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The New Strategy for Wales

The Mental Health and Wellbeing Strategy for Wales


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 these services.

•  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.

•  Delivery 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.


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, Effectiveness, Efficiency"

•  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

•  the 2001 strategy for child and adolescent mental health services "Child and Adolescent Mental Health Services: Everybody's Business".

 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 justice pathway."

•  "Adult and Older Persons' Community Mental Health Teams and Crisis Resolution

Teams, as well as Home Treatment and Assertive Outreach Services, developing across Wales."

•  "Mental health investment increased as a proportion of overall NHS expenditure."

•  "Service users, carers and their families increasingly involved in developing policies and legislation, and in service planning and design at a local level."

•  "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 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 direct payments"

-    "increase 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 experience.

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 reduced.

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:

"Population 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 Outcome A:

"The mental 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 Outcomes

High Level 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 on 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 being achieved;

-    identifying 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 group.


Chapter 2 Outcomes

High Level 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 as follows:

•  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 better recognised

•  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 Outcomes

High Level Outcomes

11.  Service users experience a more integrated approach from those delivering services.

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 discharges

•  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.

Chapter 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:

•  safeguarding the most vulnerable, patient safety and public protection

•  promoting independence

•  improving psychological interventions and therapies

•  improving interventions for "co-occurring conditions", including substance misuse, eating disorders, personality disorders, learning disabilities and autism, sensory impairment and victims of sexual violence

•  improving services for older people with mental health problems, and

•  improving the care and support for people with dementia.

The 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 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 for Hafal.

It begins 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 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 and empowering.

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 (MHCJPGs).

•  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 across LHBs
-    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.


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