Mental Health Officer Services: Structures and Support

MENTAL HEALTH OFFICER SERVICES: STRUCTURES AND SUPPORTS

CHAPTER FOUR: MAPPING PROFORMA AND TELEPHONE INTERVIEW FINDINGS II: MHO SERVICE DEVELOPMENT

INTRODUCTION

4.1 Chapter Three presented findings from the mapping proforma and the telephone interviews relating to the structure and organisation of MHO services. Using the same two data sources, this chapter examines MHO service development, looking firstly at issues of training, support and supervision and audit and monitoring. This is followed by an exploration of the relationship between MHO structures and service quality and effectiveness. The chapter concludes by considering the steps taken and required to ensure local MHO services are able to meet current and imminent new legislative demands. As in Chapter Three, the combination of data from the mapping and from the telephone interviews allows the presentation of factual information alongside qualitative and subjective perspectives. Again, the sequence of presentation follows the themes explored in the mapping proforma and the telephone interviews.

TRAINING AND PROFESSIONAL DEVELOPMENT

Criteria to approve appointment of MHOs

4.2 Half of the local authorities had as their only criteria to approve the appointment of MHOs satisfactory completion of the MHO training course. Others noted that in addition to this training candidates would be expected to have relevant experience and knowledge of local resources and processes.

4.3 A small number of authorities had a requirement to interview candidates. One operated a system of interview which involved the recommendations of the assessment panel being put to the head of service for approval. In other authorities formal approval was required from the Chief Social Work Officer, by the housing and social work committee or by senior management.

Provision of training to prepare MHOs

4.4 In addition to the formal training for MHOs provided by regional consortia, authorities noted preparation and support provided in-house for two purposes: to give prospective MHOs an introduction to the MHO role in advance of the formal training programme and to ease newly trained MHOs into their responsibilities. To achieve this, authorities referred to:

Support from senior MHO offer advice and guidance on local operational policies.
Shadowing in the course of the training programme itself
Informal induction and support from peers locally
Gradual introduction to the MHO rota

Conversion from Approved Social Worker (ASW)

4.5 Differences in mental health legislation between Scotland and England and Wales mean that social workers approved under English legislation to perform statutory mental health functions are not authorised to practise in Scotland. Local authorities were asked to indicate the steps they took to convert Approved Social Worker training and enable someone to be approved as an MHO.

4.6 Several areas noted that this eventuality had not arisen for some time. Others stipulated that completion of selected parts of the MHO training was a prerequisite. A third set of authorities made reference to a bridging course offered by the training consortia, focusing in particular on the Scottish legal framework for MHO service provision, which would allow an ASW to achieve MHO recognition.

4.7 A number of authorities stated that protocols had been established setting out the knowledge and competencies that an ASW would have to demonstrate to gain MHO status. This included for example preparing an SCR to acceptable standard, completing a resource summary for the area to indicate familiarity with local service provision and undertaking a written exercise on the law. Evidence of previous professional competence as an ASW was also required.

Maintaining and updating skills and knowledge

Legislation

4.8 The steps taken to promote training on new legislation included examples of specific training programmes, in particular in relation to the implementation of the AWIA, and more informal opportunities for information sharing and updating through peer support:

Time approved to attend Scottish and UK events promoting professional development
Training consortia providing regular continuing professional development days throughout the year
Identified annual budget for mental health training, including elements for MHOs. Divisional MHOs or SSW had a role in identifying training needs and in liasing with in-house training division
Joint training initiatives had been undertaken with other social work and health colleagues, in relation to implementation of the AWIA
Several authorities had appointed a local AWIA co-ordinator whose role included training
Training was often a standing item for local MHO Support Groups / Forums. This had led to a range of developments including a 3 day training programme, developed organised and delivered by MHOs and SSWs across 3 local authorities, with plans for follow on
Examples were also given of external training, from a local University

Developments in policy

4.9 Most local authorities reported that regular monthly or bimonthly MHO meetings

were the main vehicle for updating MHOs on local and national policy developments. Local forums or support groups were also a means for managers to maintain two-way communication with MHOs and gain their input to policy development. MHOs in some local authorities met monthly as group and also came together quarterly with MHOs from neighbouring authorities to look at common issues, including policy. In one area, the Principal Officer (Mental Health) and Adult Senior Social Worker with responsibility for mental health meet monthly with MHOs. In the same authority, information on policy issues also came through meetings with local team leaders and area service managers, in addition to the MHO Forum.

