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National Mental Health Services Assessment: Final Report

1. INTRODUCTION

Remit

1.1 The Mental Health (Care and Treatment) (Scotland) Act 2003 was passed in April 2003 and will be implemented by April 2005 (apart from the right to appeal against the level of detention, which does not come into force until the following year). The new legal requirements will put pressure on already hard pressed services and concerns were raised in Parliament about the capacity and capability of the services to meet the demands. The Minister for Health and Community Care therefore proposed an assessment of the current ability and readiness of the partner agencies to comply with the Act and to report on the implications for local services. A small team was established, seconded from the care services.

1.2 We were given a very broad remit:

1.2.1 The project work included:

1. mapping existing services for people with needs for mental health services in Scotland

2. identifying gaps or duplication in the provision of services, including areas where re-prioritisation would be possible, or shortcomings in the quality of services

3. reviewing available evidence about the organisation, management, efficiency and effectiveness of mental health services

4. assessing the implications for services of the introduction of the new Act

5. considering priorities for development of services in light of these implications

1.3 What was not included, because it is covered elsewhere, was examination of:

• training needs

• the functioning of the new Tribunal system

• the work of the Mental Welfare Commission for Scotland

Methodology

1.4 We were asked to involve and consult service users and carers, NHS bodies, local authorities, the voluntary sector and other interested parties at the same time as taking into account the wide range of available information on existing services. Although the major focus was on the provision of current services, it was important to take account of likely changes in demand for services resulting from demographic trends, changing patterns of morbidity, changing patterns of care and other factors. Not least was the difficult question of resources.

1.5 Given the wide remit and relatively short timescale, we adopted a
multi-faceted approach. Obtaining information from a number of sources in different ways was necessary to ensure that all components of the remit were addressed and that wherever possible there was more than one source of information before reaching any conclusion. We worked from 3 principles:

a) Focus on people

• those who use the services and those who care for them

• staff and managers who provide care

• people who have responsibility for planning services

  b) Use existing information

• previous consultation

• joint community care plans and other strategic documents

• community care statistics

• annual reports

• publications from monitoring and inspectorate organisations

  c) Validation

• data should be collected from more than one source

• discrepancies should be clarified and understood

1.6 The main part of the project consisted of 3 overlapping exercises, based on prior review of the literature and a questionnaire. First, a member of the team (himself a service user) visited users and carers throughout Scotland seeking their views about current services and priorities for the future. Some of these people were prepared to share their experiences of detention under the current Act and we are extremely grateful to them. Chapter 3 summarises the views of users and carers and the full account can be found at http://www.show.scot.nhs.uk/mhwbsg/.

1.7 The second phase involved field-work by visiting every NHS Board and local authority area to learn about local service provision and potential problems that would need to be resolved in order to implement the new Act. This formed the basis of the locality reports published with the Interim Report in December 2003. At the request of the Royal College of Psychiatrists, we concentrated on local services for adults, aged 15-64, because this was the group of people most likely to be detained. We had been tasked with producing a relatively brief report linked to the Act, not a definitive review of all mental health services. It was with regret that we were unable to visit services for older people or those with a learning disability, for whom the Act has particular relevance also. These services were, however, included in the third phase and are reported on in Chapter 4.

1.8 In the third phase we looked at national themes and issues, the final strand of the work. The information was not obtained from site visits, but was based primarily on the opinions of multidisciplinary groups from the different agencies. It became clear that there was a false perception that if a particular group or issue was not going to be mentioned then it would be excluded from future planning and resource allocation. This is not the case and we are sorry we did not have enough time or space to include everything that is important.

1.9 The assessment process involved contact with a wide range of people and every effort has been made to capture and convey their views and experience. Although not all the information is reflected in its entirety in this report, contributors can be assured that all points were given due consideration and influenced the report.

1.10 The volume of documentation that we obtained is a testament to the commitment and dedication of all concerned. This in itself became something of a problem. There was a wealth of information that had to be rigorously condensed and edited to a manageable size, therefore much of the detail had to go, especially for some sections such as Older People or Mentally Disordered Offenders, where considerable research had been undertaken.

1.11 We ended up with the paradox of being swamped with information, yet unable to obtain some basic data. For example, it was not easy to obtain workforce numbers, out-of-hours detentions under the Mental Health Act (Scotland) 1984 or the percentage of inpatients detained. The principle of validating information was much more difficult than imagined as a lot of data was contradictory and there was considerable discrepancy between figures obtained locally and those held centrally. This is discussed in Chapter 5.

General Adult Psychiatry: Conclusions from the Interim Report

1.12 In many ways it is artificial to separate the different components of a service because they all relate to one another. The conclusions in the interim report from the locality visits, which focused on general adult psychiatry, cross-over into the national overview of other parts of the service and vice versa. The interim and locality reports can be found at http://www.show.scot.nhs.uk/mhwbsg/.

1.13 The following is a summary of the conclusions in the Interim Report:

1. There would be value in central guidance to inform local training action plans that must be implemented within a fixed timescale. This should include consideration of the human resource and organisational issues. Funding for continuing training should be reviewed.

2. There may be merit in a national or regional review of out of area admissions, with the aim of rationalising the management of mental health beds in Scotland. Correlations between the development of community services and admissions to hospital should be explored.

3. Flexible and responsive 24-hour support services should be developed and planning should include service users.

4. By the time the new Act is implemented in 2005, everyone with a serious mental health problem should have their assessed community needs met by a jointly provided multidisciplinary community mental health team, or its equivalent, and the voluntary sector should play a significant role.

5. A full range of treatments and activities, including psychosocial approaches, should be available at the appropriate times for people both in hospital and in the community. The need for, and access to, these services should be monitored as part of performance management.

6. There should be greater clarity about the roles of different organisations and different staff groups. Across staff groups, issues need to be clarified about generic versus specialist roles and about senior responsibility. Users and carers need to know who can do what, the limits of their skills and responsibility and how to contact the right person, whether in advocacy, health, social work, the voluntary sector or mainstream local authority services.

7. The organisation, management and training of mental health officers should reflect the importance of their extended role.

8. The National Mental Health Workforce Group should work closely with all professional groups and others to seek solutions to the workforce issues.

9. The administrative infrastructure to support the new Act needs to be considered in all planning for delivering the new Act. The grading of staff also needs to reflect the responsibility involved.

10. There should be greater transparency, monitoring and accountability of financial resources for mental health. Additional money for the new Act needs to be negotiated in detail and tracked accordingly.

1.14 The prime reason for undertaking this review was to assess the readiness of the services to meet the provisions of the Act when it comes into place in 2005; therefore the next chapter summarises the Act.

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