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National Mental Health Services Assessment
Locality Report

FIFE

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. Fife has a population of approximately 350,700 ¹, (229,000 adults) with levels of ill health and deprivation above the Scottish average. Planning is based on the estimate that over 100,000 people (2 in 7 of the population) in Fife will ask for help from mental health services at some time in their lives.

2. Mental health services are organised into 3 sectors; Central Fife, North and East Fife, and West Fife. The amalgamation of what were separate NHS Trusts enables better planning although there remains some local tension about how hospital services will be reconfigured. Fife Council has the same geographical boundaries as NHS Fife and the social work mental health services are based at 3 local offices in Cupar, Dunfermline and Kirkcaldy.

3. In 2002 the Clinical Standards Board for Scotland (CSBS) undertook an assessment of compliance with some of its standards for the treatment and support of the 600 people in Fife with a diagnosis of schizophrenia. Better information for patients and improved documentation and audit were required as was training about substance misuse by people who have schizophrenia. These are all being taken forward.

4. ' Right for Fife' - the overall health strategy for Fife - describes the work being taken to focus on projects that emphasise multi-agency working and user and carer involvement. There is a range of targets:

• expansion of supported accommodation

• improved support to carers

• seven-day services from community mental health teams

• better access to psychological services

5. The development of community services is going hand-in-hand with the hospital reconfiguration and 3 sites are under consideration. While this has the potential for the health side of the agenda to dominate, social work health and the voluntary sector are working jointly with health colleagues to ensure that this does not happen. At a service delivery level there are strong cohesive working relationships and a commitment to taking forward redesign projects jointly and finding local solutions to gaps in services. Joint working has been demonstrated by the pioneering and successful adoption of the Care Programme Approach in Fife.

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

7. The use of emergency detentions is the fourth lowest of the mainland NHS Board areas and the number of short and long term detentions in Fife is close to the average for Scotland.

8. Table A - Detentions in Fife under the Mental Health Act (Scotland) 1984 in 2001-02/ 2002-03 ²

   	No. of detentions in Fife	No. per 100,000 people in Fife	Average number per 100,000 people in Scotland
   Sections 24 and 25 3	270/276	77/79	85/90
   Section 26 4	189/161	54/46	51/56
   Section 18 5	88/80	25/23	21/23

9. In July 2003 there were 13 Fife patients resident in The State Hospital, including 5 women. This is proportionally higher than for other areas. Three non-restricted patients have been waiting for transfer back to Fife for more than 3 months. Another individual is waiting for pre-transfer assessment by Fife psychiatric services. From 2006 patients will have the right to appeal against the level of security and this will be especially important for people delayed in The State Hospital.

10. Table B - Average number of detentions 1994-02, related to population size and used to estimate the potential number of hearings.⁶

    Local Authority	Population size	% of Scottish detentions	Estimated Tribunal hearings under the 2003 act
    Fife	357,000	7.12%	214

11. 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).

12. There are 34 doctors in Fife who are approved under Section 20 ⁷ of the 1984 Act and 24 WTE consultant psychiatrists (no vacancies), 13 are general psychiatrists. The service does not have separate forensic psychiatrists and general psychiatrists take on this work, meaning they will have a higher number of Tribunal hearings than general psychiatry colleagues elsewhere.

13. There are 43 approved Mental Health Officers in Fife with around three quarters 'active' in carrying out MHO duties in the last year. This works out at about 10 per 100,000, (the Scottish average is 11.5). Only 37% of social workers with the MHO qualification actually work in the mental health field in Fife. No arrangement has been made about additional payments for MHOs called out during the day, although payments are being made for out-of-hours services at the rate of 60 per night.

14. Table C - Mental Health Officers in Fife⁸

    Local authority	No of MHOs	Practising mhos	MHOs working in mental health	Additional payment
    Fife	43	35	16	No (except for out-of-hours)

15. MHOs locally considered that they could not take on any extra burden and felt they were already stretched with the additional work for the Adults With Incapacity (Scotland) Act 2000.

16. Hospital Services

17. Hospital services are provided from four sites:

Four acute admission wards

• One at Stratheden Hospital, Cupar (30 Beds)

• Two at Whyteman's Brae Hospital, Kirkcaldy (53 beds)

• One at Queen Margaret Hospital, Dunfermline (30 Beds)

One intensive psychiatric care unit

• Stratheden Hospital (10 beds)

Two rehabilitation wards

• Stratheden Hospital (50 beds)

Two adult long stay wards

• Stratheden (50)

One occupational therapy rehabilitation service

• Ceres Centre at Stratheden Hospital

Table D - Hospital bed numbers in Fife and Scotland⁹

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

13. There has been a continuing reduction in hospital beds for both adults and older people over the last 3 years. Although adult beds are about the Scottish average, the number of beds for older people is significantly below the average.

14. For this population size, it is suggested that adult admission bed numbers ¹⁰ range from 57 to 114, depending on other services being available. There are 113 admission beds in Fife with an occupancy rate of around 75% at Stratheden Hospital, which does indicate some spare capacity and an opportunity to redistribute resources towards community care. In practice it means that when beds are full elsewhere people can be admitted to Fife. Out of 1,601 discharges from Fife psychiatric services in 2001-02, 53 came from elsewhere in Scotland, behind only Argyll and Clyde and Greater Glasgow in the numbers of people admitted from outside the area.

