Cynulliad Cenedlaethol Cymru

National Assembly for Wales


Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee


Ymchwiliad i iechyd meddwl yng nghyd-destun plismona a dalfa’r heddlu

Inquiry into Mental health in Policing and Police Custody




Ymateb gan Fwrdd Iechyd Prifysgol Aneurin Bevan

Evidence from Aneurin Bevan University Health Board



Aneurin Bevan University Health Board Response to the Health, Social Care and Sport Committee Inquiry into Mental Health in Policing and Police Custody


Executive Summary


This submission is made of behalf of Aneurin Bevan University Health Board and aims to provide relevant information in relation to the inquiry into mental health in policing and police custody.

Key points to note from this submission include;

·         Crucial to this is that we have a shared language and understanding across agencies regarding ‘mental health’.

·         The majority of individuals do not require access to specialist mental health services, but agencies must work in partnership with communities to implement care and support that promotes emotional and psychological well-being for the entire population.

·         Within Gwent a multi-agency approach is being taken to transform support for those with a mental health need who present in crisis. A number of initiatives within the programme aim to prevent people experiencing a mental health crisis having to be taken into police custody and these are described in the paper.

·         In order to ensure individuals are conveyed to hospital in a manner that protects the individuals’ privacy and dignity, the Gwent region has invested in a 24 hour conveyance service.

·         Within Gwent the number of people arrested under section 136 of the Mental Health Act 1983, where police custody is being used as the first place of safety, is 17 people since the implementation of the Police and Crime Act in December 2017.


·         Continued challenges within the region include the management of violent and intoxicated people in the designated health based place of safety.

·         We believe that there are appropriate joint working and governance arrangements in place in order to implement the Mental Health Crisis Care Concordat.

Defining Mental Health Need and the Wider Context of Well-Being

In order to set the context for the current response, we believe it is important to recognise some of the different terminology used in agencies. Many people find it difficult to manage their emotions and engage in behaviours that areoften viewed as chaotic or engage in behaviours that may cause harm to themselves such as self-harm or substance misuse. Many of these individuals will have experienced Adverse Childhood Experiences and have been exposed to wider socioeconomic determinants of poor emotional well-being such as poverty, lack of access to meaningful occupational/learning opportunities, poor housing or loneliness. The majority of these individuals would not have a formal mental health diagnosis and do not access support from specialist secondary care mental health services. Whilst some statutory agencies would describe individuals who present in this way as having a “mental health need” it is vital that we collectively acknowledge the factors that contribute to the individuals’ presentation and statutory and third sector agencies work in partnership with communities, to implement seamless care and support that improves overall population well-being building on the existing assets within communities.

A key initiative being taken forward within Gwent to promote the physical and psychological well-being of the population is the implementation of place based Integrated Well-being Networks (IWBN). The diagram below provides a summary of the key elements of an IWBN and the Regional Partnership Board has recently had Transformational Funding approved from the Welsh Government to support the further development of IWBNs.


Text Box:

“Whole Person, Whole System” Acute and Crisis Model


Within the Gwent region, statutory agencies and third sector organisations are working together to transform support and service provision for those with a mental health need who present in crisis and also support for their carers. This programme of work focusing on a “Whole Person, Whole System” approach is overseen by the Mental Health and Learning Disability Strategic Partnership which in turn reports to the Gwent Regional Partnership Board. Agencies represented within the programme include the Health Board, the five Local Authorities, Gwent Police, Housing and the third sector.


The implementation of the Mental Health Crisis Care Concordat is one of the key drivers for the above programme alongside service user and carer feedback, stakeholder feedback across agencies, the need to develop sustainable models of support and broader Welsh Government strategic context such as the Social Services and Well-being Act, The Well-being of Future Generations Act and ‘A Healthier Future’.


One of the key outcomes from a multi-agency Action Learning set that was jointly facilitated with the International Mental Health Collaborating Network in 2016 was the development of a proposed Gwent “Whole Person, Whole

System” Acute and Crisis model and over the last two years partners have been working together to implement the model. It is important to emphasise that this model needs to be in addition to the wider population wide Integrated Well-being Networks described above that promotes emotional and psychological well-being for the entire population. The key elements of the model are described below in Figure One.

