Mental Health Strategy
Good afternoon. The first item of business this afternoon is a debate on motion S4M-05444, in the name of Michael Matheson, on Scotland’s mental health strategy.
We published Scotland’s mental health strategy—“Mental Health Strategy for Scotland 2012-2015”—in August last year, and I will use this opportunity to set out some of the priorities and commitments in that strategy. I also want to hear from members about their views on the strategy and the feedback that they have received on it from other stakeholders.
Mental illness is one of the top public health challenges in Europe. The challenge that we face in improving mental health and mental health services in Scotland is great. However, it is not that different from the challenge anywhere else in the western world. Across a range of mental health indicators, Scotland is broadly in the middle.
The picture is similar with the rates of suicide, and mental disorder is strongly related to suicide. The average annual suicide rate in Europe is 13.9 per 100,000; in Scotland, in 2010, the rate was 14.5. That puts us a little above the European average, but our suicide rate has continued to fall. It is also worth noting that the prevalence of mental illness does not seem to have changed significantly over time.
In Scotland, we have made good progress in closing the treatment gap and ensuring that people with mental health problems are more likely to seek help, get a diagnosis and receive evidence-based treatment. In particular, we have had success with depression and alcohol misuse. However, the bigger challenge is in the detail under the headline figures.
Mental ill health affects our communities unequally. People from our most deprived communities are much more likely to experience mental illness. Again, Scotland is not unusual in that, as the picture is similar in other countries in Europe.
Scotland has much to be proud of in how seriously the country takes mental health. It is telling that the Parliament has debated mental health issues on a number of occasions. Those debates have been initiated by the Government, by committees and in members’ business. That demonstrates the progress that has been made in tackling stigma and being able to talk about and debate mental health issues openly and frankly.
Although the challenge is big, we have made some significant changes in recent years, and I will mention a few of those. Each is an area that the Scottish Government set as a priority and in which it supported delivery of the change. However, one of the key messages is that the change and improvement were delivered locally by national health service boards, local authorities and the third sector working with service users and carers.
I want to carry that theme into how we implement the new mental health strategy. I want to build consensus on what to prioritise and to work in partnership with those who wish to support change.
Given that the strategy builds on existing Scottish Government policy, why has the Lanarkshire mental health services plan—which was in line with the strategy and approved by Nicola Sturgeon, when she was Cabinet Secretary for Health, Wellbeing and Cities Strategy, in August last year—still not been implemented? Is the minister aware that, since 26 September, when the minister took over responsibility for the plan, Alex Neil has continued to be involved as Cabinet Secretary for Health and Wellbeing and that he wrote to Pamela Nash MP on the matter on 5 November?
As I mentioned, the changes and improvements are delivered locally. It is for the NHS board to make any changes that it thinks are appropriate and to refer to ministers any matters that must be referred to ministers. As the cabinet secretary has made clear, if there are any changes that require ministerial input, I will consider them at the time, when NHS Lanarkshire brings them forward.
There has been a steady reduction in the number of people who are discharged from hospital and then readmitted. Between 2004 and 2009, there was a 25 per cent reduction in the number of readmissions. Being admitted to hospital has social and economic implications, so reducing the number of readmissions is important. The reductions have been delivered through work to improve the quality of in-patient and community services, and by improving discharge planning. We intend to build on that as part of the new strategy, in which we will look to develop better indicators of the quality of community services.
Another area in which progress has been made is the prevention of suicide. Between 2000 to 2002 and 2009 to 2011, there was a 17 per cent reduction in the suicide rate. That figure is based on the three-year rolling average. I will discuss how we intend to do further work to reduce the incidence of suicide and self-harm in Scotland later in my speech.
I want us to continue to work to deliver our existing commitment to offer faster access to specialist mental health services for children and young people, and to psychological therapies. I want to capitalise on what we have achieved and to deliver a set of commitments that are designed to increase the pace of change across the system. To do that, we need to focus on a number of areas. For example, we must reduce variation in the availability of good-quality mental health services, such as intensive home treatment and first-episode-psychosis services. We will build on the prevention agenda by placing a greater focus on the first years of life, and we will work with other policy areas, such as employment, justice and the early years, in which mental health has an important contribution to make.
There are two areas in which we are making developments outwith the mental health strategy, the first of which is dementia. We are in the middle of an engagement process to develop a successor to Scotland’s first dementia strategy, which will be published in June. We have also made a commitment to engage on a new suicide and self-harm strategy that will follow on from the suicide reduction and choose life work that has been done to date. That engagement will start in the next few weeks.
We had a great response to our consultation on the mental health strategy. We received more than 340 responses to the written consultation, and people attended our national event and numerous local events. Seven themes emerged from the consultation, which we have used to describe the way in which we want to deliver the commitments in the strategy. Those themes, a few of which I will mention, support the quality ambitions that healthcare should be person centred, safe and effective.
Families and carers have an important role to play in providing support to people with mental illness, but they can often feel excluded from making the contribution that they would like to make. Learning from suicides tells us that better work with families can lead to safer care and better outcomes, so we are working with VOX—Voices of Experience—and others to identify how we can increase the involvement of families and carers in mental health service delivery.
Another key theme that has come through in the consultation is tackling discrimination. Through the see me campaign, Scotland is internationally recognised for tackling the stigma of mental illness. As part of our work with the Scottish Association for Mental Health and other partners to continue to develop our anti-stigma agenda, we will work to reduce the discrimination and exclusion that many people with mental illness experience.
I did not read all the consultation responses, but I looked through the strategy, and I do not think that it mentions personality disorder. Will the minister consider improved diagnosis, treatment and care in relation to personality disorder?
If Mary Scanlon will bear with me, I will come on to that issue.
As well as the themes, we identified four key change areas. I will talk a little about each one. The period between pregnancy and four years is a crucial period in shaping children’s life chances. Secure attachment and competent and confident parenting are significant protective factors, which provide a child with confidence, resilience and adaptability. Poor attachment in infancy has been linked to a number of severe mental health problems in later life.
Evidence-based parenting programmes, such as incredible years and triple P—the positive parenting programme—are powerful ways of addressing conduct disorders and produce long-term benefits for the child and for society. They take a positive, assets-based approach to strengthening parenting competency. NHS Greater Glasgow and Clyde and Glasgow City Council are in the process of making triple P available to all parents in Glasgow and, through NHS Education for Scotland, we are starting a national roll-out of triple P and incredible years to the parents of all three and four-year-olds with severely disruptive behaviour.
As part of that, will the minister consider issues to do with postnatal depression and its diagnosis? Postnatal depression can have an impact on attachment, which can lead to the disruptive behaviour to which he referred.
That is part of the wider, holistic approach that we must take, to ensure that we address issues that might affect a child in the early years, such as the mother experiencing postnatal depression.
I want continued improvement across child and adolescent mental health services. We have supported a 35 per cent increase in the specialist CAMHS workforce since 2008. As a result, there have been significant improvements in access to services. The most recent data show that 89 per cent of children and young people are being seen within the existing 26-week target and that the average wait is eight weeks. The 26-week target is to be replaced by an 18-week target by the end of 2014.
We have not seen the scale of change that I hoped for on reducing admissions of young people to adult beds. There has been progress across Scotland, particularly in the south of Scotland, where the development of new models of care in the community has created additional capacity in the in-patient unit and significantly reduced admissions of young people to adult beds. I want the rest of Scotland to perform at a similar level.
Another key change area is to do with rethinking how we respond to common mental health problems. How people access treatment services is an important aspect of addressing the challenge in that regard. There is evidence of significant health service delivery in relation to psychological therapies, which is why it is right that we focus on improving that part of the system. Scotland is the only country that has introduced a waiting times target in the area.
We want a system in which psychological therapies are readily available to the people who require such support. We also want a wider range of services to be available, including social prescribing, self-help and peer-group support, so that people can get the service that best meets their needs and addresses their mental health issues.
A well-functioning mental health system needs a range of community, in-patient and crisis services. We set out a range of areas in which we intend to build on developments in services, to ensure that we implement the strategy effectively.
A strong message that emerged from the consultation was about the importance of employability. A person being in the right work can have a benefit on their health, quality of life and wellbeing. That is true for people with mental health problems, too, so we want to make further progress in the area.
Will the minister take an intervention?
I am afraid that I have very limited time and I want to cover the issue that Mary Scanlon raised.
The minister is concluding.
Yes.
We recognise that there is a particular need for work around the justice system. The report of the commission on women offenders identified mental illness and personality disorder as key contributors to women’s offending and the likelihood of their going to prison. We are building on the work that has already been undertaken in Cornton Vale to test the effectiveness of training prison staff to use a mentalisation approach to working with women with a personality disorder or women who have experienced trauma. We are already extending that work into NHS Lothian with a community-based personality disorder programme to see how we can learn from that and roll it out nationally.
I have not had the opportunity to cover all the areas of the strategy, but I am sure that all members will recognise that good progress has been made in improving Scotland’s mental health services in recent years. The new strategy provides us with an opportunity to ensure that we build on the momentum that has already been achieved.
I move,
That the Parliament welcomes the publication of Scotland’s Mental Health Strategy; recognises the challenges that Scotland, in common with other western nations, faces in tackling mental ill-health; notes the significant progress that has been made in mental health improvement, improving mental health services and reducing suicide, and believes that the priorities identified in the strategy will build on and increase the pace of change in mental health in Scotland.
We are rather tight for time for the debate. Dr Richard Simpson has up to 10 minutes.
14:45
At the outset, I should draw members’ attention to my membership of SAMH, the Scottish Drugs Forum and the British Medical Association. I am also a fellow of the Royal College of Psychiatrists and the Royal College of General Practitioners, and a member of William Simpson’s.
I very much welcome the minister’s tone and the approach that he is taking in wanting to listen to members. The new strategy for 2012 to 2015 is evidence of the Government’s ability to produce strategies in which stakeholders are listened to. I hope that the Government will listen to the other parties today.
We do not intend to be highly critical of the review, which is excellent. It builds on the previous work that has been done by successive Governments, including the mental health framework report in 1997. However, there is one difference. The first framework was immediately accompanied by two things, one of which was a monitoring and supervisory implementation group. That meant that those in the field could see where the variations that the minister mentioned were and could try to address those issues.
The other good news at that time, of course, was that the framework was followed by Labour’s doubling of NHS funding. It is quite clear that that is not open to the current Government. The challenges are therefore different.
That investment by Labour, the modernisation of the estate, and the increase in the number of mental health workers have changed the landscape. The number of beds has reduced and the old asylums are largely a thing of the past; even the state hospital has been renewed and its bed numbers have been halved, with medium-secure units being developed. Community care intensive home treatment and crisis interventions have increased. In particular, the level of readmissions, which I mention in my amendment, has reduced by 30 per cent. The Government and Labour take some credit for that. That is no mean feat, and it indicates the quality of the treatment that is being offered. Therefore, the Scottish National Party inherited the service in a better place.
Other factors that were external to the NHS were the positive one-third reduction in child poverty during our time, the reduction in pensioner poverty and nearly full employment. As we know, all those things contributed to a better place for mental health.
The 36 commitments are welcome, but there are things in the report that may reflect when it was drawn up. The challenges of a stalled reduction in child poverty, 20 per cent youth unemployment, increased part-time working, higher unemployment generally and a reduced standard of living for all confront us in considering where we will proceed on mental health.
In its briefing, the Royal College of Psychiatrists painted a somewhat starker picture for us. Suicide, drug misuse and alcohol, including the rapidly rising rates of alcoholic liver disease, contribute to premature mortality rates and other health inequalities in Scotland. That is now well recognised. The poor general health of people with psychiatric illness, which the report mentions, and their high rates of tobacco use have become increasingly evident as one of the causes of premature mortality. The impact of poor parental mental health and their substance misuse has an enduring effect on the development of children.
In the brief time that I have, I want to look at some of the pressure points on the system.
The minister mentioned health inequalities. The reconstitution of the health inequalities task force is an opportunity to look again at premature mortality due to poor physical health and excess smoking among those with mental illness. They have a significant effect. There is up to 10 years’ loss of life expectancy for that group. I hope that the minister will assure me that that will be one of his priorities in the re-established health inequalities task force.
On the elderly, the Government is to be commended for building on the work of Irene Oldfather, the cross-party group on Alzheimer’s and Alzheimer Scotland by adopting and pursuing an effective strategy on dementia, which I very much welcome. Among the elderly—the minister referred to this, but he did not emphasise the point enough—depression is three times as common as dementia. Those suffering from delirium are another important group. Among the elderly, depression is estimated to have a prevalence of around 13.4 per cent and is predicted by the World Health Organization to become the second-highest health burden in the western world by 2020. Depression is also strongly linked to disability. However, only 10 to 15 per cent of such patients are treated; unlike younger adults, fewer elderly people present to psychiatrists with depression or are diagnosed by general practitioners as having depression.
