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National Mental Health Services Assessment: Final Report

5. WIDER ISSUES

5.1 POSITIVE MENTAL HEALTH

5.1.1 Historically health services have tended to respond to illnesses and their treatment, but have placed lesser importance on promoting healthy life styles. While mental health services have a crucial role to play in responding to the needs of people who develop mental health problems, there is of course a much wider public policy agenda on illness prevention and health promotion.

5.1.2 Work taken forward through the National Programme for Improving Mental Health and Well-being initiative is demonstrating the importance and commitment at a national level to this broader agenda. Mental health promotion is an important issue against a backdrop of limited national awareness of the prevalence of mental illness.

5.1.3 This assessment has focused on the role of mental health services in relation to the new Act. In a broader context it is clear that more can be achieved in preventing serious problems through improved public awareness, better understanding and changes to the attitudes and behaviours of people across Scotland.

5.1.4 The key aims of the National Programme are to:

• raise awareness and promote mental health and well-being

• eliminate stigma and discrimination

• prevent/reduce suicide

• promote and support recovery

5.1.5 The Millan Committee ⁴ recommended there should be a campaign of public education designed to improve public understanding of mental disorder and the " see me…" campaign ⁶ has undoubtedly made a positive start to tackling the issