Dumfries and Galloway Development Of: Group (Mental in July 2001

MENTAL HEALTH AND WELL BEING SUPPORT GROUP VISIT TO DUMFRIES & GALLOWAY – 11 JUNE 2002

This document contains:

The 6-month progress report dated December 2002 (pages 2 to 7)

The Report of visit to Dumfries & Galloway 11 June 2002 (pages 8 to 22)

1 VISIT REPORT PROGRESS REPORT AREAS FOR ATTENTION / ACTION ACTION INITIATED / REQUIRED LEAD GROUP / TIMESCALE INDIVIDUAL Funding and Investment Plan

The lack of a clear financial plan was raised by the The emphasis of the MH&WBSG on the need for local Senior Management June 2003 Support Group on its first visit to Dumfries and Galloway development of: Group (Mental in July 2001. We were disappointed to note the limited - a clear funding and investment plan, Health) progress that had been made in this respect in the past - including redesign and a shift away from year. We appreciate impeding factors such as the current inpatient facilities, Joint Commissioning spending deficit and the complex issue of agreeing and - all managed effectively and jointly Manager (Mental aligning baseline budgets with social services. The is accepted as the major challenge for mental Health) absence of a clear financial planning framework cannot health services in Dumfries and Galloway. but help to delay the prioritisation and implementation of service developments. Its absence also impacts upon Your second point about the impact on independent sector service providers in the independent sector who are providers is incorrect. The independent sector in currently reliant on short-term funding. Dumfries and Galloway has seen very rapid expansion in recent years and their service provision is increasingly We understand that moves are underway to adopt a valued. All services are underpinned by a contracting Programme Budgeting approach and that a paper is to be framework offering clear funding arrangements which are put to the NHS Board in December that will prioritise not short term. areas for development and investment. There is a recognition that this needs to be underpinned by a Joint Recent work has centred around the Mental Health Mental Health Board which is working towards the Section of the Health and Community Care Plan which continued redesign of services and shifting of resources offers a clear and concise vision for future services and an away from inpatient facilities. The Support Group action plan. A copy is attached. considers this an area requiring priority attention and looks forward to learn of progress in the next 6 months. The next stage is completion of a more detailed costed development plan, and the aim is to achieve this by June 2003.

Whilst this remains a significant challenge for us, in terms both of agreeing a joint vision and resourcing that vision, it is agreed this is an immediate priority essential to the development of effective services.

2 Integration and Involvement of LHCCs in the Planning Process

In the first round visit report we commented favourably on The planning and development of specialist mental health Joint Mental Health Ongoing the well-developed links between Local Health Care Co- services is inclusive of the Primary Care perspective. This Board operatives (LHCCs) and Dumfries and Galloway Council mainly occurs through LHCC representation on the Joint and that this formed a good model for future service Mental Health Board and the Mental Health Senior Director of Mental development and redesign. On this visit we were Management Group. At an operational level the Mental Health concerned that, despite a structure that facilitates LHCC Health Lead Clinicians and Lead GPs meet monthly at the involvement on a strategic level, the integration of Trust’s Operational Management Group. All service Primary Care into the planning process remains a development proposals will find their way through this challenge. This was readily acknowledged by Trust strategic and operational structure. While the structure is management who remain disappointed that a closer not perfect, our GP colleagues have indicated that they working relationship at this level has not evolved. are, on the whole, satisfied that they have the opportunity to influence mental health planning. At present, planning is led by secondary care services. Mental Health is not seen as an LHCC priority. The The proposed development of a Joint Board for apparently good working relationships at the service Community Care Services later this year (see next section) delivery level should be a good base upon which to will necessitate revisiting our current arrangements in improve the level of participation at the strategic level. order to maintain Primary Care and LHCC involvement.

The Support Group will be interested in learning what steps are being taken to address this issue and what progress has been achieved as a result of these efforts. Joint Planning Arrangements

Difficulties in the strategic planning machinery were There has been real commitment to joint planning of Joint Mental Health commented upon in last year’s report. While attention is mental health services in Dumfries and Galloway for a Board being paid to the Joint Mental Health Board in setting number of years. Whilst the arrangements and machinery priorities and funding levels, much work remains to be for joint planning were under review when the done. The lack of local authority elected members on the MH&WBSG visited in June, that review was more around Joint Mental Health Board may have contributed to the ensuring the arrangements are as effective as possible disproportionate focus on health related services. The rather than any specific difficulties. Similarly whilst there issues of Joint Mental Health Board accountability, was a discussion with elected members about their participation of elected members and clarity of funding representation on the JMHB, this was never identified need to be addressed as a priority if the Board is to be the locally as a critical issue and any disproportionate focus engine for the redesign and modernisation of services. on health services is unlikely to be related to the issue of 3 elected member representation.

