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National Mental Health Services Assessment: Final Report

4. DIFFERENT MENTAL HEALTH SERVICES FOR DIFFERENT PEOPLE

4.1 SERVICES FOR MOTHERS AND BABIES

4.1.1 Section 24 of the new legislation includes provisions to improve the hospital care and surroundings of mothers admitted with a mental illness around the time of childbirth (perinatal mental illness, including postnatal depression) and, specifically, to allow mothers to be admitted to hospital with their child when appropriate. The exact provisions within the legislation are as follows:

Current work

4.1.2 The Review Team welcomed the appointment of a Short Life Working Group which, since May 2003, has been working to produce outline guidance to help inform the preparation and planning processes required by agencies to comply with these new provisions, and through that process contribute to the successful implementation by April 2005.

4.1.3 The guidance will anticipate what will be needed in terms of care, quality standards and accommodation to comply with the legislation and will serve as an agency planning and audit tool for this important service.4.1.4 The Short Life Working Group has reached an advanced stage in its considerations and the planned guidance is expected to be published in March 2004.

Current and planned services

4.1.5 NHS Greater Glasgow is advanced in the preparation of their perinatal mental health accommodation and service. It is planned that this will be operational from May or June 2004. Other NHS Boards are/will be considering their own responses to the new statutory requirement, whether through area provision or within a consortia arrangement with partner agencies to provide a regional service. Once published, the guidance will help the associated planning, implementation and ongoing quality monitoring processes.

4.1.6 In terms of the overall organisation of provision it is for NHS Boards, in consultation with their partner agencies, to consider how best to respond to the assessed and anticipated needs of their area(s). This will involve discussions on whether a regional or local provision and service support is the more appropriate in each case. These considerations will include bed numbers, length of stay trends shown elsewhere with estimates translated to the Scotland population. The Royal College of Psychiatrists ⁷ suggests that around 30 beds will be needed in Scotland.

4.1.7 Beds and accommodation are only part of the overall joint care and support needed for the mothers and babies, and of course for their partners and wider families, which will be reflected in the coming guidance. This whole person and family approach should include support and interventions from early screening, through inpatient stay in both maternity and the planned new dedicated units, discharge planning, continuing care arrangements and ongoing follow up and support. The range of agencies and inputs that may be involved will include among others, health (including primary care and the role of the health visitor in addition to specialist mental health services), social services, housing, child services, justice, the voluntary sector, advocacy, transport and the Scottish Ambulance Service. Effective co-ordination between all these services will be essential.

4.2 SERVICES FOR CHILDREN AND ADOLESCENTS

4.2.1 A review of child and adolescent mental health child has already been undertaken through the Scottish Needs Assessment Programme (SNAP) ⁸. The report, published in March 2003, provides a comprehensive assessment of the mental health needs of children and young people in Scotland and what action is needed to strengthen support for them throughout childhood and adolescence.

Almost 25% of Scotland's population is under 18 years old and 9.5% of younger people (around 100,000) have mental health problems that are severe enough to affect their daily lives ⁹. Many become involved with specialist mental health agencies, and a small number require residential care. Recent years have seen more effective use of community services and day treatment programmes for this important care group.

4.2.2 Section 23 of the new Act will introduce from April 2005 and, for the first time, specific responsibilities on NHS Boards in relation to those under age 18, whether they are being treated on a compulsory or voluntary basis.

4.2.3 The exact provisions in the new legislation are as follows:

(1) A Health Board shall provide for any child or young person who:

4.2.4 In this section "child or young person" means a person under the age of 18 years.

Current services

4.2.5 A number of themes emerged from the 2002-03 Performance Assessment Framework exercise undertaken with NHS Boards. It is clear that current child and adolescent psychiatric service capacity is insufficient to meet existing need. Most NHS areas reported significant waiting times for children and adolescents, particularly for young people with a learning disability who have mental health problems. A key contributory factor is difficulty with recruitment and retention of key skilled staff and the funding of specialist training. Significant investment has been made in some parts of the country to address these issues, while elsewhere services remain under developed.

4.2.6 Most areas and services accept child and adolescent referrals from a variety of sources including: educational psychologists; social workers; GPs and health visitors. The services provided are multidisciplinary and multi-agency so that younger people's global needs can be addressed, including their needs for education and family contact. Outpatient clinics are well established throughout the country and are provided from a number of bases in the larger NHS Board areas, with the island NHS boards receiving added visiting support service from the Scottish mainland. Outpatient and community services form the backdrop of the service.

Inpatient provision

4.2.7 Compared to 127 in 1994, there are currently 44 NHS beds in dedicated units for children (9) and adolescents (35). Inpatient services are provided in Glasgow, Edinburgh and Dundee and are accessed by other NHS Boards across Scotland. An increase to 24 adolescent beds is planned in Glasgow. However, access to psychiatric beds for children and adolescents will continue to be limited, with emergency admissions likely to remain a particular problem, especially for NHS Boards who rely on out of area provision.

4.2.8 In some places, for example the West of Scotland, formal arrangements exist between NHS Boards for the commissioning of inpatient beds. However, commissioning arrangements across Scotland are neither consistent nor stable and together with staff recruitment and retention difficulties, this means that the current level of inpatient provision is insecure.

4.2.9 The SNAP report ⁸ on child and adolescent mental health highlighted the need for investment in and expansion of residential or hospital beds for children and young people with severe mental health difficulties. The report also noted that it is not appropriate to locate those beds in wards designed for adults unless specific arrangements have been made to adapt that environment and provide appropriate care to meet young people's needs. The SNAP review found that this could not be said of the majority of adolescent admissions to adult wards.

4.2.10 Effective assessment will always be crucial to ensure appropriate placement. Some children are admitted to paediatric wards for assessment and treatment and sometimes adolescents go to adult wards. This may lead to some difficulty given the different needs of younger people. A 3 year study ⁹ in central Scotland of early onset psychotic illness in people between 5 to 18 years old found that most were admitted to psychiatric units and 80% of the young people were first admitted to adult wards. Most NHS Boards appear to have a protocol for care for such situations.

4.2.11 The Mental Welfare Commission for Scotland ¹⁰ found that of the 127 young people under 18 years old compulsorily detained under the 1984 Act, only 1 in 4 was cared for in an adolescent unit. In 2002 the Commission requested that they be informed routinely when an adolescent is admitted to an adult bed (even if a voluntary admission), but only 3 NHS Boards indicated that they complied. When the new Act is implemented this will have to be monitored systematically.

4.2.12 Establishing a national multidisciplinary outreach service would be valuable. This would provide consistent and comprehensive assessment and treatment in community settings, including local authority secure units.

