The Mental Health (Wales) Measure: Views of RCPsych in Wales Members on its implementation

Transcription

1 The Mental Health (Wales) Measure: Views of RCPsych in Wales Members on its implementation Contents Introduction 2 Summary 4 Respondents 5 Survey Results 7 Lack of Clarity around aspects of the Measure 7 Unintended Consequences of the Measure Positive aspects of the Measure Conclusion and Next Steps 26 Appendix 1 27 Page 1

2 Introduction The Mental Health (Wales) Measure ( the Measure ) is pioneering legislation that sets out statutory duties placed upon local mental health partners (Local Health Boards and Local Authorities) to meet the needs of people receiving primary and secondary care mental health services. The Measure aims to ensure more efficient services in primary care for patients, particularly through appropriate and timely assessment and referral, and to provide patients in secondary care ( relevant patients ) greater ownership of, and support with, their treatment and recovery. The Measure creates a right for relevant patients to refer themselves back to mental health services without the need for GP intervention. Finally, the Measure extends advocacy services for those detained under the Mental Health Act 1983 to all relevant patients. Like the Welsh mental health strategy, the Measure prescribes a holistic approach to patient assessment and care, and places an emphasis on personal ownership to recovery. Since the consultations that developed the Measure, the Royal College of Psychiatrists in Wales (RCPsych in Wales) has been active in presenting to Welsh Government the views of its Members regarding the legislation. We attended numerous meetings with Government Officials, we discussed our views at Executive Committee meetings and at individual Faculty meetings, we responded to five Consultations on the Measure, and we held a joint event with the British Medical Association, presenting feedback from the main Faculties on the Measure in practice. Whilst we fully support the intentions behind the Measure, several concerns were raised about particular elements during this process, and a number of further concerns have been expressed by Members following implementation. In the light of the extent of concerns expressed by Members, in the Autumn of 2013 RCPsych in Wales conducted a survey of Members in Wales to capture their views about the implementation of the Measure. The following report is a summary of the quantitative and qualitative data collected. The survey was based on a pilot survey conducted by the Child and Adolescent Faculty of RCPsych in Wales. It differs from the pilot survey. Only our Members were surveyed. We did not approach patients or non-medical mental health professionals. The survey sought responses on all four parts of the legislation and not just Part 2 of the Measure, which concentrates on Care Coordination and Care and Treatment planning. The survey captured information from Members working in all subspecialties of Psychiatry. RCPsych in Wales intends to write a Position Statement outlining the main themes captured in our survey and other consultation processes with our Members. We will use the data from this survey to highlight the concerns of some of our Members and we will recommend that Welsh Government consider the implications of these views as part of their statutory duty to review the implementation of the Measure. Our hope is that we can facilitate discussion with Page 2

3 Welsh Government and mental health partners on overcoming unintended consequences of the Measure and optimising the intended outcomes. We would like to thank all of our Members who responded to the survey. In particular, we would like to thank Gemma Williams, Omer Minhas, Kavitha Pasunuru, Alka Ahuja and Raman Sakhuja for their support. Page 3

4 Summary RCPsych in Wales conducted a survey in the knowledge that our membership was concerned about some aspects of the Measure. We focused our questions on the issues that had been raised at a number of RCPsych in Wales meetings and events. We looked at our Members understanding of the Measure, its impact on mental health services, on their workload and on patient care. Although the survey was conducted as rigorously as possible under the circumstances, the method has significant flaws. It cannot be regarded as a definitive judgement on the implementation of the Measure, which is a continuing process. The Survey has five main sections: one to cover general issues and one section for each of the four Parts of the Measure. This is outlined in Table 1 below: Table 1: Outline of RCPsych in Wales survey on Members views on the implementation of the Mental Health (Wales) Measure Section General Questions on the Mental Health (Wales) Measure Part 1 Local Primary Care Mental Health Support Services Part 2 - Care Coordination and Care and Treatment Planning Part 3 - Assessment of people who have previously used secondary mental health services Areas of interest Training or preparedness for the implementation of the Measure Perceptions in levels of clinical activity Perceptions in the quality of patient care now being given Unintended consequences of the Measure Legal anomalies. Patient numbers in primary care Number of referrals from primary care Understanding of primary care services access to Part 1 schemes/implementation leads Understanding of relevant patient Understanding of the role of the Care Coordinator Requirements for completing Care and Treatment Plans (CTP) Tendency to discharge patients Number of self referrals Part 4 - Independent Mental Health Advocacy Difficulty or ease in accessing advocacy The survey proforma is appended in Appendix 1. RCPsych has 550 members in Wales, 22% of whom responded to the survey. Whilst it is obvious that this is highly unlikely to be a representative sample if we Page 4

