National Assembly for Wales

Health and Social Care Committee

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

Evidence from Flintshire County Council – MHM 14

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

Submission of Evidence

Your Name: Organisation (If applicable): Email address: Telephone number: Your address:

Neil Ayling, Chief Officer, Social Services.  Flintshire County Council XXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXX Flintshire County Council, County Hall, Mold. CH7 6NN.

Flintshire County Council (FCC) welcomes the opportunity to provide contributory evidence to the Post-legislative scrutiny of the Mental Health (Wales) Measure 2010 process.

This response has been formulated by the FCC Mental Health Services in conjunction with The Flintshire Advocacy Service and Service User representatives from the Unllais Service. Information focusing on areas of importance from the Flintshire perspective has been collated and is represented within this document.     

We would like to thank the Health and Social Care Committee for the opportunity to contribute to this Post-legislative scrutiny of the Mental Health (Wales) Measure 2010, recognising its significance to social care.

Theme 1 (achievement of stated objectives)

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?

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

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

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?

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

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

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?

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?

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?

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

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

Response:

1.1 We acknowledge the creation of the Mental Health (Wales) Measure 2010 as an essential component in the evolutionary development of Mental Health Services, providing much needed guidance and clarity on the intended direction of travel and way forward for Mental Health Service Provision in Wales. However it is also firmly recognised that whilst this measure has been successful in specific areas and generated a number of improvements there is still a great deal of further work required in order to ensure we are improving the lives of people using mental health services, their carers and their families. In addition, there is a strong consensus that any reflections of this legislation or proposals for future change should be made giving due regard to the current challenging economic climate and the increasing pressures faced by services to achieve higher quality and productivity without increasing their expenditures and with gradually decreasing resources. A key barrier highlighted by all professionals consulted was that a lack of specified funding provided to support the application of the Measure has been the greatest obstacle to its full and consistent implementation. It is therefore incumbent that the Welsh Government consider evidence presented on public need, and give an assurance that any future change proposal regarding the Measure will be deliverable and affordable for all statutory and non statutory services.

1.2 There is a consensus between professionals that generally Primary Mental Health Services have improved the accessibility for service users to assessments and treatment.

Unllais consulted with a number of Service Users regarding primary care access. The findings reflect this professional consensus; with 68% of those consulted reporting that access to Primary Care Services was found to be easy or very easy, 18% reported access to be okay and 14% reported access to be not easy or difficult.

1.3 Professionals were however further keen to assert that consistency of application and delivery of this element of the Measure is not always uniform and can vary depending on the level of onsite support available in individual primary care services, for example some GP’s Surgery’s have onsite provision and others do not, this can impact on the experience of the service user in terms of the ease of access to assessment and treatment. Another influential factor linked to this area of consistency of application is the varied utilisation of training initiatives available to primary care services. Professionals in primary services report that where training has been proactively sought access to assessment and treatment appears to be more improved and service users have a better experience overall than in those services not involved with training initiatives. The views of professionals in this instance were supported by services user representatives who were separately consulted by Unllais. The majority of service users agreed that GP's could benefit from training in mental health in areas such as information sharing, diagnosis and personal experiences. It is highly important that primary care services endeavour to provide support beyond known historical medical interventions, promoting community based activities and wider services such as those linked to housing and leisure, which are known to aid recovery in many cases, particularly when promoted in conjunction with supporting people to take more control over their lives and take responsibility for their own mental health and wellbeing (The Recovery Model). Regular training for primary care services is key to the delivery of good Mental Health Care and the Measure itself. It is however acknowledged that with gradually declining training and development budgets, this may become increasingly challenging and will require creative and flexible targeted training solutions to progress initiatives in the future.

1.4 Again there is a consensus between professionals that the outcomes for people using primary mental health services have been improved by the introduction of the Measure. Professionals within the care provider service arm recognise a clear improvement in the quality and consistency of referrals received from primary care services, stating the paper work received is much improved when completed fully and allows for faster involvement, which in turn has an impact on service users outcomes. Consistency in this area can be variable and it is important to note that it may be advantageous that any change initiatives heighten the importance of the full and accurate completion of relevant forms.   

