In this section we provide a narrative overview of the key policy developments in England and Wales in relation to care planning and co-ordination. A list of key policy documents referred to in this review can be found in Appendix 7. A‘diagrammatic map’ of key policies and relevant literature is shown in Appendix 8. The political devolution of power to the Scottish Executive and the Welsh Assembly Government has often been identified as a trigger for the unravelling of a UK-wide NHS. Some commentators dispute the description of a unified pre-devolution NHS, stating that not insignificant differences between the three countries existed long before political devolution,110particularly in the field of community care.111In the
context of CMH services the image of a cohesive pre-devolution policy landscape is dealt a blow when we consider that the CPA, first introduced in England in 1990, was only formally introduced into Wales in 2003, 4 years after devolution.
It is also worth noting that the findings from our literature review clearly demonstrate that major
differences existed in terms of implementation of the CPA within England, as health regions were afforded total autonomy in how they chose to introduce changes to CMH working practices. In terms of the CPA, we conclude, therefore, that no unified‘English’ policy approach existed at the outset, making any intra- or cross-national policy comparisons difficult.
Health policy from 1990: changes to community mental health working in England and Wales
Initial moves towards a different way of organising and delivering CMH services can be located within a brief health and LA circular policy document for England.112Produced in the context of an accelerating,
policy-driven shift away from hospital care, the circular emphasised the importance of‘systematic
arrangements for deciding whether a patient referred to the specialist psychiatric services can, in the light of available resources and the views of the patient and, where appropriate, his/her carers, realistically be treated in the community’. To this end, the document specified that health and social care needs should be assessed and planned and a‘keyworker’ appointed to oversee and review the delivery and co-ordination of interagency and interprofessional services.
The circular appeared shortly after the publication of plans for an across-the-board reorganisation of community care via the White Paper Caring for People. Subsequently incorporated within the NHS and Community Care Act,113this placed a responsibility on LAs to implement‘care management’. With their
parallel systems of care co-ordination, for many years thereafter the health-led CPA, and the social care-led care management, ran in unhelpful parallel.
Uppermost in the minds of policy-makers in the early 1990s was the management of the risks associated with the community care of people with severe, long-term, mental health problems. As a result,
‘supervision registers’ were introduced, this again being an initiative within England only, where they were implemented as an add-on to locally structured CPA arrangements.114Supervision registers promoted care
planning and co-ordination as a mechanism for risk assessment and its management. However, as with the introduction of the CPA, no additional resources were provided to support those appearing on supervision registers.
Building Bridges115was a detailed document produced for NHS England in 1995, which promoted the
importance of interprofessional CMH teams and the CPA as the‘cornerstone’ of care.115(p. 45)A year later
guidance on the community care of people with mental health problems in Wales was published,116which
formally introduced into the Welsh mental health system the ideas of health and social care assessment, care planning, review and key-working. Neither this nor subsequent additional guidance117mentioned this
as the introduction of the CPA into Wales.
META-NARRATIVE REVIEW AND COMPARATIVE CROSS-NATIONAL POLICY ANALYSIS
NIHR Journals Library www.journalslibrary.nihr.ac.uk 24
Meanwhile, the election of New Labour to government in 1997 coincided with a significant raising of the profile of mental health as an area for policy action in England, with new guidance on‘modernising’ the CPA being introduced towards the end of the decade.118This reaffirmed the central place of the CPA in
modern systems of care but also highlighted where changes needed to be made, noting professionals’ complaints that the CPA resulted in a significant administrative burden for time-pressed care co-ordinators and service users’ views on patchy and inconsistent experiences of care planning.
In post-devolution Wales, a new national strategy for adult mental health services included a section on care planning and co-ordination and on the imperative for all users to have a written plan of care overseen by a‘keyworker’.119Two years later came the formal introduction, for the first time in Wales, of something
directly referred to as the CPA.2This talked, very clearly, about the CPA as a vehicle assisting service users
towards recovery, supporting empowerment and the embracing of holistic care. The current situation in England and Wales
In England, a further review and‘refocusing’ of the CPA was undertaken1which was strong on minimising
bureaucracy and on simultaneously driving up the quality of care planning via a commitment to national-level consistency. The CPA was presented as a values-based process through which care is tailored uniquely to the individual and serves to promote social inclusion and recovery. For the first time a set of approved training materials were produced to support practitioners.120In current mental health policy for England, represented
most completely in the cross-government No Health Without Mental Health121and its ancillary documents,
the CPA takes something of a back seat as the focus shifts to cross-sector and cross-government action to improve mental health across the board.
Meanwhile, in Wales, care planning and co-ordination have taken a distinct turn in recent years. An influential, critical, review of the CPA122contributed to the power to make new mental health law
devolved to the National Assembly for Wales. This process led to the eventual passing of the Mental Health (Wales) Measure [MH(W)M] and its attendant documents, including a code of practice123and a raft
of training material. Part 2 of the Measure obliges health and LA services to produce CTPs for all users of secondary mental health services. The phrase‘CTP’ supersedes ‘CPA’, although each is required to be developed by a care co-ordinator working collaboratively with the service user and other providers. CTPs must be in writing, and kept actively under review by care co-ordinators who must now be drawn from a prescribed range of professional groups. Since the passing of the Measure, a new overarching strategy for mental health across the lifespan in Wales has been produced,5along with an initial plan for delivery.124
Current policy frameworks across both England and Wales emphasise the importance of mental health services in promoting recovery and tailoring care to the needs of the individual. Where the biggest difference remains is in the context of arrangements for care planning and co-ordination, and in the use of a statutory instrument in Wales within which CMH care is overseen. Current mental health policy in England also heavily features the term‘personalisation’, with no use of this term appearing within current mental health policy in Wales.
Personalisation, through service users holding personalised budgets, is portrayed in policy documents from England as a means of‘giving people greater choice and control over their care and treatment’.121(pp. 32–3) In Wales, an Independent Commission on Social Services rejected this view of personalisation, stating that ‘We believe that the label ‘personalisation’ has become too closely associated with a market-led model of consumer choice’.6(p. 15)The Commission is clear that the focus instead should be on personalised budgets
offering the means of establishing patient and public‘voice’ as a force for improving services that meets the diverse needs of the population of Wales, rather than promoting individualised consumerist choice as a means of improving services through market forces. Peckham et al.125similarly identify that different
political ideologies are increasingly apparent in policy rhetoric, objectives and mechanisms introduced within devolved national policy, although the question of how visible such differences are at the level of mental health service organisation and service delivery remains to be seen. Such is the focus of this study.