Official Report 785KB pdf
Welcome back. The next item on our agenda is our periodic scrutiny of the work of the Mental Welfare Commission for Scotland. I welcome to the committee, from the Mental Welfare Commission for Scotland, Claire Lamza, executive director of nursing; Suzanne McGuinness, executive director of social work; and Julie Paterson, chief executive officer. We will move straight to questions.
I declare an interest in that I am a practising NHS GP.
Thank you for coming along today. I want to start by discussing the BBC’s “Disclosure” documentary, which raised serious concerns. Could you explain why issues were not identified and acted on sooner? What action is now needed to ensure that the failings are not repeated?
The documentary was hugely concerning. It was awful to hear about the experience of the five young people over that seven-year period. You will be aware that, on two occasions in that seven-year period, the Mental Welfare Commission visited the setting on an unannounced basis.
We are reflecting on those concerns in our work. As you know, we are not an inspectorate or a regulator. We do not have the powers to close wards that a regulator would have. The Care Inspectorate can close care homes; we do not have those powers.
If you had had those powers, would that have made a difference?
As was stated in the Scottish mental health law review, we require additional powers. However, our reflection is that we could do things differently. As you know, when we visit services, we visit them for a day, so it is a snapshot in time. Our focus is based on the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults with Incapacity (Scotland) Act 2000—our duties and powers relate to those laws.
When we meet people on the wards, we want to hear about their experience and what matters to them. We also want to hear from families and carers, as well as the staff on the wards. Not everybody on the wards feels able to speak to us when we visit. We need to reflect on and understand why that is, because it is really important that we hear a range of views and experiences. We have been reflecting on how we can engage with people—young people in particular—more. That could include not just being on a ward on a one-day basis, but having a greater presence on the ward. If we were there over two or three days, for example, people might get to know us and feel more able to speak to us.
We are also reflecting on how we can engage with people who attend the ward. For example, mental health officers who are social workers who work with young people and adults who are detained under the mental health legislation routinely visit people on the ward. What can we do to engage with them more to hear about their experience and what they have witnessed? If they have concerns, how do they address them? How do they raise them? Everybody has responsibilities in relation to child and adult protection. We are reflecting on how we can enhance our visits, rather than providing a snapshot on one day.
You say that you are reflecting. What is your reflection?
That is our reflection. We will start to undertake enhanced visits to learn about the approach that we are planning to take to improve the work that we do.
It is important to say that our functions are very much set down in law; we cannot force people to speak to us. In the documentary, one person said that they thought that their experience was normal in that setting—they did not appreciate that it should not have happened. We need to do more work to ensure that children and young people, and adults, are aware of their rights in a care setting so that they know what is normal and what is not.
11:00We have work to do collectively with the other professionals who attend and visit the ward, with the staff who work on the ward and with the families, carers and young people. We need to engage across the board—we have a shared responsibility to ensure that we engage with all those people.
You are going to visit those settings, but how do we ensure that we never get into a position in which that type of abuse is happening? As a medic, I was horrified to see from the documentary that people had been treated in that way by fellow professionals. What is needed to prevent such a situation from even beginning?
The Mental Welfare Commission’s roles and responsibilities extend beyond visiting. We visit, as I have just explained, but we also provide advice and guidance on best practice according to the law and on what people can expect in relation to their rights being respected.
We also undertake investigations and, when we are made aware of concerns, we will investigate them at various levels. They can be addressed locally or they can lead to a 12-month investigation by the commission, which will lead to a publication.
We also have an advice and guidance line for people to call us on, and we receive about 3,500 to 4,000 calls each year. Those calls can involve providing advice and guidance on what people can expect from their care and treatment, or they can involve people raising concerns about the care and treatment that they are receiving. In addition, families or professionals might raise concerns or ask questions. About 49 per cent of those calls come from people who are using services or from carers or relatives, and 51 per cent come from staff who are working in mental health settings.
From that work, we are able to highlight the concerns that exist, and that will inform our work, too. For example, the committee may be aware that we published “Authority to discharge: Report into decision making for people in hospital who lack capacity” in May 2021. That work came about because individuals had raised concerns through our advice line that people were being moved from hospital to care homes unlawfully. People who did not have the capacity to make decisions about moving to a care home during the Covid pandemic were moved unlawfully, and we would not have known that had people not contacted us on our telephone advice line. That led us to do the work that we did, which led to the training programme for all staff in relation to adults with incapacity.
We do a range of work that comes together to enable us to try to mitigate any experiences such as the experience that you described at Skye house. We can only do our best, in partnership with everybody else, to make sure that that experience cannot be repeated and that we learn from it.
Did you receive any calls about Skye house via the phone line that you just mentioned?
I am aware that we received one or two calls in relation to individuals, and we picked up those issues and addressed them with the service over the seven years. We work very much with individuals, but, when we find that there is a range of issues, we will go in and do more detailed work. We did not do that in relation to Skye house, but there will be other areas of work in which a wealth of information has come through that will lead us to act and undertake more enhanced or detailed visits.
How transparent is the process of looking at cases and deciding what merits an investigation taking place? If you had received calls about Skye house during those years, that would raise a lot of concern, given what happened.
We receive calls from individual people, and we address those on an individual basis. Our focus is very much on individuals, not on services. I direct you to our investigations in relation to Mr E, AB and Mrs F. We focus on the individual circumstances of each person.
When there is a range of people and the issue is more systemic, we will probably refer that to a regulator, for example, but in the circumstances that we are talking about, it is about individuals. Our practitioners pick up individual cases and address them, and when the issues are not addressed, they would raise those. We work with individuals at every level, and we work with a number of individuals across a range of services throughout Scotland in the hope of addressing the circumstances for those individuals. That is our focus.
I declare an interest in that I am a registered mental health nurse with current Nursing and Midwifery Council registration, and I am employed as a bank nurse by NHS Greater Glasgow and Clyde.
You talked about hearing and listening to views, and you said that you see a snapshot and are considering enhanced visits. However, over that seven-year period, there was obviously very poor practice—if I can put it as mildly as that—in Skye house that the Mental Welfare Commission appeared to be completely oblivious to. What will you do to ensure that you do not miss that in other areas?
I will pass over to Claire Lamza to say a wee bit more about Skye house and the work that we did, and then I will answer the question about what we are going to do in the future.
In response to the point about us being oblivious, I go back to the fact that it is a one-day snapshot that we take. For those who are not aware, I point out that it is a one-day visit. There might be two or three practitioners out of the group of 19 staff from the Mental Welfare Commission. They are knowledgeable, experienced and experts in their field, so they would not be oblivious. However, if the visit has been announced, the focus on the day will be the people who have indicated that they want to speak to us. If the visit is unannounced, we go round and find people who are willing to engage—that might be family members who are visiting.
A lot of the effort and energy on the day of a visit goes into co-ordinating and getting views on that day. We might speak to staff, individuals who are happy to speak to us and family members or carers who are there. After that, to get corroborative information, we would have an opportunity to review the records.
I have found that, during that seven-year period, we acknowledged that things were going on at Skye house, and there were changes. Before the pandemic, there were issues with staffing. Across Scotland, the commission has repeatedly raised our concerns about the use of agency and bank staff, which came through strongly in our reports—
On that point, from looking at our papers, it seems that the terms “agency staff” and “bank staff” are interchangeable for the Mental Welfare Commission, but they are completely different things. Are we talking about agency staff, bank staff or a combination of both?
It is both, because both were used in the Skye house team.
At that point, we highlighted that, at times, there were not enough staff. At times, there were agency staff who did not know the environment. At times, there were bank staff who clearly knew the service and would come in if numbers were down. There were concerns about staffing.
The other thing that came through in the records and our reports was about the complexity of and the change in the group of people who were coming in. We highlighted that in our most recent report, in which we said that Skye house was working on the model of care because it recognised that there were more young people with eating disorders or with autism spectrum disorder. All the way through, we have highlighted concerns, whether those have been about staffing, the type of staff or the model of care.
Across all our mainstream work, the commission uses recommendations. The recommendations support us in influencing and challenging practice, within our legal parameters. That has been our route, rather than using requirements or standards that we work to. We have been aware of concerns and have raised them in the way that the commission does, through our processes, whether those are about what we have heard, the use of the Mental Health (Care and Treatment) (Scotland) Act 2003 or the Adults with Incapacity (Scotland) Act 2000, or activities.
We have taken the intelligence that we have gathered on one visit and used it repeatedly—for example, the report for 2023 highlighted findings that we picked up in previous years. I think that we wrote that we had raised the issue in previous years, rather than it being a one-off.
I absolutely get that, but the Mental Welfare Commission did not seem to pick up on the malpractice that was occurring in the unit, despite the numerous visits and despite other issues being raised that might have rung alarm bells. You say that you make recommendations. Do you think that the Mental Welfare Commission needs more teeth?
We have made recommendations repeatedly—that is what we have talked about reflecting on through our intelligence focus. That ties in with other work that has come through from the sharing intelligence network, the Scottish mental health law review and the review of forensic mental health services about the role of the commission, what would be useful for assurance and scrutiny, and how the process could be more robust.
There are bits of work in which recommendations have been made on how the commission should move forward. We have to repeat recommendations, because that is how we have used the processes and systems until now. Having more teeth, to the point that we would have the ability to use them, would be useful.
