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National Mental Health Services Assessment
Locality Report

ARGYLL AND CLYDE

December 2003

Introduction

The remit for the National Assessment means that the focus in the locality reports is on what needs to be done locally to deliver the new provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003. With that in mind the many examples of good care seen across Scotland are not covered in the individual reports. This should not be taken as a negative.

Every effort has been made to achieve consistency in each report. There are however variations in those cases where the local arrangements vary sufficiently to warrant some variety in the presentation of findings. For example not all information was available for or from each area in the same format or with the same coverage and where this is the case it is stated.

The wide-ranging nature of the responsibilities that the Act places on local authorities means that it was virtually impossible to assess the services provided by them or the voluntary sector in a short timescale, although there are examples of services across Scotland in the Final Report. In no way should this be seen as devaluing the local authority contribution or minimising the additional demands placed on the Councils.

The findings arising from the visits and review of existing information can only represent a snapshot in time and in many cases the local situation will now be different. However, the purpose is to provide a shared, validated information base to start from and to plan for the successful and timely implementation of the new legislation. The reports should not be used in the form of league tables or as negative criticism.

These reports will now inform the local planning process and will be useful reference documents in the preparation of the joint local implementation plans announced in the Department's letter of 19 November 2003 (see Annex A).

Some general principles:-

• The Mental Health (Care and Treatment) (Scotland) Act 2003 applies to all age groups, although the greatest number will be adults of working age.

• Where the reports refer to Adult Mental Health Services this covers services and support for those aged 16/18 to 64. Where possible we have been more accurate, but this is the standard definition used by the Information and Statistics Division of the Common Services Agency and the local authorities.

• The year of the data source is stated in each case and represents the latest available.

• Regard was given to the wide range of archive, published and other material throughout the entire Assessment process for ongoing context, progress and other relevant considerations.

• References to the organisation of local authority Mental Health Officer (MHO) services or Responsible Medical Officer services should not be taken as implying or suggesting any preferred structure.

Locality

2. Argyll and Clyde covers 2,880 square miles and has one of the most diverse populations in Scotland with a population of 418,750 ¹, (298,800 adults) living in island, rural or urban communities, each with strong local identities.

4. Mental health services are provided by 5 local authorities, (Table A), NHS Argyll and Clyde and the voluntary sector. This often complex organisation can make negotiations time-consuming. NHS Greater Glasgow provides services to two thirds of East Renfrewshire while NHS Argyll and Clyde covers the remainder. West Dunbartonshire is also linked partly to NHS Greater Glasgow services. Until recently mental health services were provided from 2 separate NHS Trusts and a degree of separation still exists in practice.

6. There have been serious financial problems in the health services in Argyll and Clyde leading to wide-ranging senior management changes, which may have hindered the pace of development of full joint working between the NHS and each local authority. Nevertheless, there are now good examples of partnership at the service delivery level, for example the strong cohesive teams in Dunbartonshire and Inverclyde.

8. Argyll and Bute Hospital (in Lomond and Argyll) has been partly refurbished and good use has been made of Mental Illness Specific Grant money to start up some community services in Bute, Cowall, Mid-Argyll, Kintyre and Lorn. Further investment is needed for community services.

10. East Renfrewshire Council aims to have the same level of NHS service provided for the NHS Argyll and Clyde part of the Council (Levern Valley) as is currently provided in NHS Greater Glasgow. Inverclyde has not yet agreed a financial framework to underpin its mental health strategy, although a jointly funded co-ordinator has been appointed. Renfrewshire also has no agreed financial framework, but a draft reprovision plan for Dykebar has been prepared proposing a shift in the balance of care. In West Dunbartonshire, the number of people receiving mental health services is steadily rising and new Community Care Assessments have almost doubled in the past 2 years. In order to manage the demand, the Council and NHS Board are discussing a financial framework, not yet agreed (December 2003).

