The Mental Health Strategies 3 April 2001

Pauline Jarman:

I declare an interest as a member of Rhondda Cynon Taff County Borough Council, which is a social services provider.

As many as one in six adults suffer from mental health problems ranging from depression to schizophrenia at any one time, and according to the Office for National Statistics around 10 per cent of five to 15-year-olds suffer from one or more types of mental disorder. Severe social and economic discrimination attached to any kind of mental illness and mental illness services have traditionally received low political priority from Government.

Currently in Wales, mental health services for children and teenagers are in disarray, under-developed and random. Some health authorities spend seven times more than others on services. One in ten trusts have more than a six-month waiting time for a routine appointment. Almost half of all child psychotherapist posts are in the London region and few are north of Birmingham because until recently almost all training was undertaken in north London. Only 1 per cent of child psychotherapy posts is in Wales. Staff shortages are so chronic that, in some areas, there is a 40 per cent vacancy rate for psychologists.

I will comment briefly on the background to the strategies, which as we all know, were presented to the Health and Social Services Committee in draft form in January and August 2000. At that time, Plaid Cymru criticised substantially the fact that the analysis of problems was not connected to a strategic response, particularly that there was not an analysis of recruitment, retention or monetary resources. The first of the less-than-ambitious conclusions of the adult strategy was that an Assembly mental health development group should be formed to oversee the implementation of a strategy and national service framework for Wales. Secondly, that the routine information on mental health services in Wales was limited and that better information was needed to monitor the progress of this strategy, and finally, that there were many gaps in existing mental health services provision and that additional financial resources were needed if the strategy was to be fully implemented.

As far as Plaid Cymru—The Party of Wales is concerned, the child strategy was broadly welcomed as a useful starting point during consultation, but the adult strategy received some damaging criticism from patient and professional groups alike, to reaffirm what David Melding said earlier. Our criticisms are reflected broadly in our amendments. We are pleased that the Minister has indicated support for five of the seven amendments tabled by Plaid Cymru—The Party of Wales. However, the fact that the two amendments that refer to funding to drive forward a high quality mental health and illness service as a priority will not be supported by the partnership Government is a grave disappointment to us.

3:40 p.m.

In conclusion, the strategies are a useful starting point to ensure that mental health services finally receive the political priority that they deserve. However, they are not really strategies yet. There must be a thorough needs assessment of the mental health situation in Wales, as set out in amendment 10, including an in-depth look at requirements for recruitment, retention and commitment of resources. The Minister says that she will support that. However, much of the latter has been achieved through the Minister’s commitment today.

Alison Halford:

I am surprised that there are not more members of the Health and Social Services Committee present. I am not a member of it and, fortunately, to my knowledge, I have never suffered from the debilitating situation of being mentally ill.

I am pleased that the treatment of mental health is one of the National Assembly’s top priorities on health. That does the administration great credit. I know people who have schizophrenics in their families. I do not know how they live and look after individuals who suffer so much. It is a huge cross for the patient, carer and family to bear. Although 80 to 90 per cent of schizophrenic people are harmless to others, the harm that they can do themselves is much greater. I do not know how my friends have coped with having to hide the kitchen knives, being flattened by a fist when anger overflows and the dosage is not right, being pursued around the garden with the knife that was not hidden and the police having to be called, or visiting a loved one in hospital because they have flung themselves into the local river in a failed suicide attempt.

Those are nightmare scenarios familiar to many people in this country. Schizophrenia is a major mental illness. Any strategy—and Jane is on the right course—must ensure that a strong national service framework provides guidance and information to assist practitioners in their support and service delivery to the health sufferers and their families. That means a realistic number of social workers properly trained and recruited. It also means appropriate and efficacious medication, not driven primarily by cost considerations, but to ensure that the treatment hits the spot. The right medication should not be refused in favour of cheaper, but less effective, treatments.

The Minister touched on choice, which must be practical, for clients and carers, to help the recovery from the acute stage of the illness, but also to help readjustment back into society. Another problem with schizophrenia is the failure of bureaucracy to ensure that benefits and other support are given constantly. Therefore, the individual hits the nightmare of constantly having to prove the need. That applies in terms of housing, occupational and educational considerations. That puts even more stress on the ill person.

