Mr James John

National Assembly for Wales

Post-legislative scrutiny of the Mental Health (Wales) Measure 2010

Evidence from Cwm Taf University Health Board – MHM 08

Sent by email to: HSCCommittee@wales.gov.uk

Dear David,

Subject: Post-Legislative Scrutiny to assess the Implementation and operation of the Mental Health (Wales) Measure 2010

The feedback below has been gathered from our staff within the Adult Mental Health Directorate and Child and Adolescent Mental Health Directorate.

Theme 1 (achievement of stated objectives): The Measure was implemented during 2012. Please answer any of the following questions in relation to the impact of the Measure on which you feel able to comment.

a) 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?

Overall this development is viewed as extremely positive and locally implementation has (thanks to the commitment and dedication of our staff) been a major success and the impact has succeeded expectations.

The establishment of Local Primary Care Mental Health Support Services has delivered a much more appropriate and accessible route into Tier 1 services for people with less complex needs.

Barriers are sheer numbers of referrals with limited resource making it hard to maintain compliance with MHM performance targets and maintain good quality care and treatment.

Locally this service now consist of 23.9 practitioners with administrative support spread across 4 bases at a total cost of £1.1 million while the funding from Welsh Government (which was based on the adult population of Cwm Taf) totalled £269,000. The Welsh Governments decision to include children and young people in the Measure post the funding decision has meant that resources have been stretched even further (21% of our population is under 18).

In order to both manage the demand and reduce unnecessary referrals Cwm Taf are establishing a comprehensive Tier ‘0’ service in partnership with the third sector to enable people who simply want information and advice and support to help themselves without further assessment.

While we aim to provide an ageless service the current skill set of our staff does mean that working age adults are able to access a wider range of interventions than children and young people and older people with a cognitive impairment. While CAMHS provide Part 1 service these have been restricted due to the statutory nature of the service and the withdrawal of Local Authority managed funding for the previous ‘primary mental health workers’ within CAMHS whose role working with effectively schools and families rather than via GP referral was not properly considered when the service was required to be ageless.

While we work with all adults on the basis of need primary care service for older adults are still developing, here in Cwm Taf we are currently reconfiguring or service for older adults to ensure that our primary care service can adequately meet the needs of those older people with a functional mental illness while also ensuring timely access to memory services for those with a cognitive impairment.

Capacity within the service has been stretched and meeting the current performance measures has caused strain on staff however despite the demand everyone referred is offered a comprehensive assessment and a stepped range of interventions based on their needs including Mindfulness and Stress Control courses, structured group work and counselling and psychotherapy provide both by the third sector and Health Board therapists. Our service also offers all GPs access to consultation sessions with the sector consultant psychiatrists in each locality.

Initially one of the biggest drawbacks we found with the implementation of Part 1 has been some resistance to change and the need to develop people’s understanding of what the service can offer.

The other major issue for Part 1 services stems from the other elements of the Measure particularly Part 2 and the fact that all the changes were required to be implemented in quick succession and probably in the wrong order. Part 2 has meant that high numbers of patients who were being monitored by their psychiatrist but did not meet the criteria for Care and Treatment planning have been discharged into the care of their GP, while this is positive and will support a better system in the future the impact of this at a time when primary care services had just commence development has created major problems and a degree of misunderstanding both within some elements of mental health services, among GP but also unfortunately for those patients who feel they no longer have a service.

Had a Primary Care service that could provide effective support to GPs been bedded in first some of these issues could have been avoided and patients and service users in secondary care as well as GPs may have felt more assured.

We are aware that across Wales the interface between primary and secondary care services is still presenting problems for referral of some patients and with every Health Board developing different solutions this risks inequity of timely access.

b) What has been the impact of the Measure on outcomes for people using primary mental health services?

Prior to the Measure a snapshot of referrals to our CMHTs indicated that 80% where inappropriate and related to mental distress caused by life events and social problems, prior to the measure our ability to provide a timely response and appropriate intervention was very limited.

While there have been difficulties coping with the demand and as people have become more use to the new service and confidence has grown this has started to improve and people are recognising that the new resources in PC will help to educate and treat people at an earlier stage and hopefully prevent further deterioration in not only the person’s mental health but also lessen the impact on their family, work and social lives. It is important to deliver the message that we wish to enable people to cope with their own difficulties rather than disable them by fostering a dependency on services.

c) What has been the impact of the Measure on care planning and support for people in secondary mental health services?

