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National Mental Health Services Assessment
Locality Report

LOTHIAN

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. Lothian has a population of approximately 779,000 ¹, (528,560 adults). There are proportionately fewer older people than the national average. Most live in densely populated communities, although a reasonable proportion lives in more remote and rural settings where transport can be an issue. Levels of deprivation and morbidity are overall below the national average, but there are pockets of deprivation especially within some Edinburgh housing schemes.

2. Mental health services are provided by NHS Lothian and four local authorities: East Lothian, City of Edinburgh, Midlothian and West Lothian Councils. They work in partnership with many voluntary agencies and care providers. Edinburgh Primary Care Trust and East and Midlothian Primary Care Trust merged in 2001, which makes some of the long-term calculations complex. West Lothian Healthcare NHS Trust provides both acute and primary care. The Clinical Standards Board for Scotland (CSBS) estimated 1,144 people (16-65 years) with a diagnosis of schizophrenia were being cared for in Edinburgh, East and Midlothian and 300 in West Lothian.

3. The Mental Health and Well Being Support Group (October 2002) noted progress with a transport protocol for mentally disordered offenders, improved recruitment to child and adolescent mental health services and the development of an Integrated Care Pathway for postnatal depression in West Lothian. All of these are directly relevant to the new Act.

4. Lothian is developing a mental health strategy that includes consideration of greater centralisation of hospital sites.

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

6. A larger number of people receive hospital treatment under compulsion in Lothian than the Scottish average. A November 2003 snapshot of the Royal Edinburgh acute wards showed around 40% of patients subject to detention orders. Explanations should be explored though this may not be a simple task.

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

   	Actual number of detentions	No. per 100,000 in Lothian	No. per 100,000 in Scotland
   Sections 24 and 25 3	865/818	111/105	85/90
   Section 26 4	506/483	65/62	51/56
   Section 18 5	218/234	28/30	21/23

8. The estimate of the likely number of Tribunals shown in the following table has been based on the average detention rate over 8 years. These may be underestimates because the trend in the number of detentions has been rising year on year.

9. Table B - Average number of detentions 1994-2002 related to population size and used to estimate the potential number of hearings⁶

   Local authority	Population size	Percentage of Scottish detentions over 8 years	Estimated Tribunal hearings under the 2003 act
   East Lothian	90,750	1.04%	31
   Edinburgh City	448,080	14.70%	443
   Midlothian	80,500	Figures not available	unknown
   West Lothian	159,960	3%	90

10. The Orchard Clinic at the Royal Edinburgh Hospital is currently (December 2003) the only custom-built forensic psychiatric unit and service in Scotland, though others are planned. It provides a 50 bed regional service covering Forth Valley, Borders and Fife as well as Lothian and at existing occupancy levels has the capacity to admit patients from other areas. Delays can arise in finding appropriate step-down placements in continuing NHS care or in highly supported community settings.

11. There are 29 Lothian patients currently in The State Hospital, including two women. Five ⁷ have been waiting for more than 3 months for transfer back to the local services following clinical agreement. Another 2 have been waiting less than 3 months for transfer. One reason for delays arising can be the admission criteria for the Orchard Clinic. The facility does not admit people with a principal diagnosis of learning disability, traumatic brain injury or personality disorder. There is not always a clear distinction because people may have both a learning disability and a mental illness.

12. Accepting The State Hospital diagnosis of the primary mental disorder, there are 3 people with learning disability from Lothian waiting for an agreed transfer. Two people with a learning disability have been waiting for a transfer for more than 12 months. From 2006 under the new Act people can appeal against the level of security and lessons need to be learnt from the experience of the Orchard Clinic when developing similar services across Scotland.

13. 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).

14. Table C - Mental Health Officers in Lothian⁸

    Local Authority	No of MHOs	Practising MHOs	MHOs working in mental health	Additional Payment
    East Lothian Council	9	7	3	No
    Edinburgh City Council	89	69	4	No
    Midlothian Council	9.5	8.5	0	Yes
    West Lothian Council	17	17	5	No

15. There are 101.5 WTE Mental Health Officers working in Lothian (out of 124.5 trained people), which is 13 per 100,000 (the national average is 11.5). They said they felt very stretched already with the pressure of work, partly due to the high detention rate. The additional pressures caused by the Adults With Incapacity (Scotland) Act 2000 were pointed out as was the need for greater convergence with the new legislation.

16. Social workers would welcome the increased responsibilities under the new Act were the implementation accompanied by training and development, to allow MHOs to deliver effective care to people subject to detention orders, given the new extended role and support was available with adequate numbers of staff.

