support/treatment, and recovery. A well supported ... Based on analysis of the survey data, and the comments made by pri
Experiences of delivering primary mental health care A report by the Wales Mental Health in Primary Care network March 2015
M P
C H
About WaMH in PC The Wales Mental Health in Primary Care Network (WaMH in PC) was established in 2003 to help promote and improve primary mental health care across Wales. We are set up as an RCGP Wales special interest working group under the guiding principles and aims of our Constitution, which was adopted in October 2008 and updated in February 2011. WaMH in PC aims to provide a Welsh forum for like-minded individuals to work together to: • Improve the profile of mental health care services • Promote primary mental health care services • Develop new ways of thinking about and working with mental health problems in a primary care setting
The Royal College of General Practitioners (Wales) is a network of over 1900 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards. Royal College of General Practitioners (Wales) Regus House, Falcon Drive, Cardiff Bay, Cardiff, CF10 4RU Telephone: 020 3188 7755 Fax: 020 3188 7756 Website: www.rcgp.org.uk/wales Royal College of General Practitioners is a registered charity in England and Wales (Number 223106) and Scotland (Number SC040430)
Contents Introduction
3
Executive Summary
4
Recommendations
6
Demographic of respondents
8
Experiences of delivery
9
Challenges facing delivery
18
Broader context
22
Introduction Welcome to the third Wales Mental Health in Primary Care (WaMH in PC) survey of Primary Care mental health. WaMH in PC is a working sub-group of the Royal College of General Practitioners in Wales and is made up of individuals and organisations that have an interest in Primary Care mental health. This report is independent and we have received no funding to produce it. We sent an email request to all GP practices in Wales in February 2014 asking GPs and practice nurses to complete a short internet-based ‘Survey Monkey’ questionnaire. This year we also invited workers from the new Local Primary Care Mental Health Support Services to also give us their opinions. The site was open from February 2014 to May 2014 to give maximum opportunity for staff to enter their views. The survey was intended to supplement previous surveys (2011 and 2009) with some previous questions asked again. The results we present in this report are those from the 2014 survey with occasional reference to the 2011 survey where relevant However, there were also some new areas we were keen to hear about; in particular practitioner well-being, the impact of welfare changes, and the effectiveness of Part 1 of the Mental Health (Wales) Measure for Primary Care staff. We also wanted to mirror some of the evidence from Gofal’s reports on the patient experience in Primary Care. The survey was conducted 16 months after the introduction of Part 1 of the Mental Health (Wales) Measure, and is therefore a snapshot of opinion about the early stages. WaMH in PC is very supportive of the Measure, and the fact that mental health legislation is taking account of the needs of Primary Care. We are therefore disappointed that at the time the survey was carried out that Primary Care practitioners were less than enthusiastic about the impact of the Measure. However, we hope that as the new services bed-in and mature, they create more positive outcomes for patients and Primary Care practitioners. This report communicates the views and perspectives of practitioners working in Primary Care settings. It is not trying to describe a “truth” but gives another side to the dialogue on mental health services in Wales. The survey was open and inclusive, but we can only capture the views of those who engaged with it. They may be the enthusiastic ones, or they may be the most dissatisfied. Or more likely a combination. This report will be shared across Wales with the practitioners who completed the survey, Welsh Government, Health Boards, Public Health Wales and Third Sector organisations and will be freely available to download from our website. We wish to thank all those who responded to the questionnaire, as well as those members of the WaMH in PC Core Group who collaborated in developing this report. Any correspondence should be directed to
[email protected]
Dr. Mark Boulter Chair, Wales Mental Health in Primary Care
3
Executive Summary Some key themes have emerged from this survey, which need to be heard by as wide an audience as possible. The four main headings provide a framework to deal with the issues raised.
