Official Report (Hansard)

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Northern Ireland Association for Mental Health

22 January 2009

Members present for all or part of the proceedings: 
Mrs Michelle O’Neill (Deputy Chairperson) 
Mr Thomas Buchanan
Dr Kieran Deeny 
Mr Alex Easton 
Mr Tommy Gallagher 
Mr Samuel Gardiner 
Mrs Carmel Hanna
Mr John McCallister 
Ms Claire McGill

Witnesses:
Mr Alan Ferguson ) Northern Ireland Association for Mental Health 
Mr Graham Logan ) 
Mr Michael Parsonage ) Sainsbury Centre for Mental Health

The Deputy Chairperson (Mrs O’Neill):

I welcome Alan Ferguson, chief executive of the Northern Ireland Association for Mental Health (NIAMH), Graham Logan, policy development manager for NIAMH, and Michael Parsonage, health economist and senior policy adviser at the Sainsbury Centre for Mental Health. You are all very welcome. I invite you to lead with your presentation, which will be followed by Committee members’ questions.

Mr Alan Ferguson ( Northern Ireland Association for Mental Health):

I thank the Committee for giving us the time to speak to you this afternoon. We are here to refer to the report, ‘Mental Health Promotion: Building an Economic Case’, of which members have copies. The report is also summarised in the briefing paper. It was a piece of research that was Michael Parsonage and another colleague of ours carried out in November 2007. It does what it says on the front page — that is, it builds an economic case for mental-health promotion.

Since we requested a meeting with the Committee, I have been asked by the Chief Medical Officer, Michael McBride, to chair a strategic-development group to look at mental health and emotional well-being. I will say a few words about that first, because it helps to put the report into some context.

The group’s overall aim is to develop a population-based approach to promoting positive mental health and emotional well-being in Northern Ireland, and, as part of that, to draw on the international evidence base, as well as effective delivery models that exist in other jurisdictions, from which we may learn. The group has been asked to advise the Department on key objectives and actions that are to be contained in a new mental-health and emotional well-being strategy.

Members may be aware that, currently, there are three key reports in that field of endeavour: ‘Promoting Mental Health’, the strategy and action plan that covered the years between 2003-08, so its time frame has just expired; ‘Protect Life — a Shared Vision’, the current draft suicide-prevention strategy that is being chaired by Colm Donaghy; and the mental-health promotion element of the Bamford Review, which relates to mental health and learning disability.

Dr McBride has asked the strategic development group to consider progress against the delivery of the actions and the recommendations arising from those three existing reports. He wants us to highlight any gaps in those three reports; appraise relevant evaluative research by drawing on the international evidence base and consider whether it would be transferable to this jurisdiction; and consider opportunities and approaches that will help to build resilience, at both individual and community levels by building on a settings approach. That means looking different settings involving young and older people, such as schools and employment.

It is important to say that, when building resilience, we are interested in taking a population-based approach. We are not specifically dealing with only that part of the population that may be suffering from diagnosed mental illnesses but are considering the entire population. Nor, in this context, are we looking at those suffering from a learning disability.

The ultimate aim of the group that I am chairing is to provide advice and strategic direction to the Department of Health, Social Services and Public Safety to assist with the development of a new mental-health and emotional well-being strategy.

That request from the Chief Medical Officer was made between our requesting a meeting with the Committee and today’s meeting. However, it is very relevant, because whatever recommendations and actions that we may put to the Department of Health on emotional well-being and mental-health promotion will, in all likelihood, have resource implications. As the Committee will know, in all cases concerning health expenditure these days, one must make an economic case as to why it is good value to spend on one particular issue and not on something else.

That brings us to the essence of the report that is before the Committee. The work that Michael Parsonage has done in producing that report takes us some way down that road. It makes the case as to why it is good sense to invest in mental-health promotion and prevention, as opposed to solely putting all the resources into dealing with psychiatric illness and ill-health.

