Memorandum submitted by Hafal (CBPS 44)

1. Background and Introduction to Hafal

1.1 Hafal is the principal organisation in Wales working with people recovering from severe mental illness, their families and carers. Every day our 150 staff and volunteers provide help to nearly 1000 people affected by severe mental illness across all the 22 counties of Wales.

1.2 Hafal is run by the people it supports: people with severe mental illness and their families and carers. The charity is founded on the belief that people who have direct experience of mental illness know best how services can be delivered. In practice this means that at every project our clients meet to make decisions about how that service will move forward and the charity itself is led by its 1000 members, almost all of them people with severe mental illness and their carers, and managed by a board of elected Trustees, most of whom have either had severe mental illness themselves or are the carers of a person with a mental illness.

1.3 Hafal has been actively involved in several strategic reviews and forums concerned with mental illness, and which also relate directly to the theme of cross- border public services. Hafal staff, and service user consultants with extensive experience have been key contributors to these. They include the following: i) the Assembly Government's Implementation Advisory Group, concerned with the implementation of the National Service Framework and mental health issues generally, ii) the Welsh Assembly Government Strategic Review of Secure Services in Wales, iii) the Welsh Assembly Government Review of Mental Health Services, iv) the Welsh Assembly Government Reducing Re-offending Task Group. Further information and associated publications produced by Hafal are also available on our website: www.hafal.org

2. Hafal's key points and concerns in respect of cross-border public services relating to mental illness:

2.1 Acute mental health services: Hafal has no doctrinaire position against the right kind of cross-border provision and understands the context for and supports appropriate cross border arrangements especially in respect of acute mental health services, where these work efficiently and effectively in the interests of the individual service user: however, in practice such arrangements are by no means always in the interests of service users. In some areas Welsh patients are obliged to access acute mental health services in England, for example, people living in the Welshpool, Montgomery, and Newtown areas of Powys access acute services in Shrewsbury. This arrangement is long-established, and the co-ordination and continuity of care between the two areas appear to work adequately with, for example, staff from Powys regularly attending ward rounds in Shrewsbury. In the recent past, Hafal was commissioned to produce Welsh language materials for Welsh-speaking patients accessing the Trust service in Shrewsbury. In the absence of accessible alternative provision, this arrangement appears to work adequately, and is supported by the Central Wales - West Midlands Cross Border Collaboration Agreement. In North-East Wales patients from Flintshire have previously accessed acute services in Chester but disinvestment from Chester (which is currently being re-invested in new and additional provision in Wrexham) will mean Flintshire residents no longer accessing Chester services. While this investment means improvement in care in Wales, we are told that the Wrexham option does not provide easier access to some Flintshire residents.

2.2 Specialist low secure mental health services: Hafal supports Local Health Boards' efforts in actively seeking the repatriation of individuals and investment from low secure provision in England back into Wales, ensuring family and other local social / support networks is key to individuals' progress to recovery. There is a paucity of low secure provision available to patients in Wales resulting in many people being accommodated in England at some distance from family and other social support networks. It is clear from the experiences conveyed to us by our service users and carers that more low secure provision should be made available in Wales.

2.3 Specialist medium and high secure mental health services: Hafal appreciates issues of proportionality in respect of the number and location of specialist medium and high secure mental health services. However, we strongly argue that there is scope for significant change and improvement in respect of: i) more sensitive placement of Welsh individuals in existing provision based both on location and level of need and risk, and ii) the need for some new and additional provision in Wales. There are only three medium secure units in Wales, and no high secure provision. These places are commissioned and funded by Health Commission Wales. As part of the Strategic Review of Secure Mental Health Services in Wales Hafal undertook a survey of Welsh patients in high secure provision in England which highlighted (among other things), a high level of homesickness and issues resulting from the lack of Welsh language facilities. This is the result of being placed so far away from home making it difficult to sustain family and other social support relationships - in one case, an individual reported not having seen their family for several years because of the distance and cost of transport. In addition, the work called into question whether individuals were suitably placed at the right level of provision in the context of the level of need presented and risk posed. Hafal believes a large number of the patients currently in high secure hospitals in England could be placed in specialised medium secure (or indeed less intensive) provision. The Fallon Enquiry Report (1999) recommended, among other things, that high secure provision should be developed as smaller units across the UK. We also believe that in the future a high secure unit could and should be established in Wales along the lines of this recommendation.

2.4 Criminal Justice System: Hafal is concerned by the need to significantly improve the interface between the criminal justice system and mental health services for the benefit of individuals with serious mental illness who commit offences - in particular: i) access to appropriate mental health services and secure provision for individuals with serious mental illness in custody, ii) the need to divert individuals with serious mental illness away from the criminal justice system (at the point of arrest / sentencing), and iii) the need to ensure continuity and co-ordination of care on release from prison (especially difficult for women with mental illness in custody in England). There are four prisons in Wales, all located in south Wales, all of which cater for men only. Welsh women are largely held in custody in HMP Eastwood Park in Gloucestershire, and HMP Styal in Cheshire. Mental illness is a significant issue for many prisoners and Hafal is concerned that significant improvement is required in the criminal justice pathway to divert those with mental illness away from the criminal justice system and into appropriate mental health services at the point of arrest and / or sentencing. Furthermore, once in the criminal justice system, those with serious mental illness should be able to access / be transferred to appropriate mental health services at the point that they are needed / and required. Finally, significant improvements are required in the continuity and co-ordination of care on discharge from prison to ensure a seamless transition back into the community.

2.4 Commissioning: Hafal is concerned by the number and configuration of commissioning bodies responsible for funding mental health services, which is exacerbated by financial constraints and lack of locally accessible provision resulting in perverse incentives which delay transfers to appropriate provision when individuals' circumstances change. With 22 Local Health Boards, 22 local authorities and Health Commission Wales all responsible for commissioning mental health services and funding individual placements, there is no doubt that the excessive bureaucracy of internal commissioning arrangements in Wales has led to over-use of services outside Wales. Local Health Boards specifically commission Trust services, and low secure provision delivered by Trusts and the independent sector. Health Commission Wales specifically fund medium and high secure services delivered by Trusts and the independent sector. Feedback from our client group and the work undertaken with criminal justice agencies clearly illustrate the difficulties experienced in the communication and co-ordination of activity between Local Health Boards and Health Commission Wales in respect of the transfer of individuals between low and medium secure provision, and between prisons and Health Commission Wales in respect of transfers out of prison to appropriate secure provision.

25 March 2008