Making prudent healthcare happen

Making prudent decisions in mental health services

  • Professor Keith Lloyd, Head of College of Medicine, Swansea University

Why mental health is important

Mental health problems range from worries about everyday life through to the most serious and disabling mental illnesses, such as dementia, schizophrenia or bipolar disorder.

It has been estimated by the World Health Organisation that mental health problems are some of the biggest causes of disability across the world, accounting for about 20% of the overall burden of disease. This is a larger share than any other single health problem, including cardiovascular disease (16.2%) and cancer (15.6%). Poor mental health and mental illness have a significant impact on individuals, society and the economy overall [1]. Across the world, schizophrenia, bipolar disorder, depression, epilepsy, dementia, alcohol dependence and other mental, neurological and substance misuse disorders are the biggest contributors to the global burden of disease surpassing both cardiovascular disease and cancer.

Depression is the third leading contributor to global disease burden and alcohol and illicit drug use account for more than 5%. Every seven seconds, someone develops dementia, costing the world up to $609bn in 2009. By 2020, an estimated 1.5 million people globally will die each year by suicide and between 15 million and 30 million people will attempt suicide [2].

In Wales, mental health services account for the single biggest area of NHS expenditure. According to 2012-13 Welsh Government figures, spending on clinical programmes ranged from £7.66 per head of population on hearing problems to £200.87 per head on mental health problems. The situation is similar in other developed countries. For example, in England, mental health, which includes patients with dementia, is also the largest single category of NHS expenditure followed by circulation problems (relating to the heart, and the circulation of blood in central and peripheral vessels) and cancers and tumours (including people suspected of having, or at risk of developing, cancer) [3,4].

Quite apart from the direct costs of looking after people suffering with mental health problems, there are also considerable indirect costs. People with more severe mental illnesses may require access to a range of community services, including support with housing, personal care, and employment and training opportunities.

The common mental disorders of anxiety and depression are the most frequently encountered forms of poor mental health in the general population and there are links between poor physical health and poor mental health [5,6]. These conditions are managed almost exclusively in primary care.

The biggest barriers to people seeking and obtaining help and support for a mental health problem are the availability of services, stigma and reluctance of people to seek help [7]. This particularly applies to certain conditions, such as suicidal behaviour and self harm, and to particular groups in the populations, such as young and middle aged men or people from certain communities [8].

The burden, the cost, an aging population, social inequalities and professional and societal attitudes towards mental health problems make it an area where prudent healthcare can potentially have a major impact. Here are three concepts to consider in relation to prudent mental healthcare.


The Welsh Government’s suicide and self harm prevention strategy Talk to Me 2 [9], which is currently subject to public consultation, identifies three concepts to consider when delivering services. These are: priority people; priority care providers and priority places. These principles can also be extended to other areas of mental health provision.

Priority people

Priority people are groups of people who are particularly vulnerable to mental health problems, suicide and self harm and there are others specifically responsible for or well-placed to respond to people in crisis. Here the prudent healthcare principle of first do no harm is particularly relevant. The range of services needs to be tailored to meet the needs of high-risk groups to improve their mental health and care pathways need to be as short and simple as possible  Examples of this approach, which also address the prudent healthcare principle of doing no harm are:

  • Psychiatric liaison services for the elderly – Abertawe Bro Morgannwg University Health Board has well-established consultant-led psychiatric liaison services for older people with mental health problems. The Welsh Government has also provided £1.1m Invest to Save funding to help Cwm Taf University Health Board set up a consultant-led psychiatric liaison service for older people with mental health needs and a new acute assessment service covering unscheduled care activity.

These new services aim to ensure that patients are assessed more rapidly when arriving at hospital; reduce length of stay, reduce waiting times in accident and emergency departments and improve patient experience.


