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.

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