Good morning, and thank you for being here. I declare an interest in that I am still a registered nurse. My background and experience are as a general nurse.
I am interested in the Scottish mental health law review, which made some recommendations. The convener has already touched on this a wee bit. Given that the Mental Welfare Commission does not have enforcement powers, how does it ensure that the recommendations that it makes following its visits lead to meaningful service improvements?
To answer Ms Haughey’s question about whether we need more teeth, the answer is yes, we do. In response to your point, Ms Harper, we are not a regulator, so we do not have powers to compel anything to happen. As Claire Lamza explained, we rely heavily on our influence and expertise, which works to a certain extent, but there are areas in which we need additional teeth in order to deliver changes.
That point came through in the Scottish mental health law review, which recommended that we should have more teeth. The review, which involved three years of evidence gathering, was very clear about the need to extend the Mental Welfare Commission’s powers and strengthen our role. We very much welcome that, and we are keen to see where those recommendations land and how they progress.
The review talks clearly about the practice that Ms Haughey referred to, and the chapter on coercion recommends a range of additional powers for the commission. That links to some of the practice that we heard about at Skye house, such as the use of restraint. We would like to monitor restraint across Scotland more, because that is a key area in which practice is not currently monitored in the way that we would hope.
The Scottish mental health law review made 202 recommendations, a number of which relate to the Mental Welfare Commission. We are keen to see those progress, because we need additional powers. At the minute, we use our influence, which works well. Claire Lamza will give more detail on this, but we make recommendations through an investigation report or a visit report. Since 2021, we have been publishing the responses to our recommendations, so that we can show evidence to the public that we are closing the loop on recommendations.
We make recommendations, but the feedback from some people is, “So what?” We have started publishing our reports in order to say, “Here’s the ‘So what?’—here’s what the service has done in response to what we said we would do.” We follow up three months after every visit, and we follow up after our investigation reports. We did not previously publish reports about what had been undertaken in response to our investigations, but we have started doing that as well. It is important that, when we make recommendations, people have confidence that action is being taken and that we can publicly share that.
A seven-year period is covered in the Skye house documentary. You have talked about unannounced visits and other visits. How many visits are we talking about, especially if you go back to investigate three months later? Do the visits involve speaking to the staff and the teams on the ground in each of the three ward areas? I am curious as to why the culture—which, as the documentary showed, evolved into something quite disturbing—was not picked up on sooner.
Absolutely. To clarify, we do not go back after three months—we provide a report with recommendations, and we expect a response and an action plan after three months.
I will pass over to Claire Lamza, who will explain exactly what we do on the ground for visits.
We start off before the day of the visit. In general, most of the areas that we visit are known by the area co-ordinator—that is the case for Skye house, in particular—so information is already available, and we would look for intelligence.
Before we visit, we will already have spoken to the team, the senior charge nurse and the nurse managers, and we might have spoken to other members of the multiprofessional team, to get as much information as we can. On the day of the visit, there might be two, three or four members of staff. Skye house is a big service, so, on any particular visit, there might have been three or four individuals looking at a particular area. However, as we have said, if the visit is unannounced, we might not find the same number of people who are willing to speak to us.
11:15With regard to children’s and young people’s services, getting engagement during a one-day snapshot visit can be almost as challenging as it can on a visit to an adult acute ward where people are very unwell. There might be people on the ward who have no contact with the commission because they are there of their own volition. A range of factors might affect how we get intelligence on that particular day.
As Julie Paterson said, we might discover things from the information that is gathered during the visit. With regard to the individuals who we saw that day, it might be that there was no use of restraint or intramuscular medication for us to follow up on, but, if there was, we would check through the process. Fundamentally, however, we build our report around what we find when we speak to people. When we did our reports in 2022 and 2023, there were people who said that their experience was positive. Therefore, what we find is contingent on a number of factors with regard to what happens on the day of the visit.
As you will see from some of our visit reports, when we are concerned and we get intelligence during the pre-visit work or on the day of the visit, or post-visit follow-up information that we ask for or get from our feedback session, we have an opportunity to confirm that information or to get more details through that approach. We will then go back within the six-month timeframe, because there is a three-month period from the local visit to the report being published and our processes taking place, and there is then a three-month opportunity for the service to respond to our recommendations. Primarily, it will do that in an action plan. If we have concerns, we go back.
On Skye house, it was devastating for us to hear the level of the distress of the young people who came forward in the documentary. That was not what we had heard during the visits. We had heard concerning things about staffing and about the different types of staff, and we had heard concerns about different approaches, but not to that extent.
If you were to be given more powers, what powers would you want to have?
