OVERVIEW OF THE STRATEGY “TOGETHER FOR MENTAL HEALTH”
The Welsh Government launched its new mental health strategy, “Together for Mental Health – A MentalHealth 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 forHealth, Wales’ 2011 strategy for the NHS, and Sustainable Social Services,Wales’ 2011 vision for Social Services, and that together these provide themental health strategic context for the next 10 years. Some of the key points of Together for MentalHealth (as explained in the introduction and further summarised on page 16 ofthe 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 mentalhealth problems, as well as improving mental health services. It also has the aims of intervening earlywhen people are diagnosed with psychiatric illness and of reducing the impactof serious mental illness.
A Strategy for all Ages
It is alsoWales’ 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 agegroups, but the Strategy seeks to improve transitions for people who move betweenthese services.
The Mental Health Measure
The Strategy builds on the Mental Health (Wales) Measure which the Welsh Government passedin 2010 and which places legal duties on Health Boards and Local Authorities toimprove how treatment, care and support are offered to people with mentalill-health and which wedescribe 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, isalso central to the Strategy.
The Strategy seeks to be outcome focused with 6high level outcomes and 18 lower level outcomes. We explain what this means in moredetail below but essentially it is about trying to ensure that the strategydoes make a real and measurable difference, or as the Strategy itself states to”measure services from the perspective of the individual” and through “aservice user lens”. So each chapter hasboxes saying how the outcomes will be achieved and then chapter 5 sets out “theactions the Welsh Government and partner organisations will undertake to makethe Strategy’s vision a reality”.
The Strategy also seeks to take a human rightsapproach, aiming both to tackle stigma and discrimination and to address issuesof equality and diversity.
Finally the Strategy is backed up by a Delivery Plan, which explains how theStrategy will be implemented in the initialthree years (2013 to 2016). The DeliveryPlan includes a three-year programme of improvement, setting out theprogress required for service delivery and with the emphasis on making “best use ofresources”. Implementation of theStrategy 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 willlook 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 healthservices “Adult Mental Health Services for Wales: Equity, Empowerment,Effectiveness, Efficiency”
- the 2005 MentalHealth National Service Framework (NSF) which set out a range of Standards and Key Actionsto ensure the successful implementation of the strategy
- the2001 strategy for childand adolescent mentalhealth 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 positivechange. It says they have “acted ascatalysts for significant progress over the last 10 years” and includes (page14) 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 isextending primary care provision and driving more holistic, personalisedrecovery centred approaches.”
- “The development of Criminal Justice Liaison Services identifying and divertingof people with mental health problems as early as possible in the criminaljustice pathway.”
- “Adult and Older Persons’ Community Mental Health Teams and CrisisResolution Teams, as well as Home Treatment and AssertiveOutreach Services, developing across Wales.”
- “Mental health investment increased as a proportion of overall NHSexpenditure.”
- “Service users, carers and their families increasingly involved indeveloping policies and legislation, and in service planning and design at alocal level.”
- “Investment in innovative schemes provided by the Third Sector and anincrease in partnership working between the Statutory and Voluntary sectors.”
- “New integrated NHS bodies making it easier to join up care pathwaysbetween both primary and secondary services.”
Hafal would certainly agree that services haveimproved along these lines over the last 10 years, and indeed we havecampaigned for many of these developments and played a part in them. We would, however, have liked to seeimprovements taking place more quickly and more uniformly across Wales. If Together forMental Health achievesfaster and more uniform improvements, we will very much welcome this.
THE STRATEGY IN MOREDETAIL – OUTCOMES
The language of “outcomes” is used extensively throughoutthe Strategy. There are good reasons forthis. Any strategy is of little use ifit does not have a clear and positive impact on people’s lives, and thisStrategy sets out its intended impact in terms of a number of “outcomes”.
“Outcomes” usually seek to explain the intendedconsequence or goal of a service. Ideally they should be easy to understand andalso be measureable. So when a personvisits their GP with a relatively straightforward illness, the outcome they areseeking is that their illness is clearly diagnosed and treated, and thisoutcome can usually be measured by the extent to which they feel better.
The outcomes in the Strategy are, of course, rathermore complex, but perhaps also a little confusing. There are 24 outcomes in all, 6 high leveloutcomes and 18 lower level outcomes.
High Level Outcomes
In the box below are the 6 “high level outcomes” copieddirectly from the Strategy. They areimportant statements and ones Hafal fully support. However, in most strategies they would bestated as aims or objectives rather than outcomes and assuch they probably make rather more sense. Added towards the end of the Strategy are a number of “TechnicalAnnexes” and Technical Annexe 2 sets out outcome measures for these 6outcomes. However, whether these measuresreally do justice to the high level outcomes is also very questionable. For example, outcome D is of very realimportance to Hafal and its members, but the Technical Annexe includes just 3 measures:
- “number of adult service users receivingdirect payments”
- “increasein 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 measurescan really gauge progress around this important aim or outcome, and the onlyreliable measure would be to ask service users for feedback about theirexperience.
|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 importantaims that Hafal fully support. They areslightly more specific that the high level outcomes, although they still remainfairly general in nature. For examplelower level Outcome 1:
“Populationwide physical and mental wellbeing is improved; people live longer,in better health and as independently as possible foras long as possible”
is not significantly less general than high levelOutcome A:
“The mentalhealth and wellbeing of the whole population is improved”.