Unlike the excellent progress that has been made among younger adults, suicide rates among the elderly are almost completely unchanged over the 10-year period during which the HEAT—health improvement, efficiency and governance, access and treatment—target has been in place. Psychosis is also increasingly common because we have many more people over 85, and they are a group of people who are associated with greater levels of psychosis. However, the biggest lacuna in the strategy is the absence of a significant look at depression. Malcolm Chisholm will talk more about that following our cross-party group meeting the other day.
The main concern of addiction specialists is the level of alcohol consumption among the elderly, which is another important issue. However, I feel that not enough attention is given to alcohol-related brain damage in all groups. That is a growing problem, yet progress on achieving a joined-up approach seems to have stalled—Peter MacLeod drew attention to that in his evidence to the Public Audit Committee in 2011. Although there are excellent teams such as the one in Glasgow and support is provided by groups such as SAMH, Loretto Housing Association and William Simpson’s, not enough attention is paid to the issue. One case study showed that an ARBD sufferer had 11 separate case notes—that is not integration. I urge the Government to have a further look at that area.
On services for prisoners—Mary Fee will say a little bit more about this—I welcome the work on borderline personality disorder that is being done in Cornton Vale, which has been extended to Edinburgh. However, unless we take the Angiolini report seriously across both justice and health, we will be having this discussion in another 10 years. I was the justice minister when we set up the time-out centre in Bath Street, which deals primarily with people who have a drug problem. That has never been extended and has not been tried for men, yet many of those in our prisons have drug or alcohol problems. We have not tried extending such services to alcohol addiction, yet that is one way that we could reduce the prison population. We could reduce the need to build new prisons if we could get that group out of prison and into treatment.
On child and adolescent mental health services, the almost certain achievement of the 26-week target is welcome and the move to an 18-week target is highly commendable. The Government has done a good job on that. However, the Mental Welfare Commission has expressed a slight concern in its report that the number of admissions to adult wards has flatlined at around 140. That is the same level as in 2009, after which the numbers peaked and have since come down again. I hope that we are seeing the start of a new trend, but I have not seen any clear statement about the bed numbers. The strategy says that the number of beds will increase from 42 to 48, but the original agreement was for 56 and I do not think that the difference can be entirely due to having intensive home care work.
Although the early years strategy is very welcome—initiatives such as triple P and incredible years are excellent—we also need to work in the primary schools. For example, Place2Be provides a talking point in schools for pupils who feel under stress. That has been highly successful in Niddrie in Edinburgh and has now been extended to East Lothian and Glasgow, where it is working extremely well. Such services at a lower-tier level can prevent pressure from being put on CAMHS and help the Government to meet its target. That is not the only programme, but it is worth doing.
The suicide rate is down by 16.7 per cent, so we are moving towards the target of reducing the rate by 20 per cent. Choose life and see me have both made a big contribution to that. I also welcome the minister’s announcement about refreshing the strategy. However, although we talk about percentages, we should recognise that that is still 770 deaths, which is a lot of deaths. We have 500 deaths from drugs, 770 from suicide and about 1,000 from alcohol. Those are three areas where we will need to renew our attention and renew our effort.
The achievement of the target on psychological treatment is extremely welcome. The NHS 24 online service is useful, particularly in the Highlands and Islands, although face-to-face therapy is needed. Meeting that objective will continue to be a challenge, but I agree that the Government’s attempt to do so is great. The people in need of therapy are often in work, and we need a flexible approach, with appointments offered at times that will suit the workforce.
I welcome the fact that we now have a specialist deafblind community service based in Lothian, but when will the admissions to the John Denmark unit in Manchester conclude with the introduction of a unit in Scotland so that individuals do not have to travel?
The Mental Health (Care and Treatment) (Scotland) Act 2003 has not been fully implemented. I know that we will be looking at tribunals legislation shortly, but when will the Government commence section 268 of the 2003 act, giving a right of appeal against overly strict detention in non-state hospitals? The time has come for that to be implemented.
I commend Labour’s amendment to the chamber. Members will note that we have drawn attention to one or two additional priorities, but we have not drawn attention to all the priorities, because we recognise the financial restrictions on the Government. However, we are not alone in calling for a clear timetable and supervised monitored implementation. SAMH makes that same point, because only then can the welcome aspirations of the strategy be fully credible.
I move amendment S4M-05444.2, to insert at end:
“; while noting that significant progress has been made since the Framework for Mental Health Services in Scotland in 1997, the Mental Health (Care and Treatment) (Scotland) Act 2003 and Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011 including improving mental health services, suicide reduction and readmissions to psychiatric units, nevertheless recognises that depression in older people, which the World Health Organization has stated will be the second greatest health burden in developed countries by 2020, the record number of drug deaths and tackling alcohol-related brain damage all merit specific commitments along with the priorities identified in the strategy, which will build on and increase the pace of change in mental health in Scotland, and looks forward to the production of a report on progress on the 22 commitments in Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011 and on the Scottish Government’s response to the Public Audit Committee’s 3rd Report 2010: Overview of mental health services, and an action plan on the 36 commitments in the new strategy together with a clear indication of how the Scottish Government intends to monitor progress.”
14:56
I welcome the opportunity to participate in the debate.
This week, the Office for National Statistics revealed a different figure for the number of suicides from the figure that has been quoted by others, with an increase of 7.8 per cent up to 2011. No matter whose statistics we use, the issue is of concern. The debate is timely, although it should be noted—as the minister did—that the strategy, while welcome, was published a number of months ago and it could be argued that we should have discussed the issue at an earlier stage.
I note the recent slight increase in the year up to September 2012 in the number of clinical psychologists employed by our health boards. I commend the Government for that. The Scottish Government rightly recognises that faster access to psychological therapies is a key component in our efforts to tackle mental health issues. It is also key in assisting the reduction in Scotland’s suicide rate. No matter whose figures are used, suicide is still a leading cause of death among those under the age of 35. I therefore welcome the decision to include access to psychological therapies as an 18-week referral-to-treatment HEAT target from December 2014.
Although the deadline for achieving that target is still nearly two years away, I was curious to see what the picture looks like. Indeed, so was SAMH, which has asked the Scottish Government to commit to an audit of the provision of, and waiting lists for, psychological therapies. I understand from the Scottish Parliament information centre that no stats exist on waiting times for access to psychological therapies, due to delays and changes in personnel at ISD Scotland. I therefore look forward to the minister confirming in his summing up whether he will consider having that audit and when ISD Scotland will be in a position to begin publishing the statistics.
The minister will be aware that, two years ago, the coalition Government announced its own strategy, backed by £400 million of additional funding, to massively widen access to psychological therapies south of the border. The aim—which I trust is one that would be supported across the chamber—is to put mental health on a par with physical health with regard to perception and treatment, and to end the stigma that attaches to sufferers. Not only is that the right thing to do, but it will result in more than £700 million of savings to the public purse. It is an example of preventative spending at its best, and I hope that the minister is keeping a keen eye on it.
When it comes to access to much-needed psychological therapy, I am afraid that there can be no doubt that something of a postcode lottery exists throughout Scotland. We are not talking about people waiting for a minor operation or a routine scan. People are often in desperate situations, experiencing real mental anguish, and they need to be treated as soon as possible.
Currently, the national average full-time equivalent figure for clinical and other applied psychologists is 11.3 per 100,000 people, with the rate increasing to 14.8 in NHS Greater Glasgow and Clyde and 15.5 in NHS Fife, but it is 10.0 in NHS Grampian, 8.9 in NHS Highland and as low as 7.6 in NHS Forth Valley. People in the NHS Forth Valley area therefore have less than half the number of clinical and applied psychologists of their close neighbours in the NHS Fife area. That seems to signpost a postcode lottery situation, which I hope can be addressed.
I highlight in my amendment the rise in antidepressant prescribing in the NHS. There is no doubt that antidepressants are a worthwhile treatment method for some and should continue to be used, but I am concerned that we have gone from dispensing 1.26 million antidepressant prescriptions in 1994 to dispensing 5 million last year.
The member talked earlier about reducing the stigma of mental ill-health. Does he think that it is unhelpful to continue to refer to antidepressants in the way that he has done, which leads to stigma? We would not have a campaign to reduce the use of insulin for people with diabetes.
I could not disagree with the member about that. However, as I said, antidepressant prescriptions have increased from 1.26 million in 1994 to 5 million last year. A previous Government target to address the issue was quickly scrapped. I shall address the issue further in when I sum up.
I do not know whether the member is aware of a change in the prescribing guidance that was issued to doctors. That change was about moving away from using low doses of antidepressants over a short period of time to using higher doses over a longer period. Some of the statistics that the member mentioned actually refer to the definable daily dose, which means that the figures show not that more people receive the medication but that the level of the dose is higher, which gives the impression that more people receive the medication.
I ask Jim Hume to begin to conclude.
Okay.
The mental health strategy also highlights the benefits of people taking unilateral action to improve their own wellbeing, with physical activity offered as a specific example of such action.
The issue is growing—good mental health is at the core of the wellbeing of people in Scotland—and we will need to unite as a Parliament to address it. I believe that my Liberal Democrat amendment would strengthen the motion, so that we can move Scotland forward and away from any stigma. I would welcome support from all parties for my amendment.
I move amendment S4M-05444.1, to insert at end:
“; is concerned that antidepressant prescribing continues to rise and believes that patients must be able to have local access to alternative treatments, including talking therapies, when this is judged to be the best option for the individual; notes the UK Government’s investment of £400 million over the spending review period to improve access to psychological therapies in England, which it is estimated will result in over £700 million of savings to the public purse; considers that increasing access to talking therapies for all of those who need it should be a priority for the Scottish Ministers, and recognises that mental health is not just an NHS issue but is at the core of Scotland’s wellbeing and ability to flourish.”
15:02
For those of us who lead busy lives and who have little direct contact with mental health services or with people who are dealing with mental health problems, it is sometimes easy to forget that one in four of us will experience mental illness at some point in our lives. However, that is a fact of life that we should not ignore. I, for one, am grateful to my colleague Mary Scanlon, who consistently keeps mental health issues in her consciousness during her daily work as an MSP. She has done a great deal to raise awareness of the difficulties that are faced by those who are trying to cope with depression and other mental health problems by bringing such matters to the attention of Parliament on many occasions since 1999. I look forward to hearing her comments on the mental health strategy later in the debate.
Organisations that deal with mental health issues, such as the Royal College of Psychiatrists and SAMH—the Scottish charity that does such a lot to promote the interests of sufferers and to raise the profile of mental health issues—have also worked tirelessly to encourage Government to improve psychiatric services and to move mental health into the mainstream of health planning. The publication of the Scottish Government’s mental health strategy for the period between 2012 and 2015, which builds on the strategies in “Delivering for Mental Health” and “Towards a Mentally Flourishing Scotland”, has been widely welcomed, and its implementation is eagerly awaited.
The strategy’s seven themes, 36 commitments and four key change areas make very interesting reading and are to be commended but, as SAMH said in its helpful briefing for the debate and as Richard Simpson emphasised, the strategy runs only until 2015. An action plan for its completion is therefore clearly needed and a timetable needs to be in place for achieving its commitments. There is no doubt that significant progress has been made in recent years in improving mental health services and in reducing suicide, although every day two people in Scotland still die from suicide, which emphasises the urgent need for effective and properly resourced crisis services within communities across the country.
Clearly, in a six-minute speech it is not possible to deal in detail with what is a comprehensive strategy document, but I will touch on the four key changes identified in the strategy, starting with child and adolescent mental health.
It is now recognised that experience in the very early years of life has an enormous influence on later behaviour and that poor parenting at this time can result in major problems throughout life, so the priority that is given in the strategy to the early years and the focus on early intervention are welcome, along with the commitments to make infant mental health training more widely available to children’s services professionals and to increase the number of child psychotherapist trainees from this year. That should help to address the problems for children where aggression, non-compliance and emotional issues are likely to persist to cause school disruption, family stress and dysfunction and mental health problems, which we know can result in social isolation, drug and alcohol abuse and failure to gain employment, as well as, eventually, crime and antisocial behaviour.
I understand the point that the member makes. However, such problems also often arise as a result of parental mental illness. Does the member agree that categorising the cause as “poor parenting” does a disservice to those parents who suffer poor mental health?
I absolutely agree with that. Perhaps my choice of words was not appropriate, but I think that the member gets my intention.
The problems that I described are significant contributors to health inequalities. As the chief medical officer told the Health and Sport Committee just this week, most of the serious behavioural and mental health problems that affect young adults can be traced back to the first few years of life. The problems are complex, and solving them will require the co-ordinated efforts of the NHS, local authorities and charities and other third sector providers. Access to child and adolescent mental health services has taken far too long in many parts of Scotland. Although the waiting time target is still too long at 26 weeks, it is welcome, as is the plan to reduce it to 14 weeks from next year.