Developments in mental health treatment and medication

4.10 Most local authorities reported that limited or no opportunities were available for their MHOs to keep up to date with developments in mental health treatment and medication. The joint training undertaken with health colleagues tended to cover procedures and working practices but not aspects of treatment and medication. Some authorities made reference to opportunities for MHOs to access health training, particularly where MHOs worked within community mental health teams alongside NHS colleagues. In one area, MHOs were able to attend a mental health journal club at the local hospital. Other opportunities to learn of clinical developments could arise in the course of routine work, for example if an MHO regularly took part in primary care clinics and practice meetings.

Developments in services

4.11 As before, MHO Forums and Support Groups were regarded as one of the main sources of information on service developments to MHOs as a professional group. Updates from local strategic development and service planning would feed into local Forum discussions. In addition there were opportunities for MHOs to be kept informed and to contribute to service planning and development through local teams and through service management. In some areas, particularly smaller authorities, MHOs were involved in, and in some cases led, service planning and development.

Rationalising training and professional development of MHOs

4.12 According to respondents, ring fenced posts or capacity to promote MHO training and development were rare but could be effective in ensuring a planned approach to maintaining a skilled and up to date service. Three LAs were planning to create posts for this purpose in anticipation of the new MHA (2003). Others LAs may have had a similar intention but not made mention of this in their response. Four LAs made reference to a senior post or posts (such as Divisional Mental Health Officers), which carried responsibility for co-ordinating MHO training and professional development.

4.13 The following issues were raised by respondents in relation to MHO training and development:

MHOs who practised regularly may be more likely to have a stronger commitment to CPD, to keeping skills and knowledge up to date
MHOs who had little opportunity to practice were at risk of losing their skills and becoming a lost resource
For MHOs in non-mental health teams training opportunities relevant to the MHO role were not seen as a priority
There was a lack of agreed rational approach to selection of MHO training candidates
MHO training content nationally was perceived to lack standardisation
Renewing of MHO accreditation and reaccredidation needed to be addressed and there were questions to be resolved about the post-qualification training needs of MHOs
Resources for training were not always available

SUPERVISION AND SUPPORT

Formal support and supervision

4.14 In the mapping exercise, LAs were asked to describe the supervision arrangements in place to support MHOs. In interpreting the results, it is necessary to exercise caution as it was not always possible to distinguish support and supervision specific to the MHO role from support and supervision that was integral to the social work line management structure.

4.15 Twenty-four of the 32 LAs indicated that they had formal structures in place for the supervision and support of MHOs, through line management. However, in half of these authorities, the support and supervision was delivered through line management by a non-MHO senior.

4.16 An additional five local authorities indicated that provision had been made for MHO work to be supervised outside of line management structures to ensure access to expert advice and support from a manager with MHO experience. The other three authorities stated that support and supervision for MHO work was provided through peer support primarily (see below).

4.17 In some areas, where MHOs were not managed by an MHO trained manager, they had access to a team leader or manager with such training or to the DMHO for ad hoc advice, guidance or informal support on request. However, this could give rise to difficulties in workload management, as the supervising person did not have an overview of the totality of the MHOs workload. In one authority the team leader (mental illness) offered advice and support to others who supervised MHOs.

4.18 Despite the existence of line management arrangements, many respondents indicated in interview that they considered formal routine supervision of MHOs in their statutory role to be lacking or limited.

4.19 In interview, some respondents expressed the view that senior and very experienced MHOs were able to take responsibility for their own professional skill development and learning through Continuous Professional Development arrangements. These respondents suggested that more experienced MHO staff could provide informal support, consultation and advice to less experienced staff. However, the reliance on informal, peer support alone caused concern among respondents, in that it could not be guaranteed that MHOs would make use of such opportunities. The need remained to devise more effective methods to assure quality and consistency of practice, in particular as the new Act came into force.

Informal support and supervision

4.20 In describing local arrangements for support and supervision of MHO work, all authorities attached considerable weight to peer support and informal networking and discussion among MHOs, usually through a local MHO Forum or Support Group. These were regarded as important in particular where MHOs were line managed by non-MHO seniors. Informal contacts with the mental health team or equivalent was a further source of support.

4.21 Several authorities also mentioned support from a more senior level where an identified senior, team leader or DMHO was available to provide informal support and supervision as required (see above). In interview, respondents mentioned that local MHO forums could provide informal supervision by creating opportunities for discussion of complex cases or other topics of interest.