Current work

4.2.13 The Scottish Executive's Child Health Support Group (which draws on the expertise of colleagues from NHSScotland, education, social work and the voluntary sector) has established a Child and Adolescent Mental Health Development Group to promote development in child and adolescent public mental health and support a strategic approach to development of specialist child and adolescent mental health services in Scotland. The major focus of the Group's work is to support implementation of the recommendations made in the SNAP report ⁸ on child and adolescent mental health. The Review Team welcomes this focus and, in particular, the work now underway to develop a "template" for child and adolescent mental health services, expanding on the Child Health Support Group Template for Child Health Services ¹¹. The template will set out the essential components of a comprehensive CAMH service and will serve as an important agency planning and audit tool. The template is being developed in consultation with service-users and multi-agency staff and is expected to be launched later this year.

4.2.14 The Child Health Support Group has also established a separate focus group to consider a strategic approach to commissioning psychiatric inpatient services for children and young people, expected to report with recommendations in 2004. NHS Boards and Regional Planning Groups will need to consider these recommendations carefully in the context of the new duties under section 23 of the Act.

4.3 SERVICES FOR OLDER PEOPLE

4.3.1 There are 804,900 people aged 65 and over in Scotland, 20% of all adults ¹². While the Mental Health (Care and Treatment) (Scotland) Act 2003 does not specifically refer to services for older people, age is one of the features that must be taken into account to avoid discrimination and prejudice ¹³. As well as this new Act, the Adults with Incapacity (Scotland) Act 2000 will continue to have a significant role in the care of older people. Figures from the Office of the Public Guardian show the vast majority of applications for both Intervention and Guardianship Orders to be for people over 60. ¹⁴

4.32. Robust inter-agency working is a crucial requirement for older people and must involve general medical services, old age psychiatry, social work services, housing and benefits agencies and the voluntary sector. Carers need full support and may be elderly themselves.

Mental Health (Scotland) Act 1984

4.3.3 The number of older people subject to detention under current legislation is broadly in the same proportion as for adults. In August 2003, 357 older people were detained under Section 18 ¹⁵.

4.3.4 Sometimes older people with dementia may be subject to what is termed 'de-facto detention' when wards are sometimes locked and the Mental Welfare Commission has repeatedly expressed concerns about this. This situation is addressed in Section 291 of the new Act which allows for applications to Tribunals in relation to 'unlawful detention'.

Provision

4.3.5 As community based services have developed, the number of Old Age Psychiatry staffed beds in Scotland has reduced from 6,000 beds in 1991 to about 3,500 in 2003 ¹⁶. There is considerable local variation, ranging between 217 and 648 beds per 100,000 in different parts of Scotland. The change in NHS bed numbers must be considered alongside the expanding care home sector although there is little correlation at a local level between the number of hospital beds and the number of care home places.

4.3.6 Nationally, there has been an increase in care home beds of over 7% since 1995. The rise is in nursing home beds, the number of residential home places having actually reduced (the services are no longer separate, becoming generic 'care homes' in 2003). In the last 7 years there has been an increase of 3,060 care home places, despite only 2,500 hospital beds being closed over the last twelve years. The system is complex and many other variables influenced the rise in nursing home places, including the changing pattern of services for frail older people and the increasing proportion of older people in the population. It is possible that the rate of rise will slow down when the balance between hospital and community places becomes stabilised.

4.3.7 Last year 52% of the 7,051 older people discharged from NHS Old Age Psychiatry inpatient services (both acute and continuing care) were able to return home; 14% transferred elsewhere in the NHS; 22% moved into care homes; and sadly the remaining 12% died ¹⁶.

4.3.8 The introduction of National Care Standards and the phased extension of service inspections carried out by staff of the Scottish Commission for the Regulation of Care will regulate services for older people living in care homes. Early indications from the Care Commission ¹⁷ suggest that while care homes are relatively small in number, they generate more complaints than other services. More work needs to be done before firm conclusions can be drawn, but among the issues identified is the difficulty in recruiting and retaining good quality trained staff and support workers.

4.3.9 The number of significant changes aimed at improving the delivery of care has put pressure on many people, users and carers as well as staff and managers. This includes not only the major transition from hospital to community care, but also the introduction of the Adults With Incapacity Act and the Joint Future agenda, including the single shared assessment policy. Impending organisational change will put further stress on the service. At a time of such flux it is important to support staff in the task of ensuring an optimal quality of life for older people with mental health problems.

4.3.10 Services for older people are predominantly geared towards dementia or physical frailty. There are 57,000 people in Scotland with dementia and this is expected to increase to 192,000 by 2040 given the demographic changes ¹⁸. Early assessment and diagnosis, the establishment of memory clinics, and a range of treatment and care options, are essential.

4.3.11 To comply with the new Act, more robust assessment and follow up procedures must be created to address the needs of older people with severe and enduring mental illness and those with a late onset of illness. Such protocols should consider needs before age, and incorporate the needs of any carer or supporter.

4.3.12 Provision of services for older people must continue to include the statutory voluntary and private sectors. Each has a significant role to play.

Community teams

4.3.13 Three broad models of Community Mental Health Teams (CMHT) exist for Old Age Psychiatry:

• Fully integrated - with joint funding, care budget availability and joint management. Links with primary care will be clear and may include the GP as a team member

• Health led, dual-agency - co-located with local authority staff

• Health multidisciplinary - health staffing only, with social work services provided through liaison (the most common arrangement seen).

4.3.14 A challenge for all is to ensure appropriate collaboration for the benefit of users and carers.

Single shared assessment

4.3.15 Nationally, progress toward Single shared assessment for older people (a Joint Future initiative) remains patchy and incomplete. This needs to be addressed, especially given the planned extension of these arrangements to mental health generally (from April 2004) in order to support successful implementation of the new legislation.

Care pathways

4.3.16 Some areas have adopted care pathway approaches for their dementia services, some based on models developed by Alzheimer Scotland - Action on Dementia. ¹⁹ The Dementia Services Development Centre has also traced a patient journey and care pathway. ²⁰ That guidance places Primary Care and Acute Services in the vanguard of provision for early diagnosis and recognition and appropriate treatment of people with dementia in general hospitals. Similar pathways need to be developed for older people with other mental health problems. The Review Team welcomes the attention being given to dementia services by SIGN (Scottish Intercollegiate Guidance Network) and it was interesting to hear from the platform at the 2 February SIGN event that "…sometimes, more important than who does what, is of course, what is done."