The powers are set out very clearly in the Scottish mental health law review, which was based on three years of evidence gathering from people who use mental health services and their families, various stakeholders, third sector partners in the community and advocacy services.
We would like to have powers in relation to a range of things. There are clearly opportunities, as was recommended in the Scottish mental health law review, for us to take matters to court, if necessary. In the past, when we have needed to do that, we have gone to another partner to do that for us. For example, our partners in the Equality and Human Rights Commission took a matter to court for us with regard to a concern that we had in relation to people’s care and treatment. We would like to be able to do that ourselves.
As I said, we would also like to have additional powers in relation to coercion, restraint and the use of community compulsory treatment orders. We have done a piece of work on that in response to the Scottish mental health law review. Community compulsory treatment orders came in in 2005, under the 2003 act. Those orders were meant to support people to stay out of hospital, recover at home and get well. They would then come off the order. However, we and the Scottish mental health law review found that people had been on those orders for 17 years or more, which is coercion in the community. We need to look at how that can be stopped, too, because, unless people are supported to recover and receive the service that they are entitled to, they should not have orders in place to compel them to do things.
There is a range of things in the Scottish mental health law review in relation to which we would like to have the powers to extend our role so that we could be more effective. We also need to be resourced. You will know from our papers that we are a small body. We have a budget of around £4.6 million, and we do our best with the resources that we have, but we would like to extend and expand based on the Scottish mental health law review’s recommendations.
We will move on to another area of work on which the Mental Welfare Commission has published a report—“Hospital is not home” was published in January this year. What is your perspective on the effectiveness of the dynamic support register in improving visibility and transition planning for individuals with learning disabilities?
The Scottish Government commissioned that piece of work to consider the lack of progress—or apparent progress—in relation to people coming home from hospital.
We are very clear that people should not be in hospital unless there is a clinical need for them to be there. It is not the right place for people to be in. We were concerned when Public Health Scotland reported that, at that time, 30 people had been in hospital for 10 years or more. When the Mental Welfare Commission contacted all health and social care partnerships to ask who was on the dynamic support register, we were told that there were 55 people on it. That was within four months of the Public Health Scotland figures, so the numbers are growing.
We focused on people who had been in hospital for 10 years or more. The average stay of those 55 people is 18 years. We are really concerned about the lack of movement and dynamic support planning, despite the dynamic support register and delayed discharge planning. There is quite a significant industry in HSCPs that focuses on delayed discharge, yet people with learning disabilities and complex needs, and people with mental health conditions, are still stuck in hospital.
We found that it is early days in relation to the dynamic support register and the peer support network, which was set up through the “Coming Home” report. I think that the network first met in October 2024. Those two aspects offer hope. The peer support network is so important. We identified that people are getting stuck in hospital because they have very complex needs. There is really good practice in some areas, and, with a national strategic overview, that good practice can be shared nationally and creative solutions can be developed in communities. Solutions exist—the issue is that some areas do not know about them. The peer support network has the potential to make a significant difference in that regard.
The use of the dynamic support register has been quite inconsistent so far. It was unclear who would end up being placed on it and who would not. Likewise, it was hard to know who would be placed on delayed discharge lists. Probably more worrying is that there are people who are not on any list, and they should be. We are quite concerned about that, because there are people who are almost lost and hidden.
Sometimes, an older person might stay in hospital because there is no exit strategy for them. Those people also have a right not to stay in hospital and not to be in hospital if there is no clinical need for them to be there. We also found that there is a lack of dynamic care planning for some of those people. Rather than thinking that creating something for a person who has very complex needs is too expensive, people should be thinking that a dynamic look at services could be more cost effective if that is done as part of the peer support network. The “Hospital is not home” report highlighted all those things, but it followed our “Out of NHS area placements” report as well. There were very similar themes in that regard.
I will maybe pass over to Claire Lamza to talk about our finding that people who were placed outwith NHS Scotland are sometimes forgotten about, because they are in England or in private settings. They have a right not to be there either, but we found that, sometimes, when people were outwith NHS Scotland, their care teams or the host authority would not maintain contact and people would stay there.
We might move on to discuss that a bit further. Do you think that the register is effective or not?
The register is in its early days. At the minute, the register is not as effective as it could be, because it is so inconsistent as to who is and is not placed on it. Likewise, the peer support network, which is a recommendation of “Coming Home”, was set up only on 24 October. There is time for that to improve. It clearly can make a difference and will make a difference if that co-ordination is in place.
We recognise that health and social care partnerships are extremely busy. They are very busy on their day-to-day work and it is quite difficult to look to your fellow HSCP or one that is quite far away to find out whether some people have similar complex needs and to look at creating a creative solution together. The peer support network will allow that to happen.