External access MHOs have to legal advice, information and support

4.22 Respondents from each MHO service were asked to name the sources of advice, information and support available to their local MHOs. The following external sources of information, advice and support on legal issues were detailed:

Mental Welfare Commission
Network of LA Solicitors
Legal Services Agency
Scottish Executive website
Office of the Public Guardian
External private legal firms contracted to work with LAs
Scottish Health Advisory Service
BASW MHO Forum website

Steps taken to review individual MHO competence to continue to practice

4.23 Fourteen authorities stated that they had instituted measures to review MHO competence to practice. In most of these authorities, line management and supervision of work were seen as the main method of quality monitoring and of identifying concerns about practice competence. Personal development plans were also a means of reviewing performance. In some areas, the DMHO role was to monitor quality and identify and raise issues with individual MHOs.

4.24 Several areas were in process of developing more systematic arrangements to review competence:

Under discussion in one LA were proposals for MHOs to maintain a portfolio of work to meet future accreditation
Another authority was in process of introducing a Competence Initiative scheme for all staff including MHOs
In a third authority, the issue of MHO competence was under scrutiny. A Joint Service Manager Mental Health had been given responsibility for issues of MHO competence and for MHO training to meet the demands of the new legislation and satisfy standards

4.25 Eighteen authorities did not have a formal procedure to review competence to continue to practice. These 18 included LAs of differing sizes, but were mainly authorities serving smaller populations.

TECHNICAL SUPPORT

4.26 The effective operation of a local MHO service requires that individual MHOs are provided with practical support to fulfil their functions. Respondents were asked to describe the support available to MHOs in their authority, with the following results.

Administrative support available to MHOs

4.27 It was reported that 29 LAs provided typing support for their MHOs, whilst three did

not. Notifications of renewals required were provided in 20 LAs. Other kinds of

administrative support available included an AWIA database, guidance on producing Social Circumstance Reports, maintenance of activity statistics and general office administration such as photocopying.

Technical equipment available to MHOs

4.28 In 22 LAs, MHOs had access to their own personal computer. Shared computers were available in 17 LAs (in some authorities some MHOs had their own computers, while others shared). Twenty eight LAs provided mobile phones to their MHOs and 12 provided pagers. In one LA a home phone allowance was given.

4.29 One LA stated that it had a protocol in place to identify the need for MHOs to request back up when visiting a client and also had lone working procedures. Others may have had similar arrangements but simply not recorded them.

Support provided to assist MHOs with transport

4.30 In 27 LAs, MHOs had authorised car user status. In 28 LAs MHOs had mileage allowances. Other kinds of transport support included assisted car purchase, car leasing schemes, bus tokens, local pool car access and taxis for MHOs who did not drive.

Links and relationships within the LA regarding legal, property and finance advice to MHOs

4.31 In each LA services were provided to MHOs from the council legal section, including advice and representation on applications, capacity, property and finance matters. All respondents were very satisfied with the services delivered by their legal colleagues, describing the relationship positively using words such as 'responsive', 'exceptional', 'proactive' and 'brilliant'. Respondents noted the importance of good quality advice and working relationships with legal services at a time when legislative change could become overwhelming for MHOs.

4.32 Good working relationships with legal services were facilitated in some authorities by having access to identified solicitors who dealt with the AWIA and the MHA (1984) and through the establishment of joint protocols to guide the use of legal services. Seventeen LAs had a clear policy or procedures for MHOs accessing legal advice, information and support.

4.33 Respondents suggested the following as areas for improvement or clarification in the provision of legal advice to MHO functions:

Interpretation and implementation of the AWIA. This is particularly problematic when trying to access private legal advice through legal aid
Resolution over 'caution' or personal insurance under the AWIA
More clarity and support for MHOs on finance and property issues
Engaging more effectively with housing departments
Training opportunities for legal staff
Ensuring legal services are involved when financial intervention orders and guardianships are being considered
Support with interpretation and implementation of measures contained within the new MHA (2003), with concern expressed about the capacity that would be available within LA legal sections for this

LOCAL AUDIT/MONITORING ARRANGEMENTS

Monitoring information collected on individual MHO activity

4.34 All LAs collected MHO activity data, many using their own log sheets and recording sheets. Respondents reported that the following information items were collected:

Referrals and general activity
All statutory reports under MHA (1984)
Time taken to complete guardianship orders
Giving / withholding consent
Applications
Individual case involvement in anticipation of registration and continuing professional development demands

4.35 Rota information was collected on the activities of teams. In addition the activity data described above were collated at team level. The concept of collecting information on a team basis was not always perceived to be relevant, as MHO work could undertaken by a practitioner who was not in a team with other MHOs.

