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National Mental Health Services
Assessment Locality Report

DUMFRIES AND GALLOWAY

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. Dumfries and Galloway is a predominantly rural region covering 2,500 square miles with an estimated population of 147,310 ¹, (93,000 adults). Within this rural setting there are pockets of multiple deprivation of similar severity to inner city areas (for example, in areas of Dumfries, Stranraer and Upper Nithsdale) ².

2. Mental health services are provided by NHS Dumfries and Galloway and Dumfries and Galloway Council, in partnership with the voluntary sector. The council is coterminous with the Dumfries and Galloway health service area.

3. The wide geographical spread and rurality combine to present challenges for the design and delivery of services and pose particular problems in recruitment and retention of staff, especially consultant psychiatrists. There is also a shortage of community staff including psychiatric nurses and allied health professionals.

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

5. The number of compulsory admissions is similar to elsewhere in Scotland, with somewhat higher numbers of long-term detentions. On this basis the estimated number of Tribunal hearings is forecast at 104 ³.

6. There are currently 6 people from Dumfries and Galloway resident in The State Hospital. None are waiting transfer. The lack of a local IPCU or forensic secure unit and service, if continued, may cause problems were people to be delayed returning to the local area when the right to appeal against the level of security comes into effect in 2006. The West of Scotland consortium is already looking at this issue and is considering managed clinical and care network approaches.

7. Table A - Detentions in Dumfries and Galloway under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03⁴

   	Actual no of detentions in Dumfries and Galloway	No per 100,000 people in Dumfries and Galloway	Average number per 100,000 people in Scotland
   Sections 24 and 25 5	128/120	87/82	85/90
   Section 26 6	72/78	49/53	51/56
   Section 18 7	38/38	26/26	21/23

8. There are 6 general adult consultant psychiatrists in Dumfries and Galloway, with a further 3 consultants for older people, and 3 for children and adolescents. There is one consultant for learning disabilities and overall 14 doctors are currently approved under Section 20 of the 1984 Act, including a specialist psychiatric registrar. There have been 1.5 Whole Time Equivalent vacancies in consultant posts for around a year with the full time post being adult psychiatry and the part time in learning disabilities. Funding is available for the posts, but recruitment has proved difficult to date (December 2003).

9. The local authority is also having problems recruiting and retaining staff and is in competition with other councils who are offering financial incentives. There are particular problems about providing rural cover, Mental Health Officer services to court, out-of-hours services and meeting the demands of the Adults With Incapacity (Scotland) Act 2000. It was said that more needed to be done to clarify the roles, responsibilities and working relationships between health and social work in joined up teams, as well as with the MHOs who do not work in mental health settings.

Table B - Mental Health Officers in Dumfries and Galloway: SDC Structures and Supports MHO survey 2003

Hospital services for adults

Two admission wards

• Crichton Royal Hospital with 46 beds in total

Two rehabilitation units

• 32 rehabilitation beds for adults split between two wards (Wellgreen and Lahraig).

8. The closure of beds for adolescents is worrying, given the level of bed provision for this care group around Scotland and the coming requirement in the new Act for age-appropriate admission services. Dumfries and Galloway will have to contribute to a managed clinical/care network to provide for adolescents to be admitted to adolescent, not adult, services.

9. The number of psychiatric beds in Dumfries and Galloway for adults and older people has reduced in line with the move to community based care. There are 101 beds per 100,000 in Dumfries and Galloway for all specialties, (the lowest in Scotland).

10. At the time of the visit there was a serious problem with lengthy delays in transfers from acute admission to rehabilitation beds. People with a wide range of problems are admitted to the wards, including for detoxification with 4 admission beds set aside for this purpose. Increasing numbers of complex care cases and attendant security and risk issues are evident. The senior management team sees the acute admission services as a top priority for change not just in terms of the bed pressures, but the poor quality of the environment.

11. The mental health strategy is being reviewed with particular attention to the numbers and location of beds, and attention to levels of investment. It is likely that proposals will be put forward for a new hospital building although this has still to be formally agreed. The lack of an Intensive Psychiatric Care Unit means that people who are severely ill have to be treated in the admission ward or transferred to Hartwoodhill Hospital.

12. Discharge figures ⁸ from hospitals and day services (all ages in mental health) in Dumfries and Galloway in 2001-2002 show 748 from Dumfries and Galloway, plus 9 who were resident elsewhere. 44 Dumfries and Galloway residents had been treated out of the area and then discharged. 679 people with a learning disability were treated and discharged from within Dumfries and Galloway in the same year.

