National Assembly for Wales

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

Evidence from Gwent Mental Health & Learning Disability Partnership – MHM 21

Committee Clerk, 4^th September 2014

Health and Social Care Committee,

National Assembly for Wales,

Cardiff Bay,

CF99 1NA

HSCCommittee@wales.gov.uk.

Dear Colleague,

RE : POST – LEGISLATIVE SCRUTINY : MENTAL HEALTH (WALES) MEASURE 2010

Thank you for inviting comment in respect of the above.

The attached response, has been prepared on behalf of the Mental Health & learning Disability Partnership in Gwent and as such provides response from the 5 Local Authorities in Gwent and the Aneurin Bevan University Health Board.

It has been structured in line with the questions posed in the invitation to comment.

Should you require any points of clarity, please do not hesitate to contact Claire Harding via XXXXXXXXXXXXXXX or XXXXXXXXXXXXXX.

Yours sincerely

Mr Simon Burch

Director of Social Services Monmouthshire County Council

(As Chair of the Mental Health & Learning Disability Partnership Board)

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?

There is no doubt that the introduction of Part 1 of the Measure has greatly increased access to assessment and treatment across the age range. Significantly more people are assessed and seen for a therapeutic intervention by the LPMHSS in Gwent than had previously been the case by services operating at the same ‘Tier’ of intervention (i.e. First Access Teams, Primary Care Counselling Service, Primary Mental Health Team for children / young people). Patient satisfaction questionnaires consistently highlight that patients are happy with the service that they receive from the Gwent PCMHSS. GP satisfaction questionnaires also highlight that on the whole GPs are satisfied with the service, in particular the ease of making a referral to the service (and thus the accessibility of the service) and the quality of the service that is received.

People are also on the whole seen earlier for assessment and treatment than had been the case prior to the implementation of Part 1 of the Measure, though this is not uniformly the case across Gwent and the Gwent LPMHSS is currently not consistently meeting WG Tier 1 targets for assessments and interventions. However, the fact that these targets are ‘Tier 1’ targets has raised the profile of mental health services for common mental health and behavioural problems, and led to a closer level of attention to performance (in terms of earlier access) at a Divisional and Board level. It is worth noting that while GP feedback on the service has largely been positive, waiting times for assessments and interventions has been the strongest area of negative feedback for the PCMHSS from GPs.

The main barrier to ensuring better and earlier access to treatment has been a level of demand on the service that currently outstrips the service’s capacity to meet that demand. The implementation of Part 1 of the Measure raised the profile of common mental health and behavioural issues in GPs, and thus led to an increase in the referral rate. The current demand / capacity imbalance is something that we are working hard to address. A further barrier to meeting demand is the requirements for only certain professional groups to be able o undertake assessments. We feel this could be extended for example – counsellors.

Regarding the issue of better (as well as earlier) access to services, while WG’s Tier 1 targets will undoubtedly contribute to people being seen earlier, these targets do not necessarily lead to the service that is accessed being better, and indeed current pressure to see people earlier risks contributing to a deterioration in service quality. This is an issue that it would be important for WG to redress in time, to ensure that patients are receiving an excellent, as well as prompt, service from LPMHSSs across Wales.

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

Feedback from patients consistently highlights a high level of acceptability of the services provided by the LPMHSS in Gwent. Details of this are contained in reports that have been produced for ABUHB by the ABUHB Community Health Council.

The Gwent LPMHSS, monitors clinical outcomes using the CORE-34 Outcome Measure, though to date practitioner compliance with outcome monitoring procedures though to date, embedding the use of this outcome tool has not been a key priority issue for the Gwent LPMHSS. Additionally, clinical outcomes were not measured by services that were operating in ABUHB before the implementation of part 1 of the Measure. Consequently, it is not possible to comment confidently on the impact of Part 1 of the Measure in terms of clinical outcomes. However, we are currently working to strengthen our processes in terms of routinely monitoring clinical outcomes. While this won’t allow us to comment on whether the outcome that the LPMHSS is achieving are better than the outcome that were achieved prior to October 2012 (because we don’t know what these outcomes actually were), we will at least know about what outcomes we are achieving for patients.

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

The introduction of the measure has ensured that an increased number of service users have a current care and treatment plan which is regularly reviewed. It has strengthened the existing arrangements that were in place under Care Programme Approach by providing a legal framework for practitioners and service users to work within.