Use of monitoring information to review practice and inform service development

4.36 One in three authorities stated that the local MHO service had not been subject to

review. These were all small authorities, including two island authorities. However, most authorities indicated that they were either in the process of conducting such a review or recognised the need to do so in the near future.

4.37 A number of LAs were including in their review the preparation of a development plan for the MHO service that included considerations of projected demand as well as of performance targets and standards.

4.38 Authorities made mention of various approaches that were currently used to assess and improve the performance of the MHO service:

Regular statistical monitoring of activity (on a monthly, quarterly or annual basis)
Quality monitoring of performance in relation to statutory requirements (e.g. SCRs)
Practice focussed improvements are agreed in some cases with health colleagues
Review of workloads and equity of allocation
Identification of general trends e.g. increased activity, activity by specialism or geographical sector
Mechanisms to implement recommendations arising from external reviews or inspections by MWC or the Social Work Services Inspectorate
Steps taken to gather feedback from key stakeholders locally and nationally: service users, consultants and other health professionals, MWC
Review of personal development plans of MHOs

4.39 It was also stated that practice was reviewed in supervision and through MHO forums where there was opportunity to gather more qualitative information than that offered through activity statistics.

4.40 It was considered to be important to utilise monitoring and evaluative information to inform service development, for the following reasons:

To identify growing and diminishing areas of need, gaps in meeting needs, demand and work volume. This helps the management of MHO capacity in terms of manpower and identifies the need for further resources
To raise awareness of the MHO role amongst other professional and agency partners
To consider reasons leading to detention for future prevention
To identify future training needs for the service in general
To review cross-boundary working situations

Mechanisms used to collect the views of service users on the quality of MHO services

4.41 Twenty-six LAs had no formal mechanisms other than complaints procedures in place to collect the views of the quality of their MHO services. Two LAs undertook questionnaire surveys to users and their carers and in three LAs, local service user reference groups or user forums were consulted. In one LA an MHO had been given the responsibility of improving liaison between MHOs and service users.

Mechanisms used to collect the views of health professionals on the quality of MHO services

4.42 Eighteen LAs indicated that they had formal mechanisms to collect the views of health professionals on the quality of MHO services, 14 did not. Examples of the kind of mechanisms in place included:

Regular meetings with Consultant Psychiatrists
Debriefing sessions on individual clients
Active collection of health professionals views via an MHO forum
Joint operational and other regular management meetings
One off consultations for 'Best Value' work or service reviews

4.43 It was also noted that many MHOs receive informal feedback on the service they provide, although it was not clear how such information was being collated and used to inform service planning and development.

Mechanisms used to collect the views of other stakeholders on the quality of MHO services

4.44 Fourteen LAs stated explicitly that they had no formal mechanisms to collect the views of other stakeholders on the quality of MHO services. The others used a variety of methods: one had carried out a consultation with their voluntary sector partners as part of the 'Best Value' project; several authorities had consulted with providers, advocacy services and legal services.

IMPACT OF STRUCTURES ON MHO SERVICE QUALITY AND EFFECTIVENESS

How management structures support MHO functions

4.45 MHO services were located within different structures, and therefore had differing arrangements for lead responsibility and operational management and differing sets of relationships and interfaces with other social work functions.

4.46 In relation to the deployment of MHOs and management arrangements, the following patterns were discernible:

In some small authorities all MHOs were line managed by MHO trained staff
In other small authorities (mainly those serving rural areas), there were difficulties of capacity and deployment which meant that MHOs were unlikely to be managed by a senior with MHO training
In larger authorities the MHO resource tended to be dispersed across different teams and specialism with a concentration in mental health teams
MHOs within the mental health teams would be likely to have an MHO trained manager
In some instances management of MHOs located in non-mental health teams had been aligned to bring them under the MHO trained Community Care manager

