Cabinet paper: Mental health and suicide prevention strategies

Cabinet is asked to approve the direction of travel in the development of the successor strategies to Together for Mental Health/Talk2Me2; to commit to action with individual portfolios to support delivery of these strategies; and, to agree in principle to identifying a set of measurable, cross-government indicators to track progress.

1. Improving mental health and wellbeing is a key priority for the Welsh Government with a number of related Programme for Government Commitments.

2. The wider determinants of good mental health include employment, education, housing, financial inclusion and tackling poverty. Delivering on the Welsh Governments commitment for improved mental health and wellbeing requires cross-Government action.

3. Officials have undertaken a broad programme of work to evaluate the existing strategies and engage a range of services, service users and stakeholders to help shape priorities for the next iteration of the Together for Mental Health and Talk to Me 2 Strategies. Collectively, these reviews have drawn together the views of service users and carers, practitioners, service delivery providers and the public to provide a comprehensive insight to inform future planning.

4. This has helped shape early thinking about themes and priorities for the future strategies. They are set out below for Cabinet agreement.

5. Since this will require cross departmental input to deliver, this paper seeks continued buy-in from across Cabinet in line with the Cabinet paper CAB(22-23)38 (January 2023) and agreement to identify a set of cross-government indicators to track progress.

6. This paper sets out, for Cabinet agreement, a summary of work to date to develop the successors to the Together for Mental Health/Talk to Me 2 strategies; the developing high-level visions to be contained in the draft strategies; and the need for cross-government support.

7. In 2012 the Welsh Government published the Together for Mental Health (T4MH) strategy and in 2015 the Talk to Me 2 (T2M2), the suicide and self-harm prevention strategy, both of which ran until the end of 2022. The Deputy Minister for Mental Health and Wellbeing has publicly committed to the development of successor strategies and to an independent evaluation of the outgoing strategies to assess their impact and inform our next steps.

8. As part of a wider programme of reviews, Opinion Research Services (ORS) was commissioned to undertake research into the impact of both existing strategies and extensive external engagement was carried out by ORS with service users and carers, practitioners, service delivery providers and others to inform that work. The key findings were:

1. There was strong support for developing T4MH and T2M2 successor strategies. 
2. Progress has been made towards the key objectives across both strategies but there is more work to do.
3. The impacts of poor mental health were thought to be better recognised. However, this was not thought to extend to those experiencing more severe mental ill-health, many of whom still lack understanding and support from their communities and wider society.
4. There was support for the cross-government and multi-agency arrangements that were established to support the strategies.
5. A set of baseline measures is needed, as is embedding a means of collecting data to evidence success or otherwise.

9. Mental health continues to be the highest area of spending by the NHS in Wales. Pressures on the system are severe, with services continuing to report increases in complexity and acuity of referrals received. This is seen against a backdrop of high vacancy levels with services struggling to attract and retain suitable staff.

10. Together for Mental Health/Talk2Me2 have enabled the delivery of areas of policy that have advanced service provision and helped to improve the lives of individuals living with mental health problems. This includes implementing our own unique mental health legislation in Wales, expanding the range and improving access to services, implementing community perinatal teams and, more recently, the implementation of 111 press 2 for urgent mental health support. These strategies have also enabled collaborative and effective cross-government working, for instance the delivery of our Health and Education whole system approach in schools.

11. Together for Mental Health/Talk2Me2 are currently 2 separate strategies. They are widely seen by stakeholders as different subjects, albeit with clear interdependencies. A specific question about the need for 2 strategies was asked as part of the independent evaluation and whilst some stakeholders supported an integrated strategy with clear actions for suicide prevention, most argued the need for 2. A separate strategy for suicide and self-harm prevention is needed, because:

• those who die by suicide are less often identified as having mental health issues, or in contact with mental health services (around 20-25%), and there are multiple and complex reasons why a person may decide to end their life beyond issues relating to mental health or mental health service engagement.
• there is a prevailing misconception that people who die by suicide have a mental health problem or illness, and this perpetuates misinformation and stigma, and doesn’t provide a good fit for issues relating to bereavement for example. A separate strategy would help to avoid this conflation, and ensure that resources can be identified and directed more broadly and in the right places.
• to not have a separate strategy would be a departure from the approach adopted in all of the other UK nations.

12. It is proposed that they remain as two separate but interconnected and closely linked strategies.

13. The development of the new successor strategies will be the platform in which we drive cross-government collaborative working; which will support us in providing a consistent focus and delivery across Wales; and will ensure a shared understanding of our vision and goals. This will help us draw together actions across portfolios that contribute to improved mental health.

14. We are keen to avoid circular references to other strategies as we develop this work. We want to have a mechanism in place that can provide assurance that work driven by other policy areas will be protective of mental health and that when developing policy that it is impact assessed to ensure that it has a positive impact on mental health and wellbeing and that we mitigate against any possible negative impacts.

15. Whilst there are high expectations among stakeholders that we will publish new strategies, we recognise and acknowledge that this cannot be a wish list and that we need to be pragmatic about any investment that is supporting the strategies that are developed. This work will therefore be an opportunity to manage public and stakeholder expectations around what can be delivered within available resources. Due to the constrained financial position that we are currently in, we are mindful that these strategies are being developed in the understanding that they will be a means of setting priorities, ensuring best use of existing resources, and will be an opportunity to be clear about what can realistically be delivered. The strategies will provide the high-level framework for the 3-5 year delivery plans that will be developed beneath them.