Text Box:

Figure One: Gwent “Whole Person, Whole System” Acute and Crisis model

It is envisaged that in order to fully implement the model it will take up to five years and the current document now provides a summary of some of the initiatives that have either been implemented or are in progress that will have the greatest impact on preventing people with a mental health difficulty experiencing a crisis being taken into police custody.


Re-designing Community Based Crisis Assessment Services – there are currently three Crisis Assessment and Home Treatment Teams in Gwent providing an assessment service until 10 pm at night. During 2018, the Health Board undertook a small test of change to separate the assessment function from the home treatment function with the aim of improving both elements of the service provision. In April 2019 a more extensive pilot will commence that will aim to offer a 24 hour assessment service from a single team, with three locality teams available to provide intensive home treatment. Additional investment from Welsh Government has facilitated the addition of an increase of multi-disciplinary practitioners.


Gwent Police Mental Health Triage Team - In September 2016, an 18- month pilot commenced to enable police officers to access timely specialist mental health advice whilst having face to face contact with a member of the public by having a mental health practitioner within the Police Force Control Room. Following a successful initial evaluation the service has now been expanded and since February 2018 a team of 6.0 wte staff having been providing a service 8am – 2am 7 days a week. In addition to providing support to manage “live incidents” an information sharing protocol has been developed to enable the practitioner to access health and social care information that can guide decision making to ensure appropriate support can be offered. This service is currently being evaluated by Swansea University.


Timely Access to Mental Health Care within Primary Care Settings - Many individuals with mental health need experience a crisis will initially present to primary care. The Health Board is working with Primary Care colleagues to pilot urgent access to mental health support for individuals who present to in hours primary care within 5 surgeries across the ABUHB region. A further pilot is also being undertaken to enable practitioners within the Out of Hours primary Care service to access timely specialist mental health advice.


Sanctuary Provision – the provision of a Sanctuary aims to support people in a self-defined or early stage of mental health crisis. It provides a safe place where people can go to talk to others and access self-help resources available to help people to manage the things that are causing them distress and worry. A work stream led by third sector organisations has been established to review the need for sanctuary provision with Gwent and is currently developing a proposal to seek funding to support a pilot of sanctuary provision in three different areas across Gwent.

Single Point of Contact and Access to Support – Work is starting to commence to explore the potential of developing a single point of contact within Gwent for individuals, carers or professionals who wish to seek advice and support at any point in the day or night 7 days a week. It is envisaged that the service will provide an opportunity for the individual to discuss their difficulties and agree and facilitate access to what support the individual may require.


Conveyance of individuals to hospital in a manner most likely to protect their dignity and privacy


There are a range of circumstances where people experiencing mental health crisis need to be conveyed from the community to hospital for assessment. In addition there are circumstances where patients need to be conveyed between hospitals, from and between places of safety, returned to a unit if they are absent without leave, or are subject to a Community Treatment order and are being recalled from the community. Many of these people will be detained under the Mental Health Act (MHA) 1983 amended 2007 and many will be voluntarily coming to hospital. The most common situations requiring conveyance are:


·      taking a person to hospital who has been assessed and detained under the mental health act or agreed to a voluntary admission following the assessment

·      taking a person to or between places of safety under S136 or S135 so an assessment can take place

·      transferring a patient from one hospital to another so they can obtain appropriate assessment and treatment

·      returning detained patients to hospital who are absent without leave

·      returning people subject to Guardianship to the place they are required to reside

·      taking Supervised Community Treatment (SCT) patients or conditionally discharged patients to hospital on recall

·      transferring patients to and from court


A number of individuals and agencies have a key role to play to coordinate conveyance including the Approved Mental Health Professionals, Responsible Clinicians, hospital Managers, Ambulance staff and the Police. Those responsible for taking patients from one place to another must ensure the most humane and least restrictive method of conveying the patient is used, consistent with ensuring no harm comes to the patient or to others. There are a range of factors to be taken into account when deciding the most appropriate method for conveyance including:

·         the guiding principles in Chapter 1 of the MHA Code of Practice for Wales (CoPfW)

·         the wishes and views of the patient, including any relevant care plan or advanced statement

·         the nature of the mental disorder and its current course

·         any physical disability that the patient has

·         the impact that any particular transport will have on the patient’s relationship with the community to which he or she will return

·         the availability of various transport options

·         the distance to be travelled

·         the patient’s need for support and supervision during travel

·         the availability of transport to return to home/office base for those who accompany the patient (including whether the professionals will need to return to their own vehicles)

