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

About Gofal:	Gofal is a leading Welsh mental health and wellbeing charity. We provide a wide range of services to people with mental ill health, supporting their independence, health, wellbeing and recovery. We lobby to improve mental health policy, practice and legislation, and we campaign to increase public understanding of mental health and wellbeing.
Contact:	Katie Dalton (Public Affairs Manager)
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Website:	www.gofal.org.uk
Address:	Derwen House, 2 Court Road, Bridgend CF31 1BN

Theme 1: Achievement of stated objectives

Part 1 – Primary mental health services

1.1 Gofal research: Since Part 1 of the Measure was implemented in October 2012 we have published two reports about people’s experiences of primary mental health services. These are based on data from two national surveys conducted in 2012 and 2013. Our second report Snapshot 2: One Year On can be accessed here but we have outlined some of the key findings below, referencing specific charts and case studies where appropriate.

1.2 Understanding and Empathy: 57.9% of respondents in 2013 described their GP as ‘extremely’ or ‘very’ understanding and empathetic – an increase of 4.1% compared to 2012 (Chart 3c, page 8). However some respondents are still very unhappy with their GP’s attitude. Importantly, numerous comments (both positive and negative) indicated that the level of understanding and empathy has a huge impact on people’s experiences of services. This was reinforced by the survey data, which showed that respondents with a more understanding and empathetic GP experienced better outcomes in relation to their mental health and wellbeing (Chart 3f, page 10).

1.3 Advice, treatment and support offered: The 2013 survey found that medication is still the dominant offer, with 71.6% of respondents reporting that they had been offered this treatment option (Chart 4b, page 13). However, it was very pleasing to see an increase in the proportion of people offered advice and information - from 34.8% in 2012 to 65.1% in 2103. It was also positive to see increases in the proportions of people offered a further assessment (11.4%), psychological therapies (11.7%), referral to another organisation or service (9.1%) or signposting to another organisation or service (9.5%). Nevertheless, we would like to see 100% of people offered advice and information and a much greater proportion offered alternatives to medication. The survey data showed that people who were offered medication, advice and another form of support experienced better outcomes than those who were only offered medication (Chart 4c, page 15). It also showed that patients offered CBT and/or another talking therapy experienced better outcomes than those who were not (Chart 4d, page 16).

1.4 Waiting times: Data collected by health boards indicates that an increasing proportion of people are accessing more comprehensive mental health assessments and treatment/support services within the Welsh Government’s target timescales. However, our research conducted during the autumn of 2013 showed that many people were still experiencing lengthy waiting times, with some (who can afford it) resorting to private counselling services (page 20-21). Crucially, our data shows that patient outcomes are negatively affected if people have to wait more than four weeks for an assessment or to access treatment and support (Chart 5d, page 18 and Chart 5j, page 23). As a result, it is important that the Welsh Government, health boards and local authorities continue to focus on improving waiting times.

1.5 Access: Approximately half of all respondents answered ‘yes’ or ‘mostly’ to the question ‘Did you manage to access the advice, treatment and/or support services you needed?’ (Chart 6b, page 24).Respondents reported that barriers to access included lengthy waiting times, a lack of Welsh language psychological therapies and poor out-of-hours provision for people who work full time. We also received an interesting case study in which the individual had been referred to the local primary mental health service and had received an assessment and offer of support within the recommended timescales. However, despite meeting the Welsh Government targets, she did not feel that she had been offered the services she needed (case study, page 36).

1.6 Outcomes: Fewer than 40% of respondents answered ‘yes’ or ‘mostly’ to the question ‘Did the services accessed through primary care lead to improved mental health and wellbeing?’ (Chart 7b, page 28). Patient outcomes should be the key indicator of success and should be measured by health boards and the Welsh Government alongside the ‘process’ measures (i.e. waiting times) that they currently collect.

1.7 Barriers: There are still a number of barriers to achieving the Measure’s intended outcomes, including the disparity in funding between mental and physical health; the lack of understanding and empathy demonstrated by some GPs and primary care staff; lengthy waiting times for psychological therapies; and patients only being offered medication, rather than being given choice and control in relation to their treatment options. These factors could also deter patients from returning to services in the future, potentially leading to unnecessary deterioration in their mental health and the need for secondary services – the opposite of the Measure’s aim.