Workforce Primary Care is under immense pressure. Our survey shows that the mental health workload is perceived to be increasing and that GPs often do not feel it is an easy subject area to manage. 70% say it is either ‘Difficult’ or ‘Very Difficult’! It has been identified that GPs feel more confident recognising, diagnosing and treating mental health problems compared to last time, but that they feel much less confident in managing complexity, and where there are significant issues outside of their control which may be causing emotional distress and mental health problems. It would appear that the medical model that has underpinned medical training and professional behaviour may be of little help when dealing with these situations. Another area to be addressed is the low level of confidence in promoting mental well-being and the scope for joint working with health promotion bodies to increase levels of knowledge and competence. It is apparent that the areas GPs feel less confident about are also the areas where they feel the least supported. Traditionally there have been poor lines of communication between Primary Care and Local Authorities. The same can be said for the Third Sector. This has to change if we are to improve the welfare of Welsh patients. This chimes well with the Together for Mental Health, which recognises that health services alone cannot deal with the mental health needs of Wales, and that this is everyone’s business. Many GPs have indicated that their own mental health and well-being has been affected by the pressure of increased volume and complexity of workload; this should be a major concern to Government and Health Boards. The combination of a rising workload, perceived lack of support and low levels of confidence will lead to poor performance and poor patient outcomes. Without a well-functioning Primary Care sector, Mental Health Services will suffer greatly.
Workload Over 50% of respondents identify that they are spending over 20% of their working days dealing with Mental Health issues. This is far greater than for any other area of their broad case-load; the time spent on Mental Health seems to be getting greater. To add to that, there have been other issues such as changes to the Welfare Benefits System which have introduced major stress to large sections of Welsh society. If there is no effort to support Primary Care then we can foresee greater mental health problems within this essential primary care workforce, as well as a concomitant reduction in the service given to patients. Practitioners will struggle to listen, be empathetic and holistic when they are in distress themselves. There is an urgent need to look at ways of supporting teams to become more resilient, the LPMHSS teams may be one way to deliver on this by training and supporting primary health care teams and giving them key skills in managing stress. The area that GPs feel least confident is in promoting mental well being. We propose that mental health promotion bodies in Wales work together with Primary Care to develop these skills. 4
Wider mental health economy 16 months before we ran this survey, the Mental Health Measure was introduced in Wales. WaMH in PC has been highly supportive of the Measure, and feel it is a step in the right direction. From our survey, it appears that it is taking some time for LPMHSS teams to fully form and collaborate with other services, with some areas taking shape more quickly than others; as a consequence , it has not been as effective for Primary Care (in the short-term) as GPs had hoped. This is not necessarily a reflection of the success of the Measure, it may be because the expectation of Primary Care was too high, or that expected outcomes were not deliverable via the Measure. Comments within the Survey show significant concerns about Mental Health services across Wales. Particular concerns exist relating to CAMHS services, the boundary with Secondary Care, waiting times, and most significantly access to Psychological Therapies. There has been an apparent focus within the new LPMHSS on assessment, and this has led to other aspects of Part 1 of the Measure receiving less support and recognition; yet they are enshrined in Law. There is an urgent need for greater engagement with the LPMHSS teams, particularly regarding support and training for the Primary Care workforce. In addition, the treatment aspects of the service have often been neglected, and the new teams need to develop the skills to provide appropriate Psychological Therapies at a community level. Respondents to the survey have identified that investment in Psychological Therapies would have the greatest impact. In addition, they feel that Service Capacity and timely access to Secondary Care services are also key areas for investment.
Outside pressures Society is changing. There is a greater level of expectation of the types of support and treatment people should have access to. Primary Care will need to catch up with these expectations, and help and support is required to promote confidence in utilising alternative avenues of support and treatment. The financial downturn and reduced budgets for Health and Social Care in Wales however has created a pressure at Primary Care level. There have also been changes to social security imposed on Wales, creating an additional level of work for GPs and their teams. Primary Care is a central point of contact for all people in Wales. It is local, nonstigmatizing, accessible and highly popular. However, over the last few years there have been increasingly negative depictions of Primary Care in the media. This and the workload/workforce pressures have had a marked effect on morale and recruitment/ retention. We feel there is an urgent need for a political cease-fire, as well as overt support and recognition for work carried out in Primary Care. Wales’ approach to improving mental health has to include mental health promotion and positive mental health, the recognition and management of mental health problems, and a system that allows a smooth flow from presentation, through to assessment, support/treatment, and recovery. A well supported primary care system is central to early intervention, health promotion and supporting the prudent healthcare agenda. Many of the key social determinants of mental well being are outside of the control of Primary Care teams. If we are to have an impact in these areas, there needs to be closer collaboration between Primary Care, Local Government and the Third Sector, especially in areas of social and economic deprivation. This will require concerted efforts to bring these services as close as possible to Primary Care teams as well as simplify communication channels and foster trust. 5
Recommendations WaMH in PC welcomes and recognises the potential of Part One of the Mental Health (Wales) Measure, however, more focus is required in the implementation of this legislation. In particular, it is important that the ‘spirit of the Measure’ is delivered across Wales, not just the letter of the law. Based on analysis of the survey data, and the comments made by primary care practitioners across Wales, the following section offers a series of achievable and prudent recommendations.