The second proposed change is to rethink how we respond to common mental health problems such as the impact of excessive alcohol consumption, debt, trauma and distress. There is a commitment to identify the challenges and opportunities that are linked to the mental health of older people, notably in relation to depression, which looks set to become a serious and increasing problem in the next few years of rapid increase in the elderly population. Allied to that, of course, is dementia, and we look forward to the updated dementia strategy that was promised for later this year.
There is to be more focus on personal involvement in improving mental health and a drive to encourage more people to become physically active, because research has shown a clear benefit to all health, including mental health, from regular and sustained physical activity. Other areas for action include the continuing movement from in-patient to community-based services, which is proven to reduce admissions and readmissions, and the commitment to carry out an audit of those who use in-patient services and the reasons why they do so, which will, I hope, result in further progress in that area.
The Government’s work on armed forces veterans is increasingly important as more of them return to the community from arenas such as Afghanistan and face the difficulties of integrating into civilian life after the ordered life of the forces. As I have learned from my membership of the cross-party group on armed forces veterans, mental health issues ranging from depression and alcoholism to post-traumatic stress are all too common in those people.
Dr Milne, could you conclude, please?
Yes.
I have dealt with the target for access to child and adolescent mental health services. The other targets that I would refer to are the 18-week referral to treatment time for psychological therapies, which is far from being achieved as yet, and the target to reduce the suicide rate, which is being achieved quite well.
We welcome the mental health strategy for Scotland and are happy to support the motion, but careful monitoring of the implementation of the strategy’s commitments will be important. The work that has been done so far is commendable, but it is work in progress. We will follow it closely in the months ahead, hoping that the pace of change in relation to mental health in Scotland will indeed increase as a result.
A number of members wish to speak in the debate, so I ask for speeches of up to six minutes, please.
15:09
The motion asks us to recognise the challenges that Scotland faces in tackling mental ill health. They are considerable. The minister mentioned some of the key statistics in his opening remarks. Mental ill health is estimated to affect more than a third of the population at any one time, and although Scotland’s suicide rate is improving, it is still slightly above the European average. There is also growing evidence of the role that environmental and social stressors play in mental health. For example, the Government’s strategy reflects on the comparatively high levels of mental illness that can be found in welfare benefit claimants.
I worry—we should all be worried—about the impact that the new welfare reforms might have on those people. I certainly fear that the reforms will result in a further widening of income inequality across the United Kingdom. That matters. In 2010, The British Journal of Psychiatry carried an article by Kate Pickett and Richard Wilkinson that reported data that showed that a range of health and social problems, including mental health problems, are more common in more unequal societies.
On Tuesday we heard about citizens advice bureaux funding suicide awareness courses for their advisers, and that is also highlighted in the strategy.
If we recognise the continuing and developing challenges in this area of policy, however, we should also recognise the positive achievements to date. As I said earlier, Scotland’s suicide rate has decreased over the past decade. Although I agree that one suicide is one too many, I also think that an overall reduction of 17 per cent is noteworthy, although there is clearly some way to go to meet the 20 per cent target in the choose life strategy.
In addition, I warmly welcome and have been delighted to support SAMH’s see me campaign. One of the key factors to securing meaningful long-term progress in delivering the mental health strategy is tackling the stigma that is, sadly, still associated with mental illness, since it can present a significant barrier to people accessing help when they need it. That point is also made in the article that I referred to. I therefore welcome the prominence that the new strategy gives to tackling that stigma and the Government’s commitment to working with SAMH and other partners to keep pushing that agenda forward.
I also commend the strategy’s recognition of the early intervention agenda. We all know of the argument that good parenting has a material effect on adult mental health, whereas poor attachment in infancy can be linked to severe mental health issues in adult life.
This is not simply an issue for our health service; it is one of the key messages that the late Campbell Christie urged us to recognise. Early intervention will be successful only if it is delivered at the local level with community planning partners in local authorities and other agencies. Local social work and education departments will have a strong role to play, as they do in Dumfries and Galloway, for example, where the incredible years parenting training that is referred to in the strategy is being made available to the parents of vulnerable three-year-olds.
The inclusion of a commitment on social prescribing is also welcome. Although we should be clear that mental illness is no different from any other form of illness, and that, where medication is required, it should be prescribed, we should also investigate the possibility that there are other forms of therapy that may be effective.
Preparing for last week’s debate on biodiversity, I read SAMH’s submission on the 2020 biodiversity targets. It reflects on the impact that physical activity can have on promoting good mental health and improving the quality of life of people who experience mental health problems and on the importance of natural environments as part of that therapeutic benefit.
In the Stewartry, in the south of Scotland, which has a significantly higher than average elderly population, a social prescribing project that is joint-funded by NHS Dumfries and Galloway and the local authority is trying to reduce the level of antidepressant prescribing through other forms of therapeutic provision. I hope that the Government, as part of commitment 15 in the strategy, will have a look at what that project delivers and how it might link to the quality ambitions and core themes in the strategy. For my part, I hope that the project will be able to realise some of SAMH’s ambitions about the use of nature to help promote mental wellbeing.
A further welcome inclusion in the Government’s strategy is consideration of the issues that relate specifically to veterans. I am aware, for example, that the First Base Agency in Dumfries raises around £10,000 a year to pay for two half days a week of psychological therapy for veterans who have come to the agency looking for help. Clearly, that is a valuable service that is being funded through third sector action, but there must be a better way of funding that provision. I would argue that the Ministry of Defence has a level of responsibility in this area. It can and should be making the modest funds available to support people who have served this country under its direction and who now suffer mental ill health as a result of their experiences.
The mental health strategy represents a valuable opportunity to take stock of what has been done to date and also to include developing policy themes for the future. Fundamentally, however, it also represents this Government’s commitment to providing high-quality mental health services. It is, in the best sense of the phrase, a work in progress, and one which I am pleased to support.
I support the motion in the name of Michael Matheson.
15:14
A report produced last year by a group of Scottish GPs who compared notes on the impact of welfare reform on some of Scotland’s most deprived areas identified one overriding issue: a huge increase in the number of patients presenting with deteriorating mental health.
The patients fell roughly into two groups: those who had been well but were suffering from anxiety and depression because of job insecurity and financial pressures; and those whose welfare payments for poor mental health had been removed on reassessment. One GP described the test that his patients were subjected to as “unnecessary and avoidable” and another described the decisions reached as “medically inappropriate”. The report not only revealed systemic failure but uncovered a startling absence of understanding and imaginative sympathy.
The lack of compassion for mental illness is not confined to the welfare system; it permeates society on both sides of the border. I welcome the Scottish Government’s recognition of the severity of mental illness and its subsequent commitment to improving Scotland’s mental health as outlined in its mental health strategy for 2012 to 2015. As the strategy states, although we have made great strides in recent years, there is still much to be done.
Will the member give way?
I am sorry—I cannot do so at the moment.
If we are to make those improvements, it is essential that we listen to and act on the advice of medical professionals, mental health charities and service users. We must also endeavour to ensure that national strategies such as the mental health strategy are adhered to both in word and in action.
In January 2011, NHS Lanarkshire published “Modernising Mental Health Services in Lanarkshire”, a set of proposals aimed at rebalancing the delivery of mental health services
“away from institutional models ... towards community based provision”
and as such aligned to the “long-term trend” articulated in the mental health strategy. It was recommended that the number of psychiatric beds be reduced by consolidating acute in-patient mental health services at two dedicated facilities: the first in North Lanarkshire at Wishaw general, where an intensive psychiatric care unit would also be situated, and the other in South Lanarkshire at Hairmyres hospital. The wards would be fully equipped and resourced to provide complex treatment and care.
The proposals were influenced by an extensive consultation process encompassing health professionals, local and national politicians and umbrella bodies representing service users. The Scottish Government was also fully behind the plans, with the former health secretary, Nicola Sturgeon, stating that she was
“content that NHS Lanarkshire proceed to implement its proposals to modernise mental health services across the board area.”
One individual who vocally opposed the proposals was the MSP for Airdrie and Shotts Alex Neil—and I am sorry that he is not in the chamber to hear what I am about to say.
The proposals were due to be presented to the NHS Lanarkshire board in September 2012 for approval, but that did not happen. When I investigated, I was told that the new Cabinet Secretary for Health and Wellbeing, the aforementioned Mr Neil, had
“asked for some time to review the proposals.”
On 26 September, Mr Neil confirmed the delay in this chamber, stating that NHS Lanarkshire is
“revising its original proposal for ... mental health”
services
“at Monklands.”—[Official Report, 26 September 2012; c 11895.]
When I wrote to Michael Matheson, who I was advised had ministerial competence on this issue, to query this apparent U-turn, he informed me that the Scottish Government had “some reservations” about NHS Lanarkshire’s proposals.
On 19 December, I asked Mr Neil in this chamber when he, or any other individual acting on his behalf, had
“last contacted NHS Lanarkshire regarding the”
provision
“of mental health services”
at Monklands hospital. He told me he had
“decided early on in my tenure to give responsibility for that matter to my deputy Michael Matheson, as I did not want any perception of any potential conflict of interest between my role as MSP for Airdrie and Shotts—where Monklands hospital resides—and my role as cabinet secretary.”—[Official Report, 19 December 2012; c 14922.]
I have since seen an email from the deputy performance manager at the directorate for health workforce and performance regarding the decision to delay the proposals to modernise mental health services. The email, which was sent to the head of communications at NHS Lanarkshire, states:
“Mr Neil has confirmed ... that he is reviewing the proposals before a decision is made, and that decision will be made soon.”
That was sent on 15 September 2012, less than 10 days after Mr Neil was appointed cabinet secretary.
I will recapitulate: until September 2012, when Nicola Sturgeon was replaced as health secretary by Alex Neil, NHS Lanarkshire’s modernisation of mental health proposals had the Scottish Government’s approval. Then Alex Neil took over and expressed “reservations”, and a decision was deferred while NHS Lanarkshire revised the proposals at the cabinet secretary’s behest.
I find this turn of events both confusing and frustrating—and I am not the only one. I have received a letter from Francis Fallan MBE, the chairperson of Lanarkshire Links, on behalf of mental health service users in Lanarkshire, that expresses “great disappointment” at the cabinet secretary’s decision to intervene to delay the proposals. The letter refers to the “rigorous” consultation that informed NHS Lanarkshire’s modernisation of mental health proposals, which Lanarkshire Links supported.
The letter states:
“what is most important is that all decisions are taken in an open, honest, and informed way.”
It closes by asking:
“why are we now being ignored?”
That is a very good question.
Attached to the letter are the views of some of the Lanarkshire Links members. One individual sums up matters perfectly by saying that
“Two years of consultation and hard work”
have been
“turned round”
and we are
“back to square one”.
NHS Lanarkshire officials devoted time, effort and expertise to producing the modernising mental health proposals. They consulted widely. Health professionals and service users agreed with the proposals, as did Nicola Sturgeon, but Mr Neil did not agree and, because of that, the plans were shelved, apparently indefinitely.
We are left asking: does the cabinet secretary agree with the fundamental components of the mental health strategy or does he favour a piecemeal approach whereby a strategy is adhered to or ignored depending on who is the health secretary at any given time? To quote one disillusioned member of Lanarkshire Links:
“Can we get a straight answer from Mr Neil?”
We are tight for time, so speeches of up to six minutes would be welcome. I call Dennis Robertson, to be followed by Mary Fee.
15:21
Thank you, Presiding Officer—I will try to accommodate that and be as brief as possible.
It is a privilege to take part in the debate, and I sincerely hope that my contribution will be one of positivity. The mental health strategy is to be welcomed, and great strides have been made towards improving people’s mental health. However, we all acknowledge that there is still a lot to be done. I think that the strategy acknowledges that, and the minister has certainly done so.
Dr Simpson is absolutely right that depression among the elderly is often linked to disability. As I spent more than 30 years working in that field, I know that appropriate social care and intervention at the right time can provide positive results, especially for those with sensory impairment, who can find depression confusing and debilitating. I believe that, when the health and social care integration takes place, elderly people who are suffering from depression will have the facilities and resources at hand to get the services that they need at the time of need.
Jim Hume made a point about the number of antidepressants that are being prescribed. I feel that there is a degree of positivity in that. That might sound strange, but I believe that the number of antidepressants being prescribed is perhaps a result of more people coming forward because the stigma has been removed. I congratulate the National Union of Students on the work that it does with students to bring them through difficult times during exams and through various other problems that many students have in their lives. However, it is perhaps a good thing that people turn to antidepressants to enable them to cope rather than try to hide the symptom and bury their head in shame, because it is not a shameful thing to be mentally ill. It has been said that one in four people will have some degree of mental illness in their lifetime.
