Official Report 282KB pdf
“Overview of mental health services”
Because of the number of witnesses on the panel, I will not ask for opening contributions. Knowing some of you, I think that we would be here all week, never mind all day.
Different barriers are pertinent to different localities. NHS Lanarkshire's submission highlights that we have a legacy issue around investment. Although we have close partnerships and a well thought through service strategy, which is now being backed with additional investment by the existing NHS board, our biggest hurdle—as the Audit Scotland report, "Overview of mental health services", bears out—is the rate of investment in mental health services relative to other areas in Scotland.
I will return to resources later: I know that Cathie Craigie wants to ask specifically about investment in Lanarkshire. We will stick to the generalities just now.
There are three areas that present challenges—I am not sure whether you would call them barriers—for us. The first is dealing with the implications of multiple deprivation, the impact it has on individuals' mental health and wellbeing, and how we cope with that. The second concerns the implications of alcohol, which are linked to deprivation and to co-morbidity problems. That problem involves dealing not only with individuals who have alcohol issues and the impact that that has on their mental health, but with the impact that alcohol has on communities and family life, and the consequences of that on individuals' mental health and wellbeing.
I will come back to deprivation and alcohol later, and will deal first with the negative view of antidepressant prescribing. Exhibit 10 on page 25 of the Audit Scotland report shows that there was a huge increase in antidepressant prescribing between 1993-94 and 2007-08, which Willie Coffey mentioned before the meeting began. According to the report, the defined daily dose per thousand people more than quadrupled in that period. Is that simply because more people are suffering from mental health problems? Has there been a change in policy or medical opinion that would justify that increase? What has driven that staggering increase?
It is a multifaceted issue. Jill Morrison, from the University of Glasgow, produced a good piece of research about the factors that influence antidepressant prescribing and the variations that exist across Scotland. I cannot summarise it just now—it would probably take me the entire meeting to do so—but this committee and Audit Scotland might want to read her results. She closely examined 983 practices and considered all the factors that contribute to antidepressant prescribing and the increase in prescribing. She found that the types of antidepressant that are being used have changed over time and that some now require higher dosages to be prescribed and to be taken for longer.
Is there any indication in that report that the level of prescribing has increased more in deprived communities, or has the increase been broadly similar across Scotland? Is the increase higher in certain pockets? We might delve into this issue in detail at a later stage, but I would appreciate a little information at the moment.
Where there is social deprivation and educational deprivation—where people's educational attainment is particularly low—the levels of antidepressant prescribing are higher.
That is quite worrying.
Do you feel that sufficient resource has been allocated to tackling deprivation in the greater Glasgow area?
That is a huge challenge. The problem of deprivation covers many areas, such as housing, urban regeneration, employment and so on. In terms of resource, much of our effort around trying to change the shape of the more deprived parts of the entire patch is channelled through the relatively robust community planning process that NHS Greater Glasgow and Clyde has.
I accept that you are saying that you could never have enough resource. However, I am asking whether the resources that are being allocated are being used effectively and efficiently.
That is a good question. I would say that we are much better now than we have ever been. The planning processes are much more robust, and community planning helps in that respect. Of course, the situation could always be better.
Does anyone else want to address the issue?
I would like to make a couple of comments on the opening question, which was about barriers.
Peter MacLeod mentioned the preventive agenda and wellbeing. I know that we will come back to resources, but limited resources mean that the emphases of our services are on severe and enduring mental illness. We have important and positive strategies in place. The legislation has provided the basis for a positive view of mental health in Scotland, but we need the opportunity to develop community capacity and to invest in change.
I will offer a different perspective on the challenges that we face. In the Highlands, the challenges are about getting services out to people in remote and rural areas. According to the Highland user group, one of the biggest challenges is transport. Both the availability and the cost of transport affect people's ability to get to services, to socialise and to take part in events.
After Raymond Bell has spoken, we will move on to accessibility, on which Harriet Dempster touched.
The challenge that you pose—how we tackle deprivation in communities—is a live one in Glasgow. The audit work that we have done suggests that, if someone is unwell and ends up in one of our more traditional mainstream services, the service that they get is usually of a high quality and their outcomes are pretty good.
Good morning. I will ask about accessibility, which is an issue that came out of Audit Scotland's report. Some work was done in examining what were in some cases very long waits for access to services, particularly for children and adolescents. Many of you have addressed the issue in your written submissions.
Would Ken Proctor or Bobby Miller, who have not contributed, like to comment?
One of the main areas in which we have been criticised in the past is psychology services, so we have a major redesign under way around that. It is an interesting issue to think about for a minute. To answer the convener's first question, our biggest challenges have been around stigma. There is stigma as mental health services have generally been a bit of a Cinderella service for a very long time. The new policy direction on the health improvement, efficiency, access and treatment targets are making a significant difference and are bringing regularly to the health board table the issue of mental health, one aspect of which is how we access services.
Colin Sloey highlighted funding issues around services and CAMHS would certainly come into that category in Lanarkshire. I am sure that Colin Sloey would be happy to tell you about some of the plans that have been prepared in the national health service, subject to funding availability.
Targets can be important in driving and achieving change in practice, but sometimes the focus is on the target. If we are talking about supporting resilience and developing a wide range of support so that the right people get the right service at the right time, we must be careful how we target that so that people get access to a wide range of support at an earlier stage.