Transitions

4.3.17 Older people in psychiatric hospitals are more likely to experience delays in their discharge arrangements: 64% of discharges delayed for 13 weeks or more were for older people. ²¹ Lack of finance and continuing care complexity are contributing factors.

4.3.18 While informal arrangements exist, no examples were seen across Scotland of protocols to manage the care of people who enter old age with an enduring mental illness. Good practice dictates early, planned transitions, which take account of age and needs for all people, at all times.

4.3.19 Those with an enduring mental disorder who are graduating from 'adult' to 'older people' services can sometimes experience a reduction in support choices given that some support projects restrict services to the under 65 age group. Continuity of support is important and the transition needs to be carefully managed. In some small rural or island settings, services are generic and offer continuity of support.

Advocacy

4.3.20 The advocacy services' map for 2003/04 ²² shows a lack of provision for both older people and for all people with dementia. Age restrictions arise again with some projects limiting provision to those aged 18-65. There are few services specifically for older people.

4.4 SERVICES FOR PEOPLE WITH LEARNING DISABILITIES

4.4.1 It is estimated that there are around 120,000 people in Scotland who have a learning disability. About 20 people in every thousand have a mild to moderate learning disability and 3-4 in every thousand have a severe or profound disability.

4.4.2 A detailed Learning Disability Needs Assessment Report is due to be published in spring 2004 which will provide information on the needs of children and adults with learning disabilities in Scotland. Studies elsewhere point to:

• a cumulative annual increase of about 1% in the prevalence of people with learning disabilities over the past 35 years, with this trend continuing over the next 10 years ²³

• an increasing number of older people with learning disabilities

• people moving away from home in order to receive treatment

• hospital closure programmes leading to some parts of the country having significantly higher numbers of people with learning disabilities than would be expected, although these trends have not necessarily informed service development and investment

4.4.3 People with learning disability have a high prevalence of mental illness at all ages. Children and young people with learning disabilities have a 30% to 40% risk of experiencing mental ill health and the prevalence of mental illness is higher amongst adults with learning disabilities than among the general population (an estimated 40-50%). Psychiatric morbidity is found in 62% of adults over the age of 65 and there is also a significantly higher number of people with Downs Syndrome who suffer early onset dementia as opposed to the general population. Between 10% and 40% of people with learning disabilities display problem behaviour. ²³

Mental Health (Scotland) Act 1984

4.4.4 The same as you?⁵ reported that a small number of people with learning disabilities were detained under the current procedures. Around half were detained on the basis of having a learning disability plus a co-existing mental illness, and half on the grounds of mental impairment or severe mental impairment. Of this group:

• most people were on a Section 18 order, with very few short term detentions

• very few request a review of their detention (two in the last year)

• very few appeal to the Sheriff

• the use of the detention procedures varies significantly across Scotland, raising questions about the criteria used for detention

4.4.5 In addition there are around 30 people with a learning disability detained in The State Hospital under current civil and criminal orders.

Policy context

4.4.6 The same as you? set the national policy framework for health and social care services for learning disabilities in Scotland. During 2003-04, The same as you? Implementation Group, (SAYIG) will consider services for children, advocacy and day care. A 2003 report ²⁴ on hospital closure and community based reprovision suggests four beds per 100,000 population are needed for assessment and treatment for people with mental health needs, offending behaviour or challenging behaviour. The Review Team was told that better long-term outcomes are achieved with individual support plans in community settings. A robust community infrastructure is essential.

Other developments

4.4.7 There are a number of initiatives being taken forward, including:

• The Association of Directors of Social Work sub-group, looking at the needs of individuals who offend and those with challenging behaviour.

• A managed clinical/care network (MCN) has been established for the NHS Board areas of Forth Valley, Lothian, Borders and Fife to focus on the needs of people with very severe challenging behaviour, autistic spectrum disorder and offenders.

• The Right Place; The Right Time ²⁵ recommends the establishment of a national managed care network for mentally disordered offenders. Linked to this, a network across Northern Ireland and Scotland is being established to focus on the needs of people with learning disabilities/intellectual disabilities who offend.

• A survey of people with learning disabilities in prisons and secure settings is underway, commissioned by the Scottish Executive in the context of The same as you? ⁵ recommendations.

• Progress with hospital closure across Scotland

4.4.8 There has been a major reduction in learning disability beds from over 7,000 in 1980 to 1,000 in 2002, and all long stay hospitals are scheduled to close by 2005. A small number of people have been identified as requiring NHS continuing care, but this varies across the country. People with similar assessed needs may be considered for continuing care in one area but not in another. 652 people in long stay beds are to be discharged to alternative suitable care and support, when available, excluding those in forensic and assessment beds. The majority will be discharged during 2004. Within these numbers are 89 in out-of-area NHS hospitals or other NHS funded services, awaiting transfer, including specialist assessment/treatment, long stay and forensic services. Their particular needs will have to be taken into account in any future service/location change.

4.4.9 There is very limited provision for mental health services for children and young people with learning disabilities.

4.4.10 In the context of hospital closure, people with learning disabilities are now more likely to be admitted to adult psychiatric wards, although all areas have retained, or are developing, some assessment and treatment inpatient learning disability services. Difficulties are often experienced by people with learning disabilities in acute psychiatric wards, and in most places there is no agreed protocol or joint working between mental health and learning disability services.

Mental Health (Care and Treatment) (Scotland) Act 2003

Tribunals

4.4.11 Extra demands on staff are anticipated from the new provisions and staffing shortages in all professions give rise to concern. The shortage of consultants in the psychiatry of learning disability will lead to added pressure. There are 28 in post compared to the 50 recommended by the Royal College of Psychiatrists.

4.4.12 There is a need to increase access to independent advocacy, with access to information in appropriate formats and better support for communication. Independent advocacy is probably already best developed in the area of learning disabilities It is available, to some extent, in all learning disability hospitals and there have been developments supported partly by the Change Fund Initiative. However, the continuity of advocacy provision for people leaving hospital and for those already in the community is an issue needing attention.

4.4.13 Tribunals may have to consider using technology such as videos and providing information on interactive CD-ROMs in order to assist and support people with learning disabilities. The Scottish Consortium for Learning Disabilities (SCLD) and others could assist with the development of suitable information.

Care/Treatment Plans

4.4.14 Preparation of advance statements and the preparation of accessible information will need specialist support. The provision of age appropriate facilities for children and young people with learning disabilities and the care to be attached to transitions are especially important for this care group.

4.4.15 With regard to offences (Section 311/319) there is a need to integrate the development of relevant policies (in the context of wider vulnerable adult policies) across health, local authority and criminal justice services, along with the provision of appropriate guidance and training.