The treatment process should move the client towards independent living and finding a niche for that person in society. Everyone, however ill, has a niche somewhere. The cruellest aspect of this disability is its invisibility. As a society, we have less difficulty in coping with physical disability, but we all feel stressed and worried about mental disabilities. Jane Hutt is proposing, in consultation with the experts, something of which we should be proud in this principality. I will take a delight in sharing what is going to happen, or what is proposed, with my friends with mental needs. They should feel much more reassured that they have a happier future in front of them.

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Helen Mary Jones:

Some of the points that I wished to make have already been covered, but I will make some brief remarks about some of the mental health needs that perhaps these draft strategies do not tackle fully.

We need to promote mental health, as I think the Minister has agreed, and not just treat mental illness. This is not a job for the health services alone. For example, successfully tackling bullying in schools could contribute hugely to promoting children’s mental health. We need to look beyond the link with social services and into the whole range of public services that we require. We need to consider economic development, for example, in terms of promoting the ability of people who have had mental illness to get back into the workforce. We desperately need treatment for children and young people in Wales who suffer mental illness, as Pauline Jarman rightly said. With a view to prevention, it is equally important to use the personal and social education framework to promote self-esteem and respect for others.

It is equally vital that the elements of discrimination in the system are addressed, and the Minister has touched briefly on some of these. We cannot continue to accept a situation where, for example, black men in Britain are 10 times more likely to be diagnosed with schizophrenia than white patients presenting with mental illness, where women who are physically ill or are perhaps being domestically abused get treated for depression rather than having their real physical illness or social circumstances dealt with, and where it is still impossible for Welsh speaking patients and patients who wish to speak minority languages to get treatment in their choice language. There are huge implications in terms of training and resources if this kind of discrimination is to be ended, but unless it is the strategy will undoubtedly fail.

One area that the draft strategies fail dismally to address is eating disorders. We have no specialist services in Wales, either community or hospital based for either adults or children. The strategies have little to say on this, yet eating disorders are highly dangerous and often fatal diseases. They are not, as they are sometimes seen, fads indulged in by silly, self-absorbed young girls. I would argue that the lack of services for treating eating disorders arises from gender discrimination. Eating disorder is seen as a women’s problem that is not as serious as, for example, schizophrenia which is often seen as an illness suffered by men.

I hope that the Minister will assure us today that this crucial gap in the strategies will be filled, and that effective community-based and hospital services will be developed across Wales. Vitally, I hope that she will assure us that an effective link will be made between adolescent and adult services in all areas of mental health treatment, to ensure continuity of care for any young patients who need it.

We need to consider the legislative framework within which these strategies may have to be enacted. If we end up, for example, with compulsory treatment orders, we must have the services in place to enable that treatment to be delivered. We must also seek a reciprocal right to treatment and, as the National Schizophrenia Fellowship in Wales has pointed out, the right to a second opinion. I trust that the Minister will agree.

It is clear that the Assembly gives a high priority to developing effective mental health services. That is welcome. I know from talking to constituents who suffer from mental illness that they see a transformation in the priority given to mental health services since the establishment of the Assembly. We have that priority in place, but the Government must act urgently to put the policies in place to deliver on that priority.

Kirsty Williams:

I welcome the considerable time spent in Plenary this afternoon on a subject that in the past has been pushed to one side, stigmatised or ignored. By allocating significant time in Plenary and in the Health and Social Services Committee, we begin to recognise the true extent of mental distress and illness in Wales and reflect the Assembly’s determination to put in place services that respond to the needs of those sufferers. It is also opportune for the Plenary to discuss this so that the concerns of all Assembly Members and not just those on the Health and Social Services Committee—who, I assure Alison, are well-represented here this afternoon—can add their views as we turn this draft strategy into a final one that will deliver for the people of Wales. We need to consider this draft strategy as a starting point.

3:50 p.m.

