Item 2 on the agenda is a round-table discussion on the mental health budget. We have many documents that provide background for the discussion. Before we begin, I will remind everyone of the basis on which we run these round-table sessions. This year, we are focusing on the Scottish Executive's mental health budget. As well as considering the figures for 2007-08, we are examining the trends in order to see the wider picture. We have, therefore, commissioned Dr Seán Boyle of the London School of Economics, who is with us today, to undertake research into spending on mental health by all area health boards. He has also conducted more detailed interviews with NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde and NHS Tayside, all of which are represented here today.
I am the deputy convener.
I am the director of the Mental Welfare Commission.
I am a member of the committee.
I am the director of finance with NHS Ayrshire and Arran.
I am a member of the committee.
I represent the Association of Directors of Social Work, whose mental health group I chair.
I am a member of the committee.
I am the chief executive of the Scottish Association for Mental Health.
I am the head of the Scottish Executive's mental health division.
I am director of the mental health partnership in NHS Greater Glasgow and Clyde.
I am the chief executive of the Scottish Development Centre for Mental Health.
I am a member of the committee.
I am the director of health strategy with NHS Tayside.
I am a member of the committee.
I represent Samaritans.
I am a member of the committee.
The next two gentlemen are official reporters. They are taking down every word that you say, so you have that hanging over your head.
I am the budget adviser to the committee.
For the purposes of this discussion, Seán Boyle is also a witness, so he can be included in the questioning. Feel free to ask him about anything that has arisen in the context of his paper.
The first area of discussion today concerns the allocation of expenditure to mental health. I want to draw people's attention to one or two things in the background paper from the adviser. All three boards with which our adviser conducted detailed interviews seemed to base their mental health expenditure on past levels of spend, rather than on a formula. However, none of the boards seemed to have a clear idea of what their spend on mental health was as a proportion of the total spend, how that compared with other boards or the national formula and whether it bore any relation to local needs for mental health services. There were also issues about ring fencing, which none of the boards thought was a good idea, and there was some criticism of the Arbuthnott formula, as it relates to mental health. Finally, there was some criticism of the Scottish Executive's role in assisting in the implementation of mental health policies.
How much money we allocate to mental health services is important. Our experience, which I think is shared by other boards in Scotland, is that boards use the historical budget as a starting point, but are continually looking at needs, which are expressed through a variety of sources, such as population information, information from service users and carers, good practice guidance from the Executive and so on. It is important to stress that, across all health boards, the position is not a matter of simply rolling out a budget. In fact, in Tayside, there will be extensive investment over the next five years in virtually all areas of mental health care. That is being driven by an assessment of needs for particular groups, such as older people with mental health problems, adults in general, people with eating disorders and so on. Needs assessment is important, but boards would not subscribe to doing a global assessment of all mental health needs. That would be difficult to undertake.
Since 1993, Greater Glasgow and Clyde NHS Board has tried to have a clear strategic plan for mental health services. The issue is not simply to do with looking back on historical spending levels; it is about trying to plan for the future. Realistically, such plans are usually based on five-year chunks. We are in the last stages of Glasgow's current five-year strategy on modernising mental health, and we are about to work up a new strategy that will take us through the next five years.
It was said that none of the boards has a clear idea of a number of things, including the spend on mental health as a proportion of total spend. In our annual accounts, we provide detail on all the various care groups and so forth, so there is clarity on what is spent on mental health at least annually and, in terms of monitoring, on an in-year basis.
I would like to broaden the discussion to include the wider financial envelope. SAMH commissioned research from the Sainsbury Centre for Mental Health on the social and economic costs of mental health problems in Scotland. We will launch the report in November—the timing is not brilliant for the committee, unfortunately. The Sainsbury centre has already done similar research in England and Northern Ireland.
That is great, but do you have any practical suggestions on how that might be brought about?
We tend to consider things in silos. Mental health problems affect the health service, which we are considering today, but they have a cross-cutting impact on every Executive portfolio. We must ensure that we consider the impact of the money that we spend in the health budget on people's economic outputs and social circumstances. We may make some practical suggestions in the report, but we must ensure that mental health is a cross-cutting priority that applies not only to health but, for example, to employment. We must look at the changes that are happening in employment, which may compound people's mental health problems. There is a lack of opportunity for people to get back into the workforce after having had a mental health problem and been out of work.