Is there sufficient discussion between social work and health boards on setting targets?
The problem is that when targets are imposed centrally, that form of discussion is not allowed. One of our criticisms is that the targets are very medically or health oriented in their description; that focuses the health services on meeting particular targets, but the local authority appears to play a lesser role. If we were allowed to reinterpret those targets more widely, we could bring in the agenda that my colleagues have talked about.
So, at national level there is insufficient communication in the setting of meaningful targets between those who are responsible for social work and those who are responsible for health.
Yes, but housing, education and other services need to be included, too. The resilience agenda is a joint agenda. Social work and health have an important role to play with those who are at the severe and enduring end of the spectrum, but other services will play a more critical role at the preventive end.
In Highland, we have been doing redesign work around the getting it right for every child programme and CAMHS in trying to promote accessibility by a single door and ensuring appropriate triage so that we get the right help to children at the right time. One of the issues with CAMHS is that multiple referrals have come in from everywhere, but they might have not been the right referrals for the right children at the right time. Our approach will get better outcomes, while using existing resources.
It is important to recognise that there are different types of target. The HEAT targets are driven centrally, but, from a health perspective, there has always been an opportunity to play into those targets. We also have local access targets for our community mental health teams, for example, which are agreed with our social work colleagues and are jointly managed.
Our submission refers to our capacity planning system in NHS Lanarkshire. The idea is to track referral rates, and to consider how we triage and how we admit those persons to the case load. The system enables us to consider the relationship between supply and demand. As Anne Hawkins said, such a tool enables clinicians and teams to use the data to consider the efficiency of their services, how long patients are on the case load, what the evidence base tells us about the appropriateness of that, and how we manage did-not-attend rates so that they are not wasteful and so that we can provide other people with such appointments. The bottom line is that we have been able to use that data to identify gaps in the service.
I did not want to give the impression that targets were a bad thing. Targets in themselves are okay, but it is possible to hit the target and miss the point. We have used the targets as important by-products of the redesign and modernisation of the service. The example from NHS Highland would be the readmission target. It is easy to say, "We're going to reduce readmissions to Newcraigs by X", but to achieve that we have to go right back upstream and start with the GPs, then the community mental health teams, then access to other services. In the past five years, we have had a seven-day-a-week hospital—we did not have that before. We have a community psychiatric nurse service at weekends and in the evenings. An overnight specialist nurse is available at Newcraigs. Those are all things that we have put in place and which have enhanced the service for patients. In addition, we have hit the target. However, that was a driver rather than an end in itself, and we are continuing to develop.
I add my thanks to those of the convener. Your submissions were excellent and I found them interesting.
May I respond to that? Just to let the committee know: I am not a psychiatrist but a GP.
Ah, even better!
How long have you got? The new general medical services contract that started in 2004 has fundamentally changed how general practice works and how GPs are beginning to think. If we reflect back to Anne Hawkins's comments on the report from the University of Glasgow, it is clear that our newer breed of GPs is very different from the traditional one—dare I say it, from the Dr Finlay model—whereby the GP had a 24-hour, seven-days-a-week commitment, understood risk and took risks. We are moving rapidly away from that. I think that that was part of the discussion about why more antidepressants are prescribed. We now have a different cohort of GPs, who are trained in hospital in a different way, which is to work in teams and shifts. They continue to do that in general practice, and they do not tend to work in isolation.
How will you ever achieve the target, if the GPs do not co-operate?
Under the new GMS contract, there are ways of encouraging GPs to co-operate. We have a locally enhanced service. If I say that we dangle a little money in front of them, I am not being flippant. General practice is a business and is run as such. If the price is right—again, I do not mean that flippantly—GPs are exceedingly good at changing what they do, following guidelines and proving that they do that.
NHS Quality Improvement Scotland has introduced one generic and five condition-specific integrated care pathways, one of which is around depression. GPs are pivotal in that process in the identification and diagnosis of depression and the use of validated measurement tools, not only at the point of first assessment but in bringing patients back to reassess. We encourage GPs to ensure that any prescription is part of an overall package of care that may or may not include psychological therapies, rather than to look singularly to prescribe antidepressants. However, we recognise that everything does not need to be medicalised. We need to look, too, to community planning partners to optimise the use of available community supports through education, recreation, job opportunities and volunteering, all of which have an evidence base around them that shows that that can improve people's self-esteem and mood. GPs have co-operated particularly well in those processes—certainly from a Lanarkshire perspective—which augurs well for the future.
We move on to minority ethnic issues.
I want to ask about access to mental health services for people from minority ethnic communities. As you would expect, my question is not specific to Glasgow—as everyone in the room is aware, if someone needs access to mental health services it does not matter where they live. The challenge is perhaps even greater in areas in which there are fewer people from minority ethnic backgrounds.
I do not have either with me or in my head the data on the number of black and ethnic minority communities who access statutory social work services. However, I am happy to share with the committee uptake figures for the bulk of adult mental health service provision in Glasgow that is outsourced and purchased from the voluntary and private sectors. They are not good; last year, there were 4,530 service users of our purchased services, of whom 92.7 per cent were white Scottish, 1.9 per cent were of Pakistani origin, 1 per cent were other Asian and 4.4 per cent were of other origin. As a result, the percentage is low compared with the size of our community.
Let me try to pick up on the various points that Anne McLaughlin made.
