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National Mental Health Services Assessment
Locality Report
WESTERN ISLES
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
Eileanan Siar (the Western Isles) lies 30 miles off the West coast of Scotland, with a population of 26,200 (16,400 adults) living on 11 islands, in a straight geographic 125 miles long. The population has the lowest proportion (63%) of adults of working age in Scotland, so the number of older people has a significant impact on services. The main centre of population is Stornoway (10,000 residents).
The population is scattered throughout the area making transport a major issue for the provision of services. Despite this, most reviews have been positive about the quality of care. In 2001 the Scottish Health Advisory Service praised the quality and approach of staff, the work of the
I Reach Project, and the Fast Action Support Team (FAST) which addresses joint working between health and social work. The Mental Health and Well Being Support Group highlighted the significant progress in the development of local services provided by voluntary organisations as well as service users and carers.
The 2002 Clinical Standards Board for Scotland (CSBS) review of compliance with the first tranche of its standards for the treatment of schizophrenia reported that there were 62 people with schizophrenia in the area currently receiving treatment. Several standards had been met fully (more than in many places elsewhere in Scotland). These included a guideline for initial diagnosis with a full range of investigations, alignment of general practices with community mental health staff, involvement of carers, documentation of prescription changes, social work notification of respite care needs and a local social inclusion programme. People are routinely assessed about the use of alcohol or illicit drugs.
Strategic planning is carried out by the multi-agency Western Isles Mental Health Partnership, which was originally established to implement the Framework for Mental Health Services in Scotland. The Partnership includes representatives from the local authority, NHS Board, voluntary agencies and service user and carer groups.
There is one admission ward in the Western Isles Hospital in Stornoway.
Use of the Mental Health (Scotland) Act 1984
Given the population size, the number of people being treated on a compulsory basis is small; nevertheless the trend, as elsewhere in Scotland, is upward. (Comparative rates per 100,000 people cannot be shown given the small numbers). The introduction of the Adults With Incapacity (Scotland) Act (2000) has led to increased requests for Guardianship Order applications, which has increased the workload for MHOs. An independent consultant will provide local training on the joint application of both Acts. Some additional training for the Mental Health (Care and Treatment) (Scotland) Act 2003 will take place locally and will in part be in conjunction with Highland Region.
Table A - Detentions in the Western Isles under the Mental Health Act (Scotland) 1984 in 2001-02/2002-03
1
| No of detentions in the Western Isles |
Sections 24 and 25
2 | 16/20 |
Section 26
3 | 5/7 |
Section 18
4 | 0/2 |
The new Act will put pressure on all services, especially given the small number of staff working in relative isolation. There are 5 Mental Health Officers, 4 of whom have been active in the last 12 months and the other will be shortly, having transferred from the English system. None of them work in the mental health field specifically, although all use mental health skills in their generic work. The increased casework role that the new Act will bring means that more formal supervision and support will be needed, in addition to local and Highland MHO forums.
A review of the MHO services in the Western Isles has been completed with the aim of identifying gaps and ways to make the service as effective as possible. A dedicated Mental Health Senior Practitioner has been proposed and would be welcomed by the MHOs. As part of a temporary restructuring of the social work department a MHO co-ordinator has been appointed and she will oversee the implementation of the new Act in the Western Isles.
Table B - Mental Health Officers in the Western Isles
Local Authority | No of MHOs | Practising MHOs | MHOs working in mental health | Additional payment |
Comhairle Nan Eilean | 5 | 4 | 0 | No |
There are 2 consultant psychiatrists based in Stornoway, one working mainly with older people and people with a learning disability. None of the GPs are approved under Section 20 of the Mental Health (Scotland) Act 1984 as having special experience in the diagnosis and treatment of mental disorder. The aim of the new Act is to minimise emergency detentions and ensure that a person is seen as soon as practicable by an experienced doctor in order to initiate a short-term detention. The practicability of one of the consultants travelling to the southern islands to do this will provide real challenges.
Hospital Services for Adults
The hospital services for adults are as follows:
(The ward is also the base for a day service, providing some activities).
