mhw interview: Phil Chick, Director for Mental Health

You’ve now been the Director of Mental Health since June 2003. How has the first year gone?

I feel that the first year has been very successful. I have had the opportunity to collaborate with colleagues across Wales. I have been able to travel to many parts of Wales to meet with people managing, providing and commissioning services in local council, NHS and voluntary services. Everybody I have met made me most welcome and I have been impressed by how enthusiastic and dedicated people working in mental health services are. I have not been short of invitations to visit a range of services and to speak at conferences, strategy and service launches and AGMs.

I have also worked very closely with the Policy Division for Health and Social Care within the Assembly. This has included undertaking a review of the Mental Health NSF and working closely with colleagues on other initiatives such as the Audit Commission’s review of services, the review of priority risk areas, the Welsh Assembly Government Guidance on service user engagement “Stronger in Partnership” and the Wanless review.

I have worked with the National Public Health Service on the development of a care pathway for people with a personality disorder, and the substance misuse treatment framework chairing the group looking at co-occurring mental health and substance misuse and in developing plans for the mental health promotion Framework. I have worked with colleagues working on the reforming of the mental health workforce. I have worked with the National Patient Safety Agency as a member of their mental health external reference group. I have engaged with the Social Exclusion unit on their report into mental health and Social Inclusion and with the Assembly’s mental health Bill team on the progression of the Mental Health Bill. These are some of the highlights in what has been both a hectic but rewarding first year.

The Director of Mental Health role was a newly-created one. Do you see it as a politically significant role as well as a practical one?

As my role is within the Civil Service, I am required to offer impartial advice to the Welsh Assembly Government whatever the political complexion of that Government.

The purpose of the role is to create an additional bridge between the service and Government. I am therefore in a position to inform and advise on policy matters which includes meeting the Minister and the Director of NHS Wales together with colleagues from across the Assembly to “champion” mental health services. I have also addressed the Health and Social Services Committee in my role as a Welsh Assembly Government Official. As such I am able to provide an impartial view of service and policy issues. Hopefully this has assisted in keeping mental health high on the political agenda.

You were previously Mental Health Development Manager at Bro Taf Health Authority. Has that role influenced your approach to your current position?

It has not so much influenced my approach as informed it. My background as a mental health professional was in social work. I worked in Local Government for sixteen years in practice, managerial and commissioning roles. My work in the Health Authority gave me an opportunity to gain experience and knowledge of NHS policy making, commissioning and finance. I believe that this mix of practice, management and commissioning experience in social care and health services has been invaluable in undertaking the role of Director for Mental Health.

A recent report by the Commission for Health Improvement on standards of mental health services in South and West Wales was highly critical. Why is it taking so long to raise standards in Wales?

Firstly I would like to say that standards are being driven up across Wales. We have seen both new community services developed and innovative ways of doing things within existing services. We have recently seen new mental health hospitals opened in Haverfordwest, Llanelli, Neath Port Talbot, Bridgend, Rhondda and Taff Ely, and building on the new Hospital for the Vale of Glamorgan and parts of Cardiff has begun and is due for completion next year.

But there is a lot more that still needs to be done.

Modernising mental health services to the point where service users are offered the range of choices to manage their mental health problems that I would like to see will take a number of years. To turn the service into one fit for the twenty first century requires a number of things to be in place. It requires a clear vision of what the service should look like. It requires a workforce in all sectors with the skills knowledge and experience required to deliver the model. It requires a change of expectation from not only staff working in mental health but also from service users and their carers. Where mental health services are delivered, how they are delivered and by whom will all need to change somewhat.

For instance if we are to move to a less institutional model of care as specified in the CHI review we need to rely less on hospital beds and more on support in peoples homes and in other community settings. This will require some new models such as services that help people avoid crisis when their mental health problems worsen or help them to resolve a crisis should one happen. We need services to follow people up and stay in contact with them where they have sometimes in the past lost contact with their care team only to be picked up when a crisis occurs. We don’t just need to do different things we also need existing services to do things differently. This can be hard for staff and service users because we sometimes become used to the way things have always been and find change difficult. Making change always takes time but it is made more difficult when money is not as available as we would like and when we don’t have as many staff available straight away as we need.