4.4.16 Appeals against conditions of excessive security will be available to people with learning disability as well as other forms of mental disorder and this must be borne in mind especially in the development of regional forensic psychiatry units.

4.5 MENTALLY DISORDERED OFFENDERS (FORENSIC SERVICES)

4.5.1 Mental health forensic services have two complementary objectives, to ensure safe, fit for purpose services, care, support and accommodation that meets the assessed needs of mentally ill people who have been involved with the criminal justice system, at the same time as promoting staff, patient and public safety.

4.5.2 The 1999 policy statement on services for mentally disordered offenders ²⁶ set out proposals for the organisation of safe care and accommodation, supported by joint working between all the relevant agencies. A care pathway document (2001) ²⁷ provided a planning and audit tool on which to base service design or measure progress toward the overall objectives.

4.5.3 The policy includes the development of forensic psychiatric units and services with a level of security that used to be called 'medium secure', although the term most commonly used now refers instead to the site of the service e.g. 'local forensic psychiatry units' or 'regional forensic psychiatry units'. To date, the Orchard Clinic in Edinburgh, established in January 2001, is the only fully operational unit.

Background

4.5.4 As of July 2003, the majority of people in forensic inpatient facilities were liable to detention either under the Mental Health (Scotland) Act 1984, or the Criminal Procedure (Scotland) Act 1995.

4.5.5 This report focuses primarily on services currently led by consultant forensic psychiatrists for adults between 18 and 65 with a mental illness. This includes multidisciplinary assessment and treatment of people who have severe and enduring mental illness, including schizophrenia and affective disorders. Substance misuse and a history suggestive of personality disorder are common co-morbid disorders. At present there is no service in Scotland designed specifically for patients with a primary diagnosis of personality disorder.

Mapping services

4.5.6 Conventionally, forensic services are seen as a pyramid providing inpatient and outpatient services across the range of security. The service in Scotland has The State Hospital at the top of the pyramid, then forensic psychiatric units and services (of which the Orchard Clinic is the first), then local units (low security) and finally community services and accommodation.

4.5.7 The provisions of the new Act will allow appeals against the level of security in which the patient is held, coming into force in 2006. The development of more forensic psychiatric accommodation and services will offer a range of options, help prevent inappropriate admissions to The State Hospital and facilitate speedier discharges.

4.5.8 A national review of forensic provision was commissioned by the Scottish Executive in October 2000 and informed policy thinking but there is no current national needs assessment for forensic patients.

4.5.9 Hospital accommodation alone will not deliver the safety, quality and ongoing holistic care required. This is described by MacCullough and Bailey ²⁸ as a "continuum of care which commences in maximum security and ends with patients living in the community where possible". Forensic day hospitals, assertive follow up by joint agency community forensic teams and the provision of a wide range of accommodation helps avoid facilities and services becoming "blocked".

4.5.10 Forensic services also provide inpatient assessment and treatment and some longer stay care for people with learning disabilities who show offending behaviour. Specialist secure inpatient services for people with learning disabilities are provided at The State Hospital, Carstairs. Of the 30 people with a learning disability at The State Hospital, 11 are currently ready to leave, but whose discharge is delayed because there are no services locally to meet their needs, apart from the Dykebar Learning Disability Close Supervision Unit in Paisley.

4.5.11 There is limited experience in Scotland about the potential role of secure services within the full spectrum of care. The recent development of a National Forensic Care Network will enable clearer criteria to be produced for determining the need for high secure services, forensic psychiatric units and services, or for low secure facilities. The criteria must be sufficiently broad to embrace reasonable clinical judgement, but within parameters that are sufficiently tight to minimise clinical disputes, and inappropriate placements. A system of resolving conflict where it exists is important.

4.5.12 The issue of security placement depends, in part, on a robust assessment of risk. There appears to be a significant gap in the provision of risk assessment training, except at the highest levels of security. The main instrument used is the HCR20 ²⁹, in full or in part. Risk assessment training is important and it is possible that the risk management authority proposed by the MacLean Committee ³⁰ will provide advice on the approval of risk assessors and their training.

The State Hospital

4.5.13 The State Hospital (240 beds) provides conditions of special security for both Scotland and Northern Ireland. It provides a separate ward for women and a dedicated unit for patients with learning disability.

4.5.14 In 1997 a survey ³¹ of the diagnostic and detention characteristics of the patient population concluded that significant numbers of The State Hospital population at that time could be managed in a less secure environment were the option available. This remains the opinion of psychiatrists at The State Hospital today.

4.5.15 An assessment of the numbers within The State Hospital population who could be transferred safely to care in lower secure surroundings suggests a need for between 126 and 256 forensic psychiatric beds. These figures cover the needs for Scotland and Northern Ireland and require adjustment for the Scotland only population. The existing and the planned additional facilities to follow the Orchard Clinic in 3 other areas of Scotland will go some way to address this need, but these are unlikely all to be available by 2006 when the right to appeal against the level of security comes into operation.

Regional forensic psychiatric accommodation and services

4.5.16 The Orchard Clinic accepts people for assessment or treatment of mental disorder who require medium levels of security. This does not include people with a primary diagnosis of learning disability, personality disorder or sexual disorder. It is a supra-regional service and of the 126 admissions since opening, 11 have been out of area transfers from NHS Boards outwith the South-East consortium. There is a high number of admissions for assessment, reflecting the policy of admitting all Section 52 committals (remand to hospital before trial) from Lothian to the Orchard Clinic. The average length of stay is less than one year, with only a small number staying more than 2 years. Experience in England suggests that the population varies from site to site in forensic psychiatric units and services, but is evolving towards an increased length of inpatient stay. Low secure services, supported accommodation that meets the needs of this client group and a wide range of community supports are essential to enable people to be discharged safely and appropriately.

Local inpatient forensic services

4.5.17 Although further forensic psychiatric units and services still need to be developed, nationally there are 131 low secure beds (122 occupied at the time of the review, including 8 women patients) in designated adult forensic services. Length of stay varies significantly, the average being around 18 months.

Intensive Psychiatric Care Units (IPCUs)

4.5.18 These units are discussed elsewhere in this Chapter. IPCUs tend to provide forensic services in the absence of local alternatives.

Community services

4.5.19 As at 2003 there are only 2 dedicated forensic day care facilities in Scotland (Tayside and Greater Glasgow, a total of 46 places). Forensic day hospitals provide a useful aid to discharge from a low secure inpatient service and offer important transitional support for people moving from inpatient care to community support, as in Tayside, where patients with complex needs are managed safely in the community.