I thank you both for those comprehensive responses. As a Glasgow MSP, I am obviously most interested in Glasgow, which has the highest proportion of people from minority ethnic communities. However, I am also concerned about what happens throughout Scotland. Is that challenge being addressed and met? I am interested to know whether work is being done on the issue outwith Glasgow.
For minority ethnic groups, access is a difficulty that prevails across all health services, not just mental health services. We have introduced community health educators to work with local groups that are supported by faith leaders in order to identify those people—particularly women—who do not take up general primary care provision, such as well-woman services for cervical and breast cancer screening or measles, mumps and rubella vaccination for children.
I draw the committee's attention to the fact that there is a programme of work sponsored by NHS Health Scotland that is about getting each of the regions in Scotland to network on BME issues. A woman called Dale Meller leads a small team that works across Scotland to bring together people in mental health to look at learning. The team has worked with some of NHS Lothian's targeted groups, with HUG in Highland and with the Chinese community in Forth valley. That mechanism is being used as a catalyst for learning and change on the BME agenda.
The situation is quite different in remote and rural Scotland. There are small BME communities, but they tend to be very small and, from what we can gather, they tend to be mostly eastern European. It is an issue on which I cannot give you any statistics. In comparison with the information from Glasgow, our submission is quite feeble, although we have a translation service, which general practitioners and the community mental health team can access. In crisis situations, it can be extremely difficult. Although the number of people involved is small, when there is a problem, it can be quite substantial, because we do not have the sort of infrastructure that Anne Hawkins has mentioned. Proportionately, we are talking about small numbers, but when an issue arises, it can be quite complicated. The cultural context in the north-west of Scotland is utterly different from that in Leipzig.
I have a follow-up question on the theme of access for people in minority groups. The Auditor General highlighted the difficulties that people from the deaf and deafblind community face when they try to access mental health services. How have the boards taken on that challenge?
I am aware that before I invited Cathie Craigie to ask her question, Bobby Miller had indicated that he wanted to respond on the previous issue.
I think that I can pick up on Cathie Craigie's question at the same time. There is an overlap because equality impact assessments touch on both issues. A proper equality impact assessment tackles the range of issues that might lead to a person's being excluded and having difficulty accessing services. As is happening in Glasgow, we are pursuing a review of all our services for which equality impact assessments are carried out. In addition, we have been working jointly with South Lanarkshire Council to develop some of the links that Colin Sloey talked about in relation to ethnic minority groups. In North Lanarkshire, a very small percentage of the population—1.3 per cent, I think—are from ethnic minority groups. In some ways, that means that we should be trying harder. If people are not pushing themselves forward, there is even more need for us to try to reach what is only a small sector of the population. I think that we are doing that.
It is absolutely the case that the report highlights challenges that the deaf and deafblind communities face. In Renfrewshire, we have had in place for many years a specific social work service for people who are deaf and deafblind. We also invest in services that are provided by the voluntary agencies, which Bobby Miller referred to, but having a dedicated service has a powerful effect. It means, for example, that our social work service has one of the highest proportions in Scotland of staff who are trained in the use of sign language.
I will go off at a slight tangent, although my question is still linked; it is not on communication difficulties and small numbers but on the specialist mental health care that is required for children and adolescents. In the not-too-distant past, it was not always easy to treat cases of self-harming, anorexia and the particular problems that children and adolescents have, because there was not always a specialist available to deal with those issues. What are the numbers involved? How many more people are being trained specifically to deal with children and adolescents? Has that been targeted specifically?
I want to answer the previous question first. I referred only to deafblind people in response to Cathie Craigie's question. In relation to people who are deaf, North Lanarkshire has first-stop shops in each of the six main townships. We are rolling out communication opportunities for people to come in and have direct access to assistance through the use of British Sign Language, which has been recognised as a considerable development. There are relatively small numbers of BSL users in the council area, but the development has been welcomed by that community. It is one of the routes into services that people can use.
Are there any other comments on that? I want to move on to other issues.
I want to respond to the previous question. The Health and Sport Committee, chaired by Shona Robison, has taken representation from the deafblind community about the availability of health services within Scotland. She commissioned a group that I was asked to chair to do a feasibility study on developing a specialist residential centre somewhere in Scotland, which would mean that people would not have to travel to the John Denmark unit in Manchester. That group also identified the need for the relationship between specialist residential care and the community infrastructure in order better to support people who are deaf and deafblind and who have mental health problems. It is looking to each board to build up its capacity and capability with staff who have BSL level 3 training, which will enable them to communicate and engage appropriately with such people.
Is the committee to which you refer a ministerial committee, rather than a committee of the Parliament?
It is the Health and Sport Committee, which had received petitions about—
You mean a committee of the Parliament, in that case. It is not chaired by Shona Robison—she is the Minister for Public Health and Sport.
The Health and Sport Committee conducted an inquiry on the matter. The issue was raised via the cross-party group on deafness. I am aware of that work, and I know that many deafblind people have had to make their way down to England for services in the past. Changes have now been made there. I was hoping to hear that health boards have been working jointly with local authorities to provide services for all sorts of vulnerable groups.