13. Table C - Hospital bed numbers Dumfries and Galloway and Scotland⁹(Dumfries and Galloway's adolescent unit closed in the period 2001-02)

    Hospital Beds	Dumfries and Galloway Actual beds				Dumfries and Galloway Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	282	180	159	149	190	122	108	101	161	153	145	141
    All adults under 65 years	122	94	89	78	82	64	60	53	74	70	66	64
    Older people	142	74	70	63	96	50	47	43	83	79	74	73
    Adolescent Psychiatry	12	12	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

14. In 1998 the Accounts Commission used readmission rates within 28 days as a possible indicator of the adequacy of community services post-discharge. In 2001 (latest available figures) the 28 day readmission level was 10.1% in Dumfries and Galloway, compared to the Scottish average of 7.27%. This may be another factor putting pressure on beds.

15. Table D - Hospital admissions in Dumfries and Galloway for people aged 16/18 - 64 years¹⁰

    Adults 16/18 - 64	1998	1999	2000	2001	2002
    First admission	167	149	148	140	164
    Readmissions within one year	367	361	321	390	362
    Readmission rate within 28 days	9.99%	9.56%	7.94%	10.01%	N/A

    Readmission rate = emergency readmissions/discharges x 100

    Community Services

16. Community based services are as follows

Five Community Mental Health Teams

• Annan

• Castle Douglas

• Nithsdale (2)

• Stewarty

One Day hospital

• Huntington, in Dumfries

15. Dumfries and Galloway has been a pioneer in joint health and social care working. A general manager covers mental health services between the agencies. There are 5 jointly funded community mental health teams that are linked to local health care co-operatives. CMHT team leaders come from variety of disciplines, including social work, occupational therapy and community psychiatric nursing. Some of the CMHTs have specialist pharmacy input.

16. There is a combined care programme approach and care management system and all staff, not just social workers, can 'care manage'; similarly social workers undertake therapeutic work. A link person from the CMHTs provides regular input into GP practice meetings.

17. There is not enough local social housing, especially for young people, but 14m has recently been awarded from Communities Scotland to Ayrshire and Dumfries and Galloway to help expand local provision. The broad responsibility placed on local authorities by the new Act is acknowledged and the implementation teams being created to prepare for implementation will include consideration of all the supports and agencies involved.

18. The National Schizophrenia Fellowship is developing employment and support opportunities, such as the Genesis computer training and repair service. A range of group therapies is available at the Huntington Day Hospital in Dumfries.

19. A good Benefits Advice service is available to the clients in the community and on the wards from the amalgamated welfare rights and citizen's advice bureau. Health service staff have provided training to staff from these agencies in mental health issues.

20. There is a generic independent advocacy project, covering all of Dumfries and Galloway for all people using NHS and local authority services staffed by both paid and volunteer advocates, that supports self-advocacy in learning disability users and covers all of Dumfries and Galloway. There are no dedicated advocacy workers currently in mental health, which will challenge existing services following introduction of the new Act.

21. Out-of-hours services are provided by social work via a combination of West of Scotland "standby" and local "on-call" services. The CMHTs provide a 9 am - 5 pm service. Those people who require urgent assessment by hospital services can be referred to on-call duty senior house officers at the Crichton Royal.

22. Priorities of Users and Carers in Dumfries and Galloway

23. Users

• Support for all the family.

• Ways of making friends and sustaining relationships.

• Better pay for nurses and other staff.

• Access to peer support.

• Any new hospital needs to be relaxed, homely, modern with things to do, nice grounds and privacy.

23. Carers

• If you had cancer there would be a whole range of services, sympathy and support. You get the opposite with mental illness, we need to educate society and challenge stigma.

• We need parity of investment in mental illness compared to the other main illnesses.

• We need parity of investment in rural areas where facilities are sparse.

• We need a secure unit in Dumfries and Galloway.

• Some mental health professionals can look down on us and be patronising - they need help with their attitudes.

Comments

24. Key challenges facing Dumfries and Galloway in implementing the new legislation:

• Dumfries and Galloway has the lowest number of hospital beds per 100,000 population in Scotland, so there is pressure on inpatient services and consequently on community services. If the number of beds remains low there will need to be clear alternative facilities in the community. At present there are insufficient community out-of-hours services to support community-based Compulsory Treatment Orders.

• The lack of a local IPCU needs to be looked at when reconfiguring inpatient services as part of a national policy about where best to treat people who are severely ill.

• The lack adolescent inpatient beds or separate provision for mothers and babies needs to be addressed probably through a managed care network.

• Workforce problems will be a top priority given recruitment and retention problems, both for psychiatrists and MHOs.

• The geographical isolation in parts of the region is leading to transport problems for service users and staff and joint ways of resolving this are important.

• There are no dedicated advocacy workers in mental health and this service needs to be developed.

Visiting Team

Footnotes

1 ISD Scotland

2 Dumfries and Galloway NHS Board website

3 Mental Health Act Implementation Team, Scottish Executive, 2003

4 Mental Welfare Commission Annual Report 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

10 ISD provisional data from SMR04 returns

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