11. Table A - Local authority populations in Argyll and Clyde

    Local Authority	Adult Population
    Renfrewshire [including]: Paisley, Barrhead, Johnstone, Bishopton, Erskine	114,000
    Inverclyde	54,580
    East Renfrewshire (within A&C)	24,300
    West Dunbartonshire (within A&C)	47,600
    Argyll and Bute	58,300

12. There are high levels of unemployment, deprivation and morbidity and 45% of Renfrewshire scores high on indices of deprivation.

13. Use of the Mental Health (Scotland) Act 1984

14. The use of emergency detention in Argyll and Clyde is high, but short and long-term detentions are more in keeping with the Scottish average. The 2001-02 application of the 1984 Act to detain people for treatment is shown in Table B. Using these figures for a rough prediction of the likely number of detentions under the new Act shows an estimate of 314 ² Tribunal hearings across Argyll and Clyde. This may be an underestimate because it uses the average of 8 years as the benchmark, whereas detentions have been rising year on year.

16. In addition to local services there are 21 patients from Argyll and Clyde currently in The State Hospital, with 2 waiting more than 3 months for transfer back to local services. The patient numbers in The State Hospital may reflect a lack of local forensic secure beds in Argyll and Clyde. Despite this, Dykebar is unique in having a close supervision unit for people with a learning disability who need secure care. This example could be usefully followed elsewhere.

17. Table B - Detentions in Argyll and Clyde under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03 ³

    	Actual number of detentions	No. Per 100,000 in Argyll and Clyde	No. per 100,000 in Scotland
    Sections 24 and 25 4	410/452	98/108	85/90
    Section 26 5	242/280	58/67	51/56
    Section 18 6	84/105	20/25	21/23

18. The new Act will put pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the final report).

20. There are 23 Responsible Medical Officers in Renfrewshire and Inverclyde, with 15 consultants working in general psychiatry. There are another 4 posts in Lomond and Argyll, although only one is currently filled. The Royal College of Psychiatrists has estimated that approximately 30 new consultants will be needed in Scotland to meet the demands of the new Act. This is in addition to filling the current vacancies. This estimate takes no account of the implementation of the European Working Time Directive in 2004 and its potential significant impact. Major service redesign will be needed to address these issues, especially where there are already consultant vacancies.

22. The number of additional Mental Health Officers that will be needed for the new Act is hard to estimate, given variations in MHO practice. In Scotland at present there are on average 11.5 Mental Health Officers per 100,000 population. This equates broadly with the position in Renfrewshire and Argyll and Bute. West Dunbartonshire has much lower numbers and the Council there is paying and offering enhanced rates in order to boost local recruitment and retention. Because parts of East Renfrewshire and West Dunbartonshire are covered by NHS Greater Glasgow, not all their MHOs will work within the area covered by NHS Argyll and Clyde. The lack of coterminosity between local authorities and health can cause confusion.

24. Agreement between the different NHS Board and local authority groups will allow some cross-boundary cover.

25. Table C - Mental Health Officers in Argyll and Clyde ⁷

    Local Authority	No. of MHOs	Practising MHOs	MHOs working in mental health	Additional Payment
    Argyll and Bute	15.5	11.5	8	No
    East Renfrewshire	5	3	Within generic community care teams	No
    Inverclyde	13	10	4	No
    Renfrewshire	8.5	8.5	6	No
    West Dunbartonshire	5	4.5	4.5	Yes

    The local authorities do not record the data by NHS Board area and these figures were determined by splitting the total number of MHOs equally between the two NHS boards to give a very rough approximation of numbers.