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?

The implementation of the measure has strengthened opportunity for service users to be fully involved in their care and treatment. The only way to truly understand whether this has had an impact is to ask service users about their experience. A recent survey in the Gwent area considered the views of over 100 service users. The findings were that service users were generally positive about how they had been involved in decisions about their care.

Within the ABUHB footprint area, we have secured the time of a service user who has been delivering Recovery training to care coordinators, in conjunction with trainers from the service. This training considers how service users can be and are involved in their care and treatment. It has proved a really effective way of reinforcing with practitioners the need for sustained involvement of service users in the care and treatment planning process.

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

The evidence suggests that service users are able to request an assessment and are able to re-access secondary mental health services where appropriate. Since the introduction of the measure nearly 500 requests for a reassessment have been made in the Gwent area. Through our experience, two barriers have become evident in requests for reassessment. These are :

· For service users where there may also be a physical issue

· For service users with Dementia (as a request cannot be made on their behalf).

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

Whilst the introduction of a care plan which is clearly outcome focused ensures that outcomes can be jointly identified and worked towards, it is difficult to quantify the impact on outcomes that the measure has had as there is not an outcome measurement tool used in the service currently which captures this. Since the introduction of the measure large numbers of service users have been discharged (with part 3 information) which would suggest that more service users are moving through the service and practitioners feel more comfortable to discharge back to primary care.

ABUHB have contributed to the Welsh Government led pilot to develop an appropriate outcome tool (through the service user lens).

A small pilot in the North of Caerphilly County Borough (LEAP Team) has tested a new way of working with people with mental health need. A multi-agency team including a wide range of competencies has been established with a principle of working with individuals in a different way, focussing on what is important to them and setting outcomes related to this (as opposed to over medicalising what are often socially influenced crises/presentation). The team are taking service users across the primary secondary care divide. An adaptation of the recovery star model is being used in this approach and offers the basis of a good outcomes measurement tool.

The approach has really made the team question the primary secondary care divide and would welcome sharing some of their learning with Welsh Government in respect of this.

Of additional note is the benefit that GPs have seen in working with such a team. They have asked that the approach be continued as they see this as having a significant impact on outcomes for their service users.

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?

No information received

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 perception within Gwent is that the boundaries created by the order placed during the drafting of the measure re part 1 and part 2 services is unhelpful and creates another set of thresholds that service users could fall between. (See earlier reference to LEAP team).

It is believed that further work is needed in relation to CAMHS provision, both within primary mental health teams and in the wider service pathway.

As previously noted, there are some barriers in respect of people with Dementia accessing services particularly under part 3.

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?

Whilst the establishment of a legal framework for the development of mental health services has been very helpful, there is still some way to go in raising the profile of mental health issues within the broader health and social care community, and communities themselves. People accessing services do not necessarily understand the legal construct behind the creation of the service they are accessing, and in many ways don’t need to. What is important is that they are able to access the right service at the right time, appropriate to their needs.

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

There were many different interpretations of Part one of the measure in particular, ranging from telephone triage to full redesign of the front end of the mental health system.

Within the Gwent area, we responded to part one as an opportunity to consolidate all of the resources and teams that operated at the front end of the pathway. As such our model aligned the resources from WG for the establishment of a primary mental health service, with the resources for primary care counselling, tier one CAMHS services and existing First Access Teams in some areas also including Social Work professionals. It was created with the foresight of alignment too with emerging neighbourhood care networks (Locality networks), and had an open access approach akin to primary care.

The fact that models have emerged quite differently across Wales means that :

· Measurement and evaluation cannot be consistent. An example of this is measurement of referral to assessment time. It is quite a different journey for someone being assessed via telephone triage, to someone being assessed face to face by a practitioner within an established Primary Mental Health Team (in essence comparing apples with pears)

· there is potential for inequity and variance in extent of service available across Wales dependent upon postcode.

· There is some difficulty at the boundaries of geographical areas, where services may be different and have different thresholds (this is particularly the case where a persons GP is in one Health Board area, yet they may live in another)

In relation to Part 2, this has been less of an issue. There is variance once again across boundaries (ie ABUHB & Powys) however this has been managed locally through the Care & Treatment Planning Board with members ensuring consistent training, audit processes, procedures etc.

