The New Strategy for Wales
The Mental Health and Wellbeing Strategy for Wales
OF THE STRATEGY "TOGETHER FOR MENTAL HEALTH"
The Welsh Government launched its new mental health strategy, "Together
for Mental Health - A Mental
Health and Wellbeing Strategy for Wales" in October 2012, and in it sets out its "vision for 21st century mental health services". It states that Together for Mental Health should be seen alongside Together for
Health, Wales' 2011 strategy for the NHS, and Sustainable Social Services,
Wales' 2011 vision for Social Services, and that together these provide the
mental health strategic context for the next 10 years. Some of the key points of Together for Mental
Health (as explained in the introduction and further summarised on page 16 of
the Strategy) are these.
• Mental Health and Wellbeing It is Wales'
first mental health and wellbeing strategy, and has the aim of promoting mental wellbeing and preventing mental
health problems, as well as improving mental health services. It also has the aims of intervening early
when people are diagnosed with psychiatric illness and of reducing the impact
of serious mental illness.
• A Strategy for all Ages It is also
Wales' first mental health strategy to include all age groups - children,
adults of working age and older people.
Services will continue to be delivered separately to these three age
groups, but the Strategy seeks to improve transitions for people who move between
• The Mental Health Measure The Strategy builds on the Mental Health (Wales) Measure which the Welsh Government passed
in 2010 and which places legal duties on Health Boards and Local Authorities to
improve how treatment, care and support are offered to people with mental
ill-health and which we
describe on a separate page. The focus on improved individual Care and Treatment Planning,
and on recovery and enablement, a key feature of the Mental Health Measure, is
also central to the Strategy.
• Outcome focused The Strategy seeks to be outcome focused with 6
high level outcomes and 18 lower level outcomes. We explain what this means in more
detail below but essentially it is about trying to ensure that the strategy
does make a real and measurable difference, or as the Strategy itself states to
"measure services from the perspective of the individual" and through "a
service user lens". So each chapter has
boxes saying how the outcomes will be achieved and then chapter 5 sets out "the
actions the Welsh Government and partner organisations will undertake to make
the Strategy's vision a reality".
• Human Rights The Strategy also seeks to take a human rights
approach, aiming both to tackle stigma and discrimination and to address issues
of equality and diversity.
Plan Finally the Strategy is backed up by a Delivery Plan, which explains how the
Strategy will be implemented in the initial
three years (2013 to 2016). The Delivery
Plan includes a three-year programme of improvement, setting out the
progress required for service delivery and with the emphasis on making "best use of
resources". Implementation of the
Strategy and the Delivery Plan will be overseen by a "Mental Health Partnership Board".
In the pages below we look at all these points in more
detail and offer our summary of the five chapters of the Strategy. We will
look at the Delivery Plan on a separate page.
REPLACING OR BUILDING ON PREVIOUS STRATEGIES?
Together for Mental Health replaces three previous Welsh Government strategic documents:
• the 2001 strategy for adult mental health
services "Adult Mental Health Services for Wales: Equity, Empowerment,
• the 2005 Mental
Health National Service Framework (NSF) which set out a range of Standards and Key Actions
to ensure the successful implementation of the strategy
2001 strategy for child
and adolescent mental
health services "Child and Adolescent Mental Health Services:
The Welsh Government stresses in Together for Mental Health (page 13) that these previous strategies have led to positive
change. It says they have "acted as
catalysts for significant progress over the last 10 years" and includes (page
14) a lengthy list of service improvements.
This list includes the following (although this is not the whole list):
• "The groundbreaking Mental Health (Wales) Measure 2010 which is
extending primary care provision and driving more holistic, personalised
recovery centred approaches."
• "The development of Criminal Justice Liaison Services identifying and diverting
of people with mental health problems as early as possible in the criminal
• "Adult and Older Persons' Community Mental Health Teams and Crisis
Teams, as well as Home Treatment and Assertive
Outreach Services, developing across Wales."