These lower level outcomes are directly related toeach of the 5 chapters of the Strategy and so, as in the Strategy itself, weinclude them in a box under each chapter below. The 18 lower level outcomes are also linked in the Strategy to the 6high level outcomes, and we include this information in these boxes.
CHAPTER 1 OF THESTRATEGY – PROMOTING BETTER MENTAL WELLBEING AND PREVENTING MENTAL HEALTHPROBLEMS
|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’ firstmental health strategy to include the aim of promoting mental wellbeing and preventing mentalhealth problems. Chapter 1 focuses specificallyon this aim. It covers a lot of ground briefly,summarising how wide areas of government activity can impact positively onmental well-being and cross referencing a wide range of other Welsh Government strategies and initiatives. It also refers in passing to anumber 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 tosummarise well, but in essence itsets out how mental wellbeing will be promoted at three levels.
• At a population level – This section restates what we know already thathealth inequalities and social inequalities are closely linked, and thatfactors such as poverty, social isolation, domestic and other abuse, bullying,unhealthy work environments, overcrowding, and homelessness all impactnegatively people’s mental health. It suggests that existing government strategiesseeking to reduce health inequalities in Wales will also lead to improvementsin the nation’s mental health.
• Within communities – This section further restates the link between deprivationand poor mental health, and the need for preventative action in areas ofdeprivation. It seeks to promote mental wellbeing through targeted communityprogrammes; through sensitive planning and environment policies; through positiveactivities such as sport, arts and culture; and through good practice in schoolsand in the workplace. It also makesspecific reference to implementing the recommendations of “Talk to me”, the WelshGovernment’s existing Action Plan to reducesuicide and self harm.
• For individuals – This section focuses on specific groups of peopleknown to be at increased risk of mental ill-health, and on the need to intervenepositively to reduce that risk. Specifically it refers to:
– the need to give young people the best startin life, and to intervene positively with children or parents where this is notbeing achieved;
– identifyingpeople who face particular life stresses and who may not have easy access tohealth care (such as refugees, veterans, women subject to abuse, people withinthe criminal justice system), and to target resources at these groups;
– recognising the risks faced by many olderpeople, whether through social factors like isolation or through health factorslinked to increasing age, and again intervening positively to offer preventmental health problems.
The section also looks at some of theadditional health risks run by people with long term mental health problems,including poor physical health and problems linked to smoking, drug and alcoholmisuse, and the need to target appropriate health promotion initiatives at thisgroup.
CHAPTER 2 OF THESTRATEGY – A NEW PARTNERSHIP WITH THE PUBLIC
|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 awarenessof mental health, and understanding of the needs of people with mentalill-health, across Wales. It seeks topromote a more inclusive approach so that, in effect, mental health and mentalill-health become everybody’s business, whether as service providers, serviceusers, families and carers, people with responsibilities whether as the media,employers or whatever, and the wider public. It states the Welsh Government’scommitment to improving information, access, and involvement in specific areasas follows:
• Ensuring equality – so that, whether in mental health services or services more generally, the human rights ofpeople with mental ill-health are better protected and the diversity of needbetter recognised
• Meeting the needs ofWelsh speakers – so that Welsh speakers can haveservices delivered in their first language
• Promoting mental health awareness – providing better quality information about mentalhealth and mental ill-health to the wider public, and especially around somekey issues such as improving awareness of services in Primary Care, improvingawareness of mental health issues among children and young people,raising mental health issues in the workplace and improvingawareness of dementia
• Reducing stigma anddiscrimination – acknowledging the higher levels ofdiscrimination faced by people with mental ill-health and tackling this in themedia, within services and in the population more widely
• Engaging people intheir own care – so that service users, and theirfamilies and carers, take more active roles “as partners” in planning andmanaging their own care and that there is more support for families and carers
• Involvement ofservices users – recognising the value of giving a voiceto people with direct experience of services, and involving them in their planning,design, and monitoring.
CHAPTER 3 OF THESTRATEGY – A WELL DESIGNED, FULLY INTEGRATED NETWORK OF CARE
|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 ofthe five chapters of the Strategy, is on services and service provision. As in previous mental health strategies thekey words and phrases are service providers “working together”, “inpartnership”, with “integrated management” and “pooled budgets” leading to”integrated care pathways” and “holistic care”. The Strategy specifically seeksintegrated services and pathways between:
• Primary Care, with an emphasis onearly identification of problems and effective longitudinal care, along with Community Pharmacies
• Specialist Community Services includingChild 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 butones in modern buildings with single rooms and single sex facilities, offeringbetter focussed care and treatment, and remaining closely linked with communityservices to reduce as far as possible repeated admissions and delayeddischarges
• Criminal Justice Services whichrecognise offenders right to appropriate treatment and support, and to providethese by better liaison and joint working with mental health services.
