REPORT TO THE HEALTH AND SOCIAL CARE COMMITTEE- POST LEGISLATIVE SCRUTINY OF THE MENTAL HEALTH (WALES) MEASURE 2010.
Background
The Mental Health (Wales) Measure 2010 (the Measure)[1] is a unique piece of legislation. With all party support it was designed to provide a legal framework to improve mental health services in Wales. Implementation of the services required by the Measure began, on a phased basis, in January 2012.
Section 48 of the Measure places a duty on the Welsh Ministers to review specific sections of the Measure. An Inception Report[2] was produced in 2013 which described the method proposed to fulfil that function: a collaborative process of review which could evolve and develop over time. Stakeholders were invited to suggest additions to, or changes in, the proposed evaluation process described for each of the Parts
An Interim Report[3] produced by Welsh Government was published in April 2014. This was primarily designed to note the findings to date and will contribute to the final report, for presentation to the National Assembly for Wales, which will be published prior to January 2016.
As with any new legislation some time is required both for the legal requirements to become embedded into service provision, and for the vision underpinning it to become a reality.
Creating services which embody empowerment and choice, as well as supporting recovery and maximising independence, are essential to creating a respectful society that both values, and celebrates, our differences and the contribution of all.
Encouraging emotional wellbeing, placing the importance of mental health on a par with physical health, providing effective and helpful services at an early stage, as well as ensuring those in need of specialist services receive the highest quality of care and treatment are central to the delivery of the Measure.
Further background can be found at Annex 1.
Theme 1 (achievement of stated objectives):
1a.
Do primary mental health services now provide better and earlier
access to assessment and treatment for people of all ages?
Are there any barriers to achieving this?
Before the introduction of Local Primary Mental Health Services (LPMHSS) in October 2012, there was no consistent mental health provision available at primary care level. Some local health board areas had limited services available, others had none. Information sought from local health boards during scoping work for the Measure regarding the availability and type of services offered was not available in a consistent format.
However, prior to the commencement of LPMHSS, and subsequently, work has been undertaken with key stakeholders to develop mechanisms by which both a qualitative and quantitative analysis of the services required under the Measure could be provided. These included:
· stock take of compliance with legal requirements of Part 1;
· quantitative analysis of performance measures developed with Welsh Information Standards Board;
· service user, carer and GP satisfaction surveys;
· third sector analysis and surveys;
· independent commissioned research and
· task and finish group
The findings were reported in the Interim report, the main findings for Part 1 were:
· All local health boards and their partners were able to provide evidence they were compliant with the legal requirements of Part 1 of the Measure.
· The majority of service users who had received LPMHSS positively rated the service they received.
· LPMHSSs needed to achieve a balance between undertaking assessments and the provision of appropriate and timely interventions.
· Foundation/Tier 0 level services were providing open access community based groups which empower individuals to get support at an early stage.
· There was some concern that certain practitioners were not allowed to undertake LPMHSS assessments. For example non mental health nurses working in CAMHS.
· Work to support GPs and primary care staff in understanding and developing knowledge of mental health issues and access to specialist advice remained a priority.
· A clear interface and communication process between primary and secondary services would be critical to ensure no service users fall through the ‘gap’.
Current quantitative performance information.
All local health boards submit aggregated performance information to Welsh Government on all 4 Parts of the Measure on a monthly basis via data collection forms ratified by the Welsh Information Standards Board[4].
Data collection systems across local health boards and local authorities in Wales vary significantly from paper based collation of information to comprehensive Information Technology system and work has been undertaken to improve the quality of the data available.
In order to support the development of the new LPMHSS, specific targets were set under the NHS national delivery framework.
1. The percentage of assessments undertaken within 28 days from receipt of referral against the 80% target waiting time. (56 days until October 2013)
The graph below shows the number of patients being assessed within 56 days of referral, between April 2013 and September 2013, was fairly constant at 89% -91%. This target was reduced from 56 days to 28 days in October 2013 and performance against this target improved from 53% in October 2013 to 71% in August 2014.
Between April 2013 and August 2014, 45,900 primary mental health assessments were undertaken, on average, 2,700 per month.
Local health boards are now working to achieve a balance between undertaking assessments and undertaking timely interventions alongside the other primary mental health functions, (onward referral, provision of information to patients, carers and primary care staff and support for primary care practitioners) required under the Measure. They have agreed to share the details of their services and their action plans for improvement with Welsh Government and each other. I am encouraged by this spirit of co-operation.
2. The percentage of therapeutic interventions started within 56 days following assessment.
This indicator assesses the length of time waited for therapeutic interventions, whether delivered on an individual or group basis, provided by the local primary mental health support services following assessment against the 90% target waiting time of 56 calendar days. The total number of interventions provided during the period April 2013 to – August 2014 was 21,670, an average of 1,274 per month.
Following the publication of the Interim report my officials wrote to local health boards and local authorities detailing expectations of the enhanced monitoring arrangements which would be needed to continue to improve services.
This will include a revised stock take document developed to specifically consider:
· The provision of advice, information and training for GP’s and other primary care staff
· The type, level of training and specific mechanisms needed to enable comment of the competency of staff
· A clearer understanding of Part 1 services being provided to all ages, needs and settings, including children and young people and those with a learning disability.