There is some cross-board working, particularly in relation to the issue that Anne Hawkins raised about the vulnerability of asylum seekers and women in forced marriages—rather than arranged marriages—who are very vulnerable. We rely to an extent on there being a certain level of expertise in the city of Glasgow. Anne Hawkins spoke about the challenges in Glasgow, but when just one or two people in an area fall into the categories that we are discussing, the challenge is even greater. We therefore rely on the expertise and knowledge that have been developed in the cities to support us in taking the agenda forward. We rely not just on the statutory organisations, but on such organisations as Hemat Gryffe Women's Aid, which has a lot of expertise and has helped us to understand how to proceed. We use expertise where we know it exists, both formally and informally, in order to develop our services.
I invite Ken Proctor to come in at this point; then I will call George Foulkes, who wishes to highlight the issue of resources.
I will just answer the question on cross-board working. We inherited the Argyll and Bute bit of Argyll and Clyde NHS Board, and there is now a lot of cross-board working between Argyll and Bute and Greater Glasgow and Clyde NHS Board. In the north of Scotland there is now a network for eating disorders, in which we are working together with NHS Grampian. We are always looking for cross-border working wherever we can, because of the small numbers involved and because we cannot always provide all the services ourselves.
Let us move on—we have a couple of other big issues to consider. I invite George Foulkes to discuss resourcing.
I want to talk about single outcome agreements. Renfrewshire Council has made a gallant attempt at outlining how single outcome agreements are relevant to local authorities in the context of mental health. However, I find NHS Greater Glasgow and Clyde's submission interesting. It says—I refer to page 21 of paper PA/S3/09/15/2—that single outcome agreements
The only cut to a ring-fenced budget in Glasgow following the single outcome agreement was in the former supporting people budget that was allocated to the city council.
I recognise that a valiant attempt has been made by Renfrewshire Council. I have tried to describe a theme that has emerged at several points during the meeting. It is hugely important to focus on working together to improve mental health and wellbeing in our communities, and I recognise that at issue is perhaps the robustness of what are described as "key outcomes".
I hoped that Anne Hawkins would answer my question, as I quoted from NHS Greater Glasgow and Clyde's submission. I have the national concordat with me. Nothing in the indicators specifically refers to mental health. Indeed, if we look at the ring-fenced—I was going to say "earmarked" and nearly said "ear-fenced", but members know what I mean—funds, we will see that the mental health fund was rolled up into the settlement. From what NHS Greater Glasgow and Clyde says on page 21 of paper PA/S3/09/15/2, that is creating problems in greater Glasgow and Clyde.
What we tried to say in our submission—perhaps our words are a bit robust—is that there is a fear. Members should bear in mind that we work with a number of local authorities. Because specific grant moneys are no longer ring fenced, it is much more difficult to track where money is going. That is the bottom line. However, I think that there is one specific mental health indicator in the single outcome agreement.
In the national one?
Yes. Is there not an indicator to do with mental wellbeing and utilising the Edinburgh scale?
Are you referring to the Warwick-Edinburgh mental wellbeing scale?
Yes. I think that that is the only specific indicator.
I am going to be rubbished by you and your colleagues, but I sometimes get the strong impression that local authorities are a bit reluctant to criticise the current Scottish Executive. Do you think that? If you think that things are not adequate, are you intimidated in any way?
Anne Hawkins is with the health board, so—
I mean health boards as well. I have detected that reluctance in voluntary organisations and universities, and I am now detecting it in health boards and local authorities. Are you frightened of criticising the current Scottish Executive?
With regard to opportunities for health issues to influence single outcome agreements, I took part in a meeting of the Scottish partnership forum, which is a group of individuals that includes managers and people from the staff side. We were given the opportunity, at relatively short notice, to comment on what the indicators should be and to try to contribute to the first versions of the SOAs and the concordat, but the process was carried out very rapidly, and the opportunities to contribute were limited. Like everything else, however, such involvement has to start somewhere, and grow from there.
Thank you.
We will move on to the impact of an ageing population, on which Cathie Craigie and Anne McLaughlin wish to ask questions.
All the submissions highlight concerns about the impact of the ageing population, but I would like to hear a bit more about dementia services. We are hearing that we will all live longer and that we will have to work for longer, which will be a big problem for the delivery of all services in the coming years, particularly in relation to how we face the issues that the Audit Scotland report raises.
I will set that in a national context. My chief executive, Tim Davison, is leading a group with representatives of the Convention of Scottish Local Authorities to consider what issues the demographic information presents to the public sector in relation to older people and their consumption of public services. To lead that work, a high-level group will consider the implications for service delivery.
The problem is potentially very resource intensive—everyone on the panel has spoken about resources. We have heard from the panel that GPs and people who work in the primary care sectors will be key in earlier identification of people with dementia. How do we link in with that?
The new GMS contract contains an equality and outcomes framework, as Ken Proctor highlighted. We have a target for the number of people with dementia that we can identify early on—we can then register them as such with their GP practice so that they receive the best possible health and social care support packages.
I agree with Colin Sloey about upstream work, but we also need to think about how to use existing resource for those who will definitely need support but cannot self-support or engage in social or family networks to help them sustain their independence and wellbeing. We have adopted a model in North Lanarkshire that ensures that we move away from a building-based service as much as we can. If we lock up our resources in buildings, we have no flexibility to support individual needs. We no longer have any residential accommodation in North Lanarkshire for people under 65 with mental ill health; they are now all supported in their own homes. We also support at home a high percentage—well above the national average—of older people with complex needs, many of whom have dementia. I suppose that the development of, for example, smart technology and using money more creatively is how we will have to go in the future if we are to deal with demographic changes.
