A GUIDE FOR MENTAL HEALTH SERVICE USERS AND THEIR FAMILIES
The Mental Health (Wales) Measure 2010 is a new law passed by the National Assembly for Wales and, as such, has the same legal status in Wales as other Mental Health Acts. However, whilst the 1983 and 2007 Mental Health Acts are largely about compulsory powers, and admission to or discharge from hospital, the 2010 Measure is all about the support that should be available for people with mental health problems in Wales wherever they may be living.
The Measure became law in December 2010 but significant preparation was needed before it could be implemented. So the main provisions only began to take effect between April and October 2012 and it will be some time yet before the full impact will be felt. It is important, however, that people with mental health problems and their families understand the main points of the Measure and know about the support they are now legally entitled to.
The Measure is intended to ensure that where mental health services are delivered, they focus more appropriately on people’s individual needs. It has four main Parts (Parts 5 and 6 are essentially about administrative issues), and each places new legal duties on Local Health Boards and Local Authorities to improve service delivery. The four Parts are as follows.
- Part 1 seeks to ensure more mental health services are available within primary care.
- Part 2 gives all people who receive secondary mental health services the right to have a Care and Treatment Plan.
- Part 3 gives all adults who are discharged from secondary mental health services the right to refer themselves back to those services.
- Part 4 offers every in-patient access to the help of an independent mental health advocate.
Below we will look at each of the four parts of the Measure in more detail. Parts 2 and 3 will have the greatest impact for those with serious mental illnesses and who are receiving secondary care services but, as we explain, all have some relevance. However, before moving on to parts 1 to 4, we must begin by explaining some Guiding Principles.
THE GUIDING PRINCIPLES
These Guiding Principles are set out in the Code of Practice for Parts 2 and 3 and are particularly important for these Parts, but they are also relevant for the whole Measure. There are six in total and they are as follows.
- Patients and their cares should be involved in the planning, development and delivery of care and treatment to the fullest possible extent – so that professionals seek to involve a person as fully as possible in their care and treatment in a sensitive way, and one which promotes their confidence and recovery.
- Equality, dignity and diversity – so that professionals have due regard to a person’s needs arising from their race, gender, religion, sexuality age or disability when delivering a service.
- Clear communication in terms of language and culture is essential to ensure patients and their carers are truly involved, and receive the best possible care and treatment – so that there is always an understanding that poor communication too often leads to inappropriate care and treatment, and that good communication is likely to lead to better outcomes. This principle also states that all possible steps should be taken to ensure that bilingual (Welsh and English) services are available.
- Care and treatment should be comprehensive holistic, and person-focussed – so that professionals are sensitive to the full range of a person’s needs and that they plan care, treatment and support across whatever needs will help a person’s recovery.
- Care and treatment planning should be proportionate to need and risk – so there is a recognition that, whilst on the one hand, some people with complex needs may need detailed care plans, on the other some people may need un-complicated help that will still significantly improve their situations.
- Care and treatment should be integrated and coordinated – so that when offering care and treatment, professionals recognise the range of services that may benefit a person, whether in the statutory or voluntary sectors, or whether specialist mental health services or more general services, and actively work together with other services to coordinate service delivery.
PART 1 – MENTAL HEALTH SERVICES AT THE LEVEL OF PRIMARY CARE
The aim of Part 1 of the Measure is to improve and expand what are referred to as “primary mental health services”, the services that people with milder or more stable mental health problems may receive from their GPs and other local health and social care services. These services are essentially for two groups of people:
- those who have “mild to moderate” mental health problems, for example anxiety or depression, and
- those who have more serious mental health problems but who are sufficiently recovered that their illness is stable.
There is no one document that summarises for the wider public the proposed improvements to primary mental health services, but they are set out in detail for service providers in the Welsh Government document “National Service Model for Local Primary Mental Health Support Services” (2011). What follows is a summary of some of the key elements of that document.
What services will be provided: From October 2012 local primary mental health support services are required to offer the following.