Access to psychological therapies The data indicates that waiting times for psychological therapies are unacceptable in many areas of Wales. Feedback indicates that services have prioritised processing assessments in order to meet the Welsh Government’s 28 day target; as a consequence the focus, and in some cases funding, has been diverted away from delivering psychological therapies. While we welcome Welsh Government funding announced in June 2014 for training in psychological therapies, however this will not deliver improved access unless the workforce is increased through funded posts. We believe that this is the responsibility of Health Boards, which need to ensure that access to psychological therapies is a priority in the strategic development of local primary mental health services across Wales. To support this change, we recommend that a more relevant target be created for access to psychological support reflects outcomes for patients, not processes.
Support for GPs and the primary care workforce Part 1 of the Mental Health (Wales) Measure is designed to provide support and advice to GPs and other primary care professionals, to enable them to safely manage and care for people with mental health problems. It is essential that this component of the Measure is delivered and that GPs receive the advice and support to enable them to feel confident in understanding and signposting. Additionally, they will require support to develop enhanced skills, allowing them to manage patients more effectively and use resources more prudently. If there is no change in the skills, knowledge or behaviour of Primary Care, then there will be no change in the workload for LPMHSS and CMHTs. We recommend a re-balancing of priorities within the LPMHSS teams, to ensure that support for the primary care workforce is delivered. We also believe there should be a focus on improving and maintaining the wellbeing of primary care practitioners. Our survey demonstrates that they are under a lot of pressure, and we recommend that Health Boards become more proactive in protecting the health and wellbeing of primary care practitioners.
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GP involvement and democratic participation We believe that GPs need to be fully involved as partners in the decisions that determine the development and delivery of mental health services in primary care. We recommend that Health Boards and Local Authorities ensure that GPs are fully engaged in the development of local primary mental health care schemes alongside service users.
Integration Some of the comments made by primary care practitioners indicate that there are still problems with integration across different parts of mental health services, such as referrals to CAMHS, secondary care teams and specialist clinicians. It is crucial that the Measure does not inadvertently reinforce barriers between different parts of mental health services and that all sectors providing mental health services review and improve the interfaces between their services. We know that many social factors affect mental health and wellbeing, and that the health service cannot deliver improvements to whole population wellbeing alone. The survey also shows that GP confidence is dropping and they need more support, when it comes to promoting wellbeing and being aware of services in other sectors that can help deliver this agenda. The development and delivery of the new Social Services and Well-being (Wales) Act and the Well-being of Future Generations (Wales) Bill need to address the issue of supporting and working with Primary Care more effectively in order to deliver holistic, person centred care. We recommend that Health Boards and Local Authorities consider ways to better integrate services that support mental health and wellbeing. For example, locating some Local Authority and Third Sector services within GP surgeries on certain days, or at certain times so that referrals to housing or welfare reform advice services is both easy for the GP, and accessible for the patient.
7
Demographic of respondents 152 people working in primary health care responded to the 2014 WaMH in PC survey. The following charts illustrate the professional background, age, gender and Health Board of the respondents. The majority of respondents (nearly 75%) were GPs, over 85% were aged 41 or older and nearly 60% of respondents were female. People working across all of the Welsh Health Board areas responded to the survey, with the highest proportion working in the Betsi Cadwaladr, Abertawe Bro Morgannwg or Aneurin Bevan University Health Boards. Age
Professional background 100% 90% 80%
>51
70% 60%
41-50
50%
31-40
40% GP Practice Nurse Local Primary Health Support Service Worker Other
Which Health Board do you work in?
