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National Mental Health Services Assessment
Locality Report

GRAMPIAN

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. Grampian covers 3000 square miles and has a population of approximately ¹ 350,200 adults, 40% of them in Aberdeen City (144,800 adults). Aberdeenshire has 149,280 adults and Moray 56,100 adults. Levels of deprivation and morbidity are amongst the lowest in Scotland, although the level of alcohol misuse is high. A major factor having an impact on service delivery is the large geographic spread and accompanying transport problems.

2. Mental health services are provided by NHS Grampian and three local authorities together with a wide range of voluntary organisations and care providers. Together, the Councils are coterminous with the Grampian health service area. Grampian also provides consultant outpatient services and hospital admission facilities for Orkney and Shetland.

3. The Clinical Standards Board for Scotland found 407 people (16-65 years) with a diagnosis of schizophrenia being cared for in the service.

4. The Mental Health and Well Being Support Group (2002) was particularly impressed by effective joint working, strategies for mentally disordered offenders and child and adolescent mental health. It was noted that an integrated care pathway had been developed for postnatal depression. Collective advocacy had been developed in Aberdeenshire for users and support workers. All of these are directly relevant to the Act.

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

6. Table A shows the number and rate of detentions in Grampian in 2001-02 and 2002-03 and Table B Section 18 ² applications by Local Authority. In addition there are currently 19 Grampian patients in The State Hospital, 3 of who have been recommended for transfer and referred to Grampian for assessment. This is a relatively large number overall and preparations need to be made for potential increased demands once the appeals against the level of security ³ are introduced in 2006.

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

   	Actual no. of detentions	No. per 100,000 people in Grampian	Average no. per 100,000 people in Scotland
   Sections 24 and 25 5	408/340	78/65	85/90
   Section 26 6	251/220	48/42	51/56
   Section 18 2	94/99	18/19	21/23

   Table B - Applications for detentions under Section 18 of the Act in 2001-02 and 2002-03

   Local Authority	Total Population Size	Section 18 applications 2001-02	Section 18 applications 2002-03
   Aberdeen City	209,270	63	58
   Aberdeenshire	227,280	22	25
   Moray	86,740	17	22

8. The Act puts pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and Responsible Medical Officers (the pressures on administration and advocacy services will be discussed in the Final Report). The extra workload will come primarily in preparing for and attending Tribunals.

9. There are 45.2 WTE doctors approved under Section 20 of the 1984 Act ⁷, with 5.3 WTE vacancies, 1.3 of them in general psychiatry. Overall, and assuming all back-up services are available, the establishment is already low. In addition, there are 12 GP vacancies in Banff and Buchan. These are hard to provide cover for because they are distant from the city and consultants on call have to travel large distances to initiate Sections.

10. Difficulties also exist in recruitment and retention of other disciplines including allied health professionals and psychology, limiting opportunities for delegation and development of roles. The exception is nursing which has no recruitment problems and, as a result, development of consultant nurses may contribute to the solution. Other suggestions offered included a separate emergency team, minimising staff travelling time by bringing people into the hospital (although transport difficulties could be an issue) and exploring the potential for teleconferencing assessments.

11. Table D shows the MHO numbers in the different local authorities. There are 81 trained Mental Health Officers in Grampian; however a 2003 survey found that only 26 had undertaken MHO work in the previous 12 months ⁸. Recruitment and retention of MHOs is not a problem.

12. TABLE C - Mental Health Officers in Grampian

    Local Authority	No Of MHOs	Practising MHOs	MHOs working in mental health settings	Additional Payment
    Aberdeen City	39	11	11	No
    Aberdeenshire	33	11	11	No
    Moray	9	4	4	No

    Hospital Services

13. Hospital services are arranged as follows:

• 16 wards at Royal Cornhill Hospital (Aberdeen). Includes intensive care services, forensic services, continuing care and a brain injury unit.

• One ward at Dr Gray's Hospital (Elgin).

• Two rehabilitation units, Great Western Road (forensic) and Polmuir Road (Aberdeen).

• Two Community Rehabilitation Units managed by Scottish Association for Mental Health but with seconded Trust nursing staff in Aberdeen and Elgin.

• A liaison psychiatry service provided to Grampian University Hospitals NHS Trust.

• Two day hospitals, Fulton in Aberdeen and West Lodge in Elgin.

