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National Mental Health Services Assessment
Locality Report

LANARKSHIRE

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. Lanarkshire has a total population of approximately 552,900 (214,400 adults in North Lanarkshire and 199,800 adults in South Lanarkshire ¹). Most are resident in towns with high levels of deprivation and morbidity in comparison to the rest of Scotland. Mental health services are provided by NHS Lanarkshire and two local authorities, North and South Lanarkshire Councils, working with a wide range of voluntary organisations and care providers.

2. The council areas are not coterminous with Lanarkshire health services, as both local authorities also cover parts of the NHS Greater Glasgow Board area.

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

4. Compulsory hospital admissions are lower in Lanarkshire than elsewhere. The reasons need to be examined as part of local preparations for the new Act. If local residents have access to adequate, appropriate and acceptable treatment on an informal basis then this is to be welcomed. The availability of developed community services will have an impact, and any such correlation should be carefully checked and also considered in terms of inequities in access to community services.

5. Table A - Detentions in Lanarkshire under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03²

   	Actual number of detentions in Lanarkshire	No. Per 100,000 in Lanarkshire	No. per 100,000 in Scotland
   Sections 24 and 25 3	270/392	49/71	85/90
   Section 26 4	149/226	27/41	51/56
   Section 18 5	66/72	12/13	21/23

6. Low application of emergency detentions will not necessarily reduce the anticipated extra workload with the new Act. The workload will be increased mainly by the Tribunal process, which is linked to Compulsory Treatment Orders. These are roughly equivalent to the current Section 18 and in Lanarkshire the figures for detentions under this Section are more in line with the national average.

7. There are 13 Lanarkshire patients in The State Hospital, two of whom are waiting to return to local services. Agreement to return has been reached for one person, who is subject to a restriction order. The other is waiting assessment by Lanarkshire services. No Lanarkshire patient detained at The State Hospital has been waiting for more than 3 months, an impressive record given the current lack of a local forensic psychiatric unit and service. This should be considered in the context that, from 2006, patients will have access to an appeal against the level of security in which they are being held.

8. The use of the Intensive Psychiatric Care Unit as a step-down facility is however not the best alternative to dedicated forensic beds, especially since the layout of the ward is on 3 floors, making observation difficult. The internal design is less than welcoming. The location and number of forensic beds and services in Scotland is currently under review.

9. Table B - Estimated number of Tribunal hearings⁶

   	Estimated no. of Tribunals
   Lanarkshire NHS Board	196 - 203
   North Lanarkshire Council	42
   South Lanarkshire Council	136

10. Added pressures will fall primarily on consultant psychiatrists and Mental Health Officers, although there will be stress on administration and advocacy services also. There are 18 WTE consultant posts in general adult psychiatry but of these 8.9 WTE are currently unfilled (except for one locum). This is nearly a 50% vacancy level, creating a major problem in terms of optimum provision for the population size.

11. Current staff shortages make it difficult to provide a full range of services now, and these difficulties will be compounded when the Act is implemented. There is an overall shortage of consultant general psychiatrists in Scotland and neighbouring NHS Boards have better resources and community infrastructure in place, which is helping them to attract staff more easily. Added investment needs to be put into other disciplines and grades of multidisciplinary staff to free up more consultants' time, including (but not limited to) administering the Act.

12. Approximately 1 in 6 of the MHOs employed by both Councils work in Glasgow, although the workload for MHOs employed by North Lanarkshire is negligible. There are 9.2 MHOs per 100,000 of the local population, which is lower than the national average (11.5 per 100,000) and recruitment and retention will need to be a continued priority to meet the new legislative demands. Most of the trained MHOs continue to carry out MHO functions, so there will be an experienced group of people to help with the transition to the new Act. This is offset by the fact that less than half currently work in mental health settings and will need considerable updating on current mental health practice in order to carry out such duties as presenting care plans to the Tribunal.

13. Table C - Mental Health Officers in Lanarkshire⁷

    Local authority	No of MHOs	Practising MHOs	MHOs working in mental health	Additional payment for MHOs
    North Lanarkshire	35	28	10.5	No, but can regrade to Senior Practitioner
    South Lanarkshire	28 (including 7 working at The State Hospital)	21 (+5 working at The State Hospital)	11	Yes

    Hospital Services

14. Hospital services are arranged as follows:

Six acute adult admission wards

• two at Monklands Hospital (Monklands/Cumbernauld Sector), 48 beds

• two at Hairmyres Hospital (Hamilton/East Kilbride Sector), 50 beds

• two at Wishaw Hospital (Motherwell/Clydesdale), 46 beds

One Intensive Psychiatric Care Unit

• Hartwoodhill Hospital, 22 beds

Brain Injury Unit

• Hartwoodhill, 24 beds

Three rehabilitation units

• Caird House (10 adult beds)

• Coathill Hospital (10 Beds)

• Airbles Road Centre (10 Beds)

Three continuing care wards

All at Hartwoodhill Hospital (90 beds for adults)

Liaison Psychiatry Service

• Monklands Hospital (nursing)

• Wishaw General Hospital (nursing +0.5 WTE Consultant - vacant post)

Day Hospitals

• Monklands

• Hairmyres

• Wishaw General (one third of attendees are on Section 18)

11. There are 788 beds in Lanarkshire for all psychiatric specialties, which is the sixth lowest ratio in Scotland. In the last 3 years 31 beds for adults (16-64) have closed leaving 307 beds for this service, 164 of which are for acute admissions (not including the IPCU, which is reported as a forensic service).

12. Following ward closures in October there are now 409 beds for older people, 142 contracted directly from nursing homes.

