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National Mental Health Services Assessment
Locality Report
SHETLAND
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
The population of the Shetland Isles is about 22,000
1, (14,300 adults). The area consists of 15 inhabited islands with the majority of people living around Lerwick, a town of 10,000. There is also a transient population linked to the North Sea oil and fishing industries.
The proportion of older people is among the lowest in Scotland and levels of deprivation and morbidity are also low. Unemployment on the islands is less than 2% and the Council supports employment opportunities for people with mental health problems with a high success rate.
Mental health is already incorporated in the local Joint Future working between health and social services. There are flexible packages of care based around assessed need. In the past Shetland Islands Council has been well resourced and this is reflected in the good local infrastructure.
Key local priorities are transport and housing, and the Mental Health and Well Being Support Group (2002) also identified the need for attention to older people's and child and adolescent mental health services. The Clinical Standards Board for Scotland (2002) was unable to identify the number of local people with a diagnosis of schizophrenia apart from 4 were admitted to hospital in the last 12 months. CSBS identified that while independent advocacy was available, not everyone knew how to access it.
Use of the Mental Health (Scotland) Act 1984
In 2002-03 there were 21 episodes of detention under the Mental Health Act (Scotland) 1984 in Shetland. On the Scottish mainland comparisons can be drawn by looking at the numbers per 100,000 population, but in the smaller island communities this is not meaningful. There are no patients from Shetland currently resident in The State Hospital.
Although the number of mentally disorder offenders is low, preventive anger management programmes are provided by the local criminal justice system.
Table A - Detentions for all ages in Shetland under the Mental Health Act (Scotland) 1984 in 2001-02/2002- 032
| NUMBER OF DETENTIONS |
Sections 24 and 25
3 | 18/14 |
Section 26
4 | 10/5 |
Section 18
5 | 3/2 |
The estimated number of Tribunal hearings (based on current Sections 26 and 18) has been calculated on the average rate of detentions over 8 years, although this might be an underestimate given that numbers have been rising across much of Scotland. This does not apply to Shetland, where compulsory treatment seems to be reducing. Once again, however, the numbers are too small for this to be a good predictor of the number of Tribunal hearings. The estimated number is very small, with 2 hearings at most.
6
Table B - Estimated number of Tribunal hearings
Local Authority | Population size | Estimated Tribunal hearings under the 2003 act |
Shetland Islands | 21,940 | 2 |
Preparation and participation for Tribunal hearings will add to the workload for all professionals and for Mental Health Officers (social workers) and Responsible Medical Officers (consultant psychiatrists) in particular.
Shetland Islands Council is the largest employer in Shetland. There are only 2 MHOs.
Table C - Mental Health Officers in Shetland Isles7
Local Authority | Approved MHOs | MHOs working in mental health | Additional Payment |
Shetland | 2 | 1 | Can be regraded to senior practitioner |
There is one consultant psychiatrist in Shetland and the service is viewed as "consultant delivered" not "consultant led". If the consultant is on leave or on another island a GP covers for emergencies. There are no Section 20
8 approved general practitioners, but there are plans to develop GPs with a special interest in mental health in order to ensure a sustainable service. The appointment of a staff grade doctor with a special interest in dual diagnosis patients with severe mental illness and alcohol problems is a main priority. New funding has been secured and the post has been advertised, so far (December 2003) without success.
Hospital Services
Shetland has no mental health beds, although some older people with dementia are admitted to the Gilbert Bain Hospital in Lerwick. Otherwise everyone has to travel to the Royal Cornhill Hospital, Aberdeen for inpatient treatment. In 2002-2003, 43 people from Shetland were admitted to Cornhill, 27 adults, 8 older people and 8 with a learning disability. The average length of stay was 19 days, which is much lower than in Orkney, which has a similar population.
The readmission rate within 28 days can be used as a possible indicator of the amount of community support. In Shetland emergency admissions have been steadily reducing.
Table D - Hospital admissions in Shetland for people aged 16/18-64 years9
Adults 16/18 - 64 | 1998 | 1999 | 2000 | 2001 | 2002 |
First admission | 17 | 16 | 11 | 13 | 10 |
Readmissions within one year | 27 | 19 | 18 | 14 | 11 |
For psychiatric emergencies the consultant, in discussion with his Aberdeen colleagues, makes the decision on whether an admission to the Royal Cornhill Hospital is appropriate. Both Shetland and Orkney have had problems in transporting patients by air ambulance to Aberdeen. Some pilots are reluctant to take a patient in a small plane where there is direct access to the cockpit. Time delays occur while waiting for the routine air service. In cases of detention, the nurse escorts come from Cornhill. This process can add to the delays, which are compounded when there is bad weather.
