Item 4 is this morning’s second round-table evidence session. This one is on mental health. I wonder whether the witnesses will agree to introduce themselves the first time they speak in order to save time. [Interruption.] There seems to be a problem with the microphones, so we will have a slight pause to get it sorted out.
We have agreed, at least by our silence, that we will introduce ourselves the first time we speak. As usual with such sessions, I will, for preference, give the floor to our panellists.
The first question is from Richard Simpson
With the Mental Health (Care and Treatment) (Scotland) Act 2003, Scotland led the way in the UK, because all previous mental health legislation had been created by the UK Parliament and then tartanised. The introduction of the Millan principles was clearly very important at the time. Do you think that the proposed revisions to the act are appropriate? Have compulsory treatment orders and the community element of those provisions worked? What do those from whom we have received evidence feel about the McManus review and the proposed revisions?
I am head of policy and campaigns at the Scottish Association for Mental Health.
As Richard Simpson said, the 2003 act was groundbreaking; it has human rights at its heart and contains a number of very welcome provisions. I believe that the new bill will be introduced later this month, but we have, with regard to the draft bill that we have seen, a number of concerns about elements of the McManus review that are not included. We felt that the McManus review was very comprehensive and thorough; it has, as members know, taken some time for a response in the shape of a bill to be put together.
SAMH has submitted a very thorough response on the bill, but I would like to highlight a few areas of concern. First, the consultation draft bill suggested that it would be possible to detain a person on the basis of only one medical report. We are very concerned about that.
Secondly, we want changes other than those that have been proposed to be made to the named persons provisions. The Scottish Government stated its intention that no one should have a named person if they do not choose to have one, but that would not be the effect of the provision in the bill.
We have a number of other concerns about the absence of advocacy, which was a real strength of the original legislation. I do not think that the right to advocacy has been fully realised and we are disappointed not to see more of that in the new bill.
We will obviously wait to see the revised version, but those are a few of our initial concerns.
I am from Voices of Experience. I want to add to what Carolyn Roberts has said. Obviously we agree on all the issues that Carolyn has raised, but I would like to add that we had been looking for the onus being placed on an individual to drive completion of the advance statement, which would mean that somebody from the care team would have responsibility for that. That is a really good idea in the context of the recent talk about capacity being challenged. The idea is that we seek every opportunity for supported decision making, as opposed to taking decisions away from the service user.
I am associate nurse director for mental health in NHS Ayrshire and Arran, but I am here as a front-line Royal College of Nursing Scotland member.
Our concerns relate to nurses’ holding powers and the proposal to change the length of time for which they can hold a patient. We do not agree with it because of reciprocity and the fact that the 2003 act was based on rights. We see the proposal as infringing rights. There is no need to extend the time for holding; the nurse’s holding power is for two hours, and if the doctor arrives before the end of the two hours, the nurse can detain for a further hour.
To change the 2003 act to say that a nurse can have the power to detain someone, even when there is a doctor present, will not place on the service the reciprocity that is within the 2003 act. Holding will become a workforce issue as opposed to being about tending to someone who is being considered for detention, which means that they are unwell, and we should prioritise that. RCN members do not agree with the proposal.
The mental health nursing forum in Scotland, which is a group of senior mental health nurses, also discussed the proposal and also disagrees with it. There is no need to change the 2003 act’s provision, and none of us understands where the proposal came from or what the driver for it is.
The Mental Health Foundation agrees with all those points, and we have echoed them in our submission.
The two issues that I came here to concentrate on today are equity and equalities, and mainstreaming mental health. Both deserve to be explored in discussion of the draft bill, so that they can widen the discussion within the bill process.
The draft bill appeared to many stakeholders to be extremely technical. As Richard Simpson pointed out, in the process of creating the 2003 act, Scotland paid regard to the differences in mental health services in Scotland and the work that had been done on various national programme activities. It is fair to say that, from our perspective, the paradigm has shifted in the past 10 years; a new bill—potential new mental health law—deserves to be examined in the light of how the paradigm has shifted.
We would like discussions on the bill to focus on people who are the subject of inequalities, on how the bill’s provisions will be applied, on how the provisions of the 2003 act are applied to people from inequality groups—asylum seekers, refugees and young people, for example—and on where their right to advocacy and so on works.
We would also like the bill to revisit sections 25 to 31 of the 2003 act, which deal with the obligations on local authorities to promote recovery and access to other services, including employability and education, all of which are bound up in issues around welfare reform and other things that, I am sure, will come up today. They deserve an airing so that local authorities can mainstream their work on mental health in the context of single outcome agreements and other activities that are new since the 2003 act.
