Duty to Review: Mental Health (Wales) Measure Task and Finish Group s. Call for Evidence

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1 We would appreciate if you would complete the attached questionnaire. It is anticipated in most instances this would take approximately 10 minutes. Duty to Review: Mental Health (Wales) Measure 2010 Task and Finish Group s Call for Evidence Please indicate below who has provided the response Part 1 Part 2 Part 3 Part 4 Name of organisation and or individual and role Gofal Katie Dalton (Public Affairs Manager) on behalf of Ewan Hilton (Executive Director) Contact details katiedalton@gofal.org.uk Four issue-specific task and finish groups have been constituted by the Welsh Government to: review the eligibility of certain practitioners to conduct primary mental health assessments. (Part 1 group); review the content and the form of the prescribed Care and Treatment Plan and the eligibility of certain practitioners to become care co-ordinators. (Part 2 group); provide evidence as stakeholders and to consider evidence from a wider list of stakeholders on the specific question of expanding the ability for another person to ask for an assessment, under Part 3 of the Measure, on behalf of someone else. (Part 3 group); review the role of the IMHA in cases of non instructed advocacy and the process for accessing IMHA services in general health settings. (Part 4 group). The following questions have been designed by stakeholders represented in those groups to facilitate a report commenting upon their findings and providing advice and recommendations to the Welsh Government regarding any potential change to legislation and/or guidance.

2 Part 1: Background information Part 1 of the Measure ensures the provision of local primary mental health support services (LPMHSS) which will carry out a holistic assessment of an individual s mental health (this includes children, young people, adults, older adults and those with learning disability). Regulations identify which practitioners are able to conduct primary mental health assessments and that the practitioner must demonstrate he or she has appropriate experience, skills or training to undertake the role. We are reviewing these requirements: Part 1 The eligibility of certain professionals to undertake Local Primary Mental Health Support Service(LPMHSS) assessments Do you think that any professional(s) should be added to the list (see list 1) of those able to undertake a LPMHSS assessment? Overall, we feel that the list as it currently stands is appropriate. Gofal staff felt strongly that the professionals conducting assessments need to have a comprehensive understanding of mental health issues and were reluctant to see the list extended to people who may not possess the appropriate level of knowledge and expertise. There were concerns that diluting the list to include professionals without the appropriate level of knowledge and expertise could impact on the quality of assessments and lead to patients being unable to access appropriate services or interventions in a timely manner. This could of course result in further deterioration of their mental health and wellbeing, which would counteract the intention of part one of the Measure in respect of early intervention and prevention. It could lead to the person requiring secondary mental health services as well as potentially impacting on their education, work, family relationships, accommodation, finances and other areas of life. The impact on patients should be the primary consideration if the list is to be extended. We do however recognise some of the calls from organisations representing counsellors for this group of professionals to be added to the list. We have also heard from some managers in health boards that their inability to allow counsellors to conduct assessments can impact on their capacity to deliver timely assessments and recruit people who are able to provide both assessments and psychological interventions. If Welsh Government considers adding counsellors to the list of eligible professionals we believe that there would need to be confidence in nationally recognised levels of accreditation (as with the other groups of professionals listed in regulations).

3 Do you think any professional(s) should be removed from the list? There were some queries as to whether a learning disability nurse would have appropriate understanding of mental health issues. However, this could be addressed by ensuring strong compliance with a robust competence test and we do recognise that specialist learning disability knowledge is very important for patients who have a co-occurring learning disability. Practitioners eligible to undertake a LPMHSS assessment must also be competent to undertake the role. How do you think this competence should be demonstrated? The individual must demonstrate clear understanding of mental health issues and the importance of the recovery approach. The individual must demonstrate a clear understanding and appreciation of the importance of early intervention and prevention to ease the impact of mental health problems. The individual must demonstrate an understanding of the holistic, whole person approach to mental health and wellbeing, appreciating how mental health can affect and be affected by other areas of life such as finances, accommodation, family relationships, education, work and social/cultural opportunities. The individual must demonstrate a clear knowledge and understanding of other statutory and non-statutory organisations which they can refer or signpost individuals to. (For example: third sector mental health organisations, general advice organisations such as CAB, debt management advice services, substance misuse organisations and housing related support organisations.) There should be continuing professional development in the field of mental health, rather than relying on a one-off qualification to demonstrate competence. There should be regular supervision, review and audit of performance and files. The All Wales Curriculum for Primary Mental Health Workers was developed to support the delivery of effective and efficient primary mental health services and includes the following five units: 1. Conducting Primary Care Mental Health and Wellbeing Assessments 2. Conducting Psycho-Social Interventions in Primary Care 3. Managing Onward Referral from Local Primary Mental Health Support Services 4. Providing Information and Advice to Primary Care Providers about Mental Health and Wellbeing

