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National Mental Health Services Assessment
Locality Report

BORDERS

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

1. Borders has a scattered rural population of about 107,400 ¹ (68,000 adults) with the highest proportion of people over 65 in Scotland. It is an area of relatively high employment with the lowest levels of deprivation and morbidity in Scotland.

2. Mental health services are provided by NHS Borders and the Scottish Borders Council, in partnership with a number of voluntary sector organisations.

3. Following the closure of Dingleton Hospital in 2001, inpatient services have been dispersed to a number of new small units providing much improved care environments. Users of services were involved throughout the planning process.

4. The Mental Health and Well Being Support Group (2002) commented on issues relevant to implementing the new Act, including lack of advocacy specifically for mental health and for carers, a need to develop an integrated care pathway for postnatal depression, and workforce challenges. The Clinical Standards Board for Scotland in 2002 recorded 122 adults with a diagnosis of schizophrenia. The CSBS standards that were fully met were the alignment of each general practice with a community mental health team, notification to social work of the need for respite care and routine reviews about alcohol and illicit drugs.

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

6. The number of detentions under the current Mental Health Act in Scotland has been rising and over the last two years the increase in the Borders area is above the national average. In 2001-02 the use of the long-term detention order was the second highest in the country, and the short term order, the third highest. The reasons for this need to be explored. Based on these figures it is estimated that there will be approximately 75 mental health Tribunal hearings a year under the new Act. ²

7. There are no Borders patients in The State Hospital.

8. Table A - Detentions under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03³

   	No. of detentions in Borders	No. Per 100,000 people in Borders	Average number per 100,000 people in Scotland
   Sections 24 and 25 4	95/103	89/96	85/90
   Section 26 5	63/76	59/71	51/56
   Section 18 6	34/40	32/37	21/23

9. Preparation for Tribunal hearings and attending them will put pressure on many professionals, but mainly on Responsible Medical Officers (consultant psychiatrists) and Mental Health Officers (social workers).

10. Thirteen Section 20 ⁷ approved Medical Officers are recorded for Borders: 4 consultant general psychiatrists (and one associate specialist) 1.7 Whole Time Equivalent, (WTE) in old age psychiatry. There are 1.5 WTE child and adolescent consultants. The list also includes some consultant paediatricians who had undertaken training when the local child and learning disability services were larger.

11. The number of practising Mental Health Officers per 100,000 population ⁸ (16.8) ⁹ is higher than the average in Scotland (11.5), but recruitment is emerging as a problem. Additional payment is offered as one way to minimise the recruitment difficulty. Of the 15 MHOs working on a rota system, 7 work in mental health settings linked to community mental health teams.

12. Table B - Mental Health Officers in the Borders

    Local authority	No. of MHOs	Practising MHOs	MHOs working in mental health	Additional payment
    Scottish Borders Council	18	15	7	Yes

    Hospital Services

13. The hospital services are organised as follows:

One acute adult admission unit

• Huntlyburn, Melrose

Three rehabilitation units

• Galavale Campus and Galashiels

Table C - hospital bed numbers¹⁰

Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * 10 beds in Huntlyburn acute admissions unit are dedicated for older people

11. There are 30 acute admission beds in Huntlyburn, 10 of which are dedicated for older people. The number of inpatient beds for adults has reduced, as everywhere in Scotland, although bed numbers for older people are well above the national average. The 51 beds per 100,000 for adults is now the second lowest for mainland areas, with a national range of 47-109 for mainland NHS boards. There is no Intensive Psychiatric Care Unit in Borders and patients requiring this level of care are transferred to Lothian. The Orchard Clinic in Edinburgh provides medium term forensic care. In the last 2 years, however, only 11 people who are resident in the Borders were discharged from other parts of Scotland in contrast with 37 people from elsewhere treated in Borders.

12. In 1999 the Accounts Commission ¹¹ used the adult emergency readmission rate within 28 days as a proxy for the adequacy of discharge planning and for how well people were being supported in the community. It has also been shown to be associated with assertive outreach programmes, so should be interpreted with caution. The latest available figure (2001) for Borders is 8.3%, with an average of 9.3% over 4 years. This compares to the 4 year national average of 7.27%.

