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MENTAL HEALTH OFFICER SERVICES: STRUCTURES AND SUPPORTS

CHAPTER THREE: MAPPING PROFORMA AND TELEPHONE INTERVIEW FINDINGS I: STRUCTURE AND ORGANISATION OF MHO SERVICES

INTRODUCTION

3.1 The results of the analysis of the mapping proforma completed by MHO service managers in each LA and subsequent telephone interviews, which were designed to build on the mapping exercise and explore in more detail key issues emerging from local responses, are presented together in this section and the next. Bringing these two data sources together allows the presentation of factual information on the organisational structure and context of MHO services, accompanied by more qualitative and subjective perspectives. In reporting responses, the section follows the sequence of the themes examined in the proforma and the interviews. This section describes the structure and organisation of MHO services. Chapter Four examines MHO service development, using the same data sources.

RESPONSE

3.2 Each LA in Scotland submitted a mapping proforma and a nominated service manager in each LA was interviewed by telephone, giving a 100% response. For some LAs, quantitative data regarding the use of legislation were not available within the data collection period for the research .

CONTEXTUAL INFORMATION

Populations

3.3 The populations covered by different LAs across Scotland vary greatly; they range in size from 19,245 to 600,000 with the average population being 161,745.

Impact of size and geography of population served on MHO service response

3.4 Each LA reported generally adequate MHO staffing coverage, providing equitable service provision across geographic sectors, even those rural and remote areas, allowing an effective response to need on the whole. However, there was a perception among respondents that current MHO staffing complements were fully stretched and would not have the additional capacity to be able to respond to the demands of the new MHA (2003).

3.5 Respondents from more compact and urban LA areas reported low travel for MHOs and good proximity to other agencies. However, respondents reported a number of problems related to working in rural and remote areas:

• In smaller LAs and remote areas there was a worry that the departure of a few MHOs would leave the service seriously depleted
• The allocation of MHOs to geographical sectors helped promote consistency and continuity for clients and professional partners. However, this could lead to uneven spreads of workload where there are remote and rural geographies
• Travel times and availability of MHO staff in rural and remote areas could make responding to emergency calls a challenge, although it was said to be very rare for detention under the MHA (1984) to be carried out without MHO consent
• In rural areas without psychiatric inpatient units, emergency detention under the MHA (1984) was an issue with police cells being utilised as temporary measures, providing places of safety until hospital admissions could be arranged
• In LAs covering rural and remote areas, there was a tension between having too few MHOs to cover the area and too many, diluting the opportunities for individual MHOs to practice and maintain competence

Co-terminosity with NHS bodies

3.6 LAs were asked to indicate the number of NHS organisations with which they worked. At the time of the research, Health Boards, NHS Primary Care Trusts and NHS Acute Trusts operated as separate bodies. It was therefore likely that those local authorities which were co-terminous with NHS boundaries would be working with at least three NHS bodies. This was the case for the majority: 25 LAs worked with three NHS bodies. There was also a minority who had to manage relationships with a greater number of NHS bodies: two LAs related to four NHS bodies, two LAs related to six NHS bodies, one worked with eight and one with nine NHS bodies. The details of these working relationships are given below.

3.7 Of the three island authorities, one worked with a single NHS organisation that combined the functions of planning and commissioning and service delivery of a Health Board and a Primary Care Trust. The other two related to the island health body and to a mainland Board and its Trusts for aspects of health care provision.

3.8 Twenty-six LAs worked with one Health Board, and of these 10 were coterminous. Many of the others shared the Health Board with up to three other LAs. Four LAs (which included two small authorities with populations of under 100,000 and two larger LAs with populations of over 300,000) worked with two Health Boards. The remaining small LA worked with three Health Boards.

3.9 Relationships with NHS Trusts were characterised as follows:

• The majority of LAs (24) worked with one Primary Care Trust (PCT) and 8 of these were coterminous
• Five LAs worked with two PCTs
• The remaining LA worked with three PCTs. This was a small authority that straddled three health board areas
• Twenty-seven LAs worked with one Acute NHS Trust, of these eight were coterminous
• Three LAs worked with two Acute Trusts
• The remaining LA worked with three Acute Trusts - the same authority noted above that spanned three health board areas

3.10 The complex webs of relationships described between local authorities and their local NHS partners organisations illustrate the complexities of joint working between health and social work in planning and delivering services. These are important features of the organisational context in which MHO services were evolving

Placing of social work departments in LA organisational structures

3.11 Respondents were asked in the proforma to describe the place that social work

services occupied in their local authority structure. Two main distinguishing features emerged from responses: whether social work was aligned with other functions within a departmental structure or stood alone; whether social work was an integral service or was split across two or more departments.

