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MENTAL HEALTH OFFICER SERVICES: STRUCTURES AND SUPPORTS

CHAPTER SEVEN: KEY THEMES AND CONCLUSIONS

INTRODUCTION

7.1 This concluding section draws out the main themes that relate to the study objectives and highlights key considerations for the future development of MHO service provision. It begins with a brief recap of findings before discussing key themes and presenting conclusions in relation to the following areas:

• Capacity of the MHO service
• MHO service structures
• Service quality
• Legal advice
• Monitoring
• Small areas and areas with remote and rural geographies
• Gearing up for new demands

REVIEW OF KEY FINDINGS

7.2 The key findings of the research are briefly summarised below.

Service structure and capacity

• There was evidence of the beginning of a more rational strategic approach within LAs towards MHO recruitment and deployment, placing MHO skills where there was most need and demand
• A high proportion of MHOs were inactive and had not practised in the preceding 12 months
• There continued to be considerable variation in the structures of MHO services
• Deployment of MHOs had moved more towards the community and into CMHTs where there was the greatest demand for statutory work
• There was continued deployment of MHOs across non-mental health specialties and this was seen as beneficial in many ways, in promoting wider access to MHO advice and expertise
• MHOs deployed in non-mental health specialties were less likely to be line managed by MHOs and consequently received both less support to make time for their MHO role and less formal supervision of their MHO practice. There were indications that this model of deployment could adversely affect the continuity of care provided and the opportunity for MHO practitioners to maintain practice competence and confidence
• Although most MHOs combined their MHO role with a wider social worker role, instances of dedicated MHOs had increased since the survey carried out in1998

Supervision and support

• Formal supervision was not available to all MHOs in relation to their statutory work. Those who were most likely to receive supervision were those deployed within a CMHT who had an MHO as manager
• There were many opportunities for informal support and supervision, particularly from peers and through local MHO forums. This was of particular benefit to MHOs deployed in non-mental health teams

Operational issues

• Out of hours services were managed via rota systems. In some smaller authorities, dedicated out of hours staff were not available, with reliance on a stand-by or duty system. Many LAs reported that they were struggling to maintain a consistent out of hours response
• Joint working relationships with other agencies were generally perceived to be good, especially if MHOs were deployed in mental health teams. However there was a need to improve awareness of the MHO role. Joint working with primary care and substance misuse services required particular attention

Management and leadership

• Although 31 LAs claimed that they had a lead person identified for MHO services, these were not always dedicated posts and in many instances practitioners were unaware of the lead person. The benefits of having a dedicated lead MHO post to coordinate the MHO service as a whole were recognised and all authorities aspired to achieve this
• A number of LAs had established Divisional MHOs as a means of ensuring oversight, co-ordination and quality assurance

Rural issues

• For rural areas pressures could be acute in developing and maintaining links with other, often physically distant, professionals and in maintaining practice competence. Services in some rural areas relied, to varying degrees, on practitioner good will and commitment

Local audit and review

• There was a lack of consistency and completeness in collection of routine MHO activity information regarding statutory work
• There was an emerging recognition of the MHO service as discrete and the accompanying need to review and monitor MHO service structures and delivery. However many LAs had not yet undertaken such a review and there were inconsistencies in approaches to this task. Many authorities were looking for national guidance and direction to support them in this

Future directions

• Key priorities and areas for action in the near future were:
  • clarifying procedures for implementation of the AWIA and the new MHA (2003)
  • reviewing and redesigning MHO services
  • establishing dedicated MHO lead co-ordinator posts
  • recruiting, maintaining and retaining an adequate MHO capacity
  • ensuring support from other services and agencies to put in place enhanced community care packages
  • developing joint working protocols, both internally with care management teams and externally with other professions and agencies
  • standardising and improving the quality of local and national MHO activity data collection and monitoring and evaluation of the service
  • achieving national consistency in MHO recruitment and the content of MHO training and development

CAPACITY OF THE MHO SERVICE

Steps taken towards rational planning

Adequacy of staff complement

7.3 It is difficult to gauge definitively the trends over time in the overall capacity of MHO services and in the numbers of practising MHOs, to quantify changes in capacity. The 1998 survey, which included only 29 of 32 authorities identified 618.5 MHOs, of whom 517.5 were actively practising. The size of the authorities who did not participate in the earlier survey is not known. The 2003 survey of all 32 authorities identified 682 MHOs, of whom 525.5 were practising. There are no grounds to conclude that the overall numbers of MHOs had increased appreciably over the intervening five years.