Table D - Hospital bed numbers Grampian and Scotland⁹

Adult beds include acute admission, rehabilitation and continuing care. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data

11. The bed numbers for both younger and older adults have steadily reduced. There are 126 beds per 100,000 in Grampian for all specialties, which is among the lowest in Scotland. The Scottish average is 141 (range 101 - 205) beds per 100,000. Older people's beds (70) compare with the national average (73 per 100,000), but the 47 per 100,000 adult beds in Grampian is significantly below the national average of 64. Forensic beds in Grampian account for 23% of the national resource and these bed numbers have remained static during the last 4 years.

12. It is recognised that the reduction in beds has enabled the development of community services and the transfer of all wards to a better physical state and newer accommodation.

13. The final number of adult acute beds is planned to be 125 ¹⁰ (100 in Aberdeen and 25 in Elgin). The occupancy rates are currently running at 100%, with an average last year of 85-90% and this could be one of the pressure points in implementing the Act.

14. The emergency readmission rate within 28 days was at its lowest in 1998 at 8.82% rising to its highest in 2000 at 10.17% and then falling slightly to 9.54% in 2001. The Scottish average over these years is 7.27% and Grampian's higher rate needs to be understood as a possible indicator of the adequacy of the community infrastructure. However, the falling number of first admissions suggests that community care is helping to keep some people out of hospital. This information needs to be explored to determine what the relationship is with community services.

15. TABLE E - Hospital admissions in Grampian for people aged 16/18 - 64¹¹

    Adults 16/18 - 64	1998	1999	2000	2001	2002
    First admission (i)	445	524	469	468	388
    Readmission within one year (ii)	1004	1095	1032	1034	1077
    Readmission rate within 28 days (iii)	8.82%	9.22%	10.17%	9.54%	N/A

    Information for 2002 is provisional

    (i) First ever recorded admission to psychiatric in-patient care

    (ii) Readmissions following a break in in-patient care

    (iii) (Emergency admissions/discharges)x100

16. Another important factor linked to community care services is the level of delayed discharges. In Grampian in July 2003 there were 25 delayed discharges in general adult psychiatry, representing a quarter of all adult mental health delayed discharges in Scotland. This is the second highest level for all NHS Board areas. There was also one delayed discharge in forensic psychiatry and a further 33 in the psychiatry of old age, a total of 59 in all mental health specialties.

17. With the low number of beds, high emergency readmission rates and some delayed discharges, this hospital service is working at full capacity. Locally there is not felt to be too heavy a pressure on beds, although in 2001-02 55 people with mental illness who live in Grampian were discharged from other parts of Scotland, compared to 17 people from elsewhere who were treated in Grampian (in addition to 82 people from Orkney and Shetland). This will need to be monitored carefully to make sure that admission beds remain available for both formal and informal patients. At present, the percentage of detained people in acute wards is 42%; this is similar to Lothian.

18. Lower bed numbers can put added pressure on carers. A Carers Help Group operates from the Royal Cornhill Hospital, providing carer volunteers and information. The National Schizophrenia Fellowship also runs a Grampian Carers Support Project. There is also a Carers Reference Group. This is a good base to build on to ensure that the Millan principle of Respect for Carers is adhered to.

19. When recruitment to adult general psychiatry has sometimes been difficult, the Trust has invested creatively in smaller specialties and has developed excellent services for drugs and alcohol, eating disorders and a 20-bedded unit for people with acquired brain injury. The Mental Health and Well Being Support Group ¹² gave alcohol and substance misuse services the highest rating for significant achievement in implementing the Framework for Mental Health.

20. The Blair Unit is an example of how forensic and intensive care services can be combined in a satisfactory way.

21. There is a structured approach to postnatal depression services with an integrated care pathway which will go towards complying with the section of the Act on postnatal depression (Part 4 Section 24) although access to dedicated beds will also be needed. There are no specialist beds for mothers and babies and those requiring admission are nursed in single rooms at The Royal Cornhill Hospital or Dr Gray's.

22. Children are transferred to Yorkhill Hospital for inpatient services and adolescents to Gartnavel Royal Hospital, in Glasgow.

23. Community Services

24. There are 8 Local Health Care Co-operatives (LHCCs) and, although not coterminous with the local authority boundaries, they are aligned to the geographical catchment areas of the consultant psychiatrists. A third of the consultants hold clinics in general practice and some CPNs are based in health centres.

25. There are 19 multi-disciplinary community mental health teams in Grampian, 9 in Aberdeen City, 7 in Aberdeenshire, and 3 in Moray, but finding (and funding) appropriate premises has been difficult. The focus remains primarily on people with severe and long-term illness. Most of the teams function with strong consultant input to direct patient care, different from the more common model of a multi-disciplinary team under the overall supervision of the consultant. The additional demands of the new Act will mean that consultants will have less time to spend on direct care and the current approach will be difficult to sustain, to the concern of many of the consultants. To redesign the service and change roles and responsibilities will affect everyone and people will require considerable support.

