Hafal: A Prudent Healthcare Approach to User-Led Service in Wales

Thomas, Alun1

Pearce, Matthew1

Wilson, Christine1

Hails, Euan2

Thomas, Phil1

Dugmore, Andrew1

Kitt, Frank1

Celia, Jason1



2S-CAMHS, Aneurin Bevan UHB

This work is licensed under a Creative Commons Attribution 4.0 International License.



Recovery, Mental Health, Wales, Delivery of Health Care




Hafal, which means equal in Welsh, is the principal charitable organization in Wales working with individuals recovering from serious mental illness and their families. Hafal is managed by the people it supports; individuals with serious mental illness and their families. Hafal has over 350 staff and volunteers who together provide help to over 1,000 people affected by serious mental illnesses. This includes schizophrenia, bipolar disorder, and other diagnoses which typically involve psychosis or high levels of need that may also require hospital treatment. Hafal's mission is founded on the belief that people who have a direct experience of mental illness know best how services can be delivered and formulated. As a member-led organization, Hafal provides support across all seven Local Health Board areas of Wales and is dedicated to empowering people with serious mental illness and their families so they can achieve a better quality of life, fulfill their ambitions for recovery, fight discrimination, and enjoy equal access to health and social care, housing, income, education, and employment.


On December 1st 2016 Alun Thomas took on the role as new Chief Executive at Hafal, and he did so at an interesting time. In a verbal presentation to stakeholders he commented:

We now have a progressive Welsh mental health law and strategy in place, and patients and carers have gained key new rights in recent years. However, recent figures show that Health Boards in Wales have reduced spending on services; furthermore, a report published by a Welsh Assembly Committee in November 2016 raised serious concerns about services for young people. So while Wales has some of the best mental health legislation and policy, there is evidently room for improvement in the resourcing and delivery of services.

What Can Hafal Do About it?

As a charity, Hafal's mission is simple: do everything we can to promote recovery from mental illness, either by delivering services directly to clients, or by campaigning for a better system experience for all patients and their carers. But while patients' recovery is the first and foremost aim, we also want to make an economic case for a recovery-based approach to resourcing and delivery of services. A recovery approach not only improves the lives of patients and their carers, it may also lead to significant savings in valuable mental healthcare funding.


Research evidence estimates that the cost of mental health problems in Wales is in excess of £7.2 billion per annum.1 In addition to this, people with a serious mental illness are at increased risk of developing specific physical illness. For example, they are at twice the risk of developing diabetes,2 they are three times more likely of dying of heart disease, and have a reduced life expectancy of up to 20 years.3 They are also more likely to experience what is referred to as 'unexplained' physical symptoms, caused by psychological distress which often goes unrecognized and unaddressed. Therefore, investment in mental health services also provides a realistic opportunity of seeing a reduction in physical health care budgets.

A Prudent Healthcare Approach

Wales has a devolved Government in Cardiff which has responsibility for planning, funding, and providing health and social care, independent of the United Kingdom Government in London. Pioneered by the Welsh Government, prudent healthcare is a term which is often used when discussing the future of healthcare in Wales. The main driver behind prudent healthcare in NHS Wales is not saving money but ensuring the people of Wales receive the best possible care from the available resources.4


Four of the principles of the prudent healthcare approach are:


  1. Achieve health and wellbeing with the public, patients, and professionals as equal partners through co-production.
  2. Care for those with the greatest health need first, making the most effective use of all skills and resources.
  3. Do only what is needed, no more, no less; and do no harm.
  4. Reduce inappropriate variation using evidence-based practices consistently and transparently.

The aim and ethos of prudent healthcare are to promote services, which are as effective as possible at supporting recovery and to be as efficient as possible in achieving this. There is a need to look at the human cost and the financial cost when developing services. Those costs are not inversely proportionate: recovery-focused services with an emphasis on co-production may lead to better outcomes for patients and a reduction in financial cost.

Developing a service culture with a philosophy of recovery and aspiration, as opposed to one of stability and maintenance, means that people are supported to progress and move on instead of being maintained in their current condition and situation. Recovery means long-term savings; stability and maintenance means ongoing cost, both in human and financial terms.