50%
70%
31-50%
60%
• There was a 7.6% increase in respondents who reported that their mental health workload was over 20%, compared to 2011.
21-30%
50%
11-20%
40%
• T here was a 4.7% increase in respondents who reported that their mental health workload was over 30%, compared to 2011.
30%
5-10%
20%
< 5%
10% 0% 2011
2014
Compared to the previous survey, there appears to have been an increase in the proportion of time spent on mental health related work. This could in part be due to raised awareness of mental health problems and related services, and more of a willingness from the general population to visit their GP to discuss mental health. It could also be related to the external environment and the difficult financial circumstances and pressures facing people at home and at work. It appears that the mental health workload in Primary Care is increasing; we believe that resources and planning need to respond positively to this strain, on an already over burdened area of the health care system. We need greater understanding of the causes of this increase in work load, especially as other data from the survey shows that this is an area that GPs find challenging.
9
Practitioner confidence
Q
How confident are you personally about dealing with each of the following steps in the patient’s pathway?
These results are similar to previous surveys and illustrate that GPs still feel they lack the confidence to intervene outside of the more medically-defined areas of mental health. As previously (2009), the results indicate that practitioners feel least confident when promoting mental well being. To ensure an effective service, more resource are required to help Primary Care practitioners develop skills in promoting mental health and wellbeing as well as treating mental illness. It also appears that confidence is lacking when there are complex and co-morbid physical and mental health problems. Working in a holistic patient-centred fashion is a corner stone of WaMH in PC’s values, and it is concerning that colleagues find this provision of care challenging. There is evidence to suggest that where mental and physical health problems co-exist, morbidity, mortality and physical health outcomes are improved, if mental health issues are addressed1. We know that some of the main determinants of mental well being are housing, employment, social isolation and financial constraints. We believe there needs to be stronger links with other organisations to help Primary Care to deal with these issues. The development and delivery of the new Social Services and Well-being (Wales) Act and the Well-being of Future Generations (Wales) Bill need to address the issue of supporting and working with Primary Care more effectively, in order to deliver holistic, person centred care. It is clear that the NHS in Wales is not solely responsible for supporting the mental well-being of the citizens of Wales, and that better collaborative working is required across many sectors. Support needs to be directed towards Primary Care to help it cope with the increasing level of complexity it is expected to deal with on a daily basis.
1 Long-term conditions and mental health: The cost of co-morbidities, The Kings Fund and Centre for Mental Health, 2012 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
10
How confident are you personally about dealing with each of the following steps in the patient’s pathway? 100% 90% 80%
1 (low confidence)
70%
2
60%
3
50%
4
40%
5 (high confidence)
30% 20% 10% 0%
A
B
C
D
E
F
G
H
Key: A Early / proactive detection of signs of mental health issues B Assessment and diagnosis of mental health issues C Treatment and referral decisions D Follow up and reassessment E Patient support and engagement F Managing patients with co-morbidity of mental and physical ill-health G Understanding and signposting for the social factors related to mental well-being – for example housing, diet, employment, social inclusion and others H Promotion of mental health and wellbeing in the patient community including social and economic interventions, e.g. debt counselling and third sector /social enterprise initiatives
11
Support for primary care practices
Q
How much support do you feel your practice has overall in dealing with each of the following steps in the patient pathway?
It appears that the areas where practitioner confidence is the lowest, are also the areas where perceived support is most lacking. For example, respondents have indicated mental health promotion as an area lacking in confidence, a neglected subject requiring more effective support. It is surprising that the introduction of the Mental Health (Wales) Measure has not helped to increase support more effectively. This may reflect a focus on assessments, rather than other aspects of Part 1 of the Measure. There is a possibility that the 28 day assessment target has distorted the priorities of the service, but our study also shows there are concerns about capacity and waiting times. We suggest that there is a recalibration of the emphasis of the various functions of Part 1 primary care services. This must include the stated role of the service in supporting and training primary care teams. Part 1 of the Mental Health (Wales) Measure is meant to provide support and advice to GPs and other primary care professionals, to enable them to safely manage and care for people with mental health problems. It is essential that this area of the Measure is not neglected, and that GPs receive the advice and support to enable them to feel confident in understanding and signposting for the social factors related to mental wellbeing, and promoting mental health and wellbeing. In addition, the skills of the Primary Care work force need further development to enable them to cope more effectively with the increasingly complex mental health problems that present. We also believe that further support and connections are required with other agencies such as social services, housing, education and advice services such as CAB. Primary Care practitioners are only one part of the whole system that supports citizens in their communities. We feel that the role of Local Authorities needs re-connecting to Primary Care, especially as they are supposed to be a partner in the delivery of Part 1 of the Measure. In summary, we believe that improved communication between GPs and LPMHSS, and better support and education for GPs and other primary care practitioners will lead to better management of patient mental health, and fewer inappropriate referrals to primary and secondary mental services.