1.5 This consensus was once again reflected by the services user representatives consulted. 59% of people reported they were ‘very satisfied’ with the service they had received from the GP and 41% reported the service received was ‘okay’.  It was also found that 71% of people consulted were reported to be ‘very satisfied’ with the counselling service they received with 29% feeling unsatisfied and a further 80% of people consulted reported they were ‘very satisfied’ with the group therapy service they received and 20% reported this service to be ‘okay’.

1.6 Professionals continue to raise concerns in relation to the consistency of application in this area as cited above. However the most prominent concern in relation to enabling service users to achieve outcomes is the lack of funding provided in conjunction with the Measure to develop responsive services. As stated above the Measure has improved access to mental health services and increased the numbers of people entitled to support, the resulting consequence of this is increased numbers of people are being referred to existing services, which in many cases were not funded or designed to cope with this level of demand. In turn professionals are concerned that this will eventually have an impact on the quality of services provided and without the generation of new services able to provide earlier interventions and support directly leading on from primary care referrals, there will be a consequential impact on demand for secondary services, which may increase costs and reduce quality and impact on service user outcomes.    

1.7 The developments in care planning and support for people in secondary mental health services are generally held to be improved. Specifically the increased emphasis on service user engagement and involvement as well as the living document status afforded to care and treatment plans are held to be progressive developments particularly in their ethos. However in some instances consistency in professional awareness and application can be variable. Professionals have also noted improvements in the timeliness of reviews and found that there is increased accountability and awareness of the need for greater communication between services.

1.8 Professional Advocates have reported that in some instances service users appear to have not understood fully their rights with regard to care and treatment plans failing to understand the nature of the document and their centrality to it, which can minimise the potential for  a developing sense of ownership. It is felt that an increase in Government led awareness raising initiatives in relation to the Measure and further funded training within secondary services may have a positive impact on this issue.

1.9 Whilst many areas of secondary service practice have been person centred for many years the Measure has led to some improvements in the promotion and recognition of this across the wider service area, which has increased service user involvement in their care and treatment. However the consensus among professionals is that there remains a considerable gap between specific secondary mental health services and general health secondary services with regard to the promotion and application of person centred mental health care and treatment. Many professionals have highlighted the need of further training and awareness raising specifically in general secondary health services and privately funded hospitals.

1.10 Professionals have further raised concerns that whilst the ethos and intentions of the 1.11 Measure are positive, the application of the Measure has been made considerably difficult owing to the timing of its introduction, during national austerity. The Measure has as previously stated improved access and extended availability to greater numbers of people, however no additional funding has been provided to assist with this increase in demand and as a result mental health services are finding it difficult to meet these increased levels of need.  Care coordinators, Mental Health Provider Services and Wellbeing Clinics all report increases in demand. There is considerable concern from professionals that without allocated ring fenced funding; the sustainability of this Measure could be questioned.

1.11 Professional opinion indicates that service users’ ability to re-access secondary services has been a positive development. Advocacy services note that this process in some instances has aided service users recovery by acting a stress elevation tool, giving people piece of mind that if relapse occurs that they will be able to re-access services quickly without undergoing the whole process cycle again.

1.12 This process can be effective however professionals assert there are barriers that exist, these include a lack of funding initiatives for further training and resources. Once again the increasing numbers of people requiring support continues to place pressure on services and may impact upon time scales for access and the quality of services provided.        

1.13 Professionals affirm that mental health advocacy has been extended by the Measure. Data collated by advocacy services evidences where advocates have been utilised that service user outcomes are improved. It is however noted that there are some key barriers to extending independent mental health advocacy, the two most frequently highlighted are those linked to resources and staff training.  A number of professionals were keen to emphasize that whilst the Measure has made advocacy a statutory duty in certain circumstances it has not placed any legal requirement on associated training provisions, such as Capacity Act Training, as a result some staff remain unaware or misinformed of the availability, suitability and importance of independent advocacy services. The over arching concern shared by professionals at this time is that training budgets appear to be decreasing and it is feared that these barriers will continue to grow as a result. Professionals further assert that when training is provided it can be poorly attended and this is very often due to capacity issues and resource concerns. Professionals consulted also state that further support for training initiatives from the Welsh Government and the HIW would encourage greater organisational commitment to training initiatives as would improving inspection processes.