We would wish to see progress in this respect within the What will impact significantly on joint planning April 2003 next 6 months. arrangements is the changing context provided by major local restructuring both by the NHS (toward a unified service) and by the Local Authority (with the creation of the new Education and Community Services Department).

It is now likely that there will be a new Joint Board for all Autumn 2003 community care services, including mental health. Whilst the machinery of joint planning for mental health will have to adapt to these new arrangements, the real challenge continues to be around the issues identified in your initial section of this progress report, namely: -joint vision and leadership -identification of resources/costed development plan.

This is where action is currently located. Information

The Support Group commented last year on the lack of Since November 2001 Dumfries & Galloway Joint Mental Senior Management 2003/04 local information relating to population health needs, Health Services have been actively involved in the Group (MH) quality of services and outcomes and the need to ensure development of an in-house built electronic information that service investments are based on clear evidence and system to gather activity/clinical information across all of accurate information rather than assumptions. We the Community Mental Health Teams in the region. The General Manager understand that limited work has been undertaken on development of this system has happened in line with the (MH) needs assessment in respect of certain areas, e.g. development of an Integrated Care Pathway for Mental schizophrenia, mentally disordered offenders, early Health and the newly introduced Integrated Care Planning dementia and psychological interventions, but information Process. based on a comprehensive assessment of need remains elusive. There has been no evidence of progress in We finally completed the programming of this database in commissioning an electronic database or IT system to August 2002 and commenced roll out thereafter. At assist this process. present we have 8 out of 9 of the Community Mental Health Teams connected to the IT system. It is evident that effort has been put into aligning assessment and care planning tools. Through time this We are now able to gather consistent clinical information should facilitate information gathering on a consistent electronically, region-wide, for individual care needs and region-wide basis in respect of individual care needs and the services they receive from the Joint Mental Health 4 service inputs for those receiving secondary care services. Services. The system can also provide activity reports, At present, accessing the necessary management caseload management and various other reports by information to get below the global figures to a more individual, team, GP practice, locality and region. All detailed understanding of what is being spent where, client care groups within the Mental Health sphere are remains a challenge. included.

The Support Group appreciates the complexity of the task Further detailed work regarding collation of demographic is heightened at present by the pace with which Dumfries and needs based information on clients with schizophrenia and Galloway is striving to implement the Joint Future has also commenced and this is incorporated into the agenda. We would wish to see, nevertheless, the ICP’s information system. development of an IT strategy to respond to these challenges. We would also urge early completion of the We are presently in the initial planning stages of further needs assessment for psychological interventions which is roll out to the in patient services and are in negotiations currently in progress. with LHCCs regarding access to the ICP’s system for GPs and out of Hours Services.

The development of the Integrated Care Pathways information system has been a significant piece of work involving consultations with all stakeholders. It has involved work across all of the Joint Mental Health Services looking at the future linking of all systems in use.

This fits neatly with the eCare project and the work that has been carried out to date will assist with some of the work to be done with the Modernising Government Fund Project (that is about to get under way in the region), and also some issues around Single Shared Assessments. Mental Health Promotion

Last year the Support Group commented upon the need It has been agreed that in 2003/04 Public Health will lead Director of Public March 2004 for a comprehensive timetabled strategy/action plan for on a mental health improvement programme including: Health mental health and well being. We note that the lack of such a strategy and an associated budget for its - developing a strategy implementation continue to be inhibiting factors in the - an action plan rational, prioritised development of services.

The Support Group looks forward to learning of progress Difficulties in recruitment to a specific post are likely to in the development of a Mental Health Promotion strategy delay the start of this work but the aim is that it will still within the next 6 months. be progressed in 2003. 5 Well being and positive mental health promotion/Stigma reduction

The Support Group regretted the lack of Public Health See above. participation on the day of the visit. We note clear evidence of considerable activity and enthusiasm in this area locally. A number of interesting projects across the area were brought to the attention of the group. Health Improvement Projects involving significant mental health components were operating across client groups in both the statutory and voluntary sector; e.g., in schools, primary care teams and voluntary organisations. We noted the development as well of the Public Health Workforce Project and look forward to the results of this initiative.

The Support Group remains concerned, however, that there continue to be problems in co-ordinating and communicating this work across the mental health and well being workforce. We believe that the lack of a Mental Health Promotion strategy and the budget to underpin such a strategy is inhibiting the further development of the service in a planned way and, as stated above, look forward to progress in this area. Independent advocacy services

Those present on the day who attended this group were The current PASS Business Plan is attached. Sections Senior Management Ongoing unaware of the status or the existence of an Advocacy particularly relevant for mental health services and service Group (MH) Strategy. Aside from the pilots under way with the users were discussed and agreed within the Mental Health Wigtownshire CMHT and in the Acute Wards, a generic Service. Whilst two specific developments had been Advocacy service operated by the People Advocacy agreed which you identify as “pilots”, these developments Support Service (PASS) is the main point of access for were agreed as part of the existing contract and no new service users. Lack of certainty over funding of existing resources were required. The reference to lack of projects is the cause of some concern. certainty over funding does not, therefore, reflect the actual situation. The Support Group looks forward to receipt of the local Advocacy Strategy which will place current projects in the At the same time, given the importance of advocacy in the September 2003 context of the future direction and development of new Mental Health Act and the availability of new services. resources, a significant question for 2003/04 is whether

6 mental health advocacy is developed by strengthening the existing contract or through a separate contract.