12
How much support do you feel your practice has overall in dealing with each of the following steps in the patient pathway? 100% 90% 80%
1 (low)
70%
2
60%
3
50% 40%
4
30%
5 (high)
20% 10% 0%
A
B
C
D
E
F
G
H
Key: A Early / proactive detection of signs of mental health issues B Assessment and diagnosis of mental health issues C Treatment and referral decisions D Follow up and reassessment E Patient support and engagement F Managing patients with co-morbidity of mental and physical ill-health G Understanding and signposting for the social factors related to mental well-being – for example housing, diet, employment, social inclusion and others H Promotion of mental health and wellbeing in the patient community including social and economic interventions, e.g. debt counselling and third sector /social enterprise initiatives
13
Impact on primary care practitioner wellbeing
Q
In the last 12 months have workload pressures / increased complexity / other practice-related issues had an effect on your well-being?
This is a very important area. Primary Care has undergone a huge increase in pressures over the last few years. In addition, there has been negative reporting in the media about Primary Care, which is having a profound effect on GP morale. There are many factors that have joined together in a ‘perfect storm’ to affect the well-being of practitioners, such as issues concerning workload, workforce, adverse publicity and demographic and societal changes. In the last 12 months have workload pressures / increased complexity / other practice-related issues had an effect on your well-being?
Improved (2.0%) No effect (30.7%) Detrimental (59.3%) No comment (8.0%)
There will need to be increased support for Primary Care professionals and their teams to help them deal with the effects on their well being. We must ensure that they have the skills and understanding to manage their own mental health problems, or have access to professional services to support them. It is highly unlikely that Primary Care practitioners can successfully look after the needs of others, if they themselves are distressed and not coping with the expectations that society has of them. Distressed professionals will be less likely to listen effectively and demonstrate empathy and understanding, yet these are often the key demands of patients of their doctors. There may be a role for peer networks and locality groups in supporting doctors more effectively. Part 1 services could also train Primary Care teams in the management of stress and anxiety to help them develop their own resilience, as well as pass on key skills and messages to patients.
14
Existing support networks should also be promoted on a regular basis, to ensure their presence is clear in healthcare professionals’ minds. • Royal College of Practitioners Peer Mentoring: www.rcgp.org.uk/my-rcgp/find-amentor.aspx • General Medical Council (GMC): www.gmc-uk.org/concerns/doctors_health_ concerns.asp • British Medical Association (BMA): http://bma.org.uk/practical-support-at-work/ doctors-well-being/websites-for-doctors-in-difficulty • British Doctors and Dentists Group (BDDG) website: www.bddg.org • H ealth for Health Professionals Wales (HHP Wales): www.hhpwales.co.uk or call 0800 058 2237. Health for Health Professionals Wales is a Welsh Government funded initiative which offers a free, confidential helpline to any doctor in Wales, access to 8 sessions of CBT and signposting to support resources. • Doctors Support Network: www.dsn.org.uk/ We also believe that there needs to be greater political support for Primary Care teams, and the need for more training in resilience at undergraduate and at GPST level. There should also be local provision of stress awareness and management courses in recognition of the stress that practitioners are currently facing.