The impact of the Measure on care planning and support has been less perceptible than the changes within primary care as our secondary care mental services had previously been utilising the Care Programme Approach however the service changes resulting from Part 2 have had a dramatic effect.

The administrative demands of utilising Care and Treatment Planning (CTP) mean that it would be impractical and inappropriate to put every patient onto CTP when many are only attending annual or bi-annual out patients appointments with a psychiatrist and could be more effectively managed by their GP with support available from a psychiatrist as required.

This has led (across Wales) to high numbers of patients being discharged from secondary care and while entirely appropriate it has caused anxiety among service users, this coupled with fledgling primary care services and confusion regarding Part 3 among patients, GPs and some secondary care services has not been helpful and it clearly an unintended consequences of the legislation itself.

While we feel this has enabled some release of medical resources to support Part 1 and other areas of service within mental health it has not greatly reduced caseloads or improved care with the CMHTs to date.

Given the low level of funding provided for the primary care service much of the our resource was previously committed to secondary mental health services so the gain for one is essentially offset by the loss to the other.

Despite these issues and the focus of for the first 18 months having been on achieving the Part 2 performance management targets the service is now beginning to turn the focus onto quality and how secondary care services can start to work with service users to identify and achieve the outcomes agreed within their care plans this however is still a work in progress given the administrative requirements of CTP coupled with every dwindling resources.

d) Has there been a change to the way in which service users in secondary mental health services are involved in their care and treatment?

A positive change has been increased engagement between service users and medical staff who are care coordinating.

Our partners in third sector led by our service user involvement project and ‘Together for Mental Health’ service user representatives having commenced a survey to gather feedback to find out whether people are feeling more involved in their care planning but to date the priority has primarily been to ensure defined legislative requirements and performance measures are achieved.

e) What impact has the Measure had on service users’ ability to re-access secondary services? Are there any barriers to achieving this?

Modest numbers of self-referrals under Part 3. Waiting lists are generally short and certainly shorter than a year ago.

We have not seen any reduction in the use of the MHA, in fact its on the increase so if the hope was that early access would reduce the number of emergency assessments and admissions that isn’t happening at this stage.

One major issue has been a lack of awareness of Part 3 among GPs (despite costly efforts to engage with them during the implementation phase!), this has mean that they are referring patients who could refer themselves under Part 3 and this can cause confusion and in some cases mean they are waiting longer than they need to.

f) To what extent has the Measure improved outcomes for people using secondary mental health services?

Currently we are unsure that we could evidence any improvement in outcomes as we have no useful comparative pre and post outcome data in general use. There has been an increase in completed CTP plans but this has not been a driver for performance merely a reflection of it.

This question is also very subjective and depends what is meant by outcomes. Discharge may be a good outcome for the service but not seen as such by the patient. There needs to be guidance on consistent agreed and objective outcome measures that can be replicated across services. Otherwise whether an outcome is good or not is in the eye of the beholder.

g) 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?

Here in Cwm Taf the extended advocacy service has made good inroads into the general hospitals and has been well utilised to support patients with mental health issues in these settings. General hospital staff have increased awareness of the benefits of independent advocacy for patients who lack capacity and for those staff involved in discharge planning and Deprivation of Liberty issues, where IMHA services are utilised the mental health literacy of staff is improved.

Extending the IMHA service has also been beneficial to informal patients in mental health settings and here in Cwm Taf the uptake of the service is relatively high compared to other Health Boards.

An observation would be that effective ongoing promotion and awareness raising in regard to IMHA service pays dividends – this service only improves outcomes where it is fully utilised by the staff who are responsible for referring or supporting patients to refer themselves.

h) 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?

At this stage access at a primary care level has clearly improved for working age adults and older people with less complex functional mental health issues however there seems to be a consensus particularly in relation to CAMHS services that both access to and ability to deliver services has actually been adversely effected as a consequence of this legislation primarily due to the lack of insight and understanding of how CAMHS operated prior to the Measure and the ill though out decision to make the Measure ageless post all consultation and decision making regarding resource allocation by the finance committee which base funding on the adult population in Wales..

Access to primary care mental health services still (due to the new legislation) depends on hard to reach groups being in contact with a GP this is also a flaw in other areas (Glasgow Steps for example) services are open access and focus on people opting in to interventions rather than assessment, we have tried to base our Tier ‘0’ developments on this type of approach.

i) 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?

The Mental Health Measure has definitely raised the profile of mental health issues in some areas of the health services. Locally primary care are much more informed about what we offer and have been engaged in what we’re trying to achieve both due to the Measure but also in terms of our service reconfiguration which has in part been driven but our new statutory obligations. That said however not all GPs are any more aware than they were previously..