I want to pick up on the use of telecare and other technological assistance, which is obviously part of the equation for supporting people for longer at home. However, it is not just about that, because we will have to have much more public dialogue with professionals about risk. As we discussed earlier, in some places there is quite a lot of risk-averse behaviour—we are still struggling with this in Highland because of our rurality—that jettisons people into buildings when their welfare could be sustained and promoted at home. People are worried about the risks of supporting people in their own homes and that issue must be part of the dialogue. It is linked to colleagues' helpful comments on developing communities' capacity and engagement. We need a community system approach, because we have such a big tanker coming towards us.
I echo that point about community capacity building. Unless we grasp the nettle of how we, together, enable communities to care better for those who are ageing in them, and address the vulnerabilities that Cathie Craigie mentioned in relation to dementia, we risk failing to meet need properly, and that will put people at risk. In my area, we estimate that the over-65 population will grow at a rate of 2.5 per cent from now as far into the future as we can see, which will be an enormous demand on services.
Other witnesses have spoken about people with dementia and the need for public bodies to become involved in people's lives at an earlier stage. There are challenges around how people are kept safe and how issues of risk are addressed. We are running a pilot project for the Government on personalisation and self-directed support in learning disability services in the east end of Glasgow. There is a tension between giving individuals control of how their care is organised, under the choice agenda, and ensuring that there are duties of care to keep people safe when capacity is questionable. We are riding two horses at once, so it is critical that we make the right decisions. I make that point as I understand that legislation on personalisation may be being considered. We need both to provide choice for the individual and to ensure that there is proper intervention from the state to protect people when they are at risk; there is a balance to be struck. I hope that I have explained myself properly.
First, the HEAT target on dementia starts the process—practices are now seeking actively to assess people early. The next challenge is what we do about that, especially in remote and rural areas. We have set up a specialist clinic, which is one of the few specialist clinics in Highland that is not dispersed—it is in Inverness. That is the early work that we are doing.
When we talk about older people and mental health, we almost always talk about dementia. However, is it not generally accepted that older people have the same mental health issues as the rest of the population?
I think that Anne McLaughlin has just identified for George Foulkes a more productive role for our radio colleagues.
South Lanarkshire Council has particular problems with new towns, which have populations that are rapidly ageing. That presents particular challenges for services. Community capacity building is important, but when people in the community are all ageing together, that presents different challenges, which we must consider.
The convener has had to nip out for a moment.
I thank Mairi Brackenridge for her input—we should all be aware of the issues that she raises.
Does anybody want to respond to that?
I think that I should. There is a significant shortage of consultant psychiatrists with an interest in old age. That is not an excuse. We have been trying for a significant length of time and in all sorts of innovative ways to attract more of them to Highland. We are getting there, but far too slowly.
Sometimes the efforts that Ken Proctor describes pay dividends. Our area is highlighted in the "Overview of mental health services" for the percentage of vacancies in the medical ranks for mental health services. That percentage has dropped significantly from the 22 per cent that was reported to the current 13 per cent, but that number of vacancies is still a gap in service provision. We try to make up for it by locum appointments and the contributions of other clinicians within the team. Nevertheless, we construct those teams with consultants in the lead for a good reason. We are doing everything that we can to make either substantive appointments or to make locum appointments to ensure that the full capacity of service is delivered.
I want to move on to the important issue of expenditure. I suspect that there will be quite a lengthy dialogue on this. Willie Coffey wanted to raise the issue of resource transfer.
I do not imagine that a proposed increase in the health service budget next year will generate any kind of fear factor, as suggested by my colleague George Foulkes a moment ago. It might be the opposite down south where there is a genuinely large reduction in the health service budget, but I will not ask colleagues around the table to comment on that. I will, however, ask you to comment on some of the data that appear on page 31 of the Audit Scotland report. It shows a disparate amount of spend per head on community mental health services between the NHS boards. Are we getting value for money from the money that the NHS boards allocate to local councils to deliver community mental health services? How do we know that we are? There is quite a range of spend in the various areas.
I will start. The picture of resource transfer and the story behind it is complex. NHS Greater Glasgow and Clyde has two parts to our position, which come from the Greater Glasgow Health Board position, as was, and then that of Clyde. So there are two separate histories.
I am happy to add to that. The issue is worthy of debate, and it was picked up in some submissions. As Anne Hawkins said—we had some discussion about this earlier this morning—the community care issue has a long and complex history. The National Health Service and Community Care Act 1990 created care in the community and the concept was implemented three years later.
We need to look at whether resource transfer is still a relevant currency in the integrated arena in which health and social care are delivered. Peter MacLeod referred to the national debate that is being led by Tim Davison from the NHS and Ron Culley from COSLA. They will report to Parliament in spring next year.
I think that Cathie Craigie wants to ask about the issues in Lanarkshire specifically.
We would expect the health boards to make those points, but it seems unbelievable. There is an average resource transfer figure of just over £15 per head of population across all the health boards. Lanarkshire comes in at £8.30. Glasgow, another large authority with large institutions that had to close down, as happened in Lanarkshire, is in a partnership, and there has been a transfer of responsibility over to the local authority, with the involvement of the people in the community who provide the care. There is a huge difference in the figures, and I cannot understand how that difference can be. Can you help me?