7.4 In the 1998 Mental Health Officer Survey, two out of three LAs were concerned that there were insufficient MHOs. By 2003, the majority view was that the MHO staff complement was now adequate, although fragile. However this must be set in the context of a deep concern shared by service managers and practitioners that this staff complement would not be sufficient to cope with the workload demands of forthcoming legislative changes. The 2003 study indicated, for example, that acute pressures on the service were beginning to be experienced as a result of the workload associated with the implementation of AWI legislation.

7.5 What is striking, therefore, is the high proportion of MHOs in 2003 who were not actively practising: this had risen from one in six in 1998 to one in four in 2003, representing a considerably under-utilised resource.

7.6 It might be questioned how, with no apparent evidence of an increase in MHO staff complement between 1998 and 2003, most LAs reported that they now had more adequate coverage of MHO staff, (while recognising that the service was also reported to be at capacity). The answer may be in changes in deployment and numbers of dedicated MHOs. Many respondents in this survey claimed that their LA had not undertaken a review of MHO services. However a comparison of the evidence collected in this research with that of the 1998 survey suggests that a process of rationalisation had been taking place in moving towards a more effective deployment of MHOs, to bring MHO skills and expertise closer to the needs of clients.

Dedicated MHOs

7.7 It is likely that the amount of time that each MHO dedicates to statutory work may have increased. Although comparative data regarding the number of hours spent on statutory work in 2003 and previous years were not available in this research, there was some evidence to suggest an increase in numbers of dedicated MHOs in 2003. This was identified as a national goal for MHO service development in the 1998 research.

Deployment of MHOs

7.8 In 1998, MHOs were deployed mainly in criminal justice teams, community care teams and psychiatric hospitals, although at that time it was recognised that least statutory work took place in criminal justice teams. In 2003 there had been a clear move towards community based care and deployment of MHOs mainly within CMHTs and community care teams, indicating progress in achieving the better placing of MHO skills in line with greatest need. This reflected progress towards the redeployment of MHOs in CMHTs, as envisaged in the 1998 survey.

7.9 However, it was also the case that in 2003, over 20% of MHOs were still employed in teams where they are unlikely to be regularly engaged in statutory work, for example in criminal justice and children and family services. There was recognition in both 1998 and 2003 of the benefits of MHO capacity being available within various areas of social work activity. In 2003 there was a clear recognition of the infrastructure required for this to be effective: appropriate management support, better access to supervision for those not working in CMHTs and not directly managed by MHOs, mechanisms to assure workload management and the appropriate prioritisation of MHO work relative to other demands. There was little evidence that these prerequisites were in place.

Allocation of workload

7.10 The 1998 research recommended the introduction of rotas to achieve improvement in MHO services. The 2003 data showed that all LAs now operated some kind of rota system to manage the allocation of MHO work, and that this had proved an efficient system. This development further strengthens the conclusion that MHO resources were being used more effectively than before.

7.11 Other interesting developments to note included the deployment of MHOs in learning disability and older people teams. In 1998 no MHOs worked in these areas. The introduction of the AWIA may have heightened the necessity for MHO capacity in these teams.

7.12 Therefore trends over time can be read as indicative of greater targeting in the deployment of MHOs but also of the continuing need to consider how best capacity can be deployed to make optimal use of skills and expertise.

