CADRIG
(Conwy & Denbighshire Rural Interest Group)
Rural Health Planning - Improving Service Delivery across Wales
The CADRIG Consultation Response
Background
CADRIG is the specialist rural sub group of the Denbighshire Adult Mental Health Planning Group and the Conwy MAP Group. It is made up of a range of stakeholders including first and third sector service providers and service users and carers in the area of Denbighshire south of the A55 and in Conwy south of the A55 but including the quarry villages of Llanfairfechan and Penmaenmawr. Its purpose is to provide a specialist rural viewpoint on mental health matters and to inform and advise the Denbighshire AMHPG and the Conwy MAP as well as ensuring equity of service provision in rural areas.
The WAG Rural Health Planning Consultation event at Venue Cymru, Llandudno on 4th June 2009, was exceptionally well attended by CADRIG members and additional stakeholders concerned with rural mental health. Due to this clearly demonstrated interest and concern, it was suggested at the following CADRIG meeting that CADRIG follow up the Venue Cymru event to take the consultation out to gather views from an even wider group from Conwy and Denbighshire.
Consultation Method
Four venues were selected to make the consultations as accessible as possible in rural Conwy and Denbighshire - Llanrwst, Llanfairfechan, Denbigh and Llangollen. The Unllais Service User and Carer Liaison Officer for Conwy and Denbighshire joined the Director of Services of Vale of Clwyd Mind and the Conwy and Denbighshire Rural Outreach Service Manager in the consultation "Roadshow". Invitations to the events were circulated widely among local networks (see attached flyer). Eighteen people attended the events - a mix of first and third sector service providers, service users and carers. Special thanks to Rachel at WAG who very kindly sent us hard copies of the data maps used at the Venue Cymru event.
The Director of Vale of Clwyd Mind presented a power point session on key elements and themes of the consultation document and notes of discussions were taken. The response below is based on the notes of those discussions which will be circulated to all those who attended before being submitted to the Wales Assembly Government Health and Social Services Department.
General Responses
- The themes of access, integration and community cohesion are admirable in principle and reflect our opinions based on our experiences of providing and accessing services in rural communities.
- However, we are mystified as to why the WAG did not feel it was appropriate to provide funding to continue the work of the Healthy Living Centres, which fitted in perfectly with those themes.
- It took five years hard work to gain the trust of the community in Corwen and to provide a range of truly integrated services and an effective focal point for the community. This trust was destroyed when numerous pleas for funding were unsuccessful. The work is lost. We will have to start from scratch now to regain the benefits of that work and the trust and co-operation of the community.
Specific Responses
1.1.6 - 1.1.9. Defining Rurality
- The document avoids a single definition of rurality. It is felt that without a clear definition of rurality, there is potential for some people to be excluded by service providers' own interpretations of rurality. We need a clear consensual definition so that we are all "singing from the same hymnsheet"
Fudging such a crucial element right at the beginning of the document doesn't inspire confidence about the clarity and substance of what will follow.
1.1.15 - 1.1.17 Welsh Language
- The needs of first language Welsh speakers cannot be overstated
1.2.11 - ...not an alternative health strategy..."
- We are pleased that the Rural Health Plan is " ...not an alternative health strategy but a template for translating the delivery of all-Wales strategies into meaningful service delivery mechanisms -, tailored more specifically to the needs of rural communities"
However, we feel that good practice is good practice; geography is irrelevant, so we are concerned that "tailored ...to the needs of rural communities" doesn't mean diluted or second best.
1.3.1. The Wider Policy Context
- "The work which will eventually crystallise must integrate with other strategic initiatives across Wales". We wholeheartedly agree with this statement. However, some of those present were virtually simultaneously attending the North Wales Clinical Strategy Stakeholder events. Neither of these strategies seemed to reference each other. We would suggest that strategies and strategists should "talk to each other" at the planning and consultation stage, not when they have been fully formed ("crystallised") and are too rigid to meld together.
2.3.2 - Opportunities?
- The "voluntary sector" - "to reflect the professionalism of people working in the third sector and to get away from dated associations of well meaning volunteers and amateurs, please refer to us as the "third sector"
- "specialist generalist" - an oxymoron surely?
- If "developing generic skills and specialist generalists" is good practice in rural areas, then shouldn't it also be good practice in non-rural areas? (see 1.2.11 above - concerns re dilution of standards in rural areas). Are we going to be "dumbing down" the workforce in rural areas creating inequitable access to quality services?