5 apply the most cautious interpretation, and assume that the respondents are the psychiatrists who are least happy with the Measure, these are still the views of almost a quarter of all psychiatrists in Wales. These should be taken seriously if we are to ensure that the Measure improves the experience of people who use mental health services. Page 5

6 Respondents The RCPsych in Wales represents over 550 Members including trainees, Consultants and retired Consultants. The survey used the Survey Monkey website. We ed all of our Members in Wales and received 121 responses, 22% of the Membership. The majority of respondents were Consultant grade (80%), 13% were Specialty Doctors and 7% Trainees. None of the respondents were retired. Graph 1: There were responses from psychiatrists working in all areas of Wales apart from Powys. Five worked in the private sector. Over half worked in Abertawe Bro Morgannwg HB, Aneurin Bevan HB or Cwm Taf HB. Page 6

7 Graph 2: Just over half of the respondents (50.5%) worked in General Adult Psychiatry, followed by Old Age (19%), Child and Adolescent (15%), Intellectual Disability (8%), Forensic (6%), Addictions (3%) and Liaison Psychiatry (2%). These figures roughly match the overall distribution of Members in Wales, with General Adult Psychiatry being the largest faculty. Graph 3: Page 7

8 Survey Results The findings of the survey show that all of those who responded have some concerns regarding particular aspects of the Measure and the way in which the legislation is being interpreted and implemented by local mental health partners. Concerns vary depending on Health Board or psychiatric discipline. However, there are common themes. 1. Lack of clarity. There continues to be a general lack of clarity and understanding of some fundamental aspects of the Measure. These include the definitions of relevant patient and secondary care mental health services. Getting the definitions right is vital to the success of the Measure. There is also uncertainty around primary care pathways, Care and Treatment Planning (CTP) and the Care Coordinator role, including questions regarding the role of the Psychiatrist in CTP. There is uncertainty around providing CTP for patients across country borders. There is anxiety and lack of clarity regarding the legal implications of failure to meet the requirements of the Measure. 2. Unintended consequences. Members are concerned with a number of unintended consequences brought about by the implementation of the Measure. In some areas, there has been a perceived increase in clinical workload compounded by an increase in bureaucracy since the introduction of CTP. There are concerns that there now appears to be a greater difficulty in moving between primary and secondary care mental health services, and a split between professional groups on issues regarding responsibility for CTPs. There are concerns that some patients are being referred inappropriately and that others are unable to access services at all. Many are concerned that patient care is, or is likely to be, compromised in some areas. Lack of clarity on crucial aspects of the Measure The Measure is complex legislation. After it received Royal Ascent in 2010, considerable preparation was needed before it could be implemented. Welsh Government produced a wide range of draft Regulations and guidance on Care Coordination, providing joint Schemes for part 1 of the Measure, for expanding IMHA services, and for considering the definition of secondary care mental health services. The Local Health Boards and Welsh Government provided training for mental health professionals to assist in implementing the Measure. It has been two years since the Measure was implemented. Our survey shows that there are a number of issues that require further clarification if the legislation is to be implemented properly in order to realise the intention of improving support for patients. Page 8

9 Relevant patient and secondary care mental health services Crucial to the Measure is the definition of relevant patient. Patients receiving treatment for mental health conditions are treated in either primary or secondary care. Where a patient is treated determines their statutory rights under the Measure. If treated in secondary care mental health services, the patient is covered under Parts 2 and 3. Part 2 ensures a patient has care and treatment planning with a designated Care Coordinator and Part 3 enables the patient to refer themselvesdirectly back into service after being discharged. If treated in primary care, a patient does not have these rights. In May 2011, RCPsych in Wales responded to the Welsh Government Consultation The Mental Health (Care Coordination and Care and Treatment Planning) (Wales) Regulations 2011 saying that A great deal will depend on how secondary mental health services and relevant patient are defined in practical terms and the Assembly needs to be explicit about which patients and what services are included in the Measure. Our comment during the initial consultation on the Measure in April 2010, highlighted the inherent difficulty in defining these services. We wrote, Secondary care services have changed over the last decade with the development of functional teams, e.g. Personality Disorder Services, Dual Diagnosis Teams, Assertive Outreach, Early Onset Psychosis, etc.... There is sometimes confusion if people in such services are in or out of secondary mental health services. What our survey shows is that following implementation of the Measure there is still uncertainty as to who is a relevant patient,as well as doubts regarding how the services should properly be defined. Under section 12 of the Measure, an individual is a relevant patient if: a mental health service provider is responsible for providing a secondary mental health service for the individual. An individual who does not fall within [this category] is also a relevant patient if (a)the individual is under the guardianship of a local authority in Wales; or (b)a mental health service provider has decided that the individual would be provided with a secondary mental health service if the individual cooperated with its provision. Under Section 3 of the Mental Health (SecondaryMental Health Services) (Wales)Order 2012, the meaning of secondary mental health services was clarified forthe purposes of Parts 2 and 3 of the Measure. Services and treatment which are made availableas local primary mental health support services(1) in aparticular local authority area under a scheme(2) arenot to be regarded as secondary mental healthservices(3) for the purposes of Part 2 (coordination ofand care planning for secondary mental health serviceusers) and Part 3 (assessments of former users ofsecondary mental health services) of the Measure inthat local authority area. In our survey, we asked our Members to outline the criteria they use to define a relevant patient. Most respondents believed that a person is considered to be a Page 9