As I said, there are really good examples of creative solutions in the community, but not everybody knows about them. That peer support network could make a huge difference. That potential has not quite been realised, but it is there.
When you talk about a peer support network, are you talking about interagency working and looking at best practice in particular parts of the country, such as specific local authorities or whatever?
Absolutely—
Is that as opposed to peer-to-peer support?
Yes, you are right. Peer-to-peer support often involves people sharing lived experience, but the peer support network, as recommended in “Coming Home”, is about partnerships and agencies working together to find creative solutions locally for people.
Is the Mental Welfare Commission involved in that on-going work?
The Mental Welfare Commission is involved in relation to the 55 people identified in “Hospital is not home”—
No—I am asking whether the MWC is involved in developing and sharing best practice.
No, we are not.
Is that because you were not invited to do so, or because you have chosen not to participate?
We have not been invited to join the peer support network. I guess that the people who know best what the needs are locally with regard to national strategic commissioning are the commissioners from across health and social care partnerships. We, as the Mental Welfare Commission, would then visit people in those creative solutions that are developed in the community, to be assured that the care and treatment is lawful and in accordance with the standards that we would expect, based on best practice.
What improvements do you feel are required to ensure that individuals with learning disabilities and mental health needs who are clinically assessed as being ready for discharge can be helped to transition effectively into community settings?
I do not know whether Ms McGuinness would like to contribute.
I will just start by noting that “Out of NHS area placements” highlighted that millions of pounds are being spent across the board in relation to people who are in such placements. If there was a strategic overview of that financial envelope to create something more local, it would make a difference in helping people to transition quicker in a more co-ordinated way to more local areas in Scotland.
I will pass over to Suzanne McGuinness on the social care aspect in particular.
With regard to improvements, as Julie Paterson said, there is currently a lot going on across the piece, and services are facing a lot of barriers and challenges; we see that through our work.
On assessing whether people are ready for discharge, particularly people who are affected by learning disability, it is important to ensure that there is early intervention and discharge planning and that the right resources are in the right place at the right time for people. That is fundamental to improving the outcomes for people.
What improvements need to be made? We all accept that such things need to be in place, and the commission is saying that improvements need to be made, but what are those improvements?
A lot of improvements need to be made. A lot of joined-up work is going on right now, through the agenda set by “Coming Home” and so on, and we are looking at additional resource. For example, Claire Lamza has conducted a piece of work on out-of-NHS Scotland placements, which found that—at a very conservative estimate—there was a cost of £13 million, through NHS funding, for 59 individuals. That is a lot.
Julie Paterson talked about the peer support network. Everyone is joining up and looking at how we can do things differently and be creative and innovative, but funding is an issue. As part of our role, we also hold end-of-year meetings across every health and social care partnership and every health board, and we hear about pockets of services that are trying really hard to be innovative and creative, but resources are limited, which affects what they can do. Nevertheless, we need to give them the time and space to share that best practice, because they are local and are best placed to decide what is best for people in their areas.
Does the Mental Welfare Commission have a view, other than on the need for increased resources and sharing best practice about what improvements need to be made?
11:30
That aligns with what we were saying about Skye house in relation to the intelligence. One of the things that Julie Paterson highlighted from “Coming Home” and the follow-up report, and which is highlighted in the information that we collected in “Hospital is not home”, which was replicated in the “Out of NHS area placements” report, was that the information that is given to Public Health Scotland is not always accurate. We use that data and get further information on it, but, for example, the data on delayed discharges is gathered differently across Scotland. It comes back to what Julie said about the need for standardised approaches, which would have to come from the Scottish Government and the recommendations that we made at that point.
At the core, if the information is correct, we have the authority and the ability to follow it, as we did with authority to discharge. We need the intelligence and information to check what is happening in the local area, as Suzanne McGuinness was saying, through our area co-ordinators and our end-of-year processes. If we get the information correct, we can follow up either through the individual or through the health and social care partnerships and our links with them. It comes back to knowing that what we have is accurate. At the moment, we are not sure that it is.
To go back to the dynamic support register, when we asked about the 55 people, and as we did for “Out of NHS area placements”, we found that the data is not always collected systematically across Scotland and it is not provided in a way that can be followed up to the point that we would want it to be. We want to be able to give that information back to the areas and the partnerships and ask what community resources they are putting in place and what they are doing with discharge planning.
There has to be a progressive continuum, but we also have to get the right information. The commission must be able to access that and have the resources to follow that through.
Aside from the better collection of data and increased finances, does the Mental Welfare Commission have any other recommendations for how we can help people with complex needs to transition to community places safely?
