NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
Towards implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003
Locality Reports
Dr Sandra Grant, OBE
March 2004
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
Contents
Introduction 1
Locality Reports:
Argyll and Clyde 3 Ayrshire and Arran 12 Borders 19 Dumfries and Galloway 25 Fife 32 Forth Valley 40 Grampian 48 Greater Glasgow 57 Highland 68 Lanarkshire 78 Lothian 86 Orkney 96 Shetland 103 Tayside 106 Western Isles 115
Annex A 121
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Introduction
The remit for the National Assessment means that the focus in the locality reports is on what needs to be done locally to deliver the new provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003. With that in mind the many examples of good care seen across Scotland are not covered in the individual reports. This should not be taken as a negative.
Every effort has been made to achieve consistency in each report. There are however variations in those cases where the local arrangements vary sufficiently to warrant some variety in the presentation of findings. For example not all information was available for or from each area in the same format or with the same coverage and where this is the case it is stated.
The wide-ranging nature of the responsibilities that the Act places on local authorities means that it was virtually impossible to assess the services provided by them or the voluntary sector in a short timescale, although there are examples of services across Scotland in the Final Report. In no way should this be seen as devaluing the Local Authority contribution or minimising the additional demands placed on the Councils.
The findings arising from the visits and review of existing information can only represent a snapshot in time and in many cases the local situation will now be different. However, the purpose is to provide a shared, validated information base to start from and to plan for the successful and timely implementation of the new legislation. The reports should not be used in the form of league tables or as negative criticism.
These reports will now inform the local planning process and will be useful reference documents in the preparation of the joint local implementation plans announced in the Department’s letter of 19 November 2003 (see Annex A).
Some general principles:-
• The Mental Health (Care and Treatment) (Scotland) Act 2003 applies to all age groups, although the greatest number will be adults of working age.
• Where the reports refer to Adult Mental Health Services this covers services and support for those aged 16/18 to 64. Where possible we have been more accurate, but this is the standard definition used by the Information and Statistics Division of the Common Services Agency and the local authorities.
• The year of the data source is stated in each case and represents the latest available.
• Regard was given to the wide range of archive, published and other material throughout the entire Assessment process for ongoing context, progress and other relevant considerations.
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• References to the organisation of Local Authority Mental Health Officer (MHO) services or Responsible Medical Officer services should not be taken as implying or suggesting any preferred structure.
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ARGYLL & CLYDE
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
ARGYLL AND CLYDE
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ARGYLL & CLYDE
1. Argyll and Clyde covers 2,880 square miles and has one of the most diverse populations in Scotland with a population of 418,7501, (298,800 adults) living in island, rural or urban communities, each with strong local identities.
2. Mental health services are provided by 5 local authorities, (Table A), NHS Argyll and Clyde and the voluntary sector. This often complex organisation can make negotiations time-consuming. NHS Greater Glasgow provides services to two thirds of East Renfrewshire while NHS Argyll and Clyde covers the remainder. West Dunbartonshire is also linked partly to NHS Greater Glasgow services. Until recently mental health services were provided from 2 separate NHS Trusts and a degree of separation still exists in practice.
3. There have been serious financial problems in the health services in Argyll and Clyde leading to wide-ranging senior management changes, which may have hindered the pace of development of full joint working between the NHS and each Local Authority. Nevertheless, there are now good examples of partnership at the service delivery level, for example the strong cohesive teams in Dunbartonshire and Inverclyde.
4. Argyll and Bute Hospital (in Lomond and Argyll) has been partly refurbished and good use has been made of Mental Illness Specific Grant money to start up some community services in Bute, Cowall, Mid-Argyll, Kintyre and Lorn. Further investment is needed for community services.
5. East Renfrewshire Council aims to have the same level of NHS service provided for the NHS Argyll and Clyde part of the Council (Levern Valley) as is currently provided in NHS Greater Glasgow. Inverclyde has not yet agreed a financial framework to underpin its mental health strategy, although a jointly funded co-ordinator has been appointed. Renfrewshire also has no agreed financial framework, but a draft reprovision plan for Dykebar has been prepared proposing a shift in the balance of care. In West Dunbartonshire, the number of people receiving mental health services is steadily rising and new Community Care Assessments have almost doubled in the past 2 years. In order to manage the demand, the Council and NHS Board are discussing a financial framework, not yet agreed (December 2003).
Table A - Local Authority populations in Argyll and Clyde
Local Authority Adult Population Renfrewshire [including]: Paisley, 114,000 Barrhead, Johnstone, Bishopton, Erskine Inverclyde 54,580 East Renfrewshire (within A&C) 24,300 West Dunbartonshire (within A&C) 47,600 Argyll and Bute 58,300
1 NHS Argyll & Clyde
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6. There are high levels of unemployment, deprivation and morbidity and 45% of Renfrewshire scores high on indices of deprivation.
Use of the Mental Health (Scotland) Act 1984
6. The use of emergency detention in Argyll and Clyde is high, but short and long-term detentions are more in keeping with the Scottish average. The 2001-02 application of the 1984 Act to detain people for treatment is shown in Table B. Using these figures for a rough prediction of the likely number of detentions under the new Act shows an estimate of 3142 Tribunal hearings across Argyll and Clyde. This may be an underestimate because it uses the average of 8 years as the benchmark, whereas detentions have been rising year on year.
7. In addition to local services there are 21 patients from Argyll and Clyde currently in The State Hospital, with 2 waiting more than 3 months for transfer back to local services. The patient numbers in The State Hospital may reflect a lack of local forensic secure beds in Argyll and Clyde. Despite this, Dykebar is unique in having a close supervision unit for people with a learning disability who need secure care. This example could be usefully followed elsewhere.
Table B - Detentions in Argyll and Clyde under the Mental Health Act (Scotland) 1984 in 2001-02/2002-033
Actual number No. Per 100,000 in No. per 100,000
of detentions Argyll and Clyde in Scotland Sections 24 and 254 410/452 98/108 85/90
Section 265 242/280 58/67 51/56
Section 186 84/105 20/25 21/23
8. The new Act will put pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the final report).
2 Scottish Executive Mental Health Act Implementation Team, based on Royal College of Psychiatrists scoping exercise 3 Mental Welfare Commission Annual Report 2001-02/2002-03 4 Sections 24 and 25 are emergency sections lasting 72 hours 5 Section 26 is a 28 day order that can be used when an emergency section has expired 6 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court
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9. There are 23 Responsible Medical Officers in Renfrewshire and Inverclyde, with 15 consultants working in general psychiatry. There are another 4 posts in Lomond and Argyll, although only one is currently filled. The Royal College of Psychiatrists has estimated that approximately 30 new consultants will be needed in Scotland to meet the demands of the new Act. This is in addition to filling the current vacancies. This estimate takes no account of the implementation of the European Working Time Directive in 2004 and its potential significant impact. Major service redesign will be needed to address these issues, especially where there are already consultant vacancies.
10. The number of additional Mental Health Officers that will be needed for the new Act is hard to estimate, given variations in MHO practice. In Scotland at present there are on average 11.5 Mental Health Officers per 100,000 population. This equates broadly with the position in Renfrewshire and Argyll and Bute. West Dunbartonshire has much lower numbers and the Council there is paying and offering enhanced rates in order to boost local recruitment and retention. Because parts of East Renfrewshire and West Dunbartonshire are covered by NHS Greater Glasgow, not all their MHOs will work within the area covered by NHS Argyll and Clyde. The lack of coterminosity between local authorities and health can cause confusion.
11. Agreement between the different NHS Board and Local Authority groups will allow some cross-boundary cover.
Table C - Mental Health Officers in Argyll and Clyde7
No. of Practising MHOs working in Additional Local Authority MHOs MHOs mental health Payment Argyll and Bute 15.5 11.5 8 No Within generic East Renfrewshire 5 3 No community care teams Inverclyde 13 10 4 No Renfrewshire 8.5 8.5 6 No West 5 4.5 4.5 Yes Dunbartonshire The local authorities do not record the data by NHS Board area and these figures were determined by splitting the total number of MHOs equally between the two NHS boards to give a very rough approximation of numbers.
7 Mental Health Officer Services: Structures and Supports. HMSO.2003
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Hospital Services
12. The local arrangement of hospital services is as follows:
Acute Adult Admission
• Newly built unit at Dykebar Hospital, Paisley (45 beds) • 2 wards at Inverclyde Hospital, Greenock (30 beds) • One ward at Royal Alexandra Hospital, Paisley (30 beds) • One ward at Vale of Leven Hospital, Alexandra (24 beds) • One ward at Argyll and Bute Hospital, Lochgilphead (24 beds)
Intensive Psychiatric Care Units
• Dykebar Hospital, Paisley (8 beds) • Argyll and Bute Hospital, Lochgilphead (10 beds)
Close Supervision Unit
• Learning disabilities with forensic needs, Dykebar Hospital
Continuing Care Wards
• 5 wards at Dykebar Hospital • One ward at Ravenscraig Hospital, Inverclyde (40 beds)
Rehabilitation Services
• Ravenscraig Hospital, Inverclyde (10 beds) • Blarbuie Road, Druimard, Duntrune, and Firgrove
Alcohol Treatment Unit
• Gryffe Residential Detoxification Unit, Inverclyde
13. There has been an increase in the number of people admitted with drug and alcohol problems as well as a psychiatric illness. The violent behaviour of some
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14. service users presents difficult challenges for staff and other patients. The local Police are working with the agencies to address continued illicit drug use and dealing on hospital sites. This reflects the high levels of drug misuse in the area and is not an indictment of the service.
15. The occupancy rate for adult acute beds is high (97% over 9 months in 2003), so there would appear to be little slack in the system. However, for this population size there is a large number of beds. A range of between 57 and 114 general adult acute beds has been suggested by the Royal College of Psychiatrists for this population size, depending on the level of other specialties and community services. There are currently 153 acute beds in Argyll and Clyde.
16. Hospital beds have reduced by nearly 10% over the last 3 years, the majority being those for older people. Despite this reduction Argyll and Clyde still has the highest total bed ratio in Scotland, with 205 beds per 100,000 for all specialties when the national average is 141 (Table D).
17. Argyll and Clyde has the fifth largest population in Scotland, but has no local inpatient services for children or adolescents (although there is an outpatient and day service). Beds are purchased from Yorkhill and Gartnavel Royal Hospitals in Glasgow. The lack of local child and adolescent beds makes Argyll and Clyde vulnerable in responding to the relevant provision in the new Act, similarly so in terms of specialist beds allowing mothers with a perinatal mental illness to be admitted with their babies. Forensic services also need to be developed.
Table D - Hospital bed numbers Argyll and Clyde and Scotland8
Argyll and Clyde Argyll and Clyde Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 949 916 882 857 224 217 210 205 161 153 145 141 specialties All adults under 65 496 483 468 458 117 115 111 109 74 70 66 64 years Older 453 433 415 399 107 103 99 95 83 79 74 73 people Forensic 0 0 0 0 0 0 0 0 * * * * services Child & Adolescent 0 0 0 0 0 0 0 0 * * * * Psychiatry Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. (* rate per 100,000 is too small to provide meaningful data)
8 ISD
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18. The emergency readmission rate within 28 days for adults in 1998-2001 was below the national average. Recent local reviews have shown that this is in part due to the comprehensive infrastructure in Inverclyde. Clinical redesign within Renfrewshire has improved admission procedures and discharge planning, but a great deal more needs to be done to develop community mental health services.
Table E: Hospital admissions in Argyll and Clyde for people aged 16/18-649
Adults 16/18 - 64 years 1998 1999 2000 2001 2002*
First admission (i) 507 463 483 541 519 Readmission (ii) 1406 1472 1402 1457 1399 Emergency readmission rate within 28 6.98% 6.62% 4.54% 5.85% N/A days (iii) Lomond and Argyll Trust Emergency readmission rate within 28 days (iii) Renfrewshire and Inverclyde 6.64% 6.16% 6.40% 6.75% N/A Trust (i) First ever recorded admission to psychiatric in patient care (ii) Readmission following a break in in-patient care (iii) Emergency readmission rate within 28 days of discharge (admissions/discharges x100) *Figures for 2002 are provisional
19. The average length of stay in an admission unit was 36 days in the Royal Alexandra Hospital and 27 in Dykebar, similar to Glasgow’s average of 34. The high occupancy rates are therefore not related to inappropriately prolonged stays.
20. It appears that the large number of beds in Argyll and Clyde is relieving pressures elsewhere in Scotland. In 2001-2002 Argyll and Clyde discharged10 139 people from other NHS Board areas, the largest number of out-of-area admissions in Scotland. Conversely in the same period, Argyll and Clyde had to board out 91 patients elsewhere (mainly Glasgow). In a 3-month survey in 2003 this pattern is continuing.
Community Services
21. Despite its size Argyll and Clyde has developed only 2 Community Mental Health Teams (CMHTs), a fully comprehensive one in Inverclyde and a smaller one in Paisley. There are 2 day hospitals, in Dumbarton and in Inverclyde.
22. There are no CMHTs in West Renfrewshire, Renfrewshire or Levern Valley so the main service is provided by social work and voluntary organisations backed up by consultants with the support of a small number of CPNs.
9 ISD data from SMR04 returns 10 Strictly speaking it was discharge postcodes not admissions that were analysed
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23. Many voluntary organisations provide supported accommodation, “sheltered” employment and training opportunities, befriending and drop-in facilities. Renfrewshire Association for Mental Health is a well-established voluntary provider that has enabled many users to live in the community with support from a wide range of projects. A good example of joint working across provider organisations is the Charleston Centre in Paisley. Renfrewshire and Inverclyde also have partnerships with the National Schizophrenia Fellowship (Scotland) and Inverclyde Association for Mental Health. The NHS Board contributes to the funding of generic advocacy services.
24. ACUMEN, the service user and carer network for Argyll and Clyde, is a collective advocacy group, funded by Argyll and Clyde NHS Board and the 5 LAs. Renfrewshire Association for Mental Health also provides a basic advocacy service to Renfrewshire and the Dykebar Patients Council provides collective advocacy for patients in that hospital. Equal Say provides generic citizen advocacy within East Renfrewshire and the Council intends to develop a dedicated mental health service with Equal Say. There is also a Lomond and Argyll Advocacy service. In Inverclyde collective advocacy was provided by INVOLVE, a service user group that has now unfortunately folded.
25. Within Lomond and Argyll there are also links with other providers, such as the Princess Royal Trust for Carers, Scottish Association for Mental Health, Link Clubs, ACTIVATE, Red Cross and Lomond Mental Health Forum.
Priorities for Services Users and Carers in Argyll and Clyde
26. The key issues raised by local users and carers are as follows:
Paisley Area
• Out-of-hours services beyond 11.00 at night. • 24-hour help-line for crisis. • 24-hour access to services. • Respite care. • Change the attitudes of professionals. • Make all the arrangements for discharge before people leave hospital. • Culture change – treat people with dignity and respect but acknowledge our fragility and our need to take responsibility to stand up and speak out. • Invest in the well being of the population.
Lomond
• Increase in local beds using a ‘hub and spoke’ model. • Permanent consultant psychiatrists. • Services available 24 hours a day 7 days a week. • Equity in investment across the area.
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Argyll and Bute
• Bigger premises for the link club. • More support for parents and children. • Crisis and out-of-hours services.
Comments
27. Major issues that will challenge Argyll and Clyde when implementing the new legislation are:
¾ Bed management is a serious problem with very high bed numbers, high occupancy rates and a high number of out-of-area admissions.
¾ Linked to the high bed numbers is a very poorly developed community infrastructure in most places. This is unlikely to allow the option of a community- based Compulsory Treatment Order as the least restrictive alternative.
¾ Inpatient forensic services and those for mothers and babies are not available and need to be provided either locally or from another service.
¾ More independent advocacy is necessary.
¾ The most significant problem is financial constraints and the lack of agreed joint financial frameworks.
Visiting Team
Dr. Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist The State Hospital
Doreen Kelly Director, Partners for Inclusion, Ayrshire
Tom Keenan Mental Welfare Commission for Scotland
Dr. Tom Murphy Consultant Psychotherapist, NHS Lothian
Jack Stuart General Manager, Mental Health Services, Grampian NHS Trust
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AYRSHIRE AND ARRAN
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
AYRSHIRE AND ARRAN
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AYRSHIRE AND ARRAN
1. Ayrshire and Arran covers 2500 square miles with a population of about 367,0001 (238,970 adults), which increases over summer periods because of tourist visitors. Many people from inland rural or former mining communities are migrating to the larger centres on the coast. The main centres of population are the towns of Ayr, Kilmarnock and Irvine and the island communities have some transport problems getting to the mainland for appointments or in an emergency.
2. Mental health services are provided by three local authorities coterminous with one NHS Board, in collaboration with a wide range of voluntary organisations and service providers.
Table A - Local Authority populations
Local Authority Total population Adult population
East Ayrshire 120,630 78,100
North Ayrshire 138,850 87,100
South Ayrshire 113,920 71,360
Use of the Mental Health (Scotland) Act 1984
3. The use of the 1984 Mental Health Act is in line with or slightly below national rates. The estimated number of Tribunal hearings in Ayrshire and Arran based on detention rates over an eight-year period comes to 1642, but this may well be a low estimate given the consistently rising number of detentions every year. There are 7 patients from Ayrshire currently resident in The State Hospital, one of whom has been recommended for transfer and has been referred to Ayrshire and Arran for assessment.3 There needs to be continuing contact between the local services and The State Hospital to ensure timely transfer when appropriate.
Table B - Detentions in Ayrshire and Arran under the Mental Health Act (Scotland) 1984 in 2001-02/2002-034
Actual no of No per 100,000 Average number per
detentions in people in Ayrshire 100,000 people in
Ayrshire and Arran and Arran Scotland Sections 24 and 255 312/316 85/86 85/90 Section 266 161/171 44/48 51/56 Section 187 70/18 19/21 21/23
1 ISD Scotland. Population figure covers all age ranges as of 2002 2 Scottish Executive, Mental Health Act Implementation Team. Based on the Royal college of Psychiatrists’ scoping exercise. 3 The State Hospitals Board for Scotland Medical Records Department 4 Mental Welfare Commission Annual Reports 2001-02/2002-03 5 Sections 24 and 25 are emergency sections lasting 72 hours 6 Section 26 is a 28 day order that can be used when an emergency section has expired 7 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court 13 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
AYRSHIRE AND ARRAN
4. In preparing for the Act a survey was taken of admissions under the Mental Health (Scotland) Act 1984 during June. In addition to the 28 emergency detentions there were 18 Section 26 short-term detentions and ten Section 18 long-term detentions
Table C - Emergency detentions June 2003
Working hours Out-of-hours* Section 24 6 7 Section 25 7 8 * excluding week-ends
5. The community based out-of-hours detentions, currently done by GPs, will need to be considered in the light of the new GP contract and the emphasis in the new Act on moving to short-term detentions by a specialist as soon as is practicable, minimising emergency detentions. Sometimes A&E is used by GPs as a route to having people detained. The rural geography means long travelling times for both patients and staff and it was suggested that innovative approaches were needed to get around these difficulties.
6. The working relationship between the RMOs (Responsible Medical Officers) and the MHOs is good during the day and given the small community everyone knows each other. Out of hours MHO cover comes from the West of Scotland standby service which means that it can take up to four hours for an MHO to arrive. This can lead to problems as Section 117 and 118 involving the police tend to be used in crisis situations. Ayrshire and Arran’s Redesign Project is considering how to provide appropriate 24-hour care.
7. There are significant recruitment and retention problems in social work with 50% vacancies in North Ayrshire despite the additional payments to MHOs. There are plans for joint appointments of MHOs across the three Councils to allow for greater operational flexibility. The MHOS are worried that the increased work under the new Act will lead to more formal involvement, with MHOs taking on a “quasi-legal role”. Training is seen as a vital issue.
Table D - Mental Health Officers in Ayrshire and Arran
MHOs working Local Practising Additional No of MHOs in mental Authority MHOs payment health East Ayrshire 15 15 6 Yes North Ayrshire 18 18 3 Yes South Ayrshire 25 25 11 Yes
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8. There are nearly 25 WTE consultant psychiatrists, with 11 in general psychiatry, which is within the suggested range from the Royal College of Psychiatrists for this size of adult population. The posts may not be distributed evenly, however, with North Cunninghame apparently under-resourced. There are currently 2 WTE vacancies, both within child and adolescent psychiatry.
9. The willingness of GPs to engage with mental health issues varies across Ayrshire and Arran, with some practices highly involved. The NHS Board was successful in attracting 80 GPs to a training event about the Adults with Incapacity Act. On the other hand some GPs, already concerned about the impact of Part V of the Adults with Incapacity Act, have campaigned against the anticipated additional work following the introduction of this new Act, taking the issue as far as the Health Minister. In some places there is dispute about primary care monitoring of lithium and clozepine, two mental health drugs that require regular blood monitoring.
Hospital Services for Adults
10. The hospital services for adults are as follows:
Four acute admission wards
• 2 at Ailsa Hospital (57 beds) • 2 at Crosshouse Hospital (52 beds)
One intensive psychiatric care unit (IPCU)
• Ailsa Hospital (6 beds)
One in-patient addictions/dual diagnosis unit
• Loudoun House (12 beds)
Continuing care/rehabilitation units
• Ailsa Hospital (86 beds)
Liaison Psychiatry service
• Ayr Hospital • Crosshouse Hospital
11. Ayrshire and Arran has the second lowest bed numbers per 100,000 in Scotland (especially for older people). 59 beds per 100,000 for adults is also below the Scottish average (64). The IPCU admits forensic and non-forensic patients (including the occasional informal patient). As a result the Unit is often full and seriously ill people may need to be treated on a general ward. There is no formal forensic setting, although in practice Ballantrae does admit some people who might otherwise be in a forensic ward. Ayrshire and Arran is part of the West of Scotland Consortium considering the site for a local/regional forensic psychiatric secure unit and service.
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12. The emergency readmission rate within 28 days in 1998 for adults was 2.53% dropping as low as 1.97% in 2001, compared to the Scottish average of 7.27% over the same period. This low readmission rate may indicate good discharge planning procedures and community support services preventing unnecessary readmission. In July 2003 there was only one delayed adult discharge. It helps to explain why Ayrshire can cope with so few beds. Last year 44 people from Ayrshire were discharged from psychiatric hospitals elsewhere in Scotland, compared to 26 people from elsewhere treated locally, indicating some pressure, but some of these external referrals will be to specialist units. In a census in July 2003 there were a total of 35 delayed discharges in Ayrshire and Arran (one adult, 34 older people).
Table E - Hospital bed numbers Ayrshire and Arran and Scotland8
Ayrshire and Arran Ayrshire and Arran Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 433 424 405 400 117 115 110 109 161 153 145 141 specialties All adults under 65 238 227 221 213 64 62 60 58 74 70 66 64 years
Older 195 196 184 182 53 53 50 50 83 79 74 73 people
Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional.
Table F - Hospital admissions in Ayrshire and Arran for people aged 16/18 - 64 years9
Adults 16/18 - 64 1998 1999 2000 2001 2002 First admission 507 463 483 541 519 Readmissions within one year 1406 1472 1402 1457 1399 Readmission rate within 28 days 2.53% 2.13% 1.91% 1.97% N/A Readmission rate= (emergency readmissions/discharges) x100
13. Although there is a child and adolescent consultant there are no hospital beds for children or adolescents, and those needing hospital care will either be admitted to a general paediatric ward or adult unit (which is unacceptable under the new Act) or be transferred to Yorkhill Hospital or Gartnavel Royal Hospital in Glasgow. There are similar problems with inpatient facilities for mothers with babies.