There is much to commend in it, but there is still much work to be done following the huge number of consultation responses that have been received, and the recalling of the advisory group. I welcome the Minister’s moves, in that vein, to recall that group of people to advise on redrafting the strategy. There are still several points in the adult strategy that need to be strengthened. Firstly, we need to break down the silos of our thinking in the Assembly and truly link these strategies to the plethora of other strategies that we have produced in the past. It seems sometimes that all these strategies stand alone and do little to link up with each other. I am thinking about Better Homes for People in Wales, to which a great deal of time has been given to discuss it in this Chamber, as well as Communities First, and European structural funds. All these strategies must link together, because they all have a part to play in delivering better mental health for the people of Wales.

We have already heard this afternoon about the revolutionary mental illness strategy of 1989. That was welcomed by many people and set Wales apart in driving the agenda forward. However, the draft strategy ignores the successes and outcomes of that initial strategy. This omission offers no baseline upon which to take things forward in our new strategy. Without an understanding and recognition of current levels of service provision, we cannot hope to improve. The baseline in Wales is not particularly good, especially when compared to baseline services in England and Scotland. There is a great deal to be done in Wales, especially in the field of intermediate and flexible care.

The voices of carers and service users are key. I echo what David has said that there is still a feeling that what we have in this strategy is a model that has a propensity to fit people to services, rather than the flexibility of service provision being fitted to the specific needs of service users and individuals. There has also been criticism that the strategy is too medical in its outlook. The strategy has begun to shift away from a medical model. However, it does not adequately embrace a holistic approach to treatment options or the wider agenda of housing, employment, safer communities and leisure facilities, all of which have a vital role to play, and which we can combine together to keep people well and supported, and to prevent crises from occurring.

Resources are key. I welcome the capital expenditure to date, which has seen a great deal of improvement in some of the poorest of estates. I have often talked in this Chamber about the poverty of the NHS estate. It seems that mental health provision is in the worst particular areas of NHS estate. I welcome the expenditure that has already come forward. However, it was badly needed, and it cannot be seen as the be-all and end-all to improving the situation. The Health and Social Services Committee has clearly stated from its inception that mental health and its funding is a priority, and will continue to be so. Without resources, any strategy, whether it be too aspirational or too target ridden, medical or social, will fail. I also make a plea to ensure that resources are not jealously guarded by the recipients of funding. People must work in partnership, budgets must be pooled, and voluntary organisations must be utilised.

Finally, I feel guilty that most of us this afternoon, with the exception of Gwenda, have spoken at great length regarding the adult strategy, perhaps to the detriment of the child and adolescent strategy. That is a testament to that strategy’s success in terms of the consultation. It has been widely welcomed. There is a real issue of how we provide information to young people and children regarding mental health illnesses and the services that are available to them. This is particularly acute in rural areas, which needs to be addressed in the adult and child strategies.

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Brian Gibbons:

This strategy represents a clear evolutionary step forward in the delivery of mental health services in Wales. As others have said, it has been about 12 years since the last major strategy. The essence of that strategy was to move patient care from hospitals into the community. It needs to be acknowledged that the fabric and ethos of those hospitals made them a highly undesirable place for anybody to be. Any move out of those hospitals would have been welcome in itself. However, we must acknowledge that the shift from hospital to community was not a perfect process and it did not happen without problems. Nevertheless, in the following 10 or 11 years, we have, by and large, made a fairly successful transition from hospital-based care into more community-based care. The shift from hospital to community care is not about doing the same thing in a different place; it is very much about the philosophy that underpins the type of care given. When patients in previous decades stayed in hospitals, they were isolated from their homes and families, and placed in a highly subservient and dependent position vis-à-vis their carers. Big institutions were very much detention institutions rather than an asylum and care institution or a therapeutic milieu. The shift from hospital to community, therefore, also represented an enhanced model of care for the patient.

It is now an appropriate time for us to take stock of what has been achieved and how we can move forward. No matter what people have said about this strategy, it has a number of key points that deserve to be acknowledged as representing a major step forward. The strategy clearly dictates that we should tackle the stigma associated with mental illness, promote equal opportunities for people with mental illness and combat social exclusion that occurs as a result of mental illness. It is about promoting the independence of patients and their greater involvement, along with their carers, in the formulation of individual care plans and the wider healthcare strategy.