In practice, Hafal believes a model of prudent healthcare for mental health services should focus on two principles. First, resources should be targeted efficiently in moving those patients receiving higher-end (and more expensive) services down into lower-level support services. This will have the greatest impact in terms of improving people's lives and, additionally, in reducing the cost of their care and treatment. Second, services should provide the earliest possible intervention. One cannot prevent illnesses such as schizophrenia and bipolar disorder, which require high-level care; but by treating them at the earliest possible point, outcomes may be greatly improved for patients. It is possible to reduce the effects of long-term illness by altering the illness trajectory and drastically reduce care and treatment costs and the long-term detrimental effects of illnesses such as schizophrenia and bipolar disorder. Hafal believes that people can be equipped with the right self-management skills to take care of themselves in the long term. Any savings made by applying these principles should be reinvested in mental health so that services are sustainable and well-resourced for future generations.

Indeed, early intervention services have become a priority for Hafal. In 2013, a dedicated early intervention service called Up 4 It was launched for young people in Gwent in partnership with Aneurin Bevan University Health Board. This ensures that young people receive optimal care and treatment at the earliest stage of their illness. Sarah, a 23-year-old service user, told us: "If you get timely treatment when you first experience mental illness then you can be supported to stay in education or employment and prevent the illness from damaging the rest of your life." This project is specifically aimed at preventing hospital admission, which is costly, both for the patient in disrupting their life and for the NHS.

Hafal adheres to the prudent healthcare principles of targeting care for those with the highest needs; however, it is the case that many of our clients with a diagnosis of schizophrenia or bipolar disorder have found it difficult to access evidence-based psychological therapies. All too often service users report that they receive psychiatric treatment in the form of medication, with little information about the benefits of "talk therapy." To address this issue, a campaign was launched to ensure that evidence-based psychological therapies are included in their care plan. The impact has been significant. One carer told us: "Our son has responded hugely from receiving transactional analysis, and it has helped him take ownership of his illness. Earlier intervention would have been cost effective."

In line with this work, Hafal recently launched Let's Talk!, a Big Lottery-funded project5, which aims to promote and raise awareness of evidence-based psychological therapies for people within Wales with a serious mental illness. The proposal for the Let's Talk! project was developed in close consultation with HELP, Hafal's Expert Leadership Panel. HELP is now a group of some fifteen people all of whom have lived experience of mental illness, and who use that experience to support Hafal's campaigning, and to contribute to the development of better mental health services across Wales. Currently they are actively involved in mental health research, in peer mentoring and support, and in offering presentations and training to combat stigma and to inform professionals and the wider public. A number of HELP members have received psychological therapy and believe this intervention to be a major factor in their recovery. HELP is therefore very committed to improving access to psychological therapies for other people in a similar position.

Let's Talk! About Psychological Therapies6 was launched at the Senedd (Welsh Government) on World Mental Health Day 2016, and has a number of innovative activities to promote access to evidence-based talking therapies. This includes establishing a Centre of Excellence Observatory for evidence-based psychological therapies which will provide, for the first time, a one-stop shop for information and advice for the general public and professionals seeking details of local and national service availability across all sectors, public, private, and voluntary.6

The Recovery Centre

Over ten years ago, Hafal Members and Trustees formulated a vision for in-patient mental health services in Wales. The vision was to establish a hospital led by its service users; a progressive service with a strong recovery focus based on comprehensive care planning. It required an inviting, therapeutic, and home-like environment with high-quality bedrooms, ensuite facilities, and a wealth of activities on offer. Initially the vision was perceived as unattainable and radically removed from everyday reality. After ten years of development, thanks to the work and campaigning of Hafal Members and the financial support of Big Lottery and the Welsh Government, that vision has become a reality.


The new Gellinudd Recovery Centre in Pontardawe opened in January 2017. This Recovery Centre is the first of its kind in Wales and the UK: a user-led, not-for-profit in-patient service with a recovery ethos, delivered by a third sector organization. In developing the Centre, staff travelled to Canada and the USA to see models of best practice. Academic visitors from Japan and Taiwan have travelled to see the Centre.