1.8 Summary: Part 1 of the Measure appears to be having some impact on patient experiences but there is still some way to go to achieve the intended outcomes. The first two years of implementation should be viewed as a step in the journey towards better mental health services. It is therefore important that politicians, health boards and local authorities continue to focus on the impact of this legislation and improving patient outcomes.

Part 2/3 – Secondary mental health services

2.1 Recent health board data indicates that over 90% of people using secondary mental health services have a valid care and treatment plan (CTP). We fear that this is not a true reflection of people’s experiences and believe that there should be an increased focus on the quality of these documents and the meaningful involvement of service users in their development. Gofal has recently surveyed a small sample of secondary mental health service users about their experiences of care and treatment planning and we have outlined their views below.

2.2 Patient awareness and involvement: Approximately 50% said that they had a CTP, with the rest saying that they either did not have a CTP or did not know. Of those who had a care and treatment plan, only half said that they had a copy. When asked how involved they were in the development of their care and treatment plan, responses varied from ‘very involved’ to ‘not at all involved’. The code of practice is very clear that service users should be fully involved in developing their CTP. We believe that much more needs to be done to ensure that care coordinators are complying with this part of the code of practice.

2.3 Holistic, whole person outcomes: We have always been concerned that the legislation and code of practice only require care coordinators to record outcomes for ‘one or more’ of the eight life areas listed in CTPs. When the Measure was being developed we feared that this would result in some CTPs only including outcomes in the medical category, rather than across all areas of life. Our small survey of secondary care users and anecdotal evidence from our frontline staff indicates that many CTPs do not address the full range of life areas. Although this practice complies with the letter of the law, it goes against the spirit of the law – i.e. an holistic, whole person approach to mental health and recovery. We continue to believe that the Measure should require care coordinators to work with secondary mental health service users to record outcomes for several life areas in their CTPs.

2.4 Impact on mental health and wellbeing: We received mixed responses about whether CTPs have helped to improve people’s mental health and wellbeing. The lack of involvement of some service users in this process is likely to have a negative impact on their outcomes, as well as the failure to address more than one or two life areas in the CTP. There are also concerns about the lack of involvement of carers and other professionals/services in the CTP process. We believe that CTPs need to be outcome focused and goal orientated, with individuals setting these goals in their own words/language. Success should be judged on patient outcomes and progress towards these goals – through the lens of the service user. This information should be collected and used to shape improvements to deliver the Measure’s aims.

2.5 Re-accessing secondary services: With regards to people re-accessing secondary care services through Part 3 of the Measure, it is pleasing to see that people are starting to utilise this opportunity. However, data collected by health boards also demonstrates that a significant proportion of these people are not being accepted into secondary services following an assessment. This indicates that there is still work to be done to ensure that former service users and health care staff understand the purpose and limitations of this part of the Measure. It is also important to ensure that people are not being turned away when they require help and are being signposted to appropriate primary and community services if they are judged as not requiring secondary services.

Part 4 – Independent mental health advocacy

3.1 Our staff members have indicated that our service users have been able to access the independent mental health advocacy while they have been in hospital settings. However, some commented that there was a need to improve awareness among patients and carers and ensure that people are fully informed of their rights to this service. While we can provide anecdotal evidence from our own services users and staff about the impact of Part 4 we are aware that Mind Cymru has conducted specific research into people’s experiences of this service and is therefore better placed to give a more comprehensive view on this issue.

Other issues

4.1 Access for particular groups: It is important that access for different demographics continues to be considered to ensure that the Measure benefits the whole population. For example, children and young people may well need to access primary mental health services through routes other than their GP; practitioners need to be effectively trained to respond to co-occurring conditions; and it is crucial that services are culturally sensitive to meet the needs of a diverse range of communities. The Measure is still a relatively new piece of legislation so it is important that any shortfalls in reaching certain groups are identified and addressed.

