Mental health practice in Wales: A briefing for AMs

Transcription

1 Mental health practice in Wales: A briefing for AMs This briefing provides an overview of the investment and work being done across the NHS to ensure good mental health is maintained, the support available for people living with a mental health condition and where improvements can be made across the service. Key Points Maintaining good mental health and wellbeing is key, both to an individual but also for wider society. In Wales, 13% of adults report having a mental health condition and mental ill health is associated with worse physical health, increased health risk behaviours, poor education and unemployment. NHS leaders are committed to working with partners to support good individual mental health and well-being. All of our NHS services not only our specialist mental health services play a part in maintaining and improving the mental health and well-being of our communities. This includes the universal services available across the community, such as primary care, health visiting and school nursing. It also includes the roles that other specialist and acute services take in supporting the well-being of people who use them, particularly services which have long-term relationships with their patients and clients. The role of specialist mental health services is to work with the smaller number of people who have more serious and complex mental health problems. We know that in order to achieve personcentred care and to maintain people s mental health and well-being it is vital that the NHS works collaboratively with our colleagues in the public sector, and our partners in the communities we serve. It is about all parts of the system working together so that people receive efficient and effective care with the outcomes that matter to them. To achieve this, we need services to work seamlessly together in health and social care and primary and secondary care. It is vital that we continue to advance further the integration agenda between physical and mental health services and parity of esteem between mental and physical health.

2 What do we know about mental health in Wales? In Wales: 1 in 4 adults experience mental health problems or illness at some point during their lifetime. 1 in 6 of us will experience symptoms at any one time. Between 1 in 10 and 1 in 15 new mothers experience post-natal depression. Mental health problems affect about 1 in 10 children and young people. 17% of people in Wales are lonely. 1 in 50 people will have a severe mental illness such as schizophrenia or bipolar disorder at any one time. Self-harm results in approximately 6,000 emergency admissions to Welsh hospitals every year. On average, 310 people die by suicide each year in Wales, and a further 150,000 have thoughts of suicide. 1 in 16 people over 65, and 1 in 6 over the age of 80, will be affected by dementia. Around 1,500 deaths in Wales are directly attributable to alcohol each year. In , there were 6,141 hospital admissions related to illicit drugs. 9 out of 10 people with mental health problems experience stigma and discrimination. The overall cost of mental health problems in Wales is an estimated 7.2 billion a year. The 2016 Health Statistics Wales highlights: 1 in 8 adults in Wales reported being treated for a mental illness; There were 1,606 average daily available beds; There were 1,730 formal admissions to hospital; 98% of formal admissions were under Part II of the Mental Health Act; 15% of mental illness hospital discharges were for a diagnosis of mood affective disorder and 14% were for schizophrenia, schizotypal and delusional disorders; Almost three quarters of hospital discharges were following a stay of less than one month; and 45% of the people resident on the 31st of March 2016 were aged 65 and over. 02 July 2017: Mental health practice in Wales

3 The legislative context The policy intention in Wales is clear. We have unique and pioneering mental health legislation in place The Mental Health (Wales) Measure 2010 and Together for Mental Health A Strategy for Mental Health and Well-being in Wales. The 2010 Measure places legal duties on Health Boards and Local Authorities to improve the support available for mental health conditions. The Measure also introduced local primary support services for less serious mental health conditions to be treated within community settings and ensures that mental health patients receive holistic care and treatment plans. Together for Mental Health was launched in 2012 and outlines a 10 year strategy for improving the mental well-being of all residents of Wales as well as improving the care and treatment for those experiencing mental health conditions, their carers and their families. This is a multiagency plan and sets out clear actions across Welsh Government, the NHS, Local Authorities and the third sector. Implementation is assured through Partnership Boards at national and local levels, and progress is monitored through annual reports to the Welsh Government and through the Integrated Medium Term Plans (IMTPs) of Health Boards and Trusts. this makes establishing meaningful performance indicators problematic. However, mental health conditions are clinically coded by Health Boards into separate diagnosis categories and waiting list performance for assessment/intervention in primary mental health care is comparable to urgent standards of access for physical health conditions. Expenditure Mental health is the largest of all programme budgets in NHS Wales, accounting for just over 11% of the budget. However, while significant investment is made to mental health services, mental health conditions account for 23% of ill health in Wales. Expenditure on mental health (MH) services over recent years. 2014/ / /17 All MH 634, , ,030 General 271, , ,624 MH Elderly MH 181, , ,800 CAMHS 40,248 41,320 45,817 Other MH 141, , ,787 problems Challenges Parity of esteem between physical and mental health One of the key challenges in comparing the provision of mental health services with traditional models of care designed to treat physical conditions is that mental health problems are not homogeneous. They can be any one of numerous conditions, ranging from eating disorders to dementia. It can mean having mild to moderate depression or being diagnosed with paranoid schizophrenia. It is not a single condition and Indicators, performance outcomes and data The creation of Local Primary Mental Health Support Service (LPMHSS) has meant over 80,000 people have received a holistic assessment of their mental health needs and over 42,000 people have received a therapeutic intervention since April While we know how many people have a valid Care and Treatment Plan, how many are accessing services and being assessed and how many people are receiving treatment within 28 days of referral, it is difficult to access and provide 03 July 2017: Mental health practice in Wales