I accept that antidepressants are not used only for depression problems, but at the moment one in 10 Scots is using antidepressants.
Given the minister’s explanation to Mr Hume earlier and my point, perhaps Mr Hume needs to revisit his thinking on the issue.
It will come as no surprise to members that part of my speech will relate to the experience that I, my family and others have endured because of symptoms such as eating disorders. I have had positive meetings with the minister regarding the pathways for people with eating disorders and the services that are on offer. Sometimes movement is slow, but that is okay provided that we are going down the right pathway.
The minister mentioned the link to families and carers. It is extremely important that the appropriate services are there for those people. Generally, it is families and carers who have to cope with the effects of mental illness, quite often without the knowledge or awareness of what they are supposed to be coping with. That is where there is a mismatch: the link is not really there yet. The links between working with the patient, prescribing to the patient and providing appropriate therapies to the patient are fine—that is excellent and to be commended—but we must include the families and carers at all times and at all stages if we are to see improvement and success in treatments for mental health issues such as eating disorders.
Yesterday in the chamber, Alex Johnstone led a members’ business debate on cyber-bullying. Bullying across the whole spectrum is unforgivable and distasteful, and it needs to be addressed. Bullying itself causes mental health problems, which is something that we need to tackle. In the debate yesterday we tackled work that goes on in the internet and in social media such as Facebook, but we must look at media such as television and how it promotes certain programmes to get viewing figures up. After the debate last night I went home and switched on the TV. On Channel 4 there was a programme called “Supersize vs Superskinny”. Versus? It is not a game—it is far from a game. TV producers use headlines and programme titles to get viewing numbers up. I have approached the producers of that programme before to suggest that they need to disengage from that title and portray the issue in another way.
TV does not exist to glamorise mental ill health and mental illness. People are genuinely suffering and looking for solutions, and we need to ensure that the media do not glamorise mental illness as a quick fix to get their numbers up.
Please draw to a close.
I commend the work that the Government is doing and I think that the strategy is on the right path. I look forward to further meetings with the minister on tackling eating disorders in a positive manner.
15:27
I welcome the Government’s mental health strategy, but I strongly believe that some issues related to mental health and specific sections of the population have been massively overlooked or have gone unrecognised.
The last time I spoke during a debate on mental health I put a particular focus on children. Today I will continue on the subject of children and mental health, but with a greater emphasis on children of prisoners as well as prisoners themselves.
I welcome the recognition of the link between mental health and offending in the strategy, but the focus is primarily on women offenders. I am not complaining that that often-forgotten section of the prison population has been highlighted, thanks to the report of the commission on women offenders, and I was pleased to hear the minister’s mention of women offenders. However, the strategy misses the glaring fact that 94.7 per cent of those in prisons are male. Commitments 30 and 31 both target female offenders and commitment 32 looks at community payback orders. That shows either that there is a lack of will to address the mental health of prisoners or that it is not fully acknowledged that if we can tackle the mental health of prisoners we will be on a strong footing to reduce reoffending.
Tackling mental health in prisons is a complex process, which is made all the more complex by an ever-increasing prison population and overcrowded prisons. It is estimated that 90 per cent of prisoners have some form of mental health problem. That figure was estimated by the Office for National Statistics in 1997, based on a review of English and Welsh prisons, but it would be hard to argue that the estimate does not apply to today’s prison population.
I recently asked the Scottish Government for the number of self-harm cases in Scottish prisons from 2008 to 2012. The answer showed that reported—I stress reported—self-harm incidents increased by 62 per cent over the four years, and yet the 2012 figure included incidents only from January to November. It is likely, therefore, that the final figure will be higher than the 244 cases reported in the first 11 months of that year. Given the increase in self-harm, the fact that nine in 10 prisoners have mental health issues, and the complexities in tackling mental health in prison, I am disappointed that the strategy barely scratches the surface of the issue of mental health and offending.
There is also a serious issue that the Government does not know how many prisoners in Scotland have mental health problems and what treatment they are currently receiving. The gaps in the information held on prisoners are extremely concerning and do little to improve the mental health problems in Scotland’s jails. While the Government lauds its strategy, it has sidestepped a section of the population in which poor mental health is high and disproportionate to the rest of Scotland.
Families of prisoners are often victims as well. That statement is even more significant for children of imprisoned parents. Families Outside reports that 60 per cent of all women in prison have children and that there are two and a half times as many children of prisoners as there are children in care. Even so, little attention has been given to the children of prisoners, who can suffer mental health problems that affect their development or behaviour.
There may be some looked-after children in care as a result of a parent’s imprisonment. The 2012 to 2015 strategy targets those children, but it excludes other children of imprisoned parents.
Would the member acknowledge that the getting it right for every child programme might pick up the needs of those children, given that it applies to every child?
I acknowledge the member’s comment. GIRFEC goes a long way to support children but a huge amount of work still has to be done to recognise children with mental health problems, who need help and support.
Evidence shows that children of imprisoned parents are more likely to become offenders themselves later in life. That is attributed to poor mental health as a result of parental imprisonment, leading to developmental and behavioural problems, which further restrict the future social and economic prospects of each child.
The strategy has no mention of children of prisoners and their mental health. The CAMHS targets may include children of imprisoned parents but that group of children is often as isolated as looked-after children, with similar behavioural and developmental issues. Given the Government’s focus on early years and reducing reoffending, it is beyond belief that there is no specific action or commitment to improve the mental health of those children.
Children who have a parent or even a relative in prison often experience feelings of worry, shame, anger, fear, depression, grief and burden. Those feelings can contribute to the poor mental health of children in many cases but are more commonplace in children of imprisoned parents.
There is also a serious concern about the stigma attached to those children, so I stress the importance of promoting the wellbeing of prisoners’ children. The early years agenda promotes the idea that children must be supported to become successful learners, effective contributors, responsible citizens and confident individuals. On the basis of the three-year strategy, it is clear that we have missed an opportunity to tackle the poor mental health of the prisoners’ children.
I regret that you must close, please.
Finally, the Royal College of Psychiatrists has welcomed the waiting times target for CAMHS, but I agree with it that no child should be waiting up to six months to access mental health services.
15:34
I will focus on mental health and the wider criminal justice system and will try not to duplicate the contents of Mary Fee’s well-researched contribution.
I acknowledge the expertise and commitment of the minister, who was previously in the justice brief; Dr Richard Simpson, who was also previously in the justice brief; and, of course Mary Scanlon, who we know has been committed to the issue since 1999. It is necessary to repeat that for those who are new to the Parliament.
We have already heard about how many people in the prison system suffer from mental health issues, but we should also look at the broader criminal justice system. We tend to forget that many victims of crime have mental health problems; in fact, it is reckoned that people with mental health problems are 11 times more likely to be a victim of a crime. Of course, sometimes there is hardly a sliver of difference between the victim and the perpetrator; indeed, sometimes they are one and the same person. I remember that in evidence to the committee, someone in the judicial system said that who got the knife out first determined which side of the fence people ended up on. It is very hard and very wrong to put people into strict categories.
Of course, people can come up against the police when they have mental health problems. The police have come a long way when it comes to training officers, but there are still issues around recognising when somebody is not on their medication, why they are aggressive and so on that remain to be addressed.
Then, the person with mental health problems might enter the court system. Again, staff throughout the court system need to be trained to recognise and deal with people with mental health issues, whether they are in the dock, are a witness or are just accompanying somebody. That is another issue.
We have already heard from Mary Fee about prisons. She is quite right—an overwhelming number of people in prisons have mental health problems, which are sometimes drug and alcohol-related: they may have been caused by drugs and alcohol; the mental health problem may have come first; or sometimes it is a bit of both.
The improvement that has taken place with the NHS taking over the delivery of health in the prisons is important. A recent visit to Polmont told me that. There were a few teething problems—with people changing from being employed by the Scottish Prison Service to being employed by the NHS—but I think that it was a good move.
We must also bear in mind the fact—somebody alluded to this—that the majority of prisoners in Scotland are from poor socioeconomic backgrounds, where again there is a higher prevalence of mental health problems and drug and alcohol misuse, so the issue is very complex.
I will deal briefly with Cornton Vale and women’s prisons, which have already been mentioned. Real progress is being made, and I do not use the word “progress” lightly. There is real commitment from the prison governor, from the Government, from the chief inspector of prisons and from the prison officers themselves to change what has happened in Cornton Vale.
Of course, we have now had the announcement that the new prison at Inverclyde will be adapted and allocated to be the new prison for women in Scotland—dealing specifically with women, many of whom are victims themselves and who are just coming back into the system because there has not been the proper throughcare.
We know about the throughcare issue—we have known about it for 12 years in this Parliament—and it is utterly depressing. It is getting a bit better, but what happens is that people in prison have a structure: their mental health problems are perhaps dealt with, as are their medical problems and things to do with their families—you name it, prison officers do their very best to deal with such issues. The minute that people come out of prison, that help stops. We could not deal with that, so how can they deal with it? Take a simple thing such as releasing people on a Saturday, when the benefits office is not open—if they are going to get any benefits—and the housing office is not open, so they are left cast out.
When members visited 218 in Glasgow, the provision for women trying to be rehabilitated from Cornton Vale, we were told a very simple thing: they have somebody at the prison gate to meet a woman on release, take her somewhere and ensure that she has her benefits and that she has not lost her tenancy because she has been in prison for six months. The woman has somewhere to go and someone to help her—that is very basic.
We cannot do that for every prisoner.
Does the member accept that we heard evidence at the Justice Committee that a byproduct of the NHS taking over medical care in prisons was that it gave the potential for an improved throughcare system?
I will come to that. I will say that with 15,000 prisoners being released every year, we cannot have someone meeting all of them at the gates. However, we found out a simple thing on a visit to Polmont, and I am sure that Richard Simpson and others will recognise this: many people leaving prison simply do not have a GP, so their medical records and information on their mental health, their physical well-being and all the good work that has been done in prison is lost to the winds. They come out and there is nothing to meet them. We cannot impose GPs on people, but surely to goodness we can find a system where prisoners on release have somewhere to go and somebody to help them to go there to ensure that their medical treatment—physical and mental—continues once they are released.
15:39
Successive Scottish Administrations and this Parliament have made mental health a priority. We have made much progress, and that progress continues with the strategy, which is to be very much welcomed.
I want to focus on two areas, which are inextricably linked: stigma and self-esteem.
Let us look at stigma and what goes along with it—bullying and humiliation. Whether we are talking about depression, bipolar disorder, psychosis or schizophrenia, and whether it is a one-off, periodic or on-going condition, the effects on the individual concerned are marginalisation and isolation. Those effects do terrible things to people.
If something presents in childhood or adolescence, we can imagine the legacy that the person has to carry into adulthood having suffered stigma and its associated problems for so many years. That is why the work of the see me campaign is so very important. That campaign does tremendous work, and I do not think that any member of this Parliament has not at some point taken part in an event through the see me campaign and been very impressed by the work that it does.
I also believe that if we can alleviate the stigma along the way towards eradicating it, there will be a direct effect on wellbeing and self-esteem. I do not think that we should ever underestimate the value of self-esteem and wellbeing. That fact was brought home to me a few years ago by the work of the East Kilbride dementia carers group. I remember watching the joy of dementia sufferers who, even for a short time each day, took part in something that made them laugh or smile and made them feel good. It may have been that, later that evening, those people could not remember or tell their partner, daughter or son what they had been doing, but at the time they felt good—and that is important.
What helps to promote wellbeing and self-esteem? Two things are participation and creativity—in the arts, drama, song, dance or culture. That is not to deny necessary medication and treatments but to enhance and maintain wellbeing and, in some cases, to prevent progression.
The work of Theatre Nemo is well cited in relation to the use of drama and the arts in the health and justice services. Nemo began its life in East Kilbride but has expanded through its work and recognition awards, and it is now Glasgow based.
We heard Mary Fee and Christine Grahame talking about the justice system and prison. In an article in The Herald last summer, the governor of Barlinnie prison, Derek McGill, claimed, in giving a snapshot from that time, that
“Of a prisoner population at Barlinnie of around 1100, as many as 260 could be classed as having mental health problems.”
He also said:
“there are people routinely here who are mentally ill, but not so ill they should be in a hospital. If we can stabilise them, get them taking medication and improve their self esteem, there is less chance they will reoffend when they go back into the community.”
One of the Theatre Nemo participants talked about
“Working as a team, knowing you can contribute to society and create something positive, can see yourself in a new light as someone with strengths and skills.”
The group has done a lot of good work in Leverndale, Rowanbank, Stobhill, the Southern general, Gartnavel and Carstairs.