8 ISD 9 ISD provisional data from SMR04 returns 16 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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14. Currently it is difficult to offer some assessment, therapeutic or diversional opportunities due to difficulties in recruiting psychologists and occupational therapists. It is also difficult to provide a full range of activities at Crosshouse Hospital due to an environment that offers little quiet or therapeutic space. Service users and carers describe Crosshouse as unsatisfactory and failing in its response to their needs. The environment at Ailsa is regarded as much better and has a gym, grounds to walk in and a variety of activities available. Information materials on both mental illness and support services are readily available.
Community Services
15. There are a number of user and carer advocacy groups including (this list is not exhaustive): Ayr Action for Mental Health; Health in Mind (Clubhouse); Copeline; Scottish Association for Mental Health; the Richmond Fellowship; the Panel of Reference (a pan-Ayrshire consultative service user group); and locality based advocacy services in East, North and South Ayrshire. Advocacy is therefore multi- agency and in all areas, but in small projects. Some integration may be necessary to deliver a service under the new Act and an action plan is being drawn up.
16. Community Services include 6 community mental health teams, a Day Activities team at Ailsa Hospital, Hartfield House Day Centre, a dual-diagnosis day unit, the Compass Centre in Irvine, the Three Towns Resource Centre in Stevenson, and an Intensive Continuing Crisis Service (previously the Home Options Team), which is NHS Trust-wide and provides an alternative to admission.
17. The 6 CMHTs have developed collaborative working relationships with other agencies, including voluntary organisations and housing departments, with some teams having housing officers as members. There is good joint working with single shared assessments, and good use of Supporting People initiative money.
18. There are some good employment opportunities such as the Compass Project, which has 40 semi-industrial placements (picture framing, computers etc) leading to real jobs. However, the 45% European funding for this project ends in 2005 and there are plans in place to reduce the service if no alternative funds are available. Under the Act it is a Local Authority function to provide assistance in obtaining and undertaking employment.
Priorities of Users and Carers in Ayrshire and Arran
19. Users and carers:
• Reduce overcrowding in hospitals. • Provide high quality but alternative facilities for people with drug and alcohol problems. • Provide rehabilitation for people with drug and alcohol problems. • Stop the inappropriate admission of younger people with dementia to geriatric wards. • Carers need support, information and tips on how to help care for users. • The needs of homeless people with a mental illness. • Reduce the waiting times to see a CPN.
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• See mental illness as something that everyone needs to play a part in- stop seeing it as separate. • Provide adequate accommodation on discharge – B&Bs are not appropriate.
Comments
20. Key issues that will challenge Ayrshire and Arran when implementing the new legislation are:
¾ Getting all GPs involved the development and delivery of mental health services. ¾ Improving transport. ¾ Pressure on the one forensic psychiatrist to attend Tribunals. ¾ Recruiting and retaining MHOs. ¾ Developing an integrated independent advocacy service. ¾ Arranging access to inpatient facilities for children and adolescents and mothers with babies through regional planning.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist The State Hospital
Tom Keenan Mental Welfare Commission for Scotland
Dr Tom Murphy Associate Medical Director, NHS Lothian
Dr James Strachan Consultant Psychiatrist, NHS Lothian
Angela Robertson Clinical Effectiveness Manager, The State Hospital
18
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LOCALITY REPORT
BORDERS
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BORDERS
1. Borders has a scattered rural population of about 107,4001 (68,000 adults) with the highest proportion of people over 65 in Scotland. It is an area of relatively high employment with the lowest levels of deprivation and morbidity in Scotland.
2. Mental health services are provided by NHS Borders and the Scottish Borders Council, in partnership with a number of voluntary sector organisations.
3. Following the closure of Dingleton Hospital in 2001, inpatient services have been dispersed to a number of new small units providing much improved care environments. Users of services were involved throughout the planning process.
4. The Mental Health and Well Being Support Group (2002) commented on issues relevant to implementing the new Act, including lack of advocacy specifically for mental health and for carers, a need to develop an integrated care pathway for postnatal depression, and workforce challenges. The Clinical Standards Board for Scotland in 2002 recorded 122 adults with a diagnosis of schizophrenia. The CSBS standards that were fully met were the alignment of each general practice with a community mental health team, notification to social work of the need for respite care and routine reviews about alcohol and illicit drugs.
Use of the Mental Health (Scotland) Act 1984
5. The number of detentions under the current Mental Health Act in Scotland has been rising and over the last two years the increase in the Borders area is above the national average. In 2001-02 the use of the long-term detention order was the second highest in the country, and the short term order, the third highest. The reasons for this need to be explored. Based on these figures it is estimated that there will be approximately 75 mental health Tribunal hearings a year under the new Act.2
6. There are no Borders patients in The State Hospital.
Table A - Detentions under the Mental Health Act (Scotland) 1984 in 2001- 02/2002-033
No. of Average number No. Per 100,000 detentions in per 100,000 people people in Borders Borders in Scotland Sections 24 and 254 95/103 89/96 85/90 Section 265 63/76 59/71 51/56 Section 186 34/40 32/37 21/23
1 ISD 2 Scottish Executive, based on the Royal College of Psychiatrists’ scoping exercise. 3 Mental Welfare Commission Annual Reports 2001-02 and 2002-03 4 Emergency detention, up to 72 hours 5 Short term detention, up to 28 days 6 Long term detention, up to six months in the first instance, agreed by a Sheriff 20 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
BORDERS
7. Preparation for Tribunal hearings and attending them will put pressure on many professionals, but mainly on Responsible Medical Officers (consultant psychiatrists) and Mental Health Officers (social workers). 8. Thirteen Section 207 approved Medical Officers are recorded for Borders: 4 consultant general psychiatrists (and one associate specialist) 1.7 Whole Time Equivalent, (WTE) in old age psychiatry. There are 1.5 WTE child and adolescent consultants. The list also includes some consultant paediatricians who had undertaken training when the local child and learning disability services were larger.
9. The number of practising Mental Health Officers per 100,000 population8 (16.8)9 is higher than the average in Scotland (11.5), but recruitment is emerging as a problem. Additional payment is offered as one way to minimise the recruitment difficulty. Of the 15 MHOs working on a rota system, 7 work in mental health settings linked to community mental health teams.
Table B - Mental Health Officers in the Borders MHOs working No. of Practising Additional Local Authority in mental MHOs MHOs payment health Scottish 18 15 7 Yes Borders Council
Hospital Services
10. The hospital services are organised as follows:
One acute adult admission unit
• Huntlyburn, Melrose
Three rehabilitation units
• Galavale Campus and Galashiels
7Medical practitioners approved by a health board as having ‘special experience in the diagnosis or treatment of mental disorder’. 8 Mental Health Officer Services: Structures and Supports. Scottish Development Centre for Mental Health 2003 9 Strictly speaking the number of WTE is not as relevant as the number of people given that it is not a full-time job 21 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
BORDERS
Table C - hospital bed numbers10 Borders Borders Scotland Hospital Actual staffed beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 153 145 142 119 145 137 133 127 161 153 145 141 specialties All adults under 65 67 64 62 48 63 60 58 51 74 70 66 64 years Older 86 81 80 86* 81 76 75 92 83 79 74 73 people Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * 10 beds in Huntlyburn acute admissions unit are dedicated for older people
11. There are 30 acute admission beds in Huntlyburn, 10 of which are dedicated for older people. The number of inpatient beds for adults has reduced, as everywhere in Scotland, although bed numbers for older people are well above the national average. The 51 beds per 100,000 for adults is now the second lowest for mainland areas, with a national range of 47-109 for mainland NHS boards. There is no Intensive Psychiatric Care Unit in Borders and patients requiring this level of care are transferred to Lothian. The Orchard Clinic in Edinburgh provides medium term forensic care. In the last 2 years, however, only 11 people who are resident in the Borders were discharged from other parts of Scotland in contrast with 37 people from elsewhere treated in Borders.
12. In 1999 the Accounts Commission11 used the adult emergency readmission rate within 28 days as a proxy for the adequacy of discharge planning and for how well people were being supported in the community. It has also been shown to be associated with assertive outreach programmes, so should be interpreted with caution. The latest available figure (2001) for Borders is 8.3%, with an average of 9.3% over 4 years. This compares to the 4 year national average of 7.27%.
Table D - Hospital admissions in Borders for people aged 16/18-6412
Adults 16/18 - 64 1998 1999 2000 2001 2002 First admission (i) 112 112 107 109 140 Readmission (ii) 312 255 292 286 318 Emergency readmission rate 11.59% 7.94% 9.28% 8.30% n/a within 28 days (iii) (i) First ever recorded admission to psychiatric inpatient care (ii) Readmissions following a break in inpatient care (iii) (Emergency readmission/discharges) x 100
10 ISD 11 A shared approach: developing adult mental health services. Accounts Commission for Scotland. 1999 12 ISD provisional data from SMR04 returns 22 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
BORDERS
13. There were 13 delayed discharges in June 2003, all of them older people.
Community Services
14. Sections 25 – 27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training and housing options for people who have or have had significant mental health problems. This will complement the core treatment services, although increasingly care and treatment services are becoming aligned.
15. Community services include 3 Community Mental Health Teams (CMHTs), based within each of the 3 sectors in Duns, Hawick and Melrose. Each CMHT is aligned with a day service. In addition, there is a jointly funded and managed resource centre in Galashiels. The Borders-wide community rehabilitation team works from the Galavale Campus in Galashiels.
16. There are community support workers, home care services, and work experience/employment training. Eight supported accommodation places are provided.
17. Some collective advocacy is available through New Horizons, a user-led support service, but access to independent advocacy is generally limited. A joint Advocacy Strategy has been developed, but considerable investment will be needed to meet the requirements of the new Act.
18. The Child and Adolescent Community Mental Health Service (CAMHS) operates from Selkirk. There are no psychiatric beds for children and young people in Borders. Adolescents are referred to the Young People’s Unit in Edinburgh, but there is no provision for emergency referral. Admission of children needs to be negotiated with units elsewhere in Scotland or in England. Age-appropriate inpatient services will need to be ensured.
19. The Penumbra Youth project provides support at Galashiels and Hawick, although can be accessed throughout Borders. There is a Young People Outreach Service.
20. Recruitment and retention of clinical staff of all disciplines is beginning to emerge in Borders for the first time and creative ways have been developed to fill CAMHS vacancies. Further work is required to make best use of workforce skills.
Out-of-hours
21. Out-of-hours services, as in some other parts of Scotland, are restricted. Assessment is carried out by a duty doctor and nurse at Borders General Hospital or Huntlyburn. Both staff and service users considered the out-of-hours support to be insufficient. Work is underway to look at out-of-hours provision in light of the new GP contract. Borderline is a voluntary organisation that provides a telephone helpline 3 days a week.
Priorities for service users in Borders
22. The key views expressed by local users were as follows
23 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
BORDERS
• Better staff training – especially with their attitudes • Reduce waiting times for psychological services • Better follow up on discharge • More acute service provision. • More links across services. • Provide more psychological therapies provision, especially specialist services
Comments
23. Key issues that will challenge Borders when implementing the new legislation:
¾ The need for better out-of-hours services will be a top priority although difficult to provide at a reasonable cost across the whole of Borders.
¾ Workforce planning around recruitment and retention and review of roles and responsibilities needs to be carried out urgently by both health and social services, not only in the short-term but also with the development of a long-term strategy.
¾ Independent advocacy, including services for carers, will need considerable development given the right to access an advocate that the Act specifies.
¾ Regional planning is necessary to ensure access to appropriate inpatient services for children and adolescents and mothers and babies.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Dr James Strachan Consultant Psychiatrist, NHS Lothian
Tom Keenan Mental Welfare Commission for Scotland
Graham Charlton Social Work Services Project Manager, South Ayrshire Council
Angela Robertson Clinical Effectiveness Manager, The State Hospital
Alistair Pender Operational Service Manager, Angus Council Doreen Kelly Director, Partners for Inclusion Ayrshire
Dr Alistair Philp Improving Mental Health Information Project Lead, ISD Scotland
24
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
DUMFRIES AND GALLOWAY
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
DUMFRIES AND GALLOWAY
1. Dumfries and Galloway is a predominantly rural region covering 2,500 square miles with an estimated population of 147,3101, (93,000 adults). Within this rural setting there are pockets of multiple deprivation of similar severity to inner city areas (for example, in areas of Dumfries, Stranraer and Upper Nithsdale)2.
2. Mental health services are provided by NHS Dumfries and Galloway and Dumfries and Galloway Council, in partnership with the voluntary sector. The council is coterminous with the Dumfries and Galloway health service area.
3. The wide geographical spread and rurality combine to present challenges for the design and delivery of services and pose particular problems in recruitment and retention of staff, especially consultant psychiatrists. There is also a shortage of community staff including psychiatric nurses and allied health professionals.
Use of the Mental Health (Scotland) Act 1984
4. The number of compulsory admissions is similar to elsewhere in Scotland, with somewhat higher numbers of long-term detentions. On this basis the estimated number of Tribunal hearings is forecast at 1043.
5. There are currently 6 people from Dumfries and Galloway resident in The State Hospital. None are waiting transfer. The lack of a local IPCU or forensic secure unit and service, if continued, may cause problems were people to be delayed returning to the local area when the right to appeal against the level of security comes into effect in 2006. The West of Scotland consortium is already looking at this issue and is considering managed clinical and care network approaches.
Table A - Detentions in Dumfries and Galloway under the Mental Health Act (Scotland) 1984 in 2001-02/2002-034
Actual no of No per 100,000 Average number detentions in people in Dumfries per 100,000 people Dumfries and and Galloway in Scotland Galloway Sections 24 and 255 128/120 87/82 85/90
Section 266 72/78 49/53 51/56
Section 187 38/38 26/26 21/23
1 ISD Scotland 2 Dumfries and Galloway NHS Board website 3 Mental Health Act Implementation Team, Scottish Executive, 2003 4 Mental Welfare Commission Annual Report 2001-02/2002-03 5 Sections 24 and 25 are emergency sections lasting 72 hours 6 Section 26 is a 28 day order that can be used when an emergency section has expired 7 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court 26 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
DUMFRIES AND GALLOWAY
6. There are 6 general adult consultant psychiatrists in Dumfries and Galloway, with a further 3 consultants for older people, and 3 for children and adolescents. There is one consultant for learning disabilities and overall 14 doctors are currently approved under Section 20 of the 1984 Act, including a specialist psychiatric registrar. There have been 1.5 Whole Time Equivalent vacancies in consultant posts for around a year with the full time post being adult psychiatry and the part time in learning disabilities. Funding is available for the posts, but recruitment has proved difficult to date (December 2003).
7. The Local Authority is also having problems recruiting and retaining staff and is in competition with other councils who are offering financial incentives. There are particular problems about providing rural cover, Mental Health Officer services to court, out-of-hours services and meeting the demands of the Adults With Incapacity (Scotland) Act 2000. It was said that more needed to be done to clarify the roles, responsibilities and working relationships between health and social work in joined up teams, as well as with the MHOs who do not work in mental health settings.
Table B - Mental Health Officers in Dumfries and Galloway: SDC Structures and Supports MHO survey 2003
MHOs working Additional Local Authority No of MHOs Practising MHOs in mental health Payment Dumfries and 17 17 6 No Galloway
Hospital services for adults
Two admission wards
• Crichton Royal Hospital with 46 beds in total
Two rehabilitation units
• 32 rehabilitation beds for adults split between two wards (Wellgreen and Lahraig).
8. The closure of beds for adolescents is worrying, given the level of bed provision for this care group around Scotland and the coming requirement in the new Act for age-appropriate admission services. Dumfries and Galloway will have to contribute to a managed clinical/care network to provide for adolescents to be admitted to adolescent, not adult, services.
9. The number of psychiatric beds in Dumfries and Galloway for adults and older people has reduced in line with the move to community based care. There are 101 beds per 100,000 in Dumfries and Galloway for all specialties, (the lowest in Scotland).
27 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
DUMFRIES AND GALLOWAY
10. At the time of the visit there was a serious problem with lengthy delays in transfers from acute admission to rehabilitation beds. People with a wide range of problems are admitted to the wards, including for detoxification with 4 admission beds set aside for this purpose. Increasing numbers of complex care cases and attendant security and risk issues are evident. The senior management team sees the acute admission services as a top priority for change not just in terms of the bed pressures, but the poor quality of the environment.
11. The mental health strategy is being reviewed with particular attention to the numbers and location of beds, and attention to levels of investment. It is likely that proposals will be put forward for a new hospital building although this has still to be formally agreed. The lack of an Intensive Psychiatric Care Unit means that people who are severely ill have to be treated in the admission ward or transferred to Hartwoodhill Hospital.
12. Discharge figures8 from hospitals and day services (all ages in mental health) in Dumfries and Galloway in 2001-2002 show 748 from Dumfries and Galloway, plus 9 who were resident elsewhere. 44 Dumfries and Galloway residents had been treated out of the area and then discharged. 679 people with a learning disability were treated and discharged from within Dumfries and Galloway in the same year.
Table C - Hospital bed numbers Dumfries and Galloway and Scotland9 (Dumfries and Galloway’s adolescent unit closed in the period 2001-02)
Dumfries and Galloway Dumfries and Galloway Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 282 180 159 149 190 122 108 101 161 153 145 141 specialties All adults under 65 122 94 89 78 82 64 60 53 74 70 66 64 years Older 142 74 70 63 96 50 47 43 83 79 74 73 people Adolescent 12 12 0 0 * * * * * * * * Psychiatry Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
13. In 1998 the Accounts Commission used readmission rates within 28 days as a possible indicator of the adequacy of community services post-discharge. In 2001 (latest available figures) the 28 day readmission level was 10.1% in Dumfries and Galloway, compared to the Scottish average of 7.27%. This may be another factor putting pressure on beds.
8 ISD 9 ISD 28 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
DUMFRIES AND GALLOWAY
Table D - Hospital admissions in Dumfries and Galloway for people aged 16/18 - 64 years10
Adults 16/18 – 64 1998 1999 2000 2001 2002
First admission 167 149 148 140 164
Readmissions within one year 367 361 321 390 362
Readmission rate within 28 days 9.99% 9.56% 7.94% 10.01% N/A Readmission rate = emergency readmissions/discharges x 100
Community Services
14. Community based services are as follows
Five Community Mental Health Teams
• Annan • Castle Douglas • Nithsdale (2) • Stewarty
One Day hospital
• Huntington, in Dumfries
15. Dumfries and Galloway has been a pioneer in joint health and social care working. A general manager covers mental health services between the agencies. There are 5 jointly funded community mental health teams that are linked to local health care co-operatives. CMHT team leaders come from variety of disciplines, including social work, occupational therapy and community psychiatric nursing. Some of the CMHTs have specialist pharmacy input.
16. There is a combined care programme approach and care management system and all staff, not just social workers, can ‘care manage’; similarly social workers undertake therapeutic work. A link person from the CMHTs provides regular input into GP practice meetings.
17. There is not enough local social housing, especially for young people, but £14m has recently been awarded from Communities Scotland to Ayrshire and Dumfries and Galloway to help expand local provision. The broad responsibility placed on local authorities by the new Act is acknowledged and the implementation teams being created to prepare for implementation will include consideration of all the supports and agencies involved.
10 ISD provisional data from SMR04 returns 29 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
DUMFRIES AND GALLOWAY
18. The National Schizophrenia Fellowship is developing employment and support opportunities, such as the Genesis computer training and repair service. A range of group therapies is available at the Huntington Day Hospital in Dumfries.
19. A good Benefits Advice service is available to the clients in the community and on the wards from the amalgamated welfare rights and citizen’s advice bureau. Health service staff have provided training to staff from these agencies in mental health issues.
20. There is a generic independent advocacy project, covering all of Dumfries and Galloway for all people using NHS and Local Authority services staffed by both paid and volunteer advocates, that supports self-advocacy in learning disability users and covers all of Dumfries and Galloway. There are no dedicated advocacy workers currently in mental health, which will challenge existing services following introduction of the new Act.
21. Out-of-hours services are provided by social work via a combination of West of Scotland “standby” and local “on-call” services. The CMHTs provide a 9 am - 5 pm service. Those people who require urgent assessment by hospital services can be referred to on-call duty senior house officers at the Crichton Royal.
Priorities of Users and Carers in Dumfries and Galloway
22. Users
• Support for all the family. • Ways of making friends and sustaining relationships. • Better pay for nurses and other staff. • Access to peer support. • Any new hospital needs to be relaxed, homely, modern with things to do, nice grounds and privacy.
23. Carers
• If you had cancer there would be a whole range of services, sympathy and support. You get the opposite with mental illness, we need to educate society and challenge stigma. • We need parity of investment in mental illness compared to the other main illnesses. • We need parity of investment in rural areas where facilities are sparse. • We need a secure unit in Dumfries and Galloway. • Some mental health professionals can look down on us and be patronising - they need help with their attitudes.
30 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
DUMFRIES AND GALLOWAY
Comments
24. Key challenges facing Dumfries and Galloway in implementing the new legislation:
¾ Dumfries and Galloway has the lowest number of hospital beds per 100,000 population in Scotland, so there is pressure on inpatient services and consequently on community services. If the number of beds remains low there will need to be clear alternative facilities in the community. At present there are insufficient community out-of-hours services to support community-based Compulsory Treatment Orders.
¾ The lack of a local IPCU needs to be looked at when reconfiguring inpatient services as part of a national policy about where best to treat people who are severely ill.
¾ The lack adolescent inpatient beds or separate provision for mothers and babies needs to be addressed probably through a managed care network.
¾ Workforce problems will be a top priority given recruitment and retention problems, both for psychiatrists and MHOs.
¾ The geographical isolation in parts of the region is leading to transport problems for service users and staff and joint ways of resolving this are important.
¾ There are no dedicated advocacy workers in mental health and this service needs to be developed.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Graham Charlton South Ayrshire Council
Angela Robertson Clinical Effectiveness Manager, The State Hospital
Bill Clark Head of Strategy, West Dunbartonshire Council
Stephen McLellan Chief Executive, Renfrewshire Association for Mental Health
31
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
FIFE
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
1. Fife has a population of approximately 350,7001, (229,000 adults) with levels of ill health and deprivation above the Scottish average. Planning is based on the estimate that over 100,000 people (2 in 7 of the population) in Fife will ask for help from mental health services at some time in their lives.
2. Mental health services are organised into 3 sectors; Central Fife, North and East Fife, and West Fife. The amalgamation of what were separate NHS Trusts enables better planning although there remains some local tension about how hospital services will be reconfigured. Fife Council has the same geographical boundaries as NHS Fife and the social work mental health services are based at 3 local offices in Cupar, Dunfermline and Kirkcaldy.
3. In 2002 the Clinical Standards Board for Scotland (CSBS) undertook an assessment of compliance with some of its standards for the treatment and support of the 600 people in Fife with a diagnosis of schizophrenia. Better information for patients and improved documentation and audit were required as was training about substance misuse by people who have schizophrenia. These are all being taken forward.
4. ‘Right for Fife’ – the overall health strategy for Fife - describes the work being taken to focus on projects that emphasise multi-agency working and user and carer involvement. There is a range of targets:
• expansion of supported accommodation • improved support to carers • seven-day services from community mental health teams • better access to psychological services
5. The development of community services is going hand-in-hand with the hospital reconfiguration and 3 sites are under consideration. While this has the potential for the health side of the agenda to dominate, social work health and the voluntary sector are working jointly with health colleagues to ensure that this does not happen. At a service delivery level there are strong cohesive working relationships and a commitment to taking forward redesign projects jointly and finding local solutions to gaps in services. Joint working has been demonstrated by the pioneering and successful adoption of the Care Programme Approach in Fife.
