Health and Sport Committee, 11 Jun 2008

Meeting date: Wednesday, June 11, 2008

Official Report 211KB pdf

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Mental Health Services for Deaf and Deaf-blind People

Agenda item 2 is on mental health services for deaf and deaf-blind people. It is a follow-up to the evidence session at last week's meeting, at which we heard from charities and professional bodies with an interest in the matter. I refer members to this week's committee papers, which include written submissions from the Minister for Public Health and the National Deaf Children's Society and further written submissions from LINK Scotland and the Scottish Council on Deafness.

I am pleased to welcome to the committee Shona Robison, the Minister for Public Health. She is accompanied by Scottish Government officials: Dr Denise Coia, principal medical officer—mental health; Philip Harley, senior policy officer in the mental health division; Peter Kelly, policy officer in the adult care and support division; and Dee Fraser, policy officer in the mental health division.

Does the minister want to make some opening remarks?

Yes. I thank the committee for the invitation to discuss progress and our future plans for an important group of people. I am happy to elaborate on any aspect of my submission and to follow it up with the committee as necessary.

I know that the committee has a lot on its plate, so I will just say that it has received a copy of my submission, which gives an update on the key action that is under way and is planned to improve how we and all our partners plan, assess and respond to the needs of those with a mental health problem and a sensory loss.

I make it clear at the outset that I am not entirely happy with the current position, which falls short of what we would want for those affected. However, I am happy with the attention that is being given to the need for change and the response so far. Progress is being made and there is some momentum. We always aim to better integrate groups of people with communication needs, including the deaf community and others, into mainstream provision, but I have never been of the view that that should be at the cost of sensitivity to particular needs. Those are the needs within needs, if you like, which should be considered by any service planner for any care group.

You will have heard that we are, without prejudice, helping partners to prepare the case for a specialist service and a specialist unit. Partners are aware that our help does not signal that we are minded to establish such a unit and that we, like others, are keen to see and consider the evidence base before we make any decision.

The issues that we will consider are what is workable, what is pragmatic and whether what is being suggested is a specialist service, a managed care network or a hub-and-spoke model. We will also take into account specific considerations for children. I am aware of the care and continuity benefits of having their needs addressed within children's mental health services that are linked to paediatric units, but whether to have a specialist service, unit or whatever will be considered over the next few months.

As indicated in my submission, there is other progress to report, although some might feel that it is neither fast enough nor wide-ranging enough. I understand people's frustration, but I think that we have a broad consensus on the way forward that will help to maintain momentum and to bring about change as quickly as possible.

Progress on delivering the aims of the sensory impairment action plan has addressed individual needs in part by delivering community care priorities for people with a sensory impairment. We are seeing new approaches and better retention than was the case when the original petition was submitted. For example, Glasgow has developed specialist deaf awareness training for mental health officers and other staff. NHS Lothian has set up a service, including a community mental health nurse and an occupational therapist with sign language skills, that is closely linked to social work services provided by Deaf Action. I am pleased that the initiative is centred on a new counselling service specifically for those with a mental health problem and sensory loss—that is a new approach. Evaluation will show what lessons have been learned and what gains have been made; I hope that there will not be too many disadvantages. We will seek to extend the practice that I have described to other parts of Scotland.

We have funded a leading change initiative at a Glasgow-based recovery project that focuses on two mental health client groups—people from ethnic minorities and people from the deaf community. Investment to create a bigger pool of British Sign Language-English interpreters is showing progress—65 interpreters are now available in Scotland—although there is always more to do.

Finally, our national suicide prevention strategy, choose life, provides resources on suicide prevention and awareness training in Braille and large print. In recognition of the fact that the deaf and deafened community is at no less risk—some would say, at increased risk—of suicide, we have been active in recruiting two deaf or deafened applied suicide intervention skills trainers, one of whom is based at Deaf Connections in Glasgow. A lot of work is under way, but there is still more for us to do.

I am happy to answer members' questions.

Thank you for that full statement. I advise the committee and the minister that committee clerks from the Malawi National Assembly who have been observing Scottish Parliament committee proceedings this week are in the public gallery. I met them yesterday and they are very welcome.

Minister, I have no doubt that you have looked at the evidence that was given at last week's meeting. The main problem seemed to be that—allegedly or in reality—there is huge unmet need, but no one seems to know the extent of it. It was suggested that some NHS boards do not refer to the John Denmark unit and that some general practitioners do not know about or refer patients to the one-day clinic that the unit runs in Glasgow. There seem to be problems related to awareness, communication and referral pathways. Rightly or wrongly, I concluded that we need to ascertain the critical mass of unmet need that exists before considering whether to establish a six-bed unit. What work are you doing to identify the extent of the unmet need about which we heard last week?