3.12 In 13 LAs the social work department was a stand-alone department, in seven LAs social work was amalgamated with housing, in three LAs social work was amalgamated with housing and education. Other alignments included:

• Social work located within Social Policy
• Social work as part of Social Work, Housing and Health Department coexisting with Social Justice Services
• Social work as part of a portfolio structure

3.13 Five LAs appeared to have distinctive social work service structures with social work spread across two or more departments as follows:

• SW split between Children and Community Services
• SW split between Community Care (jointly delivered with Health), Education, Child and Criminal Justice Services
• SW split between Education, Property Services and Social Services
• SW divided between Children and Families, Criminal Justice, Community Care and Support Services

3.14 In one LA, social workers were said to be employed as 'service providers'. This authority had a Social Services Policy section but no Social Work Department. In some areas the service structures within the authority appeared to be based around client groups or needs groups rather around professional services. There was therefore little standardisation in terms of the place that Social Work services had within local authorities. Nor was it possible from the data available to discern any direct association between local authority structure (as indicated by the positioning of social work) and other LA characteristics, such as geography or rurality, or population size

MHO activity levels

3.15 Tables 3.1 and 3.2 show the collated data provided by LAs on the activity levels of MHOs under different areas of the Mental Health (Scotland) Act 1984. The tables indicate the number of LAs which provided information for each of the items requested and present the total volume of activity under each item for the authorities that responded, as well as the range recorded by individual authorities.

Table 3.1. Activity Levels within LAs for the 12 months from April 2001 to March 2002 under areas of the Mental Health (Scotland) Act (1984)

Table 3.2. Activity Levels within LAs for the 9 months from April 2002 to December 2002 under areas of the Adults with Incapacity (Scotland) Act (2000)

3.16 The data in Tables 3.1 and 3.2 raise several important issues concerning the collection of and access to routine information on the use of the MHA (1984). In seeking to gather data from LAs on the use of the MHA (1984) between April 2001 and March 2002 a number of limitations were uncovered:

• Some LAs did not have access to full and accurate information on each the areas of the MHA (1984) indicated above. Several LAs mentioned that the quality of and access to their routine data was under review
• Five LAs only collected routine information on consents for emergency and short-term detention under the MHA (1984), and not for assessments
• Some LAs did not discriminate between statutory and non-statutory SCRs when recording data and five LAs had no information available on the use of SCRs

3.17 The Mental Welfare Commission routinely collates and publishes statistics in their

annual reports relating to detention and guardianship under the Mental Health (Scotland) Act (1984). A comparison of the information presented in the MWC's Annual Report for 2001-2002 with the data gathered in this study throws up a number of discrepancies between the two sources:

• The MWC recorded 3273 consents for emergency detention (S24/S25), which exceeds the 2604 reported in this study, although the latter figure excludes data from three LAs
• The MWC figures on SCRs do not accord with the figures reported by respondents in this research. The figures here totalled 1164 SCRs, of which 289 were statutory, with no data or incomplete data for 9 LAs. The MWC stated in its report that 209 statutory SCRs were required and noted that it received 110 statutory and 1215 non statutory reports
• The MWC records1133 S18 applications, compared with 1290 in the research, from 30 LAs. The Commission's data only include successful applications and it may be that LAs reported all applications in the research
• The research recorded higher figures for guardianship than the MWC, which reports 190 new guardianship. It may be that LAs have included renewals in their research responses

3.18 More recent MWC statistics on SCRs received for the following year (2002-3) indicate a considerable reduction in the number of SCRs being provided. The Commission has noted that this trend appears to be accelerating. It may be that the increased demands on the MHO workforce occasioned by the AWIA are being met in part by transferring resources from this area of work.

3.19 It was not possible within the scope of this research to undertake a more detailed investigation of activity levels. Given the incompleteness of the data in Tables 3.1 and 3.2, it was not considered useful to conduct further analysis. What does emerge from the results, however, is the need for further work on activity data. This theme will be re-visited in subsequent sections.

LOCAL AUTHORITY MHO SERVICE CAPACITY

3.20 Local Authorities were asked to identify how and when MHO capacity has been determined, reviewed and how it would be maintained.

Determining MHO capacity

3.21 Five LAs stated that the required MHO capacity was determined through ongoing monitoring and review of service provision / activity and procedures. Twenty seven LAs were unable to identify formal mechanisms to assess capacity required and to inform MHO service planning and development. For these authorities, capacity required to provide a service of acceptable standard was determined more pragmatically:

• Working to maintain the MHO establishment, which hinged on the availability of MHOs and retention of MHOs and capacity to recruit MHO trainees
• Agreement on required capacity had been achieved at the most recent restructuring or disaggregation, but with no clear rationale or mechanisms in place to test this against current need / demand
• Capacity driven by the availability of funding
• Shaping the MHO service to match existing specialist teams and service demands
• Responding to demands for geographic equity of access

Maintaining MHO capacity

3.22 Retaining MHO capacity was seen as a challenge for LAs, in view of the movement of staff and persisting problems in the recruitment of new MHOs. Two out of three local authorities reported that they had in place strategies to promote the recruitment of MHOs. Approaches included:

• Setting out to achieve geographical coverage by attracting recruits from across the area. Some areas set a quota of trainees as a target to achieve
• Trawling for possible candidates via senior staff
• Targeting basic grade workers in all functions to ensure geographical and functional spread
• Circulating information annually about MHO role and the training programme to both potential MHOs and their managers
• Holding open days for prospective candidates and their managers
• Opportunities to shadow MHOs and gain awareness and understanding of role in advance of training. One area encouraged workers interested in the training to work on mental health cases with supervision from a mental health SSW
• Using Continuous Professional Development where workers were encouraged to identify professional development goals
• Making MHO training a requirement for certain staff e.g. all social workers joining a mental health team would be expected to undertake MHO training
• Financial incentives / remuneration was mentioned by several authorities as one means of attracting recruits

Plans for reviewing and developing MHO capacity

3.23 At the time of the research, 11 LAs reported they were undertaking or planning a full review of current MHO services to assess how well they met current demands and to determine what changes needed to be put in place to meet new demands. Information on routine activity and demand was the main data source for this work. Some authorities were assessing the quality of data on MHO services to enhance the accuracy of any assessment of capacity and forecast of future requirements.

3.24 In one area a new post had been created with responsibility to deal with the implementation of the MHA 2003 and review capacity requirements. Three LAs had yet to reach a formal decision on how capacity would be reviewed.

Planned developments in MHO services capacity

3.25 Fourteen LAs had planned and funded increased MHO capacity or were introducing new MHO posts that had not yet been filled. Many LAs reported difficulties in recruiting Social Workers in general, not only MHOs. Some LAs were creating specialist mental health posts and forensic social worker posts and were trying to recruit MHOs but when unsuccessful were engaging non-MHOs and targeting training at them. Some local authorities indicated that they were offering MHOs additional payments as one means of addressing difficulties with the recruitment and retention.

MHO staffing complements

3.26 Data regarding MHO staff complements were supplied by all LAs and are summarised in table 3.3 below:

Table 3.3 MHO staffing complements

3.27 As shown in Table 3.3 there were 682 staff across Scotland approved to act as MHOs. Of these, 260 were in posts with management or supervisory responsibilities. In addition, there were 18 MHOs awaiting approval to practice and a further 64 in training, indicating an anticipated increase in MHO capacity of 8%.

3.28 Of the 682 approved MHOs, 525.5 (77%) were reported to have been 'active' i.e. engaged in using mental health legislative measures in the preceding 6 months.

Table 3.4 Staff grades of practising MHOs

3.29 The figures in Table 3.4 indicate that 197 of the actively practising MHOs held managerial or supervisory positions within social work, if senior social worker posts and above are included: 37% of all practising MHOs. Comparing this to the figures in Table 3.3, which indicated that 260 managerial or supervisory staff were qualified as MHOs, it can be observed that 63 managerial and supervisory staff who were qualified as MHOs (24%) were not actively practising. This would suggest that the levels of non-practising MHOs were similar for both basic grade staff and those holding supervisory or management positions, with one quarter of both groups not practising.

ORGANISATIONAL STRUCTURES

Leadership of MHO services

3.30 Thirty-one LAs had an identified manager with lead responsibility for the development and co-ordination of their MHO service. In many instances, these managers also carried wider responsibilities. In some LAs the manager with responsibility for the MHO service had a strategic policy role and did not have operational responsibilities.

3.31 The accounts provided by local respondents indicated that authorities were establishing methods to develop and manage their MHO services increasingly effectively, with an identified lead office assuming this role. Respondents were able to identify the potential benefits of having a lead officer for the MHO service in terms of enabling:

• Overall strategy and direction for the service
• Prioritisation and rationalisation of training
• A sharper focus on MHO retention
• Awareness and profile raising amongst partner agencies and within social work
• Changes to policy and procedures across the MHO service

3.32 Respondents also identified that good central information systems were essential to allow review of activity and to assist recruitment and deployment planning.

Divisional Mental Health Officers

3.33 When asked to describe the structure of the local MHO service, three authorities made mention of the role of the Divisional Mental Health Officers (DMHOs). It is possible that other authorities may also have deployed staff in this capacity but not stated this.

These three authorities, one large and two small, were neighbouring and, before local government reorganisation in 1996, had all been part of the same local authority regional council. The role of DMHO, although framed slightly differently in each, included the following elements:

• Consultation and supervision (as required rather than routine)
• Co-ordination of rotas and ensuring continuity between out of hours and daytime MHO services
• Maintaining an overview of the service, tracking trends in demand
• Provision of quality assurance: in one authority, for example, it was reported that the DMHO received and read all statutory reports and gave feedback to individual MHOs
• Liaising with training departments to plan training to address identified needs

Dedicated MHOs

3.34 Thirteen LAs employed staff as MHOs whose primary task was to respond to work generated by mental health legislation (dedicated MHOs), and 20 LAs did not. These 13 authorities included two large urban authorities, two medium sized authorities serving populations of between 150,000 and 200,000, two island authorities and seven smaller authorities with populations of under 150,000.

3.35 In some areas MHOs based at mental health inpatient units and specialist mental health teams took on the bulk of MHO work across the LA.

3.36 In some of the LAs which had dedicated MHOs, the latter were attached to LHCCs or localities within the LA area and were usually senior social worker grade posts. In most cases, these dedicated locality MHOs were supplemented by other non-dedicated MHOs whose responsibilities included MHO functions as only one of their areas of responsibility.

