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MENTAL HEALTH OFFICER SERVICES: STRUCTURES AND SUPPORTS
CHAPTER ONE: INTRODUCTION
BACKGROUND
Tracking the development of MHO services
1.1 The role of the Mental Health Officer (MHO) in Scotland has evolved in recent years as a consequence both of changes in the patterns of service provision for people with mental health problems or a learning disability and in response to changes and developments in legislation affecting these groups. Developments in services and in the legislative framework over the last 20 years have been extensive.
1.2 There has been a continuing shift from hospital based care for people with mental illness and learning disability to community based provision. This has had considerable implications for the locus of mental health care, treatment and support services and for the location and deployment of MHO services. The expansion of community based care has been accompanied by the development of multi-disciplinary and multi-agency community teams providing care and support for people with learning disability and mental health problems outside of hospital.
1.3 The reorganisation of local government in Scotland in 1996 and the creation of 32 local authorities meant that many local authorities had to review their arrangements for the provision of MHO services. Updated guidance was issued to the new Local Authorities in 1996 on the selection and training of MHOs (Social Work Services Group, 1996).
1.4 The Framework for Mental Health Services in Scotland (Scottish Office, 1997) set out the vision for comprehensive community based services, shaped to meet identified local needs. This policy was an important landmark in requiring local health and social work planning partners to develop joint strategies for mental health and in accelerating the shift from hospital to community based care.
1.5 In parallel with changes in organisational and service patterns, developments have taken place in the MHO role, arising from the requirements set out in the Mental Health (Scotland) Act 1984 to appoint experienced trained and accredited personnel to be involved in the compulsory detention of people with mental disorders. Under the terms of this Act, it became the responsibility of the MHO to satisfy him/herself that detention in a hospital was in all circumstances of the case the most appropriate way of providing the care and medical treatment the patient needs. The main statutory functions assigned to MHOs under the 1984 Act related to their involvement in compulsory detention, guardianship and the provision of social circumstance reports (SCRs) for the Responsible Medical Officer and the Mental Welfare Commission.
Previous research on MHO services
1.6 Previous research makes it possible to track the evolution of the MHO role and of MHO services across Scotland. In 1991, a study of Mental Health Officer Work in Scotland by Smith, provided a detailed account of the workload of MHOs in Scotland. This monitoring study identified 545 MHOs in post across Scotland in 1990, of whom three quarters had actively practised as MHOs at least once in the preceding 12 months. At that time, the bulk of statutory mental health work was undertaken by MHOs based in psychiatric hospitals and clients subject to detention were more likely to be inpatients than outpatients. A postal survey of MHO practitioners, conducted as part of the 1991 research, found that MHO work tended to be concentrated in the hands of a few and that almost three out of five of survey respondents would have preferred more opportunity to use and develop their skills and expertise in statutory work. Only one in five survey respondents had regular supervision of their MHO work.
1.7 A study by Ulas and colleagues in 1994 examined the role and responsibilities of MHOs and their interpretation of practice in relation to compulsory detention and care of people with severe mental health problems. As with the earlier monitoring study Ulas et al found that, in general, hospital based MHOs undertook substantially more statutory work than counterparts in community based services, but, for both sets of MHOs, statutory work accounted for only a small proportion of their workload. This made it difficult to manage competing demands on time and to accumulate practice experience and confidence in statutory work. MHOs, particularly those working in community settings, were found to lack formal support mechanisms. Accountability systems were perceived to require clarification in view of the tension experienced by MHOs as independent practitioners working within the priorities of the 'hierarchical organisation' which employed them. The research pointed to indications that local authorities were developing a more strategic approach towards MHO selection, deployment and training, by making more effective use of those already trained and by a selection process more closely linked to future deployment.
