Health, Wellbeing and Local Government Committee
HWLG(3)-11-09 Paper 12
Committee Inquiry into Mental Health Services in the Community – Written evidence from the City & County of Swansea (CCOS) Local Authority
Purpose
This is the City & County of Swansea (CCOS) Local Authority response to the above Inquiry into Mental Health Services in the community.
Background
There have been numerous developments within Mental Health Services in recent years as a result of legislation and strategies focussed on community provision of services and the re-provision of in-patient services. The Local Authority, in partnership with the Trust, LHB and Independent Sector, has explored avenues to strengthen local Mental Health Services in line with strategic direction (Mental Health Vision Swansea).There remains a significant need to improve a further develop existing services in Mental Health.
Response to main points raised by the Committee Inquiry:
Weakness in current provision of community services for adults:
Inadequate resources within Primary Care to meet the increasing demand for Mental Health assessments, and ‘signposting’ to appropriate services/support. As evidence of good practice, Swansea employ Primary Care Liaison Nurses based in GP surgeries but the high volume of referrals has resulted in lengthy waiting times and subsequent escalation of referrals to Community Mental Health Teams which could be avoided. Increased resources within Primary Care will alleviate pressure on CMHT’s and assist in the prevention of more serious mental illness and will promote positive mental health within communities.
Need to promote ‘recovery & outcome focussed models of care’ within mental health, challenging and changing the culture of medical/health driven model.
Workforce issues; within the next 5 to 10 years many highly skilled staff will reach retirement age, it is apparent that decreasing specialist staff within MH services will create a ‘gap’ in resources. Currently, it is difficult to recruit qualified AMHP’s, and the widening of workforce eligibility to take on the AMHP role is yet to be effective.
The high caseloads and workload of CMHT’s evidence the increased demand for Mental Health Services; this may be attributable to the growth of mental health problems associated with substance misuse and societal problems in general. CMHT’s remain the cornerstone of specialist mental health services .In recent years there has been investment in Crisis Resolution Teams, Assertive Outreach and Primary Mental Health Liaison services. These specialist services support those most in need and create expertise within their own field but we need to ensure there are clear pathways to access these services via CMHT’s.
1. Poor Integration of health and social care, in some Community Mental Health Teams.
Multi disciplinary teams are well established within Swansea and have a joint management structure. Recent NHS structural changes and its subsequent increase in size will challenge Local Authorities to continue to provide strong input into the planning and delivery of services to promote the social model of care for mental health services. Having a single point of access to services which are within accessible areas in the community will ensure working relationships remain strong.
A joint IT system (PARIS see example of good practice) has further consolidated joint working practice via use of one single electronic database.
2. Problems for 16 -18 year olds /transition issues:
CAMHS provision is inconsistent and can result in adolescents ‘falling between ‘ services, to later present in crisis to CMHT’s, e.g. CAMHS services between 16 to 18 depend on whether a person is in full time education or unemployed. Consideration needs to be given to a dedicated transition service to ensure appropriate provision; partners should include health, local authority child care and Mental Health Services.
3. Issues around alternatives to hospital admission and prompt and safe discharge , (including crisis resolution/home treatment and housing and support services:
As stated previously, there has been investment in Crisis Resolution /Home Treatment teams and more recently Assertive Outreach services in Swansea which has had a significant affect on providing real alternatives to hospital admission, also enabling improvements to quality of care within inpatient settings.
Housing and Support services; The Local Authority, LHB, ABMU Trust & Housing Providers continue to work together to provide innovative housing provision, (see example of good practice).
Concerns around the Care Programme Approach, including variable implementation across Wales: CMHT’s in Swansea followed WAG guidance to implement and include CPA within Unified Assessment (UA). This could only have been achieved using an IT system that interlinks the two assessments. However, inclusion of CPA within UA has increased the time practitioners spend writing up the assessment process and the combination of utilising two assessment processes is overly bureaucratic and as a result information is difficult to collate. The CPA assessment includes risk assessment and although it needs reviewing, having risk included in the care planning process does provide essential information on risk and need to the care planning process. There is a need to ‘shift’ a residual culture within CMHT’s and Inpatient services from service led provision to outcome focussed /recovery model of care planning . With regards to UA/CPA interface, it would be simpler to have one comprehensive assessment process within CPA.