Over the years, I have attended many Theatre Nemo events. The first time one sees someone, they are perhaps standing on the sidelines, slightly away from the crowd, watching what is happening with a bit of disdain or shyness, and it has been an absolute privilege to see the difference three or four years later. In fact, that happened recently: there was such a person at the front of the choir, singing at East Kilbride arts centre. That is wonderful—the self-esteem that such experiences bring is absolutely tremendous.
There has been a long history of the creative arts helping people to adapt to or recover from mental disorder, and there have been many academic studies on the subject. Back in 2003 to 2005, there was the arts, creativity and mental health initiative. It evaluated four arts therapies trial services across sites in Scotland. In a summary of the project, Dr Andrew McCulloch, chief executive of the Mental Health Foundation, said:
“the art therapies have a valid therapeutic role and ... arts in health projects can improve the resilience of individuals and communities.”
The findings showed that, overall, participants experienced significant improvement in their mental health and social functioning. In particular, they highlighted improved self-esteem, communication skills and social interaction.
That further emphasises the need actively to reduce the stigma that is associated with mental ill health. Society has overcome other deeply ingrained prejudices, and we must keep working on that one.
For academic and practical reasons, I am pleased that our mental health strategy has commitments. Commitment 4 concerns working with the see me campaign and commitment 15 concerns increasing local knowledge of social prescribing opportunities. We need more of that. Both those commitments work towards the prevention agenda and joined-up policy implementation. I look forward to that implementation.
15:45
I thank Nanette Milne and Christine Grahame for their kind words. I have had an interest in mental health since being elected to the Parliament in 1999, when I was deputy convener to Adam Ingram on the cross-party group on mental health. In the first two sessions of the Parliament, we worked well together on the topic.
I welcome the mental health strategy. It is progress and a step in the right direction. I also welcome the review of progress in 2015, following the introduction of an 18-week waiting time target in 2014.
Like other members, I put on record the tremendous work done by many in the voluntary sector to support people with mental health issues and to address stigma. In particular, I highlight SAMH, the Depression Alliance and the Samaritans. The Samaritans website is wonderful; it even tells us how to approach people with depression, which I think many people are nervous about.
Like other members, I welcome the 34 per cent increase in the CAMHS workforce and the waiting time target of 26 weeks for CAMHS that is to be introduced this year.
I hope that the minister will now consider increasing the psychology workforce in preparation for the December 2014 target. Although I note that waiting times are down, it is only three years since people in Easter Ross were waiting four years and seven months to see a psychologist.
I also welcome the progress on improving dementia diagnosis. However, I would also like to see improvements in treating dementia. The Scottish intercollegiate guidelines network—SIGN—guideline for dementia is now seven years old despite SIGN reviews generally being done every three years.
The Mental Welfare Commission for Scotland confirmed to the Health and Sport Committee—Christine Grahame, Richard Simpson and, indeed, the minister have been on the committee—that 75 per cent of people in care homes were being given psychoactive medications for sedation and behaviour control when the SIGN guideline states:
“In patients who are stable antipsychotic withdrawal should be considered.”
I find that figure—75 per cent—very serious. It has not been mentioned, but I trust that the minister will mention it again.
As the Health and Sport Committee did, I ask for a more consistent review of medication for older people. Not only could that save money, but it could improve health. The committee recommended that pharmacists and GPs should visit care homes more regularly to review the medication of elderly people.
I recently became aware of a woman in her late 80s who, as her daughter told me, was on eight different types of medication. She was taking them at all different times of the day. She was on hormone replacement therapy for menopausal problems—the woman is 87—and on antidepressants. Her daughter said to her, “I didn’t know you were depressed, mum.” She replied, “Oh I was feeling a wee bit down when your brother was born.” The brother is over 60. It is not unreasonable to comment on that. I think that we might find such situations throughout Scotland.
As 43 per cent of people on benefits in Scotland have a mental health issue, it is right that we give more time to mental health. Also, 79 per cent of people with a long-term mental health problem are not in work, and Siobhan McMahon and Aileen McLeod commented on that. As far as Siobhan McMahon’s point about the work capability assessment is concerned, I am not sure which period she was referring to, but I know that Professor Harrington has looked at fluctuating conditions such as ME and mental health and has ensured that they are taken into account as part of the assessment process. I welcome the Welfare Reform Act 2012, because I feel that many people with long-term mental health conditions need the two years of support that is offered to get them back into work.
The strategy also talks about
“Treating depression in those with long term conditions such as diabetes”.
It is my understanding—perhaps the minister could confirm this—that support should be given for treating depression among sufferers of many, if not all, long-term conditions, but the treatment of depression is rarely addressed or, indeed, mentioned in SIGN guidelines.
I think that I understood Jim Hume’s point very well. Early diagnosis and treatment of depression are essential. As Richard Simpson said, cognitive behavioural therapy has been a wonderful success, particularly in the Western Isles and the Highlands, but in its review of CBT, NHS 24 said that it was effective only for those people who received an early diagnosis; it had no effect at all on those who had severe, chronic and enduring depression. I think that Jim Hume’s point was that there is a place for antidepressants, but there are also times when people should be referred on to specialists and when talking therapies should be considered.
Audit Scotland’s 2009 report, “Overview of mental health services”, said that 75 per cent of people with a drug addiction had an underlying mental health problem and that 50 per cent of people with an alcohol addiction might have a mental health issue. There is no point in treating the addiction unless we treat the underlying mental health problem.
I accept what the minister said about borderline personality disorders. I ask him to continue to inform the Parliament on the issue, because I am aware of what some families go through in order to get a diagnosis and to get the very complex treatment that is required.
15:52
I want to confine my remarks to mental health problems in older people. Dementia is very much the headline mental health problem for older people. The dementia strategy was welcome and was well received but, as Richard Simpson explained, more older people experience mental health problems such as depression and anxiety than suffer from dementia; I add that I am in no way playing down the worries about dementia.
I have a huge number of statistics to provide, but given the time pressure I will go with the statistics and figures that Dr Simpson gave. Instead, I will turn to some of the remarks that Mary Scanlon made. If someone who is in their 80s needs antidepressants and has needed them for 60 years, they need them; it is not a laughing matter.
I apologise if I gave the wrong impression. The point that the lady’s daughter made was that her prescription had not been reviewed in 60 years. She suffered from depression only after having a child who is now 60 years old.
Given that we are very short of time and that I have already cut my speech, I hope that the minister will be able to respond to some of that, which was nonsense.
I would like to talk about why more older people are suffering from mental ill health. There are a number of reasons for that. We talk about multiple morbidity. It is a fact that many of us are living longer, but we are living longer with ill health, which can often be mental ill health. Many people are living in loneliness and isolation, and many are living with financial worries. Mental ill health is a serious problem among the elderly.
I cannot read out all the facts and figures that I wanted to read out, but I will mention one statistic, which relates to something that Dr Simpson said. The highest incidence of suicide is in men aged over 75. Indeed, the incidence of suicide is 11 per cent higher in that age group than it is in young men—and we know that we have a problem with suicide among young men. It is a startling fact, which we should bear in mind when we talk about mental ill health in older people and its consequences.
I thank Dr Gillian McLean, a consultant in old age psychiatry, who gave a powerful and informed presentation to the cross-party group on mental health last week.
What can we do about mental ill health in the elderly? One of the first things that we must consider is the diagnosis of ill health in the elderly. I refer to our success in diagnosing dementia in Scotland—we are world leading in that regard. We need to build on that success in diagnosing other forms of mental ill health in the elderly.
We need to raise awareness of mental ill health as a problem in the elderly. As we grow old, there are many neurobiological changes, which can affect our mental health. We should not regard anxiety and depression as just a fact of old age—we must move beyond that attitude.
People take multiple medications nowadays, so we must train our medical workforce and carers to be aware of that. A person needs to be trained to watch out for signs of an impact on their mother’s or father’s mental health each time their prescription is changed or added to.
Many conditions mask mental ill health in the elderly. For example, urinary tract infections can cause confusion. However, when an older person is confused and forgetful, we must not always say that it must be a UTI or dementia; we should explore the person’s mental health and not regard the issue as just the effect of natural ageing and cognitive decline.
We should also alleviate external factors that can lead to depression and anxiety in the elderly. I mentioned that loneliness and isolation can be a contributory factor. That is a good argument for continuing to offer concessionary bus fares to the elderly, which is one way of alleviating isolation. There are also genuine financial fears. Old folk have always worried about the pennies, but we need to realise the effect on people of the coming welfare reforms and cuts and Labour’s talk of a cuts commission and a something-for-nothing society. We need to move away from using such language.
I would have liked to have had time to talk about social prescribing and the physical activity that SAMH promotes through its get active programme.
I will finish with a message that emerged from the cross-party group’s meeting last week: clinical mental health services should be delivered not on the basis of someone’s age but on the basis of their mental health needs. I hope that the mental health strategy will enable us to live long and happy lives.
15:58
When I read the strategy, the first thing that I noticed was the amazing contrast between the completed strategy and the draft that was issued a few months ago. I do not say that in a spirit of criticism, because it probably means that the Government was listening, which is not always the case when consultation documents are issued.
On key change area 1, the draft contained little about the Scottish Government’s wider work on the early years and the focus was almost exclusively on the CAMHS specialist area. Almost the opposite is the case in the published strategy, to the extent that key CAMHS issues are ignored. One such issue is the need for an adolescent intensive psychiatric care unit, which the Royal College of Psychiatrists highlighted in its paper for members for this debate. I was more struck by the complete absence of reference to integrated care pathways for child and adolescent mental health, because the issue was mentioned in the draft and when I talked to a child psychiatrist, she said, “This is crucial; you must say that implementation support is essential for integrated care pathways.” However, integrated care pathways are not mentioned at all.
I do not say that in a carping way, because I very much welcome the wider early years agenda that is highlighted and given prominent place in the strategy, in key change area 1. A preventative, population-based approach to mental health is particularly crucial in the early years, and I have to give credit to the Government more generally for having recognised that. The minister highlighted that, of course, in pointing to the importance of attachment and in his references to programmes such as triple P and incredible years, which are evidence-based parenting programmes that the Government is quite right to roll out.
There are therefore many quite interesting and exciting things going on in the early years, the latest of which, of course, is today’s first meeting of the early years collaborative. I have seen such things in action in health and know that they can work. I believe that the early years collaborative will work, and I hope that Sir Harry Burns was right when he said today that it may have the butterfly effect. He is usually right, and I hope that he is right about that.
Finally, on children and adolescents, I want to pick up on what Richard Simpson said. Let us not just do the early years to the age of three or five. Work in schools is important. I have seen the Place2Be initiative in Forthview primary school in my constituency, so I certainly support what Richard Simpson said about that.
On key change area 2, I like the focus on common mental health problems such as anxiety and depression, including in older people, and I welcome the fact that there is now a separate section for older people. I do not think that that was in the draft document. For those commonplace, or more commonplace, problems, people can of course benefit not only from access to psychological therapies, but from physical activity, as Aileen McLeod emphasised, and from social integration.
I highlight the excellent community connecting project in Edinburgh, which has been run by Health in Mind, although it will be run in my area by the Pilmeny development project. Basically, it focuses on certain older people who have isolation and possibly depression issues and other mental health problems that are connected with that. The project pairs them up with a volunteer for four months, I think. The evidence is certainly that it has had a remarkable effect on quite a few older people in Edinburgh. That is a really good example of the wider mental health agenda for older people working. Richard Simpson said that I would say more about that, of course, but he said most of it. The matter was highlighted last week in the cross-party group in the Scottish Parliament on mental health.
I will give one statistic that really surprised me—I think that I have got it right, as I checked it. Dr Gillian McLean, who is a consultant in the minister’s health board area, said that, in secondary care, 1 per cent of older people with depression are referred to a psychiatrist, whereas 50 per cent of adults—that seems to be a high figure, but I think that Dr Gillian McLean said that—would be referred to a psychiatrist. That is certainly an amazing gap. Many older people who should be referred are not. One issue that she highlighted, perhaps not with psychiatry, is that there is a lack of clinical psychologists who specialise in the care of older people. Therefore, there are some issues, but I give credit to the Government for having recognised that and for having a section in the document about it.
Key change area 2 also deals with trauma and distress. Today and on Tuesday, Dennis Robertson highlighted the importance of eating disorders. We know that he can speak more from experience about that than anyone can, so I will not say more about it.
On trauma, I recently visited the Edinburgh women’s rape and sexual abuse centre, which does really important work on counselling for women who have suffered the trauma of rape. I highlighted the funding problems there in a previous debate. We have to look at the wider support services for people who have gone through trauma.
I have only one minute left to deal with key change areas 3 and 4, so I will start to talk a bit faster.