4 data to show how many people are benefiting as a result of the treatment they receive. Over 90% of those receiving LPMHSS have rated those services positively but we must strive for a system where we are able to measure accurately whether people s needs are being met, whether successful outcomes are being achieved, and whether more people who use mental health services are getting back into education or training, volunteering or work. Waiting times In most cases, timely intervention is key to avoiding the development of complex and enduring mental disorder and illness. Since the introduction of the Mental Health (Wales) Measure, referrals to Local Primary Mental Health Services have been high and most Health Boards are meeting the 28 day Part 1 target. There has also been Welsh Government investment in talking therapies over the last 3 years in both Adult and Child and Adolescent Mental Health Services (CAMHS) in secondary care resulting in many more practitioners trained in both Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT). Recent investments include veteran s service, eating disorders (in particular CAMHS tier 4), perinatal service and crisis intervention (CAMHS). Seamless services Over the past 30 years, service provision for people with a mental health condition in Wales has become more community based. The number of people resident in hospital continues to decrease from 1821 in 2010 to 1430 in People who have a severe and enduring mental illness often need support from a broad range of services such as health, social care, housing and employment, and so it is particularly important that all these services work together in a seamless and coordinated way. At present, service providers do not always work in a fully integrated way. There are many reasons for this - budget constraints, the lack of information sharing systems and technology to share information and organisational culture. Perinatal mental health Perinatal mental health refers to a woman s mental health during pregnancy and the first year after birth. In 2015, the Welsh Government made available 1.5m of recurrent funding to develop community services for women with perinatal illnesses, their babies and their families. Following the Welsh Government s funding announcement, Health Boards have established dedicated multi-professional teams who work directly with perinatal mental health patients and their families to ensure they experience integrated care pathways. The emotional and mental health of children and young people in Wales Transition from CAMHS to Adult Mental Health Services (AMHS) usually takes place on a person s 18th birthday and this can present a number of challenges. Problems can emerge through the transition of young people into adult mental health services as this marks a change in clinical staff, a change in environment, and a different approach to treatment. Age-appropriate services are important for safeguarding and therapeutic reasons. The threshold for adult mental health services is high, which often results in a gap in service for young people including those with neurodevelopmental problems, personality disorders and moderate/severe anxiety and affective disorders. Together for Children and Young People (T4CYP) was launched in February This multiagency service improvement Programme is chaired by Carol Shillabeer, Chief Executive of Powys Teaching Health Board and lead Chief Executive for mental health, and supported by an independent external expert and an expert reference group. The Programme is working 04 July 2017: Mental health practice in Wales