·         The risk of the patient absconding and the risk of harm in the event of the patient absconding before admission to hospital. (Chapter 9 MHA CoPfW 9.5)


In order to ensure timely access to transport that protects an individual’s privacy and dignity, since April 2017, the Gwent region has funded a 24 hour conveyance response via the use of an ABUHB vehicle based at one of the acute mental health in-patient units. The 5.5wte staff who drive these vehicles are based on the inpatient psychiatric ward as an addition to the establishment in order to respond in a timely manner to requests for conveyance. At present the model requires that the person experiencing a mental health crisis must be escorted by a suitably competent person. This may be the AMHP, Health Professional and/or Police, dependent on the circumstances of the situation.

For those whose presentation and risk assessment indicate they require a more specialist skilled paramedic response this continues to be accessed via WAST and only when the risk of significant harm to self or others necessitates the use of a police vehicle in order to manage the identified risk is a police vehicle used.


The benefits of the above provision include;


·      Improved experience for service users in crisis

·      Individuals being seen in the right place at the right time in order to receive care and /or assessment

·      Reduced waiting time for transportation thereby freeing up key resources to respond to other demands in the wider system

·      Safety benefits for those professionals involved as the response would be timely and reduce the likelihood of escalation

·      Reduction in demand on ambulance usage and freeing up of emergency vehicles

·      Assists in releasing police resources

The number of people arrested under section 136 of the Mental Health Act 1983 and the extent to which police custody is being used as a place of safety for people in mental health crisis

Partners agencies within Gwent are fully committed to ensuring that police custody is only used as a place of safety for people experiencing a mental health difficulty when there are exceptional circumstances.


Within the Gwent Police area, partnership agencies have jointly agreed that the regional place of safety for the purpose of Section 136 of the Act is Adferiad Ward at St Cadoc’s Hospital. The provision is a single suite outside the ward area for the purposes of assessment. It is currently supported by nursing staff from Adferiad Ward.


The graph below provides information relating to the use of Section 136 both prior to and post the implementation of the Police and Crime Act in December 2017).






Total s136s for the period


Total s136s going first to Custody


How many Custody were Under 18s


Total s136s going direct to Hospital PoS


How many Hospital were Under 18s

1 Dec 16 -

30 Nov 17











1 Dec 17 -

30 Nov 18











1 Dec 18 -

28 Feb 19











Graph One: Gwent Section 136 Detentions

Of the 17 people who were first detained in police custody all of these people were subsequently transferred to St Cadoc’s Hospital for assessment. Prior to December 2017, it would have been the case that some of these people would have been assessed by a Doctor and an Approved Mental Health Practitioner (AMHP) in police custody.

The graph below shows the reasons why police custody was used in the first instance and the length of time before arrival at a hospital based place of safety.




Reason, if Police PoS Used First

Time until arrival at Hospital



At Police Station when Arrested under S136

1 hour 25 mins


Arrested for Substantive Offence

6 hours


Violent behaviour

1 hour 30 mins


Arrested for Substantive Offence

20 mins


Arrested for Substantive Offence

2 hours 55 mins


Arrested for Substantive Offence

20 mins


Investigating missing person

1 hour


Arrested for Substantive Offence

25 mins


Arrested for Substantive Offence

1 hour 15 mins


Ambulance took too long

1 hour 45 mins


Arrested for Substantive Offence

30 mins


Violent behaviour

1 hour


Arrested for Substantive Offence

1 hour


Arrested for Substantive Offence

15 mins


Violent behaviour

6 hours 35 mins


Arrested for Substantive Offence

3 hours 55 mins


Located behind Police Station

45 mins

Graph Two: Number of People arrested under Section 136 with Police Custody being used as the first Place of Safety


In the majority of cases the use of the police station as the first place of safety it is because the individual has also been arrested for a criminal offence, is violent or is in close proximity to the police station at the time of detention under Section 136.


There are two occasions of note: the conveyancing delay attributed to ambulance delay and the use of police custody due to the investigation of a missing person.


In the fifteen months since the implementation of the Police and Crime Act (2017) there have been 338 detention under Section 136 of the Mental Health Act (1983). On average the single place of safety at St Cadoc’s Hospital is used on 22 occasions each month, which suggests that the provision of a single suite is sufficient to meet this demand. Due to the unplanned nature of the use of Section 136, there are times when there is concurrent use of the suite. Concurrent use is defined as a Section 136 that occurs within 4 hours of a previous Section 136.