I will add to what Claire Lamza said. In relation to our work, we have highlighted a range of improvements that are required. For example, in our report on Mrs F, there were huge concerns about the events in relation to that particular death, where there had been a lack of understanding and grasp of the importance of communicating with families and relatives and taking on board their views. That report also highlighted a lack of understanding about risk. We clearly identified that improvements are required not only in that area but across Scotland. When we do a piece of work, such as an investigation, we recognise the learnings across Scotland.
Likewise, the report on Mr E identified that health and social work did not work together, so Mr E fell between the two—social work thought that health was responsible and health thought that social work was responsible. The report was very clear that there was not an integrated approach, despite that being the intention.
Does that case relate to delayed discharge from hospital into a community setting?
That case does not relate to delayed discharge.
I am sorry—perhaps I am not being clear enough. I am talking specifically about what the Mental Welfare Commission recommends to help transition people with complex needs into community settings safely—it is about people who are clinically ready for discharge.
You identified two areas—data and finance. Is there anything else that the Mental Welfare Commission would specifically recommend that would help to facilitate that?
Absolutely. We have already recommended that reform of the Adults with Incapacity (Scotland) Act 2000 is important. The AWI legislation was of its day 20 years ago, but now it is quite clunky. It sometimes prevents people from being able to move from hospital to the community—rightly so, because the safeguarding legislation should be respected, but it could be less clunky. That is a key area, so we look forward to progress on the AWI reform.
Access to the right social care and recognising that there is a range of partners that can provide that social care is very important. Third sector partners are experts in providing social care and rehabilitation in the community. It does not have to happen in the hospital, which is also really important.
Advocacy is critical to supporting people’s voices to be heard, particularly for the people who we are talking about. Their voices are often not heard, and they often need some support. They may feel disempowered in hospital settings, and their health condition may mean that they do not have the confidence to speak.
Advocacy is very important, so we are particularly concerned to hear that, in the current fiscal environment, individual and collective advocacy could diminish rather than grow. It would be a huge concern if advocacy were not to be in place for children, adults and older people so that their views are heard and to support them to move outwith hospital to where they want to go, in a setting that is important to them.
Good morning. What do the witnesses think about the progress that has been made to date in implementing the recommendations of the mental health law review? What progress has been made? Let us be open and honest about it.
I have spoken at length about that. We welcomed the Scottish mental health law review because, as I said, the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults with Incapacity (Scotland) Act 2000 were of their day but are now decades old. They have not kept up with human rights, and there needs to be reform.
We recognise that there were 202 recommendations in the Scottish mental health review and that some will perhaps take up to 10 years to be realised, but others do not necessarily need changes in law and can be acted on much more quickly. As I said previously, there are a number of recommendations that the Mental Welfare Commission would like to see progressed and be considered. Those relate to our role and responsibilities, which we would like to be strengthened to enable us to grow our impact and make us more effective. We are keen for the recommendations to be considered and, if agreed, to be implemented at the earliest opportunity.
Thank you. I have no further questions, because the other questions have all been answered.
I thank the panel members for joining us today. I want to touch on the wider issues regarding key challenges to mental health services. The convener touched on some of the complex cases and asked how services can be better able to deal with those. What measures do—[Inaudible.]—to improve care in Scotland’s mental health system for individuals with complex needs, including autism—
Mr Sweeney, could you repeat your question? We lost a part of it.
Apologies, convener. I am keen to know what measures the witnesses feel should be taken to improve care in Scotland’s mental health system for those with complex needs, including autism, acquired brain injuries, personality disorders and dual diagnoses.
What you describe is the work of the Mental Welfare Commission. The population’s mental health and wellbeing is absolutely important—there is no doubt about that. However, our concern is for people who are at the end of the mental health continuum, who experience severe and enduring mental illnesses.
You referenced acquired brain injury. Our concern is for people who sometimes do not have a voice in the way that other people do to be able to express their views. Those are the people who are most important to the Mental Welfare Commission, because we know that they are some of the most vulnerable people in our society. That is the group of people you described, which is our focus. We need to ensure that their rights are upheld and protected and that we, with services, can support them to ensure that. That is the group of people we focus on throughout the work that we previously described—through our visits to individual people in their homes, in care home settings and in health settings.
You will have noted our previous work in relation to alcohol-related brain damage. We did a piece of work in which we visited a number of people with alcohol-related brain damage, to identify whether their care and treatment was appropriate and whether there was a recognition that people with ARBD can improve their skills and abilities. Legislation is not necessarily required to compel that.
It seems that fundamental problems have been identified in relation to resourcing. In its 2023 report “Adult mental health”, Audit Scotland noted that limited and short-term funding across many mental health services is creating additional challenges in addressing staff recruitment issues. That makes it difficult to fill vacancies, because funding is often provided only on a fixed-term basis, which is undesirable to applicants. We have seen that play out in relation to not only third-party services, but core services such as those that are provided at Skye house, where a culture of high staff turnover and a lack of leadership was identified as a key causal factor in the poor performance of that unit.