5 at pace to reshape, remodel and refocus the emotional and mental health services provided for children and young people. The Programme is now entering its third year and has work streams that cover health services, education and social. In 2015, the Welsh Government announced an additional annual investment of 7.6m in CAMHS services and the waiting times for specialist CAMHS has improved and the target is now the same as adults. Police powers and mental health In Wales in , there were 541 incidences of people being detained in police cells as a place of safety under Section 136 of the Mental Health Act. In December 2015, the Mental Health Crisis Care Concordat was signed by the Welsh Government, police forces, the NHS, councils and other agencies. The Concordat sets out how partners can work together to deliver a quality response when people with acute mental health crisis need help, have contact with the Police and who are likely to be detained under section 135 or section 136 of the Mental Health Act Partners who have signed up to the Concordat are committed to work to reduce the use of powers of detention under section 135 or 136 of the Mental Health Act 1983, to cease to use police custody suites as a place of safety and to ensure there is access to mental health professional advice 24 hours a day at the point of crisis. Through working with a range of partners, the Concordat has developed pathways of care which has led to significantly fewer numbers of people in a mental health crisis taken into custody. Dementia investment in dementia awareness and services, including: Increased public awareness and support through the Dementia Friends/ Dementia Supportive Communities campaigns; Investment in hospital settings and the community; Increased numbers of memory clinics; and Additional training to give NHS and social care staff the knowledge and skills to provide the best care for people living with dementia. Stigma and discrimination Although mental health problems are common, it can still be a taboo subject. People who experience mental illness often face stigma and discrimination in the workplace, socially and within families. The recent Time to Change Wales survey into public attitude highlighted that: 1 in 2 people believe that people with mental health problems are unpredictable; 1 in 10 people said that being around someone with mental illness can make them feel uncomfortable; 1 in 10 believe that people with a mental illness can never fully recover; and 1 in 12 believe that as soon as a person shows signs of mental illness they should be hospitalised. All Health Boards and most NHS Trusts in Wales have signed the Time To Change organisational pledge. This is a public declaration that an organisation will take positive steps to tackle mental health stigma and discrimination. It is estimated that between 40,000-50,000 people in Wales are currently living with dementia. Dementia shortens life expectancy and many people will die of dementia, but it is likely that dementia patients will experience other lifelimiting and complex illnesses at the same time. There has been significant progress and 05 July 2017: Mental health practice in Wales

6 Mental health workforce The mental health workforce is estimated to comprise of approximately 22,000 individuals; over 10,000 NHS/Social Service employees; 10,000 third sector workers (including 4,000 paid employees and 6,000 volunteers); and 2,000 workers in the independent sector. Psychiatry is recognised as a shortage speciality and recruitment into psychiatry is poor. As highlighted by the Royal College of Psychiatrists in Wales, psychiatry faces a stigma of its own, with low popularity rates globally. Recruitment into Core Training has dropped to 33% in Wales and the current numbers of trainees in General Adult Psychiatry and Old Age Psychiatry are particularly concerning. There are gaps in training schemes for these specialties and this shortfall could, in the near future, have an impact on consultant numbers working within these specialties. Retirement rates of Old Age Psychiatry Consultants has increased along with vacancy rates across the UK and retention of Psychiatrists and trainee Psychiatrists is an issue. The Royal College of Psychiatrists in Wales is redrafting their recruitment and retention strategy for Wales. However, the strategy can t be performed in isolation and will need to have multiorganisation involvement, including with medical schools, Health Boards and Welsh Government. The mental health and well-being of the NHS workforce While sickness absence rates for the NHS workforce have shown a large overall reduction over the years, anxiety and stress still account for a significant share of sickness absence. In 2015/16, Anxiety/ Stress was the second reason for NHS workforce sickness absence, accounting for 25% of all sickness absence. Well-being Programme Board to support the NHS workforce. The Board has developed a number of initiatives which are preventive in nature and are an aid to help build emotional and psychological resilience to reduce anxiety/stress of staff. These initiatives include: A module in people management skills training for managers on Well-being and Resilience for you and your team. This seeks to support managers and supervisors to understand how to increase both personal and team resilience and well-being. It will provide managers and supervisors with the skills and confidence to approach and support staff who face mental ill health and consider the reasonable adjustments that could support either an early return to work or prevention of sickness absence. Our Well-being Matters: an interactive pdf document for staff with the aim that everybody takes responsibility for their own health and well-being and that of others. It includes links to evidence-based resources and toolkits. Supporting Managers to be well: An interactive pdf document. Each section has links to web pages which support each stage e.g. reflective journals for managers, how to access coaching and mentoring, etc. Geographical Map of Wales: An interactive pdf document mapping out what health and wellbeing services are available for NHS staff. The above initiatives are in the process of being implemented across NHS Wales via the Workforce & Organisational Development and Health and Well-being communities. Health Boards and NHS Trusts have set up a partnership with NHS Trade Unions a Health and 06 July 2017: Mental health practice in Wales