In my opening remarks, I indicated that a great deal of evidence is being gathered to back up the case for establishing a specialist unit in Scotland—without prejudice, because we need to remain impartial on whether such a unit is required. The aim of the exercise is to identify the level of need in Scotland. It takes account of both current referrals to the John Denmark unit and the possibility that there is unmet need because people who would use a Scottish service currently do not want to travel to Manchester. We must also bear in mind the fact that, whenever a new unit is established, there is increased awareness of an issue, which may lead to a higher level of interest and more referrals. The evidence that will be submitted to me will seek to take account of that.

That said, one of the things that I picked up from last week's evidence is that there is a weakness in the available statistics. There are reasons for that: whether in primary care or the acute sector, it is often the complaint with which the person presents that is recorded rather than underlying problems—for example, depression compounded by isolation through deafness would not necessarily be recorded in that way—which means that we are missing some important information. I am happy to explore that with ISD Scotland and to consider, for example, how we can get better at capturing such data through the codes that GPs use to record information, which are reviewed continuously.

A lot is happening, but I agree that the statistical base has some weaknesses.

The Government has also provided £40,000 to the Royal National Institute for Deaf People for a research study into need, preferences and gaps in provision.

We have that in our briefing paper.

That study will inform future practice.

Minister, your written response to the committee is helpful in light of the evidence that we received last week. I will ask about counselling. We heard some evidence last week about the pilot project that is running in the Lothians. You say in your letter that "early indications are encouraging", but I am concerned about what will happen once the project has been independently evaluated. I note from your response that the evaluation

"will be promoted and disseminated to encourage"

other NHS boards to consider the model. I am concerned that, when a pilot in one health board area is proven through evaluation to be successful, other health boards do not necessarily start to provide a similar service in their own areas, although they might receive the evaluation report. That inevitably leads to a postcode delivery of certain services. Can the Government do anything more to guarantee that, when a pilot in one area is evaluated as being successful and effective, a more systematic approach is taken to ensuring not only that the report is disseminated, but that health boards in other areas take on the idea and start to use it?

I understand exactly where you are coming from. The health service is getting better at rolling out change and good practice than it perhaps was. We have better systems in place—for example, in the Scottish Government, we have strong performance management and change teams whose job is to go in and help health boards to redesign their services in light of current and emerging good practice. However, a level of local decision making is involved, and although a service such as the specific counselling project in the Lothians may be appropriate for some of the larger boards, it might be difficult for some of the smaller boards to deliver; they might have to think of other ways of delivering it.

We have ways of getting across particular messages about the progress that we would like to see. For example, the regular meetings that the Cabinet Secretary for Health and Wellbeing and I have with the chairs of all the health boards are often good forums for us to impart important messages and we often have people come in to outline to the chairs a particular innovative service in a health board with the clear understanding that we are asking them to consider how that practice can be developed in their own health board area.

Although it is ultimately for a health board to decide its own priorities within national policy, when something such as the counselling project works and there is a critical mass of people who could benefit from such a service—which applies particularly to the large health boards—we would give every encouragement to such a service being developed. We would also obviously keep an eye on the situation and monitor it.

There are twice-yearly visits specifically on mental health to all partners in each health board area when such issues can be promoted or queried and people can ask, "Why are you not doing it here? What is the evidence that prevented you from doing it?" That kind of promotion of all aspects of mental health is on-going, particularly when new evidence comes out that shows what works well in a given area.

So it is the sort of thing that could end up on a list of questions that might come up in the course of a review.

Absolutely.

In the two training meetings that we have had, we have tried to develop a clinical network that involves the voluntary organisations, where much of the expertise lies. Through the doing well by people with depression programme, we set up a clinical network that disseminates information on different services throughout Scotland. We aim to do the same through the network for sensory impairment. The problem is that a big training agenda is attached to that because the workforce is not trained in the way it was for the depression programme network. We have another meeting of the sensory impairment training network in September when there will be presentations on the counselling project to let people know how it has worked out.

Minister, as you will be aware, PE808 started life as a request for an in-patient service. You acknowledged that as different committees interrogated the evidence in support of the petition, different programmes have been exposed.