Further developments
Foundation level/Tier 0 Services
One of the significant developments over the past 12 months has been the increase in the availability of open access groups which help people cope with stress, anxiety and depression. For example, in Cwm Taf they have run 32 courses this year, most with between 30 and 80 attendees with a completion rate of over 90%. The ‘ACTion for Living’ course in Cardiff and the Vale developed by Dr Neil Frude has run large scale groups in church halls and community centres. These 2 hour sessions provide the health board with a way to provide effective therapy in an efficient manner to large numbers of people in the community who might be termed a “less severe” mental health problem who might not normally be able to access more specialist mental health services.
Barriers
Providing services within and alongside primary care services has required those delivering mental health services to consider a different model and concept of care. That model is not a traditional secondary mental health model rather one which incorporates key elements of primary care. It was clear close working arrangements with GP colleagues was needed to understand these concepts. To support this cultural change an All Wales Curriculum for Primary Mental Health Workers[5] was developed to provide an accredited, flexible and transferable education programme. It standardised the knowledge and skills required by Primary Mental Health Workers and is recognised nationally.
It is of note, whilst there are improvements that need to be made; (particularly in relation to access to psychological therapies) that engagement with GPs has improved. For example, in Aneurin Bevan Local Health Board over half their GPs responded to a LPMHSS satisfaction survey and of those over 84% positively rated(strongly or partly agree) the service they were receiving from the LPMHSS.
The LPMHSS is developing well; however, given the variation across Wales in terms of services preparedness to provide the new service, it has taken some services longer than others to develop clear referral pathways. The ability of services to meet demand in the current climate of economic austerity will continue to be challenging. However, this has been materially assisted by the creativity and flexibility of teams in offering this service. This has varied from telephone assessment and intervention, which can be particularly helpful for those living significant distances from their GPs, to evidenced group work and individual therapy. Supporting individuals to use community resources will continue to be crucial to these endeavours.
Practitioners’ eligibility to undertake LPMHSS assessments was prescribed in subordinate legislation; specifically, that the practitioners who could undertake holistic mental health assessments, which would also involve an assessment of risk, were required to be from specific regulated professions, as well as having evidenced competence to provide that service.
There have been suggestions from some sectors that the eligibility criterion has been too prescriptive; particularly from those who provide services for children and young people. Ensuring staff have the knowledge and skills to provide inclusive, effective and safe assessments for children and young people are essential. It underpins our work to improve CAMHS provision and supports our commitments under the UNCRC. A task and finish group has therefore been considering the current eligibility criteria for practitioners, and I will receive that report in late November.
1b. What has been the impact of the Measure on outcomes for people using primary mental health services?
As part of the qualitative evidence base for reviewing the Measure local health boards have been asked to provide Welsh Government with the results of local surveys undertaken to assess satisfaction with LPMHSS services. Tools were developed with the assistance of practitioners, the Part 1 Expert Reference group and service users.
Service User Satisfaction
On average over 95% of service users across Wales positively rated the LPMHS services they had received (strongly agreed or partly agreed) across the 10 questions.
Service users also had an opportunity to comment on what was good about their care, what needed improving and any other comments. Some examples are given Annex 2.
Specifically:
|
Question |
Average percentage of service users who positively rated services. |
|
The staff listened to me and took my concerns seriously |
99% |
|
I felt I was treated with respect |
99% |
|
The information I received was very helpful |
96% |
|
It is easy to get to the place where I have my appointment |
97% |
|
The appointments are usually at a convenient time |
95% |
|
I felt involved in making choices about my care and/or treatment |
96% |
|
The service helped me cope with my problems |
89% |
|
I feel the people who have seen me are working together to help me |
94% |
|
The facilities are comfortable |
96% |
|
I would recommend this service to other people
|
97% |
The survey results indicate high levels of satisfaction amongst the majority of people receiving LPMHSS, and support the Gofal findings[6] that though there is ground to be gained in the provision of mental health services at a primary care level, understanding, awareness and therefore the ability to receive the right level of service is improving.
Further Outcome Measures
All local health board areas have stated they have agreed methods of evaluating the outcomes of their interventions. Local health boards and partners had previously decided they did not wish to use the same methods of evaluation across Wales. They have recently agreed to find ways of sharing this information in order for there to be a clearer understanding of the impact of this part of the Measure and these finding will inform the final Duty to Review report. I intend to keep this under review.
Independent Commissioned Research
A research project has also been commissioned from an independent body, Opinion Research Services (ORS) The research is being undertaken over the period, July 2013 to October 2015 and considers all 4 main parts of the Measure from the perspective of service users, carers and practitioners. Integral to this will be the experience of Welsh speaking and bilingual service users and carers. This will add a key independent element to the evaluation of the Measure. The objectives of the research are set out in the Inception Report. A scoping report was published in April 2014; its broad findings are referred to in the Interim report and can be found at Annex 3
1c. What has been the impact of the Measure on care planning and support for people in secondary mental health services?
The Mental Health (Wales) Measure 2010 was created, in part, to respond to concerns from service users, their families and third sector organisations that Welsh Government guidance regarding the use of the Care Programme Approach was not being followed with any consistency.
A Code of Practice to Parts 2 and 3[7] of the Measure was produced to support implementation, which began in June 2012. The Code was developed with the involvement of service users, practitioners and third sector organisation in Wales and in addition, independently produced learning resources for practitioners and service users were provided throughout Wales.
In the Interim report the main findings were reported as:
· All local health boards and their partners provided evidence they were compliant with the duty to review legal requirements of Part 2 and 3 of the Measure.