While people are waiting for transport to hospital they can be cared for in the Gilbert Bain Hospital. This is not ideal and causes difficulty for all concerned. Acutely ill psychiatric patients do not fit in well with physically ill people and problems can arise in incorporating the patient within the hospital regime. The mental health service in Shetland provides home nursing as an alternative to hospital admission even for users who maybe acutely unwell and this may help to enable shorter stays in hospital
Most people the visiting team met were realistic about the need to travel to mainland Scotland for many services, even given the inconvenience. In terms of the new Act this applies especially to smaller groups such as mothers with babies. All health visitors routinely use the Edinburgh Postnatal Depression Scale and Shetland is part of the North of Scotland planning group for postnatal depression. Admissions are to the Royal Cornhill Hospital.
Although there are no child and adolescent mental health beds, services have been improved and are provided by a full-time CPN, with a consultant visiting from NHS Grampian 6 times a year for a total of 30 days. Children are admitted to Yorkhill Hospital in Glasgow.
Community Services
Social workers are multi-skilled and share responsibilities given the small population size. There is a 24-hour social work on-call service, a community care team and family support team. All care plans have contingencies about out-of-hours care that are agreed by both users and staff.
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 options for people who have or have had significant mental health problems.
Daytime services and activities have been developed, including a successful employment project and a health promotion and skills centre. There is a job coach system plus a social firm, although access to these opportunities is restricted because of transport problems. There is a supported housing scheme.
The community mental health team (CMHT) is based in the health centre in Lerwick and provides the focus for mental health in Shetland. A Grampian based clinical psychologist used to visit from NHS Grampian although this post became vacant and the service is on an adhoc basis currently. The team comprises nursing, and social work staff, plus the consultant. Currently there is no occupational therapist.
Psychotherapy and other specialist psychological treatments are not readily available because Aberdeen has a long waiting list and the cost of regular appointments would be prohibitive. As a result a range of local counselling services has been developed and is available for users at a local level in seven general practices. There are strong links between the CMHT and the GPs around the islands. The local authority also provides counselling services.
Independent generic advocacy is delivered by Shetland Patients Supporter Scheme and Advocacy Shetland and Advocacy Shetland runs a separate advocacy scheme for carers. There is a draft proposal under consideration for specialist sections in the advocacy project, which will focus on mental health users and carers. There are informal service user networks through local voluntary organisations Shetland Link Up, Depression Alliance or Women of Worth.
Priorities of Users and Carers in the Shetland Isles
The following summarise the expressed views of local users and carers.
It's really good that we'll have rights with the new Act.
We need more social activity for people who can't cope joining in with normal things.
Respite care is good, but shouldn't be in the same place where people live.
Better information for carers is needed and help in getting to hospital in Aberdeen a lot of times to see loved ones in hospital. Video-links might work for some people, but it is scary.
Comments
Key issues that will challenge Shetland when implementing the new legislation are:
The transport difficulties, especially the need to rely on air ambulance services can mean long delays, unsettling for people who are very unwell especially if they are going to be admitted against their will. The local hospital is not ideal for a long wait.
Developing a 24 hour service will be difficult because there is likely to be little uptake, given the small population and distances involved. Creative solutions will need to be found to provide adequate support in the event of a community-based Compulsory Treatment Order being the optimal way of treating someone to allow for local support rather than admission to hospital far away.
Opportunities for respite care need to be available, although the same difficulties may arise about low usage.
Recruitment and development of staff may remain a problem
Visiting Team
Dr Sandra Grant OBE | Project Director
Consultant Psychiatrist/Psychotherapist, NHS Greater Glasgow |
Dr James Strachan | Consultant Psychiatrist, NHS Lothian |
Footnotes
1 General Registry Office
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
7 MHO Services Structures and Supports, The Stationary Office 2003
8 Medical practitioners approved by a health board as having 'special experience in the diagnosis or treatment of mental disorder'
9 ISD provisional data from SMR04 returns
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