One of the recommendations to come out of the Bamford Review is that there clearly needs to be a balance in mental-health spending, between resources for psychiatric hospitals, in-patient treatment and psychiatry, plus all the other services at the sharp end of the market, and the emphasis put on dealing with mental health and emotional well-being problems through groups, particularly, as I said, for young people. That balance may form part of the basis of the recommendations that we will put to the Chief Medical Officer in due course. The time frame that he has given me is very tight; he expects a report from my committee by the end of April, and we are doing our best to deliver on that.

The work that Michael Parsonage carried out in November 2007 directly impinges on my current work for the Chief Medical Officer. Therefore, I will hand over to him to take you through the report.

Mr Michael Parsonage (Sainsbury Centre on Mental Health):

Thank you, and good afternoon. I am very grateful for the opportunity to say a bit more about the report that Alan described. The report covers two main questions: first, it explores what the general economic case is for improving mental health through promotion and prevention; and, secondly, it explores specific priorities for interventions and policies in order to achieve that. I am aware that time is limited; therefore, as both those issues are covered in the briefing paper, I will concentrate mainly on the first question. Perhaps we can have a discussion on intervention if necessary.

To put it very briefly, the case for improving mental health rests on the argument that poor mental health imposes enormous costs on individuals, their families and the wider community. Any action that improves mental health will reduce those costs. If one follows the logic that a cost saved is the same as a benefit gained, the bigger the cost of poor mental health, the bigger the scope for potential benefits through promotion and prevention.

Why are those costs so high? There are three main reasons. First, there is the prevalence of poor mental health. At any one time, around one in four of the population is affected by what can be described as a diagnosable mental-health problem. Those problems affect all age groups pretty much equally, which is very different from physical ill health. Increasingly, physical ill health is a problem of old age; however, mental-health problems are just as common among people in their 20s and 30s, as they are among people in their 60s and 70s — that is a very different pattern of ill health.

Secondly, costs are so high as a result of the persistent nature of mental-health problems, many of which are long lasting, and can even endure over a whole lifetime. It is very clear that the earlier in life that those problems start, the more likely they are to persist.

Thirdly, poor mental health has a broad impact, affecting all aspects of a person’s life. Most obviously, it reduces the quality of life, and, again, that provides an interesting contrast to physical illness. The evidence seems to show that people can adapt to a physical health problem; for example, various adjustments can be made over time in order to live with a chronic illness. It has been observed that the effects of physical illness on the quality of life reduce over time. According to the evidence, however, that is not the case for mental-health problems. The distress caused, for example, by depression is the same after a year as it is after a week. There is no adjustment — the difficulties persist at the same level. Within that breadth of impact, mental-health problems seriously affect people’s performance at school and in the labour market, again, with enduring consequences.

Moreover, mental-health problems are associated with a range of harmful and antisocial forms of behaviour, such as alcoholism, drug abuse, delinquency and crime. Poor mental health is bad for a person’s physical health, because it increases the risk of many illnesses, including heart disease, stroke, cancer, diabetes and asthma. For example, it is estimated that depression and stress account for around 30% of the total risk of having a heart attack.

Poor mental health also means that the prognosis of physical illness is worse. Again, to give an example, stroke patients who are depressed are four times more likely to die within six months as stroke patients who are not depressed. Depression has a dramatic effect.

Mental-health problems are damaging to personal relationships, and they are a major cause of social exclusion. Sadly, all those problems are compounded and magnified by stigma and discrimination — again, a clear difference between mental-health problems and physical illness.

For those three reasons — the prevalence, persistence and breadth of impact — mental-health problems impose substantial costs on society, and there is good evidence to show that those costs are bigger than for any other health condition. The World Health Organization (WHO) has carried out work on what it calls the “burden of disease”, which recognises that ill health has two dimensions. The first is the mortality effect, where ill health can lead to premature death, and the second is the morbidity component that ill health has non-fatal outcomes as well, such as disability, pain and distress. WHO has combined mortality and morbidity into a single composite measure and used that to quantify what it calls the burden of disease, and divided that up among different health conditions.