· Performance information data suggested that 89.8% of those in need of a care and treatment plan had one that had been completed and/or reviewed in the previous 12 months.
· Many of those in older adult, learning disability and child and adolescent mental health services did not previously have a specific mental health care plan. This landscape has changed significantly with reported compliance of over 90% in those areas.
· Now that Care and Treatment Plans (CTP) were in place for most people, it would be critical to support all those involved in ensuring the quality of those plans and the interventions required to support them. This would need to be evaluated by service users, service providers and independent bodies.
· There is some concern that certain practitioners are not able to undertake the care co-ordination role, for example art therapists, and that the actual words used in the prescribed care and treatment plan might not be suitable for all groups of service users.
· A clear interface and communication process between primary and secondary services would be critical to ensure no service users fall through the ‘gap’.
· It is essential that those discharged from secondary mental health services and others involved in supporting them are aware of the provisions relating to discharge plans and method of re accessing services.
· Services needed to ensure they have robust procedures in place to support timely re-access for assessment.
Current quantitative performance information.
As at August 2014, 91.8% of patients (set against the NHS Delivery framework target of 90%) had a valid CTP, reflecting an upward trend which demonstrates compliance with the Measure requirements has steadily increased (a valid CTP is one which has been completed within the last 12 months).
Barriers
Some of the criticisms levelled at Part 2 of the Measure have also been the issues others have identified as its most positive features. That is, having a named care co-ordinator and having a holistic prescribed care and treatment plan. Some psychiatrists have stated they have found the role of care co-ordinator one which they have not always felt qualified to undertake. This is being addressed via the training requirements which are being reviewed and joint work with Part 2 leads.
A co produced training package was developed by the University of Lincoln and this training material has been made available to practitioners across Wales and specific training provided for those in Learning Disabilities Services. A task and finish group, with representation from all stakeholders is currently considering care co-ordinator eligibility and the content and form of the prescribed Care and Treatment Plan. A practitioner led group is looking further at training requirements.
1d. Has there been a change to the way in which service users in secondary mental health services are involved in their care and treatment
Hafal, in their survey of people’s experience of Care and Treatment Planning, found where people have been involved in the development of their own Care and Treatment Plans (CTP) they feel more empowered and more in control. Service users and carers have described the commitment and support they receive from health and social care professionals and how important and valued good CTPs are by service users.
The quality of CTPs can vary, with some not always focused on achieving short and long term goals. There has been a range of comments from service users from those who had little or no involvement in completing their CTP to people being fully involved and invited to co write their own plan.
A recently convened working group is meeting in November 2014. It will seek:
- Support from stakeholders to revise the Part 2 and 3 stocktake document specifically to consider the type, level of training and specific mechanisms needed to enable comment on the competency of staff and whether a specific training module in care co-ordination should be developed.
- Support from stakeholders to consider satisfaction scales for Part 2 and 3 services- there will be an expectation that information is provided on service users and carers’ satisfaction with services. It is envisaged a template will be developed for potential use across Wales.
- Support from stakeholders to demonstrate that the legal requirements regarding Part 3 are being met (including compliance with timescales) – it is envisaged that a template to gather information to assure local health boards, Partners and Welsh Government will be developed.
- Support from stakeholders specifically to consider how the quality of Care and Treatment planning can be demonstrated, developed and led (by, for example, engaging with psychiatrists and other leaders within particular services).
The above will apply across all service areas and settings including, for example, the prison estate and older adult services.
1e. What impact has the Measure had on service users’ ability to re-access secondary services? Are there any barriers to achieving this?
Currently all local health boards are reporting compliance with the standard set within the NHS Delivery Framework which states:
Local Health Boards to provide assurance that:
· Individuals are re-assessed in a timely manner as described in the Code of Practice to parts 2 and 3 ; and
· A copy of a report to that individual is provided no later than 10 working days following the conclusion of the assessment in 100% of cases.
Since April 2013 on average 105 service users have requested a re assessment of their mental health following discharge from services each month. Of these, on average, 43 have moved back into secondary mental health services. The independent research commissioned by Welsh Government will report on the experiences of service users, their carers and practitioners in relation to Part 3 (arrangements for assessment of former users of secondary mental health services) and to consider, for example:
• whether the relevant discharge period for Part 3 proving to be appropriate;
• how well service users have been informed of their entitlement to assessment
following discharge;
• the experience of reassessment.
Barriers
It was initially reported there had been some confusion amongst a few people discharged from secondary services regarding their entitlement. The information about discharge and Part 3 being provided, at least for some people, was not being read or understood. It was suggested that written advice and information were insufficient and that real engagement person-to-person would be necessary for many service users and particularly those with limited literacy.
The task and finish group for Part 3 is specifically looking at the age at which a person can request an assessment. Currently this provision only applies when a person is 18 or over. The UNCRC makes clear that children and young people must be given the same rights of access to services as any one else and this principle will be central to the review of this Part of the Measure.
1f. To what extent has the Measure improved outcomes for people using secondary mental health services?
All local health boards have formally confirmed they either have or are developing processes for ascertaining the satisfaction of service users and carers within secondary mental health services.
Demonstrating outcomes from a service user lens is a key element of the mental health data set, central to ‘Together for Mental Health’[8]. The selection of tools for assessing outcomes has involved wide consultation with stakeholders, starting with the views of service users themselves. This priority was established by Welsh Government in response to consultation on the Strategy and the Measure.