15. Despite this, 44 Fife residents were in turn discharged from hospitals elsewhere in Scotland. This is most likely to be due to out of area admissions for older people, given that the data was not able to be separated into age categories and there are a relatively low number of beds for this age group.

16. One important factor in understanding bed usage is the average length of stay. For the acute adult admission wards it is averaging at 25 days over the last 2 years, which is relatively small in comparison to other places. A national average is not available because information about length of stay in acute adult wards is not collected centrally. The Intensive Psychiatric Care Unit at Stratheden averages a longer stay of 42 days, perhaps reflecting its forensic usage. In June 2003 there were 12 delayed discharges in mental health services in Fife; 11 of them were older people.

17. The emergency readmission rate (within 28 days) fell to 6.07% in 2001, compared to a Scottish average of 7.27% over this period. In 1999 the Accounts Commission ¹¹ used this as an indicator of the adequacy of discharge planning and how well people are being supported in the community.

18. Table E - Hospital admissions in Fife for people aged 16-65 years¹²

    	1998	1999	2000	2001	2002
    First admission	329	324	261	250	315
    Readmission within one year	935	848	796	725	793
    Readmission rate within 28 days	8.15%	8.23%	6.81%	6.07%	n/a

    Readmission rate= (emergency readmissions/discharges) x100

19. Fife has no dedicated forensic beds although Stratheden's Intensive Psychiatric Care Unit admits people from courts and operates as a step-down facility for patients from The State Hospital. The fabric of the IPCU needs upgrading and does not currently meet mixed sex accommodation standards. Across Scotland the function of an IPCU and the classification of forensic beds differs. The definition currently is based on the specialty of the Responsible Medical Officer.

20. There are no children's beds and the 6 adolescent beds have been temporarily closed. They had previously made up 14.6% of the Scottish provision for this age-group. Fife is unable to provide age-appropriate inpatient services for children and adolescents locally. There are no separate inpatient facilities for mothers and babies, another requirement of the Act. People with a wide-range of problems and multiple needs may be admitted together in a general ward.

21. Community Services

22. In some places community teams are well established, in others they are under developed. Fife lacks 24 hour response services, a strategic issue for both health and social services and something needs to be resolved urgently in order to make community-based Compulsory Treatment Orders a viable option. Within East Fife a proposal to introduce community psychiatric nurses to NHS 24 is being explored as well as expanding the community mental health teams across Fife to provide a 7-day out-of-hours service.

23. There are 3 adult psychiatric day hospitals, in the West, North, and East sectors. Nine community psychiatric nursing teams provide sector services with 5 teams in the North-East, 3 in Central and one in West Fife. There are a further 5 intensive out-reach teams, and a dual diagnosis service that caters for enduring mental illness and substance misuse across the whole region.

24. 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.

25. The voluntary sector in Fife has begun to widen the scope of services provided to adult mental users, although services to carers in Fife remain patchy and under developed. Fife Council has invested in projects that promote access to employment and social inclusion. A far from comprehensive list of community services and their providers includes a focused education service; horticultural therapy project; Better Futures Project; Hearing Voices Network; Fife Association for Mental Health; Scottish Association for Mental Health; Barony Housing Association's 'Contact Point'; and the National Schizophrenia Fellowship (Scotland). Fife Families Support Group provides help to carers, although there are no advocacy projects specific to carers.

26. Patients' Councils are in operation in each of the 3 psychiatric hospitals, and independent advocacy for users is available from a number of sources, co-ordinated by the Fife Advocacy Strategy Group. NHS Fife and Fife Council have shown a clear commitment to developing advocacy services, although there is often a waiting list for service users and more needs to be available for carers.

27. Priorities of Service Users and Carers in Fife

28. The expressed views of the users and carers are as follows:

• Mental health awareness training for the public.

• Change the system - the attitudes of psychiatric and medical staff.

• A centre of excellence for mental health as part of a wider health centre.

• More access to respite care.

• Access to alternative therapies.

• Better access to psychology services.

Comments

26. Key issues that will challenge Fife when implementing the new legislation are:

• The hospital reconfiguration may take up considerable managerial and staff time and involve a number of relevant issues, such as the function of the IPCU and siting of forensic beds. The IPCU needs upgrading.

• The balance between hospital and community care is too focused on the hospital side and reducing some adult beds may allow for increased community developments.

• The out-of-hours services in particular are underdeveloped and this needs to be addressed to allow the opportunity for community-based Compulsory Treatment Orders.

• Unless the adolescent beds are re- opened young people will need to go out of area for inpatient care, which would not be ideal.

• Inpatient services for mothers and babies need to be agreed with other parts of a managed clinical/ care network unless reconfiguration includes a dedicated facility.

Visiting Team

Footnotes

1 ISD Scotland

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

3 Sections 24 and 25 are emergency Sections lasting 72 hours

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

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

6 Scottish Executive, based on the scoping exercise by the Royal College of Psychiatrists

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 Support. Scottish Executive 2003

9 ISD

10 Royal College of Psychiatrists

11 A shared approach, Accounts Commission for Scotland, 1999

12 ISD provisional data from SMR04 returns

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