Use of the Mental Health (Scotland) Act 1984
6. The use of emergency detentions is the fourth lowest of the mainland NHS Board areas and the number of short and long term detentions in Fife is close to the average for Scotland.
1 ISD Scotland 33 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
Table A - Detentions in Fife under the Mental Health Act (Scotland) 1984 in 2001-02/ 2002-032
Average number No. of detentions No. per 100,000 per 100,000 people in Fife people in Fife in Scotland Sections 24 and 253 270/276 77/79 85/90 Section 264 189/161 54/46 51/56 Section 185 88/80 25/23 21/23
7. In July 2003 there were 13 Fife patients resident in The State Hospital, including 5 women. This is proportionally higher than for other areas. Three non- restricted patients have been waiting for transfer back to Fife for more than 3 months. Another individual is waiting for pre-transfer assessment by Fife psychiatric services. From 2006 patients will have the right to appeal against the level of security and this will be especially important for people delayed in The State Hospital.
Table B - Average number of detentions 1994-02, related to population size and used to estimate the potential number of hearings.6
% of Scottish Estimated Tribunal Local Authority Population size detentions hearings under the 2003 act Fife 357,000 7.12% 214
8. The new Act will put pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the final report).
9. There are 34 doctors in Fife who are approved under Section 207 of the 1984 Act and 24 WTE consultant psychiatrists (no vacancies), 13 are general psychiatrists. The service does not have separate forensic psychiatrists and general psychiatrists take on this work, meaning they will have a higher number of Tribunal hearings than general psychiatry colleagues elsewhere.
2 Mental Welfare Commission Annual Reports 2001-02/2002-03 3 Sections 24 and 25 are emergency Sections lasting 72 hours 4 Section 26 is a 28 day order that can be used when an emergency Section has expired 5 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court 6 Scottish Executive, based on the scoping exercise by the Royal College of Psychiatrists 7 Medical practitioners approved by a health board as having ‘special experience in the diagnosis or treatment of mental disorder’. 34 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
10. There are 43 approved Mental Health Officers in Fife with around three quarters ‘active’ in carrying out MHO duties in the last year. This works out at about 10 per 100,000, (the Scottish average is 11.5). Only 37% of social workers with the MHO qualification actually work in the mental health field in Fife. No arrangement has been made about additional payments for MHOs called out during the day, although payments are being made for out-of-hours services at the rate of £60 per night.
Table C – Mental Health Officers in Fife8
MHOs Local Practising Additional No of MHOs working in Authority MHOs payment mental health No (except for Fife 43 35 16 out-of-hours)
11. MHOs locally considered that they could not take on any extra burden and felt they were already stretched with the additional work for the Adults With Incapacity (Scotland) Act 2000.
Hospital Services
12. Hospital services are provided from four sites:
Four acute admission wards
• One at Stratheden Hospital, Cupar (30 Beds) • Two at Whyteman’s Brae Hospital, Kirkcaldy (53 beds) • One at Queen Margaret Hospital, Dunfermline (30 Beds)
One intensive psychiatric care unit
• Stratheden Hospital (10 beds)
Two rehabilitation wards
• Stratheden Hospital (50 beds)
Two adult long stay wards
• Stratheden (50)
One occupational therapy rehabilitation service
• Ceres Centre at Stratheden Hospital
8 Mental Health Officer Services: Structures and Support. Scottish Executive 2003 35 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
Table D – Hospital bed numbers in Fife and Scotland9
Fife Fife Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 589 547 522 489 170 157 149 140 161 153 145 141 specialties All adults under 65 276 271 266 233 80 78 76 63 74 70 66 64 years
Older people 302 266 246 225 87 76 70 64 83 79 74 73
Adolescents 11 10 10 0 * * * * * * * *
Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
13. There has been a continuing reduction in hospital beds for both adults and older people over the last 3 years. Although adult beds are about the Scottish average, the number of beds for older people is significantly below the average.
14. For this population size, it is suggested that adult admission bed numbers10 range from 57 to 114, depending on other services being available. There are 113 admission beds in Fife with an occupancy rate of around 75% at Stratheden Hospital, which does indicate some spare capacity and an opportunity to redistribute resources towards community care. In practice it means that when beds are full elsewhere people can be admitted to Fife. Out of 1,601 discharges from Fife psychiatric services in 2001-02, 53 came from elsewhere in Scotland, behind only Argyll and Clyde and Greater Glasgow in the numbers of people admitted from outside the area.
15. Despite this, 44 Fife residents were in turn discharged from hospitals elsewhere in Scotland. This is most likely to be due to out of area admissions for older people, given that the data was not able to be separated into age categories and there are a relatively low number of beds for this age group.
16. One important factor in understanding bed usage is the average length of stay. For the acute adult admission wards it is averaging at 25 days over the last 2 years, which is relatively small in comparison to other places. A national average is not available because information about length of stay in acute adult wards is not collected centrally. The Intensive Psychiatric Care Unit at Stratheden averages a longer stay of 42 days, perhaps reflecting its forensic usage. In June 2003 there were 12 delayed discharges in mental health services in Fife; 11 of them were older people.
9 ISD 10 Royal College of Psychiatrists 36 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
17. The emergency readmission rate (within 28 days) fell to 6.07% in 2001, compared to a Scottish average of 7.27% over this period. In 1999 the Accounts Commission11 used this as an indicator of the adequacy of discharge planning and how well people are being supported in the community.
Table E - Hospital admissions in Fife for people aged 16-65 years12
1998 1999 2000 2001 2002 First admission 329 324 261 250 315 Readmission within one year 935 848 796 725 793 Readmission rate within 28 days 8.15% 8.23% 6.81% 6.07% n/a Readmission rate= (emergency readmissions/discharges) x100
18. Fife has no dedicated forensic beds although Stratheden’s Intensive Psychiatric Care Unit admits people from courts and operates as a step-down facility for patients from The State Hospital. The fabric of the IPCU needs upgrading and does not currently meet mixed sex accommodation standards. Across Scotland the function of an IPCU and the classification of forensic beds differs. The definition currently is based on the specialty of the Responsible Medical Officer.
19. There are no children’s beds and the 6 adolescent beds have been temporarily closed. They had previously made up 14.6% of the Scottish provision for this age-group. Fife is unable to provide age-appropriate inpatient services for children and adolescents locally. There are no separate inpatient facilities for mothers and babies, another requirement of the Act. People with a wide-range of problems and multiple needs may be admitted together in a general ward.
Community Services
20. In some places community teams are well established, in others they are under developed. Fife lacks 24 hour response services, a strategic issue for both health and social services and something needs to be resolved urgently in order to make community-based Compulsory Treatment Orders a viable option. Within East Fife a proposal to introduce community psychiatric nurses to NHS 24 is being explored as well as expanding the community mental health teams across Fife to provide a 7-day out-of-hours service.
21. There are 3 adult psychiatric day hospitals, in the West, North, and East sectors. Nine community psychiatric nursing teams provide sector services with 5 teams in the North-East, 3 in Central and one in West Fife. There are a further 5 intensive out-reach teams, and a dual diagnosis service that caters for enduring mental illness and substance misuse across the whole region.
11 A shared approach, Accounts Commission for Scotland, 1999 12 ISD provisional data from SMR04 returns 37 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
22. Sections 25 - 27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training and housing options for people who have or have had significant mental health problems. This will complement the core treatment services, although increasingly care and treatment services are becoming aligned.
23. The voluntary sector in Fife has begun to widen the scope of services provided to adult mental users, although services to carers in Fife remain patchy and under developed. Fife Council has invested in projects that promote access to employment and social inclusion. A far from comprehensive list of community services and their providers includes a focused education service; horticultural therapy project; Better Futures Project; Hearing Voices Network; Fife Association for Mental Health; Scottish Association for Mental Health; Barony Housing Association’s ‘Contact Point’; and the National Schizophrenia Fellowship (Scotland). Fife Families Support Group provides help to carers, although there are no advocacy projects specific to carers.
24. Patients’ Councils are in operation in each of the 3 psychiatric hospitals, and independent advocacy for users is available from a number of sources, co-ordinated by the Fife Advocacy Strategy Group. NHS Fife and Fife Council have shown a clear commitment to developing advocacy services, although there is often a waiting list for service users and more needs to be available for carers.
Priorities of Service Users and Carers in Fife
25. The expressed views of the users and carers are as follows:
• Mental health awareness training for the public. • Change the system – the attitudes of psychiatric and medical staff. • A centre of excellence for mental health as part of a wider health centre. • More access to respite care. • Access to alternative therapies. • Better access to psychology services.
Comments
26. Key issues that will challenge Fife when implementing the new legislation are:
¾ The hospital reconfiguration may take up considerable managerial and staff time and involve a number of relevant issues, such as the function of the IPCU and sitting of forensic beds. The IPCU needs upgrading.
¾ The balance between hospital and community care is too focused on the hospital side and reducing some adult beds may allow for increased community developments.
¾ The out-of-hours services in particular are underdeveloped and this needs to be addressed to allow the opportunity for community-based Compulsory Treatment Orders.
38 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FIFE
¾ Unless the adolescent beds are re- opened young people will need to go out of area for inpatient care, which would not be ideal.
¾ Inpatient services for mothers and babies need to be agreed with other parts of a managed clinical/ care network unless reconfiguration includes a dedicated facility.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Tom Keenan Mental Welfare Commission for Scotland
Stephen McLellan Chief Executive, Renfrewshire Association for Mental Health
Dr Alastair Philp ISD Scotland, Improving Mental Health information Programme Manager
Jack Stuart General Manager, Mental Heath Services, Grampian Primary Care NHS Trust
Dr Linda Treliving Consultant Psychiatrist in Psychotherapy, Grampian Primary Care NHS Trust
39
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
FORTH VALLEY
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
FORTH VALLEY
1. Forth Valley is a relatively small area in central Scotland with a population of about 279,3001 (184,7002 adults) making it the fourth smallest population of all 12 mainland NHS Board areas. Although there are some areas of social deprivation the morbidity levels are at the national average. Mental health services are provided by NHS Forth Valley and 3 local authorities: Clackmannanshire, Falkirk, and Stirling Councils. Together the local authorities are coterminous with the NHS Board area.
2. The quality of Forth Valley mental health services is rated highly. The Scottish Health Advisory Service report 2002 was on the whole very positive. The Mental Health and Well Being Support Group (2002) rated Forth Valley with twice as many “significant achievements” than any other region.
3. The Clinical Standards Board for Scotland undertook the first round assessment of compliance with its standards for the treatment and support given to people who have a diagnosis of schizophrenia (490 people in Forth Valley, 154 of whom were admitted to hospital in 2001-02). The findings reflected the national picture, but Forth Valley was one of the first areas to set up training in psychosocial interventions for schizophrenia responding to one of the key CSBS standards.
4. An internal area-wide review of mental health services was completed in June 2002, which led to new initiatives such as clinical effectiveness projects and the introduction of the CORE Assessment Schedule to measure service user’s progress.
Use of the Mental Health (Scotland) Act 1984
5. Detentions in Forth Valley is considerably lower than the Scottish average 3.
6. There are 7 Forth Valley residents under conditions of special security in The State Hospital. None are currently delayed for transfer. Forth Valley purchases forensic beds from the Orchard Clinic in Edinburgh.
Table A - Detentions for all ages in Forth Valley under the Mental Health Act (Scotland) 1984 in 2001-02/2002-033
Number per Actual no. of No. per 100,000 in 100,000 in detentions Forth Valley Scotland Sections 24 and 254 184/232 66/83 85/90 Section 265 126/145 45/52 51/56 Section 186 42/47 15/17 21/23
1 ISD Scotland 2 General Registry Office 3 Mental Welfare Commission for Scotland Annual Reports 2001-02/2002-03 4 Sections 24 and 25 are emergency sections lasting 72 hours 5 Section 26 is a 28 day order that can be used when an emergency section has expired 6 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court 41
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Table B - Average number of detentions 1994-2002, related to population size and used to estimate the potential number of hearings. 7
Percentage of Estimated Scottish Tribunal hearings Local Authority Population size detentions over 8 under the 2003 years Act Clackmannanshire 31,562 0.51% 15 Falkirk 96,340 2.73% 82 Stirling 56,826 1.13% 34
7. For the purposes of this report the number of anticipated hearings (based on the current Sections 26 and 18) is based on the assumption that the average rate of detentions will remain broadly consistent with previous years, despite the fact that numbers are rising year on year. The unknown quantity of potential appeals has not been included and as a result the forecast should be taken as a conservative estimate.
8. The new Act puts pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the final report).
9. Twenty-six doctors are currently approved under Section 20 of the 1984 Act, including 208 whole time equivalent consultant psychiatrists. Eleven are general psychiatrists and one a forensic psychiatrist, the doctors most likely to be involved most often with compulsory treatment. In addition there are 2 consultants working with people who have learning disabilities, 4 old age psychiatrists and 2 people in child and adolescent services. Two of the consultants are locums. The Royal College of Psychiatrists suggests that planners should consider 15 consultants in general psychiatry for a population the size of Forth Valley.
10. The predicted increase in workload has worried the consultants and they were perhaps one of the most vociferous and articulate of their peer group in Scotland in expressing the concerns. Several had observed an increase in the numbers of people who have a dual diagnosis and also offending behaviour, and were concerned about their caseloads being skewed to this group at the expense of the broader range of psychiatric work.
11. There were 50 qualified MHOs in Forth Valley at the time of the Scottish Development Centre survey9, 34 (68%) of whom had used this qualification in the previous year. To aid recruitment and retention additional payments are available to MHOs in 2 of the 3 local authorities, with Clackmannanshire paying MHOs at a senior social work rate, and Stirling adding 2 increments to the basic grade.
7 Scottish Executive, Implementation Team Mental Health (Care and Treatment) (Scotland) Act 2003 8 Scottish Executive 9 Mental Health Officer Services: Structures and Supports. The Stationary Office. 2003 42
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Table C - Mental Health Officers in Forth Valley: SDC Structures and Supports MHO Survey 2003
MHOs working No of Practising Additional Local Authority in mental health MHOs MHOs payment settings Clackmannanshire 14 4 2 Yes Council Falkirk Council 22 22 4 No
Stirling Council 14 8 4 Yes
Hospital Services
12. The services for acutely ill adults differ in each area, with a relatively limited number of admission beds in Falkirk resulting in people from Falkirk often being referred to Stirling or Clackmannan for their care. Good co-operation exists between the 3 acute admission services, which ensure smooth, well planned transitions between the areas.
13. Mental health facilities within the area consist of:
Three acute adult admissions wards
• Falkirk Royal Infirmary (south sector 29 beds) • Stirling Royal (north sector 24 beds) • Clackmannan County Hospital (east sector 15 beds)
An Adult Intensive Psychiatric Care Unit
• Falkirk Royal Hospital (12 beds)
Three Adult Continuing Care Wards
• Bellsdyke Hospital (98 beds)
One Rehabilitation Ward
• Craigenhall (Falkirk, 14 beds)
Liaison Nursing Service
• Falkirk Royal and Stirling Royal Hospitals
14. Acute admission beds (194) for adults in Forth Valley are the third highest per 100,000 in Scotland. No overall problem about access to hospital exists, although people in Falkirk are sometimes treated further from home. The total bed numbers for all specialties is low in comparison to the rest of Scotland, but this is due to the number of beds for older people being significantly below average.
43
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FORTH VALLEY
15. In July 2003 there were 2 delayed discharges affecting younger adults and 26 affecting the transfers of older people.
Table D - hospital bed numbers Forth Valley and Scotland10
Forth Valley Forth Valley Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 369 359 359 351 133 129 129 126 161 153 145 141 specialties All adults under 65 207 195 195 194 74 70 70 69 74 70 66 64 years Older 162 164 164 157 58 59 59 56 83 79 74 73 people Forensic 0 0 0 0 0 0 0 0 * * * * Services Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
16. The emergency re-admission rate within 28 days in 1998 for adults was 0.44%, rising to 7.25% in 2001. The Scottish average over the same period was 7.27%. However the rising trend in Forth Valley needs to be understood.
17. In 2000-01 Forth Valley mental health services treated 36 people from outside the area and sent 33 elsewhere. The following year the figures were reduced, 12 people coming into the area and 20 discharged from other areas, some of the referrals outside Forth Valley were to specialist services not available locally.
18. There are no designated forensic beds in Forth Valley, but Bellsdyke does admit patients directly from The State Hospital.
19. A local survey found that more than half of the recorded 38 admissions to 2 wards occurred outside office hours. However, only 6 (15%) of these admissions were under the current Act. These are useful data given the concerns about the demand on consultants due to emergency work out-of-hours. The report goes on to suggest that extending the opening hours of community resources such as Dunrowan in Falkirk could further prevent admissions.
20. There are no local hospital inpatient services for adolescents, who will need to be sent elsewhere to meet the requirements of the new Act for age-appropriate services. Although there is no inpatient facility for mothers and babies, out-patient services for post-natal depression are good and the outcome of the considerations of the Short Life Working Group on Perinatal Mental Illness (due early 2004) will inform future decisions about this aspect of care.
10 ISD 44
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Community Services
21. Sections 25-27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training, and housing for people who have or have had significant mental health problems.
22. There is already good joint working locally between health and the 3 social work departments. Community services include 5 community mental health teams: Westbank, Falkirk, Kildean, Stirling, and Clackmannan. In addition there are 3 rehabilitation teams in Stirling, Falkirk and Clackmannan. A partial hospitalisation project operates from the Dunrowan Resource Centre in Falkirk, offering services to severely ill users with short and intensive interventions aimed at preventing inappropriate admission or facilitating early planned discharge from hospital.
23. There are many excellent examples of local voluntary sector organisations providing services ranging from supported accommodation to supported employment and advocacy services. The Caledonia Clubhouse was established in 2000 as a joint venture between the NHS Board and Falkirk Council. Forth Valley’s mental health strategy is to extend this model to other areas. Supported accommodation primarily involves the Scottish Association for Mental Health, Penumbra, Loretto and Church of Scotland. Advocacy is provided by Advocacy into Action, Forth Valley Advocacy Services, the Quality Action Group and People First Scotland.
24. Other community services include Stirling and District Association for Mental Health, which has a wide range of services including befriending, counselling, drop- in, home support and a women’s support group. Falkirk and District Association for Mental Health also provides a range of services including the Victoria Centre and Befriending Schemes and Carers Support and Development Group. Clackmannanshire Association for Mental Health provides similar opportunities. Service user groups include Open Door in Grangemouth, Falkirk Users Network and People Need People.
25. The ability to respond to crisis and provide services out-of-hours is relatively limited. Various crisis response models have been considered following consultation with users and carers. There was a consistent feedback that non-statutory services should be involved, a view held particularly by service users.
26. In Falkirk, various options were listed including crisis telephone services, a centre for face-to-face contact in a non-medical environment, an open referral policy and extended opening hours for day services. In Stirling the emphasis was that crisis support should be 24 hours a day and be multi-agency. Clackmannanshire piloted a two-bedded safe house, offering users a short-break for a maximum of 72 hours. Clackmannanshire Association for Mental Health provided the staff and the project was funded mainly by the Local Authority, but the unit however closed as a result of under utilisation.
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Priorities of Service Users and Carers in Forth Valley
27. Users and Carers
Alloa and district
• A new minibus for Devon house • Larger and more attractive premises for Devon House • Out-of-hours services.
Stirling and district
• Challenge stigma and educate the public • Better access to good respite care • Out-of-hours services • Better and more easily accessed benefits
Falkirk and district
• Out-of-hours services • Crisis Cards • More CPNs • Challenge stigma • Help and understanding • Help with friendships and relationships • Access to respite care/ a safe house • Earlier help–less waiting time for help • Improve GPs’ knowledge about mental health services • Prevention • Access to employment opportunities, challenge discrimination in the workplace and make employers more aware of mental health.
Comments
28. Key challenges for Forth Valley in meeting the demands of the new Act are:
¾ Organisational change will be needed to ensure that consultants are enabled to carry out their new tasks under the Act in partnership with Mental Health Officers.
¾ The availability of 24 hour services is already a priority locally and needs to be developed in order to provide the range of supports necessary to allow the option of community-based Compulsory Treatment Orders.
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Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Dr James Strachan Consultant Psychiatrist, NHS Lothian
Andy Dickson Head of Nursing, NHS Argyll and Clyde
Dr Stella Clark Consultant Psychiatrist, NHS Fife
Dr Tom Murphy Associate Medical Director, NHS Lothian
47
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
GRAMPIAN
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
GRAMPIAN
1. Grampian covers 3000 square miles and has a population of approximately1 350,200 adults, 40% of them in Aberdeen City (144,800 adults). Aberdeenshire has 149,280 adults and Moray 56,100 adults. Levels of deprivation and morbidity are amongst the lowest in Scotland, although the level of alcohol misuse is high. A major factor having an impact on service delivery is the large geographic spread and accompanying transport problems.
2. Mental health services are provided by NHS Grampian and three local authorities together with a wide range of voluntary organisations and care providers. Together, the Councils are coterminous with the Grampian health service area. Grampian also provides consultant outpatient services and hospital admission facilities for Orkney and Shetland.
3. The Clinical Standards Board for Scotland found 407 people (16–65 years) with a diagnosis of schizophrenia being cared for in the service.
4. The Mental Health and Well Being Support Group (2002) was particularly impressed by effective joint working, strategies for mentally disordered offenders and child and adolescent mental health. It was noted that an integrated care pathway had been developed for postnatal depression. Collective advocacy had been developed in Aberdeenshire for users and support workers. All of these are directly relevant to the Act.
Use of the Mental Health (Scotland) Act 1984
5. Table A shows the number and rate of detentions in Grampian in 2001-02 and 2002-03 and Table B Section 182 applications by Local Authority. In addition there are currently 19 Grampian patients in The State Hospital, 3 of who have been recommended for transfer and referred to Grampian for assessment. This is a relatively large number overall and preparations need to be made for potential increased demands once the appeals against the level of security3 are introduced in 2006.
Table A - Detentions in Grampian under the Mental Health (Scotland) Act 1984 in 2001-02/2002-034
No. per 100,000 Average no. per Actual no. of people in 100,000 people in detentions Grampian Scotland Sections 24 and 255 408/340 78/65 85/90 Section 266 251/220 48/42 51/56 Section 182 94/99 18/19 21/23
1 GRO 2 Long term detention, up to six months in the first instance, agreed by a Sheriff 3 The Mental Health (Care and Treatment) (Scotland) Act Part 17, Chapter 3 4 Mental Welfare Commission Annual Reports 2001-02/2002-03 5 Emergency detention, up to 72 hours 6 Short term detention, up to 28 days 49
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Table B – Applications for detentions under Section 18 of the Act in 2001-02 and 2002-03
Section 18 Section 18 Total Population Local Authority applications applications Size 2001-02 2002-03 Aberdeen City 209,270 63 58 Aberdeenshire 227,280 22 25 Moray 86,740 17 22
6. The Act puts pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and Responsible Medical Officers (the pressures on administration and advocacy services will be discussed in the Final Report). The extra workload will come primarily in preparing for and attending Tribunals.
7. There are 45.2 WTE doctors approved under Section 20 of the 1984 Act7, with 5.3 WTE vacancies, 1.3 of them in general psychiatry. Overall, and assuming all back-up services are available, the establishment is already low. In addition, there are 12 GP vacancies in Banff and Buchan. These are hard to provide cover for because they are distant from the city and consultants on call have to travel large distances to initiate Sections.