The other service area were we’ve have seen a positive raising of awareness is in the general hospital wards which have witnessed the benefit of utilising the IMHA the extended IMHA service. Staff utilising this service are more aware of the needs of patients with mental illness, issues around capacity and now know why they can get positive practical support for their patients.

Marking primary care waiting times, completed CTP’s and IMHA in all hospitals Tier 1 performance management targets has also given Mental Health a higher priority within the Health Boards it is however unfortunate the these targets take no account of actual outcomes for individuals using these services..

j) To what extent has the implementation of the Measure been consistent across Local Health Board areas?

The implementation has been broadly consistent e.g. medical input to PMHSS, CTP care plans, but there has been variation in local interpretation and implementation e.g. who does what, when and where. Every PCMHSS seems to have different operational policies and secondary care thresholds vary. This was flagged during consultation because of the possible consequences for part 3.

k) Overall, has the Measure led to any changes in the quality and delivery of services, and if so, how?

The Measure has led to increased access to appropriate Tier 0 and Tier 1 services. More service users are likely to have a care plan but quality and genuine coproduction is unlikely to be consistent at this stage. More people have had timely access to an IHMA which has helped to put more focus on quality and service delivery in hospital setting by giving patients a voice and representation.

Theme 2 (lessons from the making and implementation of the legislation): The proposed Measure was scrutinised by the Assembly during 2010 and implemented during 2012. Please answer any of the following questions in relation to the making and implementation of the Measure on which you feel able to comment.

a) 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?

This has caused the biggest problem of all as it was not resourced and has caused major disruption to CAMHS services, it has led to very experienced staff being unable to undertake their role due to being registered as child care nurses rather than RMN’s.

It has also lead to CAMHS primary care mental health services which were well targeted and working effectively with schools and other agencies being fractured, dismantled, made un-accessible now (GP referral only in some areas) and losing local authority funding as they’ve become perceived as statutory health services.

b) How effective were the consultation arrangements with stakeholders and service users during the development, scrutiny and implementation of the Measure?

Most of the issues highlighted throughout this response were raised during the consultation process…

c) How effective were the consultation arrangements with stakeholders and service users during the development, making and implementation of the associated subordinate legislation and guidance?

Limited in their effectiveness, however it should be pointed out that the Measure came about through service users and other stakeholders lobbying the Welsh Government following the review of the Mental Health Act so they were engaged and did steer the general direction of travel..

d) Has sufficient, accessible information been made available to service users and providers about the Measure and its implementation?

No, Health Boards were given an electronic version of leaflet to print and distribute, this is not the provision of adequate information.

It is highly likely that the lack of understanding among service users and patients will also impact on the quality of the evidence produced by the review.

e) 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?

Support for Health Boards while implementing the Measure was very good.

f) Did any unforeseen issues arise during the implementation of the Measure? If so, were they responded to effectively?

Issues around implications for CAMHS and some issues related to individuals with learning disabilities have not been resolved to date.

g) Are there any lessons which could be learnt, or good practice which should be shared, for the development and implementation of other legislation?

Theme 3 (value for money): The Welsh Government prepared and laid an Explanatory Memorandum to accompany the proposed Measure when it was introduced, including a Regulatory Impact Assessment. Please answer any of the following questions on which you feel able to comment.

a) Were assumptions made in the Regulatory Impact Assessment about the demand for services accurate? Were there any unforeseen costs, or savings?

The Regulatory Impact Assessment was produced before the scrutiny committee made the Measure ageless so was clearly no longer accurate and could not account for the unseen costs related to the changes made latter..

b) Have sufficient resources been allocated to secure the effective implementation of the Measure?

No.

c) 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?

The development of services under the measure has not been influenced by the ring-fencing of Mental Health Budgets, the ULHB has consistently incurred expenditure over the level of the ring-fence allocation, and has continued to increase the service budget to reflect new directed allocations, including funding for the measure.

d) What work has been done to assess the costs of implementing the Measure, and to assess the benefits accruing from the Measure?

Local costs can be defined but there is no meaningful benefits assessment at this stage as all existing capacity has been required to meet demand.

e) Does the Measure represent value for money, particularly in the broader economic context? What evidence do you have to support your view

Undertaking this type of evaluation is beyond the realms of a single health board and would require an all Wales longitudinal study which should have commenced prior to implementation.

Yours sincerely

Stephen Harrhy

Director of Primary, Community and Mental Health