It is proposed that a decision is made by September 2003. Q:\Pt-Mk\2003\forms\ProgressReportFormat.MHWBSG-doc.doc

7 MENTAL HEALTH AND WELL BEING SUPPORT GROUP REPORT OF VISIT TO DUMFRIES AND GALLOWAY – 11 JUNE 2002

A copy of this, and all reports of the Mental Health and Well Being Support Group, go on the day of publication to the Minister and Deputy Ministers for Health and Community Care

On this occasion the Support Group was represented by:

· Mr Brendan Gill, Director of Planning and Information, Lanarkshire Health Board · Mrs Elisabeth Hill, OBE, Tayside Alcohol and Drugs Alliance · Mr George Kappler, Social Work Services Inspector, Scottish Executive · Dr John Loudon, Psychiatric Adviser, Scottish Executive Health Department · Dr Ian Pullen, Consultant Psychiatrist, Borders Primary Care NHS Trust (Chairman) · Mrs Helen Welsh, Princess Royal Trust for Carers, Carer Representative

SUMMARY:

Dumfries and Galloway has much to be proud of in the way in which it has approached and the success it has achieved in the modernisation of its mental health services. It has ambitiously embraced the implementation of the Joint Future agenda. It has sought to maximise the input of service users and carers and independent sector partners in the direction and pace of change. It has developed an infrastructure of jointly managed Community Mental Health Teams (CMHTs) upon which its service is to be based in future.

There is an urgent need to develop a clear strategic and financial plan, the lack of which is severely inhibiting the prioritisation and implementation of service developments. The continued enthusiasm and commitment of staff as well as stakeholders will need to be sustained by the commitment of management in both health and social services to the implementation of the change agenda. An essential component of the mental health strategy will be the development of a focused Mental Health Promotion Strategy. The future implementation of the mental health strategy will also be dependent upon securing adequate management information across health and social services upon which to base decisions.

FINDINGS:

The Support Group was particularly impressed by the following:

· Joint Future Agenda

There have been significant developments in the past year that demonstrate initiative in progressing elements of the Joint Future agenda. The further development of CMHTs for Older People on a jointly managed and staffed basis; agreement on an integrated care pathway (ICP) in which Care Programme Approach (CPA) and Care Management arrangements are synthesised into a single system for care co- ordination; and agreement on the structure for aligning health and social services budgets are all

8 significant steps on this journey. While much work has yet to be done to reach the goal of fully integrated resourcing, management and provision of services, the structures are now taking place and the will to achieve the goal appears strong on all sides.

· Models of Care

The Support Group commented last year on the need to achieve a greater clarity on the role of CMHTs and how they are to be resourced. Dumfries and Galloway has attempted to address these matters in the past year. Lead clinicians have been appointed for Adult and Old Age services and there appears to be much greater clarity in the functioning of teams in respect of both community and inpatient services. This has been facilitated by the development of the ICP. We look forward to hearing of the further work of the Redesign Project in establishing and extending the role of CMHTs.

· Child and Adolescent Mental Health Services (CAMHS)

The Support Group noted developments in the service despite the absence of a clear strategic plan. One example is the creation of a joint CAMHS/Adult Mental Health post focusing on working with children in transition to adult mental health services as well as with children of parents with psychiatric illness.

· Involvement and Advocacy

There is considerable evidence of the continued effort to engage service users and carers in service planning and development and the further development of Advocacy services. Examples include: the development of a carer support post based in acute wards; the advocacy pilots in acute wards and Wigtonshire CMHT; the soliciting of input from service users and carers on the provision and design of acute inpatient services in the “Fit for Patients” report; the production of the “Change in Mind” newsletter; and putting in place mechanisms to reimburse service users and carers for contribution to the formal consultation process.

· Postnatal Depression

It is evident that work has been done with enthusiasm and commitment to develop an ICP for postnatal depression, based on the SIGN Guideline and MEL(1999)27, which will be launched later this year. The Support Group is pleased to note that working relationships between different professions and services are good on the ground, and that there has been wide consultation about the ICP.

The Support Group identified some areas that require particular attention and while not attaching individual timetables for action in each case, it will look to see early attention and action with an update on progress shown in the joint response six-month progress report.