Deployment of MHO staff

3.37 Table 3.5 indicates the deployment of staff appointed as MHOs in Scotland at the time of this research.

Table 3.5 Deployment of MHO staff

3.38 Thirty-four per cent of MHOs were deployed within a mental health team, 21% in assessment and care management teams. The other main services in which MHOs were deployed included: criminal justice and offending, children and families, learning disabilities and older people's services. Two percent of MHOs were hospital based (3 including State Hospital) and a similar proportion was deployed in an out of hours team.

3.39 Seven LAs pointed out that their MHOs often worked across a number of specialist areas. It was also indicated by 5 LAs that assessment and care management were included within other teams such as Community Mental Health Teams (CMHTs) or incorporated specialist areas of work, such as learning disabilities, older people and physical disabilities. This could also have been the case in other authorities, who failed to mention this.

3.40 The deployment of MHOs across a number of social work specialities, for example in children and family teams and older people's services, rather than in mental health teams only, may bring a number of benefits and disadvantages. A clear benefit reported by respondents was the facility for the MHO service to 'plug-in' to different specialisms. It was also perceived that the wider dispersal of MHOs meant that they were able to contribute to driving the mental health agenda in specialist areas, such as criminal justice and childcare teams. MHO alignment with Local Health Care Co-operatives (LHCCs) was regarded as beneficial as it helped foster a close knit multi-professional community

3.41 The perceived disadvantages associated with deployment of MHOs in specialist areas other than mental health related primarily to support and supervision, to the maintenance of practice experience and confidence and to continuity of care (see below).

3.42 It was noted that problems could arise when MHOs were managed by senior social workers who were non-MHOs, although the data reported did not give an indication of how common this might be. In such situations, non-MHO managers could fail to recognise the statutory workload demands on individual MHOs, or the standards to which they are expected to practise. Consequently prioritisation of statutory work could be difficult for MHOs. This was thought to be particularly pertinent for AWIA cases which required longer-term input.

3.43 Being based in community mental health teams was perceived to help facilitate good

links with and access to colleagues for joint working on assessment and care management. It also helped assure access to supportive management and supervision.

OPERATIONAL PROCESSES

Out of hours services

Hours

3.44 The majority of areas were covered by a dedicated regional MHO standby service that spanned several authorities and covered non-office hours, that is, evenings, weekends and holidays. There were several other models described, for example:

• A (generic) Social Work Emergency Duty Team, which had an MHO on duty at all times. All staff on this service were MHO trained
• An island authority which operated a generic social work out of hours service, contactable through a community alarm scheme. MHOs took part in the Social Work generic rota, which meant that some parts of the island chain might have MHO cover for 3 out of every 8 weeks
• Services which were able to provide office based cover up to midnight, after which MHOs were on call from home
• Mixed models of provision: one area, which covered both urban, and remote and island populations used a regional standby service to cover part of its 'patch' but did not have out of hours MHO cover for the more outlying areas
• In two other areas there was insufficient MHO capacity to provide rota cover and out of hours cover was contingent on the availability and willingness of a small number of MHOs (two in one authority, four in the other) to be called out. These authorities were acutely aware of the fragility of the service that could be provided in this way

Staffing

3.45 Regional out of hours services operated blanket coverage across all the participating authorities and did not provide a specific service targeted at individual local authorities.

Some regional services also drew on day shift MHOs within agreed limits. One area which did not have out of hours MHO cover for part of its area was looking into the health and safety and professional issues involved, should staff be called out, out of hours, and then be expected to be available for work the next day.

Follow on arrangements

3.46 Next day referrals of cases requiring follow on work were picked up in various ways:

• Notification of the relevant mental health senior manager or team leader who would then allocate the case
• Notification of the Divisional MHO and case picked up through the day time MHO duty rota

3.47 Referrals tended to be communicated by fax with a supporting phone call if the situation was urgent.

Access to MHO service

Information on access routes

3.48 Twenty-eight authorities reported they had a strategy to communicate information on accessing the local MHO service round the clock. Typically, strategies included information widely circulated to LHCCs, GPs and consultants, council staff and other services, giving contact details, in a number of formats: laminated leaflets for all GP practices, stickers and flyers, with contact details, letters and memos. Some areas stated that this information was updated every 3-4 months. MHO rotas were also circulated widely and regularly.

3.49 Other methods of promoting awareness included DMHO input to the induction of junior doctors to ensure they are aware of access routes and MHO participation in meetings with primary health care and secondary mental health care staff.

3.50 Three authorities, all serving small populations of 150, 000 and under, stated they had no strategy for the routine dissemination of information on access routes. There was no response from one authority to this question.

Day time access procedures

3.51 Two in three authorities had protocols in place covering daytime access to the MHO service and some of these protocols set out expected standards for response times to requests for an MHO service.