We are concerned about the lack of mention of independent advocacy in the proposed mental health (Scotland) bill. One of the strengths of the 2003 act was that it was the first legislation in the UK to give people the right of access to independent advocacy.
What happens in practice throughout Scotland does not, however, reflect people’s rights under the legislation; access to advocacy has been really patchy over the past few years. Some groups still do not have the levels of access that they should have. We have produced various pieces of research: most recently, the Mental Welfare Commission published some research yesterday, which said that people with dementia still do not have access to advocacy. Lots of people still do not know about advocacy. The commission discussed units that had not had any input from advocacy for the past six months. We are concerned about such developments.
It has been said that advocacy safeguards people’s rights and ensures that people have access to the right kind of support, care and treatment. We think that an opportunity has been missed. There needs to be something to strengthen people’s right to access independent advocacy and to remind local authorities and health boards about their duty to ensure appropriate levels of access, so that people with learning difficulties, older people, people with dementia and children and young people do not fall into the gaps in provision that we see all the time.
We are in the process of producing some new research. One of the target groups has been mental health service users, in respect of whom the process has been disheartening and depressing. A number of people have said that they wished that somebody had told them about advocacy years ago, because it would have made a huge difference to their lives and they might not have been in their current situation. That highlights the role of advocacy in prevention and in avoiding situations becoming more difficult and complex.
Advocacy helps people on the road to recovery. When advocacy is involved, people have a stronger sense of control and more choices, and they have the ability to make better decisions, which we hope can prevent situations from escalating.
We are really concerned that the draft bill does not recognise the importance of advocacy.
We strongly support the principles of the proposed mental health bill. To reflect some of the previous comments, I say that the bill is tightly drafted, and it seems to be meeting a legislative framework—understandably—rather than reflecting developments and changes that have taken place over the past 10 years in how mental health services are delivered. We would like those to be reflected in the proposed bill through expansion of mandated treatment, which includes, for example, input to families by way of psychological care, where that is appropriate.
Developments in England in mental health legislation have expanded the role of other clinicians in providing specialist reports, and the role of the responsible clinician has now developed. The British Psychological Society has supported appropriately qualified psychologists in taking on that role. Appropriately qualified nurses are also taking on that role in England. We particularly note the suggestion that one report could be used, and we echo the concerns about it that are in other consultation responses.
We appreciate that there may be resource issues, but there is an opportunity through the proposed legislation to consider more widely who can provide a second opinion. For instance, some issues within learning disability are more clearly psychological—for example, where there may be neuropsychological difficulty—and so would sit well with the expertise of psychologists. We are keen for that to be considered.
Do you want to add some comments, Mr Barron?
11:30
I do not completely agree with Carole Allan on turning the role of the nurse into what would previously have been a mental health officer role. The MHO role provides a safeguard, so I am not sure that we would support nurses taking on the role that they take down in England.
That is a legitimate view, but what will be helpful is information coming from England about how things are working, who has taken on the roles and whether safeguards are in place. That is to be investigated and evaluated. That is simply a comment; I cannot speak on behalf of nurses and would not dream of it.
That has been a useful introduction. I should have declared a couple of interests, as a fellow of the Royal College of Psychiatrists in Scotland and as someone who has a chair in psychology at the University of Stirling.
The named person concept is interesting. I wonder whether others would like to comment on it, because the roles of individuals are definitely changing; if you go back 40 years, a nurse’s role was quite different to what it is now, and the range of roles has also become quite different. The same is true for psychologists. In 1979, a person could not see a psychologist without being referred by a psychiatrist. I did some research that showed that that was complete nonsense, and the system then changed. Should the bill be drawn in such a way as to allow the possibility of extended roles for a limited number of nurses with specific qualifications, and for psychologists and others to provide a second report, if we retain the second report?
Unsurprisingly, I absolutely support the extended role for nurses. In Ayrshire, we have advanced nurse practitioners in Crosshouse hospital who do away with the need to have a psychiatrist overnight. We have on-call consultants, but not junior doctors, so I absolutely agree with that provision. However, to take, in the bill, a step away from that protective element requires careful consideration. I understand the point about specialists and advanced practice, but I would be cautious because what we currently have is rights-based legislation that protects individuals; if nurses and doctors are too close in one team, that could be a risk that needs active consideration.
We are well aware that the general practitioner provision for the second report has not worked particularly well, so to substitute another professional in that role is fine. What Derek Barron is talking about is the need for a second report and an MHO safeguarder, and the need not to confuse the two reports—not to use the MHO’s report as the second report, in any circumstance. That should be the inviolate bit of the legislation.