Since December 2017, there have been 19 instances of concurrent use of the suite. This means that 95% of all people detained under Section 136 are able to be immediately supported in the Section 136 suite at St Cadoc’s Hospital, without waiting for the suite to be vacated.

Remaining Challenges


The implementation of the Police and Crime Act (2017) has resulted in an increase in the numbers of people detained in the designated suite at St Cadoc’s Hospital. It has also resulted in a change in the profile of people with a subsequent increase in the numbers of people presenting with violent and intoxicated behaviour, which is not always in the context of a mental health problem. This has proven to be a challenge for Health Board clinical staff and is resulting in a review of how the designated 136 suite is staffed and supported through the 24 hour period.


Joint Working Arrangements


In addition to the governance structure established to oversee the implementation of the Gwent “Whole Person, Whole System” Acute and Crisis model described earlier Gwent has also established a multi-agency group to specifically focus on the implementation of the Mental Health Crisis Care Concordat. This group reports to the Gwent Mental Health and Learning Disability Criminal Justice Planning Forum which in turn reports to the Mental Health and Learning Disability strategic partnership. The most recent version of the delivery plan (see attachment) is currently being implemented and monitored.


In addition to local assurance mechanism senior representation from Gwent attend the Welsh Government National Mental Health Crisis Care Concordat Assurance Group. In addition to providing assurance regarding progress being made in implementing the delivery plan the national group also provides an opportunity for shared learning and this is welcomed.


At a practice level, Health Board practitioners work in partnership with the Police and AMHP colleagues to review individual cases where there is opportunity for learning. This provides an opportunity to review practice in order to prevent future incidents.


In addition to the formal structures described above a Crisis Support Community of Practice has also been established across Gwent that brings together people across Gwent who share a common interest in improving support for those with a mental health need who experience a crisis and their carers. The community of Practice is currently meeting three times a year and has over 100 people on the membership list.


Text Box: Mental Health Crisis Call Concordat Delivery Plan:
 Improving the care and support for people experiencing or at risk of mental health crisis in respect of 135/136 of the Mental Health Act.
 Custodian of the Delivery Plan: Area - Mental Health Criminal Justice Partnership (Planning) Board



Mental Health Crisis Care Concordat: the joint statement


This Concordat is a shared statement of commitment, endorsed by senior leaders from the organisations most heavily involved in responding to mental health crisis.

The Welsh Government, its partners from the Police, NHS, the Welsh Ambulance Services NHS Trust, Local Authorities and third sector are committed to work together to improve the system of care and support for people in crisis due to a mental health condition and who are likely to be detained under section 135 and136 of the Mental Health Act 1983.

As partners we agree to work together and to intervene early, if possible, to reduce the likelihood of people presenting a risk of harm to themselves or others because of a mental health condition deteriorating to such a crisis point.

They will be helped to find the most appropriate support needed in whatever situation that need arose and whichever service they turn to. Assistance with personal recovery is paramount. We will work to ensure that any intervention is carried out without recourse to unnecessary or inappropriate placement; for example within police custody.

We agree to work together toward delivering this commitment across Wales.


Within the published Crisis Care Mental Health Concordat, area Mental Health Criminal Justice Partnership Boards (MHCJPB) are asked to revise their regional ‘Section 136’ delivery plans to include the following indicative performance indicators:

·        %         Reduction on overall rate of use of Section 136

·        %         Ratio – Achieve a Health/Police place of safety ratio of (85/15)

·        No use of Police based place of safety for Children and Young People

·        Strategic development of alternative places of safety (non Health/Police)

The previous template plans focussed mainly on the police and health service interactions during a mental health crisis. In order to move the work forward this template plan looks across the four main areas of the concordat and we are looking for MHCJPBs to align activity to deliver on those outcomes, namely:

o   Access to support before crisis

o   Urgent emergency access to crisis care

o   Quality treatment and care

o   Recovery from crisis and staying well


This approach also reflects the findings of the early review of the Concordat. The Concordat Assurance Group is also suggesting adding two further areas in relation to:

o   Data and analysis

o   Communications and partnerships


The purpose of these is to create a deeper understanding of the information available on a local level and how this can be used to inform local plans and to ensure that the local plans are being communicated to other partnerships that have a role to play.