7 Services and projects provided by the NHS across Wales The case studies below highlight the range of services and projects provided by the NHS across Wales. Tier 1 Mental Health counselling (Abertawe Bro Morgannwg UHB) The Bridgend East GP Cluster identified that significant demand was being placed on their primary care services by individuals who would benefit from low level mental health interventions to meet their needs more appropriately than repeat visits to a GP following initial assessment. The East Cluster has commissioned a tier one counselling service using Welsh Government cluster funding, namely Pen Y Bont Health. The service is designed for people who are experiencing mild to moderate mental ill health issues, who would benefit from counselling sessions and may also benefit from an introduction to selfmanagement/recovery groups including Mindfulness, Stress Management, signposting and referrals to other services. The service has had a positive impact on ensuring individuals are able to access the most appropriate professional at the right time and has proven successful in facilitating a smooth pathway for patients. The did not attend rate is low, at 4%, which supports the necessity of the service for those patients experiencing emotional distress. The majority of patients who have received counselling have both set and achieved goals throughout their therapy. As a result of the introduction of this service, the East GP Cluster anti-depressant prescribing item growth is roughly half that of the ABMU average. Increasing the Mental Health and Well-being awareness of staff and pupils (Aneurin Bevan UHB) A collaborative project between staff from adult mental health services, CAMHS, Primary Care Mental Health Support services and education commenced in October 2016 with a view to increase awareness among staff and pupils of mental health and well-being. These sessions were delivered during the early summer term of This pilot project aimed to support children and young people to have a greater understanding of some conditions and how they may emerge and present, so that children and young people feel better equipped to seek support for themselves or their peers. This initiative focuses on building resilience in young people so as to promote early and appropriate help seeking, engagement with services, effective treatment and recovery and, where necessary, appropriate self-management. The project stemmed from two service users explaining their own personal case studies to a review of a secondary mental health service and how the onset of their illnesses left them confused, isolated, despairing and fearful. Some examples of pupil feedback following the session on body image included; I have learned that you don t have to look like someone else and you don t have to be like someone else. It s ok to be different, don t follow the crowd, be yourself, don t let people judge you. 07 July 2017: Mental health practice in Wales

8 Caniad (Betsi Cadwaladr UHB) Caniad is a service commissioned by Betsi Cadwaladr UHB and North Wales Area Planning Board to involve people who use mental health and substance misuse services in the planning, design and delivery of services and to collate feedback to help inform the development of a North Wales Mental Health Strategy. Caniad employed people with lived experience (involvement facilitators) of services who facilitated a number of engagement events for service users and their carers. Five open workshop events were held across North Wales, while engagement events were also held in all of the inpatient mental health units, all of the rehabilitation units, and the medium secure unit. Older persons units were also visited to gain feedback from inpatients and carers. People unable to attend the open workshops were given an opportunity to contribute their ideas and opinions through an online survey. One to one appointments were also offered to allow people to talk about their own personal experiences of mental health services. People who use mental health or substance misuse services often have fantastic ideas about how they can be delivered more effectively and economically. There s been pockets of fantastic engagement work in the past, but also a lot of tokenism and an attitude that service providers know best. The work carried out through Caniad has changed that and made a real difference. We now have a situation where senior managers are sitting shoulder to shoulder with service users, and they are really listening. Over the last 12 months we ve seen a trickle-down effect. The feedback we have given has been taken on board by the Health Board and included in their strategy. Caniad has given the voiceless a voice. It has been empowering and makes the people involved feel as though they really matter. Ieuan Davies former substance misuse service user who is currently working as a facilitator for Caniad. Vale of Glamorgan Dispersed Housing Scheme (Cardiff & Vale UHB) The Vale of Glamorgan Mental Health Dispersed Housing Scheme consists of a multi-agency group focussed on agreeing a service model appropriate to the needs of those with mental health problems in the Vale of Glamorgan. Gofal work alongside the Intensive Rehabilitation and Integration Service (IRIS) at Cardiff and Vale UHB to assess suitable clients for the scheme; then work together to develop and provide care and support for clients who have been provided with their own tenancy in a one bedroom flat in Barry. The project went live with its first tenant signed up in March The Scheme was evaluated in March 2016 and found that the scheme s working model of delivering collaborative and integrated services has proven successful. The positive outcomes for clients included: No hospital readmissions due to relapse in the mental health condition of clients since the beginning of the scheme; Issues being picked up before they escalate into crisis situations; More appropriate interventions in a more timely fashion with greater flexibility allowing for potentially damaging situations to be dealt with more effectively; and Improvements in the independence and confidence of service users. Service user improvements in mental health, daily living skills, physical health and self-care and taking responsibility. 08 July 2017: Mental health practice in Wales

