mhGAP training has been proved to be effec- developing States’. To realise these targets by tive to improve the trainees’ knowledge and atti- 2030, countries need to invest more in mental tudes towards people with mental disorders, but health, especially in human resources. Mental close monitoring and supervision is needed to health services do not require expensive equip- change their clinical practice. ment, but they do need more trained human It is crucial to raise awareness on mental health resources. mhGAP is one effective solution, but and also on the availability of mental health services there is also need to increase human resources to increase help-seeking behaviour. Awareness rais- at all levels – specialists, non-specialists and com- ing and mental health service capacity building munity/village health workers. need to go hand in hand. Weak health information systems make moni- References fi toring and evaluation dif cult. There is a need United Nations (2016) Sustainable Development Goals. UN. Available to integrate and strengthen health information at https://sustainabledevelopment.un.org/sdgs (accessed 1 November systems, and to report on a core set of mental 2016). health indicators. World Health Organization (2008) mhGAP: Mental Health Gap Mental health has been included in Action Programme: Scaling up Care for Mental, Neurological, and Sustainable Development Goals (United Nations Substance Use Disorders. WHO. Available at http://www.who.int/ 2016); for example, target 3.4 states: ‘By 2030, mental_health/evidence/mhGAP/en/ (accessed 1 November 2016). reduce by one third premature mortality from World Health Organization (2010) mhGAP Intervention Guide for non-communicable diseases through prevention Mental, Neurological and Substance Use Disorders in Non-Specialized and treatment and promote mental health and Health Settings. WHO. Available at http://www.who.int/ ’ mental_health/publications/mhGAP_intervention_guide/en/ well-being . Target 3.c recommends an increase (accessed 1 November 2016). in the health workforce in SIDS: ‘Substantially increase health financing and the recruitment, World Health Organization (2016) mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized development, training and retention of the health Health Settings – Version 2.0. WHO. Available at http://www.who.int/ workforce in developing countries, especially in mental_health/mhgap/mhGAP_intervention_guide_02/en/ (accessed least developed countries and small island 1 November 2016).

THEMATIC 52 degrees south: mental health services PAPER in the Falkland Islands Karen Rimicans1 and Tim McInerny2

1RMN, Specialist Practitioner in The Falkland Islands are situated approxi- Community Mental Health This article discusses the factors that have mately 8000 miles from the UK and 400 miles Nursing, Nurse Teacher, and shaped the development of the new mental Senior Community Psychiatric from South America. The islands are geographic- health legislation within the Falkland Islands. Nurse, Falkland Islands ally remote with limited access by sea and air. 2 The process of implementing new legislation Visiting Psychiatrist, Falkland There are 700 islands, of which 50 are sparsely Islands; South London and within this remote island community is Maudsley National Health Service populated, spread across an area of 12 000 square discussed, including the aspirations underlying Foundation Trust, Bethlem Royal miles. The Falkland Islands have 2931 residents, Hospital, Beckenham, UK; email the new legislation, the management of [email protected] composed of islanders mainly of British descent psychiatric emergencies and the needs of the who immigrated in the 1800s, and expatriates fl clinical team. Con icts of interest. None. from the UK, St Helena, Chile, Peru, the doi:10.1192/bji.2017.15 Philippines and other countries. Of the residents, 62% have lived in the islands for more than 10 © The Authors 2018. This is an The management of mental health needs in the years. The majority of people live in Stanley, the Open Access article, distributed fl under the terms of the Creative British Overseas Territories is in uenced by capital of the islands, while the remainder live in Commons Attribution- many factors, including economic capacity to Camp, the local term for the countryside outside NonCommercial-NoDerivatives licence (http://creativecommons. invest in services, organisational structure and Stanley (Falkland Islands Government, 2015). org/licenses/by-nc-nd/4.0/), which resources, perceptions of mental health need Transient visitors to the islands include sea- permits non-commercial re-use, fi distribution, and reproduction in and the accessibility of mental health resources farers and shermen who work on the inter- any medium, provided the ori- within neighbouring countries or the UK. national commercial fishing ships within Falkland ginal work is unaltered and is fi properly cited. The written per- The Falkland Islands are self-governed and Islands waters. The shing industry has a unique mission of Cambridge University self-funded with the exception of defence. Public working environment and holds the unenviable Press must be obtained for com- mercial re-use or in order to cre- administration, including health and education, rank of highest occupational mortality rate, with ate a derivative work. operate in parallel to English systems with local fishermen being considered 52.4 times more likely adaptations in place. to have a fatal accident at work relative to other