Nurse-staffed accommodation

4.5.20 A range of accommodation for discharged mentally disordered offenders exists, principally tenancies in mainstream accommodation or supported accommodation, usually from a voluntary sector provider. The latter tend to be generic providers and vary in their expertise in managing mentally disordered offenders. Designated nurse-staffed accommodation is only available in Grampian (8 places), which accepts detained patients. Wider availability of appropriate supported accommodation will contribute to the speed with which patients can be safely discharged from hospital care. There are particular problems in securing accommodation for people who have sexually offended.

Community forensic teams

4.5.21 There are community forensic teams in Greater Glasgow, Ayrshire and Arran, Argyll and Clyde, Forth Valley, Lanarkshire and Grampian. One community psychiatric nurse (CPN) is attached to the Orchard Clinic service. CPNs under the supervision of a consultant forensic psychiatrist normally support the court liaison schemes where these exist. There are recognised difficulties in recruiting psychologists, social workers and CPNs and in some areas this has compromised the ability to set up a court liaison scheme.

4.5.22 CPNs normally have 10-15 clients needing intensive involvement. At present community forensic teams have very few social workers or psychologists.

Court liaison schemes

4.5.23 Formal court liaison services operate in Greater Glasgow, Forth Valley, and in parts of Ayrshire and Arran and Lanarkshire. These arrangements act as filters to ensure offenders with a mental disorder are identified quickly and the Department of Health (England and Wales) has advised that mentally disordered offenders should not be routinely remanded in custody solely for the preparation of psychiatric reports (as can happen in Scotland).

4.5.24 An audit of the Forth Valley service in 2002 showed that 55 individuals were referred, 89% men, the majority aged between 20 and 40 and charged with public order offences or theft. A significant minority (14%) were charged with sexual, murder or attempted murder offences. Many had previous contact with Forth Valley mental health services, usually related to alcohol/drug dependence although a few had a history of major mental illness. 14% were admitted formally to hospital after the court liaison. ³²

4.5.25 Audits of the Glasgow service between 1994 and 1997 showed a fall in hospital admissions from 46% to 14% over this period when a liaison scheme was established.

Prisons

4.5.26 Forensic services also provide specialist input to a number of prisons. Nationally, the Scottish Prison Service purchases 32 sessions per week of consultant psychiatrist/consultant forensic psychiatrist time.

4.5.27 Davidson et al ³³ reviewed remand prisoners in Scotland. Many complained of minor affective disturbance, but only 2.3% were assessed as having a major mental illness. Despite this there remains serious concern about the number of suicides within prison, particularly with respect to women.

4.5.28 The mental health input to prisons normally involves a multidisciplinary team, although this is limited partly by staff shortages. The size and makeup of a team varies considerably between institutions.

4.5.29 The role of the prison mental health team includes:

• identification of mentally disordered offenders and arrangements for the safe transfer to hospital of those acutely unwell

• management of less severe mental disorders

• participation in the assessment of suicidal behaviour

• advising on the management of difficult prisoners

4.5 30 During 2001/02, 27 remand and 34 sentenced prisoners were transferred to hospital ³³. There appeared to be little difficulty in securing transfer to hospital of mentally ill men, but it is less easy finding places for women prisoners, especially if there is significant self-harm and personality problems. Agreement for transfer to the local psychiatric service varies significantly across Scotland.

Multidisciplinary working

4.5.31 The core assessment and treatment for mentally disordered offenders in hospital lies with nursing and consultant medical staff, usually supported by doctors in basic or higher specialist training. While there are mental health officers (MHOs) attached to teams at The State Hospital, Lothian, Greater Glasgow and Grampian, other services have ad hoc arrangements or other contact with local teams, so there may be little sense of continuity of involvement by MHOs in the management of detained offender inpatients. Routine involvement of social work happens where the Care Programme Approach (CPA) is adopted, but Care Programme Co-ordinators are not in post throughout the service.

4.5.32 The new Act attempts to ensure the provisions which relate to people detained via the Criminal Procedure Act are as similar as possible as those for civil detention. In doing so, local authorities will have to appoint a 'designated mental health officer' in all substantive interventions under the Act that involve assessments and detentions for psychiatric care, which originate from the criminal court or prisons. These MHOs will be responsible for contributing to the patient's assessment and future care planning throughout the period of detention. The new local authority responsibilities will help ensure greater multidisciplinary working for this vulnerable client group.

4.5.33 The Review Team found that access to psychological or "talking therapies" was easier for those in higher levels of security and there was a concern about the discontinuity of treatment approaches on transfer, particularly for patients coming from The State Hospital. Particular concerns surround the dynamic risk assessment and management of sex offenders. A few services had trained nursing staff to deliver:

• cognitive behavioural treatment for residual psychotic symptoms

• psycho-educational and relapse prevention groups to manage substance misuse

• cognitive behavioural individual work to manage anger

• cognitive skills

4.5.34 Some forensic teams can access such treatment through generic services, but there are waiting lists for clinical psychology services nationally, sometimes amounting to as long as one year. In Ayrshire and Arran, Greater Glasgow and Lanarkshire the dual diagnosis services can be accessed by forensic teams.

Services for women

4.5.35 The only single sex forensic facility for women in Scotland is in The State Hospital, where substantial expertise has been developed for those with complex mental health needs, and in particular for those with borderline personality traits. Only Ayrshire and Arran and Forth Valley NHS Boards have female beds, although within mixed sex wards. There are proposals to re-provide a small single sex unit in Forth Valley and preliminary discussions about creating another forensic facility for women in Tayside. Otherwise female mentally disordered offenders are admitted to intensive care units. Staff at Cornton Vale Prison are concerned about the lack of national agreement on the detainability and management of women with serious self-injury. The national Forensic Care Network could facilitate regional planning for this small group of people.

Emerging picture

4.5.36 Forensic mental health services are entering a development phase with the establishment of a managed care/clinical network as proposed in Partnership for Care³⁴ and the The Right Place; The Right Time ²⁵. The Forensic Mental Health Services Managed Care Network Advisory Board has now been established, there are forensic management groups (at NHS Board level) and the 4 supra-regional consortia are planning for care across NHS Board areas.

4.5.37 Lanarkshire, Ayrshire and Arran, Argyll and Clyde and Dumfries and Galloway NHS Boards have undertaken a joint needs assessment for forensic psychiatry accommodation and services (36 beds). Grampian, Tayside, Orkney, Shetland and Highland NHS Boards are also jointly exploring the need for a supra-regional service. Greater Glasgow NHS Board has funding and planning permission for a 72 bed forensic facility designed to include long stay beds and a specific resource for women and those with learning disability.