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

Whilst waiting times in the ABUHB area are higher than we would like, this is due to the comprehensive nature of the model in place. What we do know from feedback from service users, GPS and the Community Health Council, is that the experience of people when they access the service is very good. There would be value across Wales in comparing models to consider issues of quality, outcome and effectiveness.

The focus on part 2 of the measure over the past two years has largely been ensuring that it is fully implemented, however there is now a greater focus on quality with rolling audits and reviews via caseload management.

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?

For the Gwent LPMHSS, an ambitious model was developed whereby service delivery would be truly age-inclusive. The Gwent LPMHSS sees patients across the age range, including children and young people, and at the outset the tier one CAMHS service, was integrated into the LPMHSS. Additionally, training has been provided to a subset of LPMHSS practitioners who had previously worked with adults to enable them to develop the skills and knowledge necessary to work with children and young people at a primary care level. We have therefore worked hard in ABUHB to ensure that the spirit of Part 1 of the Measure is delivered in terms of the service being age-inclusive, rather than operating a predominantly consultation-based model with very few children or young people being seen for assessment or therapeutic intervention.

We are mindful that this ambitious model for service delivery broadens the scope of the LPMHSS and thus contributes to our current performance issues against Tier 1 targets

On issue that we would welcome further consideration of is of Paediatric nurses being able to act as care co-ordinator. They are not currently registered to do so and this has caused us challenges to implementation. We would request that they are added as a staff group to the health professionals list.

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

Consultation arrangements were broad and inclusive. There were multiple documents supporting the measure which at times was confusing, however which is probably necessary given the complexity of it.

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?

Again approach was inclusive, however there were some aspects where feedback was given around the practical application of the legislation which were not fully taken account of or reflected in the legislation or guidance, and which continue to present challenges in delivery. Of specific note are the following :

· Ability for Wales to have multiple models at part 1

· The placing of the order that separated part 1 from part 2

· The issues related to geographical boundaries and how the interfaces could be managed

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

Across Wales a wide range of approaches to distributing information appears to have been attempted. The information provided by voluntary sector partners has been very helpful (eg HAFAL ‘How to get a good care and treatment plan’ booklet)

At the local level, voluntary sector providers and services within health and social care actively seek to make people aware of their rights. A service user forum regularly meets and this is a further way of disseminating information and gaining feedback about mental health services.

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 implementation of a new service is often complex. Dependent upon the extent of change required (note earlier comments re differing models across Wales) the transition times may have been more challenging to some than others. Regular information was provided, however there was no room for variance in respect of implementation date which may have impacted on the extent of change that some areas embarked upon.

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

The late entry of children and young people and the placing of the order that separated parts 1 & 2 are two areas that were legislative changes and have impacted implementation.

On a more practical level, the areas already outlined continue to present challenges to the delivery of the service. No Wales wide solution appears to have yet been addressed.

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 approach to consulation and engagement was very good, the response and consideration of practical application of issues raised would need some improvement.

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?

No specific response

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

As there are 1 in 4 people that experience a mental health challenge at any one time, additional investment is needed in mental health services overall. The allocation at outset of the measure was small and has been enhanced locally be the realignment of other services.

There has been a lot of previously unmet demand that has emerged as a result of the creation of Primary Mental Health Services. Some work is about to commence in the ABUHB area that will seek to more accurately model this demand and the capacity to respond to it.

The LEAP initiative previously mentioned in this response is starting to show us the root cause behind many presentations and as such there may be need for a more structural/social response to many of the presenting factors.

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?

Ring-fencing has meant that the service areas are protected. This can only be helpful to all mental health services.

An issue that does need to be addressed in the historical investment pattern across third sector services as a result of the previous WCVA grant. Many areas are undergoing exercises to better align this with the requirements of the measure and the development of tier 0 services.

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

No specific response

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

Whilst too early to tell at this point, we believe that our LEAP initiative in Gwent will offer insight to the determining factors behind presentations of mental health distress. This will help us better understand the kind and type of service provision and competencies that will be needed to deliver future mental health services.

Concluding remarks

Despite the comments included above, we recognise this is new legislation and as a result new and developing services. We will carefully monitor to ensure the best implementation of the measure locally.

______________________________________________________