    Hospital Services

26. The local arrangement of hospital services is as follows:

Acute Adult Admission

• Newly built unit at Dykebar Hospital, Paisley (45 beds)

• 2 wards at Inverclyde Hospital, Greenock (30 beds)

• One ward at Royal Alexandra Hospital, Paisley (30 beds)

• One ward at Vale of Leven Hospital, Alexandra (24 beds)

• One ward at Argyll and Bute Hospital, Lochgilphead (24 beds)

Intensive Psychiatric Care Units

• Dykebar Hospital, Paisley (8 beds)

• Argyll and Bute Hospital, Lochgilphead (10 beds)

Close Supervision Unit

• Learning disabilities with forensic needs, Dykebar Hospital

Continuing Care Wards

• 5 wards at Dykebar Hospital

• One ward at Ravenscraig Hospital, Inverclyde (40 beds)

Rehabilitation Services

• Ravenscraig Hospital, Inverclyde (10 beds)

• Blarbuie Road, Druimard, Duntrune, and Firgrove

Alcohol Treatment Unit

• Gryffe Residential Detoxification Unit, Inverclyde

15. There has been an increase in the number of people admitted with drug and alcohol problems as well as a psychiatric illness. The violent behaviour of some service users presents difficult challenges for staff and other patients. The local Police are working with the agencies to address continued illicit drug use and dealing on hospital sites. This reflects the high levels of drug misuse in the area and is not an indictment of the service.

17. The occupancy rate for adult acute beds is high (97% over 9 months in 2003), so there would appear to be little slack in the system. However, for this population size there is a large number of beds. A range of between 57 and 114 general adult acute beds has been suggested by the Royal College of Psychiatrists for this population size, depending on the level of other specialties and community services. There are currently 153 acute beds in Argyll and Clyde.

19. Hospital beds have reduced by nearly 10% over the last 3 years, the majority being those for older people. Despite this reduction Argyll and Clyde still has the highest total bed ratio in Scotland, with 205 beds per 100,000 for all specialties when the national average is 141 (Table D).

21. Argyll and Clyde has the fifth largest population in Scotland, but has no local inpatient services for children or adolescents (although there is an outpatient and day service). Beds are purchased from Yorkhill and Gartnavel Royal Hospitals in Glasgow. The lack of local child and adolescent beds makes Argyll and Clyde vulnerable in responding to the relevant provision in the new Act, similarly so in terms of specialist beds allowing mothers with a perinatal mental illness to be admitted with their babies. Forensic services also need to be developed.

22. Table D - Hospital bed numbers Argyll and Clyde and Scotland ⁸

    Hospital Beds	Argyll and Clyde Actual beds				Argyll and Clyde Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	949	916	882	857	224	217	210	205	161	153	145	141
    All adults under 65 years	496	483	468	458	117	115	111	109	74	70	66	64
    Older people	453	433	415	399	107	103	99	95	83	79	74	73
    Forensic services	0	0	0	0	0	0	0	0	*	*	*	*
    Child & Adolescent Psychiatry	0	0	0	0	0	0	0	0	*	*	*	*

    Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data

23. The emergency readmission rate within 28 days for adults in 1998-2001 was below the national average. Recent local reviews have shown that this is in part due to the comprehensive infrastructure in Inverclyde. Clinical redesign within Renfrewshire has improved admission procedures and discharge planning, but a great deal more needs to be done to develop community mental health services.

24. Table E: Hospital admissions in Argyll and Clyde for people aged 16/18-64 ⁹

    Adults 16/18 - 64 years	1998	1999	2000	2001	2002
    First admission (i)	507	463	483	541	519
    Readmission (ii)	1406	1472	1402	1457	1399
    Emergency readmission rate within 28 days (iii) Lomond and Argyll Trust	6.98%	6.62%	4.54%	5.85%	N/A
    Emergency readmission rate within 28 days (iii) Renfrewshire and Inverclyde Trust	6.64%	6.16%	6.40%	6.75%	N/A

    (i) First ever recorded admission to psychiatric in patient care

    (ii) Readmission following a break in in-patient care

    (iii) Emergency readmission rate within 28 days of discharge (admissions/discharges x100)

    Figures for 2002 are provisional

25. The average length of stay in an admission unit was 36 days in the Royal Alexandra Hospital and 27 in Dykebar, similar to Glasgow's average of 34. The high occupancy rates are therefore not related to inappropriately prolonged stays.