8. Difficulties also exist in recruitment and retention of other disciplines including allied health professionals and psychology, limiting opportunities for delegation and development of roles. The exception is nursing which has no recruitment problems and, as a result, development of consultant nurses may contribute to the solution. Other suggestions offered included a separate emergency team, minimising staff travelling time by bringing people into the hospital (although transport difficulties could be an issue) and exploring the potential for teleconferencing assessments.
9. Table D shows the MHO numbers in the different local authorities. There are 81 trained Mental Health Officers in Grampian; however a 2003 survey found that only 26 had undertaken MHO work in the previous 12 months8. Recruitment and retention of MHOs is not a problem.
TABLE C - Mental Health Officers in Grampian
MHOs Local Practising working in Additional No Of MHOs Authority MHOs mental health Payment settings Aberdeen City 39 11 11 No Aberdeenshire 33 11 11 No Moray 9 4 4 No
7 Approved by the NHS Board as having special expertise in the diagnosis and treatment of mental disorder 8 Mental Health Officer Services: Structures and Supports. Scottish Executive 2003 50
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Hospital Services
10. Hospital services are arranged as follows:
• 16 wards at Royal Cornhill Hospital (Aberdeen). Includes intensive care services, forensic services, continuing care and a brain injury unit. • One ward at Dr Gray’s Hospital (Elgin). • Two rehabilitation units, Great Western Road (forensic) and Polmuir Road (Aberdeen). • Two Community Rehabilitation Units managed by Scottish Association for Mental Health but with seconded Trust nursing staff in Aberdeen and Elgin. • A liaison psychiatry service provided to Grampian University Hospitals NHS Trust. • Two day hospitals, Fulton in Aberdeen and West Lodge in Elgin.
Table D - Hospital bed numbers Grampian and Scotland9
Grampian Grampian Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 733 686 659 657 139 130 125 125 161 153 145 141 specialties All adults under 65 264 252 252 248 50 48 48 47 74 70 66 64 years Older 426 391 363 366 81 74 69 70 83 79 74 73 people Forensic 43 43 43 43 * * * * * * * * Services Adult beds include acute admission, rehabilitation and continuing care. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
11. The bed numbers for both younger and older adults have steadily reduced. There are 126 beds per 100,000 in Grampian for all specialties, which is among the lowest in Scotland. The Scottish average is 141 (range 101 - 205) beds per 100,000. Older people’s beds (70) compare with the national average (73 per 100,000), but the 47 per 100,000 adult beds in Grampian is significantly below the national average of 64. Forensic beds in Grampian account for 23% of the national resource and these bed numbers have remained static during the last 4 years.
12. It is recognised that the reduction in beds has enabled the development of community services and the transfer of all wards to a better physical state and newer accommodation.
9 ISD 51
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13. The final number of adult acute beds is planned to be 12510 (100 in Aberdeen and 25 in Elgin). The occupancy rates are currently running at 100%, with an average last year of 85-90% and this could be one of the pressure points in implementing the Act.
14. The emergency readmission rate within 28 days was at its lowest in 1998 at 8.82% rising to its highest in 2000 at 10.17% and then falling slightly to 9.54% in 2001. The Scottish average over these years is 7.27% and Grampian’s higher rate needs to be understood as a possible indicator of the adequacy of the community infrastructure. However, the falling number of first admissions suggests that community care is helping to keep some people out of hospital. This information needs to be explored to determine what the relationship is with community services.
TABLE E - Hospital admissions in Grampian for people aged 16/18 – 6411
Adults 16/18 – 64 1998 1999 2000 2001 2002 First admission (i) 445 524 469 468 388 Readmission within one year (ii) 1004 1095 1032 1034 1077 Readmission rate within 28 days (iii) 8.82% 9.22% 10.17% 9.54% N/A Information for 2002 is provisional (i) First ever recorded admission to psychiatric in-patient care (ii) Readmissions following a break in in-patient care (iii) (Emergency admissions/discharges)x100
15. Another important factor linked to community care services is the level of delayed discharges. In Grampian in July 2003 there were 25 delayed discharges in general adult psychiatry, representing a quarter of all adult mental health delayed discharges in Scotland. This is the second highest level for all NHS Board areas. There was also one delayed discharge in forensic psychiatry and a further 33 in the psychiatry of old age, a total of 59 in all mental health specialties.
16. With the low number of beds, high emergency readmission rates and some delayed discharges, this hospital service is working at full capacity. Locally there is not felt to be too heavy a pressure on beds, although in 2001-02 55 people with mental illness who live in Grampian were discharged from other parts of Scotland, compared to 17 people from elsewhere who were treated in Grampian (in addition to 82 people from Orkney and Shetland). This will need to be monitored carefully to make sure that admission beds remain available for both formal and informal patients. At present, the percentage of detained people in acute wards is 42%; this is similar to Lothian.
17. Lower bed numbers can put added pressure on carers. A Carers Help Group operates from the Royal Cornhill Hospital, providing carer volunteers and information. The National Schizophrenia Fellowship also runs a Grampian Carers Support Project. There is also a Carers Reference Group. This is a good base to build on to ensure that the Millan principle of Respect for Carers is adhered to.
10 New Horizon - A Joint Endeavour: a Framework for Mental Health Services in Grampian 1998-2004 11 ISD provisional data from SMR04 returns 52
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18. When recruitment to adult general psychiatry has sometimes been difficult, the Trust has invested creatively in smaller specialties and has developed excellent services for drugs and alcohol, eating disorders and a 20-bedded unit for people with acquired brain injury. The Mental Health and Well Being Support Group12 gave alcohol and substance misuse services the highest rating for significant achievement in implementing the Framework for Mental Health.
19. The Blair Unit is an example of how forensic and intensive care services can be combined in a satisfactory way.
20. There is a structured approach to postnatal depression services with an integrated care pathway which will go towards complying with the section of the Act on postnatal depression (Part 4 Section 24) although access to dedicated beds will also be needed. There are no specialist beds for mothers and babies and those requiring admission are nursed in single rooms at The Royal Cornhill Hospital or Dr Gray’s.
21. Children are transferred to Yorkhill Hospital for inpatient services and adolescents to Gartnavel Royal Hospital, in Glasgow.
Community Services
22. There are 8 Local Health Care Co-operatives (LHCCs) and, although not coterminous with the Local Authority boundaries, they are aligned to the geographical catchment areas of the consultant psychiatrists. A third of the consultants hold clinics in general practice and some CPNs are based in health centres.
23. There are 19 multi-disciplinary community mental health teams in Grampian, 9 in Aberdeen City, 7 in Aberdeenshire, and 3 in Moray, but finding (and funding) appropriate premises has been difficult. The focus remains primarily on people with severe and long-term illness. Most of the teams function with strong consultant input to direct patient care, different from the more common model of a multi-disciplinary team under the overall supervision of the consultant. The additional demands of the new Act will mean that consultants will have less time to spend on direct care and the current approach will be difficult to sustain, to the concern of many of the consultants. To redesign the service and change roles and responsibilities will affect everyone and people will require considerable support.
24. Although there is an out-of-hours service, access varies across Grampian, being most limited in Moray. Nowhere provides the 24-hour service requested by users and carers, except through the Accident and Emergency or the Royal Cornhill Hospital. Transport is a particular problem in accessing services and support.
25. Advocacy is a key component of the Act (Section 259). Advocacy Services Aberdeen provides generic services in the City. Advocacy North East provides a generic service in that locality and also includes collective advocacy. Moray Advocacy was established in 2001 and as yet has only 2 workers. None of these services are available for those under 18. In 2002 the Mental Health and Well Being Support Group acknowledged that independent collective and individual mental
12 Mental Health & Well Being Support Group Report of Visit to Grampian, 23 April 2003 53
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health advocacy were areas needing attention; developing these areas will be even more important in relation to the Act.
26. In terms of access to work, leisure and training, there is a wide range of services provided by the voluntary sector with more than 50 groups, only a few of which can be mentioned:
• Alford drop-in centre • Aberdeen Counselling and Information Service • Marchburn Hostel for younger people aged 18-35 • Aberdeen Supported Housing Project • Square One social enterprise • Rehab Scotland • Branch Out • Pillar
27. Despite the increasing demands on these services there has been a decrease locally in funding in real terms and this has led to reductions in the number and/or grade of staff. Given the responsibilities of local authorities to provide such support services (Sections 25-27) additional, sustained financial investment will be needed.
Priorities of Users and Carers in Grampian
28. The following summarises the key points of the local users and carers:
Aberdeen City (3 meetings)
Users and Carers
• Use Elmhill House as a user-run resource providing function suites, workshops, a place to relax, do gardening etc, with innovative work opportunities (new computers not papier-mâché). • Create a small safe house and a greater range of drop in services. • Put more activities and resources on the wards and make observation levels in hospital therapeutic. • More facilities for young people including in-patient beds. • More out-of-hours services, with a rapid response to crisis. • More user and carer run services and initiatives. • Mental health awareness training for professionals. • Access to spiritual help. • Increase young people’s awareness of mental health and promote mental health first aid courses/skills. • Include users and carers on interview panels. • Provide greater access to independent advocacy.
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Aberdeenshire
Users
• Access to holidays – some time out for enjoyment. • Better education in mental illness for GPs. • Out-of-hours services and not just crisis based ones. • Joint working and seamless services are needed. • Training for people working at the grass roots. • Stop the division between mental illness and physical disabilities; it seems that if people have both conditions one or the other is ignored.
Aberdeenshire Carers
Meeting 1
• Training for GPs in mental illness. • Early intervention. • Challenge stigma and educate people – treat users and carers as human beings. • See carers as part of the solution, not the problem. • 24-hour helpline.
Meeting 2: Carers (Eating Disorders)
• Immediate help at first diagnosis – it can alter the outcome. • Training of GPs about eating disorders. • Information about illness and help-lines. • Reduce the waiting time to get help. • More specialist eating disorder staff.
Moray
Users and Carers
• Access to talking treatments. • Consultant psychotherapist in Moray. • More activities in ward 4. • Long term residential supported accommodation for people with high support needs. • Alternatives to hospital when in crisis. • More respite. • More follow-up for those in the community.
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Comments
29. The key challenges that Grampian will need to face in implementing the Act are as follows:
¾ Recruitment and retention of consultants and service redesign needs to be a top priority. Mental Health Officer posts are under less pressure at present, but MHOs and social work managers need to be included as part of the redesign process.
¾ There is little spare bed capacity and bed management may come under pressure.
¾ Independent specialist mental health advocacy needs to be increased.
¾ Community services need to be developed to ensure equity and allow the least restrictive option of a community-based Compulsory Treatment Order.
¾ Out of hours and crisis services need to be strengthened with access to community supports.
¾ Access to child and adolescent beds needs to be ensured and monitored.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Dr James Strachan Consultant Psychiatrist, NHS Lothian
Tom Keenan Mental Welfare Commission for Scotland
Graham Charlton South Ayrshire Council
Angela Robertson Clinical Effectiveness Manager, The State Hospital
Alistair Pender Operational Service Manager, Angus Council
Doreen Kelly Director, Partners for Inclusion
Dr Alastair Philp ISD Scotland Improving Mental Health Information Programme Manager
56
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LOCALITY REPORT
GREATER GLASGOW
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
GREATER GLASGOW
1. Greater Glasgow has a population of about 866,0001 (577,511 adults) living mainly in densely populated urban areas. There are 136,580 older people, (a lower proportion than the national average). The estimated number of people with a diagnosis of schizophrenia is 1,9802. Levels of deprivation and morbidity are very high.
2. Six local authorities provide social work services to the NHS Board area: East Dunbartonshire, East Renfrewshire, Glasgow City, North Lanarkshire, South Lanarkshire, and West Dunbartonshire. Only Glasgow City and East Dunbartonshire are totally within the boundaries of NHS Greater Glasgow. Within the Greater Glasgow area, mental health services are organised into 3 sectors, East and North, South and West. Necessarily much of the information contained in this report reflects information for the Greater Glasgow NHS area and is not always disaggregated to Local Authority areas, 4 out of the 6 of which relate to other areas also.
3. Greater Glasgow has pioneered the move towards community care and intermediate forms of care in Scotland. An ambitious 5 year strategy is being implemented, replacing old hospital buildings with modern, purpose built inpatient facilities, while community services are being improved and extended. This strategy involves £17m of growth funds to leverage service redesign through the redirection of the totality of the £100m expenditure locally on mental health. The Mental Health and Well Being Support Group (2002) stated that the positive position in Greater Glasgow was the result of a decade of work to replace hospital-based care with services provided in local communities. NHS Greater Glasgow, Glasgow City Council and Greater Glasgow Primary Care Trust are undergoing service redesign towards an integrated community network
Use of the Mental Health (Scotland) Act 1984
4. The detention rates in the table are for the NHS Greater Glasgow area only, given difficulties in disaggregating numbers for the separate local authorities, when 4 relate to other NHS areas also. On the basis of the available information the forecast number of Tribunal hearings is in the region of 543 per year.3 An added burden on local authorities is the duty to find accommodation etc for Tribunals.
1 Greater Glasgow NHS Board 2 Quality Improvement Scotland. Clinical Standards Board for Scotland, Schizophrenia Standards report. 3 Scottish Executive, based on the Royal College of Psychiatrists’ scoping exercise. 58
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Table A - Detentions in Greater Glasgow under the Mental Health Act (Scotland) 1984 in 2001–02/2002-034
No. of detentions No. per 100,000 Average number in Greater people in Greater per 100,000 people Glasgow Glasgow in Scotland Sections 24 and 255 1030/935 119/108 85/90 Section 266 649/562 75/65 51/56 Section 187 208/191 24/22 21/23
5. In addition to local services, there are 76 patients resident in The State Hospital, 9 of who are waiting agreed transfer back to Greater Glasgow. A further 5 have been referred for pre-transfer assessment to local Greater Glasgow services. Those 14 patients represent around 32% of the current State Hospital “ready for transfer” list. Greater Glasgow has made progress in speeding up transfers from The State Hospital to Leverndale Hospital for people needing lower levels of security, but generally there remain delays for some, especially female patients.
6. A major recent success has been receipt of planning approval for the construction of a Local Forensic Psychiatric Unit (LFPU) at Stobhill Hospital. Work is expected to start in Spring 2004 and the Unit and service should be fully operational by 2006, in time to respond to the new appeals against the level of security allowable under the new Act.
7. Preparation for Tribunal hearings and attending them will put pressure on many professionals, but mainly on Responsible Medical Officers (consultant psychiatrists) and Mental Health Officers (social workers).
8. There are 85 consultant psychiatrists in Greater Glasgow and 5 vacancies. There are 97 doctors currently approved under Section 20 of the 1984 Act as having special experience in the diagnosis and treatment of mental disorder. The need for service and job redesign, which will have an impact on the whole service, is well understood by the consultants, despite major concerns about the extra workload.
4 Mental Welfare Commission Annual Reports 2001-02 and 2002-03 5 Sections 24 and 25 are emergency sections lasting 72 hours 6 Section 26 is a 28 day order that can be used when an emergency section has expired 7 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court. 59
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Table B - Consultant psychiatrists and Section 20 doctors in Greater Glasgow
Consultant specialty No. of WTE consultants Section 20 approved General adult 50.6 52 Old age 12.2 14 Psychotherapy 4.6 6 Forensic 6 7 Substance misuse 6.6 6 Learning disability 6.1 7 Adolescent psychiatry 5.2 5
9. The 6 local authorities have 107 Mental Health Officers working in Greater Glasgow, although only 24% currently work within a mental health setting. Enhanced salaries as a recruitment incentive are offered by 2 local councils and additionally Glasgow City has now developed plans to enhance both salaries and the attractiveness of job roles. Recruitment and retention of MHOs is a major problem and social workers are finding it increasingly difficult to carry out MHO duties at the same time as managing the other social work tasks.
Table C - Mental Health Officers in Greater Glasgow 2003
Practising MHOs in Additional Local Authority No of MHOs MHOs mental health payment
East Dunbartonshire 7 7 3 No
East Renfrewshire* 5 5 0 No
Glasgow City 79 51 15 No
North Lanarkshire* 6 5 2 No
South Lanarkshire* 7 7 3 Yes
West Dunbartonshire* 5 4 4 Yes *MHO figures reflect the active MHOs in that area, with additional social workers covering neighbouring NHS Board areas not appearing in these totals.
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Hospital Services
10. The current hospital services are arranged as follows:
Thirteen acute admission wards
• 3 at Stobhill Hospital • 3 at Parkhead Hospital • 3 at Gartnavel Royal Hospital • 2 at Leverndale Hospital • 2 at the Southern General Hospital
Four Intensive Care Units
• Stobhill Hospital • Parkhead Hospital • Gartnavel Royal Hospital • Leverndale Hospital
Rehabilitation services
• Leverndale Hospital • Gartnavel Royal Hospital • Phoenix House
Continuing care
• Ruchill Hospital
Liaison psychiatry services
• Glasgow Royal Infirmary • Stobhill Hospital • Victoria Infirmary
11. The construction of a new 15 bed addiction inpatient unit at Stobhill has begun, which will replace existing addiction beds at Ruchill and Parkhead Hospitals. This will provide new, purpose built accommodation for people with a drug or alcohol problem.
12. Plans are also being taken forward to develop a specialist inpatient facility at the Southern General Hospital for mothers who experience mental illness after the birth of their child, to be admitted with their baby. This will meet requirements within the new Act and there will also be beds available for admission from elsewhere in Scotland as part of a managed clinical/care network.
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Table D - Adult acute beds in Greater Glasgow October 20038
Average no. of Average length of Sector No. of beds admissions a stay month North 60 57 34.3 days East 76 71 38.2 days West 68 84 25.8 days South 110 96 35.9 days Total 314 308 33.5 days
13. Greater Glasgow has a good internal bed management system and is also able to admit people from elsewhere when required. In the year ending March 2002, 135 people (all mental health specialties) were discharged back to other areas and 18 people with a learning disability9.
Table E - Use of Intensive Psychiatric Care Units10
Average no of Average length of Sector Beds admissions stay Per month North 6 29 days 7 East 5 24 days 7 West 12 40 days 10 South 12 50 days 11 Total 35 36 days 35
14. The emergency readmission rate for adults within 28 days of discharge in 2001, the last figure available, was the highest rate in Scotland at 10.34%, (the Scottish average was 7.27% over the years 1998-2001). This is probably linked to the high levels of deprivation, but Greater Glasgow has well-established community services both within the statutory and voluntary sector, so this should be monitored when more up to date information is available.
8 Information provided by Greater Glasgow Primary Care Trust 9 ISD 10 Information supplied by Greater Glasgow Primary Care Trust 62
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Table F - Hospital admissions and readmissions in Greater Glasgow for people aged 16-64 years11 1998 1999 2000 2001 2002
First admission 1088 1110 1124 1048 739
Readmission within one year 2807 2750 2957 3073 2914
Readmission rate within 28 days 11.19% 11.68% 11.93% 10.34% n/a Readmission rate= (emergency readmissions/discharges) x100
15. Beds for all psychiatric specialties in Greater Glasgow (150 per 100,000 population) are 9% above the Scottish average (141), although hospital bed numbers for all specialties have shown a reduction of 139 beds over the period 2000–2003. Forensic beds have increased by 64.7%. Older people’s beds have reduced but the rate per 100,000 but still remain 5% higher than the national average.
16. While the number of hospital beds for child and adolescents remains low, Greater Glasgow’s figures account for over 45% of child and 19.5% of adolescent national bed provision. Innovative community services for young people have been developed with The Parry Jones service, providing treatment for young people with anorexia.
Table G - Hospital bed numbers Greater Glasgow and Scotland12 Greater Glasgow Greater Glasgow Scotland Hospital Actual staffed beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 1440 1442 1338 1301 161 166 154 150 161 153 145 141 specialties All adults under 65 643 603 578 548 74 70 67 63 74 70 66 64 years Older 745 786 701 676 85 91 81 78 83 79 74 73 people
Forensic 33 34 36 51 * * * * * * * * services
Child 8 9 10 10 * * * * * * * * Psychiatry
Adolescent 10 10 14 16 * * * * * * * * Psychiatry Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
11 ISD provisional data from SMR04 returns 12 ISD 63
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Community Services
17. Sections 25 and 26 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training and housing options for people who have or have had significant mental health problems. This has to complement the core treatment services, although increasingly care and treatment services are becoming aligned.
18. Community services for adults in Greater Glasgow include 16 community mental health teams, 2 day hospitals and a community rehabilitation unit. Additionally each sector has a range of intermediate services that fulfil functions of assertive outreach, home treatment and early discharge/ alternative to admission. However the balance of these functions is variably developed with no area having all of these components of service delivery in place leading to inequitable access to such supports. The East Sector has an assertive outreach team, a homeless team, and a team specialising in helping people with both a mental illness and a drug or alcohol problem.
19. There are several examples of new building projects including the Stewart Centre in Castlemilk, which opened in 2002 to provide a community mental health base. More recently the construction of the East City Centre Resource Centre will replace 3 resource centres in East Glasgow.
20. Primary Care Mental Health teams continue to be established and are already in place in Anniesland, Bearsden and Milngavie, Riverside/Westone, Eastern and Maryhill/Woodside. These teams provide treatment and advice to people suffering mild to moderate mental heath problems such as anxiety or depression and offer a range of therapies and social support.
21. Greater Glasgow’s strategy for supported employment was agreed in 2001 and is led by a multi-agency task group. ‘Building Pathways to Employment’ was set up to take forward the plans presented by mental health users and last year a Mental Health Employment Co-ordinator post was established to oversee this, initially within the Govan area of Glasgow.
22. To ensure that the voice of users and carers is central to the planning process funding was released to establish the Mental Health Network. This service user network functions independently of health/social work structures and has members in many planning groups to advise on the needs and views of relatives and carers and report back on progress with the modernising agenda. A network of local user groups has also been established across the city to ensure that their views are represented consistently across all the care groups. Some service users in the Rutherglen/Cambuslang area also link in with “Lanarkshire Links” an area wide service user and carer organisation.
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23. Advocacy Matters offers advocacy services for patients using hospital and community mental health services across Glasgow with a base in each psychiatric hospital. The aim is to assist people to have more say in the treatment they receive and to obtain information to allow them to make more informed choices. The service is managed independently by Glasgow Association for Mental Health and is funded from the NHS board, social work and the primary care trust. Other examples of independent advocacy projects include joint funding between South Lanarkshire Local Authority, NHS Greater Glasgow and NHS Lanarkshire using Mental Illness Specific Grant in the case of the Advocacy Project in Rutherglen/Cambuslang. Independent advocacy services will need to be increased considerably to meet the demands of the new Act.
24. Greater Glasgow has about 300 supported accommodation places consisting of a range of registered and unregistered schemes. As part of the Modernising Mental Health agenda and to assist with the further shift in balance from hospital to community care, the NHS board, local authorities, primary care trust and representatives of the voluntary sector will implement a strategy for homelessness services for Greater Glasgow. A further 54 places will be commissioned over the next 3 years.
25. The NHS and Glasgow City Council’s social work services provide a range of specialist services for homeless people, most of which have been established since 2000. In brief, they comprise:
• A multidisciplinary Homeless Addiction Team that provides medical, social work, occupational therapy and psychological services for homeless people with addictions and alcohol problems, serving mainly the city centre population.
• Homeless Mental Health Services (community psychiatric nurses plus a consultant psychiatrist) undertake outreach work linked with inpatient beds at Parkhead Hospital.
• A nurse-led Homeless Physical Team provides health services for hostel dwellers and other homeless people, again principally within the city centre.