9 Pet therapy at Ysbyty Cwm Rhondda (Cwm Taf UHB) Dementia patients in Cwm Taf UHB are being treated to visits from golden retriever, Kai, as part of a new programme of pet therapy at Ysbyty Cwm Rhondda. Nine-year-old Kai and his owner, Hannah Brunskill, started calling into the ward a few months ago, as it s been shown that interaction with pets can have a calming effect and bring much joy to patients in hospital. Hannah, who works as a graduate trainee manager for Cwm Taf UHB and volunteers with charity Pets As Therapy, brings Kai to the hospital every few weeks. She said: The patients love Kai, and it s been really good to see their positive reactions when we come to visit. He s so docile and not very demanding, so he just enjoys getting the attention. Staff on the ward say Kai s visits have been really popular with patients and they plan to continue with pet therapy in the future. Therapy Nurse, Claire Jones, said: It s been amazing to see the patients smiling and interacting with Kai. It s very calming for them too and it s all they ll talk about the next day. It brings them happiness. The patients families are also really pleased we ve had good feedback so we will definitely be carrying on with the visits. ACTivate for Students at Aberystwyth University (Hywel Dda UHB) Local Primary Mental Health Support Services in Ceredigion have been asked to deliver ACTivate to an intake of new students at Aberystwyth University. Data at a recent student well-being meeting showed that: More than 450 students have self-referred to the Student Well-being Service (approx. 7% of the student population) with 38.2% identify themselves as having a metal health problem; 51.1% of registrants are currently self-harming; 65% have considered taking their own life; 19.2% have acted upon thoughts of taking their own life; and 2.4% (11) had current plans to take their own life at registration. Activate Your Life is particularly useful for the more common presenting issues identified in the data (e.g. anxiety, depression, eating & sleeping) and GPs and allied health professionals can refer students onto this. Students can also self-refer. A pilot with the Institute of Biological Environmental and Rural Sciences Department, with over 400 students and the largest cohort on the campus, will be delivering Activate Your Life as part of the department s mandatory induction this coming academic year. To establish the value of this pilot, researchers at the University will evaluate outcomes to establish an evidence base for its future inclusion in all students timetables. Discussions have taken place with student well-being in Lampeter and Local Primary Mental Health Support Services are in the process of rolling out ACTivate if a robust evidence base for improved student health and well-being can be demonstrated by the research undertaken at Aberystwyth University. 09 July 2017: Mental health practice in Wales