10 relevant patient based on the level of complexity of their mental illness and intensity of their care needs. Those with serious mental illness, complex psychosocial needs, co-morbidities, risk factors, poly-pharmacy are regarded as relevant patients. Respondents included several other criteria, from specific illnesses to the type of services they receive or have received. These are outlined in Table 1 below. Table 1: The Range of Criteria Members used to define a relevant patient Specific illnesses or disorders Personality disorder with complex needs Psychotic disorders Severe depression Dementia Type of Services Those who are known to the services Those who are seen by any member of the secondary care team for treatment Those who come under Section 117 aftercare A CMHT patient Outpatients who are seen more frequently than 3 monthly by Consultant MHSOP only Anyone who has been reviewed twice or more in Out-Patients A patient who has been recently discharged from HTT or the Ward A former user of secondary care services Those who require other professional involvement like OT, CPN, Social Workers etc. A person with complex needs that cannot be managed by GP Tier 4 CAMHS Despite this comprehensive list of criteria, there is considerable debate and differences across Wales over how patients are defined and as a result who falls within primary and secondary care. 14 respondents said that they either do not know or are unsure who is a relevant patient. We asked respondents if there was a clear and explicit formal agreement with reference to relevant patient and care coordinator. A large proportion (41%) gave no response to the question. Of those who answered, only 9% felt that there was a clear and explicit formal agreement, 51% felt that definitions were not formal but through a shared understanding. 40% felt that there was no formal or informal agreement. On my ward patients are occasionally admitted out of hours straight from A&E effectively with little real assessment as a "safe" option for review by my team in the morning. A significant number of these patients are not mentally ill and do not require secondary services. It is my understanding that these people are now subject to part 3 of the measure despite maybe only being admitted for a few hours. - General Adult Consultant, ABMU Responses to the survey show that there is also uncertainty and a lack of continuity regarding what constitutes a secondary care mental health service, Although the definition of secondary care services is written in the Regulations and further explained in the Mental Health (Secondary Mental Health Services) Page 10

11 (Wales) Order 2012, there is an element of tautology in those definitions. Feedback from our survey suggests that in some areas, the divide between primary and secondary care is unclear, often relying on the judgement of the clinician. An Old Age Consultant from Cardiff and Vale wrote, Discussions seem to be about the needs of the services i.e. how to (re)-classify / define secondary care so as to avoid having large numbers subject to part 2 of the measure. There is also confusion around what were traditionally known as secondary care mental health services but are now relabeled primary care although they are outpatient clinics or memory clinics run by secondary care mental health professionals. This lack of clarity about who has statutory rights under Parts 2 and 3 is perhaps most apparent within Intellectual Disability, where patients traditionally fall within social care and were previously cared for under Unified Assessment. The problem arises from the use of the term mental disorder in the Measure. (Explain) Patients with Intellectual Disability use services that are social care led. The primary needs of patients within ID services are life-long support needs. Health needs within the ID caseload straddle primary, secondary and sometimes tertiary services. The distinction between 'secondary care' and 'primary care' patients is blurred. ID teams are directed (appropriately) to develop person centred care-plans. CTPs cause confusion. It is unclear exactly who is eligible. It is also unclear if the patient now requires two care-plans? In addition, there follows disagreement between agencies about who should case/care manage. ID Consultant, HwyelDda Welsh Government have acknowledged that there had been a significant number of queries regarding applicability of Parts 2 and 3 to intellectual disability service users. In December 2012, the Mental Health and Vulnerable Groups at Welsh Government wrote to the Directors of Social Services and the Directors of Primary Community Care and Mental Health to clarify relevant patient and Secondary Mental Health Services in relation to intellectual disabilities. In the letter, it states that learning disability can fall within the definition of mental disorder. The letter suggests: it may be helpful for teams to consider whether the intervention/support being offered to a person with a learning disability is a treatment for a mental disorder (which could be their learning disability or other mental disorder), or rather, is intervention/supportbeing provided by the team because of their expertise in working with persons with learning disabilities. The letter further suggests that following an assessment, a decision in respect of whether or not a person with a learning disability will be receiving treatment for a mental disorder should usually be decided on a multi-disciplinary basis and recorded in the notes. Our survey shows that several Intellectual Disability teams have begun to set their own criteria for defining who is a relevant patient, and that these ad hoc criteria guides discussion within teams. This appears to be working well. Local Primary Mental Health Support Services Page 11