- Primary Mental Health Assessment – A person will be offered this assessment if their GP or other worker believes they would benefit from a more detailed mental health assessment, with the aim of identifying whether local primary mental health treatment or any other local service might improve, or prevent a deterioration in, that person’s mental health. The aim is for a person to wait no more than 28 days for an assessment.
- Short-Term Treatment or Support – Following assessment, a person should be offered short-term help where this is appropriate. Examples of this help could be counselling, psychological interventions including cognitive behavioural therapy, solution-focussed therapy, family work, online support, stress management, bibliotherapy or education, and it could be offered individually or through group work.
- Referral to Secondary Mental Health Services – Where a Primary Care Worker believes a person would benefit from intervention or support by secondary mental health services, it is expected that an onward referral will be offered to that person.
- Working Alongside and Supporting Primary Care – GPs and General Practice Workers will continue to play an important role in supporting people with mental health problems, and a key role of primary mental health services will be to work with them to help them do this, offering their specialist skills and knowledge where appropriate.
- Information and advice to individuals and their carers – A further key role of primary mental health services will be to develop a good understanding of the range of services in their local area, including both general services and more specialist services. This will enable them to offer appropriate information and advice as to what options for additional support may be available, and it is particularly hoped there will be “signposting” to support provided by voluntary sector organisations. A clear aim is also to provide this information, not only to service users but also their families and carers.
How services will be provided: The Guidance for this Part of the Measure falls short of setting out a blue print as to what a local primary mental health support service may look like, but it does set out a clear framework for the services across Wales. Some of the key points are as follows.
- Local Health Boards and Local Authorities must work together to establish Local Primary Mental Health Support Services across Wales, and together they will hold the funding and be responsible for the management of the service in their area.
- Whilst LHBs and LAs will remain ultimately responsible for ensuring that services are being delivered properly, services may not always be provided by them. Rather it is suggested that LHBs and LAs should actively recruit other local partners to help deliver the service, and particularly should “recognise and draw upon the contribution and expertise of specialist third sector organisations”.
- It is expected that the service will largely operate “within or alongside existing GP practices”, and will be a “specialism in the community”.
- There is considerable flexibility around the sorts of practitioners who may be recruited to act as local primary mental health support services workers. The main stipulation is that they must have the skills and competencies to fulfill all the five functions set out above.
- An important requirement is that service users know where they are in relation to the service and what they can expect. For example it should always be clear to them as to whether they are receiving a local primary mental health support service or being referred on to a secondary care service so they are not running the risk of “being lost between services”. They should also be clear about their “pathway of care” with “defined entry and exit points”.
PART 2 – CARE COORDINATION AND TREATMENT PLANNING IN MENTAL HEALTH SECONDARY SERVICES
This is a very brief part of the Measure, in fact the shortest part with just 5 key paragraphs. However, those few paragraphs include duties and rights that Hafal has campaigned hard for over many years, and which we hope will significantly improve the experience of secondary mental health services for people in Wales. Essentially Part 2 places duties on service providers (Health Boards and Local Authorities) to act in a coordinated manner to improve the effectiveness of the mental health services they provide, and it gives people who receive secondary mental health services two essential new rights:
- the right to have a Care Coordinator appointed to work with them to coordinate their care and treatment, and
- the right to an individual and comprehensive Care and Treatment Plan to assist their recovery.
Part 2 of the Measure came into force in June 2012.
Whilst Part 2 of the Measure is relatively short, it is backed up by a comprehensive new Code of Practice which runs to some 60 pages. This is a statutory Code of Practice, prepared under Section 44 of the Measure. Like the Welsh Code of Practice for the Mental Health Act, it is not law which must be automatically followed, but it is an important document as it offers “statutory guidance”, and professionals who do not follow this guidance can be challenged in court.
As well as setting out the Guiding Principles explained above, the Code of Practice has chapters on:
- Care Coordinators
- Care and Treatment Planning
- Coordination of Services
- Monitoring and Review
- Discharge from Secondary Mental Health Services.
You can access the full Code of Practice by (link). Here we summarise some key points. (Where there is a quote directly from the Code of Practice, the paragraph number is put in brackets.)