10 MasterMind project (Powys Teaching Health Board) In 2014, Powys Teaching Health Board was granted European funding through the MasterMind project to run a pilot project delivering Cognitive Behavioural Therapy (CBT) online to Powys residents. The MasterMind project explores and develops the use of online services to help people with mild to moderate depression (which affects approx. 8% of the population). Powys Teaching Health Board is delivering online CBT through a computer program called Beating the Blues. Beating the Blues consists of eight, 1-2 hour sessions which are recommended to be completed weekly. The programme is interactive. During sessions people can watch video clips, complete exercises and learn CBT techniques that can help with depression and anxiety. Each week people will be given tasks to complete during the week between sessions. The programme can be completed in the home or a number of community sites (such as a libraries). The success rate is around 40% and Powys Teaching Health Board is seeking to further improve this by the use of the Florence text messaging system to help people maintain motivation to complete the CBT programme. NHS Scotland is starting to use this method as a first line treatment offer for all eligible patients. Mental Health Pathway (Welsh Ambulance Services NHS Trust) A simple pathway was designed to improve the quality and clinical appropriateness of care provided to mental health patients that access the ambulance service. It was apparent that many patients calling 999 presenting with a possible mental health problem were in fact having an acute reaction to an event and did not require urgent help. These patients were invariably conveyed to the emergency department (ED) and had to wait for an assessment before subsequently getting discharged, often without need for treatment. The wait in the ED was inappropriate and often added to the distress felt by the patient. Direct access to the crisis team from the Paramedic on scene was facilitated to engage a mental health professional at the earliest opportunity. This phone call from the scene would result in one of three actions being recommended: 1) Discharge at scene with signposting and advice; 2) Convey to a mental health facility for immediate assessment or 3) Convey to the ED. Since December 2014, when the service went live with the pathway in Cardiff and Vale UHB, 213 patients accessed the pathway, of that: 144 were discharged at the scene with signposting or clinical follow up arranged; 26 were admitted directly to mental health unit; and 43 were taken to ED for various reasons, including intoxication, overdose and medically unfit. Those patients with an urgent need for help were seen in a far more timely and appropriate fashion in a mental health facility. Regular audits show the number of patients now avoiding the ED remain within the 80-90% range. 10 July 2017: Mental health practice in Wales

11 Clinical psychologists (Velindre NHS Trust) There is a small team of Clinical Psychologists and counsellors based at Velindre Cancer Centre who work with inpatients and outpatients, and the important people in their lives. Clinical psychologists and Counsellors work with people who are experiencing various kinds of psychological difficulties, in order to reduce distress and promote well-being within the context of medical illness. The team address issues such as: Making sense of how a person has been feeling; Adapting to and coping with diagnosis and treatment; Managing feelings such as anxiety, sadness, anger, loss and depression; Learning ways to cope with and prepare for tests, procedures and treatments; Supporting children and young people through the impact of cancer; and Relationship and sexual difficulties. Public Health Wales NHS Trust / 1000 Lives Below are some of the initiatives Public Health Wales NHS Trust (PHW)/ 1000 Lives are leading on: Public Health Network Cymru PHW has coordinated national public health networks for the topics of physical activity and nutrition, mental health promotion and sexual health for a number of years; PHW continues to lead on delivering on the Suicide Prevention Plan; and The 1000 Lives Plus Programme and PHW has a national overview on mental health service delivery in four key areas; dementia, depression, first episode psychosis and eating disorders. This work fed into the National Strategy and the leads for these areas continue to support implementation of the delivery plan. The Welsh NHS Confederation In April this year, the Welsh NHS Confederation and the Wales Alliance for Mental Health convened a round-table discussion to explore how we can work together to tackle challenges facing individuals with mental health problems in Wales. Over the next year we have agreed to focus our partnership working to develop: A national mental health care data set which is accessible and transparent and includes the experience of, and outcomes for people with mental health problems; A clear programme for taking forward the next phase of the Time to Change campaign with the NHS in Wales; and Our shared thinking about the shape and model of workforce that we need across the NHS, the public and third sectors to support good mental health and well-being. 11 July 2017: Mental health practice in Wales

12 Conclusion As highlighted, maintaining good mental health and well-being is key and all our NHS services play a part in maintaining and improving the mental health and well-being of our communities. While all NHS services, including primary, community and the acute, are key, we know that in order to achieve person-centred care it is vital that the NHS works collaboratively with our colleagues in the public sector, and our partners in the communities we serve. How can the Welsh NHS Confederation help you? Please get in touch if you want further details on any of the issues raised in this briefing. For more information, please contact Nesta Lloyd Jones, Policy and Public Affairs Manager: Nesta.Lloyd-Jones@welshconfed.org The Welsh NHS Confederation is the only national membership body which represents all the organisations that make up the NHS in Wales: the seven Local Health Boards and three NHS Trusts. You can visit our website at or follow us on 12 July 2017: Mental health practice in Wales