3.52 Contact with the MHO in some areas was made directly, via a dedicated mobile number or pager. In others, single point of contact to a central location was used to reach the duty MHO via:

• Community mental health team
• Duty referral system in area office
• Direct contact with duty MHO
• Designated Community Care Senior
• In one larger authority there was an MHO emergency access rota in each of the four sectors, with an adult SSW with responsibility for mental health in each locality
• Hospital switchboard which then linked the call with the duty MHO

3.53 CMHTs and area offices were most commonly mentioned as the route to access the MHO service in day time hours. In three larger authorities, where MHO services were organised in sectors or divisions, access routes were via the community mental health service in each sector or division. Direct access to the duty MHO was used in several of the smaller authorities. Access via the hospital switchboard featured in authorities of different sizes.

Out of hours access procedures

3.54 Twenty-two authorities had protocols in place to set out procedures for out of hours access to the MHO service. There was a cluster of ten authorities which lacked formal protocols for both daytime and out of hours access. These tended to be authorities serving smaller populations of under 150,000.

3.55 Out of hours access was through various types of single point of contact:

• Several authorities had a single out of hours service for housing and social work or for all council services, with procedures to fast track requests for MHO service to social work out of hours, who then contact the MHO on duty
• Direct contact with social work out of hours team which has dedicated MHO cover within the team
• Direct contact with the regional out of hours service
• Answering machine service giving contact for duty MHOs

Respondents' views on daytime and out of hours access arrangements

3.56 Some respondents noted the benefits of a single point of administration for the whole MHO service, which provided a service structure that was familiar to and understood by many and allowed good co-ordination and access.

3.57 Many LAs were struggling to maintain a consistent out of hours response. For LAs without a dedicated out of hours team, providing a service was dependent on the flexibility of MHO staff to work on standby which did not guarantee availability. Where dedicated out of hours staff were in place, daytime staff did not have to work nights or weekends. However, in the absence of a dedicated service, problems could occur in managing out of hours rotas and ensuring MHO availability. In any event, good communication between day and night staff was considered essential to providing a successful service.

3.58 Out of hours screening services were considered effective in ensuring appropriateness of MHO referrals but could lead to frustrations for referrers wishing to have direct access to the MHO service in an emergency. There were concerns about out of hours staff not being able to assess for consent to detentions under the MHA (1984) because of the time taken to arrive on the scene.

Allocation of MHO work

3.59 A number of different systems were operated to allocate work. Referrals to the MHO service were managed by a duty rota, in a variety of ways. The two principle mechanisms were where:

• The duty MHO took all referrals and continued to hold responsibility for any case work required in the course of the week's duty
• The duty MHO took emergency requests, with separate allocation arrangements by rota or by a senior manager for guardianships, requests for case conferences and reports relating to the AWIA

3.60 There were also other variations such as:

• In one authority covering a large geographical area of both urban and more rural and remote, dispersed populations, MHO cover was described as limited. Here, it was not possible to have MHOs available on call in each part of the area at all times. Emergency assessments were allocated by the duty social worker to the most appropriate worker available
• In one authority a daily duty system was operated by the mental health team, with MHOs aligned to consultant psychiatrists

3.61 In general, emergency work out of hours was picked up by the dedicated regional service or the MHO on duty / on call.

3.62 Longer term work was allocated to the most appropriate specialism by the mental health team manager or community care senior.

Factors that influence allocation

3.63 Allocation of work was influenced by judgements about workload, case mix and geography. In some non-mental health teams, mental health work was not prioritised and MHOs based in these teams could find it difficult to make time for MHO work. MHOs in non-mental health settings were said to have more limited opportunities to undertake a range of MHO work and could be restricted to short term duty work. For professional development, MHOs needed to maintain and extend their practice experience. Where there was a shortage of MHOs in a local service, professional development inevitably became a secondary consideration.

LINKS AND RELATIONSHIPS WITHIN THE LOCAL AUTHORITY

3.64 The MHO service has an important role as a source of expert advice for other services and has to work closely with colleagues to discharge its statutory duties. Recent years have seen a number of developments that influence the processes and working relationships between the MHO service and other LA services. Good practice in respect of guardianship requires that care management arrangements are in place before guardianship can be initiated, for instance. In addition, the development of assessment and care management as a means of structuring social work activity with different client groups has provided opportunity to bring in expertise as required to supplement the care management function, to respond to individual needs.

3.65 In both the mapping and the interviews, local authorities were invited to describe their relationships with a range of other professions and agencies and to evaluate the quality of these working links.

Requests to MHOs for advice from LA colleagues

3.66 Most LAs had informal but effective links with a range of other services within their authority and MHOs were often contacted for advice and to act as a resource to their fellow team members. In some areas more senior MHOs took responsibility for dealing with requests for advice; elsewhere the duty MHO had this responsibility.

3.67 Because MHOs were dispersed across social and health service areas, it was reported that the service could readily provide advice to a wide range of professionals such as mental health team members, occupational therapy, housing, substance misuse services, legal services.

