National Assembly for Wales

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

Evidence from Abertawe Bro Morgannwg University Health Board – MHM 12

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THE ABERTAWE BRO MORGANNWG UNIVERSITY HEALTH BOARD SUBMISSION TO THE HEALTH AND SOCIAL CARE COMMITTEE UNDERTAKING THE POST LEGISLATIVE SCRUTINY ON THE IMPLEMENTATION AND OPERATION OF THE MENTAL HEALTH (WALES) MEASURE 2010

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?

Prior to the MHM, there was a variety of primary mental health service provision across ABMU, including assessment and therapeutic interventions. With the implementation of LPMHSS across the Health Board, we now have consistent provision across the localities and a single point of access to this service. We can now monitor and report on the activity within primary care in a way we could not before. It is difficult to say whether there is earlier access as we do not have the pre Measure data to compare, although waiting lists for therapy are reduced in most areas compared to lists prior to the MHM. Assessments are now always comprehensive and consistent across all GP practices. Since the MHM, the Health Board has a clear focus on delivering a quality primary care mental health service.

The main barrier to achieving more timely access to assessment and treatment are the large numbers of referrals, despite ABMU employing more than the recommended ratio of staff per 20,000 population. Also, the requirement to assess those referred in can slow the process as a significant number of people require signposting rather than a comprehensive mental health assessment. Service users report that there are insufficiently developed tier 0 services for our Part I service to signpost them into. This is something that were are trying to develop with our partners.

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

Patient feedback on the service in ABMU is overwhelmingly positive (as reported to WG every 6 months). We do not collect outcome data on all people accessing the service.

There is outcome data collected via CoreNet for people accessing therapeutic interventions that demonstrates improvements in mental health following therapy

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

The new process has helped to ensure more focussed approaches to recovery and risk management. One challenge has been the need for crisis teams to fully complete the care plan documentation when they only have contact with a patient for a short while.

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?

Yes, but further work is required to ensure that service users and carers are at the centre of the process. We are focussing on the development of recovery and outcome focus plans and have developed some learning sets to help with this.

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

The number of patients re-accessing services in this way remains low despite its publication. Service users report not being fully aware of this part of the Measure.

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

Where service users are fully involved, they report very positive experiences, for example “without my care and treatment plan I would not be planning on going back to work, get healthier or go back to university. It just needs to be less black and white and a little more flexible” – Sarah from Swansea.

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?

The extension of Independent mental health advocacy under the Mental Health Act 1983 to effectively make advocacy available to all people receiving treatment or assessment in hospital for their mental ill health has been welcome as it has made it much simpler for people to understand. With our provider of advocacy services we have tried to make it as easy as possible for people to receive support as set out in the Act with regular attendance on inpatient environments to remove the barrier of people having to ask.

We receive regular monitoring reports from our advocacy provider and within this are included case studies showing the impact on individuals as a result of the service. These regularly report people feeling supported and more able to participate in decision making processes as well as feeling that their voice was being heard.

The uptake of IMHA services in general hospital settings has not been very high despite information and training provided. The volume of patients within acute settings for short periods of time and the fact that the support is only in relation to mental health treatment may contribute to this. We continue with our advocacy provider, to promote the availability of the service.

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?

The measure has significantly improved access to Psychological Therapies for our older people in the Part I service.

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 existence of specific Welsh legislation in relation to mental health has given mental health issues a higher profile. This legislative responsibility and its inclusion as Tier 1 targets within the NHS performance management structure has meant that there is an increased focus on mental health at executive and board level.

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

The legislation offers the opportunity for flexibility in how local partnerships can meet their statutory requirements and best meet the needs of individuals in their population, however wherever possible services have been standardised

LPMHSS has been the first service in ABM designed with cooperation of all LA partners across the localities, and the teams are all structured and operate in the same way, whilst still allowing local flexibility to meet population needs.

One area where there has been some inconsistency is in relation to access to local authority day care services as not all local authorities have revised their eligibility criteria to include primary care.