4 5. Providing Information and Advice to individuals and carers about Mental Health and Wellbeing It is our belief that this curriculum should be used by health boards to ensure that all primary mental health workers (including those conducting assessments) are able to demonstrate the required level of competency. It is especially important that professionals who are used to working in a secondary care setting understand the values and approach in primary mental health services. We also believe that either Welsh Government (on a national basis) or health boards (on a regional basis) should have to ensure that there is: A clear definition of the role and its requirements. A consistent approach across all of the professional groups that are allowed to conduct assessments. List 1-These professionals are eligible to undertake LMPHSS assessments: a qualified social worker registered with the Care Council for Wales or the General Social Care Council; a first or second level nurse, registered in Sub-Part 1 or Sub-Part 2 of the Register maintained under article 5 of the Nursing and Midwifery Order 2001(1), with the inclusion of an entry indicating that his or her field of practice is mental health or learning disabilities nursing; an occupational therapist who is registered in Part 6 of the Register maintained under article 5 of the Health Professions Order 2001(2); a practitioner psychologist who is registered in Part 14 of the Register maintained under article 5 of the Health Professions Order 2001; or a registered medical practitioner.

5 Part 2: Background information Part 2 of the Measure seeks to ensure that all individuals (this includes children, young people, adults, older adults and those with learning disability) accepted into secondary mental health services have a Care Co-ordinator and a Care and Treatment Plan. Regulations state who can be a Care Co-ordinator and prescribe the wording of the Care and Treatment Plan. We are reviewing these requirements Part 2: To review the wording of the Care and Treatment Plan and the eligibility to be a Care Co-ordinator. Do you think that any professional should be added to the list (see list 2 ) of those able to be a Care Coordinator? Overall, the team felt that the list adequately covers all suitable roles. They commented that consistency and continuity is a challenge where different groups of professionals have different approaches to the role. There were concerns that further dilution of the list could lead to less clarity and consistency and the risk of minimum standards failing to be met. There were however some questions about whether professionals in educational settings could be appropriate care coordinators for some young people as they may have more/better contact with the individual and their family. However, it was acknowledged that they are not part of a health or social care team and that this could be a barrier to eligibility. We believe that care coordinators need to better involve and include other professionals (such as those working in education and the third sector) in care and treatment planning. In our experience there is still a failure to adequately engage with professionals from external organisations during this process. Do you think any professional(s) should be removed from the list? There have been some questions raised about the inclusion of physiotherapists and speech/language therapists in the list of appropriate professionals. Although these individuals can play a critical role in relation to part of an individual s care and treatment, there were some concerns that they may not be best placed to be the care coordinator as they may not have sufficient understanding of mental health problems and recovery. There are also questions about whether these are the most appropriate professionals to coordinate all of the services and interventions required to deliver a comprehensive care and treatment plan.

6 Practitioners eligible to be a Care Co-ordinator must also be competent to undertake the role. How do you think this competence should be demonstrated? The individual must demonstrate clear understanding of mental health issues and the importance of the recovery approach The individual must demonstrate a clear understanding of the importance of involving, empowering and supporting the service user to take a leading role in their care and treatment planning where willing and able. The individual must demonstrate an understanding of a holistic, whole person approach to mental health and wellbeing, appreciating how mental health can affect and be affected by other areas of life such as finances, accommodation, family relationships, education, work and social/cultural opportunities. The individual must demonstrate a clear knowledge and understanding of other statutory and non-statutory organisations which they can involve in the care and treatment planning process. (For example: Third sector mental health organisations, general advice organisations such as CAB, debt management advice services, substance misuse organisations and housing related support organisations.) There should be continuing professional development in the field of mental health, rather than relying on a one off qualification to demonstrate competence. There should be regular supervision, review and audit of performance and files. We also believe that either Welsh Government (on a national basis) or health boards (on a regional basis) should have to ensure that there is: A clear definition of the role and its requirements A consistent approach across all of the professional groups allowed to be care coordinators Is the wording on the form used to write a Care and Treatment Plan suitable for all Service Users and Carers? Comments from our teams indicated that care and treatment plans are not always written in the service user s choice of language. It is important that people feel ownership over the content of their care and treatment plan and it is therefore crucial that they are fully involved in the process. It is also important that the plan is presented in a language and format that they understand and relate to. They have also commented that many care and treatment plans are not holistic and do not address enough of the eight areas of life. Where reviews are happening, staff have found that the process can be very medication driven and not in the holistic manner intended by the Measure.