I ask people to focus on budgets and how they are devised, and whether there are better ways of doing that. That is what we are trying to get at.
Anne Hawkins said that there are now more community-based mental health services, which are surely more expensive than hospital-based services. According to table 3 in the committee adviser's report, the total expenditure on mental health services has fallen in every health board, with the possible exception of Lothian. What is the explanation for that? Are local authorities picking up some of the expenditure by funding community-based services? Surely if health boards are spending less money on mental health it means poorer NHS services on the one hand and more reliance on more expensive community-based services on the other.
I think that that question was directed at Anne Hawkins.
Derek Lindsay and I were looking at each other to see who would answer it.
But part of the problem with mental health spend is that one gets different figures depending on how things are calculated. We want to find out whether the money allocated by the Scottish Executive for mental health services is finding its way into those services. The report says:
No, because doing so would cause problems with the overall allocation of funds in a health board. As everyone knows, boards receive a general allocation based on the Arbuthnott formula and should have a certain amount of discretion in deciding, in light of local circumstances and needs, how best to use those funds.
I wonder whether the non-health board witnesses can respond to the question, because I imagine that the witnesses from the health boards will all agree about ring-fencing.
I completely agree with Peter Williamson. The mental health delivery plan must set out what a good mental health service looks like and how it should be measured. The committee will find—as the rest of us have found—that it is difficult to link expenditure to the delivery of mental health outcomes in any meaningful and systematic way. It is simply not that easy to do with mental health services—indeed, it is certainly not as easy as, for example, measuring cancer survival rates. Of course, that does not mean that we should duck the subject. We should all look to the mental health delivery plan to help us in this matter.
For a number of years, we have argued that mental health resources need to be ring fenced, partly because they are so difficult to track. I accept some of the concerns that have been expressed, but ring fencing will be needed until we have a mechanism that allows us to see what happens to resources. I am concerned in particular about resource transfer; there is a lack of clarity on what happens to resources once they go to the local authority.
Does any other panel member think that the money should be ring fenced? It seems that nobody else agrees. We will move on.
I have a comment on resource transfer. I will also pick up on a couple of other issues. Any resource transfer that a local authority receives is fully accounted for. We are still accountable to the health board that made the transfer. There is never any dubiety on the matter because we have a clear accounting process, which is laid down in accounting practices; it is there for all—voluntary organisations or the public—to see.
My point is on ring fencing. At this morning's Finance Committee, the committee debated its cross-cutting expenditure review of deprivation report. One of that report's recommendations is that
On ring fencing, I take a somewhat different view. The money that is allocated to mental health is allocated on the basis of the needs of the national population. It would be useful to have a clear idea of the allocation at local level. If the decisions to vary priorities according to local need were clearly set out, the process would be clear.
Some of the evidence that we have been given already shows that variation exists in the degree to which health boards are aware of how local authorities and the voluntary sector in their areas spend on mental health care. It is important that boards, local authorities, voluntary sector organisations and the other partners have that working knowledge. The joint future agenda had that aim, so the evidence that that may not be happening in some areas is a bit concerning. Are the current financial and organisational arrangements sufficient to allow close partnership working between health boards and the corresponding local authorities? If not, what would make it easier for health boards, local authorities and the voluntary sector to work together to improve the mental health of the people they are duty bound to help?
We are engaged in that process. Donny Lyons mentioned the delivery plan for mental health services. We have attempted to make that a plan that not only concerns how the health service will deliver, but that takes into account issues across the board. Shona Neil and I are involved in the national group that has been working on that plan, alongside a variety of colleagues. It is important that the delivery plan is not seen as simply for health services. We are still trying to work our way round that issue.
I have two comments. The draft report goes into detail on the work of the choose life initiative and the funding that has been made available locally for that. Those local partnerships are an excellent example of how voluntary organisations and statutory bodies can work together effectively. The issue is not only about the provision of money; it is about finding new ways of working.
We are scrutinising the Executive's budget, so our principal interest is in the money that comes from what we might call small-g governmental sources rather than third parties, although that is not to say that we cannot consider such funding. Indeed, that is what our current questions are really about. We are aware that there is voluntary sector spend, but a lot of voluntary organisations get their money from Government sources, too. We are trying to tease that out.