1.14 Professionals have also suggested that a future solution to issues asserted above may be to incorporate mental health models into health and social care undergraduate courses, such as nursing and social work degrees.  

1.15 With regard to powers that extend the rights to an IMHA for those held on short term holding powers (Sec5(2) and (4) of the Mental health Act), advocacy services are currently not seeing high referral rates within this area but feel this may be due to the limited value that advocacy services can provide at this time. 

1.16 Professionals have asserted that the introduction of the Measure has had a limited impact on raising the profile of mental health issues within health services. Many professionals stress that there is a continued need for further awareness raising and training within health services, specifically within general and community hospitals where mental health may not have historically developed as an essential component of care. It is nationally recognised that Ignorance within this area impedes the development of services; further evidence suggests that mental health problems continue to be a taboo subject and are often poorly understood both by the general public and in many instances by the practitioner. Developing an enlightened and motivated workforce is a vital to sustaining the changes implemented by the Measure and is essential in achieving quality health outcomes within the current economic climate where limited resources are available.

Theme 2 (lessons from the making and implementation of the legislation)

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?

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

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?

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

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?

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

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

Response:

2.1 It is essential that children and young people with mental health issues are able to access to high quality care across Wales. The Measure has assisted in placing an increased emphasis on the improvement of access and the need for further initiatives to engage and involve children and young people in their care and treatment, however considerable challenges still remain. CAMHs services were primarily developed from a medical model of care perspective and as a result appear to struggle to expand into a more social based model of delivery, for example professionals report that the clinical nature of the service is in some cases off putting to young people and the lack of outreach and community based work acts as a barrier to access for many children and young people, this is particularly so for those who are ‘hard to reach.’ The traditional medical appointment based system of sending formally worded letters with definitive arrangements for attendance, has been found in some instances to be a further barrier to access. Professionals have also raised concerns that there are some remaining issues in relation to communication and planning between Secondary Services and CAMHs Services. Whilst it is recognised that work is being done to improve areas of engagement and involvement, it is however still important to highlight that further work is required to create more modern and flexible systems of access.    

2.2 The initial consultation for the Measure was completed with professionals and services users at numerous development stages and this was considered useful. However it was asserted that further steps to engage with frontline staff from all appropriate sectors could have been taken. Frontline staff can often be unable to attend large scale consultation events due to issues surrounding capacity, however new initiatives such as webinars and online discussion groups now provide more accessible involvement methods for frontline staff, which could be utilised in the future.  

2.3 It was also noted that further work is required with service users specifically those who may be had to ‘hard-to-reach.’ Specifically consultation methods with young people were noted as an improvement area.

2.4 Professionals found materials supplied by Hafal very useful and service user friendly, however other resources appeared to be less appropriate for key stakeholders.  

Theme 3 (value for money)

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

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

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

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?

Response:

3.1 Those consulted consider a foreseeable draw back with regard to the sustainability of the Measure, will be the lack of financial resources available for continued implementation and maintenance. A current decrease to Welsh Government funding has lead to a contagion effect for local authorities, which is further compounded by recent welfare reforms. These financial cuts mean local authorities are currently working with reduced resources and burdened with increased financial pressures. With these factors in mind it is difficult to comprehend how local authorities will be able to continue to enforce the proposed changes of the Measure as they are intended, without any further funding or long term financial provision.          

3.2 The initial implementation of the Measure has been resourced effectively and many aspects of the Measure are working well and making a positive difference to service users and staff. However as referenced above the resource and financial implications of the associated increase in demand and the ongoing requirements in relation to training and awareness raising are key barriers which require further allocated funding.

3.3 The Welsh Government’s ring fencing policy has had limited impact within the current economic climate and the increasing financial pressures have an effect on all services including those specifically developed for Mental Health.