The aim of this work is to enable service users to monitor and report upon the achievement of the outcomes agreed in their care and treatment plans. This will:
•build on and complement Care and Treatment Planning with its focus on the co- production of specific, measurable, achievable, realistic and timely outcomes;
•use an established, validated survey methodology that is easy to implement, analyse and interpret from the perspective of both the service user/carer and practitioner;
•allow for comparison between service user self assessments and practitioner/therapist rated assessments so as to enable the future development of a robust system of outcome evaluation.
Public Health Wales 1000 Lives Plus Improvement Service has worked with the third sector and service user groups and it was agreed to pilot methodologies using Goal Attainment Scaling (GAS) and Goal Based Outcomes (GBO).Both GAS and GBO were piloted widely during 2013-14 across the range of mental health services for children and young people, working age and older adults, including primary mental health service settings and this led to adaption to the tools developed.
Based on this learning, a ‘How to’ guide has been prepared to support baseline training for implementation of these tools in relation to CTP. This also acknowledges the limitations on their use, for example for people with a cognitive impairment. Learning Disability services are currently piloting the Health Equalities Framework as their preferred approach to outcome evaluation.
In implementation Phase 1, local health boards have been asked to implement GAS and GBOs, in teams across Wales, the details of which are being finalised. In September 2015, Public Health Wales will review the experiences of these teams in implementing these approaches and, based on their feedback, adjust the tools and their use accordingly. This will be key to addressing concerns which have been raised about there not being clear enough outcome based data.
Barriers
I am aware that the Royal College of Psychiatrists have commented some of their members consider the distinction between primary and secondary services to have been unhelpful. They have stated in some areas some people have been ‘re-labelled’ and moved from secondary care services into primary care without due regard. My view is that decisions regarding the appropriate level of service provision should always be on the basis on clinical need.
1g. To what extent has access to independent mental health advocacy been extended by the Measure, and what impact has this had on outcomes for service users? Are there any barriers to extending access to independent mental health advocacy?
Part 4 of the Measure expands the support available from an Independent Mental Health Advocate (IMHA) to inpatients receiving treatment for their mental disorder and those subject to the Mental Health Act 1983[9], and places the duty upon local health boards to provide such services.
By expanding statutory advocacy services to ensure that access is available to all inpatients receiving treatment for mental ill-health, whether subject to compulsion or not, Part 4 of the Measure seeks to ensure the rights of this often vulnerable group of patients are safeguarded. Statutory advocacy assists inpatients in making informed decisions about their care and treatment, and supports them in getting their voices heard.
All local health boards in Wales have confirmed they have arrangements in place to ensure advocacy is available to qualifying patients. These have largely been developed using the National Commissioning Framework[10] to work towards increasing parity of service across Wales. The Part 4 Commissioners meet on a regular basis to review their services and have developed effective working relationships with their providers.
Each local health board has confirmed the IMHAs providing services meet the appointment requirements and this includes ensuring:
· Adequate training/induction before practising as an IMHA and an expectation that all advocates will begin the specific advocacy qualification within specified time periods;
· Patients have been informed of the health board’s duty to provide them with an advocacy service in a number of ways and include: providing relevant settings with promotional materials: organising awareness raising sessions and providing an e-learning module.
· Providing adequate translation services including Welsh and bilingual advocates, those trained in BSL and specific communication tools such as Talking Mats;
· Advocacy awareness training being incorporated into mainstream Measure training and
· A texting service being available to CAMHS in patients.
Information regarding services provided under Part 4 has been collected since April 2013. As with other performance information, the figures are indicative of emerging trends rather than a complete picture. Local health boards have confirmed that within their geographical area advocacy is provided in 100% of hospitals and 100% of IMHAs are trained to the required level.
On average 368 people accessed IMHA services per month (April 2013 to March 2014). Of these almost 53 % were patients who would not have received services prior to the introduction of the Measure. The provision of the expanded IMHA services has been reported by all stakeholders as a positive development including staff providing services and those receiving support.
IMHA commissioners and providers have developed tools to demonstrate satisfaction with their services and this information is being reviewed. There will be a need to collate the information regarding the impact upon service users and carers of the provision of the service both in terms of satisfaction and outcomes to inform the final duty to review report. The standardisation of quality through the qualification of advocates has helped ensure good practice.
An all Wales collaborative approach has been developed between providers and commissioners to look at information, communication and training to raise awareness of IMHA services across all health boards. The aim is to provide a cohesive and equal service irrespective of setting and location.
There have been particular benefits for patients who are deemed to have the capacity to agree to admission to hospital but in other regards are less likely to express their point of view; these patients have now been offered the support not previously available. Reports from staff on Learning Disability wards have specifically remarked upon improved care for patients receiving secondary mental health services as a direct result of the IMHA provision.
Barriers
There still appears to be a relatively low number of referrals for the IMHA service on general wards. It is unclear at this time whether this is because the service is not required, or because not all staff are aware of the entitlement, particularly in relation to cases of non-instructed advocacy. That is, people eligible for IMHA services but, because of their mental ill health are not able to instruct an advocate.