I will put that in context. The resource transfer per head of population in Lanarkshire is £8.30; in Glasgow—Greater Glasgow and Clyde NHS Board having a similar area—it is £35.33, which is more than four times as much.
I will contextualise that. As you know from successive allocation formulas—whether Arbuthnott or the NHS Scotland national resource allocation committee—NHS Lanarkshire is itself £21.5 million below its fair share for health service provision.
But that is not the relevant point here—the point is that resources are supposed to transfer with the patient. When a patient comes out of an institutional facility, the resources are supposed to transfer with that patient, who is now being cared for and housed within a community setting. Regardless of their overall budget, health boards should have no reason to say, "We do not have enough money, so we cannot pay for such-and-such's care within the community."
That is not what is being said. We need to recognise that the level of allocation that is available to a health board is important, because the board must then distribute that allocation across all the different service areas in a way that best meets the needs of the population.
Were resource transfer and investment in mental health services affected by NHS Lanarkshire's problems with expenditure on service redesign?
Again, our service strategy clearly sets out what we require for a population of our size, based on deprivation and the demographic profile of the area.
Sorry, I am not just talking about mental health service redesign. I know that NHS Lanarkshire wanted to move resources into other areas, but that did not happen. Were resource transfer and investment in mental health services affected by the problems that were encountered with the reconfiguration of services?
Again, I think that that is an historical or legacy issue. Since 2000—
I am talking about what happened within the past couple of years, when the board wanted to close facilities and reinvest elsewhere. Have those problems had an impact?
I think that we have worked on that particularly well, as Mairi Brackenridge and Bobby Miller will perhaps confirm. We do not make decisions on such closures on a unilateral basis. Both local authorities and the health board discussed the service models, including which services would be delivered in the community and how those would be funded largely by the reduction in dependence on in-patient facilities.
We are perhaps talking at cross purposes. I am talking about when the board looked at investment in hospital services and wanted to free up resources to invest in other services. However, that did not happen. Did that have an impact on resource transfer and on investment in mental health services?
I do not understand the question that is being posed. In recent years, I do not think that our investment in community infrastructure has been impeded by our policy on beds.
So the board's proposals on hospital investment, which did not go ahead, had no impact on other investment. That seems quite clear.
From a local authority point of view—this is certainly true for South Lanarkshire Council—we considered that NHS Lanarkshire's strategy document "A Picture of Health" offered a positive way forward. However, some of those proposals have had to be reassessed because of the current situation. The point that Colin Sloey is making is that the fact that we started off with a low resource base meant that, even with "A Picture of Health", we were juggling a relatively limited pot of money to try to meet increasing demand.
I think that resource transfer has meant value for money as far as the relationship between NHS Greater Glasgow and Clyde and Glasgow City Council is concerned. After all, it allowed us to deliver all the targets set in the planning assumptions on which our financial framework from 2001 was based. In relation to adult mental health services, for example, those who can remember that far back will know that the closure of Woodilee hospital and Lennox Castle hospital was a good thing. As a result, the outcomes for service users have been huge.
What is preventing the requisite funding to which you have referred being made?
Are you talking about at a national level?
You have expressed frustration at the fact that the setting of a national policy does not always translate into money going to service providers. What is preventing that from happening?
The decision about the state hospital was taken by the NHS nationally, and NHS Greater Glasgow and Clyde made representations not only on its own behalf but on behalf of Glasgow City Council that the resource could not simply stay within the estate. The decision that no resources would be transferred was made at Government level.
But the problem does not solely lie with the state hospital. The issue that you are describing is wider. Does the problem also lie in the relationship between local authorities and health boards? What is preventing the resource transfer that you think is needed from being made?
If the local authority is given the responsibility for this national policy, it should be given the resources as part of the single outcome agreement funding arrangements.
So you think that local authorities rather than the health boards should get more in the national allocation of resources.
Yes.
What is the health board perspective?
There are big issues around resource transfer, partly because it sustains the double system of financing that ends up with everyone in a tennis match. As a result, we need a single financing system.
You make a fascinating point about the single-system approach—that chimes with a lot of what we sometimes hear. I do not know whether any of the witnesses are in a position to answer this question but, if it is agreed that a single-system approach is a worthy objective, does it fail to happen because we still have managerial responsibility in different organisations? Do the ultimate responsibilities require to be streamlined? If not, why is it not happening?
The group to which I referred earlier, which is led by Tim Davison and Ron Culley, is grappling with the key questions. The expectation is that, when it reports to Shona Robison in spring 2010, the points that you raise should be answered in its report. How do we serve the best interests of communities and provide the services that they need? Are there any organisational barriers to our achieving those aims? Will service integration and unified management present better and more cost-effective options so that we can, in one fell swoop, clear out any debate about resource transfer?
On a slightly different point, in paragraph 128 on page 33 of the Audit Scotland report, the Auditor General highlights the dangers and potential dangers to the funding of voluntary organisations. Yesterday I met people who are concerned that the City of Edinburgh Council has reduced funding to organisations that are concerned with mental health and related issues. My question is for all four local authorities that are represented here. Can you tell us whether you have maintained the funds to voluntary organisations in your area, in respect of both grants and contracts for services provided?
We will start with Glasgow.
Within adult mental health services, part of the settlement involved a reduction of £200,000 in adult mental health and supporting people services. Those savings were applied to three providers. One of the providers was able to get another source of funding, which minimised the impact on the service.