- Assessment – The Measure itself does not make specific reference to assessment in secondary care, but the Code of Practice fully recognises that effective care planning must be preceded by comprehensive assessment, stating “The aim is for the assessment process to establish information from which care and treatment planning, and future work, can take place” (2.11). Assessment should consider both need and risk. In relation to needs, it should be “holistic” and consider all the eight areas of a person’s life also included in a Care and Treatment Plan (see below) (2.14). In relation to risk, it should “seek to identify any risks the relevant patient may be exposed to and any risks they may present to themselves or others” (2.18).
- Role of Care Coordinators – A person’s Care Coordinator will be a key, if not the key, professional working with them in secondary mental health services. Their Care Coordinator will be their “principle source of information” and will be “responsible for seeking their active involvement and engagement with the care planning process” (3.5). The Care Coordinator will also be ultimately responsible for ensuring the person has a written Care and Treatment Plan and that it is reviewed and updated (3.4). The duties and functions of Care Coordinators are set out in detail in the Code of Practice (3.32 to 3.36) and amount to ensuring they are actively working with, and coordinating the care and treatment of, the people they are responsible for.
- Allocation of Care Coordinators – It is the duty of statutory service providers, normally a Local Health Board or Local Authority, to appoint a Care Coordinator, and the Code of Practice sets out in detail where this duty lies (3.06 to 3.12). It also stresses the importance of ensuring that a person knows consistently who their Care Coordinator is and lays out in detail what should happen if there has to be a change in a person’s Care Coordinator (3.13 to 3.23).
- Who can be Care Coordinators – The Code of Practice is specific as to which professionals can act as Care Coordinators, and the list has similarities with the one for Approved Mental Health Professionals (AMHPs) under the Mental Health Act. They must be mental health professionals with appropriate skills and qualifications including (3.26):
- social workers
- mental health or learning disability nurses
- occupational therapists
- speech and language therapists.
- Care and Treatment Planning – Chapter 4, the longest chapter of the Code of Practice, deals with Care and Treatment Planning. It sets out in great detail not only what a Care and Treatment Plan should look like, but also how it should be discussed, negotiated, distributed, and revised. In summary the Care Coordinator must work hard to involve the person, and/or their representative or advocate, and appropriate family members and carers, and to consult widely with appropriate team members, professionals and services (4.3 to 4.32). The Care Coordinator should aim to complete the Care and Treatment Plan within 6 weeks (4.87) and copy it to everyone with a direct interest (4.91).
- A Care and Treatment Plan – There is a set 5 page format for a Care and Treatment Plan and Care and Treatment Plans should consider eight areas of a person’s life:
- finance and money
- personal care and physical well-being
- education and training
- work and occupation
- parenting or caring relationships
- social, cultural or spiritual
- medical and other forms of treatment including psychological interventions.
A Care and Treatment Plan should include information against each of these areas as to:
- what outcomes the person is seeking
- what services are being provided or what actions are being taken
- when and who by.
Hafal has detailed publications to assist service users, and their families and carers, through the Care and Treatment Planning process and these are well worth looking at for further information and advice.
- Coordinating Service Provision – Care Coordinators have a responsibility for monitoring the implementation of Care and Treatment Plans, but they do not have the responsibility for ensuring that specified services are delivered. This wider responsibility lies with the service provider and the Code of Practice acknowledges there are likely to be instances of unmet need (5.8). When services are not provided, the Care Coordinator should review and revise the Care and Treatment Plan with the service user.
- Monitoring and Reviewing Care and Treatment Plans – Once a person’s Care and Treatment Plan has been agreed and services are being delivered, the Care Coordinator has an ongoing responsibility for monitoring the implementation of the Plan. Such monitoring should include:
- continuing assessment of the person’s mental health needs and risks
- ensuring that services are being delivered as agreed
- whether the specified outcomes remain relevant and are being achieved.
A person’s Care and Treatment Plan must then be reviewed at least yearly, but the Code of Practice goes on to say that “reviews should be needs-led” (6,11) and can be triggered by the person, carer or service provider as well as by the Care Coordinator. Reviews should be carefully prepared and organised (6.18) and properly recorded (6.16).