IMHA providers and commissioners have therefore been working to improve awareness of IMHA provisions. It has been more difficult for IMHA providers to ensure information is available on general wards. It is anticipated that this issue – the variability of the provision of information regarding the availability of IMHA services – will be addressed in the revision to the Mental Health Act 1983 Code of Practice for Wales which will be published in 2015.[11]
1h.What impact has the Measure had on access to mental health services for particular groups, for example, children and young people, older people, ‘hard to reach’ groups?
Data collected routinely by Welsh Government on the LPMHSS does not differentiate between particular age groups. However the focus on all aspects of mental health for all groups and the associated expectations has created a greater awareness of the needs of different groups. A specific plan for CAMHS has been developed which focuses on the needs of this group.
It is also particularly important that services for older people are robust and effective. The number of older people with care and treatment plans has significantly improved since the introduction of the Measure. For older people, all health boards submitted figures from April 2013 where performance was 65.1%; it is now over 91%.
Work undertaken by Gofal, supported by Welsh Government funding, and has sought to ensure ‘hard to reach’ groups are aware of the Measure and its provisions.
1i.To what extent has the Measure helped to raise the profile of mental health issues within health services and the development of services that are more sensitive to the needs of people with mental health problems?
Service providers have informed us that the introduction of the Measure has significantly increased the profile of mental health services. Introducing a legal framework and associated targets has focussed the minds of organisations. It will be essential that this however is proportionate; service user led as far as possible and focusses on quality and not just quantity.
Ensuring a culture that is respectful and empowering will be essential not only to the sustainability of future services but also to their value and usefulness to the lives of people both delivering and receiving them. We are supporting organisations undertake this work via communities of practice, involving all relevant stakeholders and which applies across all service areas
1j.To what extent has the implementation of the Measure been consistent across local health board areas?
The written evidence to the Committee makes clear the broad support for the principles and aims of the Measure and the opportunity to improve and develop services and formalise good practice has been widely expressed. However, whilst the same legislation and guidance applies across Wales, local need and the previous configuration of services have influenced the implementation of the Measure.
Over the past eighteen months there has been increasing compliance with the Measure requirements for Care and Treatment plans with greater consistency of provision. For example in April 2013 the compliance rate with CTPs was 63.8%. As of August 2014 it stood at 91.8%.
The provision of IMHA services appears generally consistent and reflects the importance of this role. We will be taking the opportunity to stress the value of IMHA in the revision to the Mental Health Act 1983 Code of Practice in relation to all patients in hospital receiving treatment for their mental disorder who wish for such support.
Part 1 services have probably reflected the greatest degree of variation. Local health boards and their partners are able to develop their individual schemes, which have given local health board areas the ability to design their LPMHSS services based upon local need. For example in Cardiff and the Vale, in addition to their individual assessments and interventions, they have invested in the provision of therapeutic groups. In Hywel Dda they have developed specific in Cognitive Behavioural Therapy. There does remain some variation in the waiting times for assessment and interventions, organisations have consequently been asked to produce action plans to address this. These plans are expected by December 2014.
1k.Overall, has the Measure led to any changes in the quality and delivery of services, and if so, how?
The implementation of the Measure which is at the heart of the mental health strategy ‘Together for Mental Health’ has started a fundamental change in the provision of mental health services in Wales.
The creation of the new LPMHSS, service users knowing exactly who their care co-ordinator is and that they have the right to a care and treatment plan which is outcome focussed and considers the areas of life important to them will, if implemented effectively, improve the quality and delivery of services.
The expanded IMHA service is having real benefits for people receiving treatment for their mental disorder in hospital. Commissioners and service providers, service users and their families, report how helpful they have found this service. It is perhaps particularly important for those in hospital informally who may because of their previous history or fluctuating capacity to make decisions about their care have agreed to an informal admission but without the safeguards provided by the Mental Health Act 1983[12].
Theme 2 (lessons from the making and implementation of the legislation):
2a. During scrutiny the scope of the Measure was widened from adult services to include services for children and young people. What, if any, implications has this had for the implementation of the policy intentions set out in the Measure as it was proposed, and as it was passed by the Assembly?
Whilst most sectors were supportive of the inclusion of young people and children, widening the scope of the Measure has presented some challenges. Some children and young people’s services have said the eligibility criteria to both undertake assessment in LPMHSS and be a care co-ordinator have caused workforce difficulties as some of their staff, though experienced in aspect of CAMHS work, did not fulfil the eligibility criteria. Equally it has been argued the care and treatment plan is not always suitable for children. Each of these issues is being addressed by the task and finish groups referred to earlier in this report.
It has however been very encouraging to see the numbers of children and young people with care and treatment plans consistently increase over time. For example in Cardiff and the Vale improving from 55% in April 2013 to over 95% by August 2014. The commitment to ensuring the right children and young people have a care plan that reflects their needs and goals is critical.
2b. How effective were the consultation arrangements with stakeholders and service users during the development, scrutiny and implementation of the Measure?
The stakeholders consulted in the development of the Mental Health (Wales) Measure 2010, the subordinate legislation and the Code of Practice for Part 2 and 3 ranged from individual service users to national professional bodies.
A wide variety of consultation arrangements, from interested party
meetings with Welsh Government officials on specific issues, for
example learning disability colleagues, to extensive public
consultations with services users, carers, third sector agencies
and statutory services were undertaken. It is of note most
organisations have commented on the inclusiveness and effectiveness
of the consultation process.