4.5.38 Forensic services have suffered in the past from a lack of co-ordination and national planning. This is now being addressed and the new Act means that the full range of forensic services need to be put in place as a matter of urgency.

4.6 MEETING THE NEEDS OF PEOPLE WITH CO-OCCURRING SUBSTANCE MISUSE AND MENTAL HEALTH PROBLEMS ("CO-MORBIDITY")

4.6.1 The origins of co-occurring substance misuse and mental health problems are complex and it is often difficult to determine which came first. Co-morbidity is a major and growing social, clinical and service issue:

• up to 3 in 4 people who use drugs have mental health problems

• up to 1 in 2 patients with alcohol problems may also have a mental health problem

• up to 2 in 5 people with mental health problems may have a drug and/or alcohol problems

• co-morbidity in general practice has risen by 62% (in England 1993 to 1998) ³⁵

4.6.2 People who have both substance misuse and mental health problems can be troubled by other complex social problems, including unemployment, homelessness, exposure to violence and the long-term effects of childhood trauma.

Provision in Scotland

4.6.3 Recent policy developments have not led to a consistent improvement across the country in collaborative planning, delivery and accountability of services for people with co-morbidity, including those with mild to moderate mental ill health. Separate planning processes exist for different components of services through local Drug and Alcohol Action Teams, (DAATs) and Joint Mental Health Commissioning Groups, inhibiting joined-up service provision.

4.6.4 The Joint Future Agenda offers the prospect of better outcomes through integrated approaches to the management, financing and day to day running of services. Integrated care for drug users, based on the principles of Joint Future, is now gathering momentum following the 2002 report by the Scottish Executive Health Department Effective Interventions Unit ³⁶ (EIU).

4.6.5 There is agreement that individuals with personality disorder are at high risk of becoming dependent on substances, but there is a lack of professional consensus on the treatment role of secondary mental health services. With only a few exceptions, service provision is rudimentary, despite the available evidence base for effective practice, intervention and management. Apart from policy initiatives for mentally disordered offenders, there is no Scottish guidance.

4.6.6 The Review Team was told that key staff are sometimes uncomfortable with their level of skill in treating this care group. The Review Team welcomes the Scottish Executive Health Department examination of the range of necessary services that should be provided. ³⁵

4.6.7 The provision of services varies across Scotland for those suffering from mental health and substance misuse problems. Issues include:

• most secondary mental health services are working on a too narrow and too short-term model of assessment and care

• a need for improved communication at both operational and planning levels between addiction and mental health services

• clarity is needed in defining the appropriate service

• specified core competencies need to be identified to address training gaps

• there is a perception that it is professionally unrewarding to work with this care group, which sometimes results in treatment not being offered or abbreviated or inappropriate and rapid referrals on to other services

• a need for aftercare support to be planned as an integral part of treatment to prevent recurrence

• a need for better partnership with the voluntary sector

• Assessment, intervention and support

4.6.8 There has been a history of a separation at both planning and operational levels between mental health and substance misuse services, resulting in disjointed services and support. A shared view is needed on what care is appropriate, how it should be delivered and by whom, regardless of professional and organisational boundaries.

4.6.9 To deliver this change will require:

• a sufficiently diverse skill mix that allows ready access to both specialist and generic services as a client's needs become apparent

• workers confident of their own abilities to construct practical care plans in the face of complex needs

• care plans that are set out clearly and understood by generic workers to allow them to contribute to tackling the less complex issues

• care plans that are understood and accepted by other potential providers, as well as care funders and commissioners.

4.6.10 Thorough assessment is needed of health needs (physical and mental); social needs; housing; and employment among others. Engaging with the client and meeting basic needs will increase the person's willingness to change.

Planning and delivery of services

4.6.11 People with co-occurring substance misuse and mental health problems present a challenge and deserve access to the most appropriate and timely services. Treatment and care can and does work for this client group, although there is no clear evidence about which model of care is most effective.

4.6.12 NHS Boards and partner local authorities should consider jointly the needs of this care group and work in partnership and across professional and geographic boundaries to ensure adequate and integrated provision of services.

4.6.13 Planners and commissioners of services need to be aware of the nature and scale of the problem for this population. The needs of individuals should be met, where possible, through mainstream generic services, with easy referral to meet more specialised needs. The voluntary sector should play a key role in both planning and delivering care to this client group, and be resourced accordingly.

4.6.14 The following should be key features of service provision:

• early intervention, which is likely to be cost-effective, avoiding inappropriate referrals to more expensive specialist services

• broadly based interventions, to include social, education, and employment elements

• person-centred interventions, not based on existing service availability

• advocacy, with key workers helping service users through treatment and care services

• positive expectations of what can be achieved through treatment and intervention being emphasised to client and to service providers alike

4.6.15 Staff, whether in mental or substance misuse services, need to develop the skills necessary to identify and understand clients with co-occurring problems, to develop the confidence to deal with these problems, and to be given the capacity to cope. Training and continuous professional development should include:

• development of assessment skills based upon substance misuse and mental health assessment frameworks

• integration of knowledge of drug and alcohol trends for individuals with mental health problems

• effective working with a range of mental health interventions and treatment modalities

4.6.16 Effective staff supervision, both clinical and managerial, is equally important. Support mechanisms should also be in place for staff at all levels to help them cope with this particularly challenging client group.

4.7 LIAISON PSYCHIATRY (Services for People in a General Hospital)

4.7.1 Liaison psychiatry services are services for people who present to any care setting with a physical illness but who also have a mental health problem. Such services may also serve as a conduit for access to social services.

4.7.2 Those with a mental health problem are no different to the rest of the population in their needs for admission to a general hospital or to attend Accident and Emergency Units. They may also have need for general hospital admission for a range of other reasons including; deliberate self-harm; attempted suicide; the physical consequences of mental health problems such as drug and alcohol misuse; or unexplained symptoms that may have a psychological origin.

4.7.3 Service users have said they feel their mental health problems are not fully understood or appreciated when they go to a general hospital setting and they can feel stigmatised by staff for not having a 'real' illness (examples of these concerns are set out at the end of this section).

Facts and figures

4.7.4 In 1999-2000 the number of short-term detention orders under the current legislation that took place within general hospitals amounted to over 25% of all emergency detentions in that period. In 1999-2000 the Royal Infirmary of Edinburgh, which has no psychiatric beds, had the fourth highest emergency detention rate under the current Mental Health Act, when compared with other NHS hospitals around the country. ³⁷

4.7.5 The level of staff training and expertise in mental health in general hospital settings is limited and patients may have been detained due to a lack of awareness of alternative treatment options. The new Act will ensure that wherever possible a psychiatrist will be called in before a detention order is invoked. Therefore, awareness training for medical staff is required to help identify and respond better to patients presenting with physical needs and who have associated or non-associated mental health needs.