Co-working on individual cases

3.68 Respondents reported that MHOs co-worked on a number of types of cases, generally those which involved complex or multiple areas of need, where the client already had a care manager. Examples of this type of work included the following:

• Cases involving measures covered by the AWIA, in which the MHO and the care manager would work together
• Childcare cases with child and family social workers, for example where the parent had mental health problems, the MHO would hold responsibility for mental health work
• MHOs could be invited as experts to case discussions such as Section 18 applications for long term detention
• Care Programme Approach cases to co-ordinate the care, treatment and support of people with serious, enduring mental health problems who were assessed as vulnerable or at risk

3.69 In some cases co-working agreements were presided over by managers or written into assessment and care management procedures.

Transferring responsibility for cases

3.70 In most cases, it was reported that transfers were formally negotiated and agreed by team leaders or managers with little difficulty. One LA had established protocols for the transfer of cases between hospital and community, criminal justice, children and families, local practice teams, neighbouring local authorities.

3.71 Following statutory work, MHOs would identify the need for their ongoing involvement with colleagues and if necessary preparations for transfer would put in place.

3.72 Four authorities (two authorities serving large populations, one that covered a large geographical area and had a medium sized population and one small urban authority) reported that case transfer could be difficult when:

• Services of more than one team were required and/or
• Workload demands meant that different teams were unable to reach agreement on the prioritisation of casework and MHOs were unable to access appropriate or timeous follow-up

3.73 An MHO's involvement would not necessarily mean that they were or became the case holder: for example the statutory MHO role could be kept separate from the therapeutic and care management function. Some MHOs had fully operational cases in other fields and were not able to take on MHO casework. The case would be returned to the existing care manager or needs addressed through transfer to appropriate services.

MHO operational links with assessment and care management

3.74 In interview, local service managers considered that working links between MHOs and care managers were generally good, allowing flexible approaches to practise. Respondents pointed out that care management had to be in place before resort to measures relating to the AWIA could be considered. Joint case discussions involving MHOs often took place before AWIA case conferences. Training on the AWIA was considered to have emphasised the importance of the joint working approach and had had a positive impact on building the necessary links.

3.75 However, there remained a need to improve and clarify the interface between care management and MHO functions and to identify more effective workload management strategies. Several respondents reported that ensuring equity of the allocation of MHO work was becoming more difficult as workloads increased with duties pertaining to the AWIA. In one urban authority it was reported that problems with recruitment of MHOs had led to an unequal distribution of MHOs across teams, with the result that those assessment and care management teams with higher numbers of MHOs were taking on a disproportionate volume of work.

LINKS AND RELATIONSHIPS WITH EXTERNAL AGENCIES AND SERVICES

Links with NHS mental health care professionals

3.76 The implementation of Joint Future has added impetus to earlier requirements for social work and health to work closely together in the planning and delivery of services. Joint Future expects local authorities and their NHS partner agencies to develop structures and procedures to ensure the integrated planning, financing, management and delivery of community care services, including mental health services, in order to achieve better outcomes for the users of services and their families.

In relation to individual cases

3.77 There was a general view that links with NHS professionals in relation to individual cases were positive and effective. MHOs working in integrated teams in the community and hospitals with health care were thought to have close working relationships with their health colleagues on individual cases, particularly where these required the use of the Care Programme Approach to ensure the co-ordination of assessment, care planning and the delivery of integrated care. In some areas MHOs were aligned to psychiatrists and/or CMHTs for continuity on individual cases.

3.78 MHOs were reported to be fully involved in case discussions routinely or as experts. In some areas joint training was provided and this was said to increase the effectiveness of joint working relationships.

In relation to wider operational issues

3.79 Senior MHO staff or managers were linked in to various strategic level multi-agency and multi-professional joint planning processes, in line with the Joint Future agenda. These include local mental health planning and implementation groups, mental health partnerships, joint integration steering groups, resource networks, and joint boards. In many LAs these arrangements were described as evolving. Some authorities were in the process of negotiating new joint management structures that would facilitate effective working with health on wider operational issues.

3.80 LAs were working with each other and with local health services to agree operational procedures for example those relating to the AWIA. Technical or clinical operational issues were also discussed at regular meetings with psychiatrists.

Joint protocols with NHS health professionals

3.81 Only five Local Authorities had a formal joint protocol that governed MHOs' working with health professionals. Those protocols covered the following areas:

• Establishing better practice in the conveying of detained patients to hospital
• Adherence of MHOs to the codes of practice relating to legislation
• Care programme approach
• The AWIA
• Community Care Orders
• Referrals

3.82 Of those LAs without formal protocols, six were working towards establishing protocols to formalise good practice or had intentions to do so, others stated that their practice followed legislative guidance.

Working with the voluntary and independent sector

3.83 MHO joint working with voluntary sector providers was regarded as important in view of the crucial role that voluntary organisations often played as the main supporting agency for vulnerable people in the community. MHOs tended to have consistent involvement on a case-by-case basis through making or receiving referrals and in review meetings. Contact with service users and carers could also be facilitated via voluntary organisations. In some areas advice and training was given by MHOs to voluntary organisations.

3.84 The nature of contact with voluntary organisations varied in different areas. In some LAs, involvement was 'as required' , whereas in others voluntary organisations were seen as partners in service delivery. In such circumstances regular meetings were held and/or joint working protocols with voluntary sector providers had been developed. Two island authorities were the only ones to report that joint working protocols with voluntary and independent sector providers.