  • Length of stay for dementia patients – Dementia patients’ memory loss worsens the longer they stay in hospital and the transition from ward to home becomes increasingly difficult [10]. A prudent mental healthcare approach would encourage shortened admission times and rapid discharge where appropriate. Crisis resolution and home treatment teams such as the one in Swansea are designed to offer crisis support, alternatives to admission, and to facilitate early discharge by offering additional support where needed.
  • Assessment of former users of secondary mental health services – Part three of the Mental Health Measure provides people who have been discharged from secondary mental health services who feel their mental health is deteriorating with the right to request an assessment by a secondary care service. This fast-track back to specialist services in the event of a relapse gives individuals the security of knowing that they can quickly re-engage with services should the need arise. Its effect has been to reduce the caseloads of specialist mental health services, freeing up capacity and enabling them to spend more time on urgent and complex cases.

The voluntary sector can have a significant role to play in making support for mental health problems more readily available and accessible. The mental health charity Hafal has worked with a number of NHS and local authority partner commissioners around Wales and developed the Recovery/Cost Pathway for people with severe and enduring mental illnesses such as schizophrenia and bipolar disorder.

To deliver prudent mental healthcare to these groups, Hafal argues a change in the culture of services is needed to introduce an ethos of recovery and aspiration where there is currently one of stability so people are supported to progress and move on instead of being maintained in their current condition. Recovery means long-term savings while stability means ongoing cost [11].

Hafal’s members believe that recovery-focused, high-quality mental
health services based on effective care and treatment plans can empower patients to move decisively from dependence on high-cost services through lower-cost support and on to economic activity, contributing to society through employment and taxation.

Implementation of care and treatment plans under the Mental Health Measure offers an opportunity to achieve a step-change in the cost-effectiveness of secondary mental health services by agreeing with individuals the short-term, practical steps towards long-term goals, which will move them along the pathway of high-dependency and into lower levels of support and, ultimately – for many – independence with very low levels of support from primary care [9].

Priority Places

There are many settings in which the prudent healthcare principle of organising the workforce around only do what only you can do is particularly relevant. One example of this is in prisons and police custody suites to minimise suicide and self harm.

Talk to Me 2 recognises that prisons and police custody suites are priority places for focusing suicide prevention efforts. People at all stages within the criminal justice system, including people on remand and those recently discharged from custody, are at increased risk of suicide. The greatest risk is in the first week of imprisonment and is higher among female prisoners.

A high proportion of offenders are young men, already at increased risk for suicide. The vast majority (up to 90%) of all prisoners have a mental health issue and/or substance misuse issues. Prisoners are separated from their family and friends and are thus isolated from their normal support networks.

Samaritans Cymru runs a prisoner Listener scheme, which operates in every prison in Wales. This is a peer support scheme where prisoners are trained and supported by Samaritans, using their same guidelines, to listen in complete confidence to their fellow prisoners. The objectives of the scheme are to assist in reducing the number of self-inflicted deaths, reducing self-harm and helping to alleviate the feelings of those in distress. The first Listener scheme started in HMP Swansea in 1991 and Swansea Samaritans continues this work today. Samaritans also provides a presence in bail hostels, for example in Swansea and Bangor.

The Welsh Government has issued policy implementation guidance Mental Health Services for Prisoners in Wales, which is designed to ensure prison and healthcare staff adopt measures which identify need, risk and potential of those admitted to custody to take their own life. The emphasis placed on reception screening, immediate follow-up of risk indications and the adoption of decent prison care standards, delivered through staff and other inmates, is stressed. The policy also sets out the duties laid down via the Mental Health Measure on health boards and the importance placed on the care and treatment of those with particular needs [12].

Giving equal weight to mental health and physical health problems

Primary care is a priority setting for delivering prudent mental healthcare, as this is where 95% of identified mental health problems are treated. This was the case in 1990 and it remains the case now meaning that mental healthcare is a core activity of general practice [13].

Local primary mental health support services
Part one of the Mental Health Measure requires health boards to have in place a range of services which allow individuals with mild to moderate mental health problems to be supported within primary care, rather than being referred to secondary care services. This directs resources to the front end of service provision, targeting individuals experiencing mental health problems at an early stage, aiming to prevent subsequent deterioration and supporting them to remain as independent as possible. In many cases this may avoid the need for more specialist intervention at a later stage.

The Royal College of Psychiatrists’ report Whole-Person Care: From Rhetoric to Reality highlighted the significant inequalities between physical and mental healthcare, including preventable premature deaths, lower treatment rates for mental health conditions and an underfunding of mental healthcare relative to the scale and impact of mental health problems [12]. It identified a number of ways in which mental health might be valued the same as physical health.