- Ending of Secondary Mental Health Services – The Code of Practice for Part 2 of the Measure finally looks a person’s discharge from secondary mental health services. This will hopefully be a positive event marking an important stage in a person’s recovery but, even when it is, it needs to be recognised that it may be a difficult time for the person involved. The Code of Practice, therefore, requires the relevant authority, whether Local Health Board or Local Authority, to provide the person with clear information about why the secondary care service is ending and where future support may be accessed. Importantly the person must also be informed of their right to a further assessment under Part 3 of the Measure which we will go on to now.
PART 3 – ASSESSMENTS OF FORMER USERS OF SECONDARY MENTAL HEALTH SERVICES
The aim of Part 3 of the Measure is to make it easier for people who are not currently receiving secondary mental health services, but who have been done so in the previous three years, to access those services again. It gives them the right, if they believe their mental health is deteriorating to the point where they need specialist care and treatment again, to refer themselves directly back to secondary services, without first having to see a GP or go elsewhere for a referral.
This part of the Measure, which came into force in June 2012, puts a duty on Local Health Boards and Local Authorities to have arrangements in place to respond to such self-referrals, and to undertake timely assessments.
The Code of Practice which we referred to for Part 2 also has a chapter, Chapter 8, about Part 3. The key points are that:
- a person over 18 who has been known to secondary mental health services within the previous three years and still lives in the local area is entitled to “seek a further assessment of their mental health, with a view to determining whether secondary mental health services (or other services) may be required to improve or prevent a deterioration of their mental health” (8.18)
- this right is for the person alone, and does not extend to families or carers, although families and carers are still encouraged to inform services of important concerns (8.20)
- an assessment has to be undertaken “in a timely manner” (8.39)
- after the assessment is completed, a report must be written setting out whether further services have been identified and this must be given to the person within 10 working days (8.38/39).
PART 4 – INDEPENDENT MENTAL HEALTH ADVOCAY (IMHA)
The Mental Health Act 2007, which amended the Mental Health Act 1983, gave people detained under the Act an important new right to receive help and support from an Independent Mental Health Advocate (or IMHA). However, this right was only available to people under longer-term sections (Sections 2 and 3) and to people living in the community subject to Guardianship or Supervised Community Treatment.
Part 4 of the Measure is the only part that directly amends the Mental Health Act for people in Wales and it does so by extending the right to IMHA to all people admitted to psychiatric hospitals. Specifically it extends the right to:
- patients on the shorter-term, emergency sections of the Act (principally Sections 4 and 5), and
- patients in hospital voluntarily or “informally” (in other words, not subject to the Mental Health Act).
This Part of the Measure came into force fully in April 2012 with the clear aim of improving the experience of mental health services for all inpatients, assisting them in making informed decisions about their care and treatment, and supporting them in getting their voices heard.
There isn’t a Code of Practice covering Part 4 but detailed guidance and further information is available in the Welsh Government document “ Delivering the Independent Mental Health Advocacy Service in Wales: Guidance for Independent Mental Health Advocacy Providers and Local Health Board Advocacy Service Planners (2011). (link)
Some key points from this guidance are (where there is a direct reference to the guidance document, the paragraph number is in brackets):
- Role of IMHAs – IMHAs must be independent (50) and have a key role in helping patients to obtain and understand information about their care and treatment. They may help a patient become involved, or more involved, in decisions made about their care and treatment, and/or represent the patient and speak on their behalf (54 to 57).
- Rights and Duties of IMHAs – IMHAs have a duty to respond to any reasonable request to visit and interview a patient they are helping, and they have the right to visit and interview that person in private. They also have the right to visit and interview any person who is professionally concerned with a patient’s medical treatment (58 to 68).
- Information about IMHAs – The Guidance sets out which statutory authority has the duty to inform the patient, or their Nearest Relative, of the right to the help of an IMHA (69 to 75).
- Responsibility for the IMHA Service – The responsibility for extending the IMHA service falls to Local Health Boards who have a duty to commission an independent organisation to provide it.