But that means that two of the providers have not been able to find alternative sources of funding.
Yes. The amount involved was just under £100,000. In the current financial year, I am working to a target of saving approximately £380,000 from adult mental health services within Glasgow City Council. There will be a reduction in the number of council staff and in money to the voluntary sector. We are in discussions about how to make those reductions in the most efficient and effective way.
I do not fully get it. I thought that the services were meant to be improving, but you are reducing the overall funding for mental health services by almost £400,000 in Glasgow in this financial year. How can you—
That is against the backdrop of significant and increasing investment, some of it on the back of Mental Health (Care and Treatment) (Scotland) Act 2003 implementation money, which has been mainstreamed. Glasgow City Council needs to deal with the financial challenges that it faces. We need to look at these services, just as we need to look at all other services. I am in dialogue, for example, with a voluntary sector provider about how it can generate efficiencies in service provision, and I have had further discussions with some providers about the whole shared service agenda, which certainly applies to council services in Glasgow—Peter MacLeod is probably involved in that across authorities. Does every voluntary sector provider need a human resource section, a payroll section or whatever? We are trying to get those efficiencies and minimise the impact on service users. I expect that there will be efficiencies to be found from the budgets over the next few years. I will meet Glasgow City Council's director of finance this afternoon, and I expect that he will say that that is the challenge that we face and will have to meet.
But all the things that we have been talking about and all the questions that we have been asking for the past two hours become almost irrelevant because you will not be able to keep up with all the targets that we have been discussing if you keep on cutting services for vulnerable people who have mental illness. Roads could remain unmaintained, other things could remain unbuilt—
Let us not just focus on Glasgow alone. Let us hear from the others.
We have tried to keep our voluntary sector funding levels as intact as possible. However, to echo what Raymond Bell has said for Glasgow City Council, we all accept that we are in almost uncharted territory in terms of the pressures on resources across the public sector. The budgetary pressure that is being placed on social care services means that I have to ask the voluntary sector organisations that provide much of the supported accommodation for people with mental health problems and other issues to seek efficiencies in the contracts that we have with them. Such contracts might be worth £2 million, and I might be asking for £200,000 or £50,000 in efficiencies. However, that does not mean that the service is being denuded; rather, it means that I have asked the organisations to consider how they can reconfigure their services or deliver them more efficiently. For example, where we have groups of services, can they be delivered better locally? Rather than spreading 10 workers far and wide, can they be grouped and managed better? Are there different service models that we can use?
Just to clarify, will the budget for mental health services and funding for voluntary organisations be maintained?
I will seek efficiencies from my contractual relationships with my voluntary sector providers, including those that provide mental health services. I do not have absolute agreement about the level of such efficiencies. As far as I am able to, I will try to keep to similar investment levels.
We in Highland Council value our voluntary sector, and we have been working with voluntary sector partners on a concordat or agreement about how we will work together to deliver services. We face a very challenging financial context. I have been asked to find savings of about £5 million from next year's social work budget, which amounts to just in excess of £100 million.
But—
Hold on. I will let South Lanarkshire Council and North Lanarkshire Council finish commenting and then bring in Nicol Stephen.
I echo what has been said. We are in an extremely challenging period. We will need to protect the statutory services, to the provision of which our voluntary sector partners contribute. Like Harriet Dempster, we see voluntary sector organisations as being important partners, not least because they give an active voice to service users and carers in the process, which creates a real sense of partnership.
We face significant challenges, as has been said. We in North Lanarkshire are particularly concerned about maintaining a community infrastructure. If efficiency savings have to be found, we do not want them all to have to be found from the community resources that prevent people becoming ill or more ill and having to move up to a higher level of service need. We are keen to maintain expenditure on initiatives such as the choose life programme and the clubnet service that we purchase from SAMH, which supports about 380 people by helping them to access mainstream activities in the community, whether in the form of employment, social or recreational opportunities.
Can we ask the health boards the question as well? Paragraph 119 of the Audit Scotland report is concerning. It is clear that the local authorities are facing challenging times, but will the health boards give us an up-to-date position on where they find themselves? The report says that only
I have now tuned into the question that you asked me, convener, and appreciate that it was not singularly about mental health services but was about the broader picture. Of course it follows that if people are required to deliver services on three sites as opposed to two, the cost base will invariably be larger, so it will be more difficult to use the available resources to develop services in other areas. I apologise for my misinterpretation.
So there has been an impact.
Retaining three hospital sites means that there are not the same economies of scale and that the workforce is not as flexible, as there must be core teams on all the sites.
There is a valid decision to be made about retaining three sites, but it is clear that that was not your preferred option. If you were looking to free up resources for other services and people elsewhere forced a decision about having three sites, were you properly compensated for retaining the three sites?
We are now mandated to deliver the services across those three sites with the resources that are available to the board. Therefore, such decisions are not up for debate at the moment.
No extra resources came in.
No. Our share of resources remains the same.
Okay. Let us return to Nicol Stephen's question.
Lanarkshire NHS Board has prioritised mental health services. The board recognised our low base, which is illustrated in the Audit Scotland report, and, since 2007-08, which is the period that is reflected in the Audit Scotland report, has invested approximately £3 million in direct service provision in the community. Much of that resource has come from closing down some in-patient accommodation; the resources are not necessarily new.