The challenge for services is to give people with mental health problems equal access to the most effective and safest care and treatment, equal efforts to improve the quality of care, equal access based on need, equal status within healthcare education and practice, equally high aspirations for service users, and equal status in the measurement of health outcomes.

Welsh Government mental health practice guidance is based on a tiered care model. This aims to ensure that resources are allocated appropriately so expertise and interventions match complexity of need and the need for multiple assessments of an individual is minimised. This model is set out in service guidance for both children and young people and for adult mental health.

Alternatives to antidepressant prescribing: Improving mental healthcare in primary care also means carrying out the minimum appropriate intervention. Welsh Government policy is to ensure that pharmaceutical interventions are used only when clinically indicated, and that a range of appropriate alternatives is available [14]. Service providers are encouraged to consider alternatives to medication for managing low-level mental health problems, where this is safe and appropriate. Alternatives to antidepressants for mild to moderate depression include talking therapies, exercise, and bibliotherapy.

Reducing stigma

The stigma attached to mental illness is a major obstacle to the provision of care for people. When a person is labelled by their illness they are seen as part of a stereotyped group. Negative attitudes create prejudice which leads to negative actions and discrimination. Such attitudes make it harder for people to access healthcare and obtain the help they need.

The stigma attached to mental illness is a major obstacle to people seeking and obtaining care for mental health problems. Stigma does not stop at illness – it marks those who are ill, their families across generations, institutions that provide treatment, psychotropic drugs and mental health workers. Stigma makes community and health decision-makers see people with mental illness with low regard, resulting in reluctance to invest resources into mental healthcare. Furthermore, stigma leads to discrimination [15].

Promoting equity and reducing stigma is a core principle of prudent healthcare. The Time to Change Wales campaign is delivered by a partnership of three leading Welsh mental health charities – Gofal, Hafal and Mind Cymru. It identifies a number of ways to challenge stigma in line with the principles of prudent healthcare.  According to these campaigners, many people say that being discriminated against in work and social situations can be a bigger burden than the illness itself.. Furthermore, they contend stigma has an impact on society and the economy too. For example when people who can work are denied the opportunity to, and when people are prevented from playing an active role in their communities. Confronting and tackling stigma thus directly addresses the prudent health care principle of first doing no harm. Through engaging the community in tackling stigma it is argued that this will help create a new relationship between the public, people with mental health problems and NHS Wales, based on openness and sharing information about stigma and mental health [16].

Independent mental health advocacy: Promoting equity also helps to reduce stigma. Part 4 of the Mental Health Measure [17] expanded the provision of advocacy to all inpatients receiving care or treatment for a mental health problem. This is designed to ensure that the service user’s voice is heard and that their preferences and concerns are recognised and addressed in care and treatment approaches.

Engagement:  Service user and carer involvement in the design and delivery of policy and services is also part of prudent health care. Service users and carers on the local and national mental health partnership boards and on the national service user and carer forum are providing a major role in monitoring performance and progress in achieving the actions in the Together for Mental Health delivery plan.

A recovery-based approach  Mental health services in Wales are based on the principle that interventions will be evidence-based and recovery-focused, with clear expected outcomes. They will be founded on a thorough assessment of each individual and delivered by suitably skilled and trained staff who are appropriately supervised. Wherever possible, agreed interventions will support individual self-management, promote mental health and prevent deterioration.

Care and treatment planning Part 2 of the Mental Health Measure embeds the co-production of care and treatment planning in legislation, with the service user placed firmly at the centre of the process as joint author of their plan.


Mental health services are a major component of NHS Wales. Delivery of prudent healthcare will only be achieved if there is equity between physical and mental health in the design delivery and funding of services. In this chapter examples of prudent mental healthcare have been highlighted at a population level with suicide prevention in primary care with liaison services, anti-depressant prescribing and psychological therapies and in secondary care with liaison services in the general hospital and within speciality mental health services. The concept of priority people and priority places is advanced as a helpful way of conceptualising prudent mental healthcare.


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Watch Professor Keith Lloyd talk more about this article, click on the video.