Queries in relation to all delivery plans can be routed via



How will we do it?

How will we know?

Who is Responsible?

Key Actions

Planning and Commissioning

Improvement Approach/Training and


Lead Agency Time -scale

Theme 1: Access to support before crisis


Gwent’ Whole Person, Whole System Acute and Crisis Model’

Crisis Support Programme Board established to oversee the ongoing development of the model.

4 Task and Finish work streams established and reporting to the programme board

·         Crisis Housing and Sanctuary provision

·         Shared Lives/Host Families

·         Review of In patient and Crisis and Home Treatment

·         Single point of contact

Regional partnership approach across Health, Social Care, Police, third sector.

Building on strengths across the whole system and identifying gaps and areas for development.

Ø  ICF bid for capital – Crisis House. Feasibility study commissioned and completed.

Ø  Separating Crisis House and Sanctuary provision

Ø  Coproduction with third sector on range of sanctuary provision- funding to be identified and bids progressed

Ø  Engaged with Gwent Shared Lives service to explore opportunities for Host Families

Model implemented across the Gwent region.

Opportunities to intervene earlier to avert crisis

é Network of sanctuary provision across the region

é Information, advice and assistance contained within CTP relapse and recovery plans for all secondary patients

é Staff across whole system aware of support and can signpost appropriately

é Uptake and satisfaction data

Alternative to hospital admission resulting in improved outcomes for people.


ê Bed occupancy

ê Length of stay

é Use of shared lives/Host families

ABuHB- Crisis Support Programme Board Ongoing – see Project Plan










Establish a Community of Practice to engage with the whole system and design together to coproduce solutions









Mental Health Triage Practitioners in Force Control Room









Quarterly Community of Practice Workshops to engage and consult with people – people with lived experience, carers and supporters, staff across organisations, leaders.







Continue to evaluate this model and develop based on evaluation and evidence base

Ø  PDSA established for review of in patient and CRHT pathway

Ø  Further consideration of SPoC




Mechanism to coproduce and design Whole Person, Whole System Acute and Crisis Model for Gwent

Engagement and Consultation Peer support and sharing ideas Test environment







Provide opportunities for a normative experience for partner organisations across the region and nationally to share the learning

é Home treatment options

é Crisis House as an alternative

é Person centred outcomes and satisfaction


Outcomes/Outputs from Community of Practice Workshops inform the ongoing design and delivery of the model

People have confidence in the model and are engaged in its design

Progress is reported and there is open and transparent communication



ê Inappropriate use of S136


ê Repeat use of S136 for individuals


é Frontline staff confidence and shared risk assessment/ decision making









ABuHB- Crisis Support Programme Board Ongoing – see Project Plan










Gwent Police and Caerphilly CBC


In place and ongoing



















Build and develop accessible information for citizens to access such as finance and debt management, positive relationships, resilience and coping with life events, positive parenting support, health and wellbeing advice including drugs and alcohol as these support mental health and wellbeing and provide opportunities for people to self-manage and to build networks of support






Access to information on which to make decisions and divert people from statutory services to sanctuary/third sector as appropriate







Make the linkages between Public Service Board ( PSB) and Regional Partnership Board( RPB) plans so that population needs assessment is understood as it relates to whole populations and communities the 7 Wellbeing Goals and 5 Ways of working in Wellbeing of Future Generations Act


Linkages with Public Health and Wellbeing Networks






WASPI- ISP in place to be reviewed December 2018 and to be GDPR compliant









Senior Leaders are sighted on the Gwent MHCC Concordat Plan


Presentation and approval of Gwent Concordat Plan by the Gwent MH/LD Partnership Board


Plan is published on partners websites and is outward facing


Partners use their internal governance structures to provide scrutiny and challenge on the delivery of the plans


é Positive feedback from service users and professionals



People are diverted away from statutory intervention to appropriate Information, advice and assistance- Data from MH Triage Team







Identified outcomes are delivered in a timely manner consistent with our collective commitment to the MHCC Concordat


People reporting increased resilience and able to find their own solutions


Peer support at a community level


Outcomes in Together 4 MH plan and Talk to Me 2 are progressed


















Gwent MH/LD Partnership Board



Dewis Cymru online information directory populated and updated


Use of Social Prescribers and Community Connectors to support people to navigate systems.
