I am from the Royal College of Psychiatrists in Scotland. I point out that I am not a practising psychiatrist.
I know that there are huge problems with getting the second report from GPs, particularly in rural areas and in areas that are short of junior doctors. Derek Barron mentioned getting junior doctors on call overnight. We have big recruitment problems in psychiatry and we have gaps in particular bits of the country and in particular specialties, so that needs to be looked at.
I would like to make a final comment about having a second independent report. The British Psychological Society has supported psychologists in England with extra training and mentoring. The Scottish Government could seek information and intelligence about development of those roles. I am reflecting some of the resource considerations that have been flagged up.
Part of the core role of a psychologist is to be able to assess situations and to produce a report that is helpful to a tribunal. My thinking about the process is that it could be beneficial.
I will make a point that might broaden out the discussion. It relates to what I said about mainstreaming mental health across a wide range of competencies and to anti-stigma work.
In the olden days, it was solely the duty of psychiatrists and latterly MHOs to deal with mental health in a legislatively defined manner. In 2014, people in a wide range of legislatively designed roles are compelled to act on people’s mental health. There is the role of practitioners in self-directed support, for example, which is in the recent act on that.
We want the widest possible workforce involvement in and understanding of the complexity of mental health. We want practitioners from the broadest range of professional backgrounds to act in their sphere of professional responsibility in a way that promotes rights and encourages people’s self-advocacy and the best possible outcomes for their recovery. If that means that mental health legislation should include options to widen the range of workforce roles that have a statutory responsibility, it would probably be good to have that, alongside a wider recognition of the impact on mental health of a range of professions in different communities and through different policies.
There are two points on professional roles. I support Derek Barron’s point about the mental health officer’s role, which is fundamental and provides safeguards. We are concerned that the number of trainee mental health officers has been falling in recent years. That is an important point that I would welcome consideration of by the committee.
Dr Simpson asked who should be able to provide the second of the two reports. As we consider the bill, it will be important to define the second report’s purpose, which will drive who should be able to provide it. We have focused on the fact that it is a GP report. We are quite positive about GP participation because it is reasonable to expect that in many cases the GP will have a relationship with the individual. The GP might be able to provide wider information, beyond that about the person’s immediate state, for example information on experiences, a previous condition or family circumstances. All those issues are relevant.
We are keen for GPs to retain a role. I understand that there are often practical difficulties in getting them to participate, but I would be concerned about changing a process that has such positives purely on the basis of resources and availability. I would prefer us at least to make efforts to address the resource-driven issues before changing the system. Something like 1,200 compulsory treatment orders are made every year and there are about 4,000 practising GPs, so the resource issues should not be insurmountable.
The focus is on the crisis, but the committee spends a lot of time discussing preventative initiatives. In reading the committee papers at the weekend, I was shocked to see some of the differences in waiting times for psychological therapies. The waiting time in Glasgow is seven weeks, but in the NHS Forth Valley area it is 17 weeks, which is just within the 18-week target. As at March, 2,700 or so people had waited more than 18 weeks.
We are looking at the point of crisis, but surely we should look at how we reduce the number of people who get into crisis. We have not mentioned children yet. In the past, we have had evidence that thousands of children present to social work staff suffering from emotional abuse and lack access to specialist support.
I represent Young Scotland in Mind, which is a forum of mainly voluntary sector organisations that work with children and young people. This is probably a relevant moment to raise issues that affect children and young people. To be honest, a host of things are absent from the proposed bill in relation to children and young people. Our members do not feel that the bill talks to them or addresses the issues that affect children and young people. Waiting times for children and young people are especially poor.
There are issues around defining an adult as someone over 16. The United Nations Convention on the Rights of the Child says that someone is a child up to the age of 18. On the back of the Children and Young People (Scotland) Act 2014, those who are looked after and accommodated can get a service up to the age of 25.
Historically, the period between 16 and 18 is poor in any service, but we are looking at a particularly vulnerable group here, especially children that have been looked after, who are disproportionately affected by poor mental health. Almost half of them leave care with a diagnosed mental health condition. Those are the people who fall through the cracks and come to adult services at the point of crisis.
There is a real lack of community-based engagement with third sector preventative work. A lot of sporadic things are going on but it is not usually joined up with the budgets of the bigger services. Sadly, the draft of the bill that we have looked at does not really do a great deal to address that. Our members feel that the issues that affect children and young people and their needs are absent from the bill. Children and young people are not an add-on group; they are not an equalities group. They represent an entire population. They are affected by parental mental health. One of the biggest indicators of a child or young person’s mental health and wellbeing is their mother’s mental health. There is a considerable gap there.