I will pick up on the issue of voluntary sector spend. To make a point similar to the one that Christina Naismith made in talking about resource transfer, voluntary organisations' accounts contain a breakdown of which money comes from local authorities and which comes from the national health service. If somebody had the time and energy, it would be possible to unpick that information. It is just like the situation with local authorities: there is no universal, Scotland-wide way of gathering and measuring that information, and indeed of measuring the output for that investment.
You made a point in the first part of your answer about the difficulty of identifying all the bits of expenditure. That is the point of this exercise. Clearly, we are trying to assess the effectiveness or otherwise of mental health expenditure in Scotland. If we cannot always identify the mental health expenditure, it can be difficult to say whether it is effective.
On resource transfer, the route often ends in voluntary organisations. For example, the closure of adult mental health continuing care beds in Ayrshire resulted in a resource transfer to local authorities, which then contracted a voluntary organisation to provide that care in the community. It might be worth the committee considering the level and total value of resource transfer, which has been increasing year on year. At some point, a vote head change from the health budget to the local authority budget will be appropriate. There is dual accountability at the moment: health boards have to account for the money that they are voted and local authorities have to account for the money that they are given by health. There is a chain.
I wish to follow up a couple of points that others have made, one of which is the link between national strategic goals for mental health—what we would like to see in Scotland—and what happens on the ground locally. Some of the more innovative developments that we are aware of as an organisation have occurred where a clear national framework has been set, with expectations, standards and targets, and there has been freedom and discretion for local service systems—the NHS, local authorities and the voluntary sector—to work together towards those standards and targets. The state of the art in mental health is such that it is quite difficult to track the relationship between costs, quality of care, quality of service and outcomes, in terms of the impact on individual service users and their families. Although that information is available for some specific services, it is not necessarily available for whole local mental health service systems.
Have the health board representatives found the development of extended local partnership agreements helpful in encouraging joint priority setting and funding with the local authorities in their areas?
My experience of the partnership agreements was in my previous role in NHS Forth Valley and I found them helpful and positive.
I do not disagree with Anne Hawkins. On extended local partnership agreements, I would put explicitly on the table how much health and local authorities are investing in mental health, so that it is visible for the first time. The next step from that is shared budgets, pooled budgets and so forth, as Anne Hawkins describes.
Briefly, I agree with both my health board colleagues. However, it would be helpful to have clear targets—perhaps they will come out of the mental health delivery plan. It is difficult to set targets in mental health, but other areas of health care have shown that targets can deliver change if they are properly thought through, used correctly and supported with funding. Mental health services could do with that drive.
I back up what Shona Neil said earlier. From the many dealings that I have had with voluntary organisations, I know that they suffer severely from short-termism. That is a major problem for people who are offering an important service.
We probably all have experience of that.
Convener, I have a question on something that has just been said.
Let us try to deal with it as quickly as possible.
All the health board witnesses have said that they support the use of one pot of money for mental health services and, I presume, for other services. Who would be accountable for that money and who would decide how it was spent?
To give an example, in Glasgow we have created a mental health partnership, which we are extending to the Clyde area. The mental health partnership's committee will be accountable to the health board and to Glasgow City Council and the other local authorities. In effect, the local authorities and the board will vest their authority in the mental health partnership for three strands of responsibilities: strategic planning, performance management and the direct management of some regional services that we have decided should continue to be managed on a Glasgow and Clyde-wide basis for the moment, but which will ultimately become the responsibility of the community health partnerships.
However, will the constituent bodies still be ultimately responsible for the decisions about how much money they put into mental health services?
Yes.
We touched on this a little earlier, but I want to spend a few moments asking about the shift from acute to community-based mental health care. Clearly, all the boards are going in that direction, although they start from different places, with some being more advanced than others. Our adviser's report gives some measurement of the reduction in the number of acute beds and it gives other information on how that shift is taking place, but how do boards measure that shift from acute to community-based care? Should it be measured? Should we have a standard way of measuring such changes so that we can see how the policy is progressing? What is the balance between the additional costs that are incurred and the savings that are made with the move from acute to community-based care?