What long-term strategies are needed to address that short-termism and to deal with the resultant issues with staff recruitment and retention that are currently being experienced across pretty much all aspects of Scotland’s mental health system?
You are absolutely right. As Suzanne McGuinness has just said, we meet most senior managers in health and social care partnerships annually, and, as Claire Lamza has described, we undertake regular, day-to-day visits, as part of which we speak to nursing, medical and social work staff on the ground.
There is a significant challenge with staffing across the board, whether we are talking about nursing and medical staff or about mental health officers, and that impacts on the care and treatment of the people who are most vulnerable. Mental health officers are a really important safeguard for people. As Claire Lamza has described, not having enough nurses or medical staff can lead to the use of bank or agency staff, who are not substantive within the setting. The use of locum medical staff can lead to a lack of consistency of care and a lack of continuity of care, because there is such a demand for the services. As Claire said, the level of acuity is increasing and our staff group is not increasing to match that. Those are areas in which it has been reported to us that staffing is a challenge, and we need to appreciate that when we visit services, because we need to understand the context.
Likewise, in relation to funding, which you mentioned, we hear from third sector providers, in particular, about the fact that, because they receive annual funding, they lack the ability to plan. Their desire is to have at least a three-year plan rather than fixed annual funding, so that they can plan ahead.
We know that there are significant challenges across the board. As I have mentioned, advocacy is really important for the people you described—the people who are most vulnerable. We need to have services that are sustainable. From our point of view, as the Mental Welfare Commission, we visit, we make recommendations and we focus on the individuals and their experience, but we hear from service providers and commissioners about the challenges that they face in providing the services that we expect them to provide for the people who are most vulnerable, who, the law says, have a right to those services. That includes the right, under sections 25 to 27 of the Mental Health (Care and Treatment) (Scotland) Act 2003, to access assessment for social care services so that they can be supported to leave hospital.
You mentioned health and social care partnerships and integration joint boards. It seems that, every financial year, decisions are made at that level that militate against the creation of long-term value in mental health services. I could rhyme off a number of recent decisions in Glasgow, such as the decisions on Flourish house, the Notre Dame Centre and the Sandyford clinic, that do not chime with the objectives that have been set nationally. There seems to be fragmentation and a lack of accountability across the system when it comes to designing services that are focused on the needs of patients.
With regard to recommendations, what do we need to do to improve a structure that leads to poor data collection, a lack of co-ordination and a lack of accountability?
The Mental Welfare Commission’s focus is very much on the needs of the people we work with. We are strongly focused on those individuals. As I said, we are not an inspector of services—we do not regulate services—but we hear stories such as those that you have described from the people we meet about the challenges that services face. The issues are interlinked. We ask for the highest level of care for people and for continuity of care, and we hear about the challenges that are faced in relation to finances and funding. Our job at the Mental Welfare Commission is to be aware of that but never to lose focus on the individuals and the care and treatment that they are entitled to under the law.
We appreciate the challenges, and we appreciate that the decisions about funding, structures and organisations sit outwith the commission—it is not for us to dictate how funding should be provided or what people should provide—but we know what services people need in order to live and to flourish. People who have mental health issues, learning disabilities and associated conditions have a right to live the lives of their choosing, to flourish and to receive the support that enables them to do that, and we will continue to make that case.
There will be themes that you gather from people’s experiences, and there will be a level of commonality that perhaps drives you instinctively towards certain recommendations. Aggregating patient experience, do you have any insights on common trends or common relationships that enable you to identify what needs to change? Could you at least offer some personal insight on that?
11:45
From our local visits, we make more than 450 recommendations. When I look at those reports, the themes seem to be fairly stable. Most of the time, it is about people wanting to feel engaged and have meaningful contact with whoever is delivering the service, including in relation to care planning and discharge planning, and it is about people wanting to be involved in what happens to them. It is also about what restrictions are put in place, which people maybe do not understand or agree with. Individuals who are being cared for can feel that a number of things are being done to them, and we often hear that families and carers are not included in decisions about someone’s future—where they will go or what will be available or on offer to them.
The themes remain pretty consistent. The individuals we speak to would like to be heard and would like their rights to be upheld when they receive care and treatment. They would like access to a broader range of, for example, allied health professionals or psychology services. That was picked up clearly in the Audit Scotland report. They also want activities in their community that are meaningful for them and that give them a life that is beneficial to them, as Suzanne McGuinness highlighted.
Environment is another factor that has an impact. Something that has come through over the past few years is that a lot of the environments that people in mental health or learning disability services can access are not fit for purpose.