The third sector has lots of ideas in relation to that. It is looking for partnerships and wants to see more community-based work. It would like to see more links between child and adolescent mental health services and schools. Information on issues such as self-harm does not exist in schools. We have surveyed our members on that and those are significant issues.
That is just skimming the surface. The opportunity to take a more preventative approach would be well supported and echoed by those in the children’s sector.
Could I add something on psychiatric recruitment? In the past couple of days, I have had an update from our child and adolescent psychiatry faculty. Recruitment of psychiatric trainees to higher specialist training—that is the last two years before becoming a consultant—is becoming an increasing problem across all psychiatric specialties, and doctors in general in Scotland. It is anticipated that there will be an increasing shortfall in consultant numbers. Those people see the most ill and the most severe psychiatric illnesses, but there will be gaps in that psychiatric workforce.
Recently, six ST4 vacancies were advertised in child and adolescent psychiatry and only one was filled. There were three vacancies in Forth Valley for consultant jobs. Last week, all three candidates withdrew. There are expectations around legislation and about beefing up the services and reducing the waiting times, but there will definitely be problems with the psychiatric workforce. I do not want to depress anybody any further.
I want to pick up on Brian Donnelly’s comment about CAMHS links and schools. Paradoxically, there are cuts to educational psychology, and workforce planning predicts that over the next four or five years about a quarter of psychologists who are linked to schools will retire. Local authority budgets are strained and under threat and posts are not being filled. I am sure that members are aware that postgraduate funding for educational psychology has been completely withdrawn. The problem is the opposite to the one that Karen Addie delineated: people want to become educational psychologists. It is an enormously popular career route for people but there are bottlenecks in our system.
These are people who work with some very disadvantaged children. We need CAMHS links in schools, but let us think about an integrated and joined-up system that delivers the support that educational psychologists can provide to these very vulnerable groups.
11:45
I will make a couple of points about young people’s mental health. We have acquired some knowledge over the past few years, both in Scotland and in the wider UK. For example, we had a programme called right here, which worked with 16 to 24-year-olds in five centres across the UK. We recognised that when it came to mental health, there was a gap in both service provision and in citizenship for 16 to 24-year-olds. That programme has developed some interesting recommendations, which I am sure we will have an opportunity to feed into the committee later on.
Our work with young people has shown us something that came up in the Christie review about co-design and the importance of involving people. It has highlighted the value of the imagination that young people bring both to defining their problems and to innovating solutions that perhaps the adults in their lives and those of us—I say “those of us” when I should perhaps say those of you—in positions of power do not bring to the same extent. I hope that the committee will take evidence from young people and others.
I bring to the committee’s attention a project that NHS Greater Glasgow and Clyde invited us to work with Young Scot on, working with young people to see how the board could involve digital in its young people’s mental health strategy, because it recognised that young people were operating pretty much seamlessly online and offline and that their demand for their mental health services to include online dimensions was reasonable. NHS Greater Glasgow and Clyde was also mindful of the fact that young people engage in all sorts of strategies—both positive and negative—to help them to manage their distress prior to the point at which they might need CAMHS. That is an issue more widely, in that we must ensure that options are available for all population groups to self-manage distress and to find their way to support downstream from the specialist services, such as CAMHS, which are so bottlenecked.
Obviously, the community situation is not good, but I would like to keep people’s minds on the top of the pyramid and the fact that our young people tend to be sent down to England for specialist services in particular circumstances. We should also keep our eye on that.
I absolutely agree and I thank Joyce Mouriki for bringing that point up. I remind the committee that, in particular, there is no in-patient provision for forensic adolescent beds and CAMHS/learning disability in Scotland and that patients tend to get shipped across the border at great cost. There is not only the financial cost but a human cost for those people’s families and those who are trying to support them. It is also quite difficult to get them back once they have been sent.
I will bring another population group to the committee’s attention. People with long-term conditions are not one of the specific inequality groups, but they make up a large population in Scotland. Having a long-term condition is strongly associated with having a greater risk of poor mental health or mental health problems. For example, 30 per cent of people with diabetes develop depression and someone is twice as likely to have depression if they have coronary heart disease. If someone has coronary heart disease and depression, they are twice as likely to die of their coronary heart disease. That in itself makes a compelling argument for addressing the mental health of people with long-term conditions.