12 The National Service Model for Local Primary Mental Health Support Services (2011) provides guidance to service providers on the requirements of Local Primary Mental Health Support Services (LPMHSS) under Part 1 of the Measure. The document outlines what services are to be provided and how they are to be provided. We asked respondents if they were clear what services are provided under Part 1 of the Measure and of the 93 responses only 33% are aware of the services, 39% are in part aware, and 28% say they are unaware of the services. (23% did not respond to the question). Graph 4: 30 respondents explained their answers. Those who said they were clear about the services knew that the Local Health Board and Local Authorities have overall responsibility for providing primary care mental health services, which are run by LPMHSS. Those who were unclear said that there is a lack of clarity in definitions between primary and secondary care, a lack of clarity as to who provides the services under part1, that there is inadequate service planning, and a lack of online information. More specifically, it is unclear how LPMHSSs are to meet the needs of children and adolescents, and those with Intellectual Disability. Again, there is confusion around memory clinics and outpatient clinics, and the role of the psychiatrist. Page 12

13 I understand what should be provided in part one but not sure who should be doing it. - Child and Adolescent Consultant in Cwm Taf We asked our Members whether they understood the access pathways to LPMHSSs. Just over half of the 90 who responded said, No but 46% were clear regarding the access pathways. We recognise that it is likely that over time pathways will be strengthened and more health professionals will become aware of the services provided in their area and how they are accessed. Many respondents said that services are still being developed and for that reason there are several grey areas. Graph 5: However, some respondents were very critical of the current situation, believing that the pathways are not set but are open to interpretation by individual clinicians. There was also comment that Local Primary Mental Health Support Services appear often to be less well informed, referring patients who should not be considered to be relevant patients to CMHTs who in turn refer back to primary care. There is often misunderstanding between services as to who is responsible for providing which services to which patients. Those patients who appear to be the worst affected are those who suffer co morbidities. According to one respondent, Referral pathways have become complicated and unwieldy and sometimes inappropriate. Another respondent is unclear if patients in secondary care can access LPMHSS. Responses from CAMHS colleagues show Page 13

14 that most believed that the pathway does not appear to be appropriate for children and adolescents. Some believed that the pathways are further complicated because there is little dialogue between primary and secondary care. An Old Age Consultant from Cardiff and Vale LHB said that there has been little or no discourse with primary care colleagues regarding what constitutes primary care. I imagine this risks worsening links with primary care (GPs already often complain they cannot access care from a psychiatrist). Open responses show on-going confusion regarding the role of Psychiatrists and GPs for primary care patients. The Local Health Boards and Local Authorities were required to develop and publish Joint Schemes covering Part 1 of the Measure, which determines how the statutory partners are to formally meet the requirement of Section 2, Part 1 of the Measure: the development and implementation of the LPMHSS. We asked our Members if they had access to the Joint Schemes of the Local Partners. 93 responded of which 24% said they did have access to the joint schemes, 12% said No and 65% said they did not know. Graph 6: We also asked if respondents were aware of who their Implementation Lead was on Part 1 of the Measure. 34% of all respondents said No and 42% said Yes. 34% did not answer the question. Page 14

15 Care Coordination and Care and Treatment Planning Although Consultant Psychiatrists have in the past taken on the role of Care Coordinator under the Care Programme Approach, only 35% of the 89 respondents felt that they should be Care Coordinators under Part 2 of the Measure. Most had concerns regarding the legal requirements that come with this role (see next section) but some respondents had questioned the appropriateness for the Consultant Psychiatrist to take on the role of Care Coordinator, particularly as now it is one of advisor and no longer appears to fit the medical model. One respondent commented on how the Care and Treatment Plan no longer appears to recognise the central role of the Psychiatrists in terms of clinical responsibility, as medical and psychological treatments is only one of the eight domains. Some felt that Consultants are not qualified to advise on issues such as housing, transport and employment and they questioned whether the Care Coordinator role is now outside of the remit of the Consultant. Graph 7: A breakdown by psychiatric discipline shows that the responses do not vary greatly depending on the type of psychiatrist. Page 15

16 Graph 8: Some respondents were still unclear about who can and cannot be a Care Coordinator and around the statutory requirements of Care and Treatment Planning. Although the regulations specify that not all of the eight domains must be completed it is unclear who decides which domains; the consultant or the patient. Cross-Border Patients Although we did not ask respondents to comment on their experiences with patients who move across the border or who have come from other parts of the United Kingdom under the Measure, we are aware that there is still confusion around meeting the statutory requirements concerning such patients, in particular those in prisons who are transferred regularly to other institutions. We feel that mental healthcare professionals would benefit from official guidance in this area. Unintended Consequences of the Measure RCPsych in Wales believes that the intentions of the Measure are sound. Its fundamental aims of strengthening the integration between the NHS and Social Services and between primary and secondary care, and to provide patients with a greater voice and ownership over their treatment and/or recovery are commendable. As with all pieces of legislation, its success is determined by how it is applied and implemented. The Measure is still in its infancy. It was rolled out in phases during 2012, initially with Part 4 in January, Parts 2 and 3 in June and finally Part 1 in October. More time is required for these changes to embed and for those who are affected directly by the Measure to adjust and accept changes to their usual practice. However, we are concerned that we are already experiencing Page 16