30 BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 02:30:03, subject to the Cambridge Core terms of use. occupations in Great Britain (Roberts, 2002, health problems. When emergency or complex p. 544). The health service provides emergency treatment is required, services are sought in the medical and psychiatric treatment for injured fish- UK or, in some circumstances, Chile or Uruguay. ermen. Fishermen bring their own unique health The expectation of the clinical team is to treat challenges as well as a range of social, economic, patients holistically, bridging the gap between spiritual and cultural needs. Providing healthcare mental health and general hospital care, as there for foreign fishermen can have a significant impact are no dedicated psychiatric in-patient facilities or on local resources. staff. Approximately 5% of all admissions to the hospital are mental health related, although a Health service provision within the minority of hospital admissions will necessitate Falkland Islands applying mental health legislation. Similar propor- tions of acute mental health presentations have Mental health services consist of a visiting liaison been found in remote rural regions of Canada, consultant psychiatrist who provides outpatient Australia and New Zealand (Happell & Plantania- clinics twice per year and year-round advice to Phung, 2005; Kim et al, 2011). the clinical team; a child and adolescent consultant clinical psychologist providing an annual clinic and Creating a new Mental Health Ordinance clinical supervision for the school nurse, and the The former Mental Health Ordinance (MHO) of two community psychiatric nurses (CPNs), who 1987 had no right of appeal, no access to legal are employed locally. The visiting psychiatrist is a advice, and no right of information for the patient forensic specialist based in the UK; this ensures and relatives; no requirement for police officers that the psychiatrist is skilled in risk assessment, who had powers of arrest and detention to have mental health law and offender management in any mental health knowledge; and no require- addition to general liaison duties. This has proven ment for clinical professionals involved to have invaluable in this remote community. specific MHO training. A patient could be Assessment and treatment of mental disorders detained for 1 year on the authorisation of a sin- is provided by the CPNs in conjunction with their gle doctor. Such an MHO was incompatible with medical colleagues. Community and in-patient the European Convention of Human Rights, to treatments involving psychological therapies, which the Falkland Islands are subject. psychoeducation and guided self-help cognitive– In 2006, a working group was convened com- behavioural therapy are available, plus a more prising the visiting psychiatrist, Chief Medical limited range of psychopharmaceuticals com- Officer, senior CPN, social work team leader, pared with that available in the UK. Senior Crown Counsel, Senior Magistrate and Mental disorders such as anxiety, depression and Police Inspector. The working group met with alcohol abuse are most prevalent, while rates of elected politicians and consulted the wider public enduring mental illnesses such as schizophrenia through local media and Team Tranquil, the local and bipolar affective disorder are low (Fig. 1). mental health charity, to agree the proposals. Child safeguarding issues present challenges for Mental health law in other small countries was local services. Sexual offender assessment and considered. A mental health bill was drafted rehabilitation is provided by the probation officer locally, and advice was sought from the Mental in collaboration with the visiting psychiatrist, Social Health Unit of the UK Ministry of Justice, Services, CPNs and other agencies as required. which approved the detailed proposals. The new The King Edward VII Memorial Hospital in MHO was enacted as law by the Legislative Stanley is a small general hospital where the health- Assembly in July 2010. A code of practice was care needs of all local residents and visitors are met, then devised in 2010 in consultation with key including the needs of those with acute mental stakeholders, such as the ward manager (Falkland Islands Government, 2010). Section fl 40 forms and information lea ets for patients, near- est relatives and the general public were drafted. 35 The MHO came into force on 1 November 2010. 30 The principles of the MHO follow the English 25 and Welsh Mental Health Act 2007, namely those 20 of purpose, least restriction, respect, participa- 15 tion, effectiveness, efficiency and equity. The 10 MHO allows the police powers to transfer indivi- 5 duals to hospital for assessment. Approved 0 Doctors can detain a patient for up to 72 h; if an EMD CMD Alcohol Forensic Dementia Approved Professional agrees during this period, related the detention can continue for up to 6 months. 2005 2015 Those who are detained receive written and ver- bal instruction on their rights, with access to Fig. 1 legal advice and a right of appeal to an independ- Overview of Consultant Psychiatrist outpatient clinic, 2005 and 2015. EMD, enduring mental illness; CMD, common ent Mental Health Tribunal. Where English is not mental illness (anxiety and depression). the person’s first language, access to a local

BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 31 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 02:30:03, subject to the Cambridge Core terms of use. interpreter or telephone interpreter is provided. also acceptance of the limitations around clinical The code of practice handbook clarifies the practice. Training devised to develop local mental requirements of Approved Practitioners. All doc- health skills and disseminate the MHO has been tors, nurses and social workers have to attend implemented since 2010. Teaching strategies MHO training run by the visiting psychiatrist include multi-agency case management role- and senior mental health nurse every 5 years to plays, tabletop exercises and ‘fire drills’, coupling achieve Approved status. problem-solving with familiarisation with the A Mental Health Tribunal must convene MHO paperwork necessary when dealing with a within 14 days of an appeal being lodged. A tribu- psychiatric emergency. Providing training has nal comprises the Senior Magistrate and two benefits including increased staff confidence and Justices of the Peace (JPs), or three JPs If the the development of a ‘cultural and community Senior Magistrate is unavailable. If statutory understanding’, which helps to create a team criteria for detention are not met, the tribunal is response to managing challenging clinical pro- obliged to discharge the patient from section. blems (Strasser & Neusy, 2010, p. 780). The cur- The Falkland Islands Constitution 2008 states rent trend towards clinical specialism within the that any detained person with a mental disorder, field of mental health practice is superfluous in including a Falkland Islander, may be removed remote areas, where specialist generalists with a from the islands against their wishes for treatment broad knowledge base across the spectrum of in the UK or, in some instances, Chile or mental healthcare are required. Uruguay. This Overseas Removal Order is made by the Chief Medical Officer to the Mental Future challenges Health Tribunal, which must be satisfied that Exploring the effectiveness of the MHO, identify- the mental disorder cannot be effectively treated ing positive patient outcomes, analysis of clinical in the Falkland Islands and that removal is neces- practice and risk management are other areas sary in the interests of the person or to protect the for future development. public. Seeking overseas treatment through the Ensuring that adequate resources and mechan- MHO is an infrequent occurrence and is primar- isms are in place to maintain consistent good clin- ily required for treatment of acute psychiatric epi- ical practice is an ongoing challenge. Staff turnover sodes that necessitate in-patient care beyond what leads to knowledge deficits, which can be coun- can be provided locally. By questioning clinical tered by regular commitments to provide training decisions, the Mental Health Tribunal ensures by mental health professionals. Since 2010, over the principles of the MHO are respected and safe- 150 professionals have received MHO training, guards patients’ best interests and rights. including legal advisors, police officers, social work- Overseas treatment understandably leads to ers, registered nurses and doctors, while over 100 extreme separation of patients from relatives qualified and unqualified health workers have par- and the local community, and challenges in plan- ticipated in mandatory training to ensure safe and ning return following recovery. Islanders are, effective team work when managing psychiatric however, used to such complications, knowing emergencies. Acknowledgement of the need for the limitations of their remote geographical loca- mental health skills across clinical roles, through tion, and appreciate the need for safe, specialised investing in people and continuing professional overseas care, whether for medical or psychiatric education, is essential (Harrison & Hart, 2006, emergencies. p. 27). The government has recognised that the hos- Clinical challenges in a remote pital, as the designated place of safety, currently community provides inadequate resources for acutely behav- The provision of mental health services within a iourally disturbed patients and plans to create remote community brings both challenges and an admission suite that is safe for all patients. rewards. Challenges include setting clinical Any increase in acute admissions will have an boundaries and patient confidentiality, where impact on local resources, so close monitoring of treating colleagues, family and friends can be an the balance between demand and resources is issue. Sensitivity to the needs of the community required. and cultivating good working relationships are essential. The local team takes pride in its References resourcefulness and finding solutions to problems Falkland Islands Government (2010) Mental Health Ordinance. can be rewarding; however, ensuring that Attorney Generals Chambers, Stanley. adequate resources are available to provide Falkland Islands Government (2015) Statistical Year Book 2014, good-quality care requires investment, forward Policy and Planning. Falkland Islands Government Secretariat, Stanley.

thinking and recognition of the diverse needs Happell B. & Plantania-Phung C. (2005) Mental health issues within that can stretch resources, to avoid any undue the general health care system: The challenge for nursing in Australia. strain on service providers. Nurse Education Today, 25, 465–471.

Maintaining professional expertise remains a Harrison A. & Hart C. (2006) Mental Health Care for Nurses: Applying challenge in a context where mental health skills Mental Health Skills in the General Hospital Setting. Blackwell are more than knowledge and experience, but Publishing.