The strategy also involves providing care and support for living, not just narrow medical care. By care and support we mean that we must take a holistic view of the needs of people who suffer from mental illness—their housing, financial and learning needs and employment opportunities, and so on. This strategy is not just about delivering tablets and injections, it looks at people in a holistic way and promotes independent living. It is a more humane—and humanistic—approach, which promotes the wellbeing and respects the integrity of the individual suffering from mental illness. However, it also does more than that. All the evidence shows that this more humane and humanistic approach also delivers a better outcome for patients, their friends and families and the community at large.


We must also acknowledge that mental illness is not an act of God, nor an abhorrent consequence of genetic mutation nor a metabolic abnormality. We know that social circumstances, such as poverty, unemployment, gender and racial stereotypes, social exclusion, the availability of drugs and alcohol, housing conditions and family breakdown, all contribute to the incidence and prevalence of mental illness. Unless we tackle this broader agenda, we will not be able to tackle the fundamental problems that this strategy sets out to address, namely to improve the wellbeing of individuals with mental illness and to promote the mental wellbeing of communities at large.

The Minister for Health and Social Services (Jane Hutt):


I have been heartened by the quality and thoughtfulness of the contributions to this debate. Our intention to support five of Plaid Cymru’s seven amendments to this motion demonstrates the Assembly’s joint commitment to improving mental health services in Wales.

You were right to say, Dai, that primary care is at the forefront of contact for users of the services. There are inequities, and that is why we need a strategy. The national service framework will provide us with the milestones, targets and the way forward that we must identify. The integration of psychotherapeutic and counselling services are vital, but many are run on a shoestring and must be rescued constantly, or are lost, because they are not seen as part of the main frame of our services. As has been said, this is a journey that we are embarking upon.

4:00 p.m.

Vital links will and must be made. I mentioned some of the links that you highlighted from all the agendas in today’s debate, such as housing, poverty, education and the way that we address issues of poverty that often result in mental ill-health. The role of pharmacists are important, Geraint. They are embraced in our multi-disciplinary local health group teams and they will be brought into the strategy and the national service framework. You are right to talk about the importance of drugs, Alison, and how they have changed dramatically. We must not have postcode prescribing in Wales in relation to the needs and access to important new drugs.

We talked about community and health and well-being services, Brian. I want to explore with officials the possibility of introducing the care programme approach in Wales. That is developing in England and we can learn from that national service framework that has already moved on. There is strong support for that approach and it is a good basis for underpinning our services. However, as you say, Brian, shifting from hospital to community care must be underpinned by a new philosophy that we move away from the dependence on our institutions. They are frequently detention institutions with appalling conditions that we inherited and still witness in Wales. We must radically change our approach.

Dai, Pauline and Alison talked powerfully about the workforce. You know that we are undertaking a social care workforce review and a NHS workforce planning review. We must consider all the issues of stress for our mental health workforce and look at retention and recruitment. I remember feeling proud when I was a member of a community and mental health trust when we were able to attract two consultant child psychiatrists to a job share. That was about five years ago. It seemed revolutionary at the time. It should not have been, but it enabled us to bring two people into Wales. The implementation groups that we are setting up must take all of that forward.

David mentioned Wales as a beacon. That is what we aspire to in this Assembly. That is what we can achieve. I am grateful for your positive response. It is vital that we get it right and give ourselves time and that is why I listened carefully. When members of the Health and Social Services Committee work together, they are a powerful force. The Children’s Commissioner’s appointment proved that and we should work together to take mental health services forward. You are right to draw our attention to the concerns about the adult mental health strategy. I was pleased that we heard from Bridgend Social Services and Bro Taf Health Authority at a briefing this morning. We are working with them to address some of their concerns. We had an advisory group and it is important for Members to know that it was an advisory group to the Assembly. We do not have an Assembly strategy yet. We must ensure that an Assembly strategy that we can adopt and support comes out of this consultation. The implementation group must have wider representation in terms of its membership, as you described.

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