Working with the police

On individual cases

3.85 In most cases the working relationship with police was described as positive with police demonstrating sensitivity towards vulnerable people and a willingness to work as part of the mental health team when required. Police were involved in CPA reviews, case conferences and crisis planning.

3.86 Engagement with the police was usually through referral from the police surgeon. Police also contacted MHOs directly for advice on whether to involve a police surgeon.

3.87 Police tended to be called on by the MHO to help with initiating a S117 warrant, S118 or when MHO might be in a potentially dangerous situation. In one LA, there was a High Risk Offenders Group that planned and reviewed complex cases with the police.

On wider operational issues

3.88 On wider operational issues, the police were involved in a variety of ways:

• Liaison meetings between mental health and police managers
• CPA monitoring group
• Training
• Forensic strategy forum
• Mental health officer support group
• Awareness raising sessions
• Appropriate adult scheme training

3.89 Six LAs had joint protocols that governed joint working with the police, specifically in areas covering out of hours, section 117, CPA, Community Care Orders and mentally disordered offenders. Of these six, two were island authorities, three were authorities serving small populations of under 150,000, the sixth served a larger population of over 350,000. The three smaller authorities included the authority mentioned above which had the High Risk Offenders Group.

3.90 One LA had a number of agreements on specific tasks such as appropriate adults, rather than a formal protocol. In some areas, more general protocols such as risk assessment covered aspects of joint working with the police.

Working with the courts

3.91 Four LAs had a joint protocol governing joint working with courts, usually covering deferred prosecutions or diversion cases. These four included the two island authorities and the larger authority noted above, that had protocols in place to guide relationships with the police, as well as one other large city authority. Protocols were said to have been developed in response to recent national policy guidance on care pathways for mentally disordered offenders.

3.92 In five LAs (one island authority, one small rural mainland authority, one small urban and two large authorities) there was a dedicated MHO within criminal justice who worked with the courts.

3.93 In other LAs, MHOs worked with the courts on a case-by-case basis. This entailed working with sheriffs and sheriff clerks on an individual basis relating to applications under mental health legislation. LA legal services council solicitors represented MHOs in court and MHOs provided reports for courts.

Working with Procurators Fiscal

3.94 MHOs had less frequent contact with the procurator fiscal than with the courts. Contact tended to entail MHOs providing a written report when someone had been convicted of an offence and need for mental health care treatment had been identified or when someone had been put on remand for the purposes of assessing need for care and treatment.

3.95 Three LAs had protocols regarding joint working with the procurator fiscal, as part of

arrangements for the care and management of mentally disordered offenders. One of these three authorities also had protocols for working both with the courts and with the police, a second had a protocol for working with the courts as well as the procurator fiscal, but not with the police.

Joint forums or networks for information sharing between MHOs and external agencies

3.96 Four LAs stated that there were no specific formal forums in which information could be shared between MHOs and external agencies. However in the other 28 LAs, information sharing took place in a wide variety of forums:

• CMHT meetings
• LHCC mental health sub-group meetings
• MHO support groups / forums / development meetings to which external agencies are invited
• Forensic Strategic Forum, Vulnerable Adults Forum
• Joint training events
• Meetings with medical staff
• Strategic Review Groups and Mental Health Partnership Groups
• AWIA multi-agency groups

Joint forums or networks for information sharing between MHOs and service user and carer groups

3.97 Thirteen LAs had no formal networks or information sharing opportunities between MHOs and service users and carers. The other 19 LAs reported various networks and forums in which information sharing occurred between MHOs and service users and carers:

• Service users and carers involved in MHO training programme
• Users and carers represented on some mental health planning groups
• Specific events with local users networks and professionals
• Allies in Change
• User and Carer reference group
• Community Care Forum
• MHOs attendance at routine user and carer group meetings

Joint training opportunities

3.98 Twenty LAs stated that they had joint training opportunities; in most cases these featured training on the implementation of the AWIA and on procedures relating to the implementation of the Care Programme Approach. These LAs were working on joint training strategies, particularly in light of the new Act.

3.100 Of the remaining 12 authorities, which had no or very limited joint training, half noted plans to implement such training in the future. These 12 LAs included three large urban authorities and nine small authorities, serving populations of under 100,000.

3.101 Several authorities stated that previous attempts at joint training had proved unsuccessful because it had proved difficult for health and social work staff to identify common training needs.

3.102 Examples of joint training undertaken or planned were:

• AWIA training involving a range of other groups such as local elected members, users and carers, GPs, paramedics
• Team building days
• Childcare issues in adult mental health
• Risk assessment
• Service user pathways
• Single shared assessment
• Computer systems
• Cognitive Behavioural Therapy
• Relapse prevention
• Guardianship

3.103 Providing local training was said to have helped some LAs to increase their MHO staff complement. Participation in Social Work Training Consortia was regarded as particularly helpful for smaller LAs who lacked resources to provide full training internally.