27. It appears that the large number of beds in Argyll and Clyde is relieving pressures elsewhere in Scotland. In 2001-2002 Argyll and Clyde discharged ¹⁰ 139 people from other NHS Board areas, the largest number of out-of-area admissions in Scotland. Conversely in the same period, Argyll and Clyde had to board out 91 patients elsewhere (mainly Glasgow). In a 3-month survey in 2003 this pattern is continuing.

28. Community Services

29. Despite its size Argyll and Clyde has developed only 2 Community Mental Health Teams (CMHTs), a fully comprehensive one in Inverclyde and a smaller one in Paisley. There are 2 day hospitals, in Dumbarton and in Inverclyde.

31. There are no CMHTs in West Renfrewshire, Renfrewshire or Levern Valley so the main service is provided by social work and voluntary organisations backed up by consultants with the support of a small number of CPNs.

33. Many voluntary organisations provide supported accommodation, "sheltered" employment and training opportunities, befriending and drop-in facilities. Renfrewshire Association for Mental Health is a well-established voluntary provider that has enabled many users to live in the community with support from a wide range of projects. A good example of joint working across provider organisations is the Charleston Centre in Paisley. Renfrewshire and Inverclyde also have partnerships with the National Schizophrenia Fellowship (Scotland) and Inverclyde Association for Mental Health. The NHS Board contributes to the funding of generic advocacy services.

35. ACUMEN, the service user and carer network for Argyll and Clyde, is a collective advocacy group, funded by Argyll and Clyde NHS Board and the 5 LAs. Renfrewshire Association for Mental Health also provides a basic advocacy service to Renfrewshire and the Dykebar Patients Council provides collective advocacy for patients in that hospital. . Equal Say provides generic citizen advocacy within East Renfrewshire and the Council intends to develop a dedicated mental health service with Equal Say. There is also a Lomond and Argyll Advocacy service. In Inverclyde collective advocacy was provided by INVOLVE, a service user group that has now unfortunately folded.

37. Within Lomond and Argyll there are also links with other providers, such as the Princess Royal Trust for Carers, Scottish Association for Mental Health, Link Clubs, ACTIVATE, Red Cross and Lomond Mental Health Forum.

38. Priorities for Services Users and Carers in Argyll and Clyde

39. The key issues raised by local users and carers are as follows:

Paisley Area

• Out-of-hours services beyond 11.00 at night.

• 24-hour help-line for crisis.

• 24-hour access to services.

• Respite care.

• Change the attitudes of professionals.

• Make all the arrangements for discharge before people leave hospital.

• Culture change - treat people with dignity and respect but acknowledge our fragility and our need to take responsibility to stand up and speak out.

• Invest in the well being of the population.

Lomond

• Increase in local beds using a 'hub and spoke' model.

• Permanent consultant psychiatrists.

• Services available 24 hours a day 7 days a week.

• Equity in investment across the area.

Argyll and Bute

• Bigger premises for the link club.

• More support for parents and children.

• Crisis and out-of-hours services.

Comments

28. Major issues that will challenge Argyll and Clyde when implementing the new legislation are:

• Bed management is a serious problem with very high bed numbers, high occupancy rates and a high number of out-of-area admissions.

• Linked to the high bed numbers is a very poorly developed community infrastructure in most places. This is unlikely to allow the option of a community-based Compulsory Treatment Order as the least restrictive alternative.

• Inpatient forensic services and those for mothers and babies are not available and need to be provided either locally or from another service.

• More independent advocacy is necessary.

• The most significant problem is financial constraints and the lack of agreed joint financial frameworks.

Visiting Team

Footnotes

¹ NHS Argyll & Clyde

² Scottish Executive Mental Health Act Implementation Team, based on Royal College of Psychiatrists scoping exercise

³ Mental Welfare Commission Annual Report 2001-02/2002-03

⁴ Sections 24 and 25 are emergency sections lasting 72 hours

⁵ Section 26 is a 28 day order that can be used when an emergency section has expired

⁶ Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court

⁷ Mental Health Officer Services: Structures and Supports. HMSO.2003

⁸ ISD

⁹ ISD data from SMR04 returns

¹⁰ Strictly speaking it was discharge postcodes not admissions that were analysed

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