Living and working in Wales (part 2) Old Age Psychiatry Dr V M Aziz, Consultant Psychiatrist, Cwm Taf Heath Board Manel Tippett, Policy Administrator, Royal College of Psychiatrists in Wales The NHS and Social Services are the key government organisations delivering local mental health services. All the recent Welsh Government's policies and strategies for both mental health and carers, including the Mental Health Strategy, the National Service Framework, and the Carers' Strategy, emphasise the need for the NHS and Social Services to work together to provide "seamless services" for service users, and their families and carers. The Welsh Government is committed to sustaining the principles of a NHS conceived and established in the Welsh Valleys. Through the Health Boards, the NHS delivers services at 3 levels. Primary care is provided by about 1,900 GPs. In secondary care, most old age psychiatry specialist services are provided in hospitals, at home or in community settings, often jointly with Social Services. Community Mental Health Teams (CMHTs) are probably the most central and important part of mental health services for service users, and their families and carers. Tertiary Care is provided by the Institute of Psychological Medicine and Clinical Neurosciences, formerly known as the Department of Psychological and Medicine and Neuroscience, Cardiff University Medical School. Particular areas of the department s strength include genetics and molecular biology of mental disorders, child psychiatry, learning disabilities and forensic psychiatry. Some of the research focuses on identifying and understanding genes and brings extensive research expertise in Alzheimer s disease (AD), developmental dyslexia and psychotic disorders. In 2009, the team identified two new susceptibility genes for AD; CLU and PICALM from a study involving over 20,000 subjects from Europe and the USA. Over the last few years Wales has developed a new confidence and there have been important developments through the National Centre for Mental Health, the Mental Health Research Network Cymru and NEURODEM, the Wales Dementias and Neurodegenerative Diseases Research Network. The Royal College of Psychiatrists in Wales is represented on the College Council, and on the Finance, Executive, Specialist Training and Public Education Committees. 1
Training in old age psychiatry Within the Cardiff University School of Medicine C21, medical students are exposed to old age psychiatry in years 1, 2 and 4. They are also exposed indirectly to the specialty during their placement in neurology and care of the elderly. Postgraduate core training in old age psychiatry is provided for six months in year 2 of training (CT2) alternating with either child psychiatry or learning disability. Everyone does an old age placement. Recruitment for ST4 posts in General Adult and Old Age Psychiatry is undertaken by the Royal College of Psychiatrists as part of national recruitment. Our aim is to make training focused, effective and attractive to impact positively on patient care and safety. We have retained many trainees as consultants. Consultants Most old age consultants in Wales are sector-based where they provide both inpatient and community services and work within the community mental health teams. A typical job plan will include seven direct clinical care activities and three supported professional activities. The job plan also includes any management and any other agreed external duties recognising that specific responsibilities and duties will vary between consultants. In some Health Boards there are dedicated older person liaison teams and in others there are outreach services for care homes. Making Wales a good place to grow older, not just for some but for everyone was the vision of the Older People s Commissioner for Wales 2011/12. This attracted me to work in Wales. Knowing that older people are not a group apart, nor do they all have the same needs but they require different levels of support and care. Knowing that older people very rarely recognise themselves as older and age alone is not the best way to define people. Knowing that older people are our mothers, our fathers, our grandparents, those we love and care about. Remembering all the above and beyond should drive us all, within Wales, to set the very highest possible standards of support and care. 2
Cynon Valley Hospital (Ysbyty Cwm Cynon) our unit Our team So what is different in consultant life between Wales and England? First, as part of the modernisation of NHS Wales the amended consultants' contract for Wales has been agreed in partnership between the Welsh Assembly Government, BMA Cymru Wales and NHS Wales. Consultants and senior trainees in Wales approved amendments with 94.2% voting in favour of the deal. It came into effect in 2003. It includes a basic full time working week of 37.5 hours, in line with other NHS staff; better definition of the working week; 3
organisational clarity through a revised job planning process; a new salary scale with enhancements and additional increments; improved arrangements for oncall remuneration; new arrangements for clinical commitment and clinical excellence awards; a commitment to improve flexible working and a shared commitment to enhance the quality of service for the benefit of patients. These amendments were intended to improve the consultant working environment, recruitment and retention, and to facilitate health managers and consultants working together to provide a better service for patients in Wales. The vast majority of consultants working in the NHS in Wales are employed directly by Local Health Boards. Each Health Board can determine its own contracts and terms of service for its employees, including consultants. However, according to the BMA very few NHS employers have deviated significantly from the 2003 agreement. http://bma.org.uk/practical-support-at-work/contracts/consultantcontracts/consultants-wales Secondly, the policy and legislative framework in Wales has changed considerably since the creation of the National Assembly for Wales under the Government of Wales Act, 1998. Sixty Assembly Members were voted into the Assembly the following year and were given powers over 20 broad policy areas, including health, education, the environment and transport. In 2011, a referendum enabled the Welsh Government to introduce