My take on the evidence that we listened to last week, about which you will have been advised, is that although we might like to have in-patient beds, the position has moved on, and the major issue in dealing with various aspects of mental health that has emerged is the need for clinicians who are absolutely fluent in BSL. That is not easy, because we are not talking about a single clinician. The issue raised is whether we would need such clinicians in all health boards or could have a core of people with BSL fluency who could act in a hub-and-spoke way across all health boards and could counsel individual patients and offer in-depth advice on their problems because they could communicate with patients in a way that someone who is not so proficient in BSL could not. The core issue raised last week was how we could achieve that—through individual health boards or centrally.

I appreciate that. I outlined in my letter some of the training developments, for example within the Royal College of Psychiatrists, which is working on the inclusion of deaf awareness training in the curriculum for trainee psychiatrists. There will be more about that later in the year. Although I recognise that deaf awareness training is not the same as training in BSL, making clinicians aware of the issues is an important part of their training. We must ensure that clinicians recognise, in the same way as they recognise the need for other interpreting services, the need to use a BSL interpreter on occasion to help in their dialogue with a patient. Ensuring that they have basic awareness of the issues is important, and that is the stage that we are at with the Royal College of Psychiatrists. As a key group of staff involved in dealing with mental health issues, ensuring that they have better awareness of the situation will be an important part of their training.

Other groups of staff will also be involved and I outlined the work that is going on to improve awareness among community mental health nurses and so on. I am not saying that that, in itself, will resolve the issue that you are talking about, but it will go some way towards ensuring that people are at least aware of the issues.

It was raised with the committee that it might be unrealistic to expect every health board to replicate that degree of interpretation. I appreciate that that raises various organisational issues. A hub-and-spoke model has been suggested, in which there are a number of people with a higher level of understanding and language to deal with the deaf-blind, particularly in relation to mental health. That could perhaps be replicated throughout health boards.

The hub-and-spoke model is a good one, particularly for some of the smaller boards, whose ability to have the right specialist services might be limited. The hub-and-spoke model could ensure that they had access to those services.

Ross Finnie makes a good point. In the case of people who have a major mental illness such as schizophrenia, and who are quite psychotic, mistakes can be made if there is no in-depth understanding of BSL. For example, a psychiatrist might not correctly pick up the flavour of a person's delusions and hallucinations. We had considered training specialist psychiatrists. There is only one psychiatrist in Scotland with that depth of understanding. There are training schemes in England, for example at St George's in London, and Ireland is starting to offer training for that specialist group of doctors. The hub-and-spoke model would work with that kind of specialist training because we could offer intensive support at a distance, while people would also be prepared to travel in to the hub for that kind of expertise.

Training other staff is important for Scotland's rural areas. We would consider ways to increase the expertise, particularly in nursing, so that services could be provided locally for people who did not need specialist care. Specialist input is a huge training agenda for the Royal College of Psychiatrists, but the resource is scarce for that at present.

It was clear from last week's evidence that people who use BSL are the best folk to deal with this issue. However, there appears to be no funding even for interpreters for counselling. We have received an additional paper from Lilian Lawson about a social worker in Glasgow who had identified 55 deaf or deaf-blind people who badly needed counselling. However, because the social worker had to raise funds for an interpreter, only one of those people got one. Even at such a basic level, because health boards are not willing to provide interpreters, the services are not available. While it is not our aspiration that the service should take such a basic form, surely health boards could be asked, as a stop-gap, to provide interpretation for people who need counselling, thereby keeping them away from the more specialist services.

Health boards have a duty to ensure that they provide their services equitably to everyone in their area. If people are not getting access to services because of interpretation difficulties, that is an issue for health boards to resolve. I am happy to discuss that with health boards and get an understanding of which ones have the biggest challenge in that direction, because I do not think that the situation is universal. I am happy to come back to the committee with a fuller answer once I have been able to do that.

I would be grateful for that.

The issue is the availability of interpreters. The provision of interpretation to people who are receiving counselling is quite a specific area. Interpreting in a therapeutic situation is complex—interpreters must have specialist expertise so that they do not misinterpret or overinterpret what is happening. The same applies to interpreting for people who are asylum seekers. My experience with boards is that sometimes the problem is not the lack of an interpreter, but the lack of an appropriate interpreter with specific expertise in mental health.

I understand that specialist interpreting is required, but the information that we have received indicates that there is a lack of financial resources for the service and that boards are unwilling to fund it. I would be grateful if you could provide us with more information.

The member is referring to paper HS/S3/08/17/6, which highlights boards' refusal to pay for the service.