Crisis services are really important. SAMH has said that they need to be rolled out across Scotland. I can certainly vouch for the fact that crisis services have been really important in Edinburgh. The crisis centre there is based in Leith. Users of mental health services campaigned for it for a long time, and it is a great model that we want to see more of.
Prisons are covered in key change area 4. Mary Fee has dealt with them, but an issue that relates to prisons is the lack of advocacy. I am still concerned that I can find nothing in the document about advocacy. I think that I asked Nicola Sturgeon a question about that when the draft strategy came out, and my memory seems to tell me that advocacy would be included, but I cannot see it. It was, of course, an issue from the McManus review, so it is supposed to be carried forward from that.
Perhaps, in winding up, the minister can tell us what will happen about the new further legislation on mental health.
I have had six minutes, so this is a good point at which to end.
16:04
We have heard many tributes to the Parliament’s mental health champions, who not only take part in debates in the chamber but continue the good work beyond it. I want to pay tribute to my former Aberdeen City Council colleague, Councillor Jim Kiddie, who served on the Millan commission on mental health and who tries to create mental health champions out of almost everyone whom he meets. People like Jim Kiddie have led us to the place where we are today, where—although I recognise that we still face challenges—we have a mental health strategy, which I think is pretty good. When Malcolm Chisholm referred to differences between the draft and final strategies, I thought that Jim Kiddie was probably one of the folks who had been in communication to say that he was not entirely happy about certain aspects of the draft.
I also pay tribute to the many groups and volunteers throughout Scotland who work to help folks with mental health difficulties. On Monday, I had the pleasure of having tea with a friends group in Aberdeen, which is entirely voluntarily run but makes a huge difference to people’s lives. Organisations like that, which often operate on a shoestring budget, are to be praised for the efforts that they make.
On health inequalities, it does no harm to reflect on the Audit Scotland report on that from December 2012. Audit Scotland notes:
“People in deprived areas have lower overall mental well-being and more GP consultations for depression and anxiety ... (62 consultations per 1,000 patients compared to 28 per 1,000 patients in the least deprived areas).
Suicide rates are three times higher among men than women and over three times higher in the most deprived areas. Between 2007 and 2011, the suicide rate in Scotland was 26.4 per 100,000 in the most deprived areas compared to 7.1 in the least deprived areas.”
Many people say to me that I come from a very rich city, but in Aberdeen we have poverty amidst plenty. We need to ensure that tackling health inequalities is a priority, so I am pleased that the minister in his opening speech mentioned that as the Government’s ambition.
My great fear about the current situation is that welfare reform will have a massive impact on some of the most vulnerable people in our country.
As the member is probably aware, welfare reform will result in many people going through appeals, in which they are subjected to rigorous questioning. The people involved often have an identified mental health problem, but that does not seem to be taken into cognisance during the appeals process.
I agree with Mr Robertson on that point. In evidence to the Welfare Reform Committee just this week, a representative of the Scottish Independent Advocacy Alliance said that her staff are having to do much more work to help folk through those processes. She gave an example of a client in East Ayrshire who had to attend an appeal tribunal in Ayr, which basically required the advocate to be with the client for the entire day. We need to ensure that those folks who perform the work capability assessments and appeals recognise that some folks have real mental health difficulties. Unfortunately, such difficulties do not always seem to be taken cognisance of.
Having gone with committee colleagues Alex Johnstone and Michael McMahon to see Atos undertake a work capability assessment—a very good actress stood in for the client, but it gave us a feel for the process—I think that the assessment process would be pretty scary for many people but it can only add an additional strain for people with mental health problems and learning disabilities.
I have a great fear that we may see deterioration in people’s health as a result of the processes that are in place. Mary Scanlon talked about the Harrington review: although that has made things slightly better, there is massive room for improvement. I hope that that will be looked at more carefully.
16:10
I associate myself with my colleague Kevin Stewart’s remarks about our former council colleague, Jim Kiddie. Having spent five years in the Aberdeen council chamber, we know that anybody who ever listened to Councillor Kiddie speak on mental health—and, indeed, on his personal experiences, about which he is extremely candid—could not have helped but have the hairs on the back of their neck raised. Councillor Kiddie emphasised to me early on—it has stayed with me since—that mental illness can affect anybody at any stage of their life, irrespective of their status or, indeed, their general health and wellbeing.
I want to cover a number of different areas. I have a lot to get through, so I hope that I can manage that within the six minutes. The first of those areas is parental mental health, which I raised in a couple of interventions. That extremely important issue needs to recognised. I pulled up Nanette Milne on the use of the phrase “poor parenting”, and she accepted that that was poor phraseology. However, at the same time, there is a perception that child mental health or behavioural issues stem from poor parenting. Sometimes that is the case, but often they are a consequence of attachment issues that develop as a result of parental mental health issues, including, but not exclusively, post-natal depression.
Post-natal depression affects around 10 to 15 per cent of women. It is estimated that, for every 1,000 live births, 100 to 150 women will suffer a depressive illness. Studies have estimated that around 10 per cent of fathers can develop and suffer from symptoms and effects of post-natal depression; that should be borne in mind.
I noted a 2008 report, “The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature”, which suggested further
“exploration of interventions that reduce risk for postnatal depression”.
That is because it is recognised that that has an impact on the mental health and wellbeing of children in the early years. I would welcome comments from the minister on how the Government sees post-natal depression fitting into the mental health strategy, particularly with regard to the application of the Edinburgh scale for post-natal depression.
I understand that the expectation is that all women should receive the Edinburgh scale. However, I have anecdotal evidence that some women, who have later been diagnosed with post-natal depression, were not given the Edinburgh scale to complete. That might not be widely prevalent, but perhaps the need to take cognisance of the Edinburgh scale needs to be re-emphasised to either health visitors or GPs—or, indeed, to both—when it comes to looking at women and women’s health postpartum.
I want to look at environmental factors, and a number of colleagues have spoken about welfare reform and the wider recession. The March 2012 report “GPs at the Deep End: GP experience of the impact of austerity on patients and general practices in very deprived areas” makes for sombre reading:
“A central concern of the Deep End practices is the number of patients with deteriorating mental health.”
Two ends of the spectrum were looked at. At one end, there are
“those who are in work, and previously well”
who found themselves under increasing stress in their jobs due to potential cutbacks and job security fears, and under the stress of taking on extra work or jobs, with the
“resultant impact on family and relationships”.
At the other end of the spectrum, there are
“those with chronic mental health issues and established physical problems who are ‘deemed fit to work’ and have their benefits cut.
Those people are
“struggling to make ends meet ... increasing contact with GPs and psychiatry ... increasing antidepressant/antipsychotic use ... self-medicating with drugs and alcohol”.
A number of testimonies were borne out in the report. One GP said:
“I observe this again and again that I cannot address medical issues as I have to deal with the patient’s agenda first, which is getting money to feed and heat.”
Another said:
“In my surgery I am hearing from patients who for 2-3 days a week cannot afford to heat their houses (many use metered cards which are more expensive than direct debit payments).”
Then there was a kind of gallows-humour comment:
“For obvious reasons, the patients in X ... area ... call Corunna House [where the Work Capability Assessments are done] ‘Lourdes’ because all the sick come out cured!”
That emphasises that the work capability assessments do not necessarily take cognisance of some of the very real issues.
The Royal College of Psychiatrists states that
“recessions have been shown to be accompanied by an increase in the suicide rates. The people most at risk of suicide at this time are those who are experiencing financial problems.”
Evidence from the Centre for Welfare Reform showed that 45 per cent of people in debt have mental health problems, but that only 14 per cent of those who are not in debt have such problems. The centre’s hypothesis is that poor mental health is linked to real poverty, which I think has been borne out by some of the evidence.
There is also an issue about the pressure that is experienced on the front line. When I was a member of the Finance Committee, I asked questions of Dr Margaret Somerville, from NHS Highland. She said:
“I have not talked much about mental health issues, but we expect an early impact on mental health services and particularly on primary care services. Again, we need community resilience and support. Uncertainties and unknowns produce stress in people, which leads to depression and anxiety. That will have an impact on primary care and on our mental health services.”—[Official Report, Finance Committee, 12 June 2012; c 1388.]
That shows clearly that welfare reform will have an impact on services.
Stigma about mental illness still exists in many ways, which makes people more reluctant to come forward about their illness. Depending on the walk of life in which people operate and work, they might not come forward because they consider that to do so will impact on their job security. We must do all that we can to tackle stigma. I think that the mental health strategy will play a strong part in that, and I very much welcome it.
16:16
In the early 1980s, when I was a fresh-faced social work student, hard as that may be to imagine now, I was in a Stirling GP surgery waiting room. On the wall was a striking poster by the Health Education Council that pictured a young woman with a bright smile and perfect complexion who radiated good health. The caption read:
“Six months after Mary had a nervous breakdown, her friends are still recovering.”
I think that Mary had a lot in common with Winston Churchill, Florence Nightingale and Gandhi, who all suffered from episodic mental illness. In Roy Jenkins’s seminal work on Churchill, Sir Winston described his depression as the “black dog”, which was perhaps not helped by his legendary drinking.
I will focus on the stigma surrounding mental illness, which Mark McDonald referred to. I will illustrate it by a couple of examples from my experience as a mental health officer, looking at social and economic implications and touching on best employment practice.
Before I move on to that, though, I want to say that the Scottish Government document on the mental health strategy for Scotland is well researched and well argued. I certainly support the three quality ambitions of being person centred, safe and effective, and the seven themes, particularly the anti-stigma work and the Scottish Human Rights Commission’s work on promoting rights for those who suffer from mental illness. I support of course the 2016 standard to have 18 weeks between referral and commencement of treatment.
Previous speakers have rightly pointed out that mental health problems cause considerable poor health in Scotland. The World Health Organization, to which previous speakers have referred, estimates that one in four people will have a mental health problem at some time in their lives. The Audit Scotland overview of mental health services reported that depression and anxiety combined is the most common mental health problem. The Scottish Government’s information service estimates that 300,000 Scots take antidepressants regularly and Audit Scotland has highlighted that socially excluded people are at greater risk of developing mental health problems. To paraphrase Nelson Mandela’s famous line: while social exclusion persists, there is no true freedom.
I think that Kevin Stewart got it right when he said that there are higher levels of mental health problems in deprived areas. For example, the suicide rate for people living in deprived areas is four times that of people living in the most advantaged areas. The Office of National Statistics reported in 2004 that nearly half of all councils’ looked-after children have mental health problems.
In 2003, as Mary Scanlon correctly said, the Scottish Executive stated that three quarters of drug users and half of those with alcohol problems may have mental health problems. Many members have mentioned the Scottish Association for Mental Health study that showed that the social and economic cost of mental ill health has reached £10.2 billion a year, which represents an increase of 25 per cent since 2004-05.
What is the solution? I highlight the groundbreaking work by BT, whose mental wellbeing strategy has led to a 30 per cent fall in mental health related sickness absence and more people returning to work after absence.
What about a personal view of mental illness? Lynsey Pattie gave evidence to my Public Petitions Committee in November. She has a mental health problem. She said in evidence:
“we need to address the stigma of mental ill health. From a young age, children are taught social education, starting with relationships in primary school and going right through to drugs and alcohol in secondary school. I feel that mental health should feature more heavily in such education, with the correct facts being given. I find it amazing and saddening that so many people have the wrong facts about mental health ... Words such as “psycho” are used daily in newspapers for no other reason than to describe a footballer making a bad tackle. Just yesterday, I heard a news reporter calling a news story “bonkers” and someone else being called a “loony” because they had a different opinion. When there is a murder, people automatically assume that the person is mentally ill.”—[Official Report, Public Petitions Committee, 13 November 2012; c 868.]
My experience as a mental health officer in the mid-1980s was that services were hospital-centric and, in the spectrum of overall healthcare, mental health was the Cinderella service. I still remember working in the locked ward at Craig Dunain hospital in Inverness, which was a Victorian institution, and watching electroconvulsive therapy being given to an elderly patient. I had nightmares for weeks afterwards.
Of course, there has been a major shift to community-based and person-centred care. I highlight in particular the excellent work that is carried out by the choose life team. Before joining the Parliament, I worked closely with the Highland team leader and saw at first hand the excellent training that is carried out with nursing, police and local authority staff in the field of suicide prevention.
We know from the Royal College of Psychiatrists briefing—and we heard earlier—that economic cycles give a clear indication of suicide trends. I was struck by the comment that more older people experience illnesses such as depression and anxiety.
On the choose life programme, the percentage of NHS staff who have been trained has improved, but it is still only 52 per cent. Does the member agree that we need to push on with further training for staff in the public sector?
You must close, Mr Stewart.
I strongly agree with the point that Richard Simpson makes.