• All homeless families who present to Glasgow City Council are referred to Glasgow’s Homeless Families Team, which includes health visitors and a GP.
• A new GP practice for homeless people with two doctors opened in early 2003, to provide a full range of health and allied health services including physiotherapy, addictions services and podiatry.
26. Out-of-hours services are accessed through NHS 24 then passed to a duty CPN working with GEMS, the out-of-hours GP service. Other people will call upon the duty social work service. Despite this support for both medical and social emergencies it is felt to be insufficient by some service users and some staff.
27. Greater Glasgow has well established community services that should help minimise crises out-of-hours, although the complex and multiple channels into these services confuses some GPs. Better links and information on mental health emergency responses may assist those in crisis to gain access to a CMHT. 65
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Priorities of Service Users and Carers in Greater Glasgow
28. The key issues that were expressed were as follows:
Meeting 1, Users
• There is a need for communication with professionals in a way that means they deal with the questions we need to ask instead of the ones they think we should ask. • There is a need for needs-led services responsive to users • Quality of life needs improving. • Increase user-led employment services. • Treat users with more respect and courtesy. • Listen to users. • Provide places where users can find comfort. • Stop professionals patronising users. • Clarify what professionals are meant to do. • Make a distinction between distress and mental illness.
Meeting 2, Users
• Provide more services in remote areas. • Provide more outreach to people who are becoming unwell. • Give more recognition to the importance of mental illness and mental health.
Meeting 3, Users and Carers
• Challenge the attitude of the public and professionals. • Get planners and decision makers to come to talk to us and really listen. • Give more financial priority to mental illness.
Meeting 4, Carers
• Research into mental illness • More investment, including investment for carers. • Demonstrate care for carers.
Comments
29. Key issues that will challenge Greater Glasgow area when implementing the new legislation are as follows:
¾ Independent advocacy needs to be increased.
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¾ Implementation of the plans for a local forensic psychiatric unit and mother and baby unit, which comply with the demands of the Act, will occupy time and resources and will additionally require capacity for throughput beyond the secure beds. There may additionally be a need to fund extra contractual referrals to meet the requirement to ensure access to placements for entrapped patients, pending the phased operational development of the full capacity of the local forensic psychiatric unit and service.
¾ There will be pressure on Greater Glasgow’s adolescent beds as other NHS Board areas look to ensure age-appropriate admission services.
¾ Service redesign and workforce development will be a top priority and difficult given the large size of the organisation
¾ Although community services are relatively well developed, there remain gaps in their comprehensiveness in terms of crisis resolution and assertive outreach. This will need to be further developed if the principle of reciprocity is to be appropriately applied in community settings and to allow the option of community-based Compulsory Treatment Orders.
¾ The development of social care services in relation to Sections 25 and 26 of the Act are patchy, although there are significant examples of good practice. Given the degree of deprivation in Greater Glasgow a comprehensive and strategic approach will be needed to meet the extra demands of the new Act.
¾ The opportunity cost of time in relation to psychiatric input to the Tribunal process will detract from the capacity for psychiatric input to local service delivery. It is also possible that Greater Glasgow psychiatrists may be called upon to contribute frequently, given vacant consultant posts elsewhere, and this could further exacerbate the costs to delivery of local services.
¾ Subsequent to the visit of the review team there is also concern that existing planned mental health commitments may be vulnerable given the overall financial position of the Board, and that such changes may impact on the Greater Glasgow position in relation to readiness to implement the Act.
Visiting team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow Ian Boddy Manager, Adult Mental Health Services, NHS Dumfries and Galloway Andy Dickson Head of Nursing, Adult Mental Health, NHS Argyll and Clyde Tom Keenan Social Care Consultant, Mental Welfare Commission for Scotland Dr Tom Murphy Consultant Psychotherapist, NHS Lothian
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LOCALITY REPORT
HIGHLAND
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
HIGHLAND
1. Highland is a large geographical area of about 10,000 square miles some of which is quite isolated making transport an important issue. The population of 208,100 includes 132,800 adults and 35,200 older people. Inverness is the main centre, but the inner Moray Firth area has a reasonably sized population as do the towns of Wick, Thurso, Aviemore and Fort William. Although levels of deprivation and morbidity are lower than the national average in Scotland, there is a high level of alcohol misuse among the population.
2. Mental health services are provided by NHS Highland and the coterminous Highland Council, in partnership with a broad range of voluntary sector services and not-for-profit care providers.
3. In 2001 the old Craig Dunain Hospital was closed and hospital services moved to new accommodation (providing a much improved care environment) built on an existing learning disability site, Craig Phadrig, to jointly become New Craigs. The choice of location was strongly influenced by the service user group.
Use of the Mental Health (Scotland) Act 1984
4. The level of emergency detentions under the current mental health act is higher than average, with only 2 other areas in Scotland making greater use of sections 24 and 25. Despite this, a survey in October 2003 showed that 21 people in Highland were admitted on a compulsory basis in October, around 15% of the whole acute admission population, which is a lower figure than in the other parts of Scotland where information was able to be obtained.
Table A - Detentions in Highlands under the Mental Health (Scotland) Act 1984 in 2001–02/2002-031
Average No Per Actual No of No per 100,000 In 100,000 People In Detentions Highlands Scotland
Sections 24 and 252 204/198 98/95 85/90
Section 263 116/119 56/57 51/56
Section 184 50/50 24/24 21/23
1 Mental Welfare Commission Annual Report 2001-02/2002-03 2 Sections 24 and 25 are emergency sections lasting 72 hours 3 Section 26 is a 28 day order that can be used when an emergency section has expired 4 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court. 69
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Table B - average number of detentions 1994-2002, related to population size and used to estimate the potential number of hearings.5
% of Scottish Estimated Tribunal Local Authority Population size detentions over hearings under the eight years 2003 Act Highland Council 208,100 5.50% 166
5. As at July 2003 there were 3 patients from the Highlands currently resident in The State Hospital with no-one waiting to transfer back to the local area. The right to appeal against the level of security, which will be implemented in 2006, is unlikely to add significantly to local burdens. Highland is involved in the planning for a Northern Regional forensic psychiatric unit and service which will offer wider care options in the future.
6. The Act puts pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the Final Report).
7. A major issue is the workforce vacancy levels in all disciplines, which is having a significant impact on the ability to deliver services in both the outlying rural areas and the city. General practitioner vacancies compound the gaps in secondary health care and social workers and service users stressed that as a consequence access to out-of-hours and crisis support is often lacking. There is large scale planning taking place about out-of-hours services as a whole, in relation to the changes to the GP contract next year, and social services need to be included at all levels.
8. There are 13.5 WTE consultant psychiatrist posts in Highland with a vacancy rate of around 22%. Some of the positions are being filled by locum doctors. Within these figures, 2 vacancies are in general adult psychiatry, one in old age psychiatry (due to maternity leave) and 1.5 vacant learning disability consultant posts. Some consultants cover more than one specialty (for example general psychiatry, forensic services or general psychiatry and older adults) so it is difficult to quantify the number of general psychiatry sessions. At full establishment Highland meets the level of provision suggested to local planners and commissioners by the Royal College of Psychiatrists. Any local planning or calculation must necessarily include travel time to outlying clinics, and the potential for overnight stays by staff.
5 Scottish Executive Implementation Team, based on the scoping exercise undertaken by the Royal College of Psychiatry 70
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9. Consultant psychiatrists discussed the difficulties in recruiting to posts over recent years and saw little hope of this situation improving, within what is a national problem. However, given the serious problem various options and possible solutions are being considered, with a major focus on recruitment and retention. For example, consultants are working to identify possible changes to roles and responsibilities within a service redesign process. The introduction of the Adults With Incapacity (Scotland) Act 2000 has compounded the sense of becoming ‘overwhelmed’ and the perception of ability to respond to a further change in practice after more legislation involving mental health and learning disability is understandably causing concern.
10. Currently there are 24 doctors approved under Section 20 of the 1984 Act, including 4 GPs, in addition to consultants, specialist registrars and staff grade psychiatrists. The new GP contract will have an impact on the work GPs undertake and continuing discussion with psychiatric colleagues is important.
11. There is an unusually high number of approved Mental Health Officers (MHOs) working for Highland Council and it was reported that 48 out of the 50 had carried out duties under the current Mental Health Act in 2002-2003. This means 23 MHOs per 100,000 of the population (comparing favourably to the national average of 11.5 per 100,000). At present only about 26% are located in mental health settings.
12. It was explained locally that the high number was to ensure there would be a relatively quick response across the area and that in practice fewer than stated will have been active in the last year. The majority of the MHOs (60%) are clustered in Inverness, Dingwall and Nairn. With the enhanced MHO role under the 2003 Act, which will include care planning, the MHOs not working in mental health may need updated training in mental health casework as well as the provisions of the Act.
13. There is currently no agreement by Highland Council to pay their MHOs enhanced rates, although a recent review supporting this is being considered with the proviso that there is at least a minimum level of detentions each year and that refresher training is completed.
Table C - Mental Health Officers approved by Highland Council
Practising MHOs in Additional Local Authority No of MHOs MHOs mental health payment Highland Council 50 48 13 No
Hospital Services for Adults
14. Mental health facilities within the area consist of:
Three acute adult admission wards
• New Craigs Hospital (72 beds)
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One intensive psychiatric care unit
• New Craigs Hospital (12 beds)
Two rehabilitation units
• 11 beds at New Craigs Hospital • 20 community based beds
15. This is a higher number of beds than that suggested by the Royal College of Psychiatrists for services where there are no additional sub-specialty day and community services. The maximum proposed number (50 per 100,000 adult population) would be 66.6 The local situation may partly reflect the lack of intensive support opportunities elsewhere in the region.
16. While it is accepted by the Project Team that there are too many acute beds for direct clinical need, the beds have been used to full occupancy. There are insufficient numbers of skilled community staff in rural areas and the large distances people travel in an emergency to get to the hospital means that it is virtually impossible to send them home on the same day.
Table D - Hospital bed numbers Highland and Scotland7
Hospital Highland Highland Scotland Beds Actual beds Number per 100,000 Number per 100,000 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 261 258 257 259 125 123 123 117 161 153 145 141 specialties All adults under 65 140 140 140 123 67 67 67 64 74 70 66 64 years Older 119 115 116 108 57 55 56 52 83 79 74 73 people Child 2 2 2 1 * * * * * * * * Services Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data.
6 Model consultant job descriptions and recommended norms. OP55 October 2002. Royal College of Psychiatrists. London 7 ISD 72
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17. Local figures show an average of 7 one-day admissions a month to acute beds, from July 2000 to March 2003. In addition there were 69 admissions without overnight stays. The rationale about long distances is not the only explanation - a surprisingly high number come from the Inverness area. Since the opening of the Braeside Day Centre, which accepts referrals from GPs, there have been considerably fewer brief admissions.
18. Although the number of adult admission beds is high the overall number of psychiatric beds for adults meets the Scottish average. There are relatively few beds for older people with only two other mainland NHS board areas having less per 100,000.
19. In 2000-01 there were 37 discharges from New Craigs who lived elsewhere (all ages) and in the converse, 29 local people were admitted to other parts of Scotland. The following year was similar; 37 people treated from outside Highland and 29 people sent elsewhere. Some of the out-of-area admissions will be due to the pressure on beds elsewhere in Scotland and some will be from the influx of tourists in summer. In July 2003 there were eighteen people whose discharge was delayed; five of these were adults, and the remaining were older people.
20. The emergency readmission rate (within 28 days) was used by the Accounts Commission8 as a possible indicator of inadequate community care. The rate rose considerably in 1999, but this is partly explained in the statistics gathered for patients transferring from the old hospital to the new facilities who technically had to be admitted again. The last available figure was below the Scottish average of 7.27%
Table E - Hospital admissions in Highland for people aged 16/18-649
Adults 16/18 - 64 1998 1999 2000 2001 2002(p) First Admission (i) 208 135 75 14 177(p) Readmissions Within One Year (ii) 567 752 846 895 675(p) Readmission Rate Within 28 Days 8.06% 11.43% 10.13% 6.76% N/A (iii) (i) First ever recorded admission to psychiatric inpatient care (ii) All readmissions following a break in in-patient care (iii)Emergency readmissions/discharges x 100 (p)Provisional data from ISD SMR04 returns refer to year 2002 only.
21. Child and adolescent services in the region have been improved with an investment of £320,000 for primary care mental health workers who link in to the Department of Child and Family Psychiatry. There is now an additional half-time consultant supported by one H grade and 2 G grade community psychiatric nurses and together they provide a 7 day service for the region. This is a good example of consultant cover being supported by specialist nurses crossing the interface of primary and secondary care. Age-appropriate admission services for adolescents are required by the Act and it is evident that small numbers of inpatient units will have to be part of a managed clinical network across Scotland. The development of good local services such as this will contribute to the network.
8 A shared approach: Developing adult mental health services. Accounts Commission for Scotland 1999 9 ISD provisional data from SMR04 returns 73
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22. The Highland Users Group (HUG) noted in their 2002 report10 that “Video conferencing has been useful for some people in remote areas who have little access to psychology. This could be expanded where appropriate.” The principle of reciprocity means that people should have access to the full range of treatments if under a Compulsory Treatment Order and this may now be community-based. The suggestion of increasing tele-conferencing is a good idea, although not acceptable to many who prefer face-to-face interactions.
Community Services for Adults
23. Community based services are as follows:
Five community mental health teams (each with sub-divisions)
• Caithness • Lochaber • East Highlands • Nairn • Inverness
Four day hospitals:
• East Highlands • Inverness • Nairn • One travelling day hospital in East Caithness
Nine drop-in centres
24. The development of better out of hours support within communities would assist GPs to help their patients safely at a local level. There is an excellent example of a primary care based CMHT in Nairn, which has a visiting psychiatrist; this has consistently been shown to reduce the admission rate. Some areas have no CMHT cover however, while others also lack some primary care staff, including GPs, because of vacancies. These difficulties are compounded by the wide geographical area. Some creative solutions were offered involving the voluntary sector and local respite places and these options should be taken further in discussion with service users and carers.
25. There are many good examples of voluntary sector provision although difficulties with short-term funding and no uplift for inflation means that some services are being ‘cut’ in real terms to manage the widening gap in finance from year to year.
10 Current issues in mental health in the Highlands 2002 74
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26. There is a Patients’ Council at New Craigs Hospital, and the Highland Users Group (HUG) is a well-established and highly regarded example of user involvement in Scotland. At present, access to independent advocacy is insufficient to meet current demands and therefore further investment will be required prior to the introduction of the new Act. Funding to increase access to individual advocacy has been slow to cascade, and while advocacy groups are well aware of the unmet need, expanding existing services will take time and planning. An Advocacy Plan was developed by Highland’s joint agencies and submitted to the Scottish Executive for approval. Following this, the Joint Committee for Action in Community Care agreed to invest £200,000 on advocacy services, although none of this money was ring- fenced for mental health service users or carers. Additional funding has now been released to the local authorities for advocacy as part of preparation to implement the Act.
Priorities of service Users and Carers in Highland
27. Users
• Adequate and consistent funding for the voluntary sector. • Escorts for the journey to hospital. • Structured activities in the community: help with motivation support and other activities that will help people keep well at home. • Help with problem-solving opportunities for people living with illness and coming to terms with it. • Out of hours services. • Challenge stigma, provide mental health awareness training and change attitudes. • Support for the rest of the family and for carers.
28. Carers
Caithness
• A place of safety as an alternative to the police station when people are in crisis. • Easier transfer to hospital – waits of 18 hours in police cells are not acceptable. • Talking treatments. • Supported accommodation.
Inverness
• More stimulation in the wards. Nurses seem to spend hours in the nursing station. • More monitoring of patients –health, diet clothing. • More involvement from the dietician to avoid the massive weight gain that occurs with some medication. • Better and quicker access to psychologists. • More investment to help users with tasks such as cooking and shopping when people are discharged home.
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29. Given the geography of the area and the dispersed population transport is a big issue, especially for emergency admissions that may require access to ambulance services. In such instances nursing staff from New Craigs are required to escort patients, often involving long periods and requiring staff to be away from the wards. Public transport to enable people to attend drop-in centres, attend out- patients or generally get involved in social activities is limited. The new Act puts additional responsibility on the Local Authority to address transport issues.
30. Another important theme raised by users was inadequate access to housing stock and this has hindered the development of supported accommodation projects. To help address this, a housing officer from Highland Council is now part of the mental health strategic planning process.
Comments
31. Key issues that will challenge Highland when implementing the new legislation:
¾ Out-of-hours services, especially in rural and remote areas, need to be developed. While Inverness had a good example of CPN triage gaps were clearly evident elsewhere and may well be contributing to unnecessary admissions to hospital.
¾ Vacancy rates in many disciplines require a continuing major focus on recruitment, retention and service redesign. When consultants develop their roles to meet the requirements of the Act other disciplines must be available to take on new duties, especially nursing staff and allied health professionals.
¾ Independent advocacy needs to be extended for users and carers.
¾ Despite relatively high numbers, MHOs are not readily accessible in remote parts of the region and this needs to be taken into account in the action plan for implementation.
¾ Users require better access to training, employment, recreation and daytime activities. There are some excellent examples; however some areas lack any such investments.
¾ There needs to be access to hospital services for children and adolescents and mothers with babies.
76
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Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Graham Charlton Social Work Services Project Manager, South Ayrshire Council
Ian Boddy Manager, Adult Mental Health Services, NHS Dumfries and Galloway
Andy Dickson Head of Nursing, Adult Mental Health, NHS Argyll and Clyde
Dr Tom Murphy Consultant Psychotherapist, NHS Lothian
77
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LOCALITY REPORT
LANARKSHIRE
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
LANARKSHIRE
1. Lanarkshire has a total population of approximately 552,900 (214,400 adults in North Lanarkshire and 199,800 adults in South Lanarkshire1). Most are resident in towns with high levels of deprivation and morbidity in comparison to the rest of Scotland. Mental health services are provided by NHS Lanarkshire and two local authorities, North and South Lanarkshire Councils, working with a wide range of voluntary organisations and care providers.
2. The council areas are not coterminous with Lanarkshire health services, as both local authorities also cover parts of the NHS Greater Glasgow Board area.
Use of the Mental Health (Scotland) Act 1984
3. Compulsory hospital admissions are lower in Lanarkshire than elsewhere. The reasons need to be examined as part of local preparations for the new Act. If local residents have access to adequate, appropriate and acceptable treatment on an informal basis then this is to be welcomed. The availability of developed community services will have an impact, and any such correlation should be carefully checked and also considered in terms of inequities in access to community services.
Table A - Detentions in Lanarkshire under the Mental Health Act (Scotland) 1984 in 2001–02/2002-032
Actual number No. Per 100,000 No. per 100,000 of detentions in in Lanarkshire in Scotland Lanarkshire Sections 24 and 253 270/392 49/71 85/90 Section 264 149/226 27/41 51/56 Section 185 66/72 12/13 21/23
4. Low application of emergency detentions will not necessarily reduce the anticipated extra workload with the new Act. The workload will be increased mainly by the Tribunal process, which is linked to Compulsory Treatment Orders. These are roughly equivalent to the current Section 18 and in Lanarkshire the figures for detentions under this Section are more in line with the national average.
5. There are 13 Lanarkshire patients in The State Hospital, two of whom are waiting to return to local services. Agreement to return has been reached for one person, who is subject to a restriction order. The other is waiting assessment by Lanarkshire services. No Lanarkshire patient detained at The State Hospital has been waiting for more than 3 months, an impressive record given the current lack of a local forensic psychiatric unit and service. This should be considered in the context that, from 2006, patients will have access to an appeal against the level of security in which they are being held.
1 ISD Scotland 2 Mental Welfare Commission Annual Report 2001-02/2002-03 3 Emergency detention for up to 72 hours 4 Short term detention for up to 28 days 5 Long term detention for up to six months 79
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LANARKSHIRE
6. The use of the Intensive Psychiatric Care Unit as a step-down facility is however not the best alternative to dedicated forensic beds, especially since the layout of the ward is on 3 floors, making observation difficult. The internal design is less than welcoming. The location and number of forensic beds and services in Scotland is currently under review.
Table B - Estimated number of Tribunal hearings6
Estimated no. of Tribunals Lanarkshire NHS Board 196 - 203 North Lanarkshire Council 42 South Lanarkshire Council 136
7. Added pressures will fall primarily on consultant psychiatrists and Mental Health Officers, although there will be stress on administration and advocacy services also. There are 18 WTE consultant posts in general adult psychiatry but of these 8.9 WTE are currently unfilled (except for one locum). This is nearly a 50% vacancy level, creating a major problem in terms of optimum provision for the population size.
8. Current staff shortages make it difficult to provide a full range of services now, and these difficulties will be compounded when the Act is implemented. There is an overall shortage of consultant general psychiatrists in Scotland and neighbouring NHS Boards have better resources and community infrastructure in place, which is helping them to attract staff more easily. Added investment needs to be put into other disciplines and grades of multidisciplinary staff to free up more consultants’ time, including (but not limited to) administering the Act.
9. Approximately 1 in 6 of the MHOs employed by both Councils work in Glasgow, although the workload for MHOs employed by North Lanarkshire is negligible. There are 9.2 MHOs per 100,000 of the local population, which is lower than the national average (11.5 per 100,000) and recruitment and retention will need to be a continued priority to meet the new legislative demands. Most of the trained MHOs continue to carry out MHO functions, so there will be an experienced group of people to help with the transition to the new Act. This is offset by the fact that less than half currently work in mental health settings and will need considerable updating on current mental health practice in order to carry out such duties as presenting care plans to the Tribunal.
6 Scottish Executive/Royal College of Psychiatrists. This is a very rough estimate and the numbers do not add up, due to rounding up of figures and problems with calculation when areas are not conterminous. 80
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Table C - Mental Health Officers in Lanarkshire7
MHOs Additional Local Practising No of MHOs working in payment for Authority MHOs mental health MHOs No, but can North 35 28 10.5 regrade to Senior Lanarkshire Practitioner 28 (including 7 21 (+5 working at South working at The The State 11 Yes Lanarkshire State Hospital) Hospital)
Hospital Services
10. Hospital services are arranged as follows:
Six acute adult admission wards
• two at Monklands Hospital (Monklands/Cumbernauld Sector), 48 beds • two at Hairmyres Hospital (Hamilton/East Kilbride Sector), 50 beds • two at Wishaw Hospital (Motherwell/Clydesdale), 46 beds
One Intensive Psychiatric Care Unit
• Hartwoodhill Hospital, 22 beds
Brain Injury Unit
• Hartwoodhill, 24 beds
Three rehabilitation units
• Caird House (10 adult beds) • Coathill Hospital (10 Beds) • Airbles Road Centre (10 Beds)
Three continuing care wards
All at Hartwoodhill Hospital (90 beds for adults)
Liaison Psychiatry Service
• Monklands Hospital (nursing) • Wishaw General Hospital (nursing +0.5 WTE Consultant – vacant post)
7 Mental Health Officer Services: Structures and Supports, Scottish Executive, 2003, Information corrected locally. 81
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Day Hospitals
• Monklands • Hairmyres • Wishaw General (one third of attendees are on Section 18)
11. There are 788 beds in Lanarkshire for all psychiatric specialties, which is the sixth lowest ratio in Scotland. In the last 3 years 31 beds for adults (16-64) have closed leaving 307 beds for this service, 164 of which are for acute admissions (not including the IPCU, which is reported as a forensic service).
12. Following ward closures in October there are now 409 beds for older people, 142 contracted directly from nursing homes.
