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National Mental Health Services Assessment
Locality Report

AYRSHIRE AND ARRAN

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. Ayrshire and Arran covers 2500 square miles with a population of about 367,000 ¹ (238,970 adults), which increases over summer periods because of tourist visitors. Many people from inland rural or former mining communities are migrating to the larger centres on the coast. The main centres of population are the towns of Ayr, Kilmarnock and Irvine and the island communities have some transport problems getting to the mainland for appointments or in an emergency.

4. Mental health services are provided by three local authorities coterminous with one NHS Board, in collaboration with a wide range of voluntary organisations and service providers.

5. Table A - Local authority populations

   Local authority	Total population	Adult population
   East Ayrshire	120,630	78,100
   North Ayrshire	138,850	87,100
   South Ayrshire	113,920	71,360

   Use of the Mental Health (Scotland) Act 1984

6. The use of the 1984 Mental Health Act is in line with or slightly below national rates. The estimated number of Tribunal hearings in Ayrshire and Arran based on detention rates over an eight-year period comes to 164 ², but this may well be a low estimate given the consistently rising number of detentions every year. There are 7 patients from Ayrshire currently resident in The State Hospital, one of whom has been recommended for transfer and has been referred to Ayrshire and Arran for assessment. ³ There needs to be continuing contact between the local services and The State Hospital to ensure timely transfer when appropriate.

7. Table B - Detentions in Ayrshire and Arran under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03 ⁴

   	Actual no of detentions in Ayrshire and Arran	No per 100,000 people in Ayrshire and Arran	Average number per 100,000 people in Scotland
   Sections 24 and 25 5	312/316	85/86	85/90
   Section 26 6	161/171	44/48	51/56
   Section 18 7	70/18	19/21	21/23

8. In preparing for the Act a survey was taken of admissions under the Mental Health (Scotland) Act 1984 during June. In addition to the 28 emergency detentions there were 18 Section 26 short-term detentions and ten Section 18 long-term detentions

9. Table C - Emergency detentions June 2003

   	Working hours	Out-of-hours*
   Section 24	6	7
   Section 25	7	8

   * excluding week-ends

10. The community based out-of-hours detentions, currently done by GPs, will need to be considered in the light of the new GP contract and the emphasis in the new Act on moving to short-term detentions by a specialist as soon as is practicable, minimising emergency detentions. Sometimes A&E is used by GPs as a route to having people detained. The rural geography means long travelling times for both patients and staff and it was suggested that innovative approaches were needed to get around these difficulties.

12. The working relationship between the RMOs (Responsible Medical Officers) and the MHOs is good during the day and given the small community everyone knows each other. Out of hours MHO cover comes from the West of Scotland standby service which means that it can take up to four hours for an MHO to arrive. This can lead to problems as Section 117 and 118 involving the police tend to be used in crisis situations. Ayrshire and Arran's Redesign Project is considering how to provide appropriate 24-hour care.

14. There are significant recruitment and retention problems in social work with 50% vacancies in North Ayrshire despite the additional payments to MHOs. There are plans for joint appointments of MHOs across the three Councils to allow for greater operational flexibility. The MHOS are worried that the increased work under the new Act will lead to more formal involvement, with MHOs taking on a "quasi-legal role". Training is seen as a vital issue.

15. Table D - Mental Health Officers in Ayrshire and Arran

    Local Authority	No of MHOs	Practising MHOs	MHOs working in mental health	Additional payment
    East Ayrshire	15	15	6	Yes
    North Ayrshire	18	18	3	Yes
    South Ayrshire	25	25	11	Yes

16. There are nearly 25 WTE consultant psychiatrists, with 11 in general psychiatry, which is within the suggested range from the Royal College of Psychiatrists for this size of adult population. The posts may not be distributed evenly, however, with North Cunninghame apparently under-resourced. There are currently 2 WTE vacancies, both within child and adolescent psychiatry.

18. The willingness of GPs to engage with mental health issues varies across Ayrshire and Arran, with some practices highly involved. The NHS Board was successful in attracting 80 GPs to a training event about the Adults with Incapacity Act. On the other hand some GPs, already concerned about the impact of Part V of the Adults with Incapacity Act, have campaigned against the anticipated additional work following the introduction of this new Act, taking the issue as far as the Health Minister. In some places there is dispute about primary care monitoring of lithium and clozepine, two mental health drugs that require regular blood monitoring.

19. Hospital Services for Adults

20. The hospital services for adults are as follows:

Four acute admission wards

• 2 at Ailsa Hospital (57 beds)

• 2 at Crosshouse Hospital (52 beds)

One intensive psychiatric care unit (IPCU)

• Ailsa Hospital (6 beds)

One in-patient addictions/dual diagnosis unit

• Loudoun House (12 beds)

Continuing care/rehabilitation units

• Ailsa Hospital (86 beds)

Liaison Psychiatry service

• Ayr Hospital

• Crosshouse Hospital

12. Ayrshire and Arran has the second lowest bed numbers per 100,000 in Scotland (especially for older people). 59 beds per 100,000 for adults is also below the Scottish average (64). The IPCU admits forensic and non-forensic patients (including the occasional informal patient). As a result the Unit is often full and seriously ill people may need to be treated on a general ward. There is no formal forensic setting, although in practice Ballantrae does admit some people who might otherwise be in a forensic ward. Ayrshire and Arran is part of the West of Scotland Consortium considering the site for a local/regional forensic psychiatric secure unit and service.