1. Funding and Investment Plan

The lack of a clear financial plan was raised by the Support Group on its first visit to Dumfries and Galloway in July 2001. We were disappointed to note the limited progress that had been made in this respect in the past year. We appreciate impeding factors such as the current spending deficit and the complex issue of agreeing and aligning baseline budgets with social services. The absence of a clear financial planning framework cannot but help to delay the prioritisation and implementation of service developments. Its absence also impacts upon service providers in the independent sector who are currently reliant on short-term funding.

9 We understand that moves are underway to adopt a Programme Budgeting approach and that a paper is to be put to the NHS Board in December that will prioritise areas for development and investment. There is a recognition that this needs to be underpinned by a Joint Mental Health Board which is working towards the continued redesign of services and shifting of resources away from inpatient facilities. The Support Group considers this an area requiring priority attention and looks forward to learn of progress in the next 6 months.

2. Integration and Involvement of LHCCs in the Planning Process

In the first round visit report we commented favourably on the well-developed links between Local Health Care Co-operatives (LHCCs) and Dumfries and Galloway Council and that this formed a good model for future service development and redesign. On this visit we were concerned that, despite a structure that facilitates LHCC involvement on a strategic level, the integration of Primary Care into the planning process remains a challenge. This was readily acknowledged by Trust management who remain disappointed that a closer working relationship at this level has not evolved.

At present, planning is led by secondary care services. Mental Health is not seen as an LHCC priority. The apparently good working relationships at the service delivery level should be a good base upon which to improve the level of participation at the strategic level.

The Support Group will be interested in learning what steps are being taken to address this issue and what progress has been achieved as a result of these efforts.

3. Joint Planning Arrangements

Difficulties in the strategic planning machinery were commented upon in last year’s report. While attention is being paid to the Joint Mental Health Board in setting priorities and funding levels, much work remains to be done. The lack of local authority elected members on the Joint Mental Health Board may have contributed to the disproportionate focus on health related services. The issues of Joint Mental Health Board accountability, participation of elected members and clarity of funding need to be addressed as a priority if the Board is to be the engine for the redesign and modernisation of services.

We would wish to see progress in this respect within the next 6 months.

4. Information

The Support Group commented last year on the lack of local information relating to population health needs, quality of services and outcomes and the need to ensure that service investments are based on clear evidence and accurate information rather than assumptions. We understand that limited work has been undertaken on needs assessment in respect of certain areas, e.g. schizophrenia, mentally disordered offenders, early dementia and psychological interventions, but information based on a comprehensive assessment of need remains elusive. There has been no evidence of progress in commissioning an electronic database or IT system to assist this process.

It is evident that effort has been put into aligning assessment and care planning tools. Through time this should facilitate information gathering on a consistent region-wide basis in respect of individual care needs and service inputs for those receiving secondary care services. At present, accessing the

10 necessary management information to get below the global figures to a more detailed understanding of what is being spent where, remains a challenge.

The Support Group appreciates the complexity of the task is heightened at present by the pace with which Dumfries and Galloway is striving to implement the Joint Future agenda. We would wish to see, nevertheless, the development of an IT strategy to respond to these challenges. We would also urge early completion of the needs assessment for psychological interventions which is currently in progress.

5. Mental Health Promotion

Last year the Support Group commented upon the need for a comprehensive timetabled strategy/action plan for mental health and well being. We note that the lack of such a strategy and an associated budget for its implementation continue to be inhibiting factors in the rational, prioritised development of services.

The Support Group looks forward to learning of progress in the development of a Mental Health Promotion strategy within the next 6 months.

OUR NATIONAL HEALTH

The Support Group is particularly interested in the following service areas, which were highlighted in Our National Health and in the HDL(2001)69. It offers the following comments on the progress being made by the agencies working in Dumfries and Galloway.

· Well being and positive mental health promotion/Stigma reduction

The Support Group regretted the lack of Public Health participation on the day of the visit. We note clear evidence of considerable activity and enthusiasm in this area locally. A number of interesting projects across the area were brought to the attention of the group. Health Improvement Projects involving significant mental health components were operating across client groups in both the statutory and voluntary sector; e.g., in schools, primary care teams and voluntary organisations. We noted the development as well of the Public Health Workforce Project and look forward to the results of this initiative.

· Primary Care /LHCC focus for service delivery

The Support Group was disappointed that it did not meet with a general practitioner, nor any representative from the 4 LHCCs. It notes the reassurance given that there is a determination on the part of Service Commissioners to involve primary care in mental health service developments. On the other hand, there is inconsistent LHCC representation at both the Mental Health Board and the Joint Commissioning Team meetings. None of the recently allocated LHCC development monies has been devoted to mental health: these decisions are a matter for LHCCs, but are indicative of the present level of interest.

11 The Support Group was pleased to hear that there is a named worker for each (CMHT) for each practice who, together with the CMHT team leaders, provide an important day to day link with LHCCs.

