Senedd Cymru | Welsh Parliament
Y Pwyllgor Iechyd a Gofal Cymdeithasol | Health and Social Care Committee
Bil Iechyd a Gofal Cymdeithasol (Cymru) | Health and Social Care (Wales) Bill
Ymateb gan Royal College of Psychiatrists Wales, | Evidence from Royal College of Psychiatrists Wales,
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RCPsych Wales welcomes the general principles of the Health and Social Care (Wales) Bill.
Research demonstrates that children in care are more likely than their non-looked after peers to have a mental health issue and lower levels of wellbeing (NSPCC 2024, pp. 13-15). Children in care are a vulnerable group, and it’s vital that every effort is made to mitigate the chances of their mental health worsening through their experience in care. Overall, we agree that private profit should be eliminated from the care of looked-after children. However, we have some concerns around the logistics of the transitions involved. These are commented on later in this response.
We welcome the proposed introduction of direct payments for Continuing NHS Healthcare as a means of giving individuals (and suitable persons) greater independence, voice and control over the way in which their health and social care needs are met. The evaluation of the Personal Health Budget pilot programme in England found that PHBs had a significant positive impact on care-related quality of life, psychological well-being and subjective well-being (Forder et al. 2012). Again, however, we have some concerns around the implementation of these proposals, which are detailed later in this response.
Forder, J., Jones, K., Glendinning, C., Caiels, J., Welch, E., Baxter, K., Davidson, J., Windle, K., Irvine, A. L., King, D., and Dolan, P. 2012. Evaluation of the Personal Health Budget Pilot Programme. Available at: https://kclpure.kcl.ac.uk/portal/en/publications/evaluation-of-the-personal-health-budget-pilot-programme
NSPCC, 2024. Statistics Briefing: Children in Care. Available at: https://learning.nspcc.org.uk/media/4j5nsulc/statistics-briefing-children-in-care.pdf
Yes
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RCPsych Wales considers that the Bill is necessary because its objectives cannot be achieved through the existing statutory framework. A new piece of primary legislation is therefore required.
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As stated previously, RCPsych Wales agrees that private profit should be eliminated from the care of looked-after children. However, we have some concerns around the logistics of the transitions involved.
Firstly, it is imperative that eliminating profit isn’t pursued to the detriment of the particular needs and vulnerabilities of children requiring secure accommodation. According to Social Care Wales (2019), out of 38 secure placements made between 1 April 2016 and 31 March 2018, only 13 were in Wales, with 23 in England and 2 in Scotland. This lack of secure beds in Wales was found to cause uncertainty and anxiety for young people and led some social services departments to create alternative secure accommodation in unregistered settings, which is unacceptable. We therefore welcome section 12 of the Bill which will require local authorities to report to the Welsh Ministers on how they have, or are expected to, increase the amount of secure accommodation available. However, it is currently unclear what consequences local authorities will face if they fail to increase such provision.
Secondly, we welcome the fact that, wherever possible, the Welsh Government wants to see placements provided for children and young people that will preserve their links with their local neighbourhoods and communities and allow as much continuity in their lives as possible. However, it is inevitable that out-of-area placements may still occur in some cases.
Local authorities and CAMHS services need to reflect the significant mental health needs of many children in care in their strategic planning, particularly around transitions. Moving children away from their local communities may result in disruptions in the continuity of their healthcare and may isolate them from their familiar means of support e.g., social workers, teachers, and CAMHS professionals. This will negatively impact their mental health. For example, research in England has identified the need to improve the continuity of social workers and carers to increase the emotional well-being of young people in care and to allow them to develop trusted relationships with key adults (Hiller et al. 2021). Furthermore, moving children away from Welsh-speaking communities into English-speaking communities, and vice versa, may present communication barriers, leaving them feeling ostracised and vulnerable to poor mental health.
In order to ensure the continuity of looked-after children’s healthcare, we consider that local authority officers responsible for looked-after children’s services should:
1. Agree multi-agency action to meet looked-after children’s health needs;
2. Ensure looked-after children are always registered with GPs near to where they’re living;
3. Ensure that when children are registered with a new GP, the transfer of GP-held clinical records is fast tracked; and
4. Ensure that a child is never refused a mental health service (or other services) on the grounds of their placement being short-term or unplanned.