17 unintended consequences which we feel is through poor application and interpretation of the legislation, consequences wepredicted prior to its implementation. In our survey we asked respondents if they were aware of any unintended consequences as a result of the implementation of the Measure. A significant majority (82% or 84/102) said Yes all of whom provided further comments. These are outlined in the following section of this report. Increase in clinical activity In our response to the Welsh Government s Consultation on The Mental Health (Wales) Measure Parts 2, 3 and 4 Regulations in May 2011, we wrote: We do not yet know the overall impact the Measure will have on secondary care mental health services but we are concerned that [it] would result in a significant increase in workload to professionals providing care. Regulations in Parts 2 and 4 of the Measure extend both groups of people who require care coordination and treatment plans and the support of Independent Mental Health Advocates, and Part 3 would result in more people returning to secondary care services and more quickly. P. 1 We asked respondents to comment on the level of current clinical activity against the level of clinical activity prior to the Measure. The survey results show that overall there was a perceived increase in clinical activity since the Measure was introduced. 100 people responded to the question, of which the majority (55) felt they had seen an increase in activity whereas only nine had seen a decrease. The remainder (26) had experienced no change. We were able to break this down further by discipline. The differences in responses are most striking in Old Age and with a 1:7 ratio (decrease: increase) followed by General Adult with approximately1:5 ratio. CAMHS and ID appeared to be least affected. Page 17

18 Graph 9: Number of respondents experiencing an increase, decrease or no change in clinical activity, by discipline. There has clearly been an increase in clinical activity in some areas; however there are other factors, such as unemployment and benefit cuts, that also may have contributed to this increase. Increase in bureaucracy In our response to Welsh Government s initial Consultation on the Proposed Mental Health (Wales) Measure in April 2010, we wrote that the Measure may result in an increase in the level of statutory bureaucracy. We wrote: There are significant concerns about the level of bureaucracy that has accompanied the CPA. Psychiatrists are concerned about the ill-considered imposition of inappropriate bureaucracy and paperwork for individuals with simple needs and care plans. As it stands the...requirement in the Measure would be met by good medical notes and correspondence. In our survey, we did not ask respondents specifically whether they had noticed a change in their bureaucratic workload, however many commented on open ended questions that the introduction of statutory Care and Treatment Plans had brought about a marked increase in paperwork. This increase in bureaucracy is most noticeable in the workload of General Adult Psychiatrists who responded. Their particular concerns were around the additional time spent on CTP for all patients attending outpatient clinics and those receiving Page 18

19 S117 aftercare, who no longer need a service as they are well but cannot be discharged from secondary care under the Measure. A Specialty Doctor in General Adult Psychiatry in Aneurin Bevan wrote [I] spend more time doing paper work than seeing patients. Care and Treatment Planning and reviewing for all relevant patients is on-going, which adds to the bureaucratic workload. At the same time, the number of patients with complex mental health needs requiring CTP is increasing, which further impacts on the existing workload and additional burden of bureaucracy. Currently in the community patient case loads are high, demand for primary care psychiatric liaison clinics are high demand for psychiatrist input into all relevant patients care remains and it is difficult to see were additional time would be found to complete additional paperwork and role of a care coordinator. More work would need to be done to define a relevant patient that all the team could accept and a greater sharing out of the patient caseload would need to happen to make that possible. - General Adult Consultant, Private Sector - Consultant time is expensive and should be used appropriately. We have expertise and experience outside the domains of bureaucracy which is often found by patients and clinicians to lack relevance or benefit to their day to day care. I find it hard to justify delaying important and complex work to complete much of the paperwork pertinent to the current dogma. Whereas relapse signatures and contact details are useful a bulk of the care plan has often been met with bemused expressions from patients. - General Adult Consultant, Cwm Taf Many respondents to our survey believed that there is an imbalanced emphasis on process rather than meeting the patient s needs. Worryingly, one respondent admitted having to cancel clinics in order to complete the necessary paperwork. The increase in bureaucracy is not only felt by General Adult Psychiatrists. A Child and Adolescent Psychiatrist in Cwm Taf wrote, The quality of care hasn't changed as patient remains our priority. However the paperwork has increased significantly. A Consultant in Intellectual Disability psychiatry at Hwyel Dda commented on S117 patients: Patients with Intellectual Disability on section 117 aftercare subsequent to an admission for 'seriously irresponsible or abnormally aggressive behaviour' in the absence of mental illness will likely remain on CTP for life even when the behaviours have long been settled and there is no need for involvement with mental health workers. Quality of patient care is compromised Many felt that the increase in bureaucracy has impacted the quality of patient care. In May 2011, we wrote in our response to Welsh Government s Consultation on the Mental Health (Wales) Measure Parts 2, 3 and 4 Regulations, With no additional funding provided to support the increase in workload, we fear that practitioners will be forced to spend less time focussing on all patients, including those with the most need. There is a serious danger that patient care will be compromised and not improved, as intended by the Regulations Page 19

