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National Mental Health Services Assessment
Locality Report

GREATER GLASGOW

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 Full 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. Greater Glasgow has a population of about 866,000 ¹ (577,511 adults) living mainly in densely populated urban areas. There are 136,580 older people, (a lower proportion than the national average). The estimated number of people with a diagnosis of schizophrenia is 1,980 ². Levels of deprivation and morbidity are very high.

2. Six local authorities provide social work services to the NHS Board area: East Dunbartonshire, East Renfrewshire, Glasgow City, North Lanarkshire, South Lanarkshire, and West Dunbartonshire. Only Glasgow City and East Dunbartonshire are totally within the boundaries of NHS Greater Glasgow. Within the Greater Glasgow area, mental health services are organised into 3 sectors, East and North, South and West. Necessarily much of the information contained in this report reflects information for the Greater Glasgow NHS area and is not always disaggregated to local authority areas, 4 out of the 6 of which relate to other areas also.

3. Greater Glasgow has pioneered the move towards community care and intermediate forms of care in Scotland. An ambitious 5 year strategy is being implemented, replacing old hospital buildings with modern, purpose built inpatient facilities, while community services are being improved and extended. This strategy involves 17m of growth funds to leverage service redesign through the redirection of the totality of the 100m expenditure locally on mental health. The Mental Health and Well Being Support Group (2002) stated that the positive position in Greater Glasgow was the result of a decade of work to replace hospital-based care with services provided in local communities. NHS Greater Glasgow, Glasgow City Council and Greater Glasgow Primary Care Trust are undergoing service redesign towards an integrated community network

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

5. The detention rates in the table are for the NHS Greater Glasgow area only, given difficulties in disaggregating numbers for the separate local authorities, when 4 relate to other NHS areas also. On the basis of the available information the forecast number of Tribunal hearings is in the region of 543 per year. ³ An added burden on local authorities is the duty to find accommodation etc for Tribunals.

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

   	No. of detentions in Greater Glasgow	No. per 100,000 people in Greater Glasgow	Average number per 100,000 people in Scotland
   Sections 24 and 25 5	1030/935	119/108	85/90
   Section 26 6	649/562	75/65	51/56
   Section 18 7	208/191	24/22	21/23

7. In addition to local services, there are 76 patients resident in The State Hospital, 9 of who are waiting agreed transfer back to Greater Glasgow. A further 5 have been referred for pre-transfer assessment to local Greater Glasgow services. Those 14 patients represent around 32% of the current State Hospital "ready for transfer" list. Greater Glasgow has made progress in speeding up transfers from The State Hospital to Leverndale Hospital for people needing lower levels of security, but generally there remain delays for some, especially female patients.

8. A major recent success has been receipt of planning approval for the construction of a Local Forensic Psychiatric Unit (LFPU) at Stobhill Hospital. Work is expected to start in Spring 2004 and the Unit and service should be fully operational by 2006, in time to respond to the new appeals against the level of security allowable under the new Act.

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. There are 85 consultant psychiatrists in Greater Glasgow and 5 vacancies. There are 97 doctors currently approved under Section 20 of the 1984 Act as having special experience in the diagnosis and treatment of mental disorder. The need for service and job redesign, which will have an impact on the whole service, is well understood by the consultants, despite major concerns about the extra workload.

11. Table B - Consultant psychiatrists and Section 20 doctors in Greater Glasgow

    Consultant specialty	No. of WTE consultants	Section 20 approved
    General adult	50.6	52
    Old age	12.2	14
    Psychotherapy	4.6	6
    Forensic	6	7
    Substance misuse	6.6	6
    Learning disability	6.1	7
    Adolescent psychiatry	5.2	5

12. The 6 local authorities have 107 Mental Health Officers working in Greater Glasgow, although only 24% currently work within a mental health setting. Enhanced salaries as a recruitment incentive are offered by 2 local councils and additionally Glasgow City has now developed plans to enhance both salaries and the attractiveness of job roles. Recruitment and retention of MHOs is a major problem and social workers are finding it increasingly difficult to carry out MHO duties at the same time as managing the other social work tasks.