The Centre has been developed in close liaison with the NHS in Wales to ensure the service provided fits with existing NHS services and meets the highest clinical governance standards. Its approach is strongly in line with Welsh law and policy including the Mental Health (Wales) Measure and the Together for Health which are Welsh Government strategies.7 The Centre is registered with Health Inspectorate Wales, and is on the NHS Framework.8 It is staffed by both registered mental health nurses and registered general nurses, and will be supported by physiotherapy, occupational therapy, psychological therapy psychiatrists, and, most importantly, by those with a lived experience of mental illness.

Criminal Justice and Mental Health

Undeniably, the likelihood of coming into contact with the criminal justice system is increased for people with mental illness. The expansion of the prison population in the last ten years coincides with significant increases in the proportion of inmates experiencing mental illness, substance misuse, or learning difficulties, to a point where nine out of ten prisoners in Wales experience these problems.9 In 2010 the National Audit Office estimated the cost to the UK economy of re-offending of those released from custody to be between £9 billion and £13.5 billion. An updated figure of up to £15 billion is reflective of 2016 prices.10 Within any process of rehabilitation, however, maintaining bonds with family and friends is considered to be most significant towards success.11 In Wales, unfortunately, those subjected to imprisonment face additional barriers due to insufficient national custodial accommodation. Of the 4,679 people imprisoned in 2014 from a home address in Wales, over 2,000 were serving their sentence in England. Some categories of prisoner, such as women or young adults, have no such accommodation in Wales.12 Unfortunately, current figures reveal the highest number of prison suicides since records began with understaffed prison mental health teams struggling to help prisoners in desperate need.13


Under the requirements of the Codes of Practice of the Police and Criminal Evidence Act 1984,14 Hafal provides an Appropriate Adults safeguarding service, which requires the police when detaining or questioning mentally disordered or mentally vulnerable adults suspected of crime, to obtain the support of an appropriate adult to counter the risk of injustice within the legal process. These invaluable interactions with staff from Hafal, who are experienced in the field of mental health, have initiated a partnership approach with offender management staff and increased the numbers of people whose offending behaviour has been identified as symptomatic of an underlying mental health problem. In turn, this has led to a more appropriate jurisprudent healthcare approach where interventions now become more focused upon the previously unmet mental health needs of the offender.


In 2015 Hafal undertook a pilot scheme, operating within the South Wales Police area, to provide a holistic recovery model approach to address identified psycho-social issues contributing to the offender's poor mental health and subsequent offending. Of 35 individuals supported via Hafal's recovery model through the scheme, only two went on to receive custodial sentences while 33 were diverted away by practical socio-psychological support.15 This pilot has provided a springboard for Hafal's current Out of the Blue Project, which now takes referrals from the National Offender Management System and is anticipated to support in excess of 200 offenders with existing mental health problems over a three-year period.


Care and Treatment Plan

One of the best opportunities for a prudent healthcare approach is the standard Care and Treatment Plan prescribed by the Mental Health (Wales) Measure which, since 2013, is Welsh law for all secondary mental health service users in Wales. The Plan is a useful tool in that it empowers patients and carers to have their say in their care and treatment. It is goal focused, it records all needs in one place, and, importantly, it is holistic, covering all areas of life.15


Health services are rarely commissioned on the basis of delivering outcomes valued by patients. Instead, many health services are arranged around the services and structures they already have, rather than the needs of those receiving healthcare.3, 4 By involving people in the process of planning their care and treatment and by identifying outcomes for that person in all areas of life, the Care and Treatment Plan offers an opportunity to counter this tendency in health services, and provides a more patient-focused live service.

Furthermore, the Care and Treatment Plan facilitates a partnership between the people who use and provide services. The Plan promotes recovery, engaging people in planning their care and treatment and working as a goal-setting tool which jointly identifies a way towards better health.

The Recovery/Cost Pathway

How can Prudent Healthcare work in practice? Hafal has worked with a number of NHS and Local Authority partner commissioners around Wales to develop the Recovery/Cost Pathway which is an analysis of service costs and to an extent, an analysis of the impact on the service users' life.16 This analysis is illustrated in Figure 1, with approximate costings included.