4.2 Profile of mental health issues: The Measure appears to have raised the profile of mental health issues within the health service, but in the context of competing priorities this can only be consolidated through additional funding. While some professionals have been extremely receptive to the potential of the Measure, others continue to demonstrate poor understanding and empathy towards people with mental health problems, which needs to be addressed.

4.3 Implementation across Wales: Part 1 of the Mental Health Measure has not been applied particularly consistently across Wales as health boards had different structures pre-implementation and have shaped their teams to meet local demands. This should not pose a problem if each health board delivers positive patient outcomes, but any inconsistencies in implementation should be addressed if this is not the case.

Theme 2: Lessons from making & implementation of the legislation

5.1 All age nature of the Measure: We welcomed the all-age nature of the Measure and believe that this approach should help to reduce the barriers that exist between different age groups, improve transition and ensure that people are entitled to a minimum level of service regardless of age. However, health boards will need to continue to consider issues such as the need for children and young people access primary mental health services through routes other than their GP. There also needs to be consideration about whether the lists of people allowed to conduct assessments and become care coordinators are appropriate for all age groups.

5.2 Consultation arrangements: Generally, we are happy with the opportunities for stakeholders to be involved during the development and implementation of the Measure. There were a number of opportunities to attend events and to make both formal and informal contributions throughout the development of the legislation and guidance. The Welsh Government also held events that were specifically targeted at service users and carers, as well as encouraging the third sector to feed in the views of people we support. We have also been members of the Mental Health Measure Implementation Group and Duty to Review task and finish groups since the Measure was implemented, allowing us to continue to feed in our views and evidence. However, we believe that it is crucial that stakeholders, service users and carers continue to be involved in work to develop and improve services and assess the impact of the Measure.

5.3 Guidance and support for service providers: Health professionals are probably better placed to comment on the effectiveness of the support and guidance that was provided to them. However, while information and guidance was provided to health professionals, they may have benefited from more support during implementation. In addition to providing guidance and monitoring compliance with the legislation we also believe that the Welsh Government should provide clear guidance and support to ensure that the spirit of the law is successfully enacted.

5.4 Unintended consequences: The introduction of the Measure has resulted in very high demand for primary mental health services, meaning that some people are still facing lengthy waiting times for support services such as talking therapies. There has also been some anecdotal evidence that people have been discharged from secondary services without appropriate advice and information and that some have become stuck between primary and secondary service providers who believe them to be ‘too ill’ or ‘not ill enough’ for their service. The challenges facing mental health services are not going to be solved within two years of implementation and we reiterate the need for a continued focus on the Measure, support for health professionals and monitoring of patient outcomes.

Theme 3: Value for money

6.1 Costs/savings: If the Measure is successfully implemented, it should deliver future savings as more people benefit from early intervention through improved access to primary mental health services. However we believe that further resources are required to support the implementation of the Measure to ensure that it meets the intended objectives and delivers long term savings. Welsh spending on mental health is approximately 11% of health spending yet is estimated to make up 20% of the overall disease burden. Investment in mental health services would therefore need to be increased in order to deliver parity of esteem with physical health.

6.2 Ring-fenced funding: We support the Welsh Government’s policy of ring-fencing mental health spending as a way of safeguarding investment in mental health services. However, we welcome the recently announced review of the ring fence and hope that this delivers improvements in its operation. It is crucial that this review maps spending against outcomes. Health boards need to demonstrate that they are spending this funding effectively and delivering the best possible patient outcomes in line with the Measure and Together for Mental Health.

6.3 Value for money: The overall cost of mental health problems in Wales is estimated to be £7.2billion per year. In light of this, we believe that mental health services which promote early intervention and recovery are worthwhile investments. However, value for money will only be achieved if the Measure is implemented successfully and follows the spirit (as well as the letter) of the law. This requires appropriate funding and support for health boards to deliver timely access to quality primary mental health services; meaningful service user involvement and empowerment in good quality, holistic, recovery-focused CTPs; and good information, advice and support for people to re-access secondary mental health services and utilise independent mental health advocacy services.

Thank you for the opportunity to contribute to this enquiry. We are more than happy to give oral evidence to the Health and Social Care Committee, particularly in respect of our research into people’s experiences of primary mental health services since the implementation of Part 1 of the Mental Health (Wales) Measure.