In 2011, the King’s Fund did a very interesting study on the economic costs of mental health problems. From its economic modelling, it discovered that mental health problems raised the total healthcare costs by 45 per cent for each person with a long-term condition and a comorbid mental health problem, which equates to about £1 in every £8 that is spent on long-term conditions being spent on the mental health aspect.
There is a need to recognise and engage with that issue more in Scotland. We, the Royal College of General Practitioners and a range of others have done a lot of work on the provision of peer support in managing long-term conditions and mental health problems. Good studies are also being done on mental health support in cancer and other areas. This area has great potential to address some of the challenges raised in Scotland by both long-term conditions and the complexity and multimorbidity that are so often behind the health inequalities that we know are so acute in this country.
That is really interesting. It would be useful to put on record that we are listening to what you are saying about workforce planning, vacancies and recruitment. It is a complicated web, and I think that all the committee members have taken that point on board.
The search for solutions often leads us back to the preventative approach and the need to ensure that mental health issues are not exacerbated by other issues. I can give a slightly tangential example. I do a lot of work with the continence management service in NHS Greater Glasgow and Clyde, and a lot of the older population first present with mental health issues because they have become housebound as a result of continence issues, after which the other issues kick in. There is always a trigger, whatever that is for each aspect of the population.
I know that there has been positive work in relation to that in NHS Greater Glasgow and Clyde. There are a variety of examples of partners working together when mental health issues kick in. For example, the Notre Dame Centre in Glasgow does excellent work with kinship care children in particular, although it could be better funded. Last week I was in Possilpark looking at a new link worker service for GP practices as part of the deep end project. The service is focused on moving the practice of some of the softer empathy skills that are needed in healthcare away from front-line GPs to other workers. Neither of those initiatives involves straightforward clinical referral processes for mental health.
There seems to be a patchwork quilt of good practice out there in the services for young people, older people and those who are suffering from the effects of welfare reform. It is a huge thing to ask any Government, or any local authority or health board, to co-ordinate that good practice in a coherent way. I am looking for a steer in that regard. We can talk about mental health strategy, but the solutions are very often local and unique to each area. How, then, do we share best practice throughout the country? Can you suggest some other things that we could be doing? I would find that helpful as an MSP.
There are a lot of hands up in response.
The point is very well made. People from a social care background have a different focus: children who have experienced abuse, neglect or violence at home get a social care service that may be about prevention or managing risk but is not always about managing the impact of that trauma on their life as they go on.
The challenge in dealing with young people—I am not the first person to say this—is that the thinking takes place in silos. We have adult mental health over there and community stuff over here, and the area of children and young people is completely different, with different money and ministerial responsibility.
There must be a way of looking at what people are doing locally, mapping that out and spreading it around. If someone works in a school where self-harm is an issue, they should know where to look. What will point them in the right direction? Are there voluntary sector services in that area that could come and work in partnership with the school, rather than the school just using the tried-and-tested medical and professional routes?
It has been said a million times—and I know that it is an easy answer—but the funding and the thinking tend to be very top down and to have a narrow focus. We need to not be scared to throw that open and start talking about what communities have. We need to look at community assets and to map them across the whole spectrum of social care.
For children who are in school now, health and wellbeing is a core part of the curriculum for excellence, and it is the responsibility of all teachers. The Children and Young People (Scotland) Act 2014 asks all paid professionals to share concerns about welfare, not just wellbeing. That is a significant change in terms of what professionals have to act on. It is not just about risk any longer—it can be, for example, that a child’s mum was hospitalised at the weekend and the child is not getting fed. The professionals will have to share those concerns. The work must be joined up; otherwise, we will just keep on doing the same stuff over and over again.
I do not have a complete answer to the challenge that Bob Doris outlined, but I am hoping that the integration of health and social care will start to provide us with some answers.
The point is well made that, as the population ages, we will all be dealing with comorbidity and complexity—and comorbid physical and mental health problems coalesce together. The Kings Fund and Lord Layard have been eloquent about the costs and the difficulties. For example, it is extremely difficult to engage someone in managing a long-term health condition if they are also anxious and depressed—and ignoring that is not an option. In addition, the issue is about managing chronic conditions. There is no pill that will sort out everything; rather, it is about the lifestyle choices that people find it very difficult to make when they are poor and up against it—taking more exercise, stopping smoking and drinking a lot less.
A stepped care model is needed. A huge amount can be done in the community and there are fantastic projects in that regard. In addition, there are levels of complexity. You would not expect a tertiary care service to deliver the broad interventions.