I suspect that my answer will be fairly similar to the answer that Colin Sloey has given. The board of NHS Highland has prioritised mental health. That takes us back to the earlier discussions about the use of the targets and how helpful they have been. We all face very tight fiscal settlements. The joint community care plan's aim of trying to get the money to follow the patient properly takes us back to Harriet Dempster's point about the integrated resource framework. We hope that that will get the money to follow patients for their individual requirements. Where that money comes from—health or social services—should not really matter. At the moment, it still does matter, because, ultimately, the board is accountable for its budgets and the social services are accountable for their budgets. Therefore, I suspect that we are entering fairly stormy waters.
In greater Glasgow, we have made a huge investment in mental health services in recent years. The board has a strategy of investment in forensic services, in the new Gartnavel royal hospital and its revenue consequences, and in enhanced community services, including a crisis service. Those are mentioned in our submission.
I thank the witnesses for those responses from the NHS boards and the local authorities. You have raised concerning issues and major challenges. I would like to continue to monitor the statistic on the percentage of spending on mental health services because, if what has been said about the priority that is given to them is correct, they should at least maintain their percentage share whatever the size of the cake that is allocated. Everyone has been reassuring and has emphasised the high priority that is given to mental health services but, if the percentage share of the cake is not at least maintained, it is difficult to believe that that priority is genuinely given at the highest level in Government, local authorities and health boards. The fact that the percentage figure in 11 of health boards was static or went down is a concern. We must continue to examine that carefully.
I have a question for Peter MacLeod and Harriet Dempster, as they are directors of social work and therefore deal with elected members. I accept everything that you have said about the need for efficiency savings, better methods of working and smart working. That approach is right even in times when money is plentiful. However, do you as professionals feel some responsibility to explain to elected members the effects on vulnerable people of the cuts that are being forced on you, and do you argue the case for such people? Do you ask elected members to consider other priorities or to realise the effect of agreeing to a council tax freeze year after year?
It is not for the witnesses to comment on the council tax freeze, but they can comment on the general point.
Yes, convener—I will comment on the first part of the question, but maybe not the second part. I think that I can safely speak for Harriet Dempster, too, when I say that an awareness of elected membership is part of the portfolio that we accept as directors of social care services. Recently, sitting in a room similar to the one that we are in now with the convener and people from across the political spectrum in Renfrewshire, we had a discussion about the competing priorities. The convener might recall that we talked about social care issues as diverse as addiction; demography and older people's care; and kinship care.
I echo Peter's comments. I regard a large part of my role as advising my elected members on social work priorities and the possible adverse impact on the community of any changes. At a national level, I play a part in advising and championing issues through COSLA and the Association of Directors of Social Work.
I thank you both for your helpful answers to what may have appeared to be slightly aggressive questioning.
I have a final question for local authorities. When a care assessment is done for someone with mental health problems, or indeed for anyone, is a written community care plan issued to the individual and their family?
We have invested considerably in assessment and planning training for all our fieldwork staff. Recently, we had several hundred people undertake six days of training that revisited the principles around the 21st century review of social work. That involved an outcome-based framework for assessment and planning.
The answer is quite simple, and it echoes Bobby's point: every person who has a community care assessment should get a copy of the plan and should contribute to it.
The answer to the convener's question is yes, but we are not where I want us to be with single shared assessment. Because the electronic capacity to share information was not available when the assessment was introduced, the process became bureaucratic. To an extent, we are still grappling with that bureaucracy in Highland. However, like North Lanarkshire, we are working hard to take an outcome-based approach and to make assessments understandable for service users and carers in dimensions that are important to them—for example, safety and wellbeing and other common matters—so that they can check whether what we do provides a benefit.
Are users given a community care plan?
We are focusing on the community care plan, of which users will get a paper copy. Our difficulty at present is that we do not have the right technology, so the plans look like a huge amount of bureaucracy, which is not helpful or service-user-friendly. We are currently working on that.
My honest answer is that I cannot guarantee that at this time. As Harriet Dempster said, there is a way to go in that context. We have been active in revising our assessment procedures, which the community health partnership director and I are about to relaunch. The procedures will be more interactive in working with the people who receive our services. At the heart of the relaunch is the need to ensure that people have copies of assessments, which I expect to happen in every case. However, I cannot say that that is 100 per cent successful at this time.
It is a legal requirement.
I appreciate that, and I acknowledge that issues relating to that have been brought to my attention. That is why we have put our energy into re-examining the matter and ensuring that our success rate is 100 per cent, now and in the future.
So although it is a legal requirement, the law might not be being implemented, for whatever reason.
I would need to look at that in detail and come back with a detailed answer, which I am happy to do following this meeting.
The expectations are clearly articulated, but they are not always applied, although I am not sure of the scale of that. As other colleagues have said, the piloting of new technology in our other care sections signposts to some extent how we will crack the issue in this area. Our addiction services are piloting the use of mobile technology to produce the assessment and the care plan when the user is present. They are then printed off and given to the user right away.
I thank you all for a full evidence session. It has been very helpful, although it was quite sobering when we discussed budgets and future pressures, which reinforced the challenges that lie ahead for mental health, social work and other services. Some of us worry from past experience that when budgets are squeezed, social work is often an easy target, and we understand the consequences of that. There are challenging times ahead, but I thank you for your attendance.