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National Mental Health Services Assessment
Locality Report

FORTH VALLEY

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. Forth Valley is a relatively small area in central Scotland with a population of about 279,300 ¹ (184,700 ² adults) making it the fourth smallest population of all 12 mainland NHS Board areas. Although there are some areas of social deprivation the morbidity levels are at the national average. Mental health services are provided by NHS Forth Valley and 3 local authorities: Clackmannanshire, Falkirk, and Stirling Councils. Together the local authorities are coterminous with the NHS Board area.

2. The quality of Forth Valley mental health services is rated highly. The Scottish Health Advisory Service report 2002 was on the whole very positive. The Mental Health and Well Being Support Group (2002) rated Forth Valley with twice as many "significant achievements" than any other region.

3. The Clinical Standards Board for Scotland undertook the first round assessment of compliance with its standards for the treatment and support given to people who have a diagnosis of schizophrenia (490 people in Forth Valley, 154 of whom were admitted to hospital in 2001-02). The findings reflected the national picture, but Forth Valley was one of the first areas to set up training in psychosocial interventions for schizophrenia responding to one of the key CSBS standards.

4. An internal area-wide review of mental health services was completed in June 2002, which led to new initiatives such as clinical effectiveness projects and the introduction of the CORE Assessment Schedule to measure service user's progress.

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

6. Detentions in Forth Valley is considerably lower than the Scottish average ³.

7. There are 7 Forth Valley residents under conditions of special security in The State Hospital. None are currently delayed for transfer. Forth Valley purchases forensic beds from the Orchard Clinic in Edinburgh.

8. Table A - Detentions for all ages in Forth Valley under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03 ³

   	Actual no. of detentions	No. per 100,000 in Forth Valley	Number per 100,000 in Scotland
   Sections 24 and 25 4	184/232	66/83	85/90
   Section 26 5	126/145	45/52	51/56
   Section 18 6	42/47	15/17	21/23

   Table B - Average number of detentions 1994-2002, related to population size and used to estimate the potential number of hearings.⁷

   Local authority	Population size	Percentage of Scottish detentions over 8 years	Estimated Tribunal hearings under the 2003 Act
   Clackmannanshire	31,562	0.51%	15
   Falkirk	96,340	2.73%	82
   Stirling	56,826	1.13%	34

9. For the purposes of this report the number of anticipated hearings (based on the current Sections 26 and 18) is based on the assumption that the average rate of detentions will remain broadly consistent with previous years, despite the fact that numbers are rising year on year. The unknown quantity of potential appeals has not been included and as a result the forecast should be taken as a conservative estimate.

10. The new Act puts 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).

11. Twenty-six doctors are currently approved under Section 20 of the 1984 Act, including 20 ⁸ whole time equivalent consultant psychiatrists. Eleven are general psychiatrists and one a forensic psychiatrist, the doctors most likely to be involved most often with compulsory treatment. In addition there are 2 consultants working with people who have learning disabilities, 4 old age psychiatrists and 2 people in child and adolescent services. Two of the consultants are locums. The Royal College of Psychiatrists suggests that planners should consider 15 consultants in general psychiatry for a population the size of Forth Valley.

12. The predicted increase in workload has worried the consultants and they were perhaps one of the most vociferous and articulate of their peer group in Scotland in expressing the concerns. Several had observed an increase in the numbers of people who have a dual diagnosis and also offending behaviour, and were concerned about their caseloads being skewed to this group at the expense of the broader range of psychiatric work.

13. There were 50 qualified MHOs in Forth Valley at the time of the Scottish Development Centre survey ⁹, 34 (68%) of whom had used this qualification in the previous year. To aid recruitment and retention additional payments are available to MHOs in 2 of the 3 local authorities, with Clackmannanshire paying MHOs at a senior social work rate, and Stirling adding 2 increments to the basic grade.

14. Table C - Mental Health Officers in Forth Valley: SDC Structures and Supports MHO Survey 2003

    Local authority	No of MHOs	Practising MHOs	MHOs working in mental health settings	Additional payment
    Clackmannanshire Council	14	4	2	Yes
    Falkirk Council	22	22	4	No
    Stirling Council	14	8	4	Yes

    Hospital Services

15. The services for acutely ill adults differ in each area, with a relatively limited number of admission beds in Falkirk resulting in people from Falkirk often being referred to Stirling or Clackmannan for their care. Good co-operation exists between the 3 acute admission services, which ensure smooth, well planned transitions between the areas.

16. Mental health facilities within the area consist of:

Three acute adult admissions wards

• Falkirk Royal Infirmary (south sector 29 beds)

• Stirling Royal (north sector 24 beds)

• Clackmannan County Hospital (east sector 15 beds)

An Adult Intensive Psychiatric Care Unit

• Falkirk Royal Hospital (12 beds)

Three Adult Continuing Care Wards

• Bellsdyke Hospital (98 beds)

One Rehabilitation Ward

• Craigenhall (Falkirk, 14 beds)

Liaison Nursing Service

• Falkirk Royal and Stirling Royal Hospitals

13. Acute admission beds (194) for adults in Forth Valley are the third highest per 100,000 in Scotland. No overall problem about access to hospital exists, although people in Falkirk are sometimes treated further from home. The total bed numbers for all specialties is low in comparison to the rest of Scotland, but this is due to the number of beds for older people being significantly below average.