13. Table D - Hospital bed numbers Lanarkshire and Scotland⁸

    Hospital Beds	Lanarkshire Actual beds				Lanarkshire Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	832	829	787	788	150	150	142	138	161	153	145	141
    All adults under 65 years	338	336	318	307	61	61	58	56	74	70	66	64
    Older people	474	472	449	409	86	85	81	74	83	79	74	73
    Forensic services/IPCU	20	20	20	20	*	*	*	*	*	*	*	*

    Adult beds include acute admission, rehabilitation and continuing carebut not IPCU which is listed as forensic. The forensic/IPCU beds were reduced to 15 at the time of the visit.

    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

    Table E - Hospital admissions for people aged 16/18-64⁹

    ADULTS 16/18 - 64	1998	1999	2000	2001	2002
    First Admission	275	384	556	594	368
    Readmission within one year	954	1,302	1,234	1,256	985
    Readmission rate within 28 days	1.63	0.42	2.88	5.84	N/A

14. Between 1998 and 2001 the number of first admissions more than doubled, but reduced again last year, although not back to the 1998 level. A similar pattern occurred for readmissions within one year. The rate of emergency readmissions within 28 days has gone up to 5.84%, a significant figure possibly due to lack of adequate discharge and after-care arrangements. It remains, however, significantly below the national average of 7.27% ¹⁰. It is important that these fluctuations in the pattern of hospital admission and readmission be understood where possible in the context of the contribution to be made through community care developments.

15. In July 2003 there was a relatively low number of delayed discharges, 5 adults and 16 older people. There has been a joint appointment between health and the local authority on the acute wards to facilitate this and is an example that could usefully be followed elsewhere.

16. Community Services

17. The Modernising Mental Health Services Implementation Project Board is decentralising secondary care services and investing in further community resources. Community services at present include 8 multidisciplinary community mental health teams and they are being reconfigured and developed into resource networks that include an outreach team, focused intervention team, social support and joint assessment and care management.

18. The plan is to have a flexible range of services less concentrated on particular buildings. Resource networks were established in Wishaw and Motherwell in 2000 as well as in Cumbernauld and Clydesdale. Networks started up in Airdrie and Coatbridge LHCC areas are not developed as far as had been planned because of resource constraints. There is considerable inequity within Lanarkshire for access to adequate community services. The inequity should be addressed as part of the 2003/04 investment in Community Services.

19. There is also a resettlement team to assist with the discharges of longer stay residents from the continuing care wards in Hartwoodhill Hospital.

20. A high priority is to improve services for individuals outside working hours and for those in crisis. Funds will be made available, with local acknowledgement that improved services are needed for both health and social emergencies. There is 24-hour social work and MHO cover through the West of Scotland SW Standby Service. Lanarkshire Association for Mental Health also provides some out-of-hours support. CMHT cover is currently restricted to weekdays, 9am to 5pm, with out-of-hours support given by GPs, Accident & Emergency departments or the duty psychiatrist. The development of 24-hour support in a range of settings will be necessary to implement the Act and make community-based Compulsory Treatment Orders possible.

21. Access to psychological interventions remains patchy. Although there has been investment in training nurses and some allied health professionals, it was reported that few people stay to carry out this work, either because they transfer elsewhere or move on promotion. Only 3 CPNs have any formal training, by attachment to the psychology or psychotherapy departments or by attendance at Caledonian University. Lanarkshire has achieved near universal access to counselling services..

22. There are no specialist facilities locally for admission of adolescents or mothers with babies and arrangements will need to be made to ensure that services are available, perhaps as part of a managed clinical network.

23. There are 2 advocacy organisations, and an advocacy café goes fortnightly to care of the elderly wards. Although the statutory services in Lanarkshire spend 1.35 per head on advocacy, against a Scottish average of 1.23, this will need to be developed further before the Act is introduced.

24. There is a range of voluntary organisations including Lanarkshire Association for Mental Health and service users groups such as the Patients' Council. A 'Connections' project works with people who are homeless or at risk of homelessness on leaving acute psychiatric care (North Lanarkshire Council area) and 'Reach Out' supports the children of people who are ill.

25. Priorities of Users and Carers in Lanarkshire

26. The following summarises the points made by the local users and carers:

• More staff - with consideration given to the balance between support workers and psychiatrists.

• More investment.

• Prevention.

• Care Pathways so that when people get ill they know what to expect and what help they can get.

• Services that emphasise normal life rather than illness.

• More user-led and managed services.

• Use the Care Programme Approach more widely to cater for relapse and to help more people.

• More recognition of advance statements.

• Person-centred planning.

Comments

24. Lanarkshire faces serious challenges in being ready to comply with the Act, including:

• The high vacancy rate in general adult psychiatry is serious and requires imaginative ways to redesign services and review job roles and responsibilities.

• Community services are lacking in several parts of the service including Hamilton and East Kilbride.

• There is no current access to dedicated medium and low secure units, although Lanarkshire is part of the West of Scotland Consortium planning such services.

• The function of the Intensive Psychiatric Care Unit and its environment needs to be reviewed.

• Inpatient services for children and adolescents, and mothers with babies are not available locally.

• Advocacy services need to be developed further.

Visiting Team

Footnotes

1 ISD Scotland

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

3 Emergency detention for up to 72 hours

4 Short term detention for up to 28 days

5 Long term detention for up to six months

6 Scottish Executive/Royal College of Psychiatrists. This is a very rough estimate and the numbers do not add up, due to rounding up of figures and problems with calculation when areas are not conterminous.

7 Mental Health Officer Services: Structures and Supports, Scottish Executive, 2003, Information corrected locally.

8 ISD

9 ISD provisional data from SMR04 returns. Discrepancies are due to rounding up numbers.

10 ISD. Latest data (2001)

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