On the first of the two points raised, one way to measure that shift is in terms of the spend, or resources, that have been transferred from hospital-based to community-based services. For example, over the period, NHS Ayrshire and Arran has had a 50 per cent increase in community-based care costs and a 100 per cent increase in resource transfer. That reflects the shift in services. Community-based services tend to be more expensive, so care in the community is not a cheap policy. Particularly for adult mental health services, significant costs can be associated with care packages.
I want to clarify that the distinction between acute services and community services is not necessarily the right one. Increasingly, acute care can be delivered in the community by a range of different community-based teams. My point is not just about the words. We need to find how to collect the information in ways that reflect the fact that a fair amount of evidence shows that community-based responses can be effective for people who have acute periods of mental illness, but they may be fairly costly.
On your initial comments, are you saying that the way in which information is collected means that it does not reflect the reality of the new way of delivering mental health care?
I suspect that it does not. The information might not have caught up with the situation yet. However, health board colleagues might be better able to respond to that point.
I want to confirm what Derek Lindsay said. We measure the shift from community care, and to an extent set targets for it, by spend. However, that is on the input side. There is a question about the output side.
We must be careful about the assumption that community services are more expensive than hospital services. If we are looking at closing long-stay beds, which are at the cheaper end of the spectrum, and investing in community services, it is probably the case that the latter are more expensive. However, as I said earlier, I worked recently in NHS Forth Valley, where we developed a whole treatment service that used the mental health joint local implementation planning moneys as transitional funding to get the service up and running. It ran for about three months and our usage of acute beds dropped rapidly as it was running. People really wanted the service, which was part of the response to crisis and avoiding admissions.
Are the health board witnesses—who represent a corporate view—content that the changes that they have instituted, particularly the sort of service about which Anne Hawkins just spoke, are generally accepted by the public?
The developments that are taking place in Glasgow are about early intervention services, increased crisis services and so on, and the final stage of development is taking place this year. They are responses to demands that the public have expressed. Seán Boyle's report refers to the report that Sandra Grant produced in advance of the implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003. Sandra Grant's report refers to focus groups in which the public requested certain services. Everything that we have put in place in Glasgow has been to meet the public's needs and demands. I am comfortable that that is the case. I cannot say the same about the Clyde area yet, but our aim is that that will also be the case there.
In the mid-1990s, a discharge programme for adults commenced in NHS Ayrshire and Arran, and about 70 beds closed. When placements were identified for the discharged people, the initial reaction from some of the public was, "Not in my back yard." However, there has been a full evaluation of the programme and, from the perspective of users and those who moved out, the change has been rated favourably. In addition, the programme has become much more accepted by the general public.
In designing and developing new services in the past few years, we have consciously involved users and carers and also consulted the wider public. Although there are different views, we have had a fairly high level of support from users and carers for the direction in which we are going. Perhaps inevitably, there are concerns about some services, but we are seeking to rectify those. People broadly support the direction of travel and they want the type of services that Anne Hawkins mentioned—responsive services that are quick off the mark and are located in local communities rather than entailing hospital admissions.
We should not think only about people who require acute in-patient care and long-term community-based services, because there is a wide range of mental health needs in the community. The work that is happening throughout Scotland is evidence of the growing capacity of primary care services to respond to people who have what are sometimes called mild-to-moderate mental health problems.
People are putting their hands up. I point out that the Deputy Minister for Health and Community Care is due to come in at 3 o'clock. We do not want to delay him, so we are slightly pushed for time.
Some good examples of crisis intervention have been highlighted. It is important to note that the vast majority of people do not end up in the hospital system, but are treated in the community. We should recognise, however, that people with mental health problems still have remarkably low expectations of what services will provide for them. Some people are prepared to settle for poor services for fear that they will lose them. We need to identify the problems and find ways to get people to comment critically on local services without being afraid that they will lose them and have no service at all. People will say that a bad service is helping them just because they are afraid that they will lose it. It is important to be able to discern between—
Assent is being signified by Donny Lyons, whom I will bring in during the next group of questions.
If we accept the general point that we want services to be transferred away from large acute hospitals to community-based care, what difficulties can hinder that move? We identified resources as one such difficulty. It is also difficult to identify data; there are low expectations; and there are problems with local reactions by the general public to the prospect of community-based care. Are there any other factors that hinder or delay the general shift to community-based care? Also, will the mental health delivery plan provide a better framework for implementing the mental health framework?
