has the potential to affect over 650 million persons with disabilities world wide. A formal ceremony for the opening of the new Convention for signature is scheduled for 30 March 2007. By ratifying the Convention countries will accept a legal obligation to promote the human rights of people with disabilities by enacting anti-discriminatory legislation or eliminating laws and practices that discriminate. The UK government has already signaled its intention to ratify the Convention and the international recognition of the rights of people with disabilities will greatly increase the awareness of the rights of people with disabilities to equal protection under the law. Further comment within the Report on the implications for people with mental health problems or a learning disability, of ratification of the Convention and how this will influence domestic law, policy and practice would be beneficial.

3.3.1 We note the use of a wide variety of data from Great Britain to highlight particular areas of concern within the Report. While there are valuable lessons to be learnt from such research and there is a considerable degree of correlation to be drawn between Great Britain and Northern Ireland, it is equally as important to draw on Northern Ireland specific data. We are aware that data to the degree and detail as in Great Britain is not always available in Northern Ireland. Given the great value of such information, however, we would welcome consideration of a strategy within the Report to obtain such data for future work in this area.

3.4.1 The Report provides a useful overview of policy and practice relating to the social inclusion of people with a mental health problem or learning disability. It also makes a number of practical recommendations on how people with a mental health problem or learning disability can lead more inclusive and meaningful lives. We are concerned, however, that the Report does not outline any new innovative models for the successful eradication of social exclusion or a radical means of promoting social inclusion for people with a mental health problem or learning disability within Northern Ireland. In particular, our experience is that there is limited cross-departmental joined up thinking in approaches to mental health and learning disability issues.

3.4.2 The Report is quite broad in its approach and in order for the recommendations to have real meaning it is important that they are implemented effectively and that positive developments result. Strategies therefore need to be put in place therefore to measure progress, including in relation to the recommendations set out in the Report, set against clear indicators.

3.4.3 A strategy for example, needs to identify how the ‘Just Like You’ principles will be disseminated across Departments to underpin their work in taking forward the Report’s recommendations. We recommend the Report contain detailed information regarding how DHSSPS and other relevant bodies will apply and administer the principles within the Report to ensure that the vision of the Review will become reality for people with mental health problems or a learning disability.

3.4.4 We welcome the recommendation of the Review to establish an inter-Departmental group, led by DHSSPS to address the stigma of mental health problems and learning disabilities. This would be an important development in the recognition and promotion of the rights of people with mental health problems or a learning disability and we would welcome further information regarding the remit of this inter-Departmental group, its membership, how it will engage with the sector and user-groups and how its work will be monitored and evaluated. As a starting point, new policies and legislation should be proofed for consequences for mental health and learning disability.

4.1 Stigma and discrimination against people with mental health problems is rife through all areas of society and its impact is far reaching and goes beyond just the impact on an individual to society as a whole. Sixty-three per cent of people surveyed in Northern Ireland underestimated the proportion of people who might have a mental health problem at some point in their lives while over half said that if they were experiencing mental health problems they wouldn’t want people knowing about it. [1]

4.2 Northern Ireland has seen two recent campaigns by BBC Northern Ireland and Rethink, to address the stigma and discrimination associated with mental health and the Health Promotion Agency has also launched a further campaign. The success of these campaigns is yet to be determined but we are encouraged by the positive work undertaken by agencies in Northern Ireland to address this issue. Further work, however, needs to be done to ensure organisations working in the field of mental health and learning disability are sufficiently resourced to enable them to work on campaigns to create long-term positive impact.

4.3 We therefore recommend the inter-Departmental group to reduce social exclusion and to implement the various recommendations made within the Report gives early priority to addressing the funding arrangements for community and voluntary groups working on mental health and learning disability issues.

5.1.1 The need for more positive views of mental health is increasingly obvious in the workplace, sixty-three per cent of employers said they wouldn’t employ anyone who ever has time off work because of mental illness.[2] The workplace has a powerful effect on an individual’s health while discrimination within the workplace has a significant impact on people with mental health problems. Mental ill health also leads to an estimated 80 million workdays being lost each year to stress, depression and anxiety.[3] Not addressing mental health problems in the workplace cost business and the public sector an estimated £9 billion each year.[4]

5.1.2 We note the Employment section of the Report does not refer to the impact of the DDO nor to the role of the Equality Commission for Northern Ireland (ECNI) in this important area. Consideration needs to be given to how the inter-Departmental group and the ECNI can work together to protect against stigma and discrimination. Stigma is not isolated; where there is stigma there is more often than not also discrimination. The inter-Departmental group, therefore, in looking at the stigma associated with people with mental health problems or a learning disability will also be faced with situations of discrimination and will need to establish an action plan for coordinating work with the ECNI.

5.2.1 The Report also refers to supported employment initiatives post Peace II funding and recommends that departments should mainstream this funding. This is an apt recommendation.

5.3.1 The Report refers to the recent Welfare Reform Bill. The move in the Bill to encourage and support more people to return to work is welcome. We are concerned, however, by the practical issues faced by many incapacity benefit claimants when it comes to securing and maintaining employment as considerable prejudice and discrimination still exists in relation to mental health within the workplace. For all the benefits of the increased support offered within the Bill, there is little point in encouraging people towards work if employers are unwilling to employ them. Further, the effects of encountering prejudice or discrimination in the workplace could have a devastating effect on the mental health of an individual who has successfully come off benefits only to return in a worse state of health.

5.3.2 Consideration needs to be given to the fact that within the Welfare Reform Green Paper the Government aimed to have one million less people claiming incapacity benefit. However, statistics confirm that there are only just over half a million job vacancies, giving rise to the issue that the welfare reform may simply be moving people off one benefit (incapacity) and on to another (jobseekers allowance).[5] We do recognise that many people will simply move from incapacity benefit to retirement pension on reaching pensionable age.

5.3.3 The Government has not adequately addressed this situation or put forward any proposals regarding the creation of employment opportunities in line with the welfare reform. We believe the Government needs to take further action to reduce the stigma and discrimination faced by people with mental health issues, across all areas but particularly in the area of employment where prejudice is very evident. The Work and Pensions Select Committee confirmed that the Government’s action on employers was “wholly inadequate” and this needs to be addressed.[6]

5.3.4 We agree that Employment Advisers should work with community mental health teams and community learning disability teams to provide pathways to employment. Considerable training will need to be available to Employment Advisers and consideration needs to be given to the allocation of resources for this purpose and training should be informed and/or delivered by those with mental health problems or learning disabilities. It is vital that Employment Advisers working with people with mental health problems or learning disabilities have a good understanding of the particular difficulties they may face and of the possible impact on their health of both accessing or being unable to access employment.

6.1 We share the Review’s concerns regarding the impact of poverty and social exclusion on mental health and well-being. Recent research has found that almost a tenth of Northern Ireland’s working population is claiming benefits for mental health and 40 per cent of all awards for Incapacity Benefit or Severe Disablement Allowance are for mental or behavioural conditions.[7]

6.2.1 As referred to above, the Welfare Reform Bill proposes significant changes to Incapacity Benefit. The main principle behind the Bill is to support and encourage more people in receipt of Incapacity Benefit to move into employment, where they are able to do so. Although many of the reforms are welcome, some of the provisions within the Bill may create particular problems for those claimants with mental health issues who make up approximately 40 per cent of all Incapacity Benefit claimants.[8]

6.2.2 We are concerned that sufficient thought has not been given to the particular needs of people with mental health issues in the drafting of the Bill and the proposals for required participation. This concept of compulsory participation shows little understanding of the fluctuating and, at times, unpredictable nature of some mental health problems. Nor does it take into account the fact that claimants with mental health issues may feel unduly pressurised to sign up to Action Plans they may be unable to fulfill rather than risk a reduction in their benefit.[9] It may result in an individual no longer meeting the criteria for Incapacity Benefit but having no other option but to remain on benefits, albeit a different benefit. This may mean a reduction in their benefit income and create further pressure on his/her personal finances.

6.2.3 As referred to at points 5.1-5.9 there are also considerable concerns regarding a move into employment for people with mental health problems or learning disabilities as employers are not equipped or not willing to deal with their particular needs. This places a further burden on people with mental health problems or learning disabilities as they may be willing to return to work but cannot secure employment.

6.3.1 The Report also refers to inadequacies in the medical assessment of incapacity and disability in the benefit system. We share these concerns. As part of the welfare reforms the Government have also committed to an overhaul of the Personal Capability Assessment (PCA) from an incapacity based tool for determining eligibility to Incapacity Benefit to a more positive and full assessment of capability to include health related interventions to assist those with a disability to engage in work.

6.3.2 New PCA proposals, as made by the Department for Work and Pensions, Health, Work and Wellbeing Directorate, include increasing the relevant areas of limitations of mental function and developing the series of descriptors within each area of mental function to parallel the assessment of physical function. These proposals will greater assist in the recognition and acceptance of the limited capabilities of those with mental health problems who need benefit assistance as a result of their condition.[10] Addressing the problems with the medical assessment should ensure that more people with mental health problems or a learning disability are able to obtain benefits and/or the assistance they require to return to work which, will help to stablise their personal finance situation. We comment further on the PCA at points 7.1.2-7.1.3

6.4.1 The Health, Work and Wellbeing Directorate also recommended that a further review on the format of the IB 50 self-assessment questionnaire also be undertaken.[11] Work was due to begin in early 2007 to allow time for development and testing of a revised IB 50 prior to implementation of the Welfare Reform Bill. We welcome the recognition within the Report that there is a considerable way to go in improving benefit claim forms so they are more accessible for people with mental health problems or a learning disability. We are encouraged that work in this area is underway.

6.5.1 We welcome the recommendation by the Review that independent advice and advocacy services should be embedded in mental health services. There should be a statutory right to independent advocacy support to ensure that people with mental health problems and learning disabilities have a protected right of participation and access to justice. Many mental health patients are unaware of their rights and feel they can be branded as troublemakers if they raise legal or service issues.[12] Legislating for the right to an advocate will go some way to increase the awareness and acceptance of having an advocate, which will greatly benefit many people with mental health problems.

7.1.1 Research has found that people with mental health problems are less likely than the general population to receive physical health advice and support.[13] We support the Review’s proposals for a more holistic approach to health and social care in Northern Ireland and agree that any assessment of the needs of people with mental health problems or a learning disability must include assessment of physical health needs alongside mental health needs.

7.1.2 This links to our comments above regarding the medical assessment component of the Incapacity Benefit. The Health, Work and Wellbeing Directorate have stated that in the longer term they will consider exploring development of a combined physical and mental function PCA. Given the frequent overlap between physical and mental illness however, there is the need for a holistic approach to the PCA to ensure that all descriptors, physical and mental are considered rather than pigeon holing a claimant into one descriptor or another and therefore providing only a partial assessment of their capability.

7.1.3 One of our main concerns with the revised PCA was that it removed the ability to combine physical and mental function scores in the PCA to meet the entitlement threshold. The new arrangements would not reflect the practical reality that many individuals ill-health has both a physical and mental ill-health component.[14] We therefore welcome the recent agreement to combine both factors.

7.2.1 We welcome the reference to the need for training and awareness-raising. Consideration needs to be given to the allocation of resources for training of GPs and other health professionals who will be involved in initial and ongoing assessments of people with mental health or learning disabilities. Training should be informed and/or delivered by people with experience of and expertise in mental health or learning disability issues. It is vital that assessors working with people with mental health problems or learning disabilities have a good understanding of the particular difficulties users may face and of the possible impact the assessment and treatment process itself may have on their mental and physical health.

7.2.2 We also have concerns regarding the continued reliance on GPs to make the initial decision regarding a person’s need for admission for treatment for mental health problems. This scope should be widened to include the involvement of other health or social professionals who have knowledge of mental health issues and /or who have been directly involved with the person concerned. Many GPs do not have the requisite level of expertise or experience in mental health to make such decisions. Decisions to deprive a person of their liberty, even for assessment purposes, should only be made by those who have a comprehensive understanding of mental health issues.

7.3.1 We have significant concerns regarding the health and social needs of children and young people with mental health problems or a learning disability. Although 1 in 10 children in the UK are known to suffer from a mental health problem,[15] Child and Adolescent Mental Health Services (CAMHS) in Northern Ireland are drastically under funded and under resourced. There are not enough CAMHS staff or facilities available to provide adequate mental health services for children and young people. Waiting times in Northern Ireland for treatment for non-emergency referrals by CAMHS professionals range from 25-72 weeks.[16] This results in children being inappropriately detained on adult psychiatric wards, putting them at physical risk and at risk of a negative impact on their treatment. In other cases children have to travel to England or Scotland to receive treatment, separating them from their family and support services.

7.3.2 This situation is not acceptable and adds to the social exclusion of children and young people with mental health problems or a learning disability as they are socially isolated from their peers, family and friends when receiving treatment. As outlined in the Review’s report ‘A Vision of Comprehensive Child and Adolescent Mental Health Service’[17], consideration needs to be given to better resourcing of services for children and young people in Northern Ireland.

8.1 People with mental health problems or a learning disability face significant disadvantages within the workplace, in accessing social services, including benefits and even other health services. There is a clear need in Northern Ireland to ensure that people with mental health problems or learning disabilities are aware of their rights and have access to appropriate advice and support. It is vital that service providers and government bodies are held accountable for the services and support provided to people with mental health problems or learning disabilities in communities across the country.

8.2 Law Centre (NI) welcomes the opportunity to respond to this consultation document. We trust you will find our comments helpful. If there is any further way in which we could contribute to this process we would welcome the opportunity to do so.

[1] Health Promotion Agency, Research into Public Attitudes to Mental Health 2006, at www.healthpromotionagency.org.uk

[2] Scope, Tackling Stigma and Discrimination in Mental Health, November 2006 at pg. 14

[3] Future Foundation, Mental Health: the last workplace taboo, for Shaw Trust June 2006

[4] Department of Health, National Service Framework for Mental Health, 1999

[5] Mental Health Foundation & Foundation for People with Learning Disabilities, Response to Government’s Welfare Reform Green Paper, April 2006, pg. 2

[6] Rethink, Rethink on the Welfare Reform Bill, at www.rethink.org

[7] Peter Kenway, Tom MacInnes, Aveen Kelly and Guy Palmer, Monitoring poverty and social exclusion in Northern Ireland 2006 at page 110-111

[8] Mind, Welfare Reform Bill 2006 Briefing

[9] Mental Health Foundation & Foundation for People with Learning Disabilities, Response to Government’s Welfare Reform Green Paper, April 2006, pg. 2

[10] Department for Work and Pensions, Physical Function and Mental Health Technical Working Group, Transformation of the Personal Capability Assessment, September 2006

[11] Ibid

[12] Northern Ireland Human Rights Commission, Connecting Mental Health & Human Rights, December 2003.

[13] Disability Rights Commission, Equal Treatment: Closing the Gap A formal investigation into physical health inequalities experienced by people with learning disabilities and/or mental health problems, 2006

[14] See Disability Alliance’s letter to Moira Henderson re the draft paper Transformation of the Personal Capability Assessment at www.disabilityalliance.org for further information regarding the case for a ‘whole person’ approach

[15] Child and Adolescent Mental Health: Special Report at www.communitycare.co.uk/Articles

[16] Department of Health , Social Services & Public Safety, Mental Health Services Follow Up: Regional Summary, June 2004

[17] The Bamford Review of Mental Health and Learning Disability (Northern Ireland), A Vision of a Comprehensive Child and Adolescent Mental Health Service, July 2006