4.7.6 People with a diagnosis of schizophrenia can now expect to be provided with a full annual medical examination and to have their needs for psychological and palliative care assessed ³⁸.

Suicide and self harm

4.7.7 The Public Health Institute for Scotland ³⁹ reported a Scottish average of 157 women and 456 men committing suicide per year over recent years. The previous pattern where women were much more likely than men to attempt suicide or harm themselves is gradually changing, with men now presenting nearly as often.

4.7.8 There are many reasons for people deliberately injuring themselves that are not connected with suicidal intent, consideration of which requires specialist expertise and insight given that one in a hundred people known to have hurt themselves go on to commit suicide within a year.

Table 1 - Patterns of physical health needs in people with a mental illness¹

Issues

4.7.9 The Public Health Institute needs assessment report commented that acute health services often do not pick up unmet psychological or physical needs in the 'non-mental-health' parts of the NHS. Given that rates of mental disorder are already high within people admitted to general hospital beds, the move towards establishing more trauma and ambulatory care units may make access to liaison services more difficult, given the additional travel involved.

4.7.10 Currently there are a limited number of liaison psychiatry posts in Scotland, with some people employed and managed directly by the acute hospital and others employed by the local Primary Care Trust. Most are part-time positions with commitments in other geographical locations. One of the principles of the Act is that where practicable a person should be detained after examination by a person experienced in psychiatry with the aim that there should less use of emergency detention which can be initiated by any doctor.

4.7.11 The new Act requires the doctor initiating a short-term detention order be an approved medical practitioner (AMP) and that this is most likely to be the liaison psychiatrist, although some accident and emergency consultants may be in a position to take on board the additional training to become approved. Awareness training is needed for all medical, surgical and psychiatric staff with responsibilities under either the Adults with Incapacity or emergency detentions in the new Act.

4.7.12 For many patients presenting in a psychiatric emergency, the local general hospital is the site where initial psychiatric assessment will occur. Given this, it is also often the place where an emergency detention order is begun, or where existing orders maybe reviewed. General hospitals often lack safe and private interviewing facilities where such sensitive procedures can be discussed and processed.

4.7.13 The review team has seen a "Self-injury Charter" produced by a service user which covers the following:

4.8 INTENSIVE PSYCHIATRIC CARE UNITS: SERVICES FOR PEOPLE AT PARTICULAR RISK

4.8.1 Intensive psychiatric care units (IPCUs) are similar to intensive care units in acute hospitals which provide expert care with a high level of observation and skill.

4.8.2 This section was informed by the Review Team site visits and by published reports from monitoring agencies, in particular the findings of the Mental Welfare Commission for Scotland (MWC) when it undertook unannounced visits in 2000. ⁴⁰

Background

4.8.3 Most people within an IPCU are likely to be detained under the Criminal Procedure (Scotland) Act 1995 or the Mental Health (Scotland) Act 1984. Despite the wards being locked around 10% of the patients will not be under any legal compulsion to remain, but are there because of their being severely and acutely ill and needing the close observation and treatment that an IPCU can provide. This can amount to 'de facto' detention and these patients should clearly be able to leave the IPCU ward ⁴¹.

4.8.4 To be admitted to an IPCU people are usually:

• too ill to be cared for safely in an acute ward (both formal and informal patients)

• on remand for assessment from the courts

• in need of a higher level of supervision because of a forensic history

• stabilised in their illness, but on a step-down programme from the special security of The State Hospital

4.8.5 An IPCU may therefore function both as a forensic ward and an extension of general psychiatric services and this duality of function may lead to some problems for both care groups. Other issues arise in providing adequate, appropriate and safe care for women patients (the MWC census ⁴¹ found 21% of beds were occupied by women) which can present a significant challenge.

4.8.6 Some of these issues will be resolved when more local forensic psychiatric units and services are developed, allowing IPCUs to focus more on acutely ill patients rather than those with forensic needs. A difficulty will remain in providing an appropriate care environment for adolescents and older people, or for people with a learning disability. This consideration needs attention, especially since the new Act requires that adolescents receive care in an age-appropriate facility. There is currently minimal access to alternative secure care within local settings.

4.8.7 One quality criterion of treatment and care is that it should be delivered as close to the person's home as possible. Yet local IPCU facilities are not viable for small or dispersed populations. Very ill people may have to travel long distances under escort to be admitted to a hospital they do not know. This, sadly, is unavoidable in small island or rural areas that have to contract services from other NHS Boards. It is much less acceptable for people from urban settings, where IPCUs are located, sometimes having to travel across Scotland, because of lack of available local beds.

4.8.8 This general bed management problem was identified in the Interim Report. Despite the fact that this issue was raised locally as a significant problem, the published statistics suggest a different picture. The MWC (in 2000) ⁴¹ found only 6 people (out of 142) in an IPCU that was not in their area. This underlines the need for better routine data collection to help inform planning and management decisions about service provision.

4.8.9 There are currently 17 IPCUs in Scotland and 181 beds (down from 219 beds in 1992).

Table 2 - Number of IPCUs and beds by population per NHS Board

4.8.10 A key finding from the 2000 Mental Welfare Commission survey ⁴¹ was the very poor physical environment in many places. Three years on the Review Team found significant improvements in the new buildings, but problems remain elsewhere. Old cramped facilities offer little opportunity for exercise or privacy, especially where there is no enclosed garden area. The layout in some places makes nursing observation difficult; for example where the premises are on several floors. Often the decoration and furniture lack colour and imagination, offering little by way of stimulation. There are difficulties in ensuring both a smoke-free environment and a smoking area that are congenial.

4.8.11 In 2002 the Department of Health (England) produced 15 National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and low secure environments ⁴¹. One set of standards covered physical environment (too detailed to summarise here). In Scotland, a few newly built intensive care psychiatric units meet most of the criteria, but others fall far short. This is an acknowledged problem within the service which is often rationalised by the long lead-in time until new developments can take place. Although the structure of the existing buildings cannot be altered very much in the interim, there must be significant and continuing attention to the décor and furnishing. Where units suffer high wear and tear, repairs should not be delayed.

4.8.12 A challenge for the staff is providing the right balance of privacy and peace alongside activities and treatments. For some service users this balance is achieved; for others, either or both aspects are not adequate to meet their needs.