Table D - Hospital bed numbers Lanarkshire and Scotland8
Lanarkshire Lanarkshire Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 832 829 787 788 150 150 142 138 161 153 145 141 specialties All adults under 65 338 336 318 307 61 61 58 56 74 70 66 64 years
Older people 474 472 449 409 86 85 81 74 83 79 74 73
Forensic 20 20 20 20 * * * * * * * * services/IPCU Adult beds include acute admission, rehabilitation and continuing care but not IPCU which is listed as forensic. The forensic/IPCU beds were reduced to 15 at the time of the visit. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
Table E - Hospital admissions for people aged 16/18-649
Adults 16/18 – 64 1998 1999 2000 2001 2002 First Admission 275 384 556 594 368 Readmission within one year 954 1,302 1,234 1,256 985 Readmission rate within 28 days 1.63 0.42 2.88 5.84 N/A
8 ISD 9 ISD provisional data from SMR04 returns. Discrepancies are due to rounding up numbers. 82
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LANARKSHIRE
13. Between 1998 and 2001 the number of first admissions more than doubled, but reduced again last year, although not back to the 1998 level. A similar pattern occurred for readmissions within one year. The rate of emergency readmissions within 28 days has gone up to 5.84%, a significant figure possibly due to lack of adequate discharge and after-care arrangements. It remains, however, significantly below the national average of 7.27%10. It is important that these fluctuations in the pattern of hospital admission and readmission be understood where possible in the context of the contribution to be made through community care developments.
14. In July 2003 there was a relatively low number of delayed discharges, 5 adults and 16 older people. There has been a joint appointment between health and the Local Authority on the acute wards to facilitate this and is an example that could usefully be followed elsewhere.
Community Services
15. The Modernising Mental Health Services Implementation Project Board is decentralising secondary care services and investing in further community resources. Community services at present include 8 multidisciplinary community mental health teams and they are being reconfigured and developed into resource networks that include an outreach team, focused intervention team, social support and joint assessment and care management.
16. The plan is to have a flexible range of services less concentrated on particular buildings. Resource networks were established in Wishaw and Motherwell in 2000 as well as in Cumbernauld and Clydesdale. Networks started up in Airdrie and Coatbridge LHCC areas are not developed as far as had been planned because of resource constraints. There is considerable inequity within Lanarkshire for access to adequate community services. The inequity should be addressed as part of the 2003/04 investment in Community Services.
17. There is also a resettlement team to assist with the discharges of longer stay residents from the continuing care wards in Hartwoodhill Hospital.
18. A high priority is to improve services for individuals outside working hours and for those in crisis. Funds will be made available, with local acknowledgement that improved services are needed for both health and social emergencies. There is 24- hour social work and MHO cover through the West of Scotland SW Standby Service. Lanarkshire Association for Mental Health also provides some out-of-hours support. CMHT cover is currently restricted to weekdays, 9am to 5pm, with out-of-hours support given by GPs, Accident & Emergency departments or the duty psychiatrist. The development of 24-hour support in a range of settings will be necessary to implement the Act and make community-based Compulsory Treatment Orders possible.
10 ISD. Latest data (2001) 83
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LANARKSHIRE
19. Access to psychological interventions remains patchy. Although there has been investment in training nurses and some allied health professionals, it was reported that few people stay to carry out this work, either because they transfer elsewhere or move on promotion. Only 3 CPNs have any formal training, by attachment to the psychology or psychotherapy departments or by attendance at Caledonian University. Lanarkshire has achieved near universal access to counselling services..
20. There are no specialist facilities locally for admission of adolescents or mothers with babies and arrangements will need to be made to ensure that services are available, perhaps as part of a managed clinical network.
21. There are 2 advocacy organisations, and an advocacy café goes fortnightly to care of the elderly wards. Although the statutory services in Lanarkshire spend £1.35 per head on advocacy, against a Scottish average of £1.23, this will need to be developed further before the Act is introduced.
22. There is a range of voluntary organisations including Lanarkshire Association for Mental Health and service users groups such as the Patients’ Council. A ‘Connections’ project works with people who are homeless or at risk of homelessness on leaving acute psychiatric care (North Lanarkshire Council area) and ‘Reach Out’ supports the children of people who are ill.
Priorities of Users and Carers in Lanarkshire
23. The following summarises the points made by the local users and carers:
• More staff - with consideration given to the balance between support workers and psychiatrists. • More investment. • Prevention. • Care Pathways so that when people get ill they know what to expect and what help they can get. • Services that emphasise normal life rather than illness. • More user-led and managed services. • Use the Care Programme Approach more widely to cater for relapse and to help more people. • More recognition of advance statements. • Person-centred planning.
Comments
24. Lanarkshire faces serious challenges in being ready to comply with the Act, including:
¾ The high vacancy rate in general adult psychiatry is serious and requires imaginative ways to redesign services and review job roles and responsibilities.
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¾ Community services are lacking in several parts of the service including Hamilton and East Kilbride.
¾ There is no current access to dedicated medium and low secure units, although Lanarkshire is part of the West of Scotland Consortium planning such services.
¾ The function of the Intensive Psychiatric Care Unit and its environment needs to be reviewed.
¾ Inpatient services for children and adolescents, and mothers with babies are not available locally.
¾ Advocacy services need to be developed further.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Andy Dickson Head of Nursing, Adult Mental Health, NHS Argyll and Clyde
Dr Tom Murphy Consultant Psychotherapist, NHS Lothian
Christina Naismith NHS Lothian and Edinburgh City Council Joint Programme Manager, Mental Health
Dr Michael Smith Consultant Psychiatrist, NHS Argyll and Clyde
85
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LOCALITY REPORT
LOTHIAN
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
LOTHIAN
1. Lothian has a population of approximately 779,0001, (528,560 adults). There are proportionately fewer older people than the national average. Most live in densely populated communities, although a reasonable proportion lives in more remote and rural settings where transport can be an issue. Levels of deprivation and morbidity are overall below the national average, but there are pockets of deprivation especially within some Edinburgh housing schemes.
2. Mental health services are provided by NHS Lothian and four local authorities: East Lothian, City of Edinburgh, Midlothian and West Lothian Councils. They work in partnership with many voluntary agencies and care providers. Edinburgh Primary Care Trust and East and Midlothian Primary Care Trust merged in 2001, which makes some of the long-term calculations complex. West Lothian Healthcare NHS Trust provides both acute and primary care. The Clinical Standards Board for Scotland (CSBS) estimated 1,144 people (16-65 years) with a diagnosis of schizophrenia were being cared for in Edinburgh, East and Midlothian and 300 in West Lothian.
3. The Mental Health and Well Being Support Group (October 2002) noted progress with a transport protocol for mentally disordered offenders, improved recruitment to child and adolescent mental health services and the development of an Integrated Care Pathway for postnatal depression in West Lothian. All of these are directly relevant to the new Act.
4. Lothian is developing a mental health strategy that includes consideration of greater centralisation of hospital sites.
Use of the Mental Health (Scotland) Act 1984
5. A larger number of people receive hospital treatment under compulsion in Lothian than the Scottish average. A November 2003 snapshot of the Royal Edinburgh acute wards showed around 40% of patients subject to detention orders. Explanations should be explored though this may not be a simple task.
Table A - Detentions in Lothian under the Mental Health Act (Scotland) 1984 in 2001-02/2002-032
Actual number of No. per 100,000 in No. per 100,000
detentions Lothian in Scotland Sections 24 and 253 865/818 111/105 85/90 Section 264 506/483 65/62 51/56 Section 185 218/234 28/30 21/23
1 ISD Scotland Lothian NHS Board population figure year ending March 2003 2 Mental Welfare Commission Annual Reports 2001-02/2002-03 3 Sections 24 and 25 are emergency sections lasting 72 hours 4 Section 26 is a 28 day order that can be used when an emergency section has expired 5 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court. 87 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
LOTHIAN
6. The estimate of the likely number of Tribunals shown in the following table has been based on the average detention rate over 8 years. These may be underestimates because the trend in the number of detentions has been rising year on year.
Table B - Average number of detentions 1994-2002 related to population size and used to estimate the potential number of hearings6
Percentage of Estimated Tribunal Local Authority Population size Scottish detentions hearings under the over 8 years 2003 Act East Lothian 90,750 1.04% 31 Edinburgh City 448,080 14.70% 443 Midlothian 80,500 Figures not available unknown West Lothian 159,960 3% 90
7. The Orchard Clinic at the Royal Edinburgh Hospital is currently (December 2003) the only custom–built forensic psychiatric unit and service in Scotland, though others are planned. It provides a 50 bed regional service covering Forth Valley, Borders and Fife as well as Lothian and at existing occupancy levels has the capacity to admit patients from other areas. Delays can arise in finding appropriate step-down placements in continuing NHS care or in highly supported community settings.
8. There are 29 Lothian patients currently in The State Hospital, including two women. Five7 have been waiting for more than 3 months for transfer back to the local services following clinical agreement. Another 2 have been waiting less than 3 months for transfer. One reason for delays arising can be the admission criteria for the Orchard Clinic. The facility does not admit people with a principal diagnosis of learning disability, traumatic brain injury or personality disorder. There is not always a clear distinction because people may have both a learning disability and a mental illness.
9. Accepting The State Hospital diagnosis of the primary mental disorder, there are 3 people with learning disability from Lothian waiting for an agreed transfer. Two people with a learning disability have been waiting for a transfer for more than 12 months. From 2006 under the new Act people can appeal against the level of security and lessons need to be learnt from the experience of the Orchard Clinic when developing similar services across Scotland.
10. The new Act puts pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the final report).
6 Scottish Executive Implementation Team, based on the Royal College of Psychiatrists scoping exercise. 7 State Hospital 88 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
LOTHIAN
Table C - Mental Health Officers in Lothian8
MHOs Local Practising Additional No of MHOs working in Authority MHOs Payment mental health East Lothian 9 7 3 No Council Edinburgh City 89 69 4 No Council Midlothian 9.5 8.5 0 Yes Council West Lothian 17 17 5 No Council
11. There are 101.5 WTE Mental Health Officers working in Lothian (out of 124.5 trained people), which is 13 per 100,000 (the national average is 11.5). They said they felt very stretched already with the pressure of work, partly due to the high detention rate. The additional pressures caused by the Adults With Incapacity (Scotland) Act 2000 were pointed out as was the need for greater convergence with the new legislation.
12. Social workers would welcome the increased responsibilities under the new Act were the implementation accompanied by training and development, to allow MHOs to deliver effective care to people subject to detention orders, given the new extended role and support was available with adequate numbers of staff.
13. There are 71 WTE consultant posts in Lothian covering all specialties and sub-specialties as well as an academic centre and some services are also provided to other parts of Scotland. The vacancy rate for consultants is small and does not include general psychiatry. There are about 20 adult general psychiatrists in Lothian Primary Care Trust and 3 in West Lothian, plus 3 forensic psychiatrists. These levels are considered appropriate.
14. The consultants discussed work-load stress, out-of-hours working and the potential for reduced job satisfaction. An additional concern was the impact were GPs to opt out of out-of-hours work under their new contract. The estimate from the Royal College of Psychiatrists is that about 30 additional psychiatrists will be needed in Scotland to meet the demands of the new Act, in addition to filling current vacancies. Recruitment and retention difficulties should be kept in mind. The consultants in Lothian are examining alternatives and changes to work practice that will be needed for the new Act.
8 Mental Health Officer Services: Structures and Supports, Scottish Executive 2003
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Hospital Services
15. Services within the area consist of:
Adult Acute Admission Wards
• Royal Edinburgh Hospital (5 wards, 125 beds) • Herdmanflat Hospital, East Lothian (19 beds) • Rosslynlee Hospital, Midlothian (19 beds) • St John’s Hospital, West Lothian (2 wards, 48 beds)
Rehabilitation/ Continuing Care Wards
• Royal Edinburgh Hospital (4 wards) • Herdmanflat Hospital • Rosslynlee Hospital
Intensive Psychiatric Care Units
• Royal Edinburgh Hospital (12 beds) • St John’s Hospital, Livingston (12 beds)
Specialist Services
• Orchard Clinic, forensic • Lothian-wide community drug and alcohol services • William Fraser Unit, 6 bedded forensic learning disability and 6 dual diagnosis beds • Robert Ferguson Unit: Acquired Brain Injury Unit • Department of psychological medicine: Royal Infirmary of Edinburgh and Western General Edinburgh • Cullen Centre, Edinburgh, eating disorders • River Centre, post-traumatic stress disorder • Psychotherapy department, covering Lothian • Clinical psychology
(Day services are listed under community services, paragraph 21 refers).
16. In 2001-02, 76 Lothian people were discharged from elsewhere in Scotland, and 72 were discharged from Lothian who in turn live in other parts of Scotland9. Some of the out of area admissions to Lothian will be for specialist services, for example the Orchard Clinic, the Young People’s Unit and both IPCUs. There is pressure on beds. From May to October 2003 the average occupancy of the acute adult wards in the Royal Edinburgh Hospital was 98%, including pass beds (82% if they are excluded). Average length of hospital stay was 30 days.
9 SMR04 returns 90 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
LOTHIAN
17. There were 117 delayed discharges in July 2003, covering all psychiatric specialties (17 adults and 100 older people). Delays affecting older people are the highest in the Scotland and bringing about an improvement is a top priority. New funding has helped open and operate a Transitional Rehabilitation Ward for one year in the Royal Edinburgh Hospital, for adult patients. A multi-agency, multidisciplinary professional team is working with this group to ensure that they are discharged to the community with appropriate levels of support.
Table D - hospital bed numbers Lothian and Scotland10
Hospital Lothian Lothian Scotland Beds Actual beds Number per 100,000 Number per 100,000 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 1208 1138 1131 1134 157 147 145 146 161 153 145 141 specialties All adults under 65 571 514 474 459 74 66 61 59 74 70 66 64 years Older 609 586 595 614 79 75 76 79 83 79 74 73 people Forensic 28 30 50 5011 * * * * * * * * services Adolescent 0 9 12 12 * * * * * * * * Psychiatry Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data
18. The emergency readmission rate within 28 days in Lothian Primary Care Trust in 2001 was 5.96% and in West Lothian 9.25%, (the Scottish average was 7.27% between 1998 and 2001). More recent figures are not available, but the difference between the two local positions should be examined for any lessons to be learned. The readmission within 28 days was used by the Accounts Commission12 in 1999 as a proxy measure for the adequacy of discharge planning and for how well people are being supported in the community.
19. Lothian is only able to provide a partial age-appropriate admission service for adolescents as some 16 and 17 year olds are treated in adult acute admission wards, which will not comply with the new Act. Despite having 12 adolescent beds there is pressure both in terms of maintaining staffing levels and accepting admissions from outside Lothian.
10 ISD 11 Only 30 beds are allocated to Lothian 12 A shared approach Developing adult mental health services. Accounts Commission for Scotland 1999 91 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
LOTHIAN
20. There are no dedicated inpatient perinatal services for mothers and babies as will be required by the new Act. A proposal to develop inpatient services for mothers and babies at St John’s Hospital is currently under discussion as part of an integrated care pathway.
Community Services
21. Community Services in each area include:
Edinburgh
• Five community mental health teams • Joint mental health programme manager • Home support services • Accommodation: residential, supported, housing with intensive support • Day facilities drop-in, educational, training, art-based, employment • Respite at Cairdeas House (Penumbra) • 14 community care teams • Multidisciplinary community rehabilitation team • Collective and individual advocacy
Midlothian
• Community rehabilitation service • Day facility at Bonnyrigg • Community care teams at Loanhead and Dalkeith
East Lothian
• CPNs attached to primary care • Community care teams at Haddington and Musselburgh • Tynepark Resource Centre • Community rehabilitation Team • Home support services
West Lothian
• Community care teams at Bathgate, Broxburn and Livingston • Two joint day services and two health day services • Supported accommodation, 47 places in four locations • Independent advocacy
22. Progress with the development of community services varies across Lothian. Some places have a well-developed infrastructure and others need even basic services to be put in place. The South Central Edinburgh sector shares a team with South West Edinburgh, but this is currently being reorganised to allow a team for every sector. East Lothian has a “Network” of community psychiatrist nurses and Midlothian has a community mental health team. Some of these teams do not deliver a seven-day service.
92 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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23. The resource centre model, developed in Edinburgh’s South East sector at Ballenden House is being replicated across Edinburgh. The centre supports over 200 users on a 7 day a week basis, as well as offering drop-in and home support if required. This model has had a positive impact on both reducing lengths of stay in hospital and number of admissions.
24. There are good examples of voluntary sector organisations providing supported work schemes such as Redhall Walled Garden Project run by Scottish Association for Mental Health, and supported accommodation through Barony Housing, Edinvar and Penumbra, among others.
25. Independent Advocacy services were seen by both users and staff as currently insufficient to meet the demands of the new Act. Lothian has examples of various advocacy services including collective advocacy, and the joint commissioning team is already exploring a plan to address the shortfall in numbers.
26. The response to crisis and out-of-hours cover is currently insufficient.
Priorities of Service Users and Carers in Lothian
27. The priorities expressed by users and carers are:
• Edinburgh Users • Create pathways of care that come into being on diagnosis. • Carry out more research • Challenge stigma and educate professionals and the public. • Change the attitude of professionals • Provide crisis services • Open up a range of alternatives to psychiatry and medication. • Provide more information on what’s available.
East Lothian Users
• Transport to get to services • A chance to get out and about and go on trips and get some variety into life • Investment in local groups, community facilities and the voluntary sector. • Employment opportunities with support for people who can’t sustain work. • Make benefits easy to get and not a barrier to normal life.
Carers
• More supported accommodation • More early intervention and proactive services • More communication with users and carers and between professionals.
Midlothian Users
• Change the attitudes of some psychiatric professionals. • Better access to talking therapies. • More supported accommodation- especially on discharge from hospital. • Full disabled access to mental health facilities.
93 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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• More places such as the Orchard Centre (a drop-in centre with arts and other opportunities) • More employment opportunities.
Carers
• Investment and money • Crisis services • Follow up in the community • Respite • Help with physical health • People with dual diagnosis or learning disabilities need recognised and helped. • Help with social activities and communication skills • Training for the police in mental illness. • Challenge the stigma of mental illness. • Carer and user led mental health awareness training is effective and important.
West Lothian users
• There is no Patients’ Council or service user forum
Carers
• Emergency out-of-hours services. • Include carers in the process more. • Rehabilitation and recovery at the user’s pace.
Comments
28. Challenges for Lothian when implementing the new legislation are:
¾ Strategic planning and reconfiguration may occupy time and use resources with the possibility of insufficient attention to the demands of the Act. ¾ Revising roles and responsibilities for both mental health officers and consultants will require a holistic review of all staff. ¾ Community services and advocacy are not provided on an equitable basis across Lothian. ¾ Plans for an admission facility for mothers and babies need to be taken forward. ¾ The extra demands on local authorities to provide support services will need to be funded. ¾ Advocacy needs to be developed, including for carers. ¾ Full 24 hour crisis and out-of-hours support should be made available.
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Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Dave Clark Regional Manager, Church of Scotland Board of Social Responsibility
Patricia McLaughlin Chair, Renfrewshire Association for Mental Health
Stephen McLellan Chief Executive, Renfrewshire Association for Mental Health
Dr Michael Smith Consultant Psychiatrist, NHS Argyll and Clyde
John Paterson Operations Director, Richmond Fellowship Scotland
95
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ORKNEY
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
ORKNEY
1. NHS Orkney provides mental health care to a total population of around 19,200 (12,300 adults1), with a higher proportion of older people than the Scottish average.
2. The population is distributed across mainly rural communities and several islands. Given the remote nature of the island communities, delivery of a wide range of health care needs is a challenge to service commissioners and staff. Levels of deprivation and morbidity are lower than the average in Scotland.
3. NHS Orkney and Orkney Council are coterminous in their boundaries.
4. The 2002 visit from the Mental Health and Well Being Support Group found the service deficient mainly in strategic planning. They and also the Scottish Health Advisory Service have commented on the high level of stigma that people can experience within small close-knit communities.
5. The Clinical Standards Board for Scotland (CSBS) in its audit of schizophrenia services in 2002 found that 16 people in Orkney had a diagnosis of schizophrenia and were receiving treatment and care. They found reasonably good consultation with service users, although links with carers could be improved, especially in terms of access to advocacy and information about their right to an independent assessment of their needs. There was insufficient standardisation of guidelines and policies and this is being worked on.
6. The CSBS follow-up visit has not been published, but verbal feedback locally from the October 2003 visit was that there have been significant improvements.
Use of the Mental Health (Scotland) Act 1984
7. It is not possible to predict the number of future detentions and possible Tribunals because of the very low numbers, although it has been suggested that 2 a year should be anticipated.
Table A - Detentions of people living in Orkney (all ages) under the Mental Health (Scotland) Act 1984 in 2001-02/2002-032
Actual no of detentions Estimated number of
in Orkney Islands Tribunals Sections 24 and 253 4/5 * Section 264 3/5 * Section 185 2/1 *
8. There are no patients from Orkney currently resident in The State Hospital.
1 ISD Scotland 2 Mental Welfare Commission Annual Reports 2001-02/2002-03 3 Sections 24 and 25 are emergency Sections for people either from the community (Section 24) or already in hospital (Section 25) lasting 72 hours. 4 Section 26 is a 28 day order that can be used when an emergency Section has expired. 5 Section 18 is a long-term order, 6 months in the first instance with the agreement of the Sheriff Court. 97 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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9. Orkney does not have a resident psychiatrist, although 2 general practitioners have recently been trained as Section 206 approved doctors and 2 more are waiting for training.
10. Social work staff raised concerns about the current capacity and skill base for Mental Health Officers (MHOs) to carry out the extended duties required of them under the new Act. The local challenge is less about the numbers of trained MHOs and more about the small number of times when MHOs are called upon given the low frequency of detentions. For people who are not currently working in the mental health field maintaining skills is an additional problem.
Table B - Mental Health Officers in Orkney7
MHOs working Local Practising Additional No of MHOs in mental Authority MHOs payment health Orkney 4 4 1 No
11. When admission to hospital is required complex issues arise due to the crossover in roles and duties between MHOs in Orkney and MHOs in Grampian. These practical issues require agreement prior to the introduction of Tribunal systems.
Hospital Services
12. As already stated there are no psychiatric beds in the Orkneys. Hospital inpatient services are provided at the Royal Cornhill Hospital in Aberdeen. A ‘place of safety’8 with a separate point of access is being developed in Balfour Hospital, Kirkwall, given the inappropriateness of using an older persons’ ward as currently happens. Creative ideas are underway involving both statutory service managers and voluntary organisation providers.
13. In 2002-03 44 people who came from Orkney were discharged from inpatient mental health services in Grampian and 2 from learning disability services. In 2002- 03 the average length of admission in Cornhill was 50 days. This is high in comparison to similar services such as those provided for Shetland, but with such small numbers figures can be easily skewed by one or two longer admissions.
14. In the mainland NHS Boards it is possible to obtain figures for the rate of emergency readmissions within 28 days, which may be an indicator of inadequate community care. Because of the very small numbers this data is not meaningful for the Island services.