17. There are 71 WTE consultant posts in Lothian covering all specialties and sub-specialties as well as an academic centre and some services are also provided to other parts of Scotland. The vacancy rate for consultants is small and does not include general psychiatry. There are about 20 adult general psychiatrists in Lothian Primary Care Trust and 3 in West Lothian, plus 3 forensic psychiatrists. These levels are considered appropriate.

18. The consultants discussed work-load stress, out-of-hours working and the potential for reduced job satisfaction. An additional concern was the impact were GPs to opt out of out-of-hours work under their new contract. The estimate from the Royal College of Psychiatrists is that about 30 additional psychiatrists will be needed in Scotland to meet the demands of the new Act, in addition to filling current vacancies. Recruitment and retention difficulties should be kept in mind. The consultants in Lothian are examining alternatives and changes to work practice that will be needed for the new Act.

19. Hospital Services

20. Services within the area consist of:

Adult Acute Admission Wards

• Royal Edinburgh Hospital (5 wards, 125 beds)

• Herdmanflat Hospital, East Lothian (19 beds)

• Rosslynlee Hospital, Midlothian (19 beds)

• St John's Hospital, West Lothian (2 wards, 48 beds)

Rehabilitation/ Continuing Care Wards

• Royal Edinburgh Hospital (4 wards)

• Herdmanflat Hospital

• Rosslynlee Hospital

Intensive Psychiatric Care Units

• Royal Edinburgh Hospital (12 beds)

• St John's Hospital, Livingston (12 beds)

Specialist Services

• Orchard Clinic, forensic

• Lothian-wide community drug and alcohol services

• William Fraser Unit, 6 bedded forensic learning disability and 6 dual diagnosis beds

• Robert Ferguson Unit: Acquired Brain Injury Unit

• Department of psychological medicine: Royal Infirmary of Edinburgh and Western General Edinburgh

• Cullen Centre, Edinburgh, eating disorders

• River Centre, post-traumatic stress disorder

• Psychotherapy department, covering Lothian

• Clinical psychology

(Day services are listed under community services, paragraph 21 refers).

16. In 2001-02, 76 Lothian people were discharged from elsewhere in Scotland, and 72 were discharged from Lothian who in turn live in other parts of Scotland ⁹. Some of the out of area admissions to Lothian will be for specialist services, for example the Orchard Clinic, the Young People's Unit and both IPCUs. There is pressure on beds. From May to October 2003 the average occupancy of the acute adult wards in the Royal Edinburgh Hospital was 98%, including pass beds (82% if they are excluded). Average length of hospital stay was 30 days.

17. There were 117 delayed discharges in July 2003, covering all psychiatric specialties (17 adults and 100 older people). Delays affecting older people are the highest in the Scotland and bringing about an improvement is a top priority. New funding has helped open and operate a Transitional Rehabilitation Ward for one year in the Royal Edinburgh Hospital, for adult patients. A multi-agency, multidisciplinary professional team is working with this group to ensure that they are discharged to the community with appropriate levels of support.

18. Table D - hospital bed numbers Lothian and Scotland¹⁰

    Hospital Beds	Lothian Actual beds				Lothian Number per 100,000				Scotland Number per 100,000
    	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
    All psychiatric specialties	1208	1138	1131	1134	157	147	145	146	161	153	145	141
    All adults under 65 years	571	514	474	459	74	66	61	59	74	70	66	64
    Older people	609	586	595	614	79	75	76	79	83	79	74	73
    Forensic services	28	30	50	50 11	*	*	*	*	*	*	*	*
    Adolescent Psychiatry	0	9	12	12	*	*	*	*	*	*	*	*

    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

19. The emergency readmission rate within 28 days in Lothian Primary Care Trust in 2001 was 5.96% and in West Lothian 9.25%, (the Scottish average was 7.27% between 1998 and 2001). More recent figures are not available, but the difference between the two local positions should be examined for any lessons to be learned. The readmission within 28 days was used by the Accounts Commission ¹² in 1999 as a proxy measure for the adequacy of discharge planning and for how well people are being supported in the community.

20. Lothian is only able to provide a partial age-appropriate admission service for adolescents as some 16 and 17 year olds are treated in adult acute admission wards, which will not comply with the new Act. Despite having 12 adolescent beds there is pressure both in terms of maintaining staffing levels and accepting admissions from outside Lothian.

21. There are no dedicated inpatient perinatal services for mothers and babies as will be required by the new Act. A proposal to develop inpatient services for mothers and babies at St John's Hospital is currently under discussion as part of an integrated care pathway.