In all parts of Britain mental health services are working to find extra money for new services and extra staff to work in them. Wales is no different. The Welsh Assembly Government has made mental health one of its top priorities, and myself and others within the Assembly and in the services across Wales are working hard to try to make this priority a reality. We are doing this at a time when many areas of health and social care are also looking for extra money and staff. Change is also difficult where we still have old mental health hospitals that need to be re-provided. This takes a lot of planning to develop not the same service in a new hospital but a new service with the hospital playing its part, new hospitals also take time to build. Finally we have in the last year and a half seen a major change in the way that health care services are planned with Local Health Boards being set up along side our local councils. These organisations have needed time to bed in. Even now that they are up and running some do not have staff with a long background in mental health and some of the services we need have to be planned and set up for a bigger area than one local health board. For this reason we are asking Local Health Boards to develop partnerships with their neighbouring boards. This is beginning to happen and in some areas it is working very well. So we have seen improvements already across Wales but we have a long way to go. We need new ways of working to make sure we have the services and staff we need and we need to see partnerships develop between local councils and local health Boards with their neighbours.

One of the four key principles that underpin the WAG Strategy for Adult Mental Health Services is: ‘Effectiveness – the provision of treatment of symptoms and causes, the prevention of deterioration and reduction of potential harm to improve the quality of life.’ However, the new Draft Mental Health Bill will place an emphasis on compulsion which is not counterbalanced with rights to early treatment. Do you see the Bill as being in contention with this aspect of the Wales Strategy?

Firstly and most importantly the mental health strategy for adults concerns all people in Wales. It is concerned with promoting mental well being for the whole population and the improvement of services for those experiencing and recovering from mental health problems. The reform of the Mental Health Act 1983 proposed in the Mental Health Bill covers only care and treatment which is provided under compulsion for a minority of people with mental health problems requiring this approach. Mental health law has always mainly been about compulsion. When people’s right to refuse treatment and care has been overruled they need the protection of the law. So the emphasis in the law on compulsion is nothing new. However, it is important that the reform of the Mental Health Act, which includes improved safeguards for detained patients, is undertaken in such a way that it first and foremost meets the needs of service users and their carers who may need to receive treatment and care under compulsion.

For these reasons it is important that the reform is right. In order to try to ensure this the Minister, the Health and Social Services Committee and stakeholders across Wales have given written and in some cases oral evidence to the Committee who are considering the proposals within the Bill before it is formally introduced into Parliament. Hopefully this Committee and Parliament will shape the reform into a workable new Mental Health Act that protects service users and their carers’ rights when they have to have their right to withhold consent overridden.

In Wales we also need to see services developed that provide a good range of community services and hospital care that promote recovery and choice. This should reduce the need for compulsion and will need to be taken forward in order that we are ready to implement a reformed Mental Health Act.

The CHI report suggests that Wales has not got the infrastructure to support more compulsory treatment, and it is acknowledged that we have an acute shortage of psychiatrists. Do you think there is a risk that the new, compulsion-focused Bill will take resources away from the already stretched services in Wales?

As I have already said any Bill proposing changes to mental health law will have to focus upon issues of compulsion and the safeguarding of the rights of those receiving care and treatment under compulsory powers. What have become known as the safeguards, that is the duty to provide statutory advocacy and an automatic hearing before a Mental Health Tribunal should compulsion beyond 28 days be required, create some of the biggest demands on existing services.

Without a reduction in the rate of the use of compulsion through the development of more effective community services there is a risk that more of doctors’, social workers’ psychologists’ and nurses’ time may be taken up in tribunals and carrying out the work that the tribunals require. The shortages we have in some professions, especially doctors, mean that whether or not the Bill becomes law we need to look at how doctors and other professions work. We need to make sure that the work they do is most suitable to their skills and we need more support workers to take the pressure off doctors, nurses, social workers, occupational therapists and psychologists. We need to use the voluntary sector more and to draw more people who have used mental services into the workforce and better community services. If we are to meet the likely demands of a reformed Mental Health Act we will need these things in place before the new law comes into force.