• "Mental health investment increased as a proportion of overall NHS
• "Service users, carers and their families increasingly involved in
developing policies and legislation, and in service planning and design at a
• "Investment in innovative schemes provided by the Third Sector and an
increase in partnership working between the Statutory and Voluntary sectors."
• "New integrated NHS bodies making it easier to join up care pathways
between both primary and secondary services."
Hafal would certainly agree that services have
improved along these lines over the last 10 years, and indeed we have
campaigned for many of these developments and played a part in them. We would, however, have liked to see
improvements taking place more quickly and more uniformly across Wales. If Together for
Mental Health achieves
faster and more uniform improvements, we will very much welcome this.
THE STRATEGY IN MORE
DETAIL - OUTCOMES
The language of "outcomes" is used extensively throughout
the Strategy. There are good reasons for
this. Any strategy is of little use if
it does not have a clear and positive impact on people's lives, and this
Strategy sets out its intended impact in terms of a number of "outcomes".
"Outcomes" usually seek to explain the intended
consequence or goal of a service. Ideally they should be easy to understand and
also be measureable. So when a person
visits their GP with a relatively straightforward illness, the outcome they are
seeking is that their illness is clearly diagnosed and treated, and this
outcome can usually be measured by the extent to which they feel better.
The outcomes in the Strategy are, of course, rather
more complex, but perhaps also a little confusing. There are 24 outcomes in all, 6 high level
outcomes and 18 lower level outcomes.
• High Level Outcomes In the box below are the 6 "high level outcomes" copied
directly from the Strategy. They are
important statements and ones Hafal fully support. However, in most strategies they would be
stated as aims or objectives rather than outcomes and as
such they probably make rather more sense.
Added towards the end of the Strategy are a number of "Technical
Annexes" and Technical Annexe 2 sets out outcome measures for these 6
outcomes. However, whether these measures
really do justice to the high level outcomes is also very questionable. For example, outcome D is of very real
importance to Hafal and its members, but the Technical Annexe includes just 3 measures:
- "number of adult service users receiving
in Care and Treatment Plans recording Welsh language and other language needs"
of care plans demonstrating service user participation in their formulation".
It seems to us unlikely that using these measures
can really gauge progress around this important aim or outcome, and the only
reliable measure would be to ask service users for feedback about their
|High Level Outcomes
|A. The mental health and wellbeing of the whole
population is improved.
B. The impact of mental health problems and/or
mental illness on individuals of all ages, their families and carers,
communities and the economy more widely, is better recognised and reduced.
C. Inequalities, stigma and discrimination
suffered by people experiencing mental health problems and mental illness are
D. Individuals have a better experience of the
support and treatment they receive and have an increased feeling of input and
control over related decisions.
E. Access to, and the quality of preventative
measures, early intervention and treatment services are improved and more
people recover as a result.
F. The values, attitudes and skills of those
treating or supporting individuals of all ages with mental health problems or
mental illness are improved.
• Lower Level Outcomes The 18 lower level outcomes also reflect important
aims that Hafal fully support. They are
slightly more specific that the high level outcomes, although they still remain
fairly general in nature. For example
lower level Outcome 1:
wide physical and mental wellbeing is improved; people live longer,in better health and as independently as possible for
as long as possible"
is not significantly less general than high level
health and wellbeing of the whole population is improved".
These lower level outcomes are directly related to
each of the 5 chapters of the Strategy and so, as in the Strategy itself, we
include them in a box under each chapter below.
The 18 lower level outcomes are also linked in the Strategy to the 6
high level outcomes, and we include this information in these boxes.
CHAPTER 1 OF THE
STRATEGY - PROMOTING BETTER MENTAL WELLBEING AND PREVENTING MENTAL HEALTH
|Chapter 1 Outcomes
|1. Wide physical and mental wellbeing is improved; people live longer, in
better health and as independently as possible for as long as possible.
||A & E
|2. People and communities are more resilient and better able to deal with
the stresses in everyday life and at times of crisis.
||A, B & C
|3. Child welfare and development, educational attainment and workplace
productivity are improved as we address poverty.
||A, C& E
We said in our Overview above that this is Wales' first
mental health strategy to include the aim of promoting mental wellbeing
and preventing mental
health problems. Chapter 1 focuses specifically
on this aim. It covers a lot of ground briefly,
summarising how wide areas of government activity can impact positively
mental well-being and cross referencing a wide range of other Welsh
Government strategies and initiatives. It also refers in passing to a
number of concepts that we know are associated with positive mental
health and wellbeing such as
"social cohesion", "social inclusion", and "resilience". It is,
therefore, a difficult chapter to
summarise well, but in essence it
sets out how mental wellbeing will be promoted at three levels.