The voluntary sector must be integrated into the planning and delivery of community mental health services and the Support Group believes that much remains to be done to develop relationships between the voluntary sector and LHCCs.

· Community services for anxiety and depression

Dumfries and Galloway was one of the 4 pilot sites in the recently completed Psychological Interventions Project, supported by the Mental Health and Well Being Development Fund (MHWBDF). The Support Group was pleased to hear that each general practice can call upon some clinical input from a clinical psychologist and a counsellor but was disappointed to find that this is not available to those over age 65. A needs assessment for psychological interventions is in progress that will take into account the findings from the MHWBDF evaluation.

Waiting times are said to be quite long and people with severe and/or enduring mental health problems, particularly schizophrenia, may have difficulty accessing psychological interventions (as required by the CSBS Schizophrenia Standards).

The Support Group urges early completion of the needs assessment and the re-engineering of the present services available to use resources to the best advantage, as outlined in the Psychological Interventions Template published by the Support Group in 2001.

· Forensic services

There are particular challenges in providing fit for purpose mentally disordered offender services to the relatively small population of Dumfries and Galloway, dispersed over a wide area. A multi-agency group had convened prior to the launch of the 1999 policy document, and the NHS Board is a member of the Non-Glasgow West Board Consortium currently considering the planning, building and commissioning of a regional forensic unit, which will be sited nearer the larger centres of population. However, this unit, when built, will only be at one end of a spectrum of care. The loss of the mental hospital, with the run down of the Crichton Royal, has left some of the continuing needs of mentally disordered offenders exposed. Local agencies have responded by closer joint working with an emphasis on a practical basis and this seems to be going well at present, however, a specific forensic care pathway needs to be in place. There is some way to go in the development of Mental Health Officer skills in this area and the knowledge and expertise, and thus confidence, of members of staff in the criminal justice teams. For example, there is no arrest referral, although there are opportunities for diversion from prosecution later on. There is an active voluntary sector involved in the provision of drop-in services, supported accommodation and services for people with substance misuse and/or alcohol problems. The Support Group recognises the difficulty of continuing service development but would encourage continuing joint agency support.

· Liaison Psychiatry

A limited liaison service is available at Dumfries and Galloway Royal infirmary, particularly through a liaison nurse whose main focus is the accident and emergency department, together with sessional input from both clinical psychologists and general psychiatrists. A recent development is the decision

12 to appoint a dementia liaison nurse and 2 care managers in an attempt to reduce the numbers of delayed discharges. The forthcoming publication of the SNAP report on Liaison Psychiatry and Psychology will set a framework for future development of liaison services. The problem of people with unrecognised mental health problems in general hospital out-patients and wards delays materially their recovery from physical illness and people with alcohol problems and who misuse substances add greatly to the workload in a general hospital. Identification of need and service development are considerably assisted by the identification of a clinical champion and the Support Group strongly recommends that NHS Dumfries and Galloway implement this at an early date. The funding should be shared between the Acute and Primary Care Trust.

· Services for children and young people

CAMHS have had recent developments with the setting up of the new community service. Gaps in service remain, however, and the strategic planning and implementation arrangements are complex and not fully representative. For example, the Children’s Executive Group developed the Changing Children’s Services Plan with the recommendation that a Mental Health Sub-Group be established, but this has yet to take place.

There is a risk that, unless there is a clear strategic plan setting out priorities to address gaps in service, new funds will not target these priorities.

· Post Natal Depression

The development of the ICP, and the good working relationships in this area were commented upon favourably above.

The Support Group was surprised to hear that the Acute Trust had not contributed its share of the funding required for a training programme involving community midwives and health visitors in the use of the Edinburgh Scale, essential to the working of the ICP. It noted that there was no GP or Obstetrician on the Working Group which prepared the ICP.

Although much domestic abuse starts during pregnancy, the Support Group was concerned to hear that some staff, particularly in the antenatal clinic, felt reticent about approaching a patient in a routine way to enquire about this. Nationally, much importance is attached to supporting those who are victims of domestic abuse. Staff who are empowered and have the necessary skills will find it easier to discharge their responsibilities.

· Allies in Change/Partners in Policy Making Programmes

There has been limited attendance at Allies in Change courses. Four Joint Action Groups (JAGs), however, bring together NHS professionals, social workers, voluntary organisations, service users and carers and give ‘formal’ opportunities for service users and carers to influence service planning. Region-wide meetings of the JAGs are planned with one having taken place by the time of the visit. The involvement of users and carers in relation to issues affecting Older People has not been specifically addressed as of yet. For younger people a number of mechanisms exist which were brought to the attention of the Support Group.

The Group noted with interest the training of all staff on Acute wards to help implement the outcomes of the User and Carer Involvement/Consultation and Involvement Trust Scotland Review of acute care services and the user-led research measuring quality standards for CMHTs.