13. Table C - Mental Health Officers in Greater Glasgow 2003

    Local authority	No of MHOs	Practising MHOs	MHOs in mental health	Additional payment
    East Dunbartonshire	7	7	3	No
    East Renfrewshire*	5	5	0	No
    Glasgow City	79	51	15	No
    North Lanarkshire*	6	5	2	No
    South Lanarkshire*	7	7	3	Yes
    West Dunbartonshire*	5	4	4	Yes

    *MHO figures reflect the active MHOs in that area, with additional social workers covering neighbouring NHS Board areas not appearing in these totals.

    Hospital Services

14. The current hospital services are arranged as follows:

Thirteen acute admission wards

• 3 at Stobhill Hospital

• 3 at Parkhead Hospital

• 3 at Gartnavel Royal Hospital

• 2 at Leverndale Hospital

• 2 at the Southern General Hospital

Four Intensive Care Units

• Stobhill Hospital

• Parkhead Hospital

• Gartnavel Royal Hospital

• Leverndale Hospital

Rehabilitation services

• Leverndale Hospital

• Gartnavel Royal Hospital

• Phoenix House

Continuing care

• Ruchill Hospital

Liaison psychiatry services

• Glasgow Royal Infirmary

• Stobhill Hospital

• Victoria Infirmary

11. The construction of a new 15 bed addiction inpatient unit at Stobhill has begun, which will replace existing addiction beds at Ruchill and Parkhead Hospitals. This will provide new, purpose built accommodation for people with a drug or alcohol problem.

12. Plans are also being taken forward to develop a specialist inpatient facility at the Southern General Hospital for mothers who experience mental illness after the birth of their child, to be admitted with their baby. This will meet requirements within the new Act and there will also be beds available for admission from elsewhere in Scotland as part of a managed clinical/care network.

13. Table D - Adult acute beds in Greater Glasgow October 2003⁸

    Sector	No. of beds	Average no. of admissions a month	Average length of stay
    North	60	57	34.3 days
    East	76	71	38.2 days
    West	68	84	25.8 days
    South	110	96	35.9 days
    Total	314	308	33.5 days

14. Greater Glasgow has a good internal bed management system and is also able to admit people from elsewhere when required. In the year ending March 2002, 135 people (all mental health specialties) were discharged back to other areas and 18 people with a learning disability ⁹.

15. Table E - Use of Intensive Psychiatric Care Units¹⁰

    Sector	Beds	Average length of stay	Average no of admissions Per month
    North	6	29 days	7
    East	5	24 days	7
    West	12	40 days	10
    South	12	50 days	11
    Total	35	36 days	35

16. The emergency readmission rate for adults within 28 days of discharge in 2001, the last figure available, was the highest rate in Scotland at 10.34%, (the Scottish average was 7.27% over the years 1998-2001). This is probably linked to the high levels of deprivation, but Greater Glasgow has well-established community services both within the statutory and voluntary sector, so this should be monitored when more up to date information is available.

17. Table F - Hospital admissions and readmissions in Greater Glasgow for people aged 16-64 years¹¹

    	1998	1999	2000	2001	2002
    First admission	1088	1110	1124	1048	739
    Readmission within one year	2807	2750	2957	3073	2914
    Readmission rate within 28 days	11.19%	11.68%	11.93%	10.34%	n/a

    Readmission rate= (emergency readmissions/discharges) x100

18. Beds for all psychiatric specialties in Greater Glasgow (150 per 100,000 population) are 9% above the Scottish average (141), although hospital bed numbers for all specialties have shown a reduction of 139 beds over the period 2000-2003. Forensic beds have increased by 64.7%. Older people's beds have reduced but the rate per 100,000 but still remain 5% higher than the national average.

19. While the number of hospital beds for child and adolescents remains low, Greater Glasgow's figures account for over 45% of child and 19.5% of adolescent national bed provision. Innovative community services for young people have been developed with The Parry Jones service, providing treatment for young people with anorexia.