• At a population level - This section restates what we know already that
health inequalities and social inequalities are closely linked, and that
factors such as poverty, social isolation, domestic and other abuse, bullying,
unhealthy work environments, overcrowding, and homelessness all impact
negatively people's mental health. It suggests that existing government strategies
seeking to reduce health inequalities in Wales will also lead to improvements
in the nation's mental health.
• Within communities - This section further restates the link between deprivation
and poor mental health, and the need for preventative action in areas of
deprivation. It seeks to promote mental wellbeing through targeted community
programmes; through sensitive planning and environment policies; through positive
activities such as sport, arts and culture; and through good practice in schools
and in the workplace. It also makes
specific reference to implementing the recommendations of "Talk to me", the Welsh
Government's existing Action Plan to reduce
suicide and self harm.
• For individuals - This section focuses on specific groups of people
known to be at increased risk of mental ill-health, and on the need to intervene
positively to reduce that risk. Specifically it refers to:
- the need to give young people the best start
in life, and to intervene positively with children or parents where this is not
people who face particular life stresses and who may not have easy access to
health care (such as refugees, veterans, women subject to abuse, people within
the criminal justice system), and to target resources at these groups;
- recognising the risks faced by many older
people, whether through social factors like isolation or through health factors
linked to increasing age, and again intervening positively to offer prevent
mental health problems.
The section also looks at some of the
additional health risks run by people with long term mental health problems,
including poor physical health and problems linked to smoking, drug and alcohol
misuse, and the need to target appropriate health promotion initiatives at this
CHAPTER 2 OF THE
STRATEGY - A NEW PARTNERSHIP WITH THE PUBLIC
|Chapter 2 Outcomes
|4. People with protected characteristics and vulnerable groups,
experience equitable access and services are more responsive to the needs of a
diverse Welsh population.
||B, C & E
|5. Welsh speakers in Wales are able to access linguistically appropriate
mental health treatment and care where they need to do so
||C, D & E
|6. People in Wales have the information and support they need to sustain
and improve their mental health and self manage mental health problems.
||A & B
|7. People with mental ill health experience less stigma and
discrimination and feel that these problems are being tackled.
||C & D
|8. People feel in more control as partners in decision making about their
treatment and how it is delivered.
||C, D & E
|9. Families and carers of all ages are involved in assessments for
support in their caring roles.
||B & D
|10. People of all ages and communities in Wales are effectively engaged in
the planning, delivery and evaluation of their local mental health services.
||D & E
This focus of this Chapter is on improving the awareness
of mental health, and understanding of the needs of people with mental
ill-health, across Wales. It seeks to
promote a more inclusive approach so that, in effect, mental health and mental
ill-health become everybody's business, whether as service providers, service
users, families and carers, people with responsibilities whether as the media,
employers or whatever, and the wider public.
It states the Welsh Government's
commitment to improving information, access, and involvement in specific areas
• Ensuring equality - so that, whether in mental health services or services more generally, the human rights of
people with mental ill-health are better protected and the diversity of need
• Meeting the needs of
Welsh speakers - so that Welsh speakers can have
services delivered in their first language
• Promoting mental health awareness - providing better quality information about mental
health and mental ill-health to the wider public, and especially around some
key issues such as improving awareness of services in Primary Care, improving
awareness of mental health issues among children and young people,
raising mental health issues in the workplace and improving
awareness of dementia
• Reducing stigma and
discrimination - acknowledging the higher levels of
discrimination faced by people with mental ill-health and tackling this in the
media, within services and in the population more widely
• Engaging people in
their own care - so that service users, and their
families and carers, take more active roles "as partners" in planning and
managing their own care and that there is more support for families and carers
• Involvement of
services users - recognising the value of giving a voice
to people with direct experience of services, and involving them in their planning,
design, and monitoring.