I refer you to my declared interests. NHS Greater Glasgow and Clyde has invested quite a lot of money in psychology support for acute services. More psychologists are working on obesity than on addiction problems in Glasgow, which is quite something. The problems associated with obesity are huge in the west of Scotland. The model is psychological but not all the treatment is given by psychologists. They carry out outreach work in the community but more complex cases are seen in a hospital, including cases where people may progress on to surgery.
We think about the levels of care, but the bulk of care will always be dealt with in a community setting using a range of providers who are close to where the client or patient is.
Bob Doris asked for solutions. None is immediately apparent, but I have some thoughts.
First, a mental health impact assessment of Government legislation—of the policy and the practice—should be carried out. We can demonstrate and the evidence supports the fact that most public policy decisions have a mental health dimension. Understanding and framing that through the legislation and the guidance can be very helpful in enabling workforce groups and the people implementing the legislation in local authorities to make the time to include mental health.
Downstream of that, it is very useful at ground level to assume a mental health dimension in any inequality or health interaction—in fact, that should be assumed in most public service interactions. Bob Doris mentioned continence services. That is a perfect example of a non-mental health service that, when it recognises its ability to encounter and engage with mental health, has the potential for great benefits.
All public service employees in Scotland should be minimally equipped to deal compassionately with disclosures of distress. Therefore, any public servant should be able to recognise the signs that someone might be experiencing distress, have a conversation about that with them in a confident and comfortable manner, and help them—if the person wants them to—to make the first step on addressing the distress. Irrespective whether that is in a continence service, a welfare advice service, a noise abatement team or whatever, people on the ground should be professionally competent in that regard.
Linked to that, peer support has a great role to play. We have considered where that support fits in mental health and there is a good evidence base on that. We have done work to transplant mental health peer support to those with long-term conditions and to carers. An element of that occurs in professions, too. Therefore, helping people to professionally use their own experiences and be comfortable in doing so is a potential avenue to follow.
I completely agree with Dr Allan that complexity is where it is at. We are no longer able to conceive of a situation where people go to a GP or a social worker, or they have any other public service interaction, with one problem that requires one appointment or one appointment for each issue. People exist in a web of complexity that usually includes mental health, long-term conditions and other social issues.
We need to gear our policy environment and our practice environment to engage with complexity and help people to unpick that. Some promising practice already enables that, from things such as deep end and the PCAM—patient centred assessment method—complexity assessment tool, which has been developed in Edinburgh and Stirling and is being trialled at the moment. There are also some approaches in the current mental health strategy to engaging with distress, trauma and other things that we hope will show promise over the next few years.
12:00
I will echo somewhat what Dr Allan has said. Integration allegedly is the answer. That is the whole purpose of integration—of what we aim to do.
Right now we have different organisations doing different things, and sometimes different organisations doing the same things twice. In the North Ayrshire shadow integration board we had a discussion about the money that the health service is spending on learning disabilities and out-of-area placements and what our local authority colleagues are spending on learning disabilities. We considered the potential to bring those things together and do them better and more cheaply, which would mean that we would have more money to do other things and to increase what we do.
I do not mean to be glib, but part of the answer is integration. Otherwise, why are we doing integration? It is not a magic wand, and it will take us a lot of time to get there, but that is the purpose of it. If that is not the purpose, we are wasting our time.
We are going to work together on things. On our shadow integration board we have the third sector, voluntary organisations, carer groups and user groups. Round that table we need to work out what we need locally and how we tailor services to local needs, which might be for children, older adults or any care group in the middle. We need to look at the totality of the situation.
Without being glib, part of the answer is integration.
Is that not Brian Donnelly’s point—that it is easier said than done? Even leaving out local authorities, we see that adult services, children’s services and community services—all with the same professionals—are working in silos.
There is the mental health silo, there is the children’s silo, and then there is the children’s mental health silo as well.
So it is challenging.
We all report to a single director. All those silos meet at one point: the director, who is responsible to elected members, the population and the health board. It will all meet in integration, whereas right now it does not meet in a single place. If one person is accountable for it, it is easier to say, “Well, you have to balance your responsibilities.”
What we do not have is what Chris O’Sullivan described as a mental health impact assessment. We are not measuring the outcomes, but we can easily identify the inputs—all the salaries that we pay.
I did not expect anyone to have all the answers. I wanted to tease out some of the good things that are going on and where we have to go further.
It is a long time since we looked at single outcome agreements. Is there a mental health outcome indicator in single outcome agreements? That will, I hope, progress on to local plans, in terms of integration and the like.
We have worked with several local authorities. At the beginning of single outcome agreements, Glasgow City Council asked us to help it to engage some of their departments that were not explicitly about mental health and the delivery of mental health outcomes, in terms of its obligations under sections 25 to 31 of the 2003 act and under the single outcome agreements to reduce suicide and improve subjective wellbeing.