The final shape of the Measure was influenced in several respects
by input from stakeholders: for example the Measure as originally
introduced, was intended only to apply to adult services; its
expansion to include children and young people’s services was
a result of feedback from stakeholders, as was the Welsh
Government’s decision to retract its original proposal to
expand the IMHA scheme to individuals detained under section 136 of
the Mental Health Act 1983.
The way the consultation was constructed has formed the basis for future consultations; for example ‘Together for Mental Health’.
Comprehensive and meaningful engagement with stakeholders presents all organisations with challenges, both in relation to the capacity of officials to attend events, and the logistics of enabling all service user voices to be heard across the geographic and demographic range. The use of social media and online discussion groups may be a useful way to address some of these issues in future.
2c How effective were the consultation arrangements with stakeholders and service users during the development, making and implementation of the associated subordinate legislation and guidance?
Similar engagement processes were used in the making of the subordinate legislation and guidance. Generally these have been accepted as useful and effective in ensuring a spectrum of citizen voices were heard, as well as professional and organisational view points. Over many issues there was broad agreement with both the principles and detail. Differing views regarding specific issues were raised, acknowledged, and ongoing input from stakeholders was pivotal in shaping the development of the care and treatment plan template and the Parts 2 and 3 Code.
2d Has sufficient, accessible information been made available to service users and providers about the Measure and its implementation?
A number of documents were made available to support the implementation of the Measure including a short one page bilingual leaflet on all Parts.
Part 1:
A National Service Model for local primary mental health support services[13]: guidance on how to achieve Part 1 duties, by:
· outlining the functions and objectives of local primary mental health support services;
· giving guidance on the requirements for the delivery of the services; and
· the operational arrangements which are needed to support that delivery.
Mental Health (Wales) Measure 2010 Policy Implementation Guidance on 'Local Primary Mental Health Support Services' and 'Secondary Mental Health Services[14]'
Guidance to assist local health boards and local authorities in meeting their duties by providing advice on:
• What is meant by ‘local primary mental health support services’ and ‘secondary mental health services’ for the purposes of the Measure, and the subordinate legislation which underpins it.
• The principles which informed the development of the Measure and the aims the legislation is seeking to achieve.
• The types of services the Welsh Government would consider to be most appropriately delivered by local health boards and local authorities under Parts 1, 2 and 3 of the Measure.
Gofal as part of their grant funded work plan were also commissioned to ensure specific group, which could be deemed hard to reach were aware of the provisions of part 1
Parts 2 and 3
A Code of Practice for Parts 2 and 3[15] of the Measure was produced, and in addition, the University of Lincoln developed online resources and workbooks to assist care coordinators and others understand the Care and Treatment planning process. These have been widely disseminated and used.
Hafal, as part of their work, produced ‘Care and Treatment planning[16]’ a step by step guide for secondary mental health service users, which was launched by my predecessor. This was widely disseminated both via third sector networks, Welsh Government and statutory bodies.
Although there are clear requirements placed on secondary mental health services to inform those discharged from services of their right to request an assessment if they feel their mental health is deteriorating, I am aware that concerns have been expressed that this has not always been done within the spirit of the Measure. That is a formal letter of discharge has been sent without a meaningful discussion regarding any signs of relapse to consider and clearly explaining the right to request a re assessment for the 3 years post discharge.
Work with the leads for Parts 2 and 3 is currently underway to address this issue, and I expect health boards to be able to demonstrate the same assurance on these aspects of the Measure, that they currently give in relation to their Tier 1 targets on a monthly basis.
Part 4
Delivering the independent mental health advocacy service in Wales: Guidance for independent mental health advocacy providers and local health board advocacy service planners[17]
· Advises on how to proceed in planning and provision of such services under the 1983 Act as amended by Part 4 of the Measure.
· Will also be useful to other advocacy providers, including those who would wish to provide services in the future.
· Replaces the Mental Health Act 1983 IMHA Guidance: Commissioning the independent mental health advocate service.
IMHA providers have produced a wide range of leaflets, guides and posters to inform patients about their services.
Information regarding all Parts of the Measure is available on the Welsh Government website, as well as that contained on individual health boards’ sites.
2e How effective was the support and guidance given to service providers in relation to the implementation of the Measure, for example in relation to transition timescales, targets, staff programmes etc.?
In addition to the guidance referred to above extra support was made available from both Welsh Government and Public Health Wales to support the implementation of the Measure. Given that Part 1 services particularly required a remodelling of existing provision in order to set up the new LPMHSS additional funding was provided to employ a specific Part 1 lead for each local health board. This was supported by an all Wales national lead for Part 1, Barbara Bowness.
Revised City and Guilds training materials were also provided for IMHA, ensuing that they reflected not only the Mental Health Act 1983 Code of Practice for Wales but also the new requirements of the Measure. All local health boards have confirmed they have suitably qualified IMHAs.
2f Did any unforeseen issues arise during the implementation of the Measure? If so, were they responded to effectively?
The learning disability community raised concerns regarding the requirement for Care and Treatment Plans for all of their service users. This related to the wording of the Measure in relation to treatment for a mental disorder. A learning disability can be described as a mental disorder.
It was never the intention of the Measure that all those individuals with a learning disability would require to a CTP but rather that those with a learning disability who were receiving secondary mental health services should have the same rights regarding CTP and care co-ordination as those without a learning disability.