20. Table G - Hospital bed numbers Greater Glasgow and Scotland¹²

    Hospital Beds	Greater Glasgow Actual staffed beds				Greater Glasgow Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	1440	1442	1338	1301	161	166	154	150	161	153	145	141
    All adults under 65 years	643	603	578	548	74	70	67	63	74	70	66	64
    Older people	745	786	701	676	85	91	81	78	83	79	74	73
    Forensic services	33	34	36	51	*	*	*	*	*	*	*	*
    Child Psychiatry	8	9	10	10	*	*	*	*	*	*	*	*
    Adolescent Psychiatry	10	10	14	16	*	*	*	*	*	*	*	*

    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

    Community Services

21. Sections 25 and 26 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 has to complement the core treatment services, although increasingly care and treatment services are becoming aligned.

22. Community services for adults in Greater Glasgow include 16 community mental health teams, 2 day hospitals and a community rehabilitation unit. Additionally each sector has a range of intermediate services that fulfil functions of assertive outreach, home treatment and early discharge/ alternative to admission. However the balance of these functions is variably developed with no area having all of these components of service delivery in place leading to inequitable access to such supports. The East Sector has an assertive outreach team, a homeless team, and a team specialising in helping people with both a mental illness and a drug or alcohol problem.

23. There are several examples of new building projects including the Stewart Centre in Castlemilk, which opened in 2002 to provide a community mental health base. More recently the construction of the East City Centre Resource Centre will replace 3 resource centres in East Glasgow.

24. Primary Care Mental Health teams continue to be established and are already in place in Anniesland, Bearsden and Milngavie, Riverside/Westone, Eastern and Maryhill/Woodside. These teams provide treatment and advice to people suffering mild to moderate mental heath problems such as anxiety or depression and offer a range of therapies and social support.

25. Greater Glasgow's strategy for supported employment was agreed in 2001 and is led by a multi-agency task group. ' Building Pathways to Employment' was set up to take forward the plans presented by mental health users and last year a Mental Health Employment Co-ordinator post was established to oversee this, initially within the Govan area of Glasgow.

26. To ensure that the voice of users and carers is central to the planning process funding was released to establish the Mental Health Network. This service user network functions independently of health/social work structures and has members in many planning groups to advise on the needs and views of relatives and carers and report back on progress with the modernising agenda. A network of local user groups has also been established across the city to ensure that their views are represented consistently across all the care groups. Some service users in the Rutherglen/Cambuslang area also link in with "Lanarkshire Links" an area wide service user and carer organisation.

27. Advocacy Matters offers advocacy services for patients using hospital and community mental health services across Glasgow with a base in each psychiatric hospital. The aim is to assist people to have more say in the treatment they receive and to obtain information to allow them to make more informed choices. The service is managed independently by Glasgow Association for Mental Health and is funded from the NHS board, social work and the primary care trust. Other examples of independent advocacy projects include joint funding between South Lanarkshire Local Authority, NHS Greater Glasgow and NHS Lanarkshire using Mental Illness Specific Grant in the case of the Advocacy Project in Rutherglen/ Cambuslang. Independent advocacy services will need to be increased considerably to meet the demands of the new Act.

28. Greater Glasgow has about 300 supported accommodation places consisting of a range of registered and unregistered schemes. As part of the Modernising Mental Health agenda and to assist with the further shift in balance from hospital to community care, the NHS board, local authorities, primary care trust and representatives of the voluntary sector will implement a strategy for homelessness services for Greater Glasgow. A further 54 places will be commissioned over the next 3 years.

29. The NHS and Glasgow City Council's social work services provide a range of specialist services for homeless people, most of which have been established since 2000. In brief, they comprise:

• A multidisciplinary Homeless Addiction Team that provides medical, social work, occupational therapy and psychological services for homeless people with addictions and alcohol problems, serving mainly the city centre population.

• Homeless Mental Health Services (community psychiatric nurses plus a consultant psychiatrist) undertake outreach work linked with inpatient beds at Parkhead Hospital.

