Adult Mental Health Services
The NHS and Social Services are the key government organisations delivering local mental health services. All the recent Welsh Assembly Government’s policies and strategies for both mental health and carers, including the Mental Health Strategy, the National Service Framework, and the Carers’ strategy, emphasise the need for the NHS and Social Services to work together to provide “seamless services” for service users, and their families and carers.
Up to September 2009 there were 22 Local Health Boards (LHBs) and 22 Social Services authorities in Wales with shared boundaries and so, in theory at least, this should have made joint working easier. In practice, however, this was not always obvious to service users, and their families and carers. In October 2009 the NHS in Wales implemented a major reorganisation and there are now just 7 LHBs, but still 22 Social Services authorities. It remains to be seen how this will work out in practice.
Commissioning and Delivering Services
Both the LHBs and Social Services have two major functions for mental health services, usually referred to as purchasing or commissioning services and providing or delivering services. This is what this means.
· Commissioning Services refers to the whole process of planning the full range of services, ensuring they are available, and they are monitored and reviewed. Planning and commissioning functions are for the most part undertaken jointly by the NHS and Social Services, and often mental health planning or commissioning staff are appointed jointly. Joint planning arrangements usually begin with a Strategic Planning Group which includes not only NHS and Social Services commissioning staff, but also representatives from other local authority departments (for example Housing), the voluntary sector and service users and carers. Through this process, it is decided what services will be provided by the NHS and Social Services, sometimes called “in-house services”, and services will be contracted out to other organisations, sometimes called “external providers”.
· Service Delivery is then undertaken either “in house” or by external providers. We explain in more detail below how the NHS and Social Services deliver local services. In general terms, however, NHS hospital services are mainly delivered “in- house”, that is by the NHS (although some specialist hospital services are provided by private organisations) whilst community care services are increasingly contracted out to voluntary or private organisations.
The NHS in Wales
As we have already said, the NHS in Wales went through a major reorganisation in October 2009. Through this reorganisation, the 22 LHBs (which commissioned services) and the 7 NHS Trusts (the number of which had already reduced from 15 through mergers and which provided services) were merged in to 7 new “unified” bodies which both commission and provide services. Somewhat confusingly these new unified NHS authorities are still called Local Health Boards (LHBs).
Through the LHBs, the NHS delivers services at 3 levels:
· Primary Care At this first level family doctors, or GPs, undertake the major role for mental health services, but primary care also includes dentists, opticians, pharmacy and other GP Practice staff like practice nurses. There are some 1,900 GPs in Wales and their critical role in mental health, along with other practice staff, includes:
– initial diagnosis of mental health problems
– prescribing medication
– referring to counselling services
– being an access point, referrer or “gatekeeper” for secondary mental health services
– and, importantly as it is sometimes overlooked, continuing to consider the physical health needs of people diagnosed with a serious mental illness.
· Secondary Care This is the important level for the delivery of services for people diagnosed with a serious mental illness. In the NHS secondary care services are specialist services, and this is so whether they are for people with major physical illnesses as cancer and heart disease or whether for people with a mental illness. Whilst specialist or secondary care services tended to be provided in hospitals, this is increasingly less so for mental health and instead services may be provided at home or in community settings, often jointly with Social Services. Specialist or secondary care services include:
– full diagnosis and assessment of serious mental illness,
– coordination of health and community services through Community Mental Health Teams (CMHTs), described more fully below,
– provision of specialist services such as psychiatric hospitals and wards and/or day hospitals, and also alternatives to hospital such as crisis teams, home treatment teams and extended hours day hospitals,
– fulfilling the roles of Responsible Clinician and Approved Mental Health Professional (AMHP) under the Mental Health Act.
· Tertiary Care Care at this level tends to be very specialist and is provided in regional or national hospitals or units, rather than within a person’s local area. People needing some tertiary services may be referred to services in England. Mental health services at this level include:
– hospital services for people with an eating disorder
– some services for people with a dual diagnosis (including mental health and substance misuse)
– intensive psychiatric care units
– medium secure and secure hospitals.
Community Mental Health Teams (CMHTs)
CMHTs are probably the most central and important part of mental health services for service users, and their families and carers. The National Service Framework requires CMHTs to be staffed and managed jointly by the NHS and Social Services. Professionals working in CMHTs include:
– community psychiatric nurses (CPNs)
– social workers
– occupational therapists
– support staff.
Some people with a serious mental illness, especially when they are managing their illness well, may choose just to have contact with their GP. However, for others, especially when there is uncertainty around their illness or they are suffering active symptoms, contact with their CMHT will be important to them. People whose treatment and care is managed through their CMHT should have one or more allocated members of the Team who act as their key worker or “care coordinator” and with whom they are in regular contact. The roles of the CMHT include:
– contributing to a person’s diagnosis and assessment being undertaken by a psychiatrist
– co-ordinating a person treatment, care and support, usually through CPA (link to CPA?)
– proving specific treatment, care and/or support as specified in a person’s care plan
– acting as the access point or gatekeeper to specialist hospital or community care services, whether provided by the NHS, Social Services, or other organisations.
A full list of CMHTs, with their contact details, is set out on our page for CMHTs (link?)
Social Services in Wales
Social Services are the most important part of the 22 Local Authorities in Wales which commission and provide mental health services, although increasingly they may be merged with other local authority departments and called something else, for example Adult Services Department, or Housing and Social Services Department. This reflects the fact that, whilst Social Services may be the most important section for people with disabilities, including mental health problems, other sections also have a significant part to play in providing services. These will include Housing, Supporting People and Community Education Departments or Sections.
As explained above Social Services have both a planning/commissioning role and a service delivery role, and these include:
- Planning and Commissioning, sharing with the NHS, the responsibility for planning and commissioning the full range of local mental health services;
- Social Work Services ensuring that social workers contribute fully to CMHTs and are available to act as Approved Mental Health Professionals (AMHPs) under the Mental Health Act. Social Workers are also required to provide Community Care Assessments as part of the Assembly Government’s Unified Assessment process and, in practice, this is increasingly undertaken in conjunction with the care planning function of CPA;
- Delivering Community Care Services whether day services, home support and care services, or supported accommodation services; or
- Commissioning Community Care Services by contracting with voluntary sector or other providers to deliver day services, home support and care services, or supported accommodation services.
Local Authorities and Social Services also have a very significant role in planning and providing for carers and this is explained on other pages.