2.4.1.4 - Mental Health Issues
- We would strongly challenge the assertion that "mental illness has a lower prevalence in rural areas". Our experience tells us that mental illness is more hidden in rural areas due to stigma and stoicism and we cannot know the unknown. Inhabitants of rural areas often move to urban areas to escape stigma and discrimination and to access services. Sweeping statements such as those above are dangerous as they could lead to fewer resources being allocated to areas where they might be needed most.
- What is needed to address this is a well resourced anti stigma campaign (like England's Time to Change) so that people feel OK about admitting they are not coping or need support.
- Why is only the farming community referenced when discussing suicide? Farming (a minority occupation) is but one of many communities of interest in rural Wales. "Farmers may or may not openly exhibit depressive thoughts prior to suicide" is a context-free and meaningless statement.
3.3.4 Outreach/mobile services
- DORIS, Vale of Clwyd Mind's mobile outreach vehicle, has become well known at rural locations and events in rural Conwy and Denbighshire. She has been successful at "reaching the other parts other services can't reach". She has taken nurses to farmers' livestock marts to do blood pressure checks as a way of engaging with them about mental health issues. Working in partnership with other health and social care organisations, she has been a great stigma - busting tool and has piloted a variety of approaches to engaging with traditionally "hard to reach" groups in rural communities. The conclusions drawn from DORIS are that these groups are not "hard to reach" - they are "more expensive to reach". Mobile units like Doris, adequately resourced and used creatively can be very effective ways of addressing the Key Themes of the document - access, integration and community cohesion.
- Therefore the "rural health premium" (3.4.12/13) is essential in allocating finance. What happened to "rural proofing?
3.4.15 Joined up solutions?
- While everyone supported the development of integrated service centres in rural locations (Healthy Living Centres anyone?) with spokes leading off these hubs, the Builth Wells model (Figure1) was thought to resemble a pack of cards randomly scattered, with no explanation of the colour code in the diagram and no apparent flow or connection between the different elements. Where are the relationships?
3.5.3 - Strong social networks?
- "..rural communities have strong social networks and infrastructures of support and help.." which is great if you're in the "in group" in these communities. But these networks can be drivers of social exclusion as much as social inclusion and isolation is heightened in rural communities if your face doesn't fit or you're not a "joiner".
A CPN stated that one 50 year old she works with has lived in the same village all her life but still doesn't feel that she belongs or fits in there. Different people don't fit in - stigma and discrimination need to be addressed.
3.5.7 - Welsh language issues
- We need to replace the concept of "language of choice" with "language of service user's need". When using the term "language of choice", there is ambiguity about whose choice this is.
4.2.2 - Case Study 11
- Mrs Jones goes shopping - a bizarre case study.
Mrs. Jones is very fortunate indeed to have a village shop.
She is also very fortunate to have access to broadband.
Are we assuming that Mrs. Jones has the skills to dismantle her washing machine to identify the fault and the part that needs replacing? And that the replacement part will arrive within 72 hours? And that she can then re-fit the part herself?
- Using this case study to formulate a parallel model of care in rural communities is therefore fundamentally flawed and unrealistic.
4.2.3 - Telehealth
- While acknowledging the benefits of some aspects of telecare, grave concern was expressed about replacing human contact with telehealth in rural areas. The benefits to health and wellbeing of human contact and relationships are widely accepted, so reducing that contact, especially to people who are already socially isolated, could be very detrimental to health and wellbeing.
- Reservations were also expressed about the Big Brother monitoring and surveillance elements of Telecare, and its potential to be misused as a means of controlling people (especially "difficult" people with mental health problems, dementia,etc).
5.2 - Responsibilities and actions for Improvement
- The role of community councils was questioned by a community councillor at one of the events.
Conclusion
We welcome the publication of this document and its intentions to improve service delivery across Wales. We are dubious about some of the underlying assumptions and research that informs the document. Some of the concepts it uses are undefined (e.g. rurality and specialist genericists).
There appears to be an overemphasis on problems associated with old age compared with other groups (e.g. people with mental health problems). There seems to be a high risk that inequity in service provision will be increased. Telecare should supplement human interaction, not replace it. There is an over reliance on IT as a solution. There is concern that the workforce in rural areas could be "dumbed down".
Welsh language issues are crucial.
How will the plan be resourced and implemented?