7 Another comment that we received was in relation to care and treatment plans only containing basic information about the service(s) they receive as part of their care and support. Although it is beneficial for a service user to know what service they are receiving, our staff have commented that the aim of the support, what it will achieve and the next steps are not always evidenced and demonstrated within the plans. In addition, our staff teams feel that there needs to be further development to ensure that care and treatment plans are aspirational and goal orientated, as well as reflecting the recovery approach. Access to care and treatment plans was also raised as an extremely important issue. Some of our staff commented that very few of our service users know where their care and treatment plan is and had not received a copy. This clearly needs to improve. As support providers and often key people in delivering care, treatment and support very few of our staff had had sight of their service users care and treatment plans or been involved in the process. They felt that this has hampered the coordinated approach that the part two of the Measure was supposed to embody. Better information sharing and involvement of support agencies to support a holistic, coordinated approach to care, treatment and support would be beneficial.

8 List 2:-These professionals are eligible to undertake the Care co-ordination role: a qualified social worker registered with the Care Council for Wales or the General Social Care Council; a first or second level nurse, registered in Sub-Part 1 or Sub-Part 2 of the register maintained under article 5 of the Nursing and Midwifery Order 2001(1), with the inclusion of an entry indicating that his or her field of practice is mental health or learning disabilities nursing; an occupational therapist who is registered in Part 6 of the Register maintained under article 5 of the Health Professions Order 2001(2); a practitioner psychologist who is registered in Part 14 of the Register maintained under article 5 of the Health Professions Order 2001; a registered medical practitioner; a dietician who is registered in Part 4 of the Register maintained under article 5 of the Health Professions Order 2001; a physiotherapist who is registered in Part 9 of the Register maintained under article 5 of the Health Professions Order 2001; or a speech and language therapist who is registered in Part 12 of the Register maintained under article 5 of the Health Professions Order 2001.

9 Part 3 Background Information Part 3 of the Measure provides those discharged from secondary mental health services with the ability to directly request reassessment of their mental health. The Code of Practice to Parts 2 and 3 states: the entitlement to make a request lies only with the individual (once over the age of 18) who was previously a relevant patient. other person can make the request on behalf of the individual (e.g. a carer), unless they are a donee or deputy under the Mental Capacity Act Part 3: The ability to request an assessment from secondary care mental health services for people who have received a service in the past three years but have been discharged from these services. Should the ability to request an assessment under part 3 be extended to people under the age of 18? We did not reach a clear consensus about where the age limit should be but many staff felt that part three of the Measure should be extended to people under the age of 18. The age of 14 was suggested by some staff members and others pointed out that there are many young carers who carry huge amount of responsibility but cannot currently request an assessment. There was a strong belief that young people need access to timely assessment and support if they are experiencing mental health problems. Overall, our staff felt that this part of the Measure should not exclude young people who have the capacity to request an assessment - should they feel that their mental health is deteriorating. Certainly, we feel that young people experiencing poor mental health should have access to timely interventions that would prevent their mental health from deteriorating further and impact on their education and family relationships. It was also suggested that for younger people it may be beneficial for an appropriate carer, family member, friend or teacher to request an assessment on their behalf. Some people feel that the duties under the Mental Health Act 1983, the NHS Community Care Act and other safeguards mean that the ability to request an assessment does not need to be extended to people other than the patient. Taking these duties into account, do you feel that the ability needs to be extended?