15
Advice, treatment and support options for patients
Q
When dealing with common mental health problems do you refer to or provide any the following? When dealing with common mental health problems do you refer to or provide any the following 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Refer Provide
We have tried to use the WaMH in PC survey to see what advice, treatment and support options GPs felt they offered or referred to. This question was designed to mirror a question in Gofal’s survey of patient experiences of primary mental health services. We felt there was extra benefit in triangulating the patient experience against the professional one to enhance to evidence about resource use in Primary Care. Gofal’s survey demonstrated that prescription medication is the dominant offer (see graph opposite). Patients who responded to the survey expressed a wish to have more options presented to them, in particular the offer of psychological therapies. However, the surveys conducted in 2013 and 2014 indicate that people are being offered a wider rage of treatment and support options, with marked increases in the proportion of people offered advice and information, psychological therapies and signposting or referral to another organisation or service.
16
Comparative data – Gofal survey In 2012, 2013 and 2014 the mental health and wellbeing charity Gofal conducted surveys of people’s experiences of primary mental health services in Wales. The surveys asked respondents which advice, treatment and support services they were offered. Were you offered any advice, treatment or support? 80% 70% 60% 50% 40% 30% 20% 10% 0%
2012 2013 2014 Please note: The question about psychological therapies was split into ‘CBT’ and ‘other talking therapies’ for the second and third surveys following feedback from health professionals.
There seems to be a disparity between what professionals say they offer patients, and what patients feel they have been offered. This may partially be due to the fact that a GP may well use the options presented but not for every patient. It may also reflect a disparity of understanding, for example, patients referred to the LPMHSS, who have an assessment followed by information and/or a brief group intervention may classify this as receiving therapy, whereas a GP might not classify this as such. However, it is gratifying to see that patients feel they are now being offered a greater number of options when they present in Primary Care; although anecdotal evidence from some GPs suggests that lengthy waiting times for talking therapies are deterring GPs from offering this form of support to patients. These results also reinforce the need to ensure that GPs have appropriate information about alternative support services in the community.
17
Challenges facing delivery Management of mental health in primary care
Q
In your opinion, how difficult is the area of mental health to manage at primary care level? In your opinion, how difficult is the area of mental health to manage at primary care level?
Very difficult (12.7%) Difficult (60.0%) Manageable (26.7%) Not at all difficult (0.7%)
We have shown yet again (compared to the 2011 survey) that GPs face a large workload of patients with mental health issues, but also that they see this area as a difficult one to manage. Not every patient who presents in Primary Care wants or needs referral to secondary care, or to the Local Primary Care Mental Health Support Service. These patients still need holistic patient centred care from their GP, but time and workload constraints can make this extremely challenging for a GP to provide. This reinforces the point made previously in this report that Part 1 of the Measure was meant to improve the advice and support to GPs. This is an essential component of the Measure, and needs to be delivered appropriately. The new Local Primary Care Mental Health Support Services need to develop GPs’ understanding of how the various care pathways work in their locality, and of other services available to help patients with mental health problems.
18
Barriers to successful delivery
Q
What are the top three barriers to the successful delivery of Primary Care mental health services? What are the top three barriers to the successful delivery of primary care mental health services? Other (please specify)
Availability of training in mental health issues Difficulties working together with other parts of the mental health services Low level of professional interest in mental health in primary care Treatment protocols Care pathways Referral processes Personal Professional knowledge of mental health issues Service capacity Timely access to secondary-care services Timely access to psychological therapies 0%
20%
40%
60%
80%
100%
As with other areas of this report, it is clear that the capacity of available services, the time taken to access secondary care services and access to psychological therapies are major issues for GPs, but more importantly their patients. GPs had hoped that the introduction of the Mental Health Measure would improve access to appropriate psychological therapies, but this has not yet happened and leaves GPs not being able to offer treatments that are recommended by NICE. However, we are pleased that a low level of interest in Primary Care is not considered a factor in hindering successful delivery.
19
Concerns about the new primary mental health services
Q
Do you have any concerns about governance issues; waiting times; communications between services; access to psychotherapeutic interventions; quality or appropriateness, of the new primary care support services?
We asked respondents whether they had any concerns about the governance, communication, quality and delivery of mental health services in primary care. As the question asked about concerns, it is understandable that many of the opinions in this section are highly critical. However, some have taken time to say how well some of their services are working, and it is important to capture the honest opinions of professionals working in primary care. Comments highlight that: • Access to psychological therapies is a major and continuing concern. • The introduction of the Mental Health (Wales) Measure has not as yet fully resolved the interface issues between Primary and Secondary Care for many clinicians. • The new services are well funded and fully supported with staff with appropriate skills and with manageable workloads. Hopefully, Health Boards will accept the new services as a valuable investment, as a means to reduce the demand for expensive secondary care services, and will commit more than the minimum funding to these services. Despite the negative comment, it is our belief that the new services brought in under the Mental Health Measure need time to mature and integrate with other services.