Chapter3 then continues with an extensive list of “service development priorities”. There are some 30+ items and again these arefairly general in nature. The list istoo long to summarise here but it include items as:
• safeguardingthe most vulnerable, patient safety and public protection
• improvingpsychological interventions and therapies
• improvinginterventions for “co-occurring conditions”, including substance misuse, eatingdisorders, personality disorders, learning disabilities and autism, sensoryimpairment and victims of sexual violence
• improvingservices for older people with mental health problems, and
• improvingthe care and support for people with dementia.
Theemphasis of this chapter is, therefore, on continuous improvement anddevelopment of services in a way which Hafal, of course, fully supports. It is, however, very general in nature, andfor example offers no clear picture, numbers, or figures about how a 21st century network of local services would look like.
CHAPTER 4 OF THESTRATEGY – 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 chapter3, the continued improvement and developmentof mental health services, but it does so from a very different perspective. So, whilst chapter 3 suggests the prioritiesfor service providers, chapter 4 sets out how these should impact positively onthe direct experience of the service user, and it focuses specifically oneffective Care and Treatment Planning. This is one of the more innovative chapters of the Strategy, buildingdirectly on the Mental Health Measure, and is therefore the critical chapterfor Hafal.
It beginsby stating the importance of a comprehensive or holistic approach to care and treatment planningand explicitly sets out expectations foreach of the eight life areas set out below. For children and young people this is a way ofensuring that the ‘7 Core Aims’ under the UNCRC are realised.
• Rights and Entitlements – Finance and Money acknowledging the negative effects ofpoverty, and the need to assist people who, because of their illness, mayneglect their personal finances and have debt problems
• A Safe Home or Accommodation acknowledging the negative effects of homelessness and poor housing, andthe 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 lifeexpectancy and the need to assist people to live healthier lifestyles andaccess good physical healthcare
• Early Years, School, Education and Training acknowledging that younger people diagnosed with a mental health problems are likely to have poorereducational outcomes and the need to offerfurther educational opportunities
• Work, Occupation and Valued Daily Activities acknowledging the importance of work orvalued occupation to good mental health and the need to offera range of initiatives to help people who may be struggling to begin, or returnto, work because of mental illness
• Family, Parenting and/or Caring Relationships acknowledging that people with mental healthproblems 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’sself-esteem and the need to help people retain or regain the support of familyand friends, and to play a part in their local communities
• Medical and other forms of treatment including psychologicalinterventions acknowledging that peoplewith mental health problems should get comprehensive treatment and support for both their psychiatricillness and any other physical health problems, and that this should include anunderstanding of side effects and other complications.
In Technical Annex 3 at the end of the Strategy, there is a table settingout how different agencies should be contributing to a person’s care plan.
CHAPTER 5 OF THESTRATEGY – 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 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 “thehow”, and sets out some key issues for implementing the Strategy.
• National Mental HealthPartnership Board (NPB) This Board, which first met inDecember 2012, has a key role in monitoring implementation of the Strategy, andthe accompanying Delivery Plan, at a national level. It includes representationfrom the Welsh Government, from the statutory, voluntary and a independent sectors,and from service users and carers. Itwill 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 morelocal level, based on the 7 Local Health Board (LHB) areas in Wales. They are to have “robust localmental health partnership arrangements” and include representation at a seniorlevel from LHBs, Social Services, Housing, Criminal Justice Agencies, Educationand the Third Sector. Service users and carers are also to be fully involved. Appropriate links are also to be made withCAMHS services and with Mental Health and Criminal Justice Planning Groups(MHCJPGs).
• The Workforce The obvious but importantpoint is made that implementing or delivering the Strategy is only possiblewith an effective workforce. This means:
– strong leadership
– staff who are well trained and have “a high level of mental healthliteracy and engagement”
– staff who are able to deliver holistic services “basedon recovery and enablement and on the appropriate management of risk”, and areable to work alongside service users
– strong links between the social care and healthworkforces, with a common understanding of mental health issues and a coherentand 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 fromcurrent and future best practice. It also refers to the importance of learningfrom mental health research, particularly research about service userexperience, and using research findings to improve services.
• Funding Finally the Strategy looks at the critical issue of funding. It is not surprising, given the difficulteconomic time in which it was published, that the emphasis is not on any newmoney but on “making every penny count”. The Strategy therefore expects expenditure tobe 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 healthservices. Currently some 12% of the NHSbudget in Wales is spent on mental health and the expectation seems to be thatspending will remain at around that level. So, to summarise, some of the key phrases used in this important sectionon money are:
– improving transparency of financial information, and checking spendingacross LHBs
– making best use of current funding and identifying savings
– ring fencing of currentexpenditure and reinvesting those savings in mental health services
– using the £9 million additional money (£4 million in 2012/13 and £5million from 2013) made available to implement the Mental Health Measurecreatively to improve access to services.