14. In July 2003 there were 2 delayed discharges affecting younger adults and 26 affecting the transfers of older people.

15. Table D - hospital bed numbers Forth Valley and Scotland¹⁰

    Hospital Beds	Forth Valley Actual beds				Forth Valley Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	369	359	359	351	133	129	129	126	161	153	145	141
    All adults under 65 years	207	195	195	194	74	70	70	69	74	70	66	64
    Older people	162	164	164	157	58	59	59	56	83	79	74	73
    Forensic Services	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

16. The emergency re-admission rate within 28 days in 1998 for adults was 0.44 %, rising to 7.25% in 2001. The Scottish average over the same period was 7.27 %. However the rising trend in Forth Valley needs to be understood.

17. In 2000-01 Forth Valley mental health services treated 36 people from outside the area and sent 33 elsewhere. The following year the figures were reduced, 12 people coming into the area and 20 discharged from other areas, some of the referrals outside Forth Valley were to specialist services not available locally.

18. There are no designated forensic beds in Forth Valley, but Bellsdyke does admit patients directly from The State Hospital.

19. A local survey found that more than half of the recorded 38 admissions to 2 wards occurred outside office hours. However, only 6 (15%) of these admissions were under the current Act. These are useful data given the concerns about the demand on consultants due to emergency work out-of-hours. The report goes on to suggest that extending the opening hours of community resources such as Dunrowan in Falkirk could further prevent admissions.

20. There are no local hospital inpatient services for adolescents, who will need to be sent elsewhere to meet the requirements of the new Act for age-appropriate services. Although there is no inpatient facility for mothers and babies, out-patient services for post-natal depression are good and the outcome of the considerations of the Short Life Working Group on Perinatal Mental Illness (due early 2004) will inform future decisions about this aspect of care.

21. Community Services

22. 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 for people who have or have had significant mental health problems.

23. There is already good joint working locally between health and the 3 social work departments. Community services include 5 community mental health teams: Westbank, Falkirk, Kildean, Stirling, and Clackmannan. In addition there are 3 rehabilitation teams in Stirling, Falkirk and Clackmannan. A partial hospitalisation project operates from the Dunrowan Resource Centre in Falkirk, offering services to severely ill users with short and intensive interventions aimed at preventing inappropriate admission or facilitating early planned discharge from hospital.

24. There are many excellent examples of local voluntary sector organisations providing services ranging from supported accommodation to supported employment and advocacy services. The Caledonia Clubhouse was established in 2000 as a joint venture between the NHS Board and Falkirk Council. Forth Valley's mental health strategy is to extend this model to other areas. Supported accommodation primarily involves the Scottish Association for Mental Health, Penumbra, Loretto and Church of Scotland. Advocacy is provided by Advocacy into Action, Forth Valley Advocacy Services, the Quality Action Group and People First Scotland.

25. Other community services include Stirling and District Association for Mental Health, which has a wide range of services including befriending, counselling, drop-in, home support and a women's support group. Falkirk and District Association for Mental Health also provides a range of services including the Victoria Centre and Befriending Schemes and Carers Support and Development Group. Clackmannanshire Association for Mental Health provides similar opportunities. Service user groups include Open Door in Grangemouth, Falkirk Users Network and People Need People.

26. The ability to respond to crisis and provide services out-of-hours is relatively limited. Various crisis response models have been considered following consultation with users and carers. There was a consistent feedback that non-statutory services should be involved, a view held particularly by service users.

27. In Falkirk, various options were listed including crisis telephone services, a centre for face-to-face contact in a non-medical environment, an open referral policy and extended opening hours for day services. In Stirling the emphasis was that crisis support should be 24 hours a day and be multi-agency. Clackmannanshire piloted a two-bedded safe house, offering users a short-break for a maximum of 72 hours. Clackmannanshire Association for Mental Health provided the staff and the project was funded mainly by the local authority, but the unit however closed as a result of under utilisation.

28. Priorities of Service Users and Carers in Forth Valley

29. Users and Carers

Alloa and district

• A new minibus for Devon house

• Larger and more attractive premises for Devon House

• Out-of-hours services.

Stirling and district

• Challenge stigma and educate the public

• Better access to good respite care

• Out-of-hours services

• Better and more easily accessed benefits

Falkirk and district

• Out-of-hours services

• Crisis Cards

• More CPNs

• Challenge stigma

• Help and understanding

• Help with friendships and relationships

• Access to respite care/ a safe house

• Earlier help-less waiting time for help

• Improve GPs' knowledge about mental health services

• Prevention

• Access to employment opportunities, challenge discrimination in the workplace and make employers more aware of mental health.

Comments

27. Key challenges for Forth Valley in meeting the demands of the new Act are:

• Organisational change will be needed to ensure that consultants are enabled to carry out their new tasks under the Act in partnership with Mental Health Officers.

• The availability of 24 hour services is already a priority locally and needs to be developed in order to provide the range of supports necessary to allow the option of community-based Compulsory Treatment Orders.

Visiting Team

Footnotes

1 ISD Scotland

2 General Registry Office

3 Mental Welfare Commission for Scotland Annual Reports 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 Scottish Executive, Implementation Team Mental Health (Care and Treatment) (Scotland) Act 2003

8Scottish Executive

9 Mental Health Officer Services: Structures and Supports. The Stationary Office. 2003

10 ISD

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