Figure 1 Recovery Cost Pathway


Hafal's members know from personal experience that recovery-focused services supported by good quality Care and Treatment Plans help to foster several outcomes.


For example, the majority of users at Medium and In-patient secure level could move faster down to 24-hour care level and below which realizes a saving of £60-125,000 per person per annum. Most patients at 24-Hour Care level can move much more quickly than traditionally down through Specialist Service: Daytime Staff level to Peripatetic level, a saving of £43-57,000 per person per annum. Users at Peripatetic level can be prevented from relapsing and entering higher-level care. Many more users overall could reach Primary Care level rather than remain stuck at high levels. The No Services level which denotes full recovery, already achieved by many people who have experienced schizophrenia for example, can be a goal for many more users. In recent years, Hafal has been particularly successful in supporting clients to move from needing 24-Hour Care level, at a cost of approximately £65,000 per annum, to needing Peripatetic Care, at a cost of around £8,000.


The benefits for patients in terms of achieving a better quality of life have been vast. Specifically, Hafal has extensive experience of bringing people in high-cost private sector care back to local third sector service provision and has found that this more therapeutic, recovery-focused service leads to move-on to lower-level and lower-cost care, and improved outcomes for the client.


Real-Life Benefits

To really see the benefit of Prudent Healthcare3, 4 you need to look at individual stories. Cath, who comes from Aberystwyth, was diagnosed with schizophrenia and spent 2 years in hospital from the age of 24; she then lived at home with her mother and was long-term unemployed. From 1996 to 2001, Cath was a tenant at Hafal's Ystwyth supported accommodation project, which enabled her to move into her own flat and become more independent. By taking part in Hafal's Recovery Program, Cath was able to set recovery goals and return to university to get a degree. She was also supported to take part in voluntary work and became Chair of the local Project Advisory Group. Taking Hafal's recovery approach, Cath's expectations were raised even further. When she moved on from the service she achieved one of her main recovery goals: to enter employment, becoming a Hafal Support Worker. She is now a Hafal Practice Leader managing high-needs supported accommodation service. In short the recovery process has empowered Cath to take control of her life, move on from services, achieve independence a good quality of life, and become a tax payer. This story is a perfect example of the Prudent Healthcare approach Hafal is employing. It shows how a progressive and ambitious program of support can empower a person to take steps towards recovery and reduce their dependence on services.


Hafal wants services in Wales to embrace this approach simply because it makes sense, in both human and financial terms. To this end, Hafal will continue to champion Prudent Healthcare, improved access to evidence-based psychological therapies, and the development of modern, innovative and effective services, designed for, and with, service users at the heart of developments.



Alun Thomas, Matthew Pearce, Christine Wilson, Euan Hails, Phil Thomas, Andrew Dugmore, Frank Kitt and Jason Celia do not have any conflicts of interest to declare regarding the publication of this article or its contents.


Corresponding Author: Christine Wilson, Hafal, Unit B3, Lakeside Technology Park, Phoenix Way, Llansamlet, Swansea, SA79FE Wales, Email:christine.wilson@hafal.org



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14.Police and Criminal Evidence Act 1984 (PACE) codes of practice. 1984[cited 2017 March 14]; Available from: https://www.gov.uk/guidance/police-and-criminal-evidence-act-1984-pace-codes-of-practice.

15.Wilson, C., et al. Linc 18-25 project evaluation final report. 2015[cited 2017 March 14]; Available from: http://www.hafal.org/wp-content/uploads/2015/06/Linc-18-25-Project-Evaluation-FINAL-REPORT-20-07-15.pdf.

16.Hafal. Care and treatment planning guide. 2012 [cited 2017 March 14]; Available from: http://www.hafal.org/pdf/Care_and_Treatment_Planning_1.pdf.

Copyright (c) 2017 Thomas Alun, Matthew Pearce, Christine Wilson, Euan Hails, Phil Thomas, Andrew Dugmore, Frank Kitt, Jason Celia

Journal of Recovery in Mental Health ISSN 2371-2376