How are you working to reduce the stigma associated with mental health problems?

I have together with Peter Lawler Head of Mental Health Policy within the assembly and colleagues across Wales done a number of things.

Firstly we have been working with the National Public Health Service for Wales to develop a mental health promotion framework to cover children, adults and older people. This will look at stigma in the different places that it occurs such as schools, businesses, the media and in care services. We will be looking especially at vulnerable people such as culturally deaf people, people from black and other minority groups, prisoners and so on. The framework will help local councils and local health Boards to develop Health Social Care and Well Being Strategies that promote good mental health and reduce the stigma of having a mental health problem. Importantly this approach means that we will be encouraging, helping to educate and enabling people outside mental health services to understand how common mental health problems are, to reduce the fear people have of mental ill health and to reduce the stigma associated with it. Some excellent work was done by a group lead by Dr Zoë Thomas who was previously seconded to work for the Assembly Government. This will be considered within the development of the framework.

I have also worked across the border in England considering the Welsh context of the Social Exclusion Unit’s report into mental health and social exclusion. A report has gone to the minister for Health and Social Services about this report and Peter and I recently took it to the Social Justice and Regeneration Board which is currently considering it.

The Implementation Advisory Group has also considered the report and their views will be used to advise the Minister.

Two things are particularly important in taking this work forward. Firstly that this is not just a matter for those of us who work in and use mental health services it needs effort from people in all walks of society to help. This needs leadership from the top and our adult mental health strategy, our child and adolescent mental health strategy and initiatives such as Health Challenge Wales place requirements on all services in Wales to work together to combat the stigma currently faced by those who experience mental health problems. People need to understand that mental distress for many can arise from everyday experiences such as workplace stress, relationship problems, or the death of a loved one and that these experiences are part of everyday life.

The recently launched initiative from Hafal focusing upon the whole person and routes to recovery is an example of how mental health services can play their part in getting mental health into the mainstream.

Secondly in taking initiatives forward we have to be sure they work. We are looking at what has been done elsewhere in the UK and abroad to plan how we can get everybody on board.

This work continues and will need to continue for at least the lifespan of the strategy because to change the way people see mental health and mental health problems will take a long time to achieve.

One of your roles is to review of the impact of the Welsh National Service Framework. Do you think it is succeeding in its targets?

Yes it is succeeding in many of its targets but for the reasons I mentioned earlier not as quickly as I and many other people would wish. We have good mental health strategies in Wales envied by many outside Wales because they keep service users at the centre of the planned change. There has been a lot of change in Wales since they were written and my review of the NSF has focused upon clearer description of the change we want based upon what has worked elsewhere. I am also seeking to make more clear who is accountable for making it happen. Next year we will produce an action plan that will include the review of the NSF and the work of a recently set up task force looking at mental health staffing. The action plan will be informed by the findings of the Audit Commission’s assessment of services across Wales and the review of the most serious risks in the service which are being carried out at the moment. I hope that the plan will help us to overcome the problems we face and help to deliver the NSF over the coming years.

Jane Hutt has just announced increased funding for health in Wales. What impact will this have on our mental health services?

Whilst there has been increased investment on health in Wales this investment has come at a time when a lot of prior commitments need to be met. This means that there is not a great deal of money available for new developments. However it is true to say that with additional investment our Local Health Boards, local authorities and NHS Trusts together with their voluntary sector partners will be helped to further improve mental health services across Wales reflecting the Ministers priority for mental health. This was certainly the case when the additional Wanless money was made available to services within Wales this year. This investment has seen approximately £4million of additional money going to mental health services from the general Wanless resources and the specific £1.8m earmarked for mental health. We are also about to see over the next two years Innovations in Care invest approximately £1million in a scheme to improve the patient journey through services. I will continue to seek any opportunities to attract investment into mental health and I am hoping that in the next round of the Service and Financial Framework that mental health targets will be set helping to ensure that we keep mental health as a top health priority.