That shows that, in the UK and other Western countries, mental illness now accounts for a bigger share of the overall burden of disease than any other health condition. It is bigger than heart disease and cancer, and miles bigger than any other chronic condition such as diabetes, rheumatism or arthritis. Mental illness contributes more to the overall burden of disease than smoking and drinking combined, and it contributes about three to four times as much as obesity. People are recognising obesity as a major public-health problem. However, in comparison with mental-health problems, I will not say that obesity is trivial, but it is much smaller.

The share of mental-health problems in the overall burden of disease is increasing over time. That is due mainly to the fact that death rates from the two big killers — heart disease and cancer — are falling. Those conditions are therefore becoming relatively less important in the overall burden of disease, resulting in a higher share for mental illness and other chronic conditions.

Overall, mental-health problems account for 20% of the total burden of disease. In comparison, NHS spending on mental health in Northern Ireland is about 10% of the total health budget. Mental illness accounts for 20% of the health burden yet attracts 10% of the health budget — a rather striking difference.

Another way of looking at the costs of mental-health problems is to express them in monetary terms. There are three main components of cost. First, there is the cost of health and social care for people with mental-health problems, which is mainly NHS spending but also an imputed value of the informal care provided by family and friends. Secondly, there are the losses of output in the economy, which are the result of the adverse effects of mental-health problems on people’s ability to work. Thirdly, there is the monetary value of the rather intangible, but crucially important, human or personal costs of mental-health problems that affect the quality of life.

Combining all those components, the total cost of mental illness is now estimated at well over £3·5 billion a year. In monetary value, that is equivalent to almost 12% of Northern Ireland’s national income, and it is more than the total amount that the NHS spends on all health conditions combined. Similar work in England has found that mental illness imposes bigger costs on society than all forms of crime added together — another striking finding.

Those figures show the cost of mental-health problems in any given year. Another approach is to look at costs over the lifetime. Mental-health problems are often persistent and long lasting — especially those that start early. There is plenty of evidence to show that there is strong continuity between adverse mental-health states in childhood and adverse mental-health states in adult life. Of all adults with a mental-health problem, about half of them first had a diagnosable mental-health problem by the age of 15, and three quarters by their late teens.

The most common mental-health problem in childhood is conduct disorder, which affects around 6% of all children, and that persists into adulthood in around 40% of cases, with a wide range of adverse outcomes, particularly of a criminal nature. Calculations in the report suggest that preventing one single case of conduct disorder would, over the lifetime, yield savings to society of about £150,000.

Effective evidence-based interventions, in the form of preschool parenting programmes, are available at a tiny fraction of that cost — about £6,000 a child. Therefore, we can see how great the benefits are — £150,000 is the potential benefit for an intervention that costs £6,000. Even if those interventions are not very effective, they are still extraordinarily good value for money. On value-for-money grounds, a success rate of only around one in 25 is needed in order to justify spending money on those programmes. Interventions can have a very low hit rate and still be an extremely good use of resources. Not surprisingly, those kind of very early interventions, preschool interventions in particular, emerge very strongly from the evidence as the single best buy in any kind of mental-health promotion and prevention programme.

I have tried to persuade the Committee that poor mental health imposes very large costs on society. You may feel that that does not quite clinch the case for spending a great deal of money on promotion and prevention, because there is always the alternative of dealing with mental-health problems after they arise, through treatment and care. If treatment were effective, that would conceivably be a sensible approach, but all the evidence points the other way.

In the report, we refer to an interesting Australian study that has examined that issue. It attempted to work out how much of the overall burden or cost of mental illness can be averted by treatment, and its conclusions are rather depressing. The study found that even if everyone with a mental-health problem received treatment, which is far from the case at present, in this country as it is everywhere else, and even if every treatment were in line with best practice, which, again, is far from the case, only about 40% of the overall burden of mental-health problems would be averted. Therefore, even if there were gold-plated mental-health services, providing the best treatment for everyone who might benefit, we would still be left with at least 60% of the cost of mental illness. The problem cannot be dealt with through treatment, because the treatment is simply not effective enough. The rather clear conclusion is that if we want to make any real progress on reducing the enormous costs of poor mental health, there really is no alternative to our making a much more concerted effort on prevention and promotion.