There are a number of challenges that are raised consistently and repeatedly, mostly around individuals and their carers and families wanting to be heard and involved.
That is helpful. I appreciate your time. Thank you.
I had some thoughts about the work that I have done previously on eating disorders. I know that the Mental Welfare Commission did an exercise to map eating disorder services in Scotland. We saw an increase in the number of people assessed and diagnosed with eating disorders during Covid. We have had lots of discussions about that and there has been additional funding from the Scottish Government. The eating disorder charity Beat has been really good at engaging with and supporting people through its activities online.
I would be interested to hear about any updates or recommendations following the mapping exercise. What would you say needs to be the number 1 priority in, for instance, referrals, given the eating disorder services that we have across Scotland? For example, in Dumfries and Galloway and in the Borders there are on-the-ground specialists, but sometimes people then need to be referred to Skye house.
Again, it comes back to the role of the commission. It would probably be the young people or adults with the most acute experience of an eating disorder and who require secondary care who would come into contact with the commission. They might contact the advice line, so that comes through as casework. At that point, we would advise accordingly and involve organisations such as Beat, which helped us when we were doing the eating disorders work. For anybody who contacted us or asked us about that, we would make the links to community-based services.
On the other side, in relation to the more extensive requirements of people with complex eating disorders, at whatever age, we do more focused work. The mapping exercise and our contact with and visits to services such as the regional eating disorder unit and its equivalent in Glasgow allow us to understand what is happening with the Scottish intercollegiate guidelines network—SIGN—guidelines, how they are being implemented and how they are working.
I am aware of tiers within the eating disorder services—someone might be dealt with under tier 4, or however they work it, and then be handed on to the community-based services. We retain an overarching understanding, but we are focused primarily on when someone is admitted to an environment where they get care and treatment. It goes back to what I was saying to Mr Sweeney. At that point, we would be interested in whether that individual had been made aware of their rights, whether they had been encouraged to develop other strategies and contact other organisations, and whether they had access to all the right care and treatment, such as dietetics, occupational therapy and psychology. We would focus more specifically on those aspects, rather than taking an overarching focus on what was happening with eating disorder treatment across the piece.
Just before Julie Paterson comes in, I note that there are issues with young people transitioning from in-patient care to community care. Eating disorders affect boys and girls—everybody thinks that they affect only girls, but they do not. I am interested in the community aspects of care.
I am sorry for interrupting you.
I will add to what Claire Lamza has said. In May, we issued our updated guidance on eating disorders, which I will send to the committee. A range of people who have experience of using services sit on one of our statutory advisory committees. Its members tell us what work we should be doing for the next business year and what is important to them, and our work on eating disorders would have come from their suggestions. We take suggestions from across Scotland about what we should focus on, because, as Claire said, we know what is important to people only if they tell us. For example, the group might raise the concern that we need to do more on eating disorders in our work on children and young people’s units and that there needs to be more learning across the board. That may well come out of our work going forward.
We will hear from Ms Callaghan next.
It appears that she is not online.
Sorry, convener. I could not unmute myself.
We have talked about families and how it is often difficult to get information when patients are very ill, which makes family support all the more important. Often, families will know the individuals best and will have the strongest desire to ensure that their wellbeing is taken care of and that they get home as quickly as possible. Is there a need to formalise family involvement? Could we have structured interviews in which family input is recorded and reviewed? Are there any other suggestions about how we could listen to what families have to say and act on their input?
Your camera must be off, Ms Callaghan.
My camera is on.
You might need to sit forward.
Your timing is perfect, Ms Callaghan. We have just completed our first themed visit for our work on carers, which has been useful. The documents that we have submitted to the committee contain information about the commission’s process with the advisory committee. The committee highlighted exactly what you have picked up, which is that we need to hear the voice of families, relatives, carers, unpaid carers and others that are included in the collective terminology. During our themed visit, we consulted a range of carers organisations, in a process that was similar to that which we followed for our work on eating disorders. We are in the process of pulling their views together, and we hope to have a series of recommendations from that work fairly soon.
It is fair to say that some of the stuff that has come through is fairly shocking for us. It is distressing to hear about the experience that carers have had and some of the difficulties that they have faced with their loved ones, as well as about the care and treatment that been provided to them that they have not been informed about. The guidance “Carers, consent, and confidentiality”, which we updated recently, highlights some concerns that carers have raised repeatedly with us through our advice line and during our visits and investigations. We have already talked about Mrs F, and we constantly have contact with people to gain an understanding of their issues. I hope that that will come through in the themed visits.
I thank the witnesses for their attendance and for their evidence. The committee will continue its work, but please feel free to leave.
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