13 Dumfries and Galloway were commended above on a number of initiatives which attempt to further engage service users and carers in the planning of services. We did receive comment from some service users on the day that they did not feel confident they were able to influence change, particularly in relation to the attitudes of some staff. Correspondence received following our visit from one organisation questioned how representative those expressing views on behalf of users and carers were. It is evident that this is an area which requires continual attention to ensure that the processes are sufficiently inclusive and the lines of communication adequately inform all stakeholders as to the nature and extent of service users’ and carers’ input.

· Independent advocacy services

Those present on the day who attended this group were unaware of the status or the existence of an Advocacy Strategy. Aside from the pilots under way with the Wigtonshire CMHT and in the Acute Wards, a generic Advocacy service operated by the People Advocacy Support Service (PASS) is the main point of access for service users. Lack of certainty over funding of existing projects is the cause of some concern.

The Support Group looks forward to receipt of the local Advocacy Strategy which will place current projects in the context of the future direction and development of services.

· Services for People with Dementia

The Group was pleased to note the progress which had been made in the development of jointly managed CMHTs for Older People with the appointment of the new team managers. Their work is assisted by the continuing development and use of integrated assessment and care planning procedures and tools. There appear to be close links between the CMHTs and Primary Care colleagues.

There are, however, continued tensions and inhibiting factors in the redesign of services. Delayed discharges, funding problems with Dumfries and Galloway social services and lack of specialist staff in care homes in the West with relevant training and experience in working with people with dementia all contribute to this. This is happening within the context of the rate of inpatient provision for psychogeriatric beds being below the Scottish average, while the cost of inpatient care for this patient group is above the national average. The dispersed population across the region has resulted in the creation of smaller NHS inpatient units such as in Stranraer and Lochmaben and the service is currently examining the most efficient use of these resources.

The growing enthusiasm and commitment to joint working in the CMHTs may be dissipated if urgent attention is not given to addressing the need for single joint bases from which to operate as well as the requisite administrative support. This is essential to maximise the teams’ effectiveness in focusing on the continuing redesign of the service for individual older adults with mental disorder.

Performance Assessment Framework (PAF) - the Overall Assessment

As part of the Performance Assessment Framework process announced in Our National Health, the Support Group invited the partner agencies in Dumfries and Galloway to assess themselves against key areas for the development of mental health services which are fit for the purpose of providing for the needs of the people of Dumfries and Galloway. Shown below is the conclusions the Support Group

14 has reached following its visit, plus full consideration of the achievements of the services in Dumfries and Galloway and the issues described above.

CONCLUSION

The Support Group looks for the issues identified and raised here to be addressed in the ongoing and future planned activity of all the agencies involved. As indicated earlier, the Support Group will request a written update on the progress made against the comments offered in this document in around 6 months. That update will be published on the web site alongside this report. (www.show.scot.nhs.uk/mhwbsg).

Finally, the Support Group would like to thank all from Dumfries and Galloway who attended and participated on the day and those whose contributions to the arrangements made the day and visit run smoothly.

MENTAL HEALTH AND WELL BEING SUPPORT GROUP July 2002

15 MENTAL HEALTH AND WELL BEING SUPPORT GROUP OVERALL ASSESSMENT

For Round 2 the overall assessment will focus on areas highlighted in Support Group’s First Round Report, Our National Health and in the HDL (2001) 69. Where the Support Group has been unable to offer a rating then the joint agency self-assessment rating will stand. These latter cases have been shaded in.

Rating score · a rating of 4 indicates significant progress with the strategic objectives · a rating of 3 indicates general satisfaction · a rating of 2 indicate satisfaction in some areas but not others · a rating of 1 would indicate a number of areas giving rise to concern · a rating of 0 would indicate a service deficiency requiring early local attention

In deciding the score the Support Group will consider: · Clarity of overall direction · Comprehensive and joint approaches. All aspects addressed · Joint assessment of need, taking into account service user experiences · Clear actions and time scales, and specified end-point · Clarity of investment to support initiatives

DIMENSION ISSUES KEY RATING Well Being · A joint local mental health promotion strategy ?T 0 1 2 3 4 Mental Health Promotion in Scotland, HEBS (1998) · Identification planning & services for individuals at risk ?T 0 1 2 3 4 · Identification planning & services for groups at risk ?T 0 1 2 3 4 · Building healthy communities by links to other ?T 0 1 2 3 4 programmes · Development & implementation of Anti-Stigma policies ?T 0 1 2 3 4 Our National Health (2000) A Shared · Inclusion of service users, carers and voluntary sector T 0 1 2 3 4 Approach views and experiences, jointly with staff in service review, assessment and commissioning, through a training and development system provided by Board and Trust resourcing for Allies in Change. Allies in Change Route Map (2001) · Development of local services provided by voluntary 0 1 2 3 4 organisations as well as service users and carers (Our National Health (2000)) · Independent collective or individual Advocacy in mental ?T 0 1 2 3 4 health available to service users and carers who require it. Independent Advocacy: A Guide for Commissioners (2001)