Mr Ferguson:

I do not want to add too much to that, because I do not want to prejudge the outcome of the work that I am doing for the Chief Medical Officer. Michael Parsonage makes a fairly compelling case, and it means that we must seriously examine interventions to improve the mental health of the population at large. That would potentially involve early interventions, and much earlier interventions than we have been used to in Northern Ireland. We must listen to the evidence that is available on issues such as parenting skills and intervening with young people in order to build their emotional resilience at an early age to complement any direct service interventions. I am sure that, from time to time, the Committee hears about those issues from witnesses, as they concern services in psychiatric hospitals, and so on. Therefore, the case has been made. In many ways, it is unanswerable. The next question is to decide on the best way in which to apply interventions that deliver. We must also consider the role of schools, parents, the workplace, and so on.

The other challenge, particularly for politicians and Ministers, is, in many ways, to adopt a generational approach — we can infer that from what Michael said. Quick fixes may not be the solution. We must invest for the long haul and make interventions that show financial benefits only over a lifetime. The real challenge for all of us, whether we are decision-makers like you, resource allocators, lobbyists or whatever, is not only to intervene in situations of crisis and acute need but to balance that with a long-term approach, over a generation. We must look to the future health benefits for children now and for their children. The challenge is to examine that matter and devise strategies that will deliver. That is part of what I need to deliver for the Chief Medical Officer.

It would be of tremendous assistance if this Committee, which leads the health cause in the Assembly, supported us in our work. It would be useful if we had another chance to speak to the Committee about what we have come up with when the report comes before the Chief Medical Officer. That concludes our presentation, and we are happy to answer any questions that the Committee may have.

The Deputy Chairperson:

Thank you very much for your presentation. You have highlighted some startling statistics. Your solution comes across as very simple: just go and do it. The challenge for us is to deliver on that.

My first question concerns whether interventions should be targeted or made on a population basis. You said that whole-population intervention is the approach that must be taken, and I understand the arguments for that. However, you also said that more than half of people who are diagnosed with a mental-health problem receive that diagnosis before they are 15 years of age. Is that an argument for making targeted intervention at age 15?

You spoke about the need to target schools, which is where children under the age of 15 can be reached. The Department of Education is rolling out a programme, although that is in its infancy, and I do not know how successful it has been to date. I would like some more information about that. Furthermore, what is the make-up of the group that was set up to consider the new strategy?

Mr Ferguson:

I will address your second question and let Michael consider the first question. We are dealing with the strategy in three ways. We have set up a core group of people, all of whom work with young people. Graham can help me if I leave anyone out, but that group includes: a headmaster; a representative from the suicide-prevention implementation group; a consultant psychiatrist; Moira Davren, who chaired the child and adolescent report for the Bamford Review; and Clare Mangan who works for young people in the South Eastern Education and Library Board. The core group, therefore, contains a mixture of people from various backgrounds.

We also have a wider reference group of people who are practitioners on the ground. We will be writing to those people and asking them to complete a questionnaire. That will give them the opportunity to feed directly into the process with their views on the strategies being delivered and the questions that the Chief Medical Officer has asked me.

The third group is made up of external advisers, such as Michael Parsonage. That group also includes: Professor Margaret Barry from the University of Galway; Gregor Henderson, who worked with the Scottish Executive to deliver their mental health and well-being campaign; Lynne Friedli, who was Michael’s colleague in producing this research; and Professor Phil Hanlon from the University of Glasgow, who is a public-health specialist.

In summary, then, there is a core group that is steering the process, a wider reference group and a group of external experts. We are also taking evidence from various people. We will be meeting Colm Donaghy to discuss the issue of suicide prevention tomorrow morning. Michael is speaking to the group, we have had Gregor Henderson over from Scotland, and we will also be meeting Dr Brian Gaffney from the Health Promotion Agency.

The difficulty is that the timescale for the report is so short. We must be focused and targeted in dealing with the challenge that has been put to me by the Chief Medical Officer. Michael may now want to say something about young people and schools.