Concerns around the adequacy of mental health services for BME groups, physically disabled people and those with children:
The proportion of the black and ethnic minority population in Swansea is slightly above the welsh average at 2.2% In partnership with BME organisations in Swansea , CMHT’s are gradually building links to support communities , however ,engagement with individuals & their families remains variable . Staff are advised to refer to LA guidelines when accessing interpreters and further guidance from BME organisations is encouraged. A recently agreed Race Equality Action Plan between health and social care partners will assist with a consistent approach across the BME community.
Needs of Children:
The NSF ‘Raising the Standard’ key action 39 states that Local Authorities must ‘identify professionals to represent the needs of children at adult mental health multi disciplinary team meetings’ and also to develop a strategy to meet the needs of children who are vulnerable as a consequence to their parent’s mental ill health. Swansea have a draft protocol which focuses on information sharing, and the roles and responsibilities of relevant parties. A practitioners group has been established across mental health and child and family services to share good practice, and identify training needs. There remains a significant need to improve joint working and communication between adult and child care services.
Examples of good practice in the delivery of services:
The Single IT system across health and social care: CMHT’s access the Local Authority ‘Paris’ IT system , this ensures all UAP/CPA records/case notes are entered via one system thus avoiding duplication & ensuring recording of essential information & risk factors . ‘Paris’ is accessible to Inpatient psychiatric services on a limited basis at present , but inpatient services will adopt full interactive patient management records in June 09. The accessibility of a joint IT system both in the community and hospital provides 24hr availability of information between the Trust and Local Authority.
The Local Authority, LHB, ABMU Trust and Housing Providers have developed needs led supported accommodation for service users as part of a Repatriation/phased process, to return patients who were in out of county placements to Swansea with the appropriate care. Savings achieved by the LHB were ring fenced and invested in psychology, assertive outreach and increased staffing.
A central referral process for all supported accommodation needs was implemented; Opportunities for accommodation & support in Swansea (OASIS). OASIS provides key information on service demand to help planning for new developments and provides a central route for all support/accommodation referrals across all housing providers in Swansea.
The CREATE partnership is a joint initiative with the statutory and voluntary sector in Swansea to provide a ‘one stop’ referral to access day care and employment services. CREATE avoids the unnecessary duplication of assessments amongst service providers and has a shared philosophy of recovery.
The Llanfair ‘Flexibilities ‘ Occupational Health Service Project :
The 1999 Health Act Flexibilities ‘policy framework set out to develop partnership working between Health and Social Services. The flexibilities grant enables the development of an OT team to foster close links between hospital and community based services, with the aim of delivery of a seamless service for clients from hospital to community. Llanfair House (a 26 bed Community Rehabilitation Unit operated by Social Services) facilitated the new OT team to work closely with service users who have a severe mental illness and history of lengthy admissions to hospital /relapse & re-admission within a community setting. A graded rehabilitation programme is devised and undertaken by the OT working closely with staff at Llanfair House , CREATE , CMHT’s and accommodation providers .This model of service has reduced the number of individuals spending lengthy periods on acute and rehabilitation wards enabling people to move in to community settings over a gradual period and improving treatment outcomes.
Services for Carers: The take up of Carers assessments within Mental Health services in Swansea was low, and to address this, a temporary Social Worker post was created to specifically work with Carers. The WAG Carers grant is utilised to provide one to one support for Carers who have confirmed that they benefit from a designated Social Worker who validates their role as Carers, providing practical, emotional & limited financial support when needed. The Social Worker for Carers works closely with The Carer Centre and other carers support groups in Swansea providing links/information/ advocacy and much needed support to carers. Ongoing employment of a designated Social Worker for Carers of mental Health Service users is dependant on future WAG grants being available.
Conclusion
There has been significant improvement in the provision of Mental Health Services over the last few years. This has been the result of Government Policy, NSF targets and the concerted efforts of partnership working.
Mental Health Services remain under resourced and organisations are hampered by financial constraints combined with increased demand on mental Health Services. Joint working is well established locally, but organisational change and restructure, places additional challenges on partners to maintain and improve service provision.