• A nurse-led Homeless Physical Team provides health services for hostel dwellers and other homeless people, again principally within the city centre.

• All homeless families who present to Glasgow City Council are referred to Glasgow's Homeless Families Team, which includes health visitors and a GP.

• A new GP practice for homeless people with two doctors opened in early 2003, to provide a full range of health and allied health services including physiotherapy, addictions services and podiatry.

26. Out-of-hours services are accessed through NHS 24 then passed to a duty CPN working with GEMS, the out-of-hours GP service. Other people will call upon the duty social work service. Despite this support for both medical and social emergencies it is felt to be insufficient by some service users and some staff.

27. Greater Glasgow has well established community services that should help minimise crises out-of-hours, although the complex and multiple channels into these services confuses some GPs. Better links and information on mental health emergency responses may assist those in crisis to gain access to a CMHT.

28. Priorities of Service Users and Carers in Greater Glasgow

29. The key issues that were expressed were as follows:

Meeting 1, Users

• There is a need for communication with professionals in a way that means they deal with the questions we need to ask instead of the ones they think we should ask.

• There is a need for needs-led services responsive to users

• Quality of life needs improving.

• Increase user-led employment services.

• Treat users with more respect and courtesy.

• Listen to users.

• Provide places where users can find comfort.

• Stop professionals patronising users.

• Clarify what professionals are meant to do.

• Make a distinction between distress and mental illness.

Meeting 2, Users

• Provide more services in remote areas.

• Provide more outreach to people who are becoming unwell.

• Give more recognition to the importance of mental illness and mental health.

Meeting 3, Users and Carers

• Challenge the attitude of the public and professionals.

• Get planners and decision makers to come to talk to us and really listen.

• Give more financial priority to mental illness.

Meeting 4, Carers

• Research into mental illness

• More investment, including investment for carers.

• Demonstrate care for carers.

Comments

29. Key issues that will challenge Greater Glasgow area when implementing the new legislation are as follows:

• Independent advocacy needs to be increased.

• Implementation of the plans for a local forensic psychiatric unit and mother and baby unit, which comply with the demands of the Act, will occupy time and resources and will additionally require capacity for throughput beyond the secure beds. There may additionally be a need to fund extra contractual referrals to meet the requirement to ensure access to placements for entrapped patients, pending the phased operational development of the full capacity of the local forensic psychiatric unit and service.

• There will be pressure on Greater Glasgow's adolescent beds as other NHS Board areas look to ensure age-appropriate admission services.

• Service redesign and workforce development will be a top priority and difficult given the large size of the organisation

• Although community services are relatively well developed, there remain gaps in their comprehensiveness in terms of crisis resolution and assertive outreach. This will need to be further developed if the principle of reciprocity is to be appropriately applied in community settings and to allow the option of community-based Compulsory Treatment Orders.

• The development of social care services in relation to Sections 25 and 26 of the Act are patchy, although there are significant examples of good practice. Given the degree of deprivation in Greater Glasgow a comprehensive and strategic approach will be needed to meet the extra demands of the new Act.

• The opportunity cost of time in relation to psychiatric input to the Tribunal process will detract from the capacity for psychiatric input to local service delivery. It is also possible that Greater Glasgow psychiatrists may be called upon to contribute frequently, given vacant consultant posts elsewhere, and this could further exacerbate the costs to delivery of local services.

• Subsequent to the visit of the review team there is also concern that existing planned mental health commitments may be vulnerable given the overall financial position of the Board, and that such changes may impact on the Greater Glasgow position in relation to readiness to implement the Act.

Visiting team

Footnotes

1 Greater Glasgow NHS Board

2 Quality Improvement Scotland. Clinical Standards Board for Scotland, Schizophrenia Standards report.

3Scottish Executive, based on the Royal College of Psychiatrists' scoping exercise.

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

5Sections 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 Information provided by Greater Glasgow Primary Care Trust

9 ISD

10 Information supplied by Greater Glasgow Primary Care Trust

11 ISD provisional data from SMR04 returns

12 ISD

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