4.47 Arrangements described included the following:

In most authorities, MHO functions were supported via the management structure within locality or specialist teams, and co-ordination and planning issues addressed across teams
The officer with lead operational responsibility for the MHO service tended to be a designated Community Care Senior or Service Manager (Mental Health)
The role of Divisional MHO could be various: to maintain an overview of the service including monitoring and standards, to provide advice and support to individual MHOs as appropriate. The DMHO might also directly supervise MHOs
Some local authorities had developed or were developing structures to provide specialist management support to mental health functions, including the MHO service, for example:
- In one, a specialist mental health manager was supervised by an experienced mental health senior social work manager, who was also an MHO
- In another, MHO accredited SSWs line managed MHOs and were themselves managed by experienced Area Team Managers. A new post was in development in this authority to focus on mental health strategic planning and development
- One area had a Service Manager for mental health services and an Assistant Service Manager with lead responsibility for MHO functions

4.48 For LAs the effective management of the MHO service was one of a number of imperatives and one of many demands on resources. Several respondents observed that MHO functions were not well served by existing management structures. In considering the implications for MHO services the following key considerations emerged from local experiences:

Locus of MHO service within locality / specialist team is viewed as helpful in ensuring access and responsiveness but this has to be set against the potential professional isolation of MHOs in non-mental health teams and concerns about the professional standards and competence of the service and the negative impact on continuity of care.
The importance of establishing clear operational responsibility for the MHO service as a whole within the authority, to achieve area-wide planning and co-ordination, and to set and maintain standards
The need for proactive planning and development of the local MHO service to anticipate need and ensure capacity and capability
To date the status of mental health work and the MHO service in particular within local authorities has been low when set alongside other client groups, specialisms and 'competing' priorities

Implications for monitoring and supervision of MHOs

Within mental health teams

4.49 Key assets were the availability of an MHO senior to provide supervision and consultation coupled with access to peer support from MHO colleagues, which was seen as a highly valuable resource for practitioners. MHOs in mental health teams were considered more likely to be able to maintain and develop competence in fulfilling the role of MHO.

In non-mental health teams

4.50 There were perceived to be several positive effects of MHO 'dispersal' including:

Enabling practitioners to broaden the range of their social work experience
Ensuring greater variety of work that may make for greater job satisfaction
Opportunity to raise awareness of mental health needs among other client groups.
Enabling colleagues to gain access to MHO advice more readily

4.51 The negative effects were:

Practitioner isolation
Difficulties in ensuring effective support and supervision of MHO work
Problems in prioritisation of workload, with demands for MHO functions potentially competing with other statutory demands of work role in CJS, or child and family services
Difficulties in ensuring consistency in monitoring patterns of MHO demand and managing workload effectively
Quality assurance and the maintenance of practice competence can be problematic

4.52 Authorities were able to identify steps that had been taken to address some of these issues:

Access to the local MHO Forum Support Group for peer support and shared learning was especially useful for singleton MHOs
In some authorities Divisional MHOs offered consultation and supervision as required, though not routinely. This post was often also responsible for monitoring quality of SCRs and promoting consistency of practice standards
The development of senior practitioner posts addressed the isolation that arose where team leader was not an MHO
In some authorities a single senior community care senior monitored and supervised all MHOs in non-mental health teams
In one authority MHOs in a non-mental health team were supervised by a SSW/MHO in respect of statutory mental health work and also took part in regular MHO meetings
In some instances, there were no supervisory structures for MHO work but MHOs had non-specific professional supervision on caseloads

Implications for line management of MHOs

4.53 There was common agreement across authorities that the line management of MHOs outwith mental health teams could give rise to difficulties on several counts:

Difficulties with workload prioritisation, if MHO work was not perceived to be a priority by the MHO's line manager in the face of other demands
Isolation and lack of support
Maintaining practice standards and professional accountability of the MHO service

4.54 On the other hand, others noted that MHO deployment within a line management structure outside of mental health was of potential wider benefit to social work services, by heightening awareness of and improving access to MHO advice.

Implications for workload management of MHOs

4.55 Authorities have to find ways of ensuring equity of access to the MHO service although MHOs as a resource are not deployed evenly. There was a view that the dispersal of MHOs across sections could facilitate more equal distribution of MHO work, enabling workers in other fields to maintain mental health skills and knowledge. However this could lead to skill erosion.

4.56 Effective management of MHO workloads was generally held to be difficult for reasons relating to:

Unpredictability and irregularity of MHO work, which fits uneasily into otherwise planned workload activities
Difficulties of maintaining standards of service and monitoring effectively
Competing demands and pressures arising from other aspects of role, which may lead to lower priority being given to MHO in allocation and case work
Manager inexperience of MHO work can limit their ability to supervise effectively and to manage workloads appropriately

Implications for the accessibility and responsiveness of the MHO service

4.57 Distribution of MHOs within area teams was considered to enhance responsiveness. A perceived major benefit of placing MHOs outside mental health teams was the service's increased accessibility to staff who did not have mental health training or experience, to provide advice and guidance.

