Poor services in Wales may hinder introduction of mental health reforms

I n 1995, Conservative Stephen Dorrell was health secretary and
Tony Blair was transforming the Labour Party into New Labour. It
was also the year England implemented person-centred mental
health.

The care programme approach (CPA) was seen as a key reform to
mental health services in England as it gave users a plan for
recovery and a greater say in their treatment.

But it will not be fully implemented in Wales until later this
year. This recently led the Nursing and Midwifery Committee Wales
to say mental health services in Wales are 10 years behind the rest
of the UK.

In evidence given to a parliamentary scrutiny committee on the
draft Mental Health Bill for England and Wales, the Nursing and
Midwifery Committee and other groups said the delay in introducing
the CPA was indicative of wider problems in Welsh mental health
services, and could make it impossible to implement the bill
effectively.

Poor Provision

Over-reliance on institution-based services, under-funding,
poorer health, and remote areas have all contributed to Wales’s
poor reputation for mental health provision.

Over the past five years the Welsh assembly has made mental
health one of its top three priorities and developed its own
National Service Framework for Mental Health. It has also started
developing a system that delivers care to more people in the
community rather than hospitals.

But critics say the basic building blocks for this new community
service are still not in place and without them the draft bill will
not work.

Chair of the assembly’s health committee David Melding says: “We
are seeing a major change in legislation at a time when we are
trying to develop the basic care model for mental health. It would
be better to implement these important changes and then have a
stable situation for the care model and then review the
legislation.”
He says the “stock” of mental health hospitals in Wales is “very
poor”, and in some areas where hospitals have been closed
replacement community units have still not been opened. “Our
services really are not fit for modern mental health care.”

Lindsay Foyster, director of Mind Cymru, says the NSF is
supported across Wales. “But there is still no agreed action plan
timetable in place for its implementation.”

This highlights concerns about the progress of the NSF in Wales.
One member of the assembly’s implementation group says there is a
lot of talk about implementing it “but not a lot of doing it”.
Doctors’ leaders believe a body similar to the National Institute
for Mental Health in England is needed to lead the project in
Wales.

Foyster adds that the CPA is also key to the bill’s successful
introduction and doubts whether it will be available across Wales
this year.

“On paper all local health boards may say they have something in
place but my concern is that not all service users will feel they
are contributing to the development of their own care plan. If the
success of the bill is based on legislation being operational and
in place this won’t apply to Wales,” she adds.

Former assembly minister for health and social services Jane
Hutt, who left her post this week, told the parliamentary scrutiny
committee in November that she was concerned about the aim to
implement legislation from the draft bill by 2007. But she said she
was also confident that implementation of the NSF was on track but
“there is concern from stakeholders, professionals and myself that
unless we have our services fully in place we will have
difficulties [implementing the bill]”.

She also said there were concerns about the timetable because of
the need to consult on a Welsh code of practice and additional
legislation.

Recruitment Difficulties

The main difficulties for implementation in Wales are the
workforce shortages and the bill’s emphasis on the compulsory
detention of people for treatment.

Assembly figures show that vacancy rates for psychiatrists have
risen from 7.5 per cent to 23.7 per cent. The assembly says 147
psychiatrists need to be recruited to implement existing
commitments and the draft bill, otherwise the existing workforce
will not be able to cope with the bill. There are fears that this
will result in more use of the broadened compulsory detention
powers.

Hutt also said that a 10 per cent increase in the use of
compulsion could lead to a 20 per cent increase in the workers’
statutory duties.

Many fear the bill could also undermine the Welsh aim to develop
a more community-centred service.

“The bill as it stands focuses too much on public safety and
goes against a lot of good practice that is being developed in
Wales,” says Dr Huw Lloyd, lead for Wales Mental Health in Primary
Care. “I fear the bill will set us back.”

Foyster says the bill “runs counter” to policy development in
Wales “where service users and carers are central to its
development” and “public safety is not the main thrust”.

Welsh service user group Hafal goes further. It has written to
the parliamentary committee raising fears that the assembly’s focus
on recruiting psychiatrists suggests a policy retreat. “We are
aware that workforce planning within the assembly is being directed
away from developing community services and into the staffing
implementation of the bill,” says a Hafal spokesperson.

These fears about resources being diverted are shared by others.
Kirsty Williams, assembly member and Liberal Democrat health
spokesperson, says: “We are concerned that implementation of this
bill would take money away from implementing the NSF and divert
meagre resources.”

But Hutt said recruiting more psychiatrists was “key” to the
assembly’s plans for the whole service for the next five years. She
told the scrutiny committee: “I can assure you that what we are
moving to is crisis resolution, home treatment, CPA,
multi-disciplinary team working.”

Even if this is so, many remain sceptical it will happen quickly
enough for the measures in the new bill to be introduced
successfully.

Problems in Powys

• Powys has the lowest level of consultant psychiatrist posts in
  Wales, with nearly half the recommended number (2.8 compared with
  5.4).
• The only acute unit in Powys is closed due to shortage of
  staff.
• There is only one on-call ASW covering the whole of Powys.
• Service users may see a different psychiatrist every four
  weeks, with a detrimental effect on treatment and users’
  morale.

From evidence given by Celia Cowie, development worker, North
Powys, to the parliamentary scrutiny committee meeting at the Welsh
assembly on 15 December.