I hope that the plan will develop further in the coming years, but it is a step forward because it provides a central drive and a consistent understanding of what needs to be achieved.
The plan has great potential to do that, but it is critical to ensure that local authorities and the voluntary sector are fully involved and that the plan is not seen as something that is owned and driven solely by the NHS.
I agree that the delivery plan has huge potential, but at the moment it lacks ambition and it picks up on things that were already in train. Allyson McCollam's point is critical: other people need to buy in to the plan and it needs to provide a clear vision of what benefits we expect for service users and their carers.
We move on to discuss the implications of the Mental Health (Care and Treatment) (Scotland) Act 2003. There are two aspects—the development of infrastructure to administer the act and the development of services to implement the spirit of the act—both of which have resource implications, particularly for health boards. As far as we understand it, most boards feel that the 2003 act provides either financial or physical resource challenges—or, more likely, both—and that, at present, insufficient resources are available to implement it. The Scottish Executive has made funds available to health boards and local authorities, but it is not perfectly clear to us how those sums were determined or whether they are sufficient.
The 2003 act is to be welcomed. It presents resource challenges, but it is important to stress that it takes mental health services in the direction that NHS Tayside hoped for.
I ask people not to do the public relations bit. I appreciate that you all want to preface your remarks with a bit of PR, but can we cut to the chase?
Right. The act reflects the direction in which boards were developing their mental health services, but there were always going to be resource challenges. The key issue for us has been the administration of certain parts of the act and the time that that has taken for responsible medical officers and mental health officers in local authorities. That is largely a result of the work of the Mental Health Tribunal for Scotland, which is much greater than we expected.
So the issue is one of physical resources.
Yes.
We are trying to deal regionally with some of the resource implications, with all health boards contributing. For example, medium-secure forensic facilities, perinatal beds and adolescent mental health in-patient beds are best delivered regionally. Local resource challenges also arise. Obviously, consultant time is taken up with involvement in the tribunal and we also require extra accident and emergency liaison psychiatry and additional nurses. Significant financial challenges arise as a result of the implementation of the 2003 act. From a human resources point of view, in Ayrshire we find it difficult to recruit child and adolescent mental health consultants—we have had three or four vacancies for about three years and we cannot recruit. Funding was made available to health boards and local authorities to implement the 2003 act, but I understand that it is non-recurring and therefore cannot be used to recruit people to permanent posts.
NHS Greater Glasgow and Clyde welcomes the 2003 act, which fits with the overall implementation of the mental health framework. We were prepared for the implementation of the act and had money associated with it, so that has not presented any problems. The administration of the processes that are associated with the Mental Health Tribunal for Scotland has caused us problems, which we are pursuing. A longer-term issue that may need to be considered is the role of consultants in relation to the 2003 act. Over time, we will not have sufficient consultants to resource the act, given the way in which the mental health consultant workforce will change.
Did you get enough money to implement the 2003 act?
We did, because of the care approach in Glasgow.
Did NHS Tayside get enough money?
To implement the act, yes.
What about NHS Ayrshire and Arran?
We must prioritise it out of our general allocation.
So the answer is no.
There is sufficient money in the total pot.
One point is the opportunity cost of people being taken away to do tribunal work.
The first point that I want to make, convener, is that you drew attention to the two strands of work around the Mental Health (Care and Treatment) (Scotland) Act 2003—infrastructure and services. The Mental Welfare Commission should acknowledge that those are not exclusively run by health services. When it commends boards it should also commend local authorities for introducing a complicated act, which we all supported. We were all around the table for many years developing it. We probably want to congratulate the Parliament on allowing that—
Can we stick to the budget issues?
The budget issues are that local authorities have had to shoulder a lot of the pain and find a lot of the budget. The work got money on an on-going basis, but I accept that that did not happen for many health colleagues.
Right now, we are trying to concentrate on what we can identify. That is the problem.
I think that that is the easy bit.
I agree. The Parliament's research programme on the 2003 act is scheduled to end in 2008, but it is crucial that it continues beyond then, until we get a handle on what is happening under the act. We still have a concern about the unintended consequences of the act, because it might mean that more resources are prioritised towards treating people who are detained than people who are being treated informally. That could lead to the development of a two-tier system, which we must guard against.