1.8 In 1998, after local government reorganisation, the Social Work Services Inspectorate for Scotland (SWSI) published a Mental Health Officer Survey, which explored the development of the MHO role in the light of changes in the mental health field and which set out to highlight good practice and problem areas. The data for this survey were collected in 1997, at the time when the Framework for Mental Health Services was issued by the Scottish Office. The survey, which had returns from 29 of the 32 authorities across Scotland, found that more than two thirds of local authorities (LAs) considered that their MHO service ran below capacity. There was evidence of targeting of MHO expertise on those with severe and enduring mental health problems and the use of MHO skills in planning, co-ordinating and managing care. There was found to be considerable variability in the structures of MHO services, in the range, methods and content of training and in the range and quality of data collected by each authority on MHO work.
1.9 Progress made and difficulties remaining in achieving optimum deployment of MHOs to ensure an effective professional service were illustrated in the profile of existing provision drawn by the survey:
- It was estimated that the 29 respondent authorities had 618 MHOs in post, deployed in a wide variety of settings and services
- Over half of the responding authorities were of the view that the current pattern of deployment of MHOs ensured expertise across geographical areas and in local communities
- One third of local authorities did not consider that the deployment of MHOs had been strategically planned
- Of the 618 MHOs in post, just over a quarter worked in mental health posts
- One in six MHOs had not undertaken statutory work in the preceding year
- The survey highlighted the fact that the setting where authorities most often reported that MHOs were placed (criminal justice teams) was also the setting where least statutory work was being processed
- A change in the patterns traced by previous research was evident with a shift of statutory work from psychiatric hospital to community settings. More than 50% of respondents were undertaking most statutory work in community settings
- Authorities were taking steps to ensure the more effective use of MHO resources, for example, over half the respondent authorities were using a rota to spread work across settings
1.10 The survey found that joint working between MHOs and their health partners was regarded as 'quite good'. Joint working was perceived to be more effective at practice than at operational level, and weakest at strategic level.
1.11 Overall, SWSI concluded that local authorities needed to give greater attention to recruitment and retention, and that effective deployment was likely to become an increasingly complex task in view of the changing pattern of mental health service provision. Further, it was recognised that there was no one model of MHO service that would fit all local requirements, but that diversity was important in view of the differences in geography, population profile and service characteristics. (The conclusions and recommendations from the 1998 SWSI survey are provided in Annex 2 to this report).
1.12 It was recommended that training of MHOs should be revised to take account of developments in policy and practice. In addition, in view of changing roles, training should incorporate the development of skills in multidisciplinary working.
1.13 More recently, continuing concerns relating to the recruitment and retention of MHOs were examined in a survey by the Mental Health Sub Group of the Association of Directors of Social Work (ADSW). This work examined whether local authorities were currently making additional payments to MHOs or were considering such a policy. In early 2003, 10 LAs reported that they were making additional payments in order to improve MHO recruitment and retention. There was considerable variability in the level of payment and the criteria, for example some authorities made additional payments to all MHOs, elsewhere payment was contingent on attaining senior practitioner status (Noyes, 2003).
The legislative framework
Adults with Incapacity (Scotland) Act 2000
1.14 The Adults with Incapacity (Scotland) Act 2000 (AWIA) introduced significant new and wide-ranging statutory duties upon local authorities in respect of the protection and management of the property, finances and personal welfare of adults with incapacity. As expert practitioners in the field of mental disorder, MHOs are specifically charged with the preparation of reports to accompany applications for intervention orders and guardianship orders which local authorities are required to take forward where necessary and not being done by anyone else. The MHO role is also key in the broader context of the relationship between the local authority, the Office of the Public Guardian, the Mental Welfare Commission, the sheriff and the range of individuals authorised with powers as proxies under the various provisions of the Act. Implementation of the AWIA was phased over time. Many of the new responsibilities for MHOs had already taken effect at the time of this research.
1.15 The review of the Mental Health (Scotland) Act 1984, conducted by the Millan Committee, led to the formulation of new legislation, the Mental Health (Care and Treatment) (Scotland) Act in 2003. This new legislation is due to be implemented in 2004/ 2005.