Mr Parsonage:

You said, Deputy Chairperson, that it is obvious what we should be doing. The intellectual case for early intervention can probably be quite easily appreciated. Many people have now accepted our argument, but nothing has happened yet in any part of the UK on any grand scale. That highlights the problem, which is not accepting the case for early implementation but the practical difficulties of implementation. A sophisticated infrastructure is required, and that takes a bit of time to build. Many professionals need to be trained in new ways of working, and so on. It is important to recognise that a gap exists between thinking that this is the right thing to do and its actually happening.

The question of population-based versus targeted approaches is pretty central to that entire area. There is no single answer. If I want to make the case for a population-based approach, I may make several arguments. First, it is difficult to identify in advance who is likely to develop a mental-health problem. We are aware of certain risk factors; however, we cannot say with 100% certainty, or anywhere near it, who will develop a mental-health problem before it happens. Therefore, in a sense, if one targets an approach at the entire population, one can be certain that it will identify everybody with a problem.

Secondly, targeted programmes can give rise to stigmatisation. In effect, particular families will be told that that they look after their children so badly that those children will develop problems. Therefore, if children are visibly identified as having a problem, that can create obvious difficulties.

Thirdly, there are many settings, such as schools, where it is much easier to target a programme at an entire group, rather than at a subgroup. Evidence shows that mental-health promotion in schools works best on a whole-school basis by aiming to change its ethos. That does not require that one hour of the curriculum should be set aside each week for mental-health promotion; rather, it is to do with the way in which staff react and relate to pupils, and how pupils relate to one other. It is much easier to apply that to an entire group rather than to one little group.

Therefore, there are good arguments for doing that, particularly in early-years settings in schools, where all the pupils are in one place. Similarly, evidence shows that workplace interventions work best when they are targeted at the entire workforce rather than at a particular section of it. It also depends quite a lot on the type of intervention.

Mr Ferguson:

One lesson that we learned from the Bamford Review was that, although there was nothing particularly wrong with previous strategies, they failed because they were not implemented. The resource and drive to take those strategies forward, and to achieve and apply their targets, did not happen in a significant enough way. Again, without prejudging my group’s outcome, we will probably remark on that issue. Often, that has been the missing link.

As Michael has said, the case, to a large extent, has been made and the evidence exists. Few people will argue against early intervention to help people with their emotional development — the trick is to do so and to get the necessary commitment. I wonder whether the review of public administration (RPA) and the establishment of the regional agency for public health and social well-being will bring focus to the issue. I also wonder whether the person who will chair that agency, and the people who will be executives in it, will be challenged with delivery of those measures. That focus may not have existed previously.

During the Bamford Review, we learned from other jurisdictions, particularly from the Scottish example. It seems to work better than most — locally, at least — because the Scottish Executive drive it. There is no shortage of examples from all around the world, so it is a matter of delivering mental health and well-being and having the commitment and the resources to do so.

You mentioned the Department of Education. You are quite right — it has set up a series of working groups under the health and well-being strategy, which aims to promote pupils’ emotional health and well-being. Again, we can be hopeful about that.

Previously, some people around the table have heard the argument that has been implicit in what we have said. I want to make that argument explicit. Although we are in front of the Committee for Health, Social Services and Public Safety, mental health and well-being is not just an issue for the Department of Health, Social Services and Public Safety; it is an issue for your colleagues on the Committee for Education and the Committee for Social Development, which deals with housing, and so on.

There are many links between mental and emotional well-being and other social determinants. For example, someone who is unemployed, who has a poor education and who lives in a poor community that lacks social capital will be at risk of mental-health problems. Therefore, although the Department is the lead agency, it is not just a matter for health and personal social services. It must be grasped across Northern Ireland’s Executive, in all their Departments and Committees.

Steps are being taken. Good things are happening, such as the Department of Education’s initiative. However, good initiatives — such as the health-promoting schools initiative — often do not reach fruition, because they are time limited, have no longevity and have no core driving force to advance them. Therefore, without prejudging my own report, we may be making such comments again.