13. Table D - Hospital admissions in Borders for people aged 16/18-64¹²

    Adults 16/18 - 64	1998	1999	2000	2001	2002
    First admission (i)	112	112	107	109	140
    Readmission (ii)	312	255	292	286	318
    Emergency readmission rate within 28 days (iii)	11.59%	7.94%	9.28%	8.30%	n/a

    (i) First ever recorded admission to psychiatric inpatient care

    (ii) Readmissions following a break in inpatient care

    (iii) (Emergency readmission/discharges) x 100

14. There were 13 delayed discharges in June 2003, all of them older people.

15. Community Services

16. Sections 25 - 27 of the new Act give local authorities a clear duty to provide a full range of care and support services to ensure leisure, recreation, employment, training and housing options for people who have or have had significant mental health problems. This will complement the core treatment services, although increasingly care and treatment services are becoming aligned.

17. Community services include 3 Community Mental Health Teams (CMHTs), based within each of the 3 sectors in Duns, Hawick and Melrose. Each CMHT is aligned with a day service. In addition, there is a jointly funded and managed resource centre in Galashiels. The Borders-wide community rehabilitation team works from the Galavale Campus in Galashiels.

18. There are community support workers, home care services, and work experience/employment training. Eight supported accommodation places are provided.

19. Some collective advocacy is available through New Horizons, a user-led support service, but access to independent advocacy is generally limited. A joint Advocacy Strategy has been developed, but considerable investment will be needed to meet the requirements of the new Act.

20. The Child and Adolescent Community Mental Health Service (CAMHS) operates from Selkirk. There are no psychiatric beds for children and young people in Borders. Adolescents are referred to the Young People's Unit in Edinburgh, but there is no provision for emergency referral. Admission of children needs to be negotiated with units elsewhere in Scotland or in England. Age-appropriate inpatient services will need to be ensured.

21. The Penumbra Youth project provides support at Galashiels and Hawick, although can be accessed throughout Borders. There is a Young People Outreach Service.

22. Recruitment and retention of clinical staff of all disciplines is beginning to emerge in Borders for the first time and creative ways have been developed to fill CAMHS vacancies. Further work is required to make best use of workforce skills.

23. Out-of-hours

24. Out-of-hours services, as in some other parts of Scotland, are restricted. Assessment is carried out by a duty doctor and nurse at Borders General Hospital or Huntlyburn. Both staff and service users considered the out-of-hours support to be insufficient. Work is underway to look at out-of-hours provision in light of the new GP contract. Borderline is a voluntary organisation that provides a telephone helpline 3 days a week.

25. Priorities for service users in Borders

26. The key views expressed by local users were as follows

• Better staff training - especially with their attitudes

• Reduce waiting times for psychological services

• Better follow up on discharge

• More acute service provision.

• More links across services.

• Provide more psychological therapies provision, especially specialist services

Comments

23. Key issues that will challenge Borders when implementing the new legislation:

• The need for better out-of-hours services will be a top priority although difficult to provide at a reasonable cost across the whole of Borders.

• Workforce planning around recruitment and retention and review of roles and responsibilities needs to be carried out urgently by both health and social services, not only in the short-term but also with the development of a long-term strategy.

• Independent advocacy, including services for carers, will need considerable development given the right to access an advocate that the Act specifies.

• Regional planning is necessary to ensure access to appropriate inpatient services for children and adolescents and mothers and babies.

Visiting Team

Footnotes

1 ISD

2 Scottish Executive, based on the Royal College of Psychiatrists' scoping exercise.

3 Mental Welfare Commission Annual Reports 2001-02 and 2002-03

4 Emergency detention, up to 72 hours

5 Short term detention, up to 28 days

6 Long term detention, up to six months in the first instance, agreed by a Sheriff

7 Medical practitioners approved by a health board as having 'special experience in the diagnosis or treatment of mental disorder'.

8 Mental Health Officer Services: Structures and Supports. Scottish Development Centre for Mental Health 2003

9 Strictly speaking the number of WTE is not as relevant as the number of people given that it is not a full-time job

10 ISD

11 A shared approach: developing adult mental health services. Accounts Commission for Scotland. 1999

12 ISD provisional data from SMR04 returns

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