Key: T Areas highlighted in Our National Health and HDL(2001)69 ? Areas highlighted in First Round Report. < Areas highlighted in Performance Assessment Framework

16 DIMENSION ISSUES KEY RATING Making It · Joint local strategy agreed between partner agencies 0 1 2 3 4 Happen Making it Happen: A Framework for Mental Health Services in Scotland (1997) · Agreed and time-tabled implementation plan < ? 0 1 2 3 4 · Explicit planning links to Community Care and Health 0 1 2 3 4 Plans · LHCCs are involved in local mental health service T 0 1 2 3 4 planning and delivery. Our National Health (2000) Resources · Clarity about continuing resource identification by each < ? 0 1 2 3 4 agency, with investment appropriate to the strategic intent A Shared Approach, Accounts Commission (1999) · Principles of JFG report A Joint Future applied to joint ? 0 1 2 3 4 mental health service development A Joint Future: Report of the Joint Future Group (2000) · Targeting of specialist mental health resources on those 0 1 2 3 4 with greatest identified need, including use of the CPA A Shared Approach, Accounts Commission (1999) · Sharing of information between agencies leading to the 0 1 2 3 4 development and evaluation of cost effective services A Shared Approach, Accounts Commission (1999) The · Process Elements 0 1 2 3 4 Framework A Framework for Mental Health Services in Scotland “Service (1997) Elements” · Core Service Elements ? T 0 1 2 3 4 (the Template) (including psychological interventions) · Service profiles : · Adults < 0 1 2 3 4 · Children and Young People < T 0 1 2 3 4 · Older People (in particular Dementia Services) < T 0 1 2 3 4 · Mentally Disordered Offenders < ?T 0 1 2 3 4 · Those who misuse Alcohol and Substances < 0 1 2 3 4 · Homeless People 0 1 2 3 4 · People with a Learning Disability AND who have a 0 1 2 3 4 mental health problem · People with a Physical Illness AND who have a mental < ?T 0 1 2 3 4 health problem · Women with PND < T 0 1 2 3 4 NHS MEL(1999)27 Services for Women with Post Natal Depression · People with an Eating Disorder < ?T 0 1 2 3 4 · Service provision for people with anxiety / depression in < T 0 1 2 3 4 the community Our National Health (2000) Key: T Areas highlighted in Our National Health and HDL(2001)69 ? Areas highlighted in First Round Report. < Areas highlighted in Performance Assessment Framework 17 Broad Indicators of Local Progress

Well Being 4.0

3.5 2.8 3.0 2.6 2.5 2.2 2.2 2.2 2.0 2.0 1.8 1.8 1.8 Rating 1.5

1.0

0.5

0.0 Argyll & Ayrshre & Fife Highland Tayside Westen Grampian Dumfries Average Clyde Arran Isles & Galloway

A Shared Approach 4.0 3.5 3.0 2.7 2.3 2.5 2.0 2.0 2.0 2.0 2.0 1.7 1.7

Rating 1.3 1.5 1.0 0.5 0.0 Argyll & Ayrshre & Fife Highland Tayside Westen Grampian Dumfries Average Clyde Arran Isles & Galloway

Making It Happen 4.0 3.5 3.0 3.0 2.5 2.5 2.3 2.3 2.2 2.0 2.0 2.0 1.8 1.5 Rating 1.5 1.0 0.5 0.0 Argyll & Ayrshre & Fife Highland Tayside Westen Grampian Dumfries Average Clyde Arran Isles & Galloway

18 Resources 4.0 3.5 3.0 2.8 2.5 2.0 2.0 2.0 2.0 2.0 2.0 2.0 1.8 1.8

Rating 1.5 1.0 0.5 0.0 Argyll & Ayrshre & Fife Highland Tayside Westen Grampian Dumfries Average Clyde Arran Isles & Galloway

The Framework "Services Elements"

4.0 3.5

3.0 2.5 2.5 2.2 1.9 2.0 1.9 1.8 2.0 1.6 1.6 1.7 Rating 1.5 1.0 0.5 0.0 Argyll & Ayrshre & Fife Highland Tayside Westen Grampian Dumfries Average Clyde Arran Isles & Galloway

Broad Indicators of National Progress no of 0s no of 4s 1% 3%

no of 1s no of 3s 23% 20%

no of 2s 53%

19 MENTAL HEALTH AND WELL BEING SUPPORT GROUP

Purpose

1. The Support Group will support, influence and advance the further development of mental health services in Scotland; offer advice locally and to the Scottish Executive on solutions and best practice in implementation of the Framework for Mental Health Services in Scotland agenda for change and improvement in mental health services; provide additional focused local activity assessments to the Scottish Executive and the agencies involved.