20
“Access to Links has greatly improved in the past few months, however, ‘talking’ therapies have a woeful waiting list.” “Availability of psychological interventions is still poor.” “Long waiting times for all forms of psychological intervention, resulting in patients deteriorating and feeling bereft of help/support.” “Referrals being rejected by CMHT without pts been seen.” “Very poor service for young people locally.” “Poor transfer care to adult services from CAMHS.” “Yes - access to mental health services via the CMHT has drastically reduced and been made more cumbersome in past 2 years.” “So far we have had access to assessments but no real improvement that I can see in the provision of psychological therapies, such as CBT.” “Our local Stress Control training course has been excellent for those with mild/moderate symptoms.” “If a patient becomes moderate to severe, we have effectively no service until they become severe or very severe.” “Hopelessly inadequate CAMHS service, with 80% referrals being returned.” “Waiting times - service not suitable for crisis intervention (unless immediate risk for life, which is rare) leads to more prescriptions of antidepressants to bridge the gap until seen.” “Waiting times are generally long. Services don’t appear to be ‘joined up’.” “Secondary services try hard to provide timely interventions but are too stretched to do this.” “The primary mental health team are professional & well managed. The problem I have is with the secondary mental health provision, which in my experience is elitist and poorly managed & offers a poor service.” “Strain on service capacity can result in lengthy/extended waiting times for patients.” “There seems to be a considerable problem when attempting to refer on for appropriate treatment/ further assessment when patients’ mental health needs cannot be met in primary care.” “Absence of some services e.g. eating disorders, psychology, PTSD counselling.” “Very limited capacity for childhood / adolescent services.” “No adult ADHD service. Big problems with OOH services and admissions.” “Big concerns about commissioning/ contracting, with consequent lack of inpatient beds, impermanent consultant psychiatrist causing lack of consistent leadership and continuity of care.” “Referrals to one part of service being returned for referral to another.” “No-one wants to know our pts they are either too sick or not sick enough for what is being provided.” “No one wants to look after mental health in primary care.” 21
Broader context Whilst developing the survey, we believed that it was important to recognise that the delivery of primary mental health care sits within a broader context of both Welsh and UK Government policy and legislation, as well as the wider economic context. The Mental Health (Wales) Measure is particularly relevant, but the UK Government’s programme of welfare reform has also had an impact on individual patients, their communities, primary care professionals and general practices. The level of investment in mental health services also remains an issue. According to an analysis published in the British Medical Journal1, mental health accounted for 23% of the UK’s “disease burden” (the burden on society of all diseases and health conditions), but receives only 11.4% of Welsh NHS spending2.
The Mental Health (Wales) Measure
Q
How effective has Part 1 of the Mental Health Measure been on your ability to manage common mental health problems (for the benefit of your patients)? How effective has Part 1 of the Mental Health Measure been on your ability to manage common mental health problems (for the benefit of your patients)? Highly effective (2.3%) Moderately effective (46.1%) Not effective (51.6%)
To date, Primary Care professionals do believe that the introduction of the Mental Health (Wales) Measure has had a major impact on their ability to manage common mental health problems. This may well be representative of the gap between expectation and reality, and in particular that patients with common mental health problems still do not have timely access to NICE recommended therapies. It may also indicate that the advice and support for GPs – promised by the Measure – has not yet become apparent to much of the primary care workforce. It is important to point out that Part 1 of the Mental Health (Wales) Measure was only implemented 16 months before our survey took place. When we held our last survey in 2011, many GPs did not know the Measure existed. We feel that this legislation and the services it introduced need more time to mature, before we witness the full effect. However, service managers need to ensure that all aspects of Part 1 are implemented at a local level. We also feel strongly that patient outcomes and the “spirit” of the Measure needs to drive its implementation, rather than process driven targets. The role of LPMHSS teams within the whole mental health system is still developing, but Part 1 services need continuing support in order to succeed. 1 London School of Economics, 2012 http://cep.lse.ac.uk/pubs/download/special/cepsp26.pdf 2 Welsh Government, 2014 http://wales.gov.uk/docs/statistics/2014/140611-nhs-expenditure-programme-budgets-2012-13-en.pdf
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Welfare reform
Q
Have the changes to the Welfare / benefits payment arrangements had an impact on your Practice?