10 Sometimes an individual experiencing poor mental health may have limited or no insight into how they are presenting. An extension of the ability to request an assessment to close family members, friends or other support agencies could be critical in creating responsive services to prevent further deterioration and enable recovery. We would of course prefer individuals to request assessments themselves but we recognise how debilitating mental health problems can be and feel it is important that the person gets the help they need in a timely manner. A patient can feel totally powerless when they are unwell and may need the help of a friend or relative to request this on their behalf. It is also important to recognise that the Mental Health Act is more relevant to situations of risk where a person may be detained involuntarily in a hospital setting. An assessment under part three of the Measure does not necessarily lead to hospitalisation but could deliver additional support, treatment in the community or a change in medication. This could prevent an individual s mental health from deteriorating to the extent that the Mental Health Act would need to be utilised. Where the patient does not request an assessment themselves, should the ability to request an assessment be extended to any other persons as long as the patient agrees? Our teams made the following suggestions: Carer Immediate family member Close friend or neighbour Support workers/agencies involved in their care If the patient is in agreement then it could include people beyond this list and therefore not exclude anyone that the individual has a good relationship with. Where the patient does not request an assessment themselves, should the ability to request an assessment be extended to any other persons if the patient does not agree? Our staff had mixed responses to this question and acknowledged that the assessment is unlikely to practicably go ahead without the agreement and participation of the patient. However, they also acknowledged that the ability for a close/immediate family or household member to request an assessment could encourage the person to seek help even if they may initially resist. It was also felt that some individuals may not recognise that their mental health is deteriorating and may need the support and encouragement from others to access timely support to prevent further deterioration.

11 However, if this was to be allowed then the list of eligible people would have to be much tighter than our response to the previous question and appropriate safeguards would have to be in place to protect the individual.

12 Part 3 supporting information Legislation which provides an entitlement to request an assessment includes: Mental Health Act 1983 The term "Nearest Relative" is used frequently in mental health legislation to refer to the person closest to a patient who is, or is being assessed with a view to being, detained under the Mental Health Act. The "Nearest Relative" may well have a significant role in caring for the patient, but does not have to be. In any event a patient's Nearest Relative has an important role under the Mental Health Act as being a safeguard for them. The Nearest Relative has some important roles or rights under the Mental Health Act. In summary Nearest Relatives should be informed about, consulted on, and be able to contribute to a range of key decisions about the patient's care and treatment. In addition they have a number of very specific legal roles specified in the Act and these include the following: to make an application for the patient's admission and detention in hospital under Sections 2, 3 and 4, or for reception into Guardianship under Section7 (although it is important to note that the Mental health Act Code of Practice states that this role is normally better left to an AMHP), to be informed about the outcome of an assessment (and to make use of their own right to make an application if the AMHP decides not to), It shall be the duty of a local social services authority, if so required by the nearest relative of a patient residing in their area, to make arrangements for an approved mental health professional to consider the patient's case with a view to making an application for his admission to hospital; and if in any such case that professional decides not to make an application he shall inform the nearest relative of his reasons in writing. The NHS and Community Care Act 1990 Section 47(1), NHS and Community Care Act 1990 states:... where it appears to a local authority that any person for whom they may provide or arrange for the provision of community care services may be in need of any such services, the authority - a. shall carry out an assessment of his needs for those services; and b. having regard to the results of that assessment, shall decide whether his need calls for the provision by them of any such services.

13 Part 4 Background Information Part 4 of the Measure extends statutory mental health advocacy provision beyond that required under the Mental Health Act 1983 to informal/voluntary patients as well as the majority of patients subject to the formal powers of that Act. IMHAs may also provide non-instructed advocacy when helping patients who are unable to express their wishes clearly, or at all, because they lack the mental capacity to instruct or have difficulties communicating. Part 4: Extending independent mental health advocacy (IMHA) to informal/voluntary patients. Do you think the current arrangements to access an IMHA in psychiatric settings are adequate? There were mixed responses to this question, with some staff teams commenting that they have no clear way of monitoring the situation but others stating that our service users have been able to access an IMHA. Others commented that people have been able to access advocacy via third sector organisations who visit the ward, but they are not an IMHA. The teams have identified a need for greater promotion of the service amongst carers groups as well as greater promotion within psychiatric settings. There is also a need to ensure that people have understood information about the IMHA service. If patients are informed during a distressing hospitalisation it is highly likely that they may not retain or understand the information. There needs to be ongoing promotion of the service to ensure that all patients can benefit from an IMHA. Do you think the current arrangements to access an IMHA in general health settings are adequate? We feel that there needs to be greater promotion of the service to both patients, as well as their families and carers. Some of our teams feel that there is a need for greater promotion of advocacy provision in general/community health settings and additional resources to extend the support to include community advocacy for people with serious mental health problems.