How will we do it?

How will we know?

Who is Responsible?

Key Actions

Planning and Commissioning

Improvement Approach/Training and


Lead Agency Time-scale

Theme 2: Urgent access to crisis care


Mental Health Practitioners in Force Control Room

See Theme 1





Timely availability of Health Base Place of Safety















Alternative model of conveyance in a crisis

Review of current availability and access to HBPoS

( Adeferiad) with particular focus on

Access- including demand/capacity

Built Environment-privacy and dignity

Patient safety- including suitability for all age

Staff- knowledge, skills and experience Policy/Procedures/Protocols



Pilot of an ABuHB conveyance solution on going until 31st March 2019

Consideration of recent audit data/ outcomes

Discussion on a review adopting a partnership approach and Vanguard Systems methodology ie Normative experience, What matters to the person, What would a perfect system look like, value work and waste in the system, system challenges and blockages




Relevant partners aware and engaged in the pilot.


Evaluation/Feedback mechanism in place


Dependant on the evaluation need to secure funding beyond the pilot.

Report of review with options appraisal and recommendations to Partnership Board


Development of an action plan to drive improvement as necessary








People are conveyed in a dignified and appropriate manner appropriate to their needs and risks.


Staff feedback is positive


é Use of the vehicle overtime leads to improved outcomes across the whole system

é Cost /benefit analysis positive and supports ongoing funding

ê Demand on WAST and inappropriate use of police vehicles

Chair Gwent MHCC Delivery Group with representation from partners and stakeholders












ABuHB – Reporting to Gwent MH/LD partnership Board Autumn 2018










Access to Mental Health assessment from an appropriate clinician for people detained in police custody









Development of a pathway that enables the identification of appropriate clinicians to assess people experiencing a mental health crisis whilst in police custody.


Agreement on funding responsibility and governance across ABuHB and Gwent Police









Consideration of upskilling custody nurses in mental health


Consideration of access to primary and secondary clinicians in and out of hours


Mental Health custody diversion service based in custody suite

ê Blockages in the whole system as people are able to move through the system in a timely manner

ê Pressure on ED and unscheduled care


S136 is not used as a mechanism to obtain access to a mental health assessment for a person arrested and detained in custody due to system failures.









Gwent Police












How will we do it?

How will we know?

Who is Respo nsible?

Key Actions

Planning and Commissioning

Improvement Approach/Training and


Lead Agency Time-scale

Theme 3: Quality treatment and care


Relapse Prevent and Crisis

Refresh as part of ongoing

CTP audits/ quality assurance


ê Crisis situations and improved outcomes


é Increased access to crisis and home treatment solutions

é Use of Crisis house and Sanctuary

ê Use of S136/135 and powers under MHA

ê Use of inpatient beds



All parts of the model are in place and the model functions as a whole system


Contingency Plans are

care coordination training

in place.


developed and coproduced

across HB and LA’s



with all people as part of CTP


Improvement plans as required


in secondary MH / LD




services and shared with


Promote the benefit of


primary care.


contingency planning to




people and their supporters to




seek early support and review




to avoid crisis.




Delivery of the Gwent Whole



Crisis Programme Board



Ongoing see 1 above




Person Whole System Acute

delivery plan



and Crisis Care model which




has Crisis Model, Recovery





Orientated services that prevent crisis and resilient communities which are self- supporting







Values and Principles of Social Services and Wellbeing Wales are understood and embedded into practice

Community of Practice to coproduce and design sustainable solutions

Public Health and Wellbeing of Future generations 5 ways of working.





We listen to understand and ensure people have voice and control ( Advocacy)

People are expert in their own lives with strengths and assets

We support people to find their own solutions

We engage by treating people with dignity and respect

We uphold the principles of equality and diversity

We support people to understand and exercise their rights and entitlements











Leaders across all organisations model the behaviours that demonstrate our collective values


We seek opportunities to recruit people with lived experience and peer mentors


We recruit staff who demonstrate a commitment to our organisational values


CTP and care coordination is person centred , coproduced and recovery focussed


Staff are have collaborative conversation training











Positive Audit and QA outcomes


ê Complaints and serious untoward incidents

ê Safeguarding ‘ duty to report’ referrals in respect of people with MH problems

é Compliments and satisfaction

é Resilience and improved wellbeing outcomes

é Improved staff morale and retention of staff











MH/LD Partnership Board


People have access to high quality care and support that adheres to Prudent Health and Social Care ( Right person, Right Time, Right Place)

Review our ‘ front doors’ and strive to make access pathways clearer whilst we develop a single point of contact/access

As part of the Crisis Programme Board develop a T&F for single point of contact/access on a regional footprint

Remove blockages and system conditions that exclude people from accessing care and support in a timely manner that promotes independence, positive risk taking and social inclusion.


