Hafal’s open letter to the new First Minister

The Chief Executive of Welsh mental health charity Hafal, Alun Thomas, has written an open letter to the new First Minister of Wales, Mark Drakeford, on behalf of the Charity’s 1600 Members.

The letter welcomes Mr Drakeford to his new role and calls for a renewed emphasis on the Prudent Healthcare approach championed by Mr Drakeford when he was Minister for Health and Social Services.

Read the letter in full here:


Dear First Minister

Warm congratulations on your appointment from Hafal and our mass membership of people with a mental illness, their families, and other supporters. We wish you the very best in your new role and we pledge ourselves to support you in your endeavour to improve the lives of those who depend on health and social care services in Wales.

You have always been a friend to Hafal and, more importantly, to everybody affected by mental ill-health. We recollect your time as Health Minister in particular and your interest in speaking directly to those with a mental illness to find out what they need. We appreciate your willingness to listen and this gives us hope for the future.

I wonder if we might presume on your time to raise two ideas of great importance to us? I should say that they both offer the prospect of making better use of existing resources rather than demanding more…

Prudent healthcare

We especially respect you as the champion of Prudent Healthcare – that commonsense and cost-effective approach to using resources most efficiently to help people. As well as promoting coproduction and equitable services across Wales you identified the necessity to “care for those in the greatest health need first” and to “do only what is needed and do no harm”.

Prudent Healthcare is still with us, underpinning the new Welsh Government Strategy “Healthier Wales”, but we are very concerned that the key principles of Prudent Healthcare are at risk of being forgotten in the current delivery of mental health services. Please let me explain…

In common with other countries in the developed world Wales has seen growing interest in mental health among the public and especially younger people. This is welcome to the extent that we all want people to recognise the importance of mental health and how we can help ourselves and others to stay healthy.

However, there has been a negative consequence as well. There is an increasing tendency for people to equate worry and sadness resulting from loss, uncertainty, and other real life problems with mental ill-health – a counterproductive “pathologising” of life’s ups and downs. Further, where people’s mental health is really under strain, there is also an increasing tendency for people to look to specialist services to get help instead of first making use of their own resources, family, and friends, or getting help from schools, employers and others. And where people go to their GPs they are sometimes offered treatment when in reality they need help with practical problems brought on by life events.

As a result there is a huge increase in calls on GPs and in referrals to specialist services, especially of young people – figures published in 2014 showed that referrals to Child and Adolescent Mental Health Services  had doubled in just four years.  This is not a result of an increase in mental health problems (there is no evidence for that): indeed there is no epidemic of mental illness but there is an epidemic of over-referral and (worst of all) inappropriate and damaging treatment. Two examples stand out among many:

  • Wales has seen a 68% increase in prescription of anti-depressant drugs in 15 years: as we found this year in our #DeedsNotWords campaign for women’s mental health these drugs are often used as substitute for real help with poverty, unemployment and disempowering relationships: the waste of resources is a small matter compared with the scandal of medicating people – many of them women – instead of giving them the practical support they need.
  • Until a few years ago we were all scandalised by the over use of drugs on children in the United States to address behavioural problems. Today this has become routine in Wales as elsewhere in the UK instead of drugs being used only exceptionally. Dr Tony Lloyd from the ADHD Foundation has said “The fact of the matter is that in the UK medication is the first line of treatment and pretty much the only line of treatment.” So “difficult” children are medicated to make them easier for parents and teachers to manage, a practice which should shock us but is now becoming the norm.

Resorting to mental health treatments as a default is unethical as well as costly. It also has the consequence of dangerously compromising the care and treatment of people who really need specialist care. Waiting lists for specialist mental health services for young people are so extended that people with a serious mental illness are put at serious risk (figures published in November 2017 showed that only 45% of referrals to CAMHS were seen within a month). We are therefore in a position where many people are treated inappropriately and a few do not get the treatment they badly need.

We suggest that there is a need to revisit first principles concerning mental health and there is an opportunity to do this when the current Together for Mental Health strategy is replaced in the next couple of years. One of your legacies as First Minister might be to require a new strategy to redress the balance – treating those in greatest need first and limiting mental health services to evidence-based treatment of properly-diagnosed mental health problems. Alongside this there is a need for revised public health advice about the reality of mental ill-health and making clear that, where people do have a mental health problem, this is usually best addressed through the support of non-specialists such as schools and employers who have these pastoral responsibilities.

Commissioning ethical and cost-effective services

We have noted your recent pledges on requiring ethical use of public funding for commissioned services and your commitment to “raise the status of the procurement profession” with an emphasis on ethical procurement and providing best-value outcomes – and we welcome your focus on this important issue.

An investigation by The Times in November this year suggested that companies are charging the NHS millions of pounds for in-patient care which is ‘sometimes sub-standard’ and which fails to provide ‘adequate or safe care’. The investigation found that patients are sometimes hospitalised against their will, and for many years, in units which do not meet the required standards.

Sir Stephen Bubb, who conducted the inquiry after a case at Winterbourne View Hospital in 2011 where staff were found to be abusing patients, commented: “It’s truly shocking that private providers are cashing in on substandard care, paying themselves liberally on money from our NHS. These institutions should be closing, not expanding. Profiting from our most vulnerable citizens leaves a bad taste.”

As you know NHS Wales still makes extensive use of private mental health in-patient provision, much of it based in England – a long way from home for the patients and surely not the best use of the “Welsh pound”. We earnestly hope you will bring our patients home and preferably to NHS or not-for-profit services.


So very best wishes in your new job: we have great respect and high hopes for you and we stand ready to assist you in serving the people of Wales, especially those who are most vulnerable and in need of our support.

Best wishes

Alun Thomas, Chief Executive, Hafal