4.58 Access to the service was in the majority of authorities via a duty rota. A number of authorities operated several rotas for different functions (for example S18 applications, S26 reports) including emergency work. No specific mention was made of possible adverse consequences that might result from such practices. However the operation of a number of rotas for different functions may pose difficulties in ensuring effective communication and the appropriate standards of continuity of care.

4.59 MHOs were generally accessed on mobiles or land lines via the published rota with named MHOs.

4.60 The rota system was thought to help ensure work was shared across all MHOs irrespective of location or placing and that the service is readily available. However, it could result in a levelling down of the standard of service and require follow on work to be transferred. There could also be difficulties in adhering to rotas because of other statutory commitments and competing demands. Duty rotas could make it harder for MHOS to establish a close working relationship with community and hospital services.

Implications for continuity of care

4.61 Two sets of arrangements were reported to provide casework management: the duty work routinely passed case work responsibility on to another social worker; the MHO who picked up referral retained responsibility to follow through case to an agreed stage, such as S24/25 to a S26 and S18. Protocols had been developed in some authorities to cover transfer of longer-term cases and to clarify responsibilities.

4.62 On going case management by mental health teams was said to pose challenges in view of the overall demands of statutory work, which were expected to increase with the new Act. Respondents had differing views about how best to ensure continuity of care. On the one hand, some considered that MHOs who routinely undertook assessment and emergency work might not be in a position to hold on to cases that required follow up work following initial assessment. Respondents from other authorities suggested that full time MHOs could make continuity of case management more feasible by ensuring protected capacity and expertise.

4.63 If an MHO was not located with community care, then on-going case responsibility would usually have to transfer to community care services with the approval of the relevant senior.

4.64 If the MHO who takes the initial referral is from the 'wrong' specialism, then the case would be passed quickly to the MHO aligned with the appropriate team. Shortages of MHOs across client group / specialisms was considered to be detrimental to continuity of care management.

4.65 The above analysis of the possible consequences of differing patterns of MHO deployment can be summed up in terms of four key considerations:

Continuity can be contingent on initial point of entry
Ensuring access to appropriateness of skills, knowledge and resources
Caseload and workload management
Clarity of roles and responsibilities for transfer

GEARING UP TO MEET NEW DEMANDS

Existing challenges

4.66 Respondents were asked to identify the key challenges they faced currently, arising from new responsibilities created by the AWIA and by preparation for the new MHA (2003). This elicited the following responses:

Implementing the AWIA appropriately, achieving clarity of policy and procedure e.g. between restrictive and statutory intervention
Ensuring that work associated with the AWIA does not dilute input to other responsibilities
Reviewing and understanding options for redesigning the MHO service to provide a quality service that is responsive to need and demand
Achieving and maintaining the required MHO capacity to meet demand
Managing increased volume of work
Ensuring equity of distribution of work between MHOs, including out of hours arrangements
Providing ongoing training to meet current and future demands
Planning for mental health in a continually changing environment
Driving support mechanisms for people with mental health problems in the community including: employment, training, day services, housing, CPA and support in the home

Challenges anticipated for a year from now

4.67 Many respondents felt that they would still be dealing with existing challenges a year from now. Additional challenges anticipated were:

Moving on to implementing restructuring of services ready for the new legislation
Anticipating and dealing with the volume of new referrals
Explaining the new act to medical staff and other agencies
Picking up on the implications of the new legislation and responding with appropriate training and guidance
Resourcing the increased numbers of MHOs required and increased pay to ensure retention
Ensuring adequate community supports for people subject to the legislation

Steps taken to develop capacity and capability to respond to new demands in relation to the Adults with Incapacity (Scotland) Act 2000

Capacity

4.68 Implementation requirements associated with the AWIA had highlighted for some authorities the limitations on capacity of the MHO service.