The 10 year old general hospital has 6 psychiatric beds, all in single rooms. This makes it possible to admit people of all ages including adolescents and older people with a functional (non-organic) illness. This will not be possible under the new Act because age-appropriate services will be required for adolescents, meaning that it will be necessary to send them for their care to the mainland. However, in the last 5 years only 2 people under the age of 16 have been admitted. Mothers with a perinatal mental illness needing inpatient care will also have to travel elsewhere for specialist treatment. An Integrated Care Pathway for postnatal depression is under development. In the years ending in March 2001 and 2002, 19 and 13 people respectively were placed out of the area as inpatients. It is not appropriate that adolescents receive inpatient treatment in an adult ward and regular arrangements need to be made for provision of services on the Scottish mainland when required. The same principle applies to mothers and babies.
In June 2003 there was one recorded whose delayed discharge from the ward for older people. In practice, the ward functions partly as a continuing care unit for a few people because there is no care home on the islands providing the necessary skilled nursing care.
A major problem in providing the service is the delay incurred while waiting for an air ambulance and escort.
Table C - Hospital admissions in the Western Isles for people aged 16/18-64
5
Adults 16/18 - 64 | 1998 | 1999 | 2000 | 2001 | 2002 |
First admission (i) | 15 | 10 | 22 | 19 | 12 |
Readmissions within one year (ii) | 81 | 24 | 68 | 69 | 64 |
Transfers (iii) | 2 | 2 | 3 | 7 | 2(p) |
(i) First ever recorded admission to psychiatric inpatient care
(ii) Readmission following a break in inpatient care
(iii) Transfers between consultants or to another hospital
P - Provisional figure only
Community Services
There is a community mental health team dispersed throughout the islands with GPs, social workers and community psychiatric nurses. Two social workers are based in Stornoway, the others in the southern Islands. Outpatient clinics are held in Barra with a locally based social worker and visiting CPN. While there are no clinical psychologists, cognitive behavioural therapy is provided by a nurse.
The creative
I Reach project, originally funded by the Mental Health Development Fund, aims to ensure that adults with severe and enduring mental illnesses receive innovative types of social support to enable them to live as independently as possible. The focus is very much on identified need and practical support for people in rural communities. The Western Isles Association for Mental Health brings together several service user groups.
A number of voluntary organisations work together; for example Crossroads and Alzheimer's Scotland provide joint services in Uist and Barra. There are sub-groups of the Western Isles Mental Health Partnership. An example is the Choose Life multi-agency steering group which has developed a Suicide Prevention Action Plan.
There is an on-call social worker and CPN rota and NHS24 will be available shortly. Penumbra provides an outreach service. Getting local help is very difficult in the more isolated places and out-of-hours services need to be developed further.
At present only generic advocacy services are available, provided by volunteers under the supervision of an advocacy co-ordinator in Lewis. There are plans to develop similar opportunities in Barra and some mental health specialist advocacy services with the new money allocated to the local authority to prepare for the new Act.
Priorities of Users in the Western Isles
The expressed priorities of local users are as follows:
Make sure that hospital provision is large enough to stop people having to leave the island for services.
To consider the provision of grounds to allow people to walk in relative privacy.
There is a need for a culture change that recognises that mental illness and mental ill health affects everyone.
There is a need for more education about mental illness; especially for those people that others may turn to for help, such as ministers.
There is a need for a facility for people to recuperate, for either when they are getting better or to escape to when they are feeling ill.
Comments
Key issues that will challenge the Western Isles when implementing the new legislation are as follows:
With such dispersed population it will be difficult to provide the level of local community supports and 24-hour care necessary to permit a community-based Compulsory Treatment Order.
Although the number of detentions is small, the extra time commitment to initiate short-term detentions and prepare for, and attend, Tribunals will place significant pressure on the consultants. Consideration should also be given to developing GPs with a special interest in mental health.
The MHO services will also be stretched and the number of MHOs will need to be increased, preferably to include a person who works within the mental health field and who can give training and support to colleagues.
Generic advocacy services are insufficient and mental health advocacy will need to be developed further.
Visiting Team
Dr Sandra Grant OBE | Project Director Consultant Psychiatrist/Psychotherapist, NHS Glasgow |
Footnotes1 Mental Welfare Commission Annual Reports 2001-02/2002-03
2 Sections 24 and 25 are emergency sections lasting 72 hours
3 Section 26 is a 28 day order that can be used when an emergency section has expired
4 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court
5 ISD data from SMR04 returns
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