The data indicates that changes to the welfare system have had a marked effect on the workload of primary care practitioners. These changes have been highly stressful for many patients, often those who are least able to deal with uncertainty. We believe there needs to be more support for Primary Care to deal with the workload demands surrounding welfare reform. Policy makers need to understand the impacts that such reforms have on individuals, communities and other services, especially Primary Care which is already under immense pressure.
Have the changes to the welfare / benefits payment arrangements had an impact on your practice? 100% 80%
Significantly more often
60%
Marginally more often
40%
No significant increase
20% 0%
‘New’ ‘Old’ patients patients attending presenting more often in surgery
Welsh Government research has suggested that a number of aspects of welfare reform could lead to a negative impact on the health and wellbeing of the population, particularly benefit claimants from low–middle income households, and non-working families with children. It also predicted that the welfare reforms were likely to result in increased pressure on health services in Wales. “The welfare reforms could potentially have a direct negative impact on claimants’ health via a reduction or loss of benefit income due to tighter eligibility criteria, conditionality requirements and tougher sanctions; increased poverty levels; new, uncertain and stricter medical assessments; appeals and reassessments; budgeting problems associated with direct, monthly benefit payments; the migration of claimants into cheaper, poorer-quality and possibly overcrowded housing; and a combination of less financial resource and increasing demand for support from the Social Fund and Independent Living Fund (ILF). There may also be indirect income effects on entitlement to a number of health-related passported benefits. These impacts are likely to lead to increased pressure on health services in Wales.” (Analysing the impact of the UK Government’s welfare reforms in Wales – Stage 2 analysis Welsh Government, February 2013)
In addition, research and anecdotal evidence from third sector organisations and social housing providers show that welfare reforms are having a negative effect on the mental health and wellbeing of individuals and communities across Wales. Although most aspects of social security are not devolved, it is essential that the Welsh Government continues to make robust representations to the UK Government, and communicate the negative impact of welfare reform on devolved services. The Welsh Government should also ensure that the impact of welfare reform is recognised and responded to in the development of Welsh health services. 23
Investment in primary mental health care
Q
Do you feel there should be a greater or lesser level of investment in time and resources in mental healthcare in Wales, relative to other primary healthcare priorities in general? Do you feel there should be a greater or lesser level of investment in time and resources in mental healthcare in Wales, relative to other primary healthcare priorities in general? Much less Somewhat less
The current level of investment is right Somewhat greater Much greater 0%
10%
20%
30%
40%
50%
41% of respondents have indicated that a much greater investment is required in mental health resources in Wales, as compared to 30.6% in 2011. Our data indicates that the proportion of time spent on mental health is increasing, and we therefore conclude that further investment in mental health is required. A recent UK Government report ‘No health without mental health’ stated that: ‘Mental ill health is the single largest cause of disability in the UK, contributing up to 22.8% of the total burden, compared to 15.9% for cancer and 16.2% for cardiovascular disease.’ In contrast, only 11.4% of NHS expenditure in Wales relates to mental health . The data from our survey shows that practitioners would welcome an increase in mental health spending, and the statistics above suggest that we are still some way from achieving parity between mental and physical health spending. We have shown that Primary Care determine the main barriers to developing services are timely access to secondary care, service capacity and most importantly, appropriate access to psychological therapies. We therefore suggest, that investment in these areas is prioritised, however, at the same time accept that we are working within a financially constrained service, and that significant investment of money is unlikely in the near future. Nonetheless, we believe that patient outcomes can be improved by promoting joint working with other agencies (such as Local Authorities, Third Sector organisations, Health Promotion Wales and others). This will help develop a service that can respond to mental health prevention and promotion, manage more effectively and refer more appropriately. The main benefit of this would be to improve “flow” within the system as a whole, and Primary Care is central to this endeavour. 24