We have had to do a brisk canter through all that because of our externally imposed timetable. As I say to everybody when they leave these sessions, if anything occurs to you that you wish you had added or feel could amplify the information that we already have, such as the talk about detentions that you have raised, you are invited to send it to the clerk after the meeting. I thank you all for attending. You are welcome to stay on for the next half hour while we take evidence from the minister.
The Executive does not see an unreasonable variation. Our view would be that we make the funding available to boards in order for them to determine their priorities in relation to the health care needs of their local populations. A range such as the one that the committee has considered seems to us reasonable.
You think that it is a justifiable range.
There is bound to be a degree of variation between areas.
Very superficially, what are the factors behind the degree of variation?
In round terms, there are a number of factors, including the health needs of the population and the nature of the infrastructure. For example, the expenditure profile of boards that are still dealing with the older psychiatric hospital type of infrastructure, with a significant number of beds, is different from those that have made more progress towards care in the community. That variation is inevitable and reasonable.
But you are content that there is nothing particularly out of the ordinary.
In broad terms, yes. Clearly, there are other aspects, relating to deprivation, age, gender and so on, which may have an impact too.
In global terms, what has been the increase in spending on health care in Scotland since 1999-2000? How much of that would you consider to have gone on mental health care?
In global terms, spending has increased from £4.9 billion a year in 1999 to £9.5 billion now. Broadly speaking, spending has doubled over that period. By next year, the figure will be nearly £10.3 billion. Over a similar period, to 2004-05, there has been an increase in mental health expenditure of the order of 43 per cent, taking the direct spend by boards to £625 million, with a further £62 million in that year in resource transfers. In rough terms, it is £700 million.
Why does our understanding of the mental health budget increases go up only to 2004-05, when you are talking about the general health budget into next year?
If you give me a moment, convener, I shall reach into the depths of my records and see whether I can give you a more up-to-date figure. It is in the same broad area. Geoff Huggins may have the figure more readily to mind.
The 2004-05 figure relates to outturn. The reports that you have been receiving are in respect of outturn against mental health expenditure whereas the overall budget allocation figure is a forecast, or the commitment. That is why one will be running after the other.
We do not yet have the published outturn figure for 2005-06, for example.
Does anyone have specific questions on the generality of this issue?
I would like to ask about the monitoring that the Scottish Executive does or does not do. The adviser's report concludes that attempts to monitor the degree to which mental health funds have been routed to mental health are ineffective. How do you ensure that the money that is allocated at the centre reaches the services?
It would be fair to say that we do not pretend to have absolute chapter and verse on that process. Having seen some of Dr Boyle's preliminary work on that, we will look at the committee's report with great interest, to improve our measurement further.
We can see the spend in historic terms. Because it is wrapped up in the overall board allocation, it is based on health board determination, which is what it comes back to. The question relates to what the service need is going to be.
Yes, but do you not think that something a bit more robust is required, given that new legislation is passed and new policies are developed that require the resources that go with them to reach the service? You are relying on health boards to do the right thing, despite the pressures they are under and the competing demands on them, but how do you know what is happening?
We accept that we need to know more. As Jane Davidson indicated, we look to boards to make judgments about their needs. To be sure that the funds are being used to deliver the objectives that we want them to deliver, we will take forward work on benchmarking in the context of the delivery plan. That is a significant change in our overall work to secure the mental health spend at a local level.
Are you surprised that the proportion of expenditure on mental health has reduced quite significantly in all but one health board area?
I am not entirely surprised. There has been a significant uplift in the level of expenditure on mental health and the statistic that you describe reflects the fact that there has been an even more significant uplift in the overall health spend. That takes us back to the convener's initial question. We have indicated to boards that this is a national priority and, accordingly, that we expect them to deliver it. We expect the mental health delivery plan to help them do that better.
One of the assumptions that could be drawn from the budget increase that is shown in table 3 in the adviser's report could be that more care is being provided in the community, which means that local authorities' spend has increased. Can you tell us how much is spent by each local authority?
I do not have the figures for each local authority in front of me, but I have the total figure, which is about £95 million in the coming year. That includes spend under a number of headings within their overall expenditure.