A working group was convened and extra training provided. Whilst it has taken time for services to ensure that the right people are in receipt of CTPs, an informed and constructive process has resulted. I have seen the types of CTP being provided for those with a learning disability and I have been impressed by the work that has been undertaken.
2g Are there any lessons which could be learned or good practice which should be shared, for the development and implementation of other legislation?
Balancing the desire for consistency, the difficulties with a one size fits all approach and ensuring there is sufficiently flexibility to ensure services can respond to a diversity of mental health need is a challenge that will face all those who develop and implement legislation.
On the one hand it is difficult accurately to assess outcomes for service users without some consistency of process and on the other flexibility is needed to meet clinical need, a matter that has always been central to mental health provision. This balance however is one leads from all the health boards and their partners are looking to achieve through the national implementation group. This group as been able to support practitioners on the ground deliver services within the sprit of the Measure. Legalisation and performance targets have increased the profile of mental health services. The focus going forward must be on outcomes.
Theme 3 (value for money):
3a Were assumptions made in the Regulatory Impact Assessment about the demand for services accurate? Were there any unforeseen costs, or savings?
When the Regulatory Impact Assessment (RIA) was completed it drew information from a variety of sources and also addressed the likely consequences of not providing a new legislative framework to support the provision of mental health services in Wales.
You will be aware from the written evidence you have received that some stakeholders have commented that the introduction of children and young people into the Measure provision was not adequately assessed and I know from listening to the providers of CAMHS that this has been of concern to them. We have therefore produced the CAMHS action plan and asked the strategy lead for Together for Mental Health to have a particular focus on these services in the next 12 months. Dame Sue Bailey, Professor and previous president of the Royal College of Psychiatrists has also agreed to take a leadership role in the development of services going forward.
Part 1
Most services in Wales have not integrated the previous provision of primary care services for children and young people into the LPMHSS. However they have or are developing effective mechanisms which give clarity to the referral pathways. We were always clear that the new LPMHSS should provide additional services.
The growing awareness of our citizens that discussing mental health is becoming acceptable is likely to have an impact on the demand for services and I am fully supportive of the Time for Change campaign which seeks to reduce sigma and discrimination. If this leads to fewer people suffering in silence and increased referrals then this must be positive. The other major factor however must be the impact of this time of austerity and particular the welfare reforms. How services respond to these challenges will be critical. I am aware that in many areas LPMHSS have led the way in designing, developing and delivering Tier 0 services
It is also expected the impact of LPMHSS staff being available to advise and inform GPs and their staff about mental health will improve services at primary care level.
Part 2
The RIA anticipated that generally the cost of placing into a legal framework what should already have been good practice should have been cost neutral and indeed in teams and organisation where the principles and ethos behind care and treatment planning were already in place the impact on services has been relatively small.
It is however of note that for some professionals and services completing the CTP has been challenging. It is anticipated that shared learning and training will embed into everyday practice the principles behind the Measure. I welcome the joint initiatives between the Royal College of Psychiatrists, Part 2 leads and the third sector organisations in developing effective audit tools and a further focus on outcomes.
Part 3
The numbers of individual referring themselves back for re assessment remains fairly small and the demand for these services does not appear to be having any adverse impact on services and at the same time has offered the safety net for those discharged.
Part 4
The numbers of informal patients currently receiving IMHA services is somewhat lower than was expected in the RIA. However the numbers are increasing as more people become aware of the service available.
3b Have sufficient resources been allocated to secure the effective implementation of the Measure?
Allied to the anticipated demand for services and change in practice is the issue of resources. The current demand for service is broadly in line with that expected. The uptake of services however will need continued monitoring to ensure that future demand can be met. At this point it is not possible accurately to estimate the impact of other legislative frameworks, for example the increase in the number of people who following a Supreme Court Judgment are now considered to have their liberty deprived and may, if appropriate, need to be assessed under the Mental Health Act 1983 and therefore eligible for support from an IMHA.
3c What has been the impact of the Welsh Government’s policy of ring-fencing the mental health budget on the development of services under the Measure?
A review of the policy of ring fencing the mental health budget is currently underway and this will consider its impact on the development of services under the Measure.
3d What work has been done to assess the costs of implementing the Measure, and to assess the benefits accruing from the Measure?
The cost of the Measure was set out in the RIA. This ring fenced money was distributed to local health boards in order for them to provide the additional services required as a result of the development of LPMHSS and the enhanced IMHA service.
3e Does the Measure represent value for money, particularly in the broader economic context? What evidence do you have to support your view?
The impact of mental health problems on our economy is significant. In 2010 the Mental Health Foundation[18] stated the cost to Wales was £7.2 billion. Investing in services that provide timely assessment and intervention much earlier must be a sensible and prudent way to ensure we do all we can to reduce the impact of mental health problems. Having Care and Treatment Plans for those in secondary services that are holistic and focus on recovery will also prove an investment in individuals that will be to benefit of all. Equally ensuring the most vulnerable in out society are provided with advocacy at a time when they may most need it is more than value for money, it is an investment in our citizens.
ANNEX 1: Further Background
The Measure Objectives
The intention of the Measure was to provide:
· local primary mental health support services at an earlier stage than was previously the case in many parts of Wales (Part 1);
· all individuals accepted into secondary mental health services with a care coordinator and a Care and Treatment Plan ( Part 2);
· those discharged from secondary mental health services with the ability to request reassessment when they believe their mental health may be deteriorating ( Part 3);
· extended statutory mental health advocacy provision beyond that required under the Mental Health Act 1983 (Part 4).