legislation on the 20 subject areas over which it had power. There have since been several legislative and policy advances which focus or impact on older people. The Mental Health (Wales) Measure 2010 was given Royal Assent in December 2010. It was designed to transform mental health services in Wales, in part by giving service users greater ownership of, and support with, their treatment and recovery. It guarantees direct referrals to secondary care services for relevant patients and it extends the advocacy services under the Mental Health Act to cover patients in hospitals or registered establishments informally (i.e. not under compulsion) who are receiving assessment or treatment for a mental disorder. The Measure also places a duty on those working in primary care to provide assessments, treatments, onward referral, information and support to individuals and their carers. Traditional primary and secondary care services have since been redefined by individual Local Health Boards with respect to their local populations. The needs of those with stable and non-complex mental health conditions are addressed and met within primary care, whilst those patients with complex and enduring mental illnesses are met within secondary care. Plans are underway to ensure that NHS, local authority and third sector staff who come in contact with older people are able to recognise and respond to signs and symptoms of mental 4
illness such as depression and other functional illness, dementia and co-morbid conditions. New Primary Care Mental Health Workers, based in or near GP surgeries, are currently being trained to assess for memory loss and common mental health conditions in older people. The first mental health strategy for Wales, Together for Mental Health, was published in October 2012. It is a cross-government strategy focussing on meeting the needs of everyone regardless of age. Underpinning the strategy is the Mental Health (Wales) Measure. A newly created National Mental Health Partnership Board (NPB), of which the chair of the Royal College of Psychiatrists in Wales is a member, will oversee the implementation of the strategy. The strategy acknowledges the importance of the role of psychiatrists, in particular to liaison psychiatry. It highlights the importance of the support provided by older age liaison psychiatry teams to the general health and wellbeing of patients, allowing better management of acute disorders such as delirium. It aims to raise the profile of the profession, encouraging other healthcare professionals to access liaison specialist teams for advice, support and training concerning older people with mental health problems or dementia. There are only a handful of liaison psychiatrists practicing in Wales, fewer per population than anywhere in else the UK. The Older People s Strategy for Wales has been implemented in phases since 2003. It focuses on understanding the specific concerns of older people and provides a structure for representation, most notably the creation of an Older People s Commissioner for Wales. It complements the National Service Framework for Older People in Wales http://wales.gov.uk/topics/olderpeople/publications/nationalserviceframeworkol derppl/?lang=en) The Government is currently running a consultation on phase three of the strategy, which focuses on wellbeing and the importance of physical health and social support on an older person s mental health. The government has also focused on specific issues that affect older people. There has been much work done to identify how services for people living with dementia can be improved. In July 2010, the Welsh government announced an additional 1.5million of funding would be available to support and implement the actions identified in a joint report with the Alzheimer s Society National Dementia Vision for Wales. The report highlights four priorities for improvement: joint-working across all sectors; early diagnosis and timely interventions; better awareness, support and advocacy for sufferers and their families; and training and research. It includes early onset dementia for which the Mental Health Strategy stipulates that Local Health Boards and their partners must meet the specific needs of these sufferers, their families and 5
carers. By December 2013, the Welsh Government and other stakeholders will update and disseminate Dementia How to Reduce your Risk guidance. The National Assembly for Wales held an inquiry into residential care for elderly people, recognising that more must be done to improve residential care. The Health and Social Care Committee listed 13 recommendations in their report, Residential Care for Older People in Wales (2012). If implemented, there would be an increase in community care and reablement or intermediate care for elderly people and more funding toward extra care. A single point information service would also be available for healthcare staff and the public, to ensure that the services (public, private and third sector) are properly advertised and utilised. Thirdly, mental health professionals are approved by the Welsh Ministers to act as approved clinicians in Wales, but in practice this approval is done under directions made by the Welsh Ministers by Local Health Boards. Approval (for five years) is undertaken on behalf of all the Boards in Wales by Betsi Cadwaladr University Health Board. Fourthly, Wales does not follow the National Dementia Strategy Implementation Plan for England We have Intelligent Targets as part of the 1000 lives plus campaign called: How to Guide - Improving Dementia Care. www.1000livesplus.wales.nhs.uk The aims of these targets are to improve memory assessment services, care in general hospital wards, community care, support for care givers, and NHS dementia inpatient units. So, life is changing rapidly in Wales mostly in a good way as the focus is on quality of patient care. David Brindle in The Guardian sings it praises. http://www.guardian.co.uk/society/2013/jan/29/wales-found-winning-formulahealthcare?cmp=twt_fd The challenge ahead is on how we all can connect to the caring ethos. I believe old age psychiatry is a specialty that can demonstrate such feeling, caring and maintaining the quality of patient care at the centre of its performance and targets. There is a lot to be grateful for in living and working in Wales, so come and join us. 6