16. Over the past 2 years or so, the Welsh Government has commissioned several reviews to engage a range of services, service users and stakeholders to help shape priorities for the next iteration of the Together for Mental Health and Talk to Me Strategies. Whilst the independent evaluation is a key element of this work, this is set in the context of a broader programme of work to shape early thinking about themes and priorities for the future plans. Collectively, these reviews (listed at Annex B) have drawn together the views of service users and carers, practitioners, service delivery providers and the public to provide a comprehensive insight to inform future planning. The overall aim was to develop themes/visions and values based on this initial engagement, which are set out below and will support further co-production as we develop the strategies.

17. The draft vision statements and underpinning principles have evolved following initial engagement and feedback from stakeholders including National Partnership Board; Wales Alliance for Mental Health; Ethnic Minorities Mental Health Task and Finish Group; Ministerial Mental Health Delivery and Oversight Board; and Welsh Government Cross-Government Mental Health and Substance Misuse Group. We have also engaged with service users through our Service User and Carer Group, including a dedicated session to hear views of the draft vision statements and principles. As a result, the vision statements now read as follows:

• People are able to take action to support mental wellbeing.
  • This vision has a focus on population wide mental wellbeing, giving people and communities the opportunities, resources and access needed to support their own mental wellbeing.
  • It will promote actions to prevent or reduce the incidence of mental ill health.
• There is cross-government action to protect good mental health and tackle stigma through the wider-determinants of mental health, for instance good work, education, housing, and safe communities.
  • This vision is about the role of other parts of Government understanding the evidence to maximise impact to support good mental health.
  • In particular, engagement will focus across the areas of life included in care and treatment plans (accommodation, education/training, finance, work, physical/social and cultural well-being).
• The whole system approach to emotional well-being is embedded across all settings including schools, youth work settings, HE/FE and workplaces.
  • This vision is about embedding existing approaches (NEST/NYTH, Whole School Approach, Trauma Informed Wales Framework) and developing new actions where there are gaps – for instance HE/FE.
• The NHS, local authorities and Third Sector provide an integrated approach to mental health services – right time, right place, right service.
  • This vision is about access to services across the tiers (from Tier 0/1 through to Tier 4). This will set out service/support expectations and legal duties for mental health in Primary Care, Secondary Care, Urgent and Emergency Care and In-patient care.
• Reduce suicide and self-harm, and timely access to appropriate support is provided for those affected by suicide.
  • This vision will include targeted support for those most at risk; tackling drivers and methods of suicide / self-harm; improving bereavement support; improving data (e.g. through Real Time Suicide Surveillance, etc).

18. The following principles have been drawn out of the work to date to reflect what is important to people and key stakeholders. The principles are cross-cutting and would need to be considered across the vision statements and the actions that develop from them. They are:

• Responsive, compassionate, person-centred and rights-based
• Equity of access (reduce inequalities)
• Quality and safety
• Evidence driven and outcomes focussed
• Preventative and prudent approach
• Better use of digital
• A sustainable and supported workforce
• Service integration and no wrong door approach
• Trauma-informed
• Coordinated and consistent data collection
• Appropriate language (de-medicalise)
• Physical environment that supports safe and dignified care
• Free of stigma and shame, blame and judgement

19. Officials have been actively involved in cross-government work that would impact on mental health including the Anti-Racist Wales Action Plan work; actions around support for refugees and asylum seekers; work with public health colleagues; and joint working with Education, Housing and Tackling Poverty. Public Health Division is leading on developing the actions to support population mental well-being and this will ensure integration with the Social Prescribing Framework which is subject to a separate Cabinet discussion, CAB(22-23)86 refers.

20. The cross-government officials groups established to support the current strategies have moved focus to the development of the new strategies. This includes a focus on alignment with the Child Poverty Plan and the establishment of a Ministerial Advisory Group on mental health in HE and FE.

21. As we go forward with the next iteration of the strategies, we aim to further strengthen the cross-government reach and co-ordination of action, in accordance with the recommendations of the paper considered by Cabinet in January of 2023(CAB(22-23)38). This includes ministerial bilaterals to discuss operational challenges and opportunities for synergies across portfolios before the draft strategies are returned to Cabinet. This would include discussion and agreement at ministerial level and co-ordinated action at official level. Through a greater recognition of shared action we will be able to maximise the impact of actions within portfolios to tackle the wider determinants of mental health, and by recognising and addressing their impacts we can support improvements to prevention and early intervention around the drivers of poor mental health. By tackling the social conditions that lead to individuals suffering mental health crises, we can help to avoid the need for medicalised interventions.

22. The vision statements contain an explicit reference to cross-government action to protect and promote good mental health through the wider-determinants of mental health, as well as taking a whole system approach to wellbeing across a range of settings.

23. The strategies will make a difference to the people of Wales by providing clarity around the vision and priorities for mental health and what we are collectively working towards. It will set out how we will be working across sectors to co-ordinate action and improve services, leading to an ever-improving mental health offer and ultimately better mental health. The strategies will be under-pinned by a series of 3-5 year delivery plans setting out the specific action that we will take. This will allow us to clearly articulate how we aim to use available resources to work towards shared goals.

24. In terms of delivery of government objectives, the PfG contains a commitment to prioritise funding for mental health, which has been met. These strategies provide a renewed vision of what that funding will deliver. It will enable better alignment of expenditure with government priorities, and co-ordination of action across government portfolios.

25. We plan to produce draft strategies for public consultation by the end of the calendar year.

Eluned Morgan
Minister for Health and Social Services

Lynne Neagle
Deputy Minister for Mental Health and Wellbeing

July 2023