Mental Health (Care and Treatment) (Scotland) Act 2003
1.16 The Mental Health (Care and Treatment) (Scotland) Act 2003 brings a new set of duties for local authorities and for MHO Services that mean a significant change to the MHO role. Implications for local authorities include:
- The duty to support independent advocacy
- A broadening of duties towards people with a mental disorder, to promote their well-being and social development
- A new duty to investigate ill treatment and neglect of people with a mental disorder living in the community
1.17 In relation to MHO Services, new duties comprise the following:
- Ensuring people subject to compulsory measures gain access to advocacy
- MHOs' playing a key role in any decision to apply for a compulsory order, with considerable emphasis on integrated care and on multidisciplinary consultation
- MHO consent to be mandatory for short-term detention. This has particular significance as it will now be possible for short-term detention to be the first step into compulsory care
- MHOs to be expected to co-ordinate the production of the care plan as part of the application for the new community treatment orders
- Formal MHO involvement in review of compulsory treatment orders
- MHO reports to be required for mental health disposals by criminal courts
- MHOs to have a role in finding out the 'named person' that an individual would wish to nominate. This mechanism has significance as the new measures no longer allow for the involvement of relatives in the process of giving consent to emergency and short-term detention
1.18 This changing legislative and service landscape in mental health and learning disability poses significant challenges for the capacity, capability and effectiveness of current MHO services in Scotland.
RESEARCH AIMS
1.19 In December 2002, following a competitive tendering process, the Scottish Executive commissioned the Scottish Development Centre to undertake this six-month research study of Mental Health Officer services in Scotland and the ways in which local authorities were gearing up for the imminent changes to mental health legislation. The findings from the research were expected to influence the development of policy and guidance for implementing the new Mental Health (Care and Treatment) Act 2003 (MHA 2003), as well as feeding into further guidance on the Adults with Incapacity (Scotland) Act 2000.
1.20 The principal aims of the research were to:
- Investigate models of MHO service provision and describe how they address the need to provide a responsive professional service which takes account of local circumstances and the demands of new and existing legislation, and existing departmental service structures
- Explore local authorities' readiness to respond to the demands on MHO services arising from the Adults with Incapacity (Scotland) Act 2000. The research also set out to examine preparations put in place for the implementation of the new Mental Health (Care and Treatment) (Scotland) Act 2003
OBJECTIVES
1.21 The specific objectives of the research were as follows:
1) To gather information on local authorities' plans for meeting the additional responsibilities associated with the Adults with Incapacity (Scotland) Act 2000 and the new Mental Health (Care and Treatment) (Scotland) Act 2003
2) To ascertain the number of MHOs currently in active practice across Scotland
3) To investigate the ways in which services were structured, including arrangements for MHO service provision out of hours and relationship with assessment and care management processes
4) To examine issues of particular relevance to small authorities, and to those operating in largely remote and rural areas
5) To examine the mechanisms for supervision and support of MHOs and arrangements for the training, professional development and review of MHOs
6) To investigate MHOs' access to legal advice and advice on management of property and finances
7) To investigate local arrangements for monitoring and reviewing MHO services
1.22 This study on MHO services was conducted at a time when the Mental Health (Care and Treatment) (Scotland) Act 2003 was still a Bill. This meant that respondents in local areas were participating in the research at a stage when they and their colleagues were not fully aware of the provisions in the new legislation. Consequently respondents may not have had a full understanding of what would be required in developing and delivering a local MHO service to meet the demands of this new legislation. Indeed, it might be expected that developing a full understanding of the requirements of the new legislation would be a lengthy process over the coming years.
1.23 There had, however, been many opportunities to contribute to consultation and to track the progress of the Bill through the Scottish Parliament. The main professional bodies, the Association of Directors of Social Work and the British Association of Social Workers were also involved in the Scottish Executive Reference Group, established to advise on the development of the new legislation.
1.24 Concurrently with this research study, the Scottish Executive was in the process of developing work on National Standards for MHO services, with a view to these standards being published for consultation later in 2003. Again this may have had implications for local responses to issues of service quality.
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