I do not really have anything to add. We recognise the difficulty of keeping track, but we have started to work with our finance colleagues on that.
Are you saying that we can be given only a global figure? It would be helpful if we could see whether the decline in health board spending was reflected by an increase in spend by local authorities, but we could do that only if we had a breakdown of the figures.
I think that local authorities have a cost book that is similar to that for health boards. We should be able to source that for the committee.
It should be possible to provide the after-the-event, or outturn, figures.
I want to ask the same question about voluntary sector spend. Can we be given a figure for voluntary sector spend? Can we be given a breakdown of that?
I do not think that we have a figure for that.
Is there no global figure available for voluntary sector spend on mental health care?
No.
Is such a figure available from any another department?
We can certainly have a look and talk to colleagues elsewhere in the Executive. By its nature, voluntary sector spend is fairly diverse and dispersed.
It is fair to say that voluntary sector spend will often be from funding that originally came from local authorities or health boards, so we would need to be careful not to double-count the figures.
Indeed, we would be keen to avoid that.
The evidence that we heard earlier this afternoon suggested that although the contract culture has been abolished in the NHS, voluntary sector organisations find that the same is not true of local authorities. Will the minister look into that? That seemed a reasonable point.
Aspects of that go beyond my area of responsibility. Over the piece, we seek to continue to engage voluntary sector organisations—and, indeed, local government—as key partners in the delivery of mental health services. Many of the efforts that we are making are about better joining up of those delivery agencies. In terms of contractual relationships, I am not sure that I would add anything specific at the moment. I look to my colleagues for their thoughts on the matter.
Much of the support that the Scottish Executive Health Department offers directly to voluntary organisations is in the form of grants made under section 10 of the Social Work (Scotland) Act 1968 or section 16B of the National Health Service (Scotland) Act 1978. Equally, local authorities provide grants and enter into contracts. There is a mixed economy that depends on the nature of the service being funded. The picture is not one of all or nothing, as was perhaps described.
Convener, perhaps we can hear about that at a later date from the organisations concerned
Okay, but I do not know that we have much time to go into that as part of our budget scrutiny.
The figures in our adviser's report obviously carry a health warning, but the story that they tell is "variation … variation … variation". That is of concern to us all. The minister accepted that there are variations, but he suggested that they might not be outrageous. I note that he did not say that the variations are raising questions. I take it that that is the case.
Yes.
I was going to put the question to Jane Davidson, but she was looking somewhat sceptical. Is there work going on, Jane?
I think the work is in relation to the mental health delivery plan.
How would that relate to addressing the variations that the committee is worried about? I am talking about budgets, delivery of services, the cost of prescription medications and so on, right across the board.
The mental health delivery plan should indicate to all those involved in providing the services what the services should look like. It creates a framework. Work in the health service in recent years around physical illnesses that have been recognised as national priorities has involved using managed clinical networks and other mechanisms to address those particular ailments and increase the ways in which boards can tackle them effectively. The mental health delivery plan is intended to do the same in relation to mental health areas. Geoff Huggins might like to say a little more about how that will work and where we are with it.
We are getting to the end of the process of developing the plan. A number of the earlier witnesses were involved in that process. The benchmarking work is interesting and is part of a wider piece of work on national benchmarking. In the area of mental health, we are looking at financial spend by health boards and local authorities, as well as activity and prescribing. Looking at one indicator or set of figures on its own does not tell us much. It is only when we see the indicators for community activity, hospital beds, expenditure and prescribing in combination that we begin to get a picture of the nature of the different services. That is not to say that we know what the right answer is for any of those areas, but we can engage with them and try to understand what is happening on the ground, which is the issue that the committee has identified today.
Will the work consider best value and best practice? Will it evaluate what is in place? Will it put monitoring systems in place? Will it consider issues such as targeting, as well as joint budgeting and working between local authorities and health boards?
It will broadly do most of those things.
That kind of work will sit alongside the plan, which is about creating the information with which we can work. It is about filling the information gap, which the committee identified earlier as an issue, and getting an understanding of the different activities in which each board is engaged.
Will that report be available to the committee?
All the information about the delivery plan is on the Health Department website, so we can give you what information is available on benchmarking from that. However, work on the benchmarking project will continue over the next two to three years. It is intended to create a data source that runs from year to year. I would hope that more people than you would want to access that to gain an understanding of what is going on.