CHAPTER 3 OF THE
STRATEGY - A WELL DESIGNED, FULLY INTEGRATED NETWORK OF CARE
|Chapter 3 Outcomes
||High Level Outcomes
|11. Service users experience a more integrated approach from those
||D, E & F
|12. People of all ages benefit from evidence-based interventions delivered
as early as possible and from improved access to psychological therapies.
||D, E & F
|13. Service user experience is improved, with safety, protection and
dignity ensured and embedded in sustainable services.
||C, D, E & F
|14. Providers are positively managing risk, supporting people to increase
their levels of hope and aspiration and enabling them to realise their full
potential through recovery and enablement approaches.
||B, C, D, E & F
The focus of this Chapter, the longest of
the five chapters of the Strategy, is on services and service provision. As in previous mental health strategies the
key words and phrases are service providers "working together", "in
partnership", with "integrated management" and "pooled budgets" leading to
"integrated care pathways" and "holistic care". The Strategy specifically seeks
integrated services and pathways between:
• Primary Care, with an emphasis on
early identification of problems and effective longitudinal care, along with Community Pharmacies
• Specialist Community Services including
Child and Adolescent Mental Health Services (CAMHS), Community Intensive Intervention Teams (CIITs), Community Mental Health Teams (CMHTs) and Crisis Resolution and Home Treatment Services (CRHTs)
• Inpatient Care with fewer beds but
ones in modern buildings with single rooms and single sex facilities, offering
better focussed care and treatment, and remaining closely linked with community
services to reduce as far as possible repeated admissions and delayed
• Criminal Justice Services which
recognise offenders right to appropriate treatment and support, and to provide
these by better liaison and joint working with mental health services.
3 then continues with an extensive list of "service development priorities". There are some 30+ items and again these are
fairly general in nature. The list is
too long to summarise here but it include items as:
the most vulnerable, patient safety and public protection
psychological interventions and therapies
interventions for "co-occurring conditions", including substance misuse, eating
disorders, personality disorders, learning disabilities and autism, sensory
impairment and victims of sexual violence
services for older people with mental health problems, and
the care and support for people with dementia.
emphasis of this chapter is, therefore, on continuous improvement and
development of services in a way which Hafal, of course, fully supports. It is, however, very general in nature, and
for example offers no clear picture, numbers, or figures about how a 21st century network of local services would look like.
CHAPTER 4 OF THE
STRATEGY - ONE SYSTEM TO IMPROVE MENTAL HEALTH
|Chapter 4 Outcomes
||High Level Outcomes
|15. People of all ages experience sustained improvement to their mental
health and wellbeing as a result of cross-Government commitment to all
sectors working together.
||A, B, C, E & F
Chapter 4 covers similar ground to chapter
3, the continued improvement and development
of mental health services, but it does so from a very different perspective. So, whilst chapter 3 suggests the priorities
for service providers, chapter 4 sets out how these should impact positively on
the direct experience of the service user, and it focuses specifically on
effective Care and Treatment Planning.
This is one of the more innovative chapters of the Strategy, building
directly on the Mental Health Measure, and is therefore the critical chapter
by stating the importance of a comprehensive or holistic approach to care and treatment planning
and explicitly sets out expectations for
each of the eight life areas set out below.
For children and young people this is a way of
ensuring that the ‘7 Core Aims' under the UNCRC are realised.