Mr McCallister:

The presentation was very interesting, and we all share your concerns about the problems around early intervention. Alan, I agree wholeheartedly that it is a cross-Government matter, involving the Department for Employment and Learning and the Department of Education, as well as the Department of Health, Social Services and Public Safety. As the Deputy Chairperson stated, the estimated £3·5 billion cost of dealing with mental-health problems in Northern Ireland is startling, for our entire health budget is only £4 billion. That is a staggering sum of money. In addition to the economic case for substantial investment in mental-health promotion, there would be much better long-term outcomes for involved individuals.

Like others, I agree that the challenge is to move from our present position to where we want to get to and where the document ‘Mental Health Promotion: Building an Economic Case’ wants to see us go. As you said, achieving that will involve much more than treatment — there should be promotion of flourishing mental health, which will require a sea change in attitudes across Northern Ireland.

Mental health is a key issue that we must get to grips with, so can you expand on the roles that you would like to see the new regional agency take on? That is why we have been so supportive of the establishment of a regional agency — it will be able to shine a light on issues such as mental health and ensure that various parts of Government work to deliver the agenda that we want. Do you envisage a regional agency’s ensuring that strategies and targets are adhered to and progressed? That is important, because mental health is an issue that Departments have left, owing to its cross-cutting nature.

Mr Ferguson:

One of the problems that the Bamford Review highlighted was the disparate approach to mental-health issues, which was at such a level that it was difficult to see a cohesive way in which to address them. I do not know enough about how the new regional agency will work, but there is hope that it will have an executive capacity, which has been lacking until now. If the Department decides to use the report to set the proposed regional agency’s agenda, there is hope that its chief executive will try to take forward its recommendations.

It is to be welcomed that the new agency will have “public health and social well-being” in its title, because, although we often say that we are talking about health, we spend most of our time talking about illness. As you said, a sea change is required — we must promote health and well-being. If that is what the proposed regional agency will be tasked with, mental-health promotion is the type of issue that we will have grasp and take forward. Another recommendation from the Bamford Review that we agree with is that someone, or some agency, should have the responsibility and the accountability to advance such issues. If that responsibility fell to an agency such as the regional agency, it would be a step in the right direction, because that is what was lacking in the past — no one was accountable or responsible for delivering those targets.

I think that that may have been a shortcoming in the past. I am not really sure how the agency will work in detail. As part of the Chief Medical Officer’s review, we are seeking a meeting with the new chief executive of the proposed regional agency for public health and social well-being. I believe that he has been appointed, so we wish to put some of those questions to him.

Mrs Hanna:

Good afternoon, you are all very welcome. It would be great if that new agency could be used as a vehicle, and I welcome the work being done with the Chief Medical Officer. Although they were so wide that it was difficult to know what was happening, we are all pleased that the Bamford recommendations are in place. However, we seem to have reached a hiatus. Michael very clearly illustrated the cost benefits and highlighted the difference it would make if even one child with a conduct disorder were to have disorder that corrected. The cost must be quantified, and it should include the potential for specific teacher training and for introducing a programme into the curriculum, in the same way that we are trying to introduce civic development. Perhaps training for midwives, or other people who have the opportunity to intervene at a very early stage, should also be included.

Intervention must happen; however, it is a question of commitment, especially financial commitment. As you know, it is very hard to get money up front. In some ways, it is easier to pick up the pieces afterwards, although, ultimately, that costs more. It is worth considering that this Committee could work with the Committee for Education, on a cross-Committee basis, focusing specifically on early intervention in mental health. Intervention must be talked up so much that it cannot be ignored. We know that that must happen, but what can we do about it?

I am trying to think of practical ideas. The Committee often talks about working across Departments but, as yet, has done little about that. There is a great deal of concern around the budget for mental-health prevention and promotion, and no Department wants to take on extra pressures. However, if those pressures were shared between two Departments — mental-health issues are covered by other Departments, but they are primarily the concern of the Department of Education and the Department of Health — an agreement to share a budget could be reached. That needs to happen, and this Committee could try to start that process.