20 As we had predicted a negative impact on patient care, we asked respondents in our survey if they had noticed a positive or negative change in the care given to patients since the Measure was implemented. Nearly half (49%) of the 101 who responded said that they had noticed a negative impact on patient care whilst 47% noticed no change. Only 5% noticed a positive change. Graph 10: Whilst it is reassuring that nearly as many (47%) respondents perceived no change compared with a negative change in the quality of patient care since the Measure was introduced, we must remember that the intention of the Measure is to improve services for patients. Breaking down the responses by discipline, we note that General Adult Psychiatrists were more likely to have noticed a negative change in the care given to patients with approximately 2:1 ratio (negative change:no change). Old Age and Addictions Psychiatrists were split with approximately 1:1 ratio. Forensic and Child and Adolescent Psychiatrists were less likely to see a negative change against no change in the quality of patient care (approximately 1:3). It is important to take note that there is wide variation between sample sizes for each discipline and many are too small to provide statistical significance. We have produced a table below to illustrate the exact number of responses by discipline. Page 20

21 Table 2: Number of respondents who have seen a negative or positive impact on patient care or no change to patient care, by discipline. Have you noticed a positive or negative change in the care given to patients since the Measure was implemented? Answer Options Positive Negative No change Response Count Addictions Psychiatry Child and Adolescent Psychiatry Forensic Psychiatry General Adult Psychiatry Intellectual Disability Psychiatry Liaison Psychiatry Old Age Psychiatry Other (please specify) answered question skipped question We asked respondents to explain their answers. The qualitative data show that the traditional care pathways appear to have been abandoned. First, many perceive that there is now a much higher threshold to secondary care services so more patients are being moved to primary care services and as a result unable to receive appropriate treatment for their illnesses. Second, there are concerns that local primary mental health support services are inadequate or are inappropriately resourced, particularly as patient numbers are rising. Third, there appears to be a high proportion of unnecessary admissions to secondary care from LPMHSSs either through a lack of experience in assessment or to deal with the sheer volume of patients. Finally, there are some patients who are being denied services altogether because it is unclear who should be providing them with care. Higher threshold to secondary care We asked respondents to indicate what percentage of their patients were regarded as primary care patients before and after the Measure was implemented. 57 people responded, of which four (7%) said they now see more patients in secondary care setting, 27 (47%) said they have experienced no change and 26 (45%) said they now have a higher percentage of patients who are regarded as primary care patients. Some respondents believed that an increase in primary care patient numbers is linked to avoiding the requirements of Care and Treatment Planning and the need for a Care Coordinator, thus avoiding possible litigation. Open responses show that there is a real concern in some areas in Wales that a rebranding of primary and secondary care mental health services has moved a large number of patients into primary care and directly impacted on the availability of services vital to their recovery. These patients have been Page 21

22 discharged from day care and OT services as these services are provided for secondary care patients only. Many respondents said that they now feel less able to provide liaison and advice for patients in primary care. Some memory clinic patients cannot access specialist mental health social work as they are now deemed as being primary care patients. I am seeing a lot more patients for a much shorter time and seem to be used for triaging patients on the borderline between Primary and Secondary care. -General Adult Consultant, Cwm Taf I am now unable to access appropriate services for many patients as they are no longer deemed to meet the threshold for secondary care. I would estimate that approximately half my caseload are now only able to access Primary care services which are brief and inadequate for their needs. General Adult Consultant, ABMU Inadequate care in LPMHSSs due to lack of experience of staff The Measure was designed to strengthen and expand primary care mental health services by creating Local Primary Mental Health Support Services (LPMHSS) to work with or alongside GPs. Their remit is to carry out assessments, provide short-term treatment and/or referrals, and to provide information and advice for those with mild to moderate mental health problems or those with more serious but stable mental health conditions. LPMHSSs would help ease the workload in secondary care as patient numbers are reduced. Some respondents were concerned regarding how the LMHPSS were being resourced. Mental health nurses in secondary care have been moved into primary care to support the LMHPSSs which in some areas has negatively impacted on staff numbers in secondary care services. Some respondents had also questioned whether the staff running the LMHPSSs were qualified or equipped to carry out their duties. There were further concerns that the LMHPSSs are over subscribed because the GP threshold for referrals now appears to be very low. Some commented that primary care services are being stretched and that the therapy being offered is too brief. [The Measure] has led to resources from specialist secondary services to be diverted into primary care to provide a second rate primary care service. -General Adult Consultant, ABMU In our initial response to the Consultation on the Mental Health (Wales) Measure Parts 2, 3, and 4 Regulations we wrote that the Measure will only succeed if primary care is substantially developed and reinforced. We believe that the Local Health Boards and Local Authorities should consider how better to support the LMHPSS. Page 22