4.69 Almost half of all local authorities had or were in the process of increasing capacity through new appointments, including:

Increasing core MHO capacity: in one area capacity was due to grow by 25% when current MHO recruits completed their training. Another LA had introduced additional payment awards for MHO line managers
Appointment of a learning disability specialist MHO
Expansion of older person's mental health service
Appointment of new senior officer posts and admin posts in finance, older people's services and adult mental health to provide support and guidance
Creation of senior practitioner posts
Establishment of co-ordinator / development post(s), mostly for a time limited period

4.70 One area had used agency staff as a temporary measure until new appointments could be made. This authority recognised that such measures were not a satisfactory solution but had found that it had not other options in the short term, until recruitment had been achieved. Many other authorities indicated that staffing and capacity were under review currently.

Service redesign

4.71 A number of areas were taking stock of implications of the legislation for service design and delivery.

Protocols and procedures

4.72 Work had been undertaken to develop joint protocols, procedures and guidance materials for local use. Several areas had developed separate rota arrangements for the allocation of AWIA work.

Training

4.73 Mandatory training had been provided for MHOs using a series of training packs on the AWIA produced by the Scottish Executive. However, the delays in this material being issued had been problematic. Training had also been provided for other LA staff and some areas had been involved in joint training with health colleagues. In one area social work and health had jointly commissioned training for senior and middle managers and operational staff across health, housing and social work.

Steps taken to develop capacity and capability to respond to new demands in relation to the new Mental Health (Care and Treatment) (Scotland) Act 2003

4.74 All local authorities were on the brink of reviewing MHO service provision to scope out the implications of the new Act and to devise training and development plans over the coming 12 months.

Capacity

3.181 It was commonly noted that authorities were awaiting the finalisation of the legislative proposals before they felt able to gauge the capacity implications of the new Act in any detail.

3.182 Growth in capacity was already being anticipated in several ways: firstly in the short to medium term authorities envisaged that increase in capacity was required to support the process of change and development that accompanied the introduction of the new legislation. Secondly, growth was perceived to be required in MHO capacity 'on the ground' to be able to meet statutory requirements. Little reference was made however to the other wider structural and infrastructural developments (such as support and supervision) needed to enable the MHO service to fulfil its new functions effectively.

3.183 Three areas were in process of addressing the first element above by appointing a planning / co-ordinating post, sometimes mirroring the approach that had been used with implementation of the AWIA.

Service design and development

3.184 Eight authorities made reference to the fact that implementation of the new mental health legislation would likely require significant change to the organisation as well as the capacity of MHO provision. The nature of any redesign required would become clearer when the Bill became statute. One area anticipated that the implications of the new Act for MHO recruitment and retention would have to be considered in the context of wider developments locally to achieve integration between social work, primary care and secondary care in the provision of mental health services. Another area, where, until now, MHO provision had been regarded as one function of a generic social work service but not as a discrete service, was giving consideration to the creation of centrally managed but dispersed MHO team.

Training

3.185 The identification of training needs and development of training plans to prepare for and support implementation were to be a major consideration of the reviews of local MHO services.

Allocation of money within local authorities to support the implementation of the Mental Health (Care and Treatment) (Scotland) Act 203

3.186 In 22 LAs, no formal decisions had been made on the ring fencing of money allocated to local authorities for the implementation of the new legislation, although some of these areas had identified priorities. In some LAs joint social work and health local planning / commissioning groups were responsible for making this decision. It was pointed out by one respondent that the Scottish Executive funding was 'targeted' and not 'ring fenced', which ran the risk of the money being allocated to other areas of work.

4.75 Where priorities had been identified and decisions made, the money was intended to be allocated to the following areas:

Enhancing provision for individual and collective advocacy
Increasing range and capacity of external providers of community services
Team leader to head up the MHO service and lead implementation of the MHA (2003)
Funding MHO training places
Training in preparation for legislative changes
Housing assistants in CMHTs
Joint planning and commissioning processes

Key issues in developing the MHO role

4.76 Local respondents were invited to identify the major issues which they considered faced MHO services in the future. The hopes and aspirations they held and the threats and concerns they perceived are set out below.

Hopes and aspirations

4.77 Among the many, more detailed issues raised, the most common was that changes heralded in the new Act promised an enhanced role for MHOs, which would raise the profile and status of the service. LAs stressed the increasing professional confidence of MHOs and the capability of the service to deliver the functions required. Several authorities drew attention to the increasing clarity of the MHO role, which was supported by well-defined operational procedures. The measures of the new Act were perceived to reinforce the core role of the MHO as independent arbiter in relation to compulsory measures and as an upholder of civil rights.