Pressures on the MHO service

7.13 The overall picture to emerge from the 2003 research is of a service that operated with increasing confidence in its role and in the expertise and experience of the practitioner body. MHO services were regarded as a highly valuable resource within mental health. Nonetheless, acute pressures on the service were reported, arising from a combination of factors:

• Continuing difficulties in achieving the optimum deployment and co-ordination of the MHO resource available locally to maintain equity of access and service quality
• Growing needs and demands on the service, which areas were not yet in a position to be able to assess fully
• Difficulties in maintaining and expanding MHO capacity

7.14 In addition, there was perceived to be a lack of understanding of and support for local MHO services at senior level within local authorities, which posed challenges for future development in the face of multiple competing priorities for resources.

Recruitment and retention of MHOs

7.15 There was evidence that, in a number of areas, growth in MHO service capacity had already been approved and funded, although difficulties were reported in filling new MHO positions. A number of hurdles stood in the way of the recruitment and retention of MHOs:

• The effects of a general recruitment crisis in social work
• A lack of consistency in financial reward systems across MHO services in Scotland
• A process of attrition may in some instances diminish the availability of MHOs as they move into managerial posts, although the research found that 15% of practising MHOs are at team manager level or above
• There was a considerable amount of untapped capacity, with one in four MHOs not actively practising
• The research suggested that the deployment of MHOs can impact on opportunities to maintain practice competence and confidence and on the availability of support and supervision

7.16 As a consequence of the above factors, in many areas the service appeared fragile and vulnerable. Local authorities and individual practitioners expressed the view throughout the study that a strengthening of MHO services was required to prepare for the enhanced functions that would fall to it in the future.

7.17 However, the research also pointed firmly to the conclusion that to strengthen the service would not only involve increasing the numbers of MHOs 'on the ground'; it would also require developing a more robust infrastructure of support to maintain standards and provide leadership and co-ordination of MHO functions within local authorities.

MHO SERVICE STRUCTURES

7.18 The study found a range of different configurations of MHO service in terms of:

• The deployment of MHOs and the extent to which MHOs were concentrated in mental health teams / service or dispersed across other specialisms
• Provision of and arrangements for management and supervision of MHOs
• Leadership, co-ordination and operational management of the service
• Interface with other social work and other LA functions

7.19 The configuration of the MHO service had implications for:

• Monitoring and supervision
• Line management and workload management
• Accessibility and responsiveness of the service
• Continuity of care
• Links and relationships with other professions and other services

7.20 It was beyond the scope of the study to evaluate the effectiveness of different models of MHO service configuration. However, there were indications that, when compared with their peers deployed in other social work contexts, MHOs in mental health teams were more likely to feel better equipped to perform MHO duties, as a result of being better trained and supported and having greater familiarity with health colleagues and health care systems.

7.21 The findings point to a set of core features that an effective local MHO service requires to respond to legislative requirements:

Strategic and structural features

• Support and commitment within the authority to the MHO service as a key LA statutory function, underpinned by clear ownership and leadership of the service at senior level
• Proactive, strategic planning and development of the MHO service: review of current capacity and effectiveness with reference to new demands
• Commitment to promote equity, in terms of access and quality of service
• Commitment to maximise capacity and sustainability of the MHO service by taking steps to attract and retain staff
• Promoting the profile and status of the service within LAs and beyond
• Ensuring the availability of monitoring information and other data, including stakeholder views, to guide the planning and on-going development of the MHO service

Operational features

• Identified leadership to take forward the operational development of the service, to assure standards and quality and to promote co-ordination and consistency
• Access for MHO practitioners to support from managers who have a grounding in and experience and knowledge of MHO functions and responsibilities. For MHOs not deployed within a mental health team/ service, this may mean ensuring that mental health statutory work is supervised and supported by a suitably experienced manager
• Optimal deployment and management of the MHO resource, recognising the unpredictability and irregularity of the work and the competing demands of other priorities
• Mechanisms to identify and address the post qualifying training needs of the MHO service
• Ensuring that continuity of care for individuals can be assured as far as possible and practicable where on-going involvement is indicated, recognising that continuity should not be contingent on point of entry to the MHO service
• Promoting joint working with health services to lay the ground for effective collaboration in discharging statutory mental health functions
• Promoting awareness and understanding of MHO functions among health care partners and with other key agencies, in order to support MHOs in performing their role effectively