3.104 Local joint training with health care partners was reported to be most common on issues such as the AWIA and in some areas health and social work had joint training agendas for mental health. Joint training and development in partnership with user and carer organisations were seen as beneficial in lessening the 'them and us' situation. In addition MHO forums provided regular discussion and development opportunities to which professionals from other agencies such as medicine or law are invited. Dissemination of articles and information was also considered to be another important route to promote learning and professional development.

Mechanisms to resolve inter-professional disputes

3.105 Twenty LAs stated they had mechanisms for the resolution of inter-professional disputes. Informal resolution of the matter was seen to be preferable but where necessary recourse could be made to the following:

• Mental Welfare Commission
• Line management and supervision
• Directors, senior officers and service managers
• Legal support
• Procedures within CPA guidance
• Senior management teams
• Court processes
• Joint mental health management group

Reflections on the quality of links and relationships with external agencies

3.106 In interview, respondents reported that local MHO services had established good relationships with a large number of agencies including: GPs, police, home care services, the voluntary sector, the Office of the Public Guardian, CPNs, psychiatric and general hospital inpatient staff, consultant psychiatrists, the Benefits Agency, housing departments and agencies and forensic services.

3.107 Nevertheless, respondents also considered that other agencies and professionals did not as yet have a sufficient understanding of the MHO role. Working relationships with GPs in particular were highlighted as an area requiring improvement, in view of difficulties encountered at the interface between MHO services and GP services. These included:

• Access to GPs
• GPs departing after signing paperwork
• Reluctance to complete medical reports for the AWIA
• Unrealistic expectations regarding MHO response times

3.108 Other relationships that respondents felt could be improved included those with Local Health Care Co-operatives and with drug services.

3.109 On a more positive note, all respondents reported good working relationships with health care staff in general. One respondent indicated a 'move away from fire-fighting' and towards a preventative approach to MHO work. Here, creative, collaborative relationships with healthcare staff were being used to consider alternatives to detention, to reduce recourse to statutory powers.

3.110 Working relationships were generally perceived by respondents to be better at ground level than at strategic level. Regular planning meetings with other agencies at practice level, at operational level and at strategic level, were viewed as key to maintaining good relationships in order to be able to work effectively in partnership on single shared assessment, discharge planning, resource allocation and resource transfer.

3.111 Where MHOs worked within CMHTs, particularly good and close relationships with other mental health and social care agencies were reported, due to the high levels of integrated working within these teams. More formalised joint working procedures such as the single shared assessment process were said to be improving joint working relationships in older people's services particularly and across other client groups.

SUMMARY OF KEY ISSUES FROM MAPPING PROFORMA AND TELEPHONE INTERVIEWS: STRUCTURE AND ORGANISATION OF MHO SERVICES

• There was considerable variability in the structure of local authority MHO services and in the management arrangements to support these
• At the time of the survey (March 2003), there were 682 approved MHOs across all 32 authorities. Of theses 77% were 'active', in that they had undertaken statutory mental health work in the preceding 12 months
• Just over a third of all local authorities employed dedicated MHOs. One in three of all MHOs worked in a community mental health team. Over 20% were employed in teams where they were likely to undertake only a limited amount of MHO work. Of those actively practising as MHOs, over a third were in the posts of senior, team manager, service, manager or above
• There was evidence that local authorities were improving the development and management of the local MHO service, through steps such as the identification of a lead person with responsibility for the service and the designation of staff such as a DMHO or other manager post to maintain quality and standards
• There were perceived to be advantages and disadvantages to the deployment of MHOs across specialisms, beyond mental health. The deployment within or outwith mental health teams had implications for line management, support and supervision, for workload management and potentially for the responsiveness and accessibility of the service, in ways that were likely to impact on service standards and quality
• Local experiences indicated the importance of establishing clear strategic and operational responsibility for the MHO service, which had often been a relatively low priority within local authorities relative to other 'competing' priorities
• Ensuring the level of out of hours cover required was a challenge in rural and remote areas
• Most local authorities were unable to identify formal mechanisms to assess capacity required to provide an MHO of the professional standard required
• Recruiting and retaining MHOs were continuing challenges for local authorities. Two thirds of all authorities had formulated strategies to address this challenge. There were plans in many authorities to increase MHO service capacity, although findings did not indicate the scale of the growth desired
• There was variability in the formalisation of policies and procedures, for example the establishment of protocols on accessing MHO services. There was some evidence to suggest that smaller authorities were less likely to have codified their procedures in this way
• Joint working relationships with other agencies, and with health in particular, were perceived to be good. The establishment of multidisciplinary teams was considered invaluable in creating a forum for better communication and for the development of mutual understanding and trust between professions, in ways which impacted favourably on the performance of the MHO role
• A minority of authorities reported that protocols were in place to guide working relationships with the police, courts and procurators fiscal. One in six authorities had a dedicated MHO working with the courts. Only one authority reported that it had protocols for working with each of these bodies and also had dedicated MHO capacity to work with the courts
• There was perceived to be a need to improve relationships between the MHO service and GPs, by building a clearer understanding of the MHO role and clarifying mutual expectations

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