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

The increased availability of support services for primary care to access without a referral to secondary mental health services has undoubtedly increased choice for individuals.

With the new LPMHSS single point of access, we can track performance and patient flow through the service with accuracy and confidence, and GPs can track when their referral has been picked up.

The need to understand and identify what constitutes a secondary mental health service when delivered to an individual has required us, together with partners to, consider carefully the tiered structure of services and our pathways. For example we have reviewed and revised the way that consultant psychiatrists operate in providing medical support to General Practitioners in managing the care of individuals in primary care which also supports the operation of local primary mental health support services.

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?

The widening of the scope to include a people of all ages made the legislation better suited to meet the policy intentions. However the practicalities of how you would implement change to deliver these objectives for people of different ages and with differing needs was made more difficult by the constraints of the single prescribed format for the care and treatment plan and the national service model guidance issued for the Local Primary Mental Health Support Service (for example, the guidance around short term interventions). There have also been some challenges in agreeing patient definitions for primary and secondary care with those in CAMHS having a different threshold for entry into secondary care.

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

Out staff and representatives from our Stronger in Partnership Group report these as being very positive.

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?

Very effective. It was noticeable that the consultation was highly visible and in depth. There were many engagement meetings and information provided in understandable formats for a wide range of people using third sector organisations to facilitate specific service user events as necessary.

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

There has been lots of information.

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?

The timing for introducing the care and treatment planning elements before the Part I service was unhelpful. It would have been better if the care and treatment plans for secondary care patients could have followed the introduction of the primary care team.

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

The definition of secondary mental health services in terms of NHS services caused some confusion regarding the application of the legislation and how it affected services to people with a learning disability. This lack of clarity and understanding led to delays in the implementation process for Part 2 and 3 of the legislation within NHS learning disability services. Once understood steps were taken to ensure all people identified as being in receipt of services that could be classed as secondary mental health services having had a care co-ordinator and a care and treatment plan. One challenge has related to those patients who need more than a time limited intervention on Primary Care, but do not have a complexity of need which would immediately qualify them for secondary care mental health services. This is an issue which we are working through with clinical colleagues.

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

The Implementation plans, guidance and communication through regular updates provided a framework within which to work. The funding for an implementation lead in relation to Part 1 was significant and if this had been replicated for Part 2 and 3 instead of relying on existing structures the change process and the pace of progress could have been improved.

The ongoing national MHM meetings ensure that all areas have the opportunity to share good practice and learn from one another to continue to deliver quality services

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?

At this stage it seems that the assessment of demand for the primary care Part 1 Service underestimated the level of unmet need within the community. Initially there was also a sense amongst clinicians that the impact on secondary care services had been overestimated. This is something that we are trying to address through our pathway work.

In respect of parts 2 and 3 the Measure has helped to improve service responsiveness following a partial implementation of the Care Programme Approach whose benefits were never fully realised

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

With regard to Part 1 of the Measure, as highlighted, the allocation of resource to support an implementation lead was helpful. However whilst the allocation of resource has been instrumental in ensuring that effective primary mental health services could be established, it has been necessary to carefully balance investment between assessments and interventions particularly in light of the high levels of unmet need within communities. At the point of inception significant resources were transferred from secondary mental health services into primary care to support a successful implementation.

With regard to the resource allocated for the implementation and development of services under part 4 of the Measure this has certainly facilitated the implementation of an effective and sustainable service.

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 ring – fencing of the mental health budget has incentivised clinicians and given services the flexibility to utilise resources effectively and sustainably. Where efficiencies and service changes and improvements have been identified any savings can be directed to support the development of new services or enhance existing ones. The ring-fence has been particularly helpful in supporting patient repatriation models facilitating the development of locally based services. This has also been a factor in allowing the movement of mental health resource to support the effective implementation of the Measure. The ring fence has also protected the value of health led third sector contracts. A similar ring fencing arrangement for Local Authorities would be very beneficial for people with mental health needs.

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

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