Has the Executive identified factors that hinder the move from large acute hospitals to community-based care? What is your observation on that, minister? Is there any danger of losing sight of actually improving acute provision for those who need it? In other words, if we all concentrate on one direction, do we run the danger of losing sight of the other direction?
There is no general answer to the question about factors that make the process difficult, because local circumstances vary. We have made the direction of travel clear to boards and it is for them to make the determination at a local level of how they deliver that. However, the indication to them that they should be making that movement is continuing and we would look for further progress on that. Again, Geoff Huggins might know whether there are particular issues that are causing difficulty for individual boards. However, none has come to me as a showstopper.
We have just known for a long time that it is difficult to make the change from one form of service to another while keeping care going for the people who receive it.
What about those for whom community-based care is not appropriate but who need acute provision?
Absolutely. In a sense, part of the point in making the move to community care for those who do not need continuing acute care is to allow, for example, acute psychiatric services to focus on the patients who do have a continuing need. That is certainly one of the changes that we would expect to see. Again, in the context of the mental health delivery plan, we would expect to lay down indicators as to how that should happen.
I have a few questions about the implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003. You might have heard our discussion about that earlier. How did you estimate the amount of money that health boards and local authorities require to implement the act? Will you comment on the fact that the money for the health boards is non-recurring whereas the money for the local authorities is recurring? Is there a technical reason for that? We would appreciate an explanation.
I ask Geoff Huggins to comment on how the estimate was made.
It was difficult for us to assess what would be required to assist with implementation. We identified a number of areas in which we knew that work would have to take place.
Do you mean geographical areas or sectoral areas?
Sectoral areas. There were training needs; it was expected that advocacy would increase; there were expectations around child and adolescent services and perinatal services; and we anticipated the need for more mental health officers in local authorities and more approved medical practitioners, who are consultant psychiatrists with particular qualifications.
Does that mean that the original estimate was a bit of a guess?
There were certain elements that we were able to assess, such as training—
You have just confirmed what we already think.
To describe it as a guess would be rather unfair. We could assess the training element and we had some idea of expenditure on advocacy, but there are other elements on which we were less certain. As you heard today, the boards considered it a fair estimate.
A fair estimate as opposed to a guess.
It was the best available estimate, I think.
What about the implementation funding for health boards and local authorities, which was granted on different bases, one being recurring funding and the other being non-recurring?
The resource that is paid to local authorities is paid through grant-aided expenditure, but we offered the resource to health boards as a top-up to the allocation. At present, that is funded through to 2008. We have not said whether we will continue to pay it beyond 2008. We will need to assess whether all the additional costs are, in fact, recurring costs. We knew that the cost of additional mental health officers in local authorities would be a recurring cost, but we are not as clear that all the costs that fall on boards will recur in the same way. There was a degree of prudence in our approach.
So the health boards will have to provide evidence that the costs are recurring.
Again, we need to consider the evidence as it comes through. The committee's inquiry will help us to make that assessment. It is fair to say that, with new pieces of legislation, we sometimes have to use the best available estimate and review it when we have seen the impact on the ground. Given where we are in the spending cycle, this is a relatively convenient time to review the actual spend and costs and to plan for any additional investment that might be required.
How much money was set aside for the information technology infrastructure so that people can communicate in multisystem working? We know that there is a lack of standardisation—for example, there are different definitions of out-patient.
We have invested in IT directly through the Mental Welfare Commission's systems and the Mental Health Tribunal for Scotland's systems. They are liaising with boards and local authorities to find out whether they can use electronic transmission of forms to improve the process.
Does that mean that we have to wait until you organise a bigger system?
That work is continuing throughout the system, in relation to the use of community health index numbers and our general approach to e-health.
You mentioned the tribunals and the fact that there will not be enough consultants to service—
Yes. It was indicated that there was greater pressure from the tribunals side of the implementation. That is pressure on time as well. I take it that such things will be monitored as we proceed.
Yes, indeed. There is a budget for the tribunals, but we want to monitor and work with them.
Is there a separate budget for the tribunals?
Yes. The budget is £8 million this year.
There do not appear to be any more questions. I thank the minister for coming for this session.
Meeting suspended.
On resuming—