6 Approved as having special expertise in mental health 7 Scottish Development Centre for Mental Health: Mental Health Officer Services; Structures and Supports. HMSO 2003 8 Sections 117 and 118 of the current Act gives the police a right to apprehend people for psychiatric examination in a ‘place of safety’ 98 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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Table C - Hospital admissions in NHS Grampian for Orkney people aged 16/18- 649
Adults 16/18 – 64 1998 1999 2000 2001 2002 First Admission (i) 19 17 15 14 14 Readmission (ii) 21 14 28 14 19 (i) First ever recorded admission to psychiatric inpatient care (ii) Readmissions following a break in inpatient care
15. For people who require periods of admission, transport to and from the Royal Cornhill Hospital in Aberdeen can be a major problem, and can very occasionally result in patients being detained under the current Mental Health Act in order to facilitate air ambulance transport, when they might have otherwise gone informally. However, this was not able to be verified.
16. When hospital admission is at such a distance this means time apart from family and friends, which places a great strain on both the user and their loved ones. Nevertheless, it was acknowledged that it would not be realistic to have psychiatric hospital base on the islands. Children and adolescents are admitted to beds in Glasgow, and mothers and babies are admitted to adult wards at Royal Cornhill.
Community Services
17. NHS Grampian provides some general psychiatry sessions from 2 consultants who each visit Orkney every 3 weeks. Some other services are available at a local level but the community infrastructure remains very small. Plans are being put in place for an older people’s consultant from NHS Grampian to provide sessions in a similar way to the general adult provision.
18. In general, services are delivered on a joint basis via an integrated team, with a joint post of Community Care Plan Co-ordinator and a joint service manager for mental health.
19. A small community mental health team is at an early stage of being established, consisting of:
• Community psychiatric nurses (WTE 7.2). • Two specialist CPNs for substance misuse, enabling the provision of home detoxification from alcohol. • Full time specialist support worker in the substance misuse and alcohol service. • A dual trained social worker/CPN (starting in January) to provide support for children and adolescents and their families.
9 ISD provisional data from SMR04 returns 99 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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20. The Orkney Blide Trust also contributes. It is a voluntary organisation providing day care and support, befriending, advice and some home support around the Islands, including a travelling day centre. The service is mainly run by service users and carers, with some administrative support.
21. Home treatment will be facilitated with the agreement of the Housing Department to provide a house with 3 bedrooms. There are 8 supported accommodation tenancies and King Street Mental Health Resource Centre in Kirkwall includes 2 respite beds and day care support.
22. At present there are 2 GPs who have been recently trained as Section 20 approved medical practitioners. Recruitment and retention difficulties have been an issue with 2 GP vacancies currently and a further expected later this year (in a complement of 27 GPs). Section 20 training includes a 6-month placement at an accredited training provider and no such venue is available on the Islands. Given family and other commitments few Orkney GPs are prepared to be away from home over a prolonged period to complete this training.
23. GPs expressed concerns about implementing the new community based Compulsory Treatment Orders given the low numbers of locally based staff to supervise people who are very ill. Despite the fact that the current level of support from both of the Grampian consultants was considered excellent and telephone support and advice was available it was felt there might be considerable risk.
24. The majority of the people the team met were supportive of the current arrangements, although others concurred with the view of the Mental Welfare Commission that a resident psychiatrist was essential. The consultants in Aberdeen also expressed the opinion that a local psychiatrist would be the optimal solution. Service users would favour a local ‘safe house’ as a development.
25. The amount of community services for users and their carers remains too low, although the voluntary sector has worked hard to develop some pockets of good practice which has made a real difference to the lives of those affected by mental illness. A good example of this is seen in the services provided by the Blide Trust.
26. The ability to respond to crises and problems out-of-hours is limited although there is a 24-hour social work standby service. The absence of a robust multidisciplinary community mental health team puts strain on what support can be provided. Local social and medical emergency support is lacking. Gaps in crisis response and out-of-hours support can have an impact on the need and use of compulsory detention and this situation should be improved.
27. Sections 25-27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training and housing opportunities for people who have or have had significant mental health problems. This has to complement the core treatment services, although increasingly care and treatment services are becoming aligned.
28. Social exclusion of mental health users is apparent in Orkney. In order to break down some of the local stigmatisation a programme of positive mental health and wellbeing promotion is needed with active input from service users and carers.
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Investment in developing training and work opportunities around Orkney could minimise the problem of stigma, enhance the life experience and also improve the productivity of those with mental illness. Although there is a very low unemployment rate on the Orkney Islands, the rate of unemployed mental health users is high. This is being tackled, for example, by funding from Orkney Enterprise.
29. Advocacy Orkney provides independent advocacy for people with learning disabilities, mental illness, and for older people. These services were felt by service users and staff to be insufficient to meet the current needs, far less the increased demands of the Act. There are no formal advocacy services for carers, although existing advocacy workers do offer support to carers when requested.
30. The availability of psychological interventions is minimal. Although the CPN service is able to deliver some treatments these are limited by the current staffing levels. Service users may have to travel to the Scottish mainland or pay for services locally from a private practitioner if they need specialist expertise.
Priorities for Users in Orkney
31. The expressed priorities for local users were:
• Employment - supported employment and a more flexible and open employment market that recognises the needs of people with a mental illness. • Local treatment - especially home treatment and not having to leave the Islands to go to hospital. • Easy access to a creative range of services that can be accessed sooner, including alternative therapies. • The recovery model is very important.
Comments
32. Key issues that will challenge Orkney services when implementing the new legislation are as follows:
¾ The current low number of Section 20 approved medical practitioners, especially given the lack of a resident psychiatrist, will make it difficult to initiate short-term detention orders ¾ In order to allow the option of community-based Compulsory Treatment Orders (especially important when hospital detention would be so far away from home) the community services would need to be considerably increased, especially out-of-hours services. ¾ Transport around the islands, and to Aberdeen, is a significant challenge and expense for the ambulance service and Local Authority. ¾ Even if there is increased funding recruitment and retention problems may prohibit developing the service. ¾ Implementing the Act will involve significant changes, even though there are only a small number of detention orders. Planning for this and other service developments will be difficult without a local psychiatrist. ¾ Provision of a range of psychosocial approaches will be necessary to ensure that there is the range of treatment options that may be included in the care plan agreed by a Tribunal.
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Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Dr James Strachan Consultant Psychiatrist, NHS Lothian
102
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
SHETLAND
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
SHETLAND
1. The population of the Shetland Isles is about 22,0001, (14,300 adults). The area consists of 15 inhabited islands with the majority of people living around Lerwick, a town of 10,000. There is also a transient population linked to the North Sea oil and fishing industries.
2. The proportion of older people is among the lowest in Scotland and levels of deprivation and morbidity are also low. Unemployment on the islands is less than 2% and the Council supports employment opportunities for people with mental health problems with a high success rate.
3. Mental health is already incorporated in the local Joint Future working between health and social services. There are flexible packages of care based around assessed need. In the past Shetland Islands Council has been well resourced and this is reflected in the good local infrastructure.
4. Key local priorities are transport and housing, and the Mental Health and Well Being Support Group (2002) also identified the need for attention to older people’s and child and adolescent mental health services. The Clinical Standards Board for Scotland (2002) was unable to identify the number of local people with a diagnosis of schizophrenia apart from 4 were admitted to hospital in the last 12 months. CSBS identified that while independent advocacy was available, not everyone knew how to access it.
Use of the Mental Health (Scotland) Act 1984
5. In 2002-03 there were 21 episodes of detention under the Mental Health Act (Scotland) 1984 in Shetland. On the Scottish mainland comparisons can be drawn by looking at the numbers per 100,000 population, but in the smaller island communities this is not meaningful. There are no patients from Shetland currently resident in The State Hospital.
6. Although the number of mentally disorder offenders is low, preventive anger management programmes are provided by the local criminal justice system.
Table A - Detentions for all ages in Shetland under the Mental Health Act (Scotland) 1984 in 2001-02/2002- 032
Number of detentions
Sections 24 and 253 18/14
Section 264 10/5
Section 185 3/2
1 General Registry Office 2 Mental Welfare Commission Annual Reports 2001-02/2002-03 3 Sections 24 and 25 are emergency sections lasting 72 hours 4 Section 26 is a 28 day order that can be used when an emergency section has expired 5 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court 104 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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7. The estimated number of Tribunal hearings (based on current Sections 26 and 18) has been calculated on the average rate of detentions over 8 years, although this might be an underestimate given that numbers have been rising across much of Scotland. This does not apply to Shetland, where compulsory treatment seems to be reducing. Once again, however, the numbers are too small for this to be a good predictor of the number of Tribunal hearings. The estimated number is very small, with 2 hearings at most.6
Table B - Estimated number of Tribunal hearings
Estimated Tribunal hearings Local Authority Population size under the 2003 Act Shetland Islands 21,940 2
8. Preparation and participation for Tribunal hearings will add to the workload for all professionals and for Mental Health Officers (social workers) and Responsible Medical Officers (consultant psychiatrists) in particular.
9. Shetland Islands Council is the largest employer in Shetland. There are only 2 MHOs.
Table C - Mental Health Officers in Shetland Isles7
MHOs working in Additional Local Authority Approved MHOs mental health Payment Can be regraded Shetland 2 1 to senior practitioner
10. There is one consultant psychiatrist in Shetland and the service is viewed as “consultant delivered” not “consultant led”. If the consultant is on leave or on another island a GP covers for emergencies. There are no Section 208 approved general practitioners, but there are plans to develop GPs with a special interest in mental health in order to ensure a sustainable service. The appointment of a staff grade doctor with a special interest in dual diagnosis patients with severe mental illness and alcohol problems is a main priority. New funding has been secured and the post has been advertised, so far (December 2003) without success.
6 Scottish Executive 7 MHO Services Structures and Supports, The Stationary Office 2003 8 Medical practitioners approved by a health board as having ‘special experience in the diagnosis or treatment of mental disorder’ 105 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
SHETLAND
Hospital Services
11. Shetland has no mental health beds, although some older people with dementia are admitted to the Gilbert Bain Hospital in Lerwick. Otherwise everyone has to travel to the Royal Cornhill Hospital, Aberdeen for inpatient treatment. In 2002-2003, 43 people from Shetland were admitted to Cornhill, 27 adults, 8 older people and 8 with a learning disability. The average length of stay was 19 days, which is much lower than in Orkney, which has a similar population. 12. The readmission rate within 28 days can be used as a possible indicator of the amount of community support. In Shetland emergency admissions have been steadily reducing.
Table D - Hospital admissions in Shetland for people aged 16/18-64 years9
Adults 16/18 - 64 1998 1999 2000 2001 2002 First admission 17 16 11 13 10 Readmissions within one year 27 19 18 14 11
13. For psychiatric emergencies the consultant, in discussion with his Aberdeen colleagues, makes the decision on whether an admission to the Royal Cornhill Hospital is appropriate. Both Shetland and Orkney have had problems in transporting patients by air ambulance to Aberdeen. Some pilots are reluctant to take a patient in a small plane where there is direct access to the cockpit. Time delays occur while waiting for the routine air service. In cases of detention, the nurse escorts come from Cornhill. This process can add to the delays, which are compounded when there is bad weather.
14. While people are waiting for transport to hospital they can be cared for in the Gilbert Bain Hospital. This is not ideal and causes difficulty for all concerned. Acutely ill psychiatric patients do not fit in well with physically ill people and problems can arise in incorporating the patient within the hospital regime. The mental health service in Shetland provides home nursing as an alternative to hospital admission even for users who maybe acutely unwell and this may help to enable shorter stays in hospital
15. Most people the visiting team met were realistic about the need to travel to mainland Scotland for many services, even given the inconvenience. In terms of the new Act this applies especially to smaller groups such as mothers with babies. All health visitors routinely use the Edinburgh Postnatal Depression Scale and Shetland is part of the North of Scotland planning group for postnatal depression. Admissions are to the Royal Cornhill Hospital.
16. Although there are no child and adolescent mental health beds, services have been improved and are provided by a full-time CPN, with a consultant visiting from NHS Grampian 6 times a year for a total of 30 days. Children are admitted to Yorkhill Hospital in Glasgow.
9 ISD provisional data from SMR04 returns 106 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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Community Services
17. Social workers are multi-skilled and share responsibilities given the small population size. There is a 24-hour social work on-call service, a community care team and family support team. All care plans have contingencies about out-of-hours care that are agreed by both users and staff.
18. Sections 25 -27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training, and housing options for people who have or have had significant mental health problems.
19. Daytime services and activities have been developed, including a successful employment project and a health promotion and skills centre. There is a job coach system plus a social firm, although access to these opportunities is restricted because of transport problems. There is a supported housing scheme.
20. The community mental health team (CMHT) is based in the health centre in Lerwick and provides the focus for mental health in Shetland. A Grampian based clinical psychologist used to visit from NHS Grampian although this post became vacant and the service is on an adhoc basis currently. The team comprises nursing, and social work staff, plus the consultant. Currently there is no occupational therapist.
21. Psychotherapy and other specialist psychological treatments are not readily available because Aberdeen has a long waiting list and the cost of regular appointments would be prohibitive. As a result a range of local counselling services has been developed and is available for users at a local level in seven general practices. There are strong links between the CMHT and the GPs around the islands. The Local Authority also provides counselling services.
22. Independent generic advocacy is delivered by Shetland Patients Supporter Scheme and Advocacy Shetland and Advocacy Shetland runs a separate advocacy scheme for carers. There is a draft proposal under consideration for specialist sections in the advocacy project, which will focus on mental health users and carers. There are informal service user networks through local voluntary organisations Shetland Link Up, Depression Alliance or Women of Worth.
Priorities of Users and Carers in the Shetland Isles
23. The following summarise the expressed views of local users and carers.
• It’s really good that we’ll have rights with the new Act.
• We need more social activity for people who can’t cope joining in with normal things.
• Respite care is good, but shouldn’t be in the same place where people live.
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• Better information for carers is needed and help in getting to hospital in Aberdeen a lot of times to see loved ones in hospital. Video-links might work for some people, but it is scary.
Comments
24. Key issues that will challenge Shetland when implementing the new legislation are:
¾ The transport difficulties, especially the need to rely on air ambulance services can mean long delays, unsettling for people who are very unwell especially if they are going to be admitted against their will. The local hospital is not ideal for a long wait.
¾ Developing a 24 hour service will be difficult because there is likely to be little uptake, given the small population and distances involved. Creative solutions will need to be found to provide adequate support in the event of a community- based Compulsory Treatment Order being the optimal way of treating someone to allow for local support rather than admission to hospital far away.
¾ Opportunities for respite care need to be available, although the same difficulties may arise about low usage.
¾ Recruitment and development of staff may remain a problem
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Dr James Strachan Consultant Psychiatrist, NHS Lothian
108
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT
LOCALITY REPORT
TAYSIDE
NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
WESTERN ISLES
1. Tayside covers 3,000 square miles and is mainly rural, although 80% of the approximate 387,420138 population is concentrated in towns. The adult population is approximately 252,000. Mental health services are provided by NHS Tayside and three local authorities; Perth and Kinross Council, Dundee City Council and Angus Council who work in partnership with a wide range of voluntary organisations. These councils together are coterminous with Tayside health services, although internally the social work area teams do not all share boundaries with LHCCs.
2. The Clinical Standards Board for Scotland (CSBS) recorded about 560 people with a diagnosis of schizophrenia in Tayside. In 2002 the Mental Health and Well Being Support Group noted successful resettlement of long-stay patients in the community, reconfiguration of services for mentally disordered offenders and progress in involving service users and carers. Concern was expressed about the lack of a clear plan to develop psychological interventions.
3. Tayside’s mental health services have attracted publicity over recent months due to ongoing consultation about the future configuration of services. This follows proposals for greater centralisation of hospital services in order to fund community developments. A range of options is now being considered.
Use of the Mental Health (Scotland) Act 1984
4. Levels of detention in Tayside are under the national average. There are 20 Tayside patients currently resident in The State Hospital and as at 2003 there were 3 people waiting transfer back to Tayside, 2 of who had been waiting for more than 3 months. This is important given the right to appeal against the level of security from 2006.
Table A - Detentions in Tayside under the Mental Health Act (Scotland) 1984 in 2001- 02/2002-03139
Actual no. of Average number per No. per 100,000 detentions in 100,000 people in people in Tayside Tayside Scotland Sections 24 and 25140 240/379 62/98 85/90 Section 26141 139/244 36/63 51/56 Section 18142 50/112 13/29 21/23
5. A rough estimate of the number of Tribunal hearings in Tayside each year is 253143, however the figure could be higher given the upward trend in long-term detentions (Tables B and C). The number of applications for detention under Part V of the current Mental Health Act has more than doubled in Tayside over the last 9 years.
138 ISD Scotland. Population figure covers all age ranges as of 2002 139 Mental Welfare Commission Annual Report 2001-02/2002-03 140 Sections 24 and 25 are emergency sections lasting 72 hours 141 Section 26 is a 28 day order that can be used when an emergency section has expired 142 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court 143 Scottish Executive Implementation Team
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Table B - Detentions and prediction of Tribunal numbers
% of Scottish Estimated Tribunal Local Authority Population size detentions over hearings under the 8 years 2003 Act 144,180 Dundee 3.98% 120 (94,670 adults) 135,160 Perth and Kinross 3.01% 91 (85,913 adults) 108,130 Angus 1.37% 42 (69,348 adults)
Table C - Applications under Part V of Mental Health 1994 Act from 1994-2002
Dundee Arbroath Perth Sheriff Year Total Sheriff Court Sheriff Court Court 1994 33 7 24 64 1995 39 5 37 81 1996 34 2 24 60 1997 34 28 37 99 1998 52 15 37 104 1999 70 9 28 127 2000 50 23 31 104 2001 37 17 33 87 2002 60 18 5 133
6. There are 53 psychiatrists in Tayside who are currently approved under Section 20144 of the 1984 Act. The number of consultant psychiatrists is shown in Table D. For a point of reference, the number of general adult psychiatrists is one more than the Royal College of Psychiatrists’ suggested figures for services that do not have adequate back-up from other specialties or community developments. Rehabilitation, substance misuse and liaison psychiatry are treated separately. This figure does not include a weighting for a rural population and consultants are worried about the possibility of having to drive to remote areas to prevent or initiate short-term detentions and therefore having to cancel routine clinics and ward rounds.
144 Medical practitioners approved by the NHS Board as having special expertise in the diagnosis and treatment of mental disorder
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Table D - Consultant psychiatrists in Tayside
Speciality Number of consultants General adult psychiatry 15 Old age psychiatry 9 + 2 vacancies Learning disability 3 Child and adolescent psychiatry 5 Addictions 2 Forensic psychiatry 3 Psychotherapy 1 vacancy
7. Difficulties are anticipated in recruiting associate specialists and staff grade doctors to provide senior medical cover and perhaps the on-call consultant will have to cover all of Tayside for their day/night on-call. The need for redrafting consultant job descriptions is understood and there is acceptance that the impact of the new Act will have to be considered as part of the job planning exercise under the new consultant contract. It was pointed out that increasing advocacy services would be likely to further increase the consultant workload. “Advocates always want to see the consultant” - an area that needs to be assessed and audited.
8. The number of Mental Health Officers on a rota varies considerably between the councils, with Dundee having a disproportionately small number. In total in Tayside there are 51 MHOs, although only two-thirds are ‘active’ and a minority work full-time in mental health. The differential payment between the councils troubles social workers and managers alike, since all services are already strained with recruitment and retention problems and ‘drift’ by staff to other areas might occur. No figures were available for checking, but the position needs to be monitored.
9. Social workers (including MHOs) felt that they could not take on any extra burden and were already stretched with the additional work for the recent Adults With Incapacity Act.
Table E - Mental Health Officers in Tayside
Local Practising MHOs working in Additional No of MHOs Authority MHOs mental health payment Dundee City 21 9 3 (+ 3 LD) No Council Perth and 12 10 4 Yes Kinross Council Angus Council 16 16 5 No
112 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
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Hospital Services
10. In 2002 the Scottish Health Advisory Service (SHAS) reported that admission beds in Tayside were under increasing pressure due to gaps in community services, although viewed the acute response team in Dundee as a model for adoption elsewhere. It said that urgent action was needed to develop community services in Perth and Kinross, but as yet no significant action has been taken.
11. Services are provided from four hospital sites and consist of:
Five acute admission wards
• Two wards at Murray Royal Hospital, Perth • Two wards at Carseview Centre, Ninewells Hospital, Dundee • Two wards at Sunnyside Royal Hospital, Angus
Three Intensive Psychiatric Care Units (IPCUs)
• Carseview (Ninewells Hospital) • Murray Royal Hospital • Sunnyside Hospital
Five continuing care wards
• Murray Royal Hospital (1 ward) • Royal Dundee Liff Hospital (2 wards) • Sunnyside Hospital (2 wards)
Three rehabilitation wards
• Murray Royal Hospital • Royal Dundee Liff Hospital • Sunnyside Hospital
Two forensic psychiatry wards
• Murray Royal Hospital
Six day hospitals
• Birnam Day Centre (forensic) • Leonard’s Bank • Alloway Day Services • Sunnyside Day Unit • Threshold
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12. Some services are provided Board-wide, including TAPS (Tayside Alcohol Problems Service), Tayside Drug Problems Service and Tayside Forensic Services.
13. Tayside’s staffed adult bed numbers have continued to reduce over the last three years. There are 161 beds per 100,000 in Tayside for all psychiatric specialties, which remains the second highest number in Scotland, which has an average of 141 and a range between 101 and 205. At 68 per 100,000 adult beds Tayside is now approaching the Scottish average, 64 per 100,000. Delayed discharge does not seem to be a major issue for this group with only five delayed discharges occurring in general psychiatry in July 2003.
14. The number of older people’s beds remains the second highest in Scotland. This may be due partly to a local commitment that patients should not leave hospital for a care home unless vigorous attempts have been made to keep people at home with intensive support (not available currently). There are 38 older people whose agreed discharge has been delayed.
Table F - Hospital bed numbers Tayside and Scotland145
Tayside Tayside Scotland Hospital Actual beds Number per 100,000 Number per 100,000 Beds 2000 2001 2002 2003 2000 2001 2002 2003 2000 2001 2002 2003 All psychiatric 868 795 681 625 217 199 171 161 161 153 145 141 specialties Adults under 65 383 367 296 262 96 94 76 68 74 70 66 64 years Older 445 391 348 330 113 100 90 85 83 79 74 73 people Forensic 26 26 26 26 * * * * * * * * services Child 7 4 4 0 0 0 0 0 0 0 0 0 Psychiatry Adolescent 7 7 7 7 * * * * * * * * Psychiatry
145 ISD
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WESTERN ISLES
15. Due to high acute adult bed occupancy rates it was said that people may often be admitted to hospital away from their home area, within Tayside itself or even further away (mainly Fife). This applies even for patients needing to be admitted to an intensive psychiatric care unit. In practice Tayside treats more people from elsewhere than it transfers out. In 2000-01 a total of 74 people who came from elsewhere in Scotland with a mental illness were discharged from psychiatric care, compared to 27 sent outwith Tayside. In the year ending March 2002 there were 75 people transferred in and 36 people sent elsewhere.146 Tayside has a high number of beds, but these are used to make up for lack of capacity elsewhere. The majority of out-of-area people treated in Tayside come from Grampian, which has a low number of beds.
16. The emergency readmission rate (within 28 days of discharge)147 might indicate people being discharged too early, or a breakdown in discharge arrangements and community supports, so leading to increased admissions and high occupancy. For adults the emergency readmission rate in 1998 was 4.46%, rising to 10.43% in 2000 before coming down again to 8.46% the next year (above the 2001 Scottish average of 7.36%). The Tayside rate over all four years is 6.86% compared to 7.27% in Scotland overall, so Tayside appears to be doing well in this regard. However, it will be important to work out why the rate fluctuated so much and to continue to monitor the figures. With current data collection it was not possible to check any correlation between readmissions and inadequate community services, or to determine how many of these readmissions were compulsory.
