Online exclusive: “I share users’ frustration.”

People concerned with mental health services in Wales have rightly kept their eye on our current Minister of Health and Social Services Edwina Hart AM.

From the moment she was appointed she rolled her sleeves up and set about major reform of the NHS bureaucracy in Wales. Mental Health Wales was the first to report her disillusion with the multiplicity of NHS bodies in Wales and her intention to simplify and reform. But who did she choose to head the Welsh NHS and put her solutions into action?

Rather than look elsewhere, the Minister appointed a well-known Welsh NHS insider Paul Williams to wield the axe on 37 separate NHS bodies and construct in their place seven all-purpose Local Health Boards.

Mental Health Wales went to see Mr Williams to check out the prospects for mental health services under the new regime.

We began by asking Mr Williams about his personal commitment to mental health in Wales.

“It’s fair to say I’ve got a commitment to mental health services having worked in the NHS for over forty years,” he said. “I feel very passionately that mental health services should not be tucked away or stigmatised, that they’re seen as a frontline service. It’s a subject never far from my mind.”

But how did he react to the National Assembly’s critical Inquiry into Community Mental Health Services which was published in September?

“Services are still patchy in parts of Wales. I don’t think it’s the result of a lack of commitment by the Government: the old system of working where you had 15 Trusts and 22 commissioners meant they all had a slightly different take on what needed to be done. When you had so many organisations looking at things differently – and for the best intentions – priorities sometimes got distorted, that’s why we have that unevenness.”

So would he understand users’ disappointment with the failings highlighted by the Inquiry?

“Yes, I’d share not only their disappointment but their frustration too.”

With the Inquiry calling for “urgent action” to implement the National Service Framework, how would the Welsh NHS respond?

“We’re right to prioritise the Care Programme Approach (CPA). My experience is that care plans were not the norm but they should be as they will underpin a lot of what we’ve got to do. Community Mental Health Teams are absolutely crucial in this; we’re reviewing the effectiveness of the teams and what we need to do to make them more effective and make sure we’ve got good spread.

“The 24-hour crisis resolution and home treatment has made a great impact but there’s more to do there too; we need to move away from an over-reliance on admitting people into in-patient settings when it’s unnecessary. We also have to learn even more from users and from organisations that represent users to ensure our services are more bespoke, more responsive. It’s not right that the NHS should attempt to do everything: other organisations are better positioned to deliver some services.”

A “Review of the Care Programme Approach in Wales” was published earlier this year and described the current CPA system as “overly complex and too bureaucratic”. Isn’t there a lot of work to do in this area?

“I think so. This in an issue of colleagues again, with the best of intentions, producing a policy but not actually understanding how it plays out in the field. There’s no point in having a system which appears perfect but is so complicated that users miss out because you can’t deliver on it.”

So when will mental health no longer be a Cinderella service?

“I’m reminded of something a colleague of mine said: ‘How can a priority service be a priority service if it’s still a priority after ten years?’ It doesn’t add up. We all have to work together to keep it on the top of the radar screen. There are so many competing demands, that’s the challenge facing the new integrated system.”

With users concerned that responsibility for mental health in the new system will be given to Vice Chairs and Directors with a broad brief and not to a specific mental health champion, how would services stay on this radar screen?

“The question is this: do you determine a product champion with the danger that everyone else on the Board says the service in question is the responsibility of the product champion? Or do you make nothing a priority so the Board has to take everything on? We need to be aware of the dangers of making a specific responsibility to Board members and saying: ‘That’s your problem’. It’s equally those Board members’ responsibility to ensure the full Board is made aware of what’s going on, of the benefits of integrating services and thinking about the whole person. We’ll have fail-safes in the system like performance management and targets so mental health can’t go off the agenda.”

And should managers who fail to implement the NSF be sacked?

“I think if a manager blatantly fails to deliver on an expressed intention of Government then difficult questions have to be asked. But equally where there have been trade-offs or overly complicated arrangements which may not have given us a sense of direction, we need to recognise that as being an issue. I place a lot of expectation on us having a much harder approach to performance management and within that having an expectation across a broad spectrum. We can’t have limited expectations or first and second order priorities.”

But how could he ensure that resources allocated to mental health service provision went to mental health?

“In my former Trust I always ring-fenced funds because I did not feel that if I had a problem in another service I could raid mental health – I never did it, others might well have had that temptation. If you look at the figures they have not declined, they’ve continued to grow but they will grow at a slower pace.”

And with the coming austerity…

“We’re still in a growth situation, the fact that we’ve had growth levels of 7 or 8% and now we’re down at 2% may feel like a cut but it’s still growth. The financial outlook is pretty challenging, it’s going to be a period where the growth we’ve enjoyed in the past will simply not be there. So how do we maintain priority for mental health services? Under this Minister – who has been a crusader for the NHS in Wales – mental health services have been ring-fenced which was absolutely right. We will continue that protection to ensure that whatever modest growth there might be, mental health gets its fair share.”

This interview appears in the forthcoming edition of the Mental Health Wales journal which will be made available online shortly.