In conclusion, I welcome the Scottish Government’s mental health strategy for Scotland. To campaign for improvements to mental health services is to lead a crusade for social justice and inclusion and to champion the fight against the tyranny of the stigma of mental illness.
16:22
I am pleased to have the opportunity to speak in this debate and to follow so many thoughtful contributions.
Mental health is affected by an extremely broad range of factors, many of which are interconnected. The reasons behind the mental health problems that we face as a nation are many and varied. That is why it is clearly right that the Scottish Government launched the consultation to update the strategy. I was pleased to hear from the minister about the strong response to the consultation.
I recognise that in the past decade progress has been made on preventing suicide, but we should also bear in mind the academic evidence from the University of Edinburgh and the University of Manchester. Last year, they published research that identified something called the Scottish effect—that is, the phenomenon that causes suicide rates in Scotland to be higher than those elsewhere in the UK. One of the authors of the report suggested that a more prevalent tendency in Scotland to treat symptoms of mental health problems with psychotropic drugs, rather than getting to the root of patients’ anxiety or depression, could be partly to blame, although it was not clear to the researchers whether that tendency was caused in the seeking of treatment or in its delivery.
There is good evidence, anecdotal and otherwise, that the use of psychotropic drugs can have seriously unwanted side effects. I am pleased that prescription of antipsychotic drugs for the elderly, particularly those with dementia, is now being actively discouraged.
The paper also suggests that alcohol and deprivation play a significant role in the Scottish effect, being responsible for 33 per cent and 24 per cent respectively of the excess suicides—“excess” meaning above the UK average. Sadly, the paper also identifies men as being at a greatly elevated risk. Indeed, the Scottish suicide information database published a report in December 2012 that showed that, according to the latest figures, three quarters of suicides involve men and that 56 per cent of those who committed suicide in 2010 had received mental health prescriptions in the year leading up to their death. The link between increased suicide risk and poor mental health is beyond question. We know that. David Stewart and others have referred to the choose life initiative, and I think that such initiatives are helpful in our attempts to make inroads against the Scottish effect, but we need to keep working at this.
Several speakers have referred to the impact of welfare reform and the recession. Clearly, we need to acknowledge the scale of the recession’s impact on mental health. A recent research paper that was published in the British Medical Journal is one of several in recent years whose conclusions suggest an increase in the prevalence of mental health problems, which seem to align with the onset and development of the recession. In fact, several papers that have been published in the past two years appear to indicate a growing problem, and some academics are investigating why it is that men appear to suffer more negative mental health effects than women as a result of the financial crisis and recession. Of course, we all know that women are suffering from the UK coalition’s policies in plenty of other ways.
The paper says that further research is needed—no doubt that is the case. We need to explain the effects on men. However, it is also increasingly clear in modern medicine and psychology that issues around gender, age, employment status, physical health and many other variables, demand a mental health strategy that is centred on patient needs.
I am pleased that the Government’s strategy contains measures that will help to deliver a more patient-centred approach to treatment. I certainly strongly support efforts in that respect.
In our debate in September 2011, I touched on the value of peer groups as a form of independent advocacy. I am pleased that, in commitment 3 of the strategy, the Scottish Government commits itself to a review of peer support. I acknowledge that that is a step in the right direction. I hope that peer support will become much more important in the future.
Many speakers have referred to stigma. I welcome the Scottish Government’s commitment to the development of the see me campaign. However, we should bear it in mind that a survey that was conducted by see me last year suggested that 56 per cent of people still would not want anyone to know if they were suffering from a mental illness. Research shows that sufferers are often reluctant to talk about it with others, whether that is because they are worried about people’s perception of them changing for the worse, or because they are embarrassed or do not want to become a burden on family, friends or colleagues.
Mental illness has been described as the last great taboo, and we must do all that we can to destigmatise it. There are signs that progress is being made, and we can be encouraged by the international reaction to some of our efforts. The see me campaign has been lauded as an example of best practice internationally, and statistics show that Scotland has progressed a great deal in the past few years when it comes to tackling stigma.
As others have said, the perception that depression is a sign of weakness can impede a sufferer’s career progression or make life difficult in a number of ways. It is depressing to note that see me’s survey says that only 35 per cent of people think that it would be suitable for someone to be a primary school teacher if they experienced depression from time to time.
Those and other forms of discrimination must continue to be tackled. I think that we are heading in the right direction to change attitudes for the better, but we have a long way to go.
On older people, I was also at the recent meeting of the cross-party group on mental health and I can confirm that Malcolm Chisholm is correct in saying that we heard evidence that only 1 per cent—in fact, I think that it was fewer than 1 per cent—of older people with depression were being referred to psychiatrists. We also heard evidence that there were not enough clinical psychologists dealing with non-drug treatments, but that is an issue that goes wider than the issue of older people. We also learned of the frustration that is felt by some elderly folk that mental health services for the elderly concentrate on dementia, without recognising the range of mental illnesses that elderly folk encounter. I am glad that the strategy takes that on board.
16:28
We have had a good and fruitful debate. Of course, there are still challenges. Dennis Robertson rightly highlighted that one in four adults in Scotland will experience mental ill health at some point in their life, with the resulting social, economic and personal cost of mental health problems estimated to be in the region of £10.7 billion annually. Mental ill health is now the dominant health problem of people of working age, and the cost to employers is now in excess of £2 billion a year. Of course, the emotional cost to families is even greater. Perhaps all of us have been touched in some way by mental health issues in our families. That is why I welcome the publication of the strategy and its important commitments.
When Kevin Stewart referred to the many mental health champions in Scotland, he should perhaps also have mentioned Tommy Whitelaw. For many years he cared for his mother, who had dementia, and witnessed her writing her name and date of birth on her arm to hide the fact that she was suffering from the condition. He is now taking his tommyontour campaign around Scotland to spread his good word.
In my opening speech, I highlighted the issue of equal access to psychologists. Proportionally, the number of clinical and other applied psychologists available to treat a patient in Kincardine is twice that available to treat someone three miles away in Clackmannan. That kind of inequity is worrying and I would like the minister in his summing-up to make a commitment not only to meeting the HEAT target by December next year but to addressing that disparity.
As has been stated, there are no statistics on waiting times for access to psychology therapies because of delays and changes in personnel at Information Services Division Scotland. I accept that the infrastructure for collecting the relevant data needs to be in place, but also note that as waiting times for psychological therapies were approved as a HEAT target more than two years ago, we should by now have some idea of where we are. Again, I would appreciate it if the minister addressed that point either when he sums up or later.
In my opening speech, I highlighted the increase in the use of antidepressants. Although I acknowledge the minister’s comments and Dennis Robertson’s remarks and experience, I think that Mary Scanlon made clear the point that I was trying to make that GPs have no formal process to support any review of patients with common mental health problems. I firmly believe that the Scottish Government should work with health boards to roll out nationwide successful pilots such as that undertaken by NHS Greater Glasgow and Clyde, in which patients on antidepressants for more than two years in 78 participating practice areas had their cases reviewed. As a result of the review, changes were made in the therapy of 28 per cent of patients, ranging from changes in dosage, the use of alternative drugs or treatment being stopped altogether. All of that led to a 9.5 per cent reduction in prescribed daily doses and, more important, better patient treatment.
One of my overriding concerns, which I know is shared by others, is that the use of antidepressants has increased because GPs lack alternatives. For example, exercise referral schemes are too inflexible or are not available during working hours and the perception is that waiting lists are too long and inaccessible. There also needs to be access to the kinds of alternative therapies that Linda Fabiani so eloquently described. I completely understand that antidepressants need to be used to treat conditions other than depression, but it is a sobering thought that one in 10 Scots are being medicated with them.
Many members have mentioned SAMH and its good work in highlighting physical activity to address stigma and improve mental health. Its see me campaign, which just about everyone has mentioned, has through its agreement with the Professional Footballers Association Scotland done great work in challenging the stigma associated with mental health in the likes of the football community. In 2011, the campaign produced five excellent short films to coincide with Scottish mental health week and I recommend that well produced video to members.
As I said, Linda Fabiani referred to creative alternative therapies. The minister knows that I have an interest in this issue through PND Borders and I appreciate and am grateful that he agreed to meet the group just a couple of months ago.
I am disappointed by the real-terms cut in the budget for physical activity. I believe that such activity is a good example of preventative spend that the Government could take up and I ask the minister to address that issue in his closing speech.
Many have mentioned suicide rates. Given the facts and figures that Roderick Campbell cited, I do not think that we should be complacent or get too excited by the claim in the strategy that the figures are going down. This is still a major concern.
I would be grateful if you could begin to conclude, Mr Hume.
The Liberal Democrat amendment in my name expresses concern at the steep increase in the use of antidepressants; outlines ways in which the Government could address the issue, including, for example, the use of “talking therapies”; notes the UK Government’s huge investment in improving access to psychological therapies; and recognises that mental health is at the core of Scotland’s “ability to flourish”. I therefore welcome support from across the chamber to show Scotland that we take the issue seriously and believe it to be above party politics.
16:34
I begin, as Richard Simpson did, by welcoming the minister’s sober and candid assessment and his tone in his introduction to the debate. We know that a strategy is in place and that advances have been made; all that is widely welcomed and has enjoyed cross-party support. The recognition that progress needs to be made in a range of other fields has facilitated the debate, which has been punctuated throughout by specialised and informed contributions on specific areas.
Richard Simpson referred to the challenge of an ageing population in all its forms. It is sometimes easy for us to pass over and simplify that issue. He also talked about the incidence of adolescents in adult wards, but he was perhaps a bit optimistic in hoping that an alternative trend is being established. There was a spike in the figure, and we have got it back to where it was, but for me to be confident that a new trend has been established, I want the figure to start to drop a little below that. I know that a plan is in place, although I take Richard Simpson’s point that there are not as many beds as was hoped. We know that the situation is not ideal, and the minister recognises that we want to see progress on that in the future.
I suppose that the major stushie of the afternoon centred on the introduction to the debate of the issue of antidepressants, as characterised by Jim Hume’s speech. I kind of understood where he was coming from. It is perfectly true that, as the minister said, the defined daily dose has gone up—from 88.4 to 120.9—but the number of items dispensed has also gone from 3.5 million to 5 million. I do not want to simplify the argument, but there is a concern somewhere in there, and the response has to go beyond Fiona McLeod shaking her head and saying that anyone who addresses it is talking nonsense.
We do not want antidepressants to become the method that we rely on to treat people. They have their part to play, and it would be reckless and foolish to suggest that they do not. That might even require an increasing incidence of their being prescribed. However, we want to know that there is something parallel and in addition to that. That is the point that members were trying to articulate.
Nanette Milne and the minister touched on the fact that the suicide rate is falling. That contradicted Mark McDonald’s point that, in a recession, it is inevitable that the suicide rate will increase. Actually, that is not the experience. However, we should not forget or ignore SAMH’s two too many campaign. If we stop and think about it, that means that, daily, two people are losing their lives by their own hand. That ought to chill us when we consider the individual, the effect on the families concerned and those around them, and the loss of potential.
Siobhan McMahon’s speech was in two halves. She had a rather personalised contribution that was addressed to an empty chair, although I hope that what she had to say was nonetheless taken account of. She, Aileen McLeod and Kevin Stewart—in the second half of his speech—touched on welfare reform. The debate is not about welfare reform, but I want to try to respond in two ways to the points that were made. I hope that they balance, taken as a piece. Some of the assessments that we are talking about were introduced by the previous Labour Government. Nicola Sturgeon, at the beginning of this session of Parliament, told the Health and Sport Committee that she supported the principles of welfare reform. There is a paint-your-bandwagon approach—members can hitch their caravan to the end of any bandwagon and start complaining about the consequences.
There is an acceptance that this country needs to face up to and address welfare reform, but that is not the equivalent of my being comfortable as an individual and as a Conservative with the consequences of the assessment process on the lives of some individuals. Therefore, I accept some of the comments and criticisms on that. The Harrington review has made progress, although it is not enough, and I hope that more lessons can be learned.
However, in itself, that is not an argument that welfare reform has no place. If we do not support specific welfare reform proposals, we have to provide alternatives. However, I accept that not everything that is happening is something that I can stand up and applaud and support, or say is an acceptable process or outcome.
Mary Scanlon and Malcolm Chisholm have long perspectives and understandings of the topic and they illustrated, through whistle-stop tours of the issues, that we can welcome the progress that has been made, and still throw some grit into the porridge and ensure that we are still prepared to probe the things that are being proposed without that necessarily becoming a confrontational or polemical exercise. We should be mature enough to accept that there will always be areas in which progress is not being made, even while it is being made in others. That is not a failure of party politics; it is a failure of our ability to make progress simultaneously on all fronts.