32 BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 02:30:03, subject to the Cambridge Core terms of use. Kim C. S., Ideker K. & Todicheeney-Mannes D. (2011) Usefulness of Roberts S. E. (2002) Hazardous occupations in Great Britain. Lancet, Aggressive Behaviour Risk Assessment Tool for prospectively 360, 543–544. identifying violent patients in medical and surgical units. Journal of Advanced Nursing, 68, 349–357. Strasser R. & Neusy A. J. (2010) Context counts: training health workers in and for rural and remote areas. World Health Organisation Bulletin, 88, 777–782.

THEMATIC Psychiatry in Shetland PAPER Martin Scholtz1 and Almarie Harmse2

1Consultant General Adult merchants, based in Bergen, Bremen, Lubeck Psychiatrist, Dorset HealthCare The Shetland Isles are a place of breathtaking and Hamburg. After the 1707 Treaty of Union, University NHS Foundation Trust, landscapes and pristine wildlife. As harsh as UK; email [email protected] the new British government ousted the Hansa the weather can be, so warm and welcoming 2Specialty Doctor in Psychiatry, and, during the 18th century, local merchant- are the people and their proud half-Scottish, NHS Shetland, UK lairds ruled the land by means of a feudal system half-Scandinavian culture. Practising fl and built lavish mansions (known as Haa houses) Con icts of interest. None. psychiatry in this northernmost outpost of the in every part of Shetland. UK involves significant challenges. The Keywords. Rural psychiatry; The First World War destroyed the markets personality disorders; reducing authors were the only two psychiatrists based for the booming herring fisheries, which at hospital admissions. on this remote island group, which is home to the turn of the century had lifted many islanders 23 000 people. doi:10.1192/bji.2018.2 out of poverty, and emigration increased during most of the 20th century. During the Second © The Authors 2018. This is an Open Access article, distributed World War, Shetland was the base for a secret under the terms of the Creative and dangerous operation that saw small fish- Commons Attribution- Where is Shetland? NonCommercial-NoDerivatives ing boats, known as the Shetland Bus, supporting ’ – licence (http://creativecommons. Shetland is Britain s northernmost community a the Norwegian resistance against Nazi org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, group of over 100 islands, 15 of which are inhab- occupation. distribution, and reproduction in ited. The main town, Lerwick, is 217 miles north By 1971, the population had dropped to just any medium, provided the ori- of Aberdeen. Norway is just over 200 miles to the ginal work is unaltered and is 17 325 compared with 31 670 in 1861. However, properly cited. The written per- east and the Faroe Islands lie a similar distance to a home-grown revival based on fishing, agricul- mission of Cambridge University the north-west, with Iceland only another 300 ’ Press must be obtained for com- ture, knitwear and tourism made Shetland s econ- mercial re-use or in order to cre- miles beyond Faroe. The Shetland Island group omy grow so strongly that, when oil and gas were ate a derivative work. stretches a hundred miles from north to south discovered offshore in the early 1970s, the and lies at a latitude of 60 degrees north. This is Council was able to strike a remarkable deal that as far north as St Petersburg and Anchorage, gave Shetland a share of oil revenues. but warm ocean currents give Shetland signifi- cantly milder temperatures. The average wind speed over the year is around force 4, and wind Culture speeds of hurricane force 12 are not unknown For historical reasons, Shetland has maintained a in winter. Shetland is served by commercial flights close relationship with Norway. The dialect spo- from five Scottish airports and by an overnight ken by Shetlanders contains many Old Norse ferry from Aberdeen (Shetland.org, 2018). words. The houses that people build in Shetland are often in a Scandinavian style and indeed are Historical overview of the Shetland Isles sometimes supplied from Norway. Norwegian Shetland was inhabited by Neolithic farmers by flags are also commonly seen, and place-names 3000 BC. Viking invasions started around 800 are almost exclusively Norse. In Lerwick, many AD, with Shetland part of the Pictish culture street names celebrate Norse figures such as prior to the arrival of the Vikings. Norse (Viking) King Harald. The spectacular annual Up-Helly- rule ended as the result of a marriage treaty in Aa fire festival is Shetlanders’ celebration of 1468 between James III of Scotland and their rich Viking heritage. Shetland has a vibrant Margaret, a Danish princess. The Danish struggled art scene and is popular with artists, writers, to raise the funds for Margaret’sdowry,sothat poets, photographers, musicians, architects, tex- Shetland was mortgaged to Scotland (Shetland. tile designers and a wide range of craftspeople org, 2018). from all over the world. Several music festivals After the Norse warlords, came four centuries take place during the year, including the world- when Shetland sold its salted fish to the outside renowned Shetland Folk Festival (Shetland.org, world through the Hanseatic League of 2018).

BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 33 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 02:30:03, subject to the Cambridge Core terms of use.