Remit

2. In delivering against this agenda, the Group will:

· have regard to the strategic and practical arrangements for change set out in the Framework for Mental Health Services in Scotland, and all other relevant guidance and material;

· visit each Health Board area on an ongoing basis to discuss with service commissioners from the relevant NHS and local authority care agencies, the progress made jointly and separately against the Framework implementation agenda;

· offer advice and guidance to the local care agencies on best practice and help identify and remove any perceived or practical obstacles to progress with implementation of the agreed joint local mental health service strategies. Findings to be fed back to the Scottish Executive and the agencies, to be taken forward in terms of ongoing performance and performance management;

· complement, but not replace, related activity of the Joint Futures Group, the mentor and advice remits of Scottish Health Advisory Service, the Mental Welfare Commission, the Clinical Standards Board for Scotland and others.

Process

3. The Support Group follows a rolling programme of visits to local authorities and the Board in each area. Local voluntary agencies and groups representing users of services and those who care for them must be included. The MH&WBSG is interested in the strategies and plans for all mental health services, for all age groups. Group members will meet their local counterparts before a plenary session with relevant NHS and local authority care agency service commissioners. In advance of each visit, Scottish Executive colleagues will brief members on current knowledge of the local position. Members will also take account of any information by other groups and agencies (i.e. SHAS reports etc). Boards and partner agencies will also be invited to suggest agenda items for discussion.

20 GLOSSARY OF TERMS

Advocate / Advocacy A person independent of any aspect of the service or of any of the statutory agencies involved in purchasing or providing the service, who acts on behalf of, and in the interests of, the person using the service. An advocate can help someone to represent themselves

Allies in Change A consortium of voluntary and independent sector organisations, Allies in Change, was established to improve the input of service users and carers into service development.

Arbuthnott A review of the 20 year old Scottish NHS Resource Allocation formula (SHARE) was established in December 1997 under the chairmanship of Professor Sir John Arbuthnott of Strathclyde University.

Assessment The process of deciding what a person needs in relation to their health, personal and social care, and what services must be put in place to meet these needs. An assessment is undertaken with the person, his or her relatives or representatives, and relevant professionals.

(Integrated) Care Pathway The pathway through the NHS taken by the patient should follow a structured and responsive route. An integrated care pathway aims for seamless transition between the relevant services. Founded on good communications and overall integration of service delivery.

Care Programme CPA. An inter-agency approach to the planning and delivery of care and Approach treatment for people with complex mental health problems, that involves the person concerned and their carers.

Carer A person who supports or looks after family, partners or friends in need of help because they are ill, frail or have a disability. The care they provide is unpaid.

Clinical Standards Board CSBS. Is a statutory body, established as a special Health Board in April for Scotland 1999. Its role is to promote public confidence that the services provided by the NHS are safe and that they meet nationally agreed standards, and to demonstrate that, within the resources available, the NHS is delivering the highest possible standards of care.

Forensic Services for people classified as Mentally Disordered Offenders.

Health Department Letter HDL (formerly known as Management Executive Letters (MELs). Formal communications from the Scottish Executive Health Department to NHSScotland.

Health Improvement Fund HIF. This investment is for improving health in Scotland and will invest more than £100 million between 2000-01 and 2003-04. NHS Boards and Local Authorities will work together to route money to local communities, with a particular emphasis on Social Inclusion Partnership areas.

21 Joint Future Group The Joint Future Group was set up to improve partnership working between agencies and to secure better outcomes for people who use services and their carers

Liaison Psychiatry Services for people whose mental health problem contributes to their physical health problems.

Local Health Care LHCC. Co-operative groups of GPs, Community Nurses and related Co-operative services working in localities.

Mentally Disordered MDO. A person with a mental disorder who has, or is considered likely Offender to, come into contact with the criminal justice system.

Mental Illness Specific MISG. A ring fenced grant from the Scottish Executive to fund specific Grant community based services for people with mental health difficulties.

Neurological Diseases of the brain and nerves in the body which together make movement and feeling possible by sending messages around the body e.g. Alzheimer's disease is a neurological disorder.

Our National Health Sets out in clear terms, the direction and hopes for improving the health of all people in Scotland.

Partners in Policy Is a leadership development programme for adults with disabilities and Making Programmes parents of children with disabilities.

Performance PAF. The new process of accountability which considers all aspects of Assessment Framework NHS performance placing equal weight on the quality of clinical and service delivery, financial management and public involvement.

Post Natal Depression PND. Depression following the birth of a child.

Primary care team GP and other health professionals who provide healthcare in the community.

Psychological Sometimes called ‘talking therapies’. Counselling treatment from trained Interventions and skilled practitioners.

Scottish Health Advisory SHAS. They review and report on the standard of local services Service

Scottish Needs SNAP. Conduct research and reviews into specific aspects of care or care Assessment Programme need.