Kevin Stewart made an uncharacteristically understated contribution that I very much enjoyed. Nanette Milne, who is sitting beside me, said that she thought that Councillor Kiddie’s contribution had been immense, so I am happy to endorse that view.
Later in the debate, the issue of stigma was touched on by Linda Fabiani and others.
I must ask you to come to a conclusion.
The debate has been constructive and has been punctuated with some very well-informed contributions. The people who are concerned about the issue can be satisfied in the knowledge that experience and interest is widespread across the chamber.
16:41
I agree with Jackson Carlaw that the debate has been absolutely interesting and largely constructive. With all due respect to my front-bench colleagues, I have to say that the debate has been owned by the back benches. I do not want to pick people out, but there have been incredibly impressive and informative speeches from Mary Scanlon, Mary Fee, Linda Fabiani and Dennis Robertson. Kevin Stewart and Mark McDonald will both be quite surprised that I mention them, too, because we do not often agree, but on this issue I thought that their speeches were very impressive.
We acknowledge the achievements of, and the progress that has been made by, the Government, the NHS and all the partners, but it is always the case that we can and should do more, although my comments are set in the context of that broad support. I echo the minister’s praise for all those who work in mental health—the health service staff and people in the voluntary sector who provide care and support daily for people who have mental health problems.
I will start where Richard Simpson started. Irrespective of political colour, we are good at producing strategies. Our shelves are littered with them. The mental health strategy rightly commands support from across the chamber, but we need to make sure that it is implemented so that it makes a difference on the ground. That is a challenge not just for the Government, but for all of us.
The minister told us about a new dementia strategy and a refreshed suicide and self-harm strategy, which are both welcome, but we need to be sure of their implementation. I ask the minister seriously to consider setting up an implementation group that has a clear action plan, a monitoring framework and a timetable for key milestones so that we can measure progress. Let us make sure that the strategy is not destined for the shelf but leads to change.
Nanette Milne rightly reminded us that one in four of us is likely to suffer from mental health problems at some point. Mental health services used to be regarded as a Cinderella service, but I think that the collective efforts of Parliament and successive Governments have changed that. However, I am concerned that, in a time of austerity, the clock will be turned back.
In many communities across Scotland there have been cuts to social care services and in others charges have been introduced for the first time. I know of constituents who face losing a service or paying £50 a week for the first time in order to retain provision that is essential for their mental health and wellbeing.
At local level, parts of my constituency in Helensburgh do not have access crisis services after 8 pm, due to lack of resources. Malcolm Chisholm rightly drew our attention to the value and importance of crisis services in his constituency. We need to be vigilant. We recognise the value of community-based services, which are often much to be preferred to inpatient care because they support people to continue with their everyday lives. Let us ensure that they are adequately resourced.
Jim Hume raised the question of statistics when he discussed child and mental health services. I welcome the Government’s HEAT target of referral to treatment within 18 weeks and the progress that the minister outlined. However, children are being admitted to adult mental health wards; I am sure that across the chamber we agree that that is inappropriate. We need action to tackle that. I press the minister to ensure that sufficient CAMHS beds are available. I know that he is committed to making progress on that.
Jim Hume also made a point about the lack of statistics, although I note that the minister was able to give us some and said that 89 per cent are being seen within the CAMHS target. However, when we asked SPICe for the statistics, it told us that there are none. We were therefore unable to measure progress. This is a critical area of policy, so will the minister advise when the data will be available? Does he agree with SAMH’s call for an audit? If we establish our baseline position, we can effectively measure progress. That would be a useful tool for us all, including the Government.
I turn to Mary Fee’s authoritative contribution on the justice system and the impacts on families of offenders, which was very much complemented by Christine Grahame’s contribution. Mary Fee was right to point out the serious omission in the mental health strategy, which is that there is no mention of the very real challenge for and impact on children of having a parent who is an offender. In the past—in a previous life in Government—we used supplementary reports to pick up on areas that needed further development. I invite the minister to do just that and to ensure that mental health support for the children of offenders is part and parcel of the mental health strategy in the future.
Many members spoke about early intervention for children. Mark McDonald raised the issue of support for parents, and post-natal depression, which has an impact predominantly on women, but also impacts on men and children. We support the many positive things that are being done by the Government, such as the triple P programme, the incredible years programme and, as children move on to primary school, the Place2Be programme. We welcome continuing investment in those initiatives.
Linda Fabiani, Roderick Campbell and many other members talked about the importance of tackling stigma and the extremely positive work of the see me campaign and SAMH in challenging stigma. Again, we commend their work to Parliament.
I turn to NHS 24 and its CBT service, which was mentioned by Mary Scanlon. When I visited the project at the Golden Jubilee hospital, I was struck not just by how flexible the project is, but by how it is making a huge difference to people predominantly in rural areas, where individual telephone support is essential to their improved mental health and wellbeing. The statistics that we are starting to see are extremely positive. I wonder whether we could roll that out beyond rural areas, where there is a need to do so.
David Stewart rightly reminded us of something that had thus far been missing from the debate: the importance of occupational health services and the importance of challenging employers’ attitudes. The majority of people who experience episodic mental ill health still need to hold down employment, and may struggle to cope with that.
I close by talking about the wider challenges of mental wellbeing. Kevin Stewart spoke very well about welfare reform; there was much in his speech with which I agreed. Although I hope that mental health organisations have contributed to the Harrington review, there is a real need to provide support and advice to people who are faced with having to reapply for their benefits. I am concerned about the preparedness of the NHS to cope with the impact.
Mark McDonald rightly referred to the deep-end group of GPs and its report about the challenges that those GPs face in providing adequate support for their patients. In my view, that will get worse with austerity.
The strategy needs to be set in the context of the likelihood of increasing levels of child poverty in Scotland; the challenge of youth unemployment and unemployment more generally, which is increasing; and the challenge of a reduced standard of living, with rising levels of in-work poverty, which leads people to have to use food banks and payday loans.
People in our communities are increasingly struggling to cope with everyday life. The need for the strategy is self-evident: the pressure on our mental health is increasing. The minister will have our support if he puts in place a robust implementation plan and monitoring framework so that this strategy really makes a difference on the ground.
16:49
Like other members who have given closing speeches, I think that this has been a very good debate, with some excellent speeches in which members have raised significant issues that they wish to see addressed.
Members will recognise that, in taking forward the strategy, we had a debate in Parliament before the consultation started. I asked all members to feel free to engage in that process and to make their views known because, as I am sure all members will recognise, the Government does not always have the answers when it comes to dealing with all the issues and challenges that the mental health system faces. We need to prioritise areas in which we believe that we can make good and sustained progress.
Since the publication of the strategy, the general feedback that I have had from the sector is that the strategy is moving in the right direction and allows us to build on the progress that has been made in previous years—not just by this Government but by previous ones. That progress is a tremendous credit to the Scottish Parliament and to the way in which NHS Scotland has taken forward the reform of our mental health services over the past 12 to 13 years, if not longer.
One of the most important areas in the mental health field that we need to focus on much more is the early years. To date, work on the early years has largely been associated with dealing with health inequalities, but mental health issues do not necessarily register among the health inequalities that we face in our society.
One aspect of the strategy is that it seeks to work with other areas of Government policy to ensure that we have a greater focus on the early years interventions that can make a difference—not only in improving people’s future health and wellbeing but in reducing the potential for them to drift into the criminal justice system or anything else that may arise from a poor experience in their early years.
As Malcolm Chisholm pointed out, today is the launch of the early years collaborative. That provides an exciting opportunity to ensure that we have much greater collaboration among agencies so that we can make a real difference in the early years where it is appropriate.
I accept Richard Simpson’s point that we should not look at the early years as purely being the pre-school years. His suggestions for work that could be taken forward in schools, particularly in primary education, are worth further consideration to see whether we can take that forward as a preventative approach as well.
Richard Simpson also raised the issue of the ministerial task force. The evidence base that is now emerging in a whole range of areas to do with physical or mental health issues shows that tackling health inequalities is not just about physical health; it is also about mental health. It is about social justice and, if we are to get to the root causes of it, we have to tackle the issues of social injustice much more effectively than has happened over many years.
A number of members referred to CAMHS and the changes that have happened to those services. Richard Simpson and Christine Grahame will recall their Health and Sport Committee inquiry into the provision of CAMHS in the previous parliamentary session. Mary Scanlon was a member of that committee as well—I apologise if I have forgotten anyone else who was a member of the committee who is in the chamber. All those members identified the need to improve access to CAMHS and the need for much earlier intervention when issues arise. I think that all members recognise that the additional resource that has been provided over the past four years has made a marked difference in improving access to services earlier. That ensures that we can intervene at the earliest opportunity to support a young person who is exhibiting mental health issues.
That brings me to the issue of improving access to psychological therapies. Although it is difficult to give exact figures at present, because the data is incomplete and not to a level that allows us to be fully confident about the scale of it, some of the data indicates that a significant number of people are making use of different psychological therapies in NHS Scotland. I hope to be in a position, when the data is of a higher quality, to publish it later this year—it is an issue of data quality rather than anything else. I have no doubt that, once that data is published, it will help to give focus to ensuring that we maintain improvement in this area and it will demonstrate the scale to which patients are benefiting from psychological therapies.
The issue of psychological therapies also sits alongside some of the issues and some of the discussion around antidepressants. Too often, there can be the simplistic read-across that the level of antidepressant prescribing means that we do not have enough psychological therapies. That is not necessarily the case. A combination of approaches may be appropriate and, in some cases, antidepressants may be the best course of action rather than some form of psychological therapy. We should not make an automatic link between the level of antidepressant prescribing and the availability of psychological therapies. I hope that members are reassured that we will try to publish the data this year once we have addressed some of the issues with its quality.
Several speakers, including Malcolm Chisholm and Richard Simpson, referred to older people and mental health issues. With people in my constituency such as Eddie Kelly, who works with Falkirk & District Association for Mental Health and is a passionate advocate of the need to improve services for older people with mental health problems, there is no way that a strategy for which I am responsible would not recognise that issue.
A number of members mentioned dementia. If we improve services for older people with mental health problems, people with dementia will be able to benefit from the improved access to psychological therapies, because those therapies are not simply for younger people or any particular age group. However, it is necessary that we recognise the number of older people who experience mental health problems. There is still some work to do to achieve that.
Dennis Robertson made a good observation about the opportunity that arises from the integration of health and social care to ensure that our local authorities and health services deliver services for older people in a much more co-ordinated, and the most effective, way.
One of the important points about improving access to psychological therapies is that the therapist does not always have to be a psychologist. Sometimes, it is about improving access to social prescribing, which the strategy also sets out, or increasing physical activity. All of those have an important contribution to make to improving older people’s mental health.
Will the minister give way?
I am trying to cover a lot from the debate, if John Pentland does not mind.
Dennis Robertson also mentioned eating disorders. I met him yesterday to discuss the progress that we are making on that and the further work that is necessary. I will continue to work with him to ensure that we do what we can to improve the delivery of services for those who experience an eating disorder.
Some members also referred to crisis services. We must get much better at delivering such services in Scotland.
I had the pleasure of opening the crisis centre in Leith to which Malcolm Chisholm referred. There is real benefit in giving people an opportunity to go to a venue that is not necessarily a health facility but gives them the time out and support that are necessary to enable them to address the issues that they find difficult.
In NHS Tayside, we are also doing pilot work to determine how we can become much better at identifying individuals who present in distress or crisis and ensure that agencies are better at tracking them when they present to services. We know from research on suicide that many such individuals, far from not having presented to services, have presented to services time in, time out but have not been picked up effectively. We must get much better at picking up such individuals. I refer not only to health services but to local authority social work departments. The criminal justice system must also be much more effective at that.
To touch briefly on the criminal justice system, I accept the points that Mary Fee and Christine Grahame raised. We need to make more progress on that. The fact that the mental health services in our prisons are now part of NHS Scotland gives us a greater opportunity to address some of the challenges.
One of the most important areas that have been highlighted is the continuing work on reducing the stigma that is associated with mental ill health in Scotland. David Stewart made a very good speech on that. We need to ensure that we maintain momentum on that to remove the stigma that can often be associated with mental health problems, but we should also take that work further.
We must tackle not only stigma but the discrimination that prevents those who have a mental health issue from engaging in services in the way in which they should or receiving the services that they deserve to receive. The work that I wish to be taken forward as part of the strategy involves a focus on the discrimination that many people with a mental health problem experience.
Malcolm Chisholm said that he noticed the difference between the draft strategy and the final strategy. I hope that members will be reassured that we have genuinely listened to all those stakeholders who have an interest in mental health services in Scotland with a view to ensuring that we have a mental health strategy that is fit for the 21st century and which will deliver real change and build on the improvements that we have made over recent years.