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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.