23 Increased admissions to secondary care from primary care mental health services A number of respondents raised concerns that some Local Primary Mental Health Support Services are referring too many patients to secondary care. Respondents have noticed a large number of admissions to secondary care from LPMHSSs, many of whom previously would not be deemed as mentally ill. Roughly one third (29/92) of those who answered the question had noticed an increase in GP referrals since the Measure was introduced. 50% had noticed no change and only 5% had noticed a decrease (13% did not know). There was some concern that many patients are referred via the LPMHSS route without having seen their GP and that there is now a general lack of discretion and proper assessment on the Assessor.1Some respondents felt that this has increased the average waiting times, which has impacted the quality of care these patients are receiving. It is important to note that although over half (46/92 or 55%) who responded to the question said that they had noticed no change in the number of primary care referrals, Part 1 of the Measure was to ensure that more mental health services are available to patients within primary care. Graph 11: Unwillingness to provide care for certain patient groups Addictions specialists were concerned that CDAT patients who have dual diagnosis often find they cannot access either primary or secondary care services. CDATs 1 The General Adult Faculty of RCPsych in Wales is currently collecting data from LHBs in Wales on the number of primary care referrals to CMHTs to determine if there has been an increase in activity. Page 23

24 are not resourced by Welsh Government to case manage SMI but there is no guarantee that those patients with SMI and substance misuse will be deemed as relevant patients by the CMHTs. One respondent said that primary care appear unwilling to accept referrals from the CDAT and secondary care will not recognise them as relevant patients so resources for treatment of mental health problems are frequently withheld from this patient group. Further it is very difficult to get patients with a probable Korsakov s Syndrome assessed for severity of cognitive impairment as psychological services are also only accessed via the CMHT or EMI for relevant patients and this group of patients is not recognised by staff who are directing resources. Care and treatment plans do not appear to be fit for purpose The overarching aim of the Care and Treatment Planning (CTP) was to ensure that all patients have ownership over their recovery and treatment. The guiding principles of CTP in the Code of Practice under Parts 2 and 3 of the Measure i are as follows: Patients and their carers should be involved in the planning, development and delivery of the patient s care and treatment to the fullest extent possible Clear communication in terms of language and culture is essential to ensure patients and carers are truly involved, and receive the best possible care and treatment. Care and treatment should be comprehensive, holistic and personfocussed Care and treatment planning should be proportionate to need and risk Care and treatment should be integrated and coordinated RCPscyh in Wales had stated in our response to the Consultation on the draft Code of Practice that we were not in favour of CTP as we felt that using proformae to govern the quality of clinicians work to drive good practice was unnecessary, rigid and impractical. Regarding the Plan itself we wrote: We do not believe that the prescribed form for care and treatment plans adds any value to patient care, particularly as the plan does not serve to either replace current Care Programme Arrangements, nor does it appear to add value to existing practices We believe that, when carried out properly, CPA is an effective tool in providing steps toward patient recovery. The focus should be on the strengthening, monitoring and delivering of the CPA rather than adding to it. We favour the most flexible approach possible; one that enables coordinators to process information efficiently and quickly, enabling them to operate effectively. Our survey included a section on Care and Treatment Planning (see Appendix 1) and the qualitative responses show that many respondents were unhappy with the Plan itself. Some felt that paradoxically, CTP actually restricts the natural flow of communication between the Consultant and the patient; documenting care has resulted in more jargon and now appears to require a stitled and uncomfortable approach. Patient care is now less seamless. Some respondents feel constrained by the Care and Treatment Plan as they feel they cannot make changes without Page 24