Table G - Hospital admissions in Tayside for adults 16 - 65148
1998 1999 2000 2001 2002 First admission 550 463 453 415 400 Readmission within one year 1329 1330 1226 1172 1161 Readmission rate within 28 4.46% 4.57% 10.43% 8.46% N/A days Readmission rate = (emergency readmissions/discharges) x100
17. The closure of the small number of children’s beds has raised concerns given the overall shortage of children’s beds in Scotland. It is now recognised that child and adolescent services have to be planned on a national basis through a managed clinical network. In terms of the Act the key importance is age-appropriate services, to avoid children with mental health problems being placed in paediatric wards or adolescents admitted to adult wards. Tayside needs to resolve this problem by linking with other areas in Scotland.
146 SMR04 returns 147 Provided on request from ISD to compare with the Accounts Commission findings in 1998 148 ISD provisional data from SMR04 returns
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18. Admission to hospital when appropriate is not the only criterion for judging the ‘reciprocity’ of services to justify compulsory treatment; there must be the full range of therapies available. Currently some inpatient facilities are unable to provide basic recreational or diversional activities to patients and staffing levels in both nursing and occupational therapy are showing growing vacancy rates. Many wards lack adequate activity rooms and quiet spaces.
Community Services
19. Sections 25 to 27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training and housing options for people who have, or have had, significant mental health problems. This will complement the core treatment services, although increasingly care and treatment services are becoming aligned within the community.
20. Community services vary across the region. Angus has three long-established multidisciplinary teams and there are four in Dundee City. Dundee also has an acute response team and a community rehabilitation, integration and support service. Perth and Kinross lags far behind with a small fledgling team. This will make it extremely difficult to allow the option of a community-based Compulsory Treatment Order instead of admission to hospital. Appeals against the level of security that will be allowed from 2006 do not only apply to The State Hospital but to all parts of the service.
21. There are many good examples of voluntary organisations providing supported accommodation, sheltered employment and training opportunities, befriending and drop-in support149, however users and carers require an improved level of services at all stages in their care. A far from comprehensive list of such services includes a community workshop, Fourways Project, Gateway Enterprises, Perth City Locality Day Service and Gowanlea Project Day Support. There are community mental health support posts and supported accommodation (Scottish Association for Mental Health).
22. Service carers and staff view Tayside Forensic Voices positively, and have lobbied strongly to improve forensic services in Tayside. People Like Us (PLUS) has a paid development worker taking forward the Users and Carers Action Plan, but lack of investment has reduced the potential impact. Angus Mental Health Association provides drop-in, group and individual support. The Motivators Angus Project in Kirriemuir provides support and advice to people experiencing mental health problems.
23. In March 2002 the Clinical Standards Board for Scotland noted that carers did not have access to advocacy services. Independent advocacy services are now established in each Local Authority areas, for service users mainly. The adequacy of current services to meet potential demand following the new Act will need to be assessed carefully.
149 Scottish Health Advisory Services, Review of Adult & Speciality Mental Health Services in NHS Tayside 2002
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Priorities of Users and Carers in Tayside
24. The main issues raised by users and carers were:
Users
Arbroath
• Training for staff and users in mental health awareness, appropriate treatment, person-centred planning, rights of users and partnerships in treatment and planning. • Greater emphasis on recovery. • Appropriate evaluation and monitoring of services to give the best evidence about what needs to develop.
Perth
• Acute beds in Murray Royal Hospital to be retained. • A 24-hour helpline staffed by people with a background in mental health. • Better information. • Certainty that there are adequate outpatient and community services available before discharge from hospital.
Carers
• Locally based hospitals. • Day services based around the community mental health team. • Opportunities to get employment and to challenge discrimination. • Access to services in every small centre of population.
Comments
25. Key issues that will challenge Tayside when implementing the new legislation are as follows:
¾ Perth and Kinross has minimal community services, so that community-based Compulsory Treatment Orders would not be safe and therefore not an option, denying a person’s rights under the Act.
¾ There are not appropriate secure facilities and services for people with learning disabilities or for women with a mental illness. Access to a medium secure unit will be necessary. The differential role and functions of IPCUs and the forensic services is not clear.
¾ The problem of capacity within Tayside’s workforce will challenge both health and social services and the solution of differential payments to allow market forces to work needs to be carefully monitored.
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¾ The consultation and strategic planning about reconfiguring the service is taking up considerable senior management time and there is the possibility that insufficient time will be available for the important operational task of ensuring compliance with the Mental Health (Care and Treatment) (Scotland) Act 2003. The high numbers of out-of- area admissions will be an important issue to be addressed.
¾ There needs to be access to inpatient services for children and adolescents, and for mothers and babies.
¾ Advocacy services need to be developed.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
Gill Urquhart Deputy Project Director Head Occupational Therapist, The State Hospital
Dr Tom Murphy Associate Medical Director, NHS Lothian
Stephen McLellan Chief Executive, Renfrewshire Association for Mental Health
Dr James Strachan Consultant Psychiatrist, NHS Lothian
Bill Clark Head of Strategy West Dunbartonshire Council
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NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
WESTERN ISLES
1. Eileanan Siar (the Western Isles) lies 30 miles off the West coast of Scotland, with a population of 26,200 (16,400 adults) living on 11 islands, in a straight geographic 125 miles long. The population has the lowest proportion (63%) of adults of working age in Scotland, so the number of older people has a significant impact on services. The main centre of population is Stornoway (10,000 residents).
2. The population is scattered throughout the area making transport a major issue for the provision of services. Despite this, most reviews have been positive about the quality of care. In 2001 the Scottish Health Advisory Service praised the quality and approach of staff, the work of the I Reach Project, and the Fast Action Support Team (FAST) which addresses joint working between health and social work. The Mental Health and Well Being Support Group highlighted the significant progress in the development of local services provided by voluntary organisations as well as service users and carers.
3. The 2002 Clinical Standards Board for Scotland (CSBS) review of compliance with the first tranche of its standards for the treatment of schizophrenia reported that there were 62 people with schizophrenia in the area currently receiving treatment. Several standards had been met fully (more than in many places elsewhere in Scotland). These included a guideline for initial diagnosis with a full range of investigations, alignment of general practices with community mental health staff, involvement of carers, documentation of prescription changes, social work notification of respite care needs and a local social inclusion programme. People are routinely assessed about the use of alcohol or illicit drugs.
4. Strategic planning is carried out by the multi-agency Western Isles Mental Health Partnership, which was originally established to implement the Framework for Mental Health Services in Scotland. The Partnership includes representatives from the Local Authority, NHS Board, voluntary agencies and service user and carer groups.
5. There is one admission ward in the Western Isles Hospital in Stornoway.
Use of the Mental Health (Scotland) Act 1984
6. Given the population size, the number of people being treated on a compulsory basis is small; nevertheless the trend, as elsewhere in Scotland, is upward. (Comparative rates per 100,000 people cannot be shown given the small numbers). The introduction of the Adults With Incapacity (Scotland) Act (2000) has led to increased requests for Guardianship Order applications, which has increased the workload for MHOs. An independent consultant will provide local training on the joint application of both Acts. Some additional training for the Mental Health (Care and Treatment) (Scotland) Act 2003 will take place locally and will in part be in conjunction with Highland Region.
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Table A - Detentions in the Western Isles under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03150
No of detentions in the Western Isles
Sections 24 and 25151 16/20 Section 26152 5/7 Section 18153 0/2
7. The new Act will put pressure on all services, especially given the small number of staff working in relative isolation. There are 5 Mental Health Officers, 4 of whom have been active in the last 12 months and the other will be shortly, having transferred from the English system. None of them work in the mental health field specifically, although all use mental health skills in their generic work. The increased casework role that the new Act will bring means that more formal supervision and support will be needed, in addition to local and Highland MHO forums.
8. A review of the MHO services in the Western Isles has been completed with the aim of identifying gaps and ways to make the service as effective as possible. A dedicated Mental Health Senior Practitioner has been proposed and would be welcomed by the MHOs. As part of a temporary restructuring of the social work department a MHO co- ordinator has been appointed and she will oversee the implementation of the new Act in the Western Isles.
Table B - Mental Health Officers in the Western Isles
No of Practising MHOs working in Additional Local Authority MHOs MHOs mental health payment Comhairle Nan Eilean 5 4 0 No
9. There are 2 consultant psychiatrists based in Stornoway, one working mainly with older people and people with a learning disability. None of the GPs are approved under Section 20 of the Mental Health (Scotland) Act 1984 as having special experience in the diagnosis and treatment of mental disorder. The aim of the new Act is to minimise emergency detentions and ensure that a person is seen as soon as practicable by an experienced doctor in order to initiate a short-term detention. The practicability of one of the consultants travelling to the southern islands to do this will provide real challenges.
150 Mental Welfare Commission Annual Reports 2001-02/2002-03 151 Sections 24 and 25 are emergency sections lasting 72 hours 152 Section 26 is a 28 day order that can be used when an emergency section has expired 153 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court
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Hospital Services for Adults
10. The hospital services for adults are as follows:
• Western Isles Hospital, Acute Psychiatric Unit (6 beds) (The ward is also the base for a day service, providing some activities). • Western Isles Hospital, Dementia (34 beds)
11. The 10 year old general hospital has 6 psychiatric beds, all in single rooms. This makes it possible to admit people of all ages including adolescents and older people with a functional (non-organic) illness. This will not be possible under the new Act because age- appropriate services will be required for adolescents, meaning that it will be necessary to send them for their care to the mainland. However, in the last 5 years only 2 people under the age of 16 have been admitted. Mothers with a perinatal mental illness needing inpatient care will also have to travel elsewhere for specialist treatment. An Integrated Care Pathway for postnatal depression is under development. In the years ending in March 2001 and 2002, 19 and 13 people respectively were placed out of the area as inpatients. It is not appropriate that adolescents receive inpatient treatment in an adult ward and regular arrangements need to be made for provision of services on the Scottish mainland when required. The same principle applies to mothers and babies.
12. In June 2003 there was one recorded whose delayed discharge from the ward for older people. In practice, the ward functions partly as a continuing care unit for a few people because there is no care home on the islands providing the necessary skilled nursing care.
13. A major problem in providing the service is the delay incurred while waiting for an air ambulance and escort.
Table C - Hospital admissions in the Western Isles for people aged 16/18-64154
Adults 16/18 - 64 1998 1999 2000 2001 2002 First admission (i) 15 10 22 19 12 Readmissions within one year (ii) 81 24 68 69 64 Transfers (iii) 2 2 3 7 2(p) (i) First ever recorded admission to psychiatric inpatient care (ii) Readmission following a break in inpatient care (iii) Transfers between consultants or to another hospital P - Provisional figure only
Community Services
14. There is a community mental health team dispersed throughout the islands with GPs, social workers and community psychiatric nurses. Two social workers are based in Stornoway, the others in the southern Islands. Outpatient clinics are held in Barra with a locally based social worker and visiting CPN. While there are no clinical psychologists, cognitive behavioural therapy is provided by a nurse.
154 ISD data from SMR04 returns
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15. The creative I Reach project, originally funded by the Mental Health Development Fund, aims to ensure that adults with severe and enduring mental illnesses receive innovative types of social support to enable them to live as independently as possible. The focus is very much on identified need and practical support for people in rural communities. The Western Isles Association for Mental Health brings together several service user groups.
16. A number of voluntary organisations work together; for example Crossroads and Alzheimer’s Scotland provide joint services in Uist and Barra. There are sub-groups of the Western Isles Mental Health Partnership. An example is the Choose Life multi-agency steering group which has developed a Suicide Prevention Action Plan.
17. There is an on-call social worker and CPN rota and NHS24 will be available shortly. Penumbra provides an outreach service. Getting local help is very difficult in the more isolated places and out-of-hours services need to be developed further.
18. At present only generic advocacy services are available, provided by volunteers under the supervision of an advocacy co-ordinator in Lewis. There are plans to develop similar opportunities in Barra and some mental health specialist advocacy services with the new money allocated to the Local Authority to prepare for the new Act.
Priorities of Users in the Western Isles
19. The expressed priorities of local users are as follows:
• Make sure that hospital provision is large enough to stop people having to leave the island for services. • To consider the provision of grounds to allow people to walk in relative privacy. • There is a need for a culture change that recognises that mental illness and mental ill health affects everyone. • There is a need for more education about mental illness; especially for those people that others may turn to for help, such as ministers. • There is a need for a facility for people to recuperate, for either when they are getting better or to escape to when they are feeling ill.
Comments
20. Key issues that will challenge the Western Isles when implementing the new legislation are as follows:
¾ With such dispersed population it will be difficult to provide the level of local community supports and 24-hour care necessary to permit a community-based Compulsory Treatment Order.
¾ Although the number of detentions is small, the extra time commitment to initiate short-term detentions and prepare for, and attend, Tribunals will place significant pressure on the consultants. Consideration should also be given to developing GPs with a special interest in mental health.
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¾ The MHO services will also be stretched and the number of MHOs will need to be increased, preferably to include a person who works within the mental health field and who can give training and support to colleagues.
¾ Generic advocacy services are insufficient and mental health advocacy will need to be developed further.
Visiting Team
Dr Sandra Grant OBE Project Director Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow
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ANNEX A NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
ANNEX A abcdefghijklm pí=^åÇêÉïÛë=eçìëÉ= oÉÖÉåí=oç~Ç= Chief Executives, NHS Boards bÇáåÄìêÖÜ=beN=Pad= Chief Executives, Local Authorities = qÉäÉéÜçåÉW=MNPNJOQQ=PTQV= c~ñW=MNPNJOQQ=OVTM= Copy to: Directors of Social Work ÜííéWLLïïïKëÅçíä~åÇKÖçîKìâ= Chief Executives, NHS Trusts = = Chief Executive, COSLA = Chief Executive, ADSW NV=kçîÉãÄÉê=OMMP
______Dear Colleague
MENTAL HEALTH (CARE AND TREATMENT) (SCOTLAND) ACT 2003
We are writing jointly to invite the co-operation of NHS Boards and Local Authorities in planning for implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003.
Ministers have now confirmed that the majority of the Act’s provisions will come into effect in April 2005. A copy of the Press Release of 19 November is enclosed. This means that we have just under 18 months to ensure that the necessary processes are in place, that staff have been trained and that the appropriate range and quality of mental health services are in place. The Department has also published an Introduction to the Act, together with the second of a planned series of newsletters on implementation. This Guide is intended to contribute to plans to put in place the processes necessary to deliver the Act’s provisions. This letter deals specifically with planning for mental health services.
Dr Sandra Grant’s Assessment
As you will recall, Ministers commissioned Dr Sandra Grant to carry out a comprehensive assessment of existing mental health provision. Dr Grant is completing an Interim Report which sets out key themes from her work together with individual locality reports for each NHS Board area. The Interim Report will be published shortly. However, we thought it would be helpful to set out next steps on implementation now.
Joint Implementation Plans
We would be grateful if you could draw on evidence about the services in your area, including Dr Grant’s assessment when it is available, to prepare a joint implementation plan. This plan should set out how NHS Boards and Local Authorities, with other partners, intend jointly to ensure that services will be ready to meet the requirements of the new Act, without detriment to the generality of mental health services. The plans should build upon and adopt the principles set out under the Joint Future initiative not least to reflect joint management and joint delivery approaches. The structure in place already for joint agency working will be of benefit in the preparation and planning of these plans.
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ANNEX A
Resources
Significant resources have already been allocated to Local Authorities to support developments necessary to implement the new Act. The Department’s letter of 16 January 2003 referred to £2m capital in each of the next two financial years and included the following table:
2003/2004 2004/2005 2005/2006 Improvements in packages of care 0 2.0 2.0 Improved day & after care 0 7.0 7.0 Additional MHOs 0 2.5 2.5 LA training for MHOs 0.7 0 0 New duties to support advocacy 0.5 1.0 1.5 Total £m 1.2 12.5 13.0
Ministers expect that NHS Boards will need to invest additional monies in mental health services in order to ensure effective implementation of the new Act. This investment will need to be drawn primarily from planned increases in overall allocations to NHS Boards.
However, Ministers have also decided to allocate new money to NHS Boards to assist with service planning and development. This fulfils commitments in Partnership for a Better Scotland. The additional resources are:
2003/2004 2004/2005 2005/2006 £m 1 6 8
In the current year, the Executive will retain some £250,000 to support national initiatives. The remaining £750,000 will be distributed to NHS Boards on an agreed formula basis to support preparation of joint implementation plans.
Resources in future years are likely to be allocated in a similar way, but this will be informed by the joint implementation plans.
Process, Timetable and Monitoring Arrangements
We would like joint implementation plans to be developed by NHS Boards in partnership with local authorities, voluntary organisations and local user and carer representatives. The process and outcomes should reflect and build upon joint management and joint delivery approaches and follow the principles set out under the Joint Future initiative. The plans should identify priorities for developments in services and set out in clear terms the individual actions proposed which should be costed, timetabled and show agreement on agency responsibilities for delivery.
As a first step, can you please let David Bolger or Phil Harley in the Mental Health Division (0131 244 3749) know as soon as possible the name and details of the lead officer for development of the plan. The target for completion of the plans, which are also to be submitted to the Mental Health Division, is 31 March 2004.
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ANNEX A
Please also contact David or Phil if you have any queries about this letter.
Progress on the plans, and in particular additional investment in services, will be closely monitored.
Yours sincerely
TREVOR JONES DR ANDREW GOUDIE eÉ~Ç=çÑ=pÅçííáëÜ=bñÉÅìíáîÉ=eÉ~äíÜ=aÉé~êíãÉåí== E^ÅíáåÖF=eÉ~Ç=çÑ=pÅçííáëÜ=bñÉÅìíáîÉ=cáå~åÅÉ= = = ~åÇ=`Éåíê~ä=pÉêîáÅÉë=aÉé~êíãÉåí= =
128 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
ANNEX A
abcdefghijklm = jÉÇá~=~åÇ=`çããìåáÅ~íáçåë=dêçìé pí=^åÇêÉïÛë=eçìëÉ= oÉÖÉåí=oç~Ç= bÇáåÄìêÖÜ=beN=Pad= = qÉäÉéÜçåÉW=MNPNJOQQ=NNNN= News Release
MINISTER OUTLINES WAY FORWARD FOR IMPLEMENTATION OF MENTAL HEALTH ACT
- Chisholm announces further £15 million funding for mental health services -
Health Minister Malcolm Chisholm today confirmed the implementation dates for provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003 and announced new funding of £15 million for mental health services in Scotland.
He confirmed that, following a consultation exercise earlier this year, the Act’s main provisions will become effective in April 2005. In addition, he confirmed that:
• provisions to allow service users to appoint Named Persons and to draw up Advance Statements will be introduced in October 2004; • the right of appeal for patients detained in excessive security will be implemented in May 2006.
The Minister also announced that the additional £15 million will be made available to partner agencies, through NHS Boards, to work together to meet Partnership Agreement commitments for developing mental health services, including crisis services. This means a total of £45 million funding - £30 million has already been allocated to local authorities - to support planning and implementation of the new Act.
Mr Chisholm said:
“The Royal Assent of this groundbreaking Act represented the conclusion of one stage for renewing mental health law in Scotland and the beginning of another. The implementation of the new Act is about ensuring the benefits offered by the Act are achieved in reality. A great deal of progress has already been made both nationally and by local agencies, and we are supporting all the agencies involved to work together to achieve the goals of the Act.
“At the heart of the success in achieving the aims of the new legislation will be the development of services and support which meet the needs of those with
129 NATIONAL MENTAL HEALTH SERVICES ASSESSMENT – LOCALITY REPORTS
ANNEX A mental health problems in communities in Scotland in the 21st century. I am pleased to announce that £15 million of Partnership Agreement funds will be allocated to meeting the commitments for planning and delivering mental health services set out in Partnership for a Better Scotland.
“Joint Local Implementation Plans are to be prepared by April 2004 and this new, additional money will also help NHS Boards, local authorities and their partners in voluntary organisations - and of course users and carers - in the development of these. The plans will identify those priorities for the provision of services and set out the actions to be taken to ensure these are delivered. It is important these joint plans reflect and build upon the joint management and delivery approaches which follow the principles of the Joint Future initiative.”
The Executive’s guide to the Act - Introduction to the Act - and the second edition of the Reforming Mental Health Law newsletter are also published today. These provide further information on provisions of the new legislation and are intended to help all those involved in the implementation of the Act and in the planning and use of services.
The Minister added:
“The measures I have announced today run alongside other developments for mental health services already underway. For example, work is in progress to support users and carers to ensure independent advocacy is available as envisaged by the Act. Furthermore, the new National Mental Health Workforce Group is working to address issues of recruitment, retention and training for those involved in providing care and support to those with mental health problems.
“I am also pleased to say that the Mental Health and Well Being Support Group will now have an enhanced role. The Group will co-ordinate the Executive’s work on service development at national level and will provide support to NHS Boards and their partners for their local planning.”
Notes to Editors
1. The Mental Health (Care and Treatment) (Scotland) Act 2003 received Royal Assent on 25 April 2003. The Scottish Executive announced consultation on dates for implementation of the Act on 19 June 2003.
2. Introduction to the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Newsletter ‘Reforming Mental Heath Law’ can be accessed at www.scotland.gov.uk/health/mentalhealthlaw. Paper copies can be obtained from Ryan Stewart on 0131 244 2591 or e-mail [email protected]
3. The £15 million Partnership Agreement funds will support commitments made in Partnership for a Better Scotland and will be allocated for a three year period. Partnership Agreement funds were announced on 11 September 2003.
Internet: www.scotland.gov.uk
130
abcdefghijkl m = eÉ~äíÜ=aÉé~êíãÉåí David Bolger= = aáêÉÅíçê~íÉ=çÑ=pÉêîáÅÉ=mçäáÅó=~åÇ=mä~ååáåÖ= eÉ~Ç=çÑ=jÉåí~ä=eÉ~äíÜ=aáîáëáçå= pí=^åÇêÉïÛë=eçìëÉ= oÉÖÉåí=oç~Ç= Chief Executives, NHS Boards bÇáåÄìêÖÜ=beN=Pad= Chief Executives, Local Authorities = qÉäÉéÜçåÉW=MNPNJOQQ=PTQV= c~ñW=MNPNJOQQ=OSMS= Copy to: Directors of Social Work a~îáÇK_çäÖÉê]ëÅçíä~åÇKÖëáKÖçîKìâ= Chief Executives, NHS Trusts ÜííéWLLïïïKëÅçíä~åÇKÖçîKìâ= Chief Executive, COSLA = Chief Executive, ADSW == = NM=aÉÅÉãÄÉê=OMMP
______Dear Colleagues
MENTAL HEALTH SERVICES ASSESSMENT
Further to the letter of 19 November announcing new resources to support the planning and implementation of the provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003, I now enclose a copy of Dr Sandra Grant’s Interim Report of her national Mental Health Services Assessment together with copies of the locality report for your own area and those for other parts of Scotland.
We are giving further thought, with others, on what additional guidance would help with the preparation of the joint local implementation plans and once this has been considered fully I will be in touch. Meantime, publication of the attached reports will, I hope, help inform drafting of joint local implementation plans.
As mentioned in the 19 November letter, it would be helpful (if you have not already done so) to let me or Phil Harley (0131 244 3749) have the name and details of the lead officer for development of your joint local plan. The submission date for the plans remains 31 March 2004, or earlier.
The final Mental Health Services Assessment report will be published in the early part of next year completing this aspect of the progress toward implementation of the new legislation.
Yours sincerely
DAVID BOLGER 131