We have developed a programme of work that we did with Glasgow and have subsequently done with the three Ayrshire local authorities and now with Highland. It is called our mainstreaming mental health programme. For each area, we interview service leads about where mental health fits in with their work and we encourage them to connect their single outcome obligations—both the explicit mental health ones about suicide and wellbeing and their implicit ones, which are many and varied. We create a space for those people to come together to discuss that, to realise what their role is in mental health, and to create a mini-action plan to develop that.
It makes for some interesting discussions. The guy who runs the lighting strategy says, “What’s lighting got to do with mental health?” You ask, “Well, why are you doing this lighting strategy?”, and the guy goes, “Well, we want to connect communities and get people to be able to walk safely at night.” “What does that do for them?” “It makes them feel more comfortable where they are.” “Well, what does that do for their mental health?” “Oh, I see.”
The guy in Ayrshire who ran the team that does house renovations when people are in hospital said to us, “We’re not mental—why are we here?” The team thought that they were coming to mental health training to learn about mental illness. I asked him, “Why do you do what you do?” He said, “We change people’s houses for them when they’re ill so that when they come out of hospital their houses are better. We’re better than some councils because they just do the bedroom and the kitchen whereas we do the garden.” “Why do you do the garden?” “So that people can get outside and see their neighbours so they don’t lose touch.” “Oh, I see.” By the end of the day, they were talking about using their own time to work with some people with mental health problems to build a garden that everybody in the community in that part of Ayrshire could be involved in.
We often find that, at the practitioner level, it is about flicking the switch and making people realise that mental health is not a psychiatrist’s job but a competence that we all have. At a strategic level, it is about getting a service lead to recognise that his obligations under a single outcome agreement have lots of relevance to mental health and are not just relevant to the suicide and wellbeing section.
Karen, do you want to comment?
Only to say that SAMH has also done a lot of work on this issue, so Carolyn Roberts wants to come in.
You are being prompted to come in, Carolyn.
Which I very much want to do, convener. Thank you, Karen.
When we have looked at single outcome agreements with a view to finding out how much they incorporate mental health, we have found that, as Chris O’Sullivan has said, that tends to be very much driven by areas where there are HEAT targets. We have seen indicators within single outcome agreements about suicide and psychological therapies. Those are good and important things, and one reason why targets are helpful is that they get issues on to people’s agendas, but that does not really reflect mental health in its broader sense.
Scotland has done a great deal of good work in developing mental health data and we now have a lot of information on outcomes and what is happening. In particular, there is a set of both adult and children’s mental health indicators that can be used to set outcomes, so we could do a lot of work there.
I also agree that, in response to the initial challenge, the answer lies with integration. We have a promising opportunity in front of us as we integrate health and social care, although I point out that the third sector does not report to a director in the same directorate, so things are not quite as straightforward as we might think. There is, however, a good opportunity.
Our concern is to ensure that, when we create the new bodies and new structures, the individual is still at the heart of them. We have a concern because we are going to create new structures and processes, which can make it easy to lose sight of the person who is at the heart of it all. There is a real opportunity to do better joint working and integrate, but we need to take a great deal of care to ensure that we do not simply further lose individuals in structures.
Others have brought the discussion back to the point that I was going to make originally. I will say two things to help with Mr Doris’s question.
First, we are one of the lead partners for commitment 1 of the mental health strategy, which is to do a mapping of mental health services across Scotland, including voluntary sector contributions; the scope is a wee bit wider this time than just the par-for-the-course, statutorily delivered services.
My second point is about all the good work that is being done on person-centred care and the collaborative that has been set up across health and social care to get that into the system. At the first national event that I went to, the people in the room said, “Let’s look to mental health to take a lead on this”, because quite often we have already engaged across health and social care to drive a patient pathway.
Finally, I suppose that people have come down to the idea that what we need is person-centred outcomes for the individual, which brings us back to Carolyn Roberts’s final point. No matter what is in the outcome agreements, let us not forget that what we are looking for are outcomes that the person wants for their own life—and that is a whole life, not just a mental health life.
I suppose that the next question is about what happens when issues are identified. Our briefing states that the Mental Welfare Commission for Scotland identified a 7 per cent increase in detentions. We have the information, but what will make a difference? It is a sad point, I suppose, that this is reactive, but even in that reactive sense, how do we engage with the Government and the agencies that are responsible to question that 7 per cent increase in detentions?