Practice features

• Ensuring that MHOs have the opportunity as far as possible to maintain professional confidence and professional competence, through effective support, supervision (formal and informal) and review
• Promoting links and relationships with colleagues in other services and professions to facilitate effective working on statutory responsibilities. In particular links need to be improved with child and adolescent and substance misuse services
• Facilitating good communication and liaison to ensure information sharing and case transfer: key players here include Medical Records, out of hours services, care management teams
• Access to advice and support for MHOs, including:
  • specialist advice for cases where individuals have multiple needs, are child and adolescents or using substance misuse services
  • legal advice on financial and other matters
• Recognition from managers of the importance and complexity of MHO functions in order to allow MHO work to be given appropriate priority

7.22 Whatever the pattern of local MHO service configuration, experience from different parts of Scotland in providing a local MHO service suggests that these features enhance an authority's capability to assure a responsive professional service.

SERVICE QUALITY

Supervision

7.23 As noted, MHO practitioners' access to supervision varied considerably as did the perceived quality of supervision received. The mapping indicated some of the ways in which MHO service structures can build in supports and supervision for MHOs individually and collectively in a variety of ways, including the designation of Divisional MHOs, senior practitioner posts and lead managers with mental health expertise to oversee MHOs deployed outside mental health teams.

7.24 The review and future development of local MHO services presents an opportunity to clarify and promote a shared understanding about the boundaries to the professional MHO role, about accountability and about the jurisdiction of LA policies.

Training and professional development

7.25 In terms of quality and consistency of professional practice standards, key issues for attention include:

• The development of clear, consistent criteria across authorities to determine eligibility for MHO training
• The need to consider how best to review and update practitioner competence of approved MHOs. At the time of the research only a small number of authorities were actively looking to develop processes to review MHO practice
• Steps to ensure that MHOs have opportunity to keep abreast of developments in mental health services and in treatment and medication, in the light of the enhanced role that MHOs play under the MHA (2003)

7.26 Not surprisingly, there was a universal recognition of the need for training to prepare for the implementation of the new Act in 2004 -2005. Preparations for the introduction of AWIA legislation appeared to have provided a good model, by providing opportunity for joint training and in some areas dedicated capacity for co-ordinated training and development.

LEGAL ADVICE

7.27 Access to legal advice and the quality of advice were perceived to have improved considerably and internal legal services were generally, though not universally, held to be a very useful and valuable resource that supported MHO functions. The opportunity to develop closer working relationships with internal legal services had been precipitated by the implementation of the AWIA legislation.

7.28 Challenges remain to ensure the capacity and engagement required to allow the continuing involvement of legal services in supporting the future implementation of all aspects of the AWIA and the new Act.

MONITORING

7.29 The 1998 study found that a common format for information collection on MHO statutory work was lacking. This situation had not been resolved by 2003. A standardised approach has not yet been developed to collect activity data on routine statutory work or to gather more evaluative data for monitoring and quality assurance. In view of the intention of many authorities to review the MHO service and to consider how best to deploy MHO resources in the light of the new legislative framework, the limitations on routine monitoring data revealed in this study are a cause for concern. Using current activity as a benchmark to gauge the future development needs of the MHO service in the light of the changes to legislation was hindered by the variability of and gaps in activity data collected, for example information on MHO involvement in assessments and on SCRs.

7.30 Local area respondents were very aware of the limitations that such a lack of information imposed on planning and development and were keen to redress this by pressing for a co-ordinated national approach.