14. The emergency readmission rate within 28 days in 1998 for adults was 2.53% dropping as low as 1.97% in 2001, compared to the Scottish average of 7.27% over the same period. This low readmission rate may indicate good discharge planning procedures and community support services preventing unnecessary readmission. In July 2003 there was only one delayed adult discharge. It helps to explain why Ayrshire can cope with so few beds. Last year 44 people from Ayrshire were discharged from psychiatric hospitals elsewhere in Scotland, compared to 26 people from elsewhere treated locally, indicating some pressure, but some of these external referrals will be to specialist units. In a census in July 2003 there were a total of 35 delayed discharges in Ayrshire and Arran (one adult, 34 older people).

15. Table E - Hospital bed numbers Ayrshire and Arran and Scotland⁸

    Hospital Beds	Ayrshire and Arran Actual beds				Ayrshire and Arran Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	433	424	405	400	117	115	110	109	161	153	145	141
    All adults under 65 years	238	227	221	213	64	62	60	58	74	70	66	64
    Older people	195	196	184	182	53	53	50	50	83	79	74	73

    Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional.

    Table F - Hospital admissions in Ayrshire and Arran for people aged 16/18 - 64 years ⁹

    Adults 16/18 - 64	1998	1999	2000	2001	2002
    First admission	507	463	483	541	519
    Readmissions within one year	1406	1472	1402	1457	1399
    Readmission rate within 28 days	2.53%	2.13%	1.91%	1.97%	N/A

    Readmission rate= (emergency readmissions/discharges) x100

16. Although there is a child and adolescent consultant there are no hospital beds for children or adolescents, and those needing hospital care will either be admitted to a general paediatric ward or adult unit (which is unacceptable under the new Act) or be transferred to Yorkhill Hospital or Gartnavel Royal Hospital in Glasgow. There are similar problems with inpatient facilities for mothers with babies.

18. Currently it is difficult to offer some assessment, therapeutic or diversional opportunities due to difficulties in recruiting psychologists and occupational therapists. It is also difficult to provide a full range of activities at Crosshouse Hospital due to an environment that offers little quiet or therapeutic space. Service users and carers describe Crosshouse as unsatisfactory and failing in its response to their needs. The environment at Ailsa is regarded as much better and has a gym, grounds to walk in and a variety of activities available. Information materials on both mental illness and support services are readily available.

19. Community Services

20. There are a number of user and carer advocacy groups including (this list is not exhaustive): Ayr Action for Mental Health; Health in Mind (Clubhouse); Copeline; Scottish Association for Mental Health; the Richmond Fellowship; the Panel of Reference (a pan-Ayrshire consultative service user group); and locality based advocacy services in East, North and South Ayrshire. Advocacy is therefore multi-agency and in all areas, but in small projects. Some integration may be necessary to deliver a service under the new Act and an action plan is being drawn up.

22. Community Services include 6 community mental health teams, a Day Activities team at Ailsa Hospital, Hartfield House Day Centre, a dual-diagnosis day unit, the Compass Centre in Irvine, the Three Towns Resource Centre in Stevenson, and an Intensive Continuing Crisis Service (previously the Home Options Team), which is NHS Trust-wide and provides an alternative to admission.

24. The 6 CMHTs have developed collaborative working relationships with other agencies, including voluntary organisations and housing departments, with some teams having housing officers as members. There is good joint working with single shared assessments, and good use of Supporting People initiative money.

26. There are some good employment opportunities such as the Compass Project, which has 40 semi-industrial placements (picture framing, computers etc) leading to real jobs. However, the 45% European funding for this project ends in 2005 and there are plans in place to reduce the service if no alternative funds are available. Under the Act it is a local authority function to provide assistance in obtaining and undertaking employment.

27. Priorities of Users and Carers in Ayrshire and Arran

28. Users and carers:

• Reduce overcrowding in hospitals.

• Provide high quality but alternative facilities for people with drug and alcohol problems.

• Provide rehabilitation for people with drug and alcohol problems.

• Stop the inappropriate admission of younger people with dementia to geriatric wards.

• Carers need support, information and tips on how to help care for users.

• The needs of homeless people with a mental illness.

• Reduce the waiting times to see a CPN.

• See mental illness as something that everyone needs to play a part in- stop seeing it as separate.

• Provide adequate accommodation on discharge - B&Bs are not appropriate.

Comments

21. Key issues that will challenge Ayrshire and Arran when implementing the new legislation are:

• Getting all GPs involved the development and delivery of mental health services.

• Improving transport.

• Pressure on the one forensic psychiatrist to attend Tribunals.

• Recruiting and retaining MHOs.

• Developing an integrated independent advocacy service.

• Arranging access to inpatient facilities for children and adolescents and mothers with babies through regional planning.

Visiting Team

Footnotes

¹ ISD Scotland. Population figure covers all age ranges as of 2002

² Scottish Executive, Mental Health Act Implementation Team. Based on the Royal college of Psychiatrists' scoping exercise.

³ The State Hospitals Board for Scotland Medical Records Department

⁴ Mental Welfare Commission Annual Reports 2001-02/2002-03

⁵ Sections 24 and 25 are emergency sections lasting 72 hours

⁶ Section 26 is a 28 day order that can be used when an emergency section has expired

⁷ Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court

⁸ ISD

⁹ ISD provisional data from SMR04 returns

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