4.8.13 IPCU provision is a small, but important, part of services but significantly important for those in most need and as such represents an important part of the spectrum of care for those in need and should remain central to planning decisions when implementing the new Act.

4.9 CRISIS SERVICES AND 24-HOUR SUPPORT

4.9.1 Service users and carers attach great importance to the ready availability of crisis services and 24-hour support. This was raised at all the user and carer meetings and has already been well documented. ^{42, 43} The need for attention to these services is recognised within A Partnership for a Better Scotland.⁴⁴

4.9.2 Crisis services and 24-hour support are part of the essential spectrum of mental health care delivery. Integrated services are needed, organised on a tiered basis so that an individual can move between primary care, mental health specialist care, intensive care outside hospital, hospital admission and long-term or tertiary specialist care, according to need.

4.9.3 Robust and comprehensive crisis prevention and resolution services, coupled with the availability of 24-hour support, help reduce inappropriate hospital admissions and facilitate early safe discharges.

Facts and figures

4.9.4 Over recent years informal admission numbers have reduced marginally and currently stand at approximately 20,000 people with 30,000 episodes of admission. The high level of re-admission within 28 days, shown in the published locality reports, may be an indication that there is insufficient intermediate care between hospital and community services. One problem in interpreting the data is the recognition that setting up community services can lead initially to increased admissions, mainly due to previously unidentified need. This position changes over time. It is in crises that emergency detentions within the community are initiated. In 2002-03 1,461 people were compulsory detained in hospital in this way.

Mental Health (Scotland) Act 1984

4.9.5 Between 1985 and 2003 there was a 47% rise in the number of emergency detentions ⁴⁵ under the existing legislation despite the gradual development of community services. However, international comparisons show that detention rates for people with mental health problems have risen consistently and one of the major factors is thought to be that society generally is becoming more risk averse. This contributes to the stigma that service users experience.

4.9.6 One major change with the new Act, under the 'least restrictive alternative' principle, is the option of a community-based Compulsory Treatment Order, making the availability of robust 24-hour support and crisis services essential. The Tribunal will make judgements on the basis of need, not on current availability of services.

Provision

4.9.7 Currently there is a confusing mixture of available (or not available) out-of-hours services ranging from the GP, duty social worker and duty junior doctor, to more specialist services. Often access is for known service users only. Several voluntary organisations provide considerable support, but this was not always known or acknowledged by the statutory sector. Crucial support comes from relatively informal networks of fellow users and carers, often insufficiently resourced.

4.9.8 In order to gather information about the different components of crisis services and 24-hour support a checklist was sent to NHS Boards, Trusts and local authorities (some users and carers also volunteered separate responses). The responses produced the following results on availability:

• Assertive (intensive) outreach from the service is provided when vulnerable people fail to turn up for appointments or activities (50%)

• Rapid response, following an expression of need (66%)

• 24-hour support available when required (49%)

4.9.9 While voluntary sector contributions may have been relatively under-reported, leading to an under-estimate of facilities, this is likely to be balanced by the replies about 24-hour support outside hospital. Some services consider 24-hour support as being fully available if access to generic services is provided, for example GP out-of-hours cover or the on-call social worker, who may not be based in a mental health setting. If this is all that exists except hospital admission, it is not adequate. Contacting the junior psychiatrist on-call at hospital is usually seen as a retrograde step in conflict with the move to community care, especially when the junior doctor has little alternative to admission.

4.9.10 Access and provision are particular problems in dispersed communities. In some cases the distance travelled by the patient may result in an 'inappropriate' admission to offset a tiring return journey the same day. Incidence can be estimated by looking at the number admitted to hospital, but discharged next day.

4.9.11 For best provision people require a range of 24-hour options, including brief respite care or user-led crisis houses. Given the range of cost-effective options failure to develop these response needs cannot be attributed solely to resource constraints. An estimated average daily cost of a crisis house can be as little as 100 per person ⁴⁴. Feedback from the organisations that provide residential places for people with increasingly severe mental health problems is that funding allocations and access to health and social work support in crisis are inadequate. Quality and appropriateness should however always dictate care choices with attention to risk an issue also. Any service must ensure appropriate staff skills and readily accessible specialist back-up.

4.9.12 Service users and carers are prepared to participate and contribute to such services and not just be on the receiving end. This is a prime area where service user feedback has been given many times and yet not responded to adequately in every case. Service users and carers have insights into what might help them cope better in a crisis or to prevent one arising and they have practical and pragmatic suggestions about arrangements for drop-in, crisis houses, places of safety and transport support.

4.9.13 Despite some examples of very good practice, it is clear that currently, there are significant gaps in the provision of comprehensive community crisis services and 24-hour support. This is not new information.

4.9.14 Gaps in any part of the system have an effect on other parts and this includes informal carers. One of the principles of the new Act is respect for carers. Carers have their own needs and should have access to help, especially in emergencies. Their views and opinions must be taken into account as they are often experts about what is required. Too often the carer's experience of help is a restricted response, sometimes under the guise of patient or other confidentiality.

4.9.15 As community services have expanded in densely populated areas, some specialist teams have come together with expertise about particular client groups. Conversely in sparsely populated areas more generic and flexible skills are necessary. It is not possible to provide direct access to highly specialised care for all groups and needs, 24-hours a day. Generic skills need to underpin specialist skills to ensure the best care. A tiered approach reflecting different needs and specialist skills is acknowledged by service users and carers to be appropriate. However, even where a range of services is available from different agencies, integration and clear communication routes are rare.

4.9.16 Particular difficulties seem to occur when a problem arises for someone in a minority group or a person who has multiple problems. This applies not only to ethnic minorities and those with sensory impairment, but to those with learning disabilities, children, adolescents and their families. Older people and others may have multiple problems and it can be confusing to know where and how best to refer for those needs to be addressed. Sometimes the crisis is actually physical, but service users talked of not being taken seriously by staff and symptoms being attributed to a mental or emotional problem or even attention seeking (see the separate section on Liaison Psychiatry).

4.9.17 People experience significant problems travelling to services, especially in outlying areas. The use of telephone helplines and video-links can compensate to some extent. Predictably, there are conflicting views about such services, some linked to personal preferences, but undoubtedly sometimes due to the quality of the service. NHS24 was described by some service users as excellent for providing information, but less so at reflective listening, though this is not their primary function. NHS24 recognises the need for skills in handling calls from people with mental health problems and is tackling this through training. The Scottish Executive funds the Breathing Space helpline, set up as part of the Choose Life⁴⁶ initiative. There are a surprising number of services provided by voluntary organisations including some small volunteer befriending schemes but it is not always clear where monitoring and accountability lies.

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