I think that the figures from the Mental Welfare Commission, whether on that issue or others, ask a question—the why question. It is absolutely right to ask that question, as you have just done.
We have talked about nurses’ holding powers. I would like nurses’ holding powers to be used more often—I would like to see that figure go up, because that gives people protection under the 2003 act. An increase in detentions is not necessarily a bad thing, because detention brings with it protection. We in the health service have a statutory responsibility to protect the individual. That is partly about advocacy and partly about having an MHO looking over the health professional’s shoulder to ask whether what they are doing is right or wrong. Detention brings with it a protection. To me, the figure that you mentioned asks a question. Let us understand the why.
I think that the figure that the convener cited relates to emergency detentions. That is a good example of how we can use the excellent data that the Mental Welfare Commission produces to make improvements. The reason why we would be concerned about an increase in the number of emergency detentions is that they do not offer the sort of protections that come with a short-term detention certificate. With a short-term detention, a mental health officer is involved; there is a lot more protection. That shows how important it is that such data is gathered. It allows us to consider why certain things are happening.
On the figure that the convener mentioned, I noticed that it was much less likely that an emergency certificate would be used when an intensive home treatment team was available. That tells us something about the kind of services that we need if we are to make a difference, which is useful to NHS boards in doing their planning. I certainly hope that such figures are considered.
We have almost come to the end of our session; we will have an informal session just after the meeting. This has been a broad session that has reflected much of what was said in the written evidence. I now give the witnesses the opportunity to put on the record any points that they feel that they absolutely need to make.
If, on the way home, you think of something that you wished that you had said, as is often the case, let us know. You do not need to do so in a formal way; you can just email us. We are quite happy for the clerks to receive any additional comments about the session and points that people wish that they had made.
Does anyone wish to take up that offer? How did I know that Chris O’Sullivan would?
You have given me a platform today. [Laughter.]
There is one issue that we have not had a chance to touch on but which we and others would be grateful if the committee were mindful of—the implementation of self-directed support in relation to mental health, which many of us are working on. We are finding that the implementation of self-directed support for people with mental health problems has been somewhat complicated, and we would like close attention to be paid to that issue over the coming months.
As the evidence on implementation has grown, we have seen some examples of poor implementation and some examples of good implementation, and concerns have been raised by service users and service provider organisations—at some point, those concerns will need to be aired.
I appreciate your taking the opportunity to put that on the record. I reassure you that, if you write to the committee to outline those concerns, we will maintain an interest in the matter.
To back up what Chris O’Sullivan said, one of our concerns with self-directed support is that a number of companies have been set up that will charge people directly for advocacy support. They are trying to encourage a move away from local authorities and health boards funding advocacy directly towards charging individuals a percentage of their social care package for advocacy support. Such a system would perpetuate the inequality and difficulties that are experienced by people who might need complicated support because of their situation. We are extremely concerned about that.
12:15
We would certainly welcome information about that. We are at an early stage in the process, but if those issues are already emerging, the committee will do all that it can to bring them to the Scottish Government’s attention.
Under the new Children and Young People (Scotland) Act 2014, all ministers are obliged to give due regard to children’s rights in any policy or legislation that affects children and young people. That is relevant to children and young people whose own health and wellbeing is affected, but decisions that are made about parents’ treatment and care also have a direct impact on them. As signatories to the UNCRC, we have to give due regard to the impact on children’s rights—the children of prisoners as well as the children of people who are hospitalised are affected, and a children’s rights impact assessment may have to go with that. I just wanted to throw that in at the end of the discussion.
I would like to comment briefly on a point that I will also cover in writing. I am sure that the committee saw reports in the papers about how poor NHS dementia care can be. I intend to write to the committee about the psychological support and development that can be put into that type of care to improve it. There is a relative disparity, as only 37 psychologists are employed in older adult services in Scotland, out of a workforce of 700. It is an incredibly popular specialty for psychologists to work in, but there are no jobs for them. I feel strongly about the care of older adults—I am getting older myself—and about people who are dementing, but I will write in about that.
We would welcome that. It is something that the committee will want to look at anyway, given our past work and our inquiry into care for older people.
Derek Barron can have the last word.
Dr Allan brought up yesterday’s report, and I should point out that the East Ayrshire community hospital was held up as an excellent example of how to integrate buildings and outside spaces in the care of older adults who have dementia. Since we are on the record, I thought that I might as well plug the good work of East Ayrshire community hospital.
You make an important point, not just for your own service, but in recognition of the fact that there is much going on in the national health service that is good, despite that disappointing report.
I thank all the witnesses for their precious time this morning.
12:17 Meeting suspended.Previous
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