25 meeting with the Care Coordinator. We were also told that CTP documentation has created barriers on Consultant-to-Consultant transfers (of which there are many) following allocation of boundaries consistent with local authority boundaries. Transfer requests between mental health services are now more difficult because of the application of different thresholds for entry into primary and secondary care services across LHB Boarders. Some respondents found that many of their patients feel the CTP document is intrusive as it requires information about people s personal lives that may be unrelated to their illness. Others said that some of their patients are apprehensive about their CTP, particularly those who have increased anxiety when they receive official information and forms. Certain ages struggle with the format of the Care and Treatment Plan and others find the domains unsuitable. Responses from Child and Adolescent psychiatry said the forms were not designed for young people who often find the process of CTP confusing (which has led to extra appointments).the CTP form also fails to adequately assess child-relevant domains. The clinical complexity of neurodevelopmental disorders in children is not adequately captured. Old Age Psychiatry pointed out that many of the eight areas of life are inappropriate of Older Peoples Mental Health Services. Finally, there is concern that CTP is discriminatory and stigmatising. Patients being treated for physical health conditions by health professionals are not required to fill in similar paperwork with their doctor or physician. Equally CTP may be regarded as discriminatory and stigmatising against mental health professionals. Reluctance to take responsibility for Care Coordination The majority of those who responded to the question (65% or 58/89) felt that Consultants should not be Care Coordinators. When asked why, they explained that the increase in paperwork around Care and Treatment Planning (which for some is further impacted by the increase in clinical workload) many felt that they are unable to meet the quality of care they would like to provide. Again, many had concerns regarding the design and intention of form itself because they view the CTP as inappropriate for their patients; such as older people or children or they feel that the role of the Care Coordinator as advisor does not fit the medical model. 35% of respondents said that they do feel that Consultant Psychiatrists should be Care Coordinators but most of these respondents felt that this should be limited to cases where the patient has complex needs and risks or where they are the only person involved with the patient. A number of respondents commented that social care professionals also appear to be reluctant to take on this role and that in general, the default position will always fall to health. Our survey asked respondents if they felt that Local Authorities were fully cooperating with the implementation of the Measure. Only 28% (29/102) who responded said Yes, nearly half (48%) were unsure and 23% felt that they are not cooperating. The survey recognises that there is variation throughout Wales. Some Local Authorities appear to work more successfully Page 25

26 towards implementing the Measure than others. There are perceived difficulties compounding this. There is a general shortage of social workers in some areas, few local authorities had received training on the Measure, and there is a lack of compatible IT systems between health and social services making appropriate checks on patients difficult. This problem existed prior to the Measure, but it is not improving. Positive aspects of the Measure We surveyed our Members to get feedback on Parts 3 and 4 of the Measure. Part 3 enables relevant patients to refer themselves back into secondary care services within three years of discharge. Part 4 extends the Advocacy under the Mental Health Act to all relevant patients. By and large the responses were positive regarding the impact these parts of the Measure has had. We asked respondents if Part 3 of the Measure has changed their tendency to discharge patients. A very small percentage (3.3%) said that they are now less likely to discharge a patient whereas over half felt that Part 3 did not change their likelihood of discharging a patient. But 41.3% felt that they are now more likely to discharge a patient knowing that they can refer themselves directly back to secondary care. We asked respondents to explain. Only those who said they were more likely to discharge responded, saying that some patients and doctors feel more comfortable knowing they can access the services again quickly. They view this as a safety net. Old Age Psychiatry colleagues said that there is an understanding through the duty desk system that patients can contact the team directly once being discharged. Most patients have already been discharged to Memory services in primary care. ID Colleagues have said that Part 3 has not impacted on their patients. General Adult Colleagues were concerned with some possible scenarios. Examples include: Those with memory problems or negative symptoms of schizophrenia may not have the insight to refer themselves back into the services. Consultants may discharge patients who they feel no longer need the services, but if the patient disagrees with this decision, they can now return back into the system very quickly. Some patients who have been using secondary care services for lengthy periods are uncomfortable with being discharged because they fear they may not be seen when needed. We wanted to determine how many patients have since referred themselves back into secondary care services under Part 3 of the Measure. Based on the information gathered, anywhere between 97 and 340 patients in the care of those who responded have referred themselves back into secondary care mental health services since the Measure was implemented 2 years ago. Many respondents (38%) do not know how many of their patients have returned. Graph 12: Page 26

27 We asked respondents if they had experienced any difficulty in accessing advocacy for relevant patients. The majority of respondents (68%) said that they have not experienced difficulty in accessing advocacy. 23% did not know. Many said that they have not yet needed to access advocacy. Only a small percentage (9%) has encountered any difficulty. Their comments are quoted below: There was one incident of difficulty/slowness for a mentally incapacitated inpatient. Services are not available for those with Intellectual Disability unless the person is detained under the Mental Health Act. There is sometimes a lack of consistency with advocates and a patient may be seen by a different person every time, having to explain their story more than once. Conclusion The RCPsych in Wales welcomes the Mental Health (Wales) Measure as a bold effort to improve the quality of care for people attending primary and secondary care mental health services. Our survey suggests that there is a range of problems associated with the introduction of some aspects of the Measure. We believe that it will be possible for the Welsh Government to address these difficulties and to overcome some unintended consequences of the legislation. Next Steps RCPsych in Wales is committed to ensuring that our Members are given the support and guidance in meeting and improving clinical standards and patient care. We view the survey of our Members as being the start of an important Page 27