14 We would also like to take the opportunity to ask you about the Measure more generally and would value your views on the additional questions below Do you think there should be any other changes to the Measure legislation? Part Two We strongly believe that the legislation needs to be changed to require more than one life area be addressed in care and treatment plans in order to ensure a holistic, whole person approach. Anecdotally we hear that only medication is covered in the majority of cases which is the bare minimum in terms of compliance with the law. We deliver a lot of housing related support in the form of supported housing and floating tenancy support where people are facing clear accommodation issues. However our staff report that they rarely see action relating to accommodation included in care and treatment plans despite pushing for this to happen. Our teams also feel that reviews are medication driven. Care and treatment plans were intended to be holistic, person centred plans that support recovery and recognise that all areas of life can affect or be affected by a person s mental health. It is important that this happens in reality and the legislation may need to be strengthened in order to deliver this aim. There have also been concerns raised about the quality of care and treatment plans. The drive to ensure compliance with the Measure and its associated targets (i.e. 90% of people having a valid care and treatment plan) is perhaps impacting on the quality of the content and meaningful engagement with the service user during the development of care and treatment plans. Do you think there should be any other changes to the Measure guidance? We believe that in a number of areas the guidance either needs strengthening or more needs to be done to ensure that professionals, health boards and local authorities are complying with it. As with any legislation there is a difference between the letter of the law and the spirit of the law. Where health boards and local authorities may be complying with the letter of the law, there are clearly still some issues with regards to enacting the spirit of the law.

15 Part One Part one of the Measure was supposed to deliver better information, support and training to primary mental health professionals, including GPs and other members of primary care teams. Our surveys and case studies about people s experiences of primary mental health services show a wide variation in the levels of understanding and empathy demonstrated by professionals and the range of advice, treatment and support services offered to patients. The survey data also shows that outcomes are far better where understanding and empathy are demonstrated and patients are offered real choice and better access to advice, treatment and support. We believe that the All Wales Curriculum for Primary Mental Health Workers should be better utilised by all of the health boards. This could help to deliver a more consistent understanding and approach towards primary mental health services. Access to talking therapies and associated waiting times remain a concern for us and we believe that more needs to be done to address this issue. Our teams also believe that there needs to be stronger guidance and monitoring in relation to different approaches being adopted as part of the primary mental health services across Wales. Some concerns have been raised about assessments being undertaken by telephone rather than in person. There is a view that this does not assist in fully utilising skills and competence and often fails to deliver the best outcome for those using the service. Our teams also felt that it was important to ensure consistency of approach between the different professional groups who undertake assessments and other elements of primary mental health support services. We also believe that health boards and local authorities should record outcomes alongside the waiting time data they collect for Welsh Government. Statutory bodies may well have met the waiting time targets set by Welsh Government but this does not necessarily mean that the patient was able to access the services they wanted and needed or that the service resulted in improved mental health and wellbeing. Part Two The Code of Practice states that all secondary patients should have a copy of their care and treatment plan. However, as described above it is clear that this is not happening in many cases and some patients are unaware that they have a care and treatment plan. The guidance also states that information sharing between professionals and agencies is important to deliver a coherent care, treatment and support package. Our staff teams do not receive information about the majority of our services users care and treatment plans and report that they are rarely asked to be involved in the care and treatment planning process. We believe that

16 there needs to be greater engagement with non-statutory agencies. In response to the question above we have advocated for the legislation to require more than one area of life to be addressed in care and treatment plans. If there is no change to the legislation we believe that the guidance needs to be strengthened and better enforced to encourage care coordinators to address more than one life area. Another issue was raised about ensuring consistency of approach between the different professional groups who undertake the roles of care coordinators. The guidance could be strengthened or training could be provided in order to deliver this. Part Three Some of our teams have reported that some people are being refused their right to assessment. This is currently anecdotal but it concerning if this is happening to people who require support and treatment.