• Rights and Entitlements - Finance and Money acknowledging the negative effects of
poverty, and the need to assist people who, because of their illness, may
neglect their personal finances and have debt problems
• A Safe Home or Accommodation acknowledging the negative effects of homelessness and poor housing, and
the need to offer a range of housing options with appropriate support
• Health, Personal Care and Physical Wellbeing acknowledging that people with psychiatric diagnoses may have significantly reduced life
expectancy and the need to assist people to live healthier lifestyles and
access good physical healthcare
• Early Years, School, Education and Training acknowledging that younger people diagnosed with a mental health problems are likely to have poorer
educational outcomes and the need to offer
further educational opportunities
• Work, Occupation and Valued Daily Activities acknowledging the importance of work or
valued occupation to good mental health and the need to offer
a range of initiatives to help people who may be struggling to begin, or return
to, work because of mental illness
• Family, Parenting and/or Caring Relationships acknowledging that people with mental health
problems have the same rights to family life as anyone else, and that they may need help and support in this area of their lives
• Access to play, sports and friends; social, cultural or spiritual needs acknowledging that poor mental health is likely to have a negative effect on a person's
self-esteem and the need to help people retain or regain the support of family
and friends, and to play a part in their local communities
• Medical and other forms of treatment including psychological
interventions acknowledging that people
with mental health problems should get comprehensive treatment and support for both their psychiatric
illness and any other physical health problems, and that this should include an
understanding of side effects and other complications.
In Technical Annex 3 at the end of the Strategy, there is a table setting
out how different agencies should be contributing to a person's care plan.
CHAPTER 5 OF THE
STRATEGY - DELIVERING FOR MENTAL HEALTH
|Chapter 5 Outcomes
||High Level Outcomes
|16. Staff across the wider workforce recognise and respond to signs and
symptoms of mental illness and dementia.
||A, B, E & F
|17. Inspirational leadership and a well-trained, competent workforce in
sufficient numbers ensure a culture which is safe, therapeutic, respectful
||C, D, E & F
|18. Evidence-based high quality services are delivered through
appropriate, cost effective investment in mental health
||B, E & F
Chapter 5 moves on from "the what" to "the
how", and sets out some key issues for implementing the Strategy.
• National Mental Health
Partnership Board (NPB) This Board, which first met in
December 2012, has a key role in monitoring implementation of the Strategy, and
the accompanying Delivery Plan, at a national level. It includes representation
from the Welsh Government, from the statutory, voluntary and a independent sectors,
and from service users and carers. It
will also have links to professional advisory groups such as the Royal Colleges.
• Local Partnership Boards (LPBs) LPBs have responsibility for implementation of the Strategy at a more
local level, based on the 7 Local Health Board (LHB) areas in Wales. They are to have "robust local
mental health partnership arrangements" and include representation at a senior
level from LHBs, Social Services, Housing, Criminal Justice Agencies, Education
and the Third Sector. Service users and carers are also to be fully involved. Appropriate links are also to be made with
CAMHS services and with Mental Health and Criminal Justice Planning Groups
• The Workforce The obvious but important
point is made that implementing or delivering the Strategy is only possible
with an effective workforce. This means:
- strong leadership
- staff who are well trained and have "a high level of mental health
literacy and engagement"
- staff who are able to deliver holistic services "based
on recovery and enablement and on the appropriate management of risk", and are
able to work alongside service users
- strong links between the social care and health
workforces, with a common understanding of mental health issues and a coherent
and consistent approach
- a workforce that changes or can be
"redesigned" in line with new and better practice.
• Improving Performance The Strategy seeks continuous improvement in services, learning from
current and future best practice. It also refers to the importance of learning
from mental health research, particularly research about service user
experience, and using research findings to improve services.
• Funding Finally the Strategy looks at the critical issue of funding. It is not surprising, given the difficult
economic time in which it was published, that the emphasis is not on any new
money but on "making every penny count". The Strategy therefore expects expenditure to
be scrutinised and for better value to be got from existing resources. It also expects savings to be made but states,
where this happens, any money released should be reinvested in mental health
services. Currently some 12% of the NHS
budget in Wales is spent on mental health and the expectation seems to be that
spending will remain at around that level.
So, to summarise, some of the key phrases used in this important section
on money are:
- improving transparency of financial information, and checking spending
- making best use of current funding and identifying savings
- ring fencing of current
expenditure and reinvesting those savings in mental health services
- using the £9 million additional money (£4 million in 2012/13 and £5
million from 2013) made available to implement the Mental Health Measure
creatively to improve access to services.