Review Delayed Transfer of Care data to understand what the blockages are and seek to find solutions in partnership.






Improved knowledge and skills across all organisations in respect of MHA/MH Measure/ MCA/DoLs

ê Delays in the system

ê Complaints about access

é Integrated pathways and MOU









ê DToC in mental health settings

é Multi agency working to find sustainable solutions to common problems that lead to delays such as housing options.


é People are afforded the appropriate rights and protections and are safeguarded




How will we do it?

How will we know?

Who is Responsible?

Key Actions

Planning and Commissioning

Improvement Approach/Training and


Lead Agency Time-scale

Theme 4: Recovery from crisis and staying well


Gwent Whole Person

Crisis House Host families Sanctuary



People are able to flow easily through the system as required accessing the appropriate support


Care Coordinators ensure people have relapse and contingency plans and know how to self-refer under MH Measure


Work with Primary and secondary services to ensure seamless response


Dewis website is populated locally and regionally with information and advice that supports recovery and wellbeing

See 1 above

Whole system model is in place and people and communities are resilient



Appropriate flow through the system

ê  People being re referred or self-referral to secondary services

ê S117 Aftercare planning is effective in supporting people to stay well

ê Reduction in readmission to hospital





Evidence of third sector consortia/partnership working.

Joint projects that have recovery outcomes as a measure.


Whole System Acute and



Crisis Model




People are discharged from


Development of pathways



secondary mental health

between primary and


services and have ongoing

secondary care that are


support from primary care

responsive and supportive to


that supports their







Refresh care coordination and



MH measure





Range of meaningful




Third sector organisations work




Third Sector

opportunities available in

together across Gwent to


the community that

enhance and develop a


support wellbeing and

wellbeing offer that promotes


universal access

and supports recovery





Community Connectors and Social Prescribers are able to support people to access their community and universal services to support recovery and staying well

Range of information available on Dewis that is regularly updated.


Use of website by public



Data from CC and Social prescribers





How will we do it?

How will we know?

Who is Responsible?

Key Actions

Planning and Commissioning


Approach/Training and Development

Lead Agency Time-scale

Theme 5: Data and analysis


Nationally agreed performance measures and performance information to enable benchmarking and comparison

Single data collection tool for all agencies with appropriate and relevant data

National tool /Regional tool is developed and agreed

Tool is rolled out Quarterly reporting data is

analysed and where indicated partners act on the system to seek improvement

Performance against the indicators across partners is tracked and supports improved performance.


Audits provide quality assurance and governance

Welsh Government then Area MH/CJ partnership boards



How will we do it?

How will we know?

Who is Responsible

Key Actions

Planning and Commissioning

Improvement Approach/Training and


Lead Agency Time-scale

Theme 6: Communications and partnerships


Gwent MHCC Concordat delivery group complete template population and agree highlanders to take forward key actions

MHCC Concordat Delivery Plan template is shared with Community of Practice for views and consultation.


Template updated following consultation


MHCJPB approves the delivery plan and monitors progress against key actions quarterly via exceptions reporting from the Chair of the Delivery Group.


Identify suitable/appropriate digital platform to publish the plan across the region

Opportunities to present the Delivery Plan across Gwent are identified and a presentation is designed.


Link with training and workforce development leads across the region and across partnerships to raise awareness of the new plan with staff


Third sector to consider promoting with people and carers


Use national days such as World MH Day and others to promote Whole Person Whole System Acute and Crisis Model


Continue to work with International Mental health Collaborating Network to learn and communicate with /from others nationally and internationally

Awareness of the MHCC Concordat and regional plan at all levels across organisations, partnerships and stakeholders




How will we do it?

How will we know?

Key Actions

Planning and Commissioning

Improvement Approach/Training

and Development

Theme 7: Other ongoing initiatives