4.78 The new Act also offered opportunities to strengthen collaborative working relationships with other professionals and with service users, carers and advocacy. In some areas the introduction of the new Act was welcomed as it was expected to lead to the development of a full time MHO service, thus reducing perceived workload conflicts.

4.79 There were hopes that the new Act would present an opportunity to give greater recognition to the pressures facing remote and island communities in providing an MHO service and to enhance working practices and relationships with distant inpatient services.

Threats and concerns

4.80 Notwithstanding the expressions of confidence in the professionalism and the capability of MHOs, the overriding concerns were about capacity:

Shortage of MHOs overall and in certain client group areas, coupled with slow pace of recruitment and training
Ever increasing workload, not least with implementation of the AWIA and a shared expectation that workloads will rise further with the introduction of the new Act
Lack of incentives to recruit and retain MHOs when in many areas there are no financial rewards attached to MHO responsibilities
Staff turnover diminishes the MHO pool, as MHOs move to promoted posts
Difficulties in securing or protecting resources for service growth when in competition for resources with other social work services. Development of the MHO service could be construed as a reduction in 'mainstream' resources

4.81 A further area of concern related to the volume and pace of change and the perceived impossibility of absorbing the implications of initiatives such as free personal care, direct payments, and delayed discharge. One respondent drew attention to the challenges of reconciling developments in MHO statutory functions within LAs with the expectations of more closely integrated working with health under Joint Future agenda.

Steps required to enhance capacity and readiness of the MHO service to provide a response in line with new legislative requirements

4.82 Respondents suggested a number of steps that were required at local level and at national level to strengthen MHO services and ensure they were well equipped to provide a professional response to the demands of new legislation:

Locally

Reinforcing departmental commitment to making the MHA (2003) work
Enhancing leadership for mental health
Making sure the service structure can deal with the demands of the MHA (2003) for example, by deploying MHOs by locality with a single MHO manager; by determining the best use of limited resources
Getting answers to questions about the MHA (2003); for example, how would the new tribunal system work?
Addressing recruitment needs
Auditing against national standards when available
Good training
Raising awareness about the MHA (2003) amongst other agencies
Prioritising supervision for MHOs
Development of weekend and evening services

Nationally

Making available new guidance and standardised training materials as soon as possible (problems with late guidance for previous legislation), to allow local policy development
Providing additional resources to remote and rural areas
Promoting the message that health also has a responsibility to prepare for the MHA (2003)
Providing direction on consistency of pay and working conditions for MHOs to improve recruitment and retention
Funding for resources required for enhanced community care packages and planning
Developing a national approach to ensure that medical practitioners, especially GPs, are brought on board

SUMMARY OF KEY ISSUES FROM MAPPING PROFORMA AND TELEPHONE INTERVIEWS: MHO SERVICE DEVELOPMENT

Support and supervision for MHOs were typically provided within line management arrangements. This meant that some MHOs, in particular those not deployed in a mental health team, were supervised by a senior social worker or manager who was not an MHO. Some authorities had taken specific steps to address this. However, the view from local authority respondents was that formal supervision of and support for MHO work were not as well developed as they would have wished. Peer support among MHOs remained a significant feature in all areas, with the local MHO support groups or forum as the focal point.
Access to legal advice from within the local authority was seen as helpful and as having improved considerably
Monitoring data collected by authorities was variable, although authorities had been making efforts to improve the extensiveness and the quality of data collection
Authorities used a variety of different mechanisms to gain feedback from other professions locally and from national bodies. However, there were significant gaps in formal mechanisms for feedback from service users and carers on MHO services and from other key stakeholders
Authorities had already been confronted with significant new demands with the introduction of the AWIA and at the time of the research were bracing themselves to address the anticipated changes to the Mental Health (Scotland) Act. This was likely to involve both increasing the capacity and capability of the MHO service, through new posts and through training, and reviewing and redesigning the organisation of the service
The measures expected within the new Act were perceived to strengthen the core MHO role as an independent arbiter in relation to compulsory measures. This was especially welcomed by some of the smaller authorities which hoped to be able to make the case for the establishment of a more robust local service as a consequence
Effective implementation of the anticipated 'new' MHO functions was perceived to hinge on: strengthening collaborative working relationships with other professionals and with users, carers and advocacy services; renewed efforts to resolve issues of capacity, through recruitment and retention and through service redesign; ensuring quality and consistency in the standards of MHO service provision; programmes of training and development to maintain practitioner and service competence

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