26. Although there is an out-of-hours service, access varies across Grampian, being most limited in Moray. Nowhere provides the 24-hour service requested by users and carers, except through the Accident and Emergency or the Royal Cornhill Hospital. Transport is a particular problem in accessing services and support.

27. Advocacy is a key component of the Act (Section 259). Advocacy Services Aberdeen provides generic services in the City. Advocacy North East provides a generic service in that locality and also includes collective advocacy. Moray Advocacy was established in 2001 and as yet has only 2 workers. None of these services are available for those under 18. In 2002 the Mental Health and Well Being Support Group acknowledged that independent collective and individual mental health advocacy were areas needing attention; developing these areas will be even more important in relation to the Act.

28. In terms of access to work, leisure and training, there is a wide range of services provided by the voluntary sector with more than 50 groups, only a few of which can be mentioned:

• Alford drop-in centre

• Aberdeen Counselling and Information Service

• Marchburn Hostel for younger people aged 18-35

• Aberdeen Supported Housing Project

• Square One social enterprise

• Rehab Scotland

• Branch Out

• Pillar

27. Despite the increasing demands on these services there has been a decrease locally in funding in real terms and this has led to reductions in the number and/or grade of staff. Given the responsibilities of local authorities to provide such support services (Sections 25-27) additional, sustained financial investment will be needed.

28. Priorities of Users and Carers in Grampian

29. The following summarises the key points of the local users and carers:

Aberdeen City (3 meetings)

Users and Carers

• Use Elmhill House as a user-run resource providing function suites, workshops, a place to relax, do gardening etc, with innovative work opportunities (new computers not papier-mâché).

• Create a small safe house and a greater range of drop in services.

• Put more activities and resources on the wards and make observation levels in hospital therapeutic.

• More facilities for young people including in-patient beds.

• More out-of-hours services, with a rapid response to crisis.

• More user and carer run services and initiatives.

• Mental health awareness training for professionals.

• Access to spiritual help.

• Increase young people's awareness of mental health and promote mental health first aid courses/skills.

• Include users and carers on interview panels.

• Provide greater access to independent advocacy.

Aberdeenshire

Users

• Access to holidays - some time out for enjoyment.

• Better education in mental illness for GPs.

• Out-of-hours services and not just crisis based ones.

• Joint working and seamless services are needed.

• Training for people working at the grass roots.

• Stop the division between mental illness and physical disabilities; it seems that if people have both conditions one or the other is ignored.

Aberdeenshire Carers

Meeting 1

• Training for GPs in mental illness.

• Early intervention.

• Challenge stigma and educate people - treat users and carers as human beings.

• See carers as part of the solution, not the problem.

• 24-hour helpline.

Meeting 2: Carers (Eating Disorders)

• Immediate help at first diagnosis - it can alter the outcome.

• Training of GPs about eating disorders.

• Information about illness and help-lines.

• Reduce the waiting time to get help.

• More specialist eating disorder staff.

Moray

Users and Carers

• Access to talking treatments.

• Consultant psychotherapist in Moray.

• More activities in ward 4.

• Long term residential supported accommodation for people with high support needs.

• Alternatives to hospital when in crisis.

• More respite.

• More follow-up for those in the community.

Comments

29. The key challenges that Grampian will need to face in implementing the Act are as follows:

• Recruitment and retention of consultants and service redesign needs to be a top priority. Mental Health Officer posts are under less pressure at present, but MHOs and social work managers need to be included as part of the redesign process.

• There is little spare bed capacity and bed management may come under pressure.

• Independent specialist mental health advocacy needs to be increased.

• Community services need to be developed to ensure equity and allow the least restrictive option of a community-based Compulsory Treatment Order.

• Out of hours and crisis services need to be strengthened with access to community supports.

• Access to child and adolescent beds needs to be ensured and monitored.

Visiting Team

Footnotes

1GRO

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

3 The Mental Health (Care and Treatment) (Scotland) Act Part 17, Chapter 3

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

5 Emergency detention, up to 72 hours

6 Short term detention, up to 28 days

7 Approved by the NHS Board as having special expertise in the diagnosis and treatment of mental disorder

8 Mental Health Officer Services: Structures and Supports. Scottish Executive 2003

9ISD

10 New Horizon - A Joint Endeavour: a Framework for Mental Health Services in Grampian 1998-2004

11 ISD provisional data from SMR04 returns

12 Mental Health & Well Being Support Group Report of Visit to Grampian, 23 April 2003

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