It was designed to achieve these intentions by:
· providing an assessment of an individual’s mental health and, where appropriate, treatment of an individual’s mental disorder within primary care, by establishing a duty for local health boards and local authorities to deliver primary mental health support services across Wales (Part 1);
· instituting statutory requirements around care and treatment planning and care coordination within secondary mental health services (Part 2);
· requiring secondary mental health services to have in place arrangements to ensure the provision of timely access to assessment for previous service users (Part 3);
· extending the groups of ‘qualifying patients’ under the Mental Health Act 1983 entitled to receive support from an Independent Mental Health Advocate (IMHA), to informal/voluntary patients as well as the majority of patients subject to the formal powers of that Act.
Subsequent to the making of the Measure in 2010 significant subordinate legislation has been made and additional guidance issued to support the implementation of the services required[19].
Duty to Review the Measure
The Explanatory Memorandum[20] to the Measure stated:
“Benefits for service users, their families and carers will consist of:
• improved access to services within primary and secondary care, measured for example by number and range of primary mental health support services available and number of service users assessed and treated within these;
• improved experience for service users, families and carers, measured for example by increased satisfaction with services;
• improved involvement of service users in decision making around their care and treatment, measured for example by improved satisfaction with care planning and engagement with advocacy services.
· improved provision of Welsh Language services by supporting access to
assessment, treatment and advocacy in the service user’s language of
need/choice.”
Benefits in the provision and use of services provided under the legislation will
consist of:
· improved delivery of services within primary and secondary care;
· reductions in referrals to secondary care which are not accepted because such services are not appropriate;
· improved availability and accessibility of independent trained and dedicated advocacy services within mental health inpatient settings.”
These benefits will be reviewed in a number of ways including:
• commissioned research into the use of primary and secondary mental health services;
• commissioned research into the use, accessibility and delivery of advocacy services;
statistical returns and management information derived from existing operational and financial systems, most typically the annual statistical returns relating to use of the Mental Health Act 1983 and the Patient Episode Database for Wales.”
The Measure, which lies at the heart of the current mental health strategy, Together for Mental Health applies to all ages and all groups of society across Wales.
ANNEX 2.
Service user’s comments regarding Local Primary Mental Health Support Services.
What was good?
· It was an opportunity to talk about my problems and find ways of coping.
· I wasn’t judged and felt that I was listened too and understood.
· I now feel more in control. I feel I can look forward and more positively.
· The course was led by a very informative person, was delivered well and helped me gain coping strategies for when my moods become low. I felt very comfortable speaking about my problems and questions I had were answered well.
· Before I was involved with the service I only felt like half a person and lost my independence, but now I feel more confident and got my life back. Thanks to you.
What needed improving?
· Not enough time in appointments to discuss everything. Longer appointments please.
· More one to one therapies – groups are not suitable for everyone.
Other comments
· I couldn’t rearrange my appointment to a more convenient time because there was only some available one day a week.
GP comments regarding Local Primary Mental Health Services.
What was good?
· Good communication.
· Approachable clinician.
· Practice based service is accessible.
· High quality, consistent service.
· Easy referral system.
· Positive response in dealing with complex patients.
· Clear guidance for patients and colleagues.
· Patients value being able to see a practitioner in the surgery.
What needed improving?
· Waiting times are far too long.
· More services needed for eating disorders.
· Too many unfilled appointments in the surgery…high DNA rate.
Other comments
· Communication can always be improved.
ANNEX 3
ORS Scoping report
Some initial findings from the report are described below:
Part 1
· teams are generally based in GP practices or in community-based clinics, the location of services in non-mental health community settings is considered to be beneficial for service users;
· the importance of taking the time to recruit and train the right staff has been highlighted;
· continuing liaison with GPs is seen as a priority to ensure that GPs are supported in making appropriate referral decisions;
· it was felt that Tier 0 services, and effective referral to such services by GPs or by direct service user access, serve to ease the pressures for assessment experienced by LPMHSS and focus attention on service users requiring more expert attention from the teams.
Part 2
· the importance of continuous training and staff development was acknowledged and particularly training about the Measure; in Care and Treatment Plans (CTP) and the recovery planning approach;
· some consultees argued that a medical model of care persists in some areas and then practice is neither recovery nor outcome focused and therefore takes little account of the social care needs of service users. ‘To make the recovery process work as embodied in the Measure, there is a need to take positive risks with service users by allowing them to lead the process. However, this requires a complete change of culture’
· some consultees pointed out that there can be a tendency for care coordinators to only deal with areas of the CTP which they consider are within their areas of expertise. Furthermore, some mentioned that formalising care planning through legislation and the introduction of increasing scrutiny has led to anxiety amongst staff and that some are unwilling to take on the care coordinator role. The timescales and targets for CTPs were considered by some to have placed pressure on staff to the detriment of quality.
Part 3:
· some consultees had witnessed confusion amongst a few people discharged from secondary services. If information about discharge and Part 3 is being provided, it appears that at least for some people, it is not being read or understood. Consultees suggested that written advice and information is insufficient and that real engagement person-to-person would be necessary for many service users and particularly those with limited literacy.
Part 4:
· these services are being delivered through contracts with four advocacy providers across Wales. Some consultees said that there should be more advocates working in general hospital settings and that more promotion is needed to increase uptake.