Hiller, R. M., Halligan, S. L., Meiser-Stedman, R., Elliott, E., Rutter-Eley, E., and Hutt, T. 2021. Coping and support-seeking in out-of-home care: a qualitative study of the views of young people in care in England. BMJ Open, 11(2). Available at: https://doi.org/10.1136/bmjopen-2020-038461
Social Care Wales, 2019. The experiences and outcomes of children and young people from Wales receiving Secure Accommodation Orders. A report for Social Care Wales written by CASCADE, Cardiff University. Available at: https://socialcare.wales/cms-assets/documents/The-experiences-and-outcomes-of-children-and-young-people-from-Wales-receiving-Secure-Accommodation-Orders.pdf
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RCPsych Wales agrees with the Welsh Government that the Bill represents a sensible opportunity through which to update and align the legislative framework for social care with current practice.
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RCPsych Wales welcomes the proposed introduction of direct payments for Continuing NHS Healthcare as a means of giving individuals (and suitable persons) greater independence, voice and control over the way in which their health and social care needs are met.
However, significant details remain to be determined and fleshed out in subsequent Regulations, not least of all how the proposed scheme will operate. Full engagement with clinicians, including psychiatrists, will therefore be crucial to ensure the success of the proposals, tackle unnecessary bureaucracy and overcome any lack of information among health professionals.
Ahead of the introduction of Personal Health Budgets in England, concerns were expressed about their potential to create additional bureaucracy for the NHS (Slasberg et al. 2014). However, personalisation need not result in greater bureaucracy for psychiatrists, as non-clinical staff can support individuals to develop a care and support plan, seeking input from psychiatrists rather than psychiatrists taking a lead (Alakeson et al. 2016, p. 37). Proper consideration must therefore be given to investing in the necessary infrastructure to support the effective delivery of direct payments for healthcare, including resources (human and financial) and guidance material.
The distinction between health care and social care is often unclear clear. Many individuals with mental health problems receive services from both the NHS and social care and the lack of integration between the two systems can be a cause for frustration. It is essential that people who come under the Mental Health Act 1983 receive direct payments to meet the full breadth of their after-care needs.
RCPsych Wales is committed to developing models of integration and to working with partners to overcome the barriers to integration in order to promote greater recovery for individuals with mental health problems. We believe that everyone who chooses to access Direct Payments should have the right to an integrated assessment across the NHS and social care, an integrated care and support plan, and an integrated review, regardless of how they choose to hold the money.
Alakeson, V., Boardman, J., Boland, B., Crimlisk, H., Harrison, C., Iliffe, S., Khan, M., O’Shea, R., and Patterson, J. Debating Personal Health Budgets. BJPsych Bulletin, 40(1), pp. 34-37. Available at: https://doi.org/10.1192%2Fpb.bp.114.048827
Slasberg, C., Watson, N., Beresford, P., and Schofield, P. 2014. Personalization of health care in England: have the wrong lessons been drawn from the personal health budget pilots? Journal of Health Services Research & Policy, 19(3), pp. 183-188. Available at: https://doi.org/10.1177/1355819614527577
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RCPsych Wales believes that, in the interests of good law-making and complete transparency, Bills should be published in draft ahead of their introduction into the Senedd. This echoes the view of a previous Senedd Committee that there should be a presumption in favour of publishing draft Bills (National Assembly for Wales, 2015). Although a public consultation on the main policy proposals of the Health and Social Care (Wales) Bill was held by the Welsh Government in 2022, a number of proposed miscellaneous amendments to the Social Services and Well-being (Wales) Act 2014 have not been subject to prior consultation.
National Assembly for Wales, 2015. Constitutional and Legislative Affairs Committee Report on Making Laws in Wales. Available at: https://senedd.wales/laid%20documents/cr-ld10379/cr-ld10379-e.pdf
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