22. Community Services

23. Community Services in each area include:

Edinburgh

• Five community mental health teams

• Joint mental health programme manager

• Home support services

• Accommodation: residential, supported, housing with intensive support

• Day facilities drop-in, educational, training, art-based, employment

• Respite at Cairdeas House (Penumbra)

• 14 community care teams

• Multidisciplinary community rehabilitation team

• Collective and individual advocacy

Midlothian

• Community rehabilitation service

• Day facility at Bonnyrigg

• Community care teams at Loanhead and Dalkeith

East Lothian

• CPNs attached to primary care

• Community care teams at Haddington and Musselburgh

• Tynepark Resource Centre

• Community rehabilitation Team

• Home support services

West Lothian

• Community care teams at Bathgate, Broxburn and Livingston

• Two joint day services and two health day services

• Supported accommodation, 47 places in four locations

• Independent advocacy

22. Progress with the development of community services varies across Lothian. Some places have a well-developed infrastructure and others need even basic services to be put in place. The South Central Edinburgh sector shares a team with South West Edinburgh, but this is currently being reorganised to allow a team for every sector. East Lothian has a "Network" of community psychiatrist nurses and Midlothian has a community mental health team. Some of these teams do not deliver a seven-day service.

23. The resource centre model, developed in Edinburgh's South East sector at Ballenden House is being replicated across Edinburgh. The centre supports over 200 users on a 7 day a week basis, as well as offering drop-in and home support if required. This model has had a positive impact on both reducing lengths of stay in hospital and number of admissions.

24. There are good examples of voluntary sector organisations providing supported work schemes such as Redhall Walled Garden Project run by Scottish Association for Mental Health, and supported accommodation through Barony Housing, Edinvar and Penumbra, among others.

25. Independent Advocacy services were seen by both users and staff as currently insufficient to meet the demands of the new Act. Lothian has examples of various advocacy services including collective advocacy, and the joint commissioning team is already exploring a plan to address the shortfall in numbers.

26. The response to crisis and out-of-hours cover is currently insufficient.

27. Priorities of Service Users and Carers in Lothian

28. The priorities expressed by users and carers are:

• Edinburgh Users

• Create pathways of care that come into being on diagnosis.

• Carry out more research

• Challenge stigma and educate professionals and the public.

• Change the attitude of professionals

• Provide crisis services

• Open up a range of alternatives to psychiatry and medication.

• Provide more information on what's available.

East Lothian Users

• Transport to get to services

• A chance to get out and about and go on trips and get some variety into life

• Investment in local groups, community facilities and the voluntary sector.

• Employment opportunities with support for people who can't sustain work.

• Make benefits easy to get and not a barrier to normal life.

Carers

• More supported accommodation

• More early intervention and proactive services

• More communication with users and carers and between professionals.

Midlothian Users

• Change the attitudes of some psychiatric professionals.

• Better access to talking therapies.

• More supported accommodation- especially on discharge from hospital.

• Full disabled access to mental health facilities.

• More places such as the Orchard Centre (a drop-in centre with arts and other opportunities)

• More employment opportunities.

Carers

• Investment and money

• Crisis services

• Follow up in the community

• Respite

• Help with physical health

• People with dual diagnosis or learning disabilities need recognised and helped.

• Help with social activities and communication skills

• Training for the police in mental illness.

• Challenge the stigma of mental illness.

• Carer and user led mental health awareness training is effective and important.

West Lothian users

• There is no Patients' Council or service user forum

Carers

• Emergency out-of-hours services.

• Include carers in the process more.

• Rehabilitation and recovery at the user's pace.

Comments

28. Challenges for Lothian when implementing the new legislation are:

• Strategic planning and reconfiguration may occupy time and use resources with the possibility of insufficient attention to the demands of the Act.

• Revising roles and responsibilities for both mental health officers and consultants will require a holistic review of all staff.

• Community services and advocacy are not provided on an equitable basis across Lothian.

• Plans for an admission facility for mothers and babies need to be taken forward.

• The extra demands on local authorities to provide support services will need to be funded.

• Advocacy needs to be developed, including for carers.

• Full 24 hour crisis and out-of-hours support should be made available.

Visiting Team

1 ISD Scotland Lothian NHS Board population figure year ending March 2003

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 Implementation Team, based on the Royal College of Psychiatrists scoping exercise.

7 State Hospital

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

10 ISD

11 Only 30 beds are allocated to Lothian

12 A shared approach Developing adult mental health services. Accounts Commission for Scotland 1999

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