I will put my question to the minister, although it relates to Mr Harley's directorate. The research that you mentioned is the key to the whole business. Until we have an estimate of overall demand for mental health services from deaf people in Scotland, we will not know what services we should provide. We are dealing with a specialist group of people, scattered across Scotland, with, we suspect, a high level of needs. It is difficult for clinicians to interpret those needs unless they are specialist psychiatrists and are assisted by people who are adept at British Sign Language. However, you will get the results of the research in about nine months' time, having spent £40,000. Can you reassure me that a proper assessment of the needs of the people concerned is achievable for such a small sum and within such a short timescale?

The research will put us in a better position; whether it will answer every question about every service that may be required is another matter. We are looking to have far better evidence on which to base some crucial decisions. There may be work for us to do beyond that, but it is a first stage that will allow us to make early decisions.

There will be a 12-month study, starting about now and reporting in 12 months' time. The study will be conducted by Glasgow Caledonian University, with the Royal National Institute for Deaf People. As the minister said, it will not be the sole source of information, but it will add information to what I accept is a low base.

I hope that the research project will be useful, but in her written evidence to us Linda Sharkey suggested that basic information at primary care level is not particularly good. What is happening at that level, given that something is likely to happen to the general practice assessment survey? Is ISD Scotland comfortable with the way in which information is being collected on this group and with the specific annotation that is being used in diagnosis? In other words, do we have data that will provide the statistical evidence that is needed, as opposed to the patient experience evidence that the RNID study will provide?

As I indicated, there is no doubt that there is an issue at primary care level. I was not aware that there are more than 100 codes covering various forms of deafness and hearing loss. The codes apply to cases in which patients present with one of those 100 conditions, but we may not always be recording conditions that are a factor in the health care need for which patients present—they give us only one part of the picture. I gave the example of depression that is compounded by isolation through deafness; important parts of that picture of a person may not be recorded.

I am happy to explore the issue further. As I said, the codes are reviewed twice a year, so we have the opportunity to consider what changes might be required. ISD Scotland keeps its information-gathering processes under constant and on-going review. We will ensure that ISD Scotland is aware of the issues that have been raised about the recording of information in this context.

Philip Harley might have something to add.

There is not much to add. ISD Scotland is reliant on the information that it receives, so it is a two-way situation.

I have a brief question on another issue that falls within the ambit of petition PE808, which urges the Government to develop a specialist in-patient mental health unit for deaf and deaf-blind people and to provide resources for mainstream psychiatric services in the community to make them more accessible to deaf and deaf-blind people in Scotland. Having read the submission from the National Deaf Children's Society, I suspect that identifying children with hearing difficulties involves a different kind of quest from identifying adults with deafness and that different kinds of services are required. I do not know whether that falls within the ambit of the various actions that are mentioned in the minister's letter.

Such specialist services are provided mainly through the paediatric intensive care that is offered at Yorkhill. Perhaps Denise Coia will say more on that.

The convener is right that the two issues need to be separated out. In children, we are dealing with developmental disorders that require full in-depth assessment of developmental issues across child and adolescent psychiatry and paediatrics. With adults, the issue is different, as we need to try to provide the specialist services but link those firmly into general adult mental health services. The two issues are separate, really.

The minister mentioned Yorkhill, but what services are offered to children in disparate areas throughout Scotland who display behavioural problems in which deafness may be just one issue or the whole thing? How is that dealt with?

We are looking across the gamut of child and adolescent mental health services—CAMHS—particularly in rural areas. We are starting to develop regional pathways for the whole range of child and adolescent services because simply putting one specialist in each area does not work. The clinical pathways that we are developing will include sensory impairment, but the pathways need to be firmly tied into education and social work so that they cover all the agencies in rural areas. We have just started that work, but I hope that those pathways will play into that agenda rather than be part of the adult sensory impairment specialist service.

To me, the spectrum of educational provision would need to be involved. Given mainstreaming, that is where the issues will arise, so the problem needs to be tackled in other portfolios as well. Is that being done?

The work on CAMHS is at a relatively early stage but, yes, officials will speak to their colleagues in the appropriate directorates to take the work forward. As the convener has identified, education is a key service that will be very much involved in the discussions on how we improve CAMHS provision.

On the issue of services for deaf children, I visited the new Donaldson's school not so long ago. I think that I am right in saying that the school's facilities are fairly underutilised. When the Government is looking at referral pathways for children, will it also look at how children can benefit from spending some time at the school? Will the expertise at Donaldson's school be utilised in the research on unmet need?

We will consider that.

That concludes this evidence-taking session. I thank the minister and her officials. Today's session has shown us again how useful petitions can be in ensuring that we explore issues that might otherwise be neglected by the Parliament at large.