7.31 The Mental Welfare Commission for Scotland provides annual activity data regarding the use of detention and guardianship statistics which may not be exploited to its full potential in terms of informing the planning of MHO services. Activity data, quality standards, and trends in demand, capacity and workload are key elements of the data set required to review and maintain quality and effectiveness. In addition it will be important to build in mechanisms to gather feedback from service users and carers and key partner agencies in reviewing the service.

7.32 The Scottish Executive plans to introduce draft National Service Standards for MHO Services in the autumn 2003. These standards should provide an opportunity to identify a common template to monitor MHO services that would allow meaningful comparison and assessment of service activity, quality and outcome across Scotland through future evaluation and research.

SMALL AREAS AND AREAS WITH REMOTE AND RURAL GEOGRAPHIES

7.33 Issues of equity and quality were a particular concern for some smaller authorities where the MHO resource was spread thinly, sometimes heavily reliant on good will for out of hours cover in particular.

7.34 This was further compounded in authorities which covered remote and rural areas where it could be difficult to comply with practice guidance, for example in responding to requests for assessment, because of the exigencies of distance, the constraints of limited MHO capacity and absence of local inpatient facilities.

7.35 In implementing the new legislation, careful consideration is needed to ensure the feasibility and sustainability of measures in rural and remote contexts, in view of the characteristics of the MHO service in these areas.

GEARING UP FOR NEW DEMANDS

AWIA

7.36 During this study, local authorities were still in the process of assimilating the requirements associated with implementation of the AWIA. The support for training nationally and locally in this area of work and the multi agency approach taken to such training were welcomed by respondents and perceived to be of longer-term benefit.

7.37 The requirement to work closely together on complex issues had strengthened links between internal legal services and MHO services. However concerns remained about the complexity of the AWIA provisions and the need to ensure greater consistency and clarity in associated policies and procedures to minimise divergences in practice.

7.38 It was noted earlier that the research suggested that MHO service capacity was adequate. There were indications from the descriptions of local service managers that the demand arising from the AWIA risked stretching the service excessively. This may be in part be due to the fact that the AWIA was relatively new and MHO services were experiencing pressure as new procedures were developed. In the longer term however, local authorities were looking for recognition of the increased workload they were already dealing with under the AWIA and of that anticipated with the imminent introduction of the new mental health legislation. Further, there was a strong need expressed by local service managers in particular for guidance and support to be provided on managing the interface between these two major pieces of legislation, the implementation of which rested with MHO services.

Reviewing local MHO services

7.39 Most local authorities indicated they were undertaking or planning a review of their MHO service to assess the capacity required to meet demand and to ensure service quality. In the light of the findings of the research, local authorities may wish to consider the following areas in reviewing their local MHO service:

Capacity and structure

7.40 Key factors to consider:

• Deployment of skills, supervision and management of MHOs and the relative benefits and disadvantages of working across non-mental health specialties in maintaining equity and quality
• Addressing the barriers to recruitment and retention of the MHO workforce

Leadership, co-ordination and management

7.41 Key factors to consider:

Accompanying revisions to service structures with steps to promote effective co-ordination, planning and leadership at strategic and operational level to ensure effective use of MHO capacity to meet local needs and demands

Quality

7.42 Key factors to consider:

• Recognising that different models of MHO service each have distinctive advantages and disadvantages. Considerations to weigh in the balance are:
  • ensuring accessibility and responsiveness of the service and continuity of care where required
  • protecting and maintaining practice standards and competence and supporting practitioners
  • facilitating opportunities to work collaboratively and develop effective working links with other professionals
• Learning from the range of different models of MHO provision in place across Scotland to inform the development of local services in line with local circumstances and needs
• Building on positive experiences and examples of effective joint working and of increased joint training; enhancing relationships with key service professionals, including GPs to respond to the shared learning needs generated by the new legislation
• Ensuring adequate and robust information systems to inform practice and service development, in ways that relate directly to the core aims of the legislation and the key functions of the MHO service in contributing to those aims
• Attending to the interfaces between different pieces of legislation to determine policies and protocols to manage work in these areas

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