Michael, you said that, even if best practice is followed, 60% of the overall burden of mental-health problems remain. That includes people with conditions such as schizophrenia, for which there is no — for want of a better word — cure. Is that where the bulk of resources would go?

Mr Parsonage:

Yes. Most spending on mental health focuses on the severe end of the scale, on conditions such as schizophrenia, bipolar disorder, and so on. Although much can be done to address the symptoms of those conditions, you are right when you say that there is not really a cure. The problem, therefore, is always there, and long-term care is required. That is why it is so expensive.

Mr Graham Logan ( Northern Ireland Association for Mental Health):

This year, the current spend on mental-health promotion in Northern Ireland is £700,000. The proportion of the health budget spent on mental-health promotion is exceedingly small.

Mrs Hanna:

Much of that money goes toward tackling lifestyle challenges such as smoking — to some extent, we have got to grips with that — alcohol abuse and obesity, rather than mental health. It comes back to what we, as a Committee, can do.

Mr Ferguson:

It would be tremendous if there were a way to link this Committee with the Committee for Education, because there is no doubt that those two Departments are the key players. Without prejudging the recommendations that we may put to the Chief Medical Officer, it seems likely to me that young people and mental-health issues will be an important element of those. Indeed, we are planning a conference on 9 March 2009, to look at early years and schools. In due course, we will send invitations to this Committee and to the Committee for Education. Anything that the Committee could do — or that NIAMH could do to help the Committee — to promote such a relationship between the two Committees would be tremendous.

Mrs Hanna mentioned the Bamford Review, which was a huge exercise. There has never been anything like it, and there may never be anything like it again. The review produced a considerable stack of reports, and I can appreciate how difficult it is for decision-makers and resource allocators to decide what to do with all that information, and where to concentrate their focus.

I am trying my very best to ensure that NIAMH’s report to the Chief Medical Officer is focused and targeted, and comes up with some clear-cut recommendations on the way forward. It may not cover every possible avenue of intervention for every possible setting, but we must focus on where we will obtain the most return for our investment. I go back to what John McCallister said — we have to start somewhere in the midst of this sea change. The report on mental health that formed part of the Bamford Review was hugely important, and it raised awareness of mental health to a higher level than I have ever witnessed in my working life, but it was a very broad report, and we must now try to concentrate our focus.

Mr Gardiner:

The NIAMH report is very well presented. It refers in its references section to a 2004 document by S Stewart-Brown titled ‘Mental health promotion: childhood holds the key?’ That is important. Can we obtain a copy of that document? Many of us are involved in primary schools, but I have never come across that document. We have a responsibility to obtain it and alert our teachers and principals. They must know what to look for so that they can arrange for a child to be referred for treatment and seen urgently. I would like to see that document. Many people have gone through childhood without treatment, and if we are to tackle the problem, we must get in at ground level.

Mr Ferguson:

We can furnish the Committee Clerk with a copy of that document.

Mr Gardiner:

Thank you. I appreciate that.

Mr Parsonage:

It is important to get the message across to teachers, and to the education establishment in general, that identifying mental-health problems is in their interest, aside from the health issues. We know that children who have mental-health or emotional problems perform badly at school. If schools, quite rightly, wish to raise standards and levels of achievement, raising awareness of mental-health issues is a very effective way in which to that.

The same applies to children with conduct problems. Children who are disruptive in school affect everyone’s performance. There is a shared agenda here: if this Committee and the Committee for Education are to work jointly on those issues, that is the starting point. It is not about imposing a health agenda on education; rather, it is something that will promote both agendas at the same time.

Mr Gardiner:

I am involved in two primary schools. My concern is that a disruptive child who is put into a special class could have a mental-health problem rather than a behavioural problem. I want to explore that and learn more about it.

The Deputy Chairperson:

Thank you. That concludes our question and answer session. We should try to arrange a joint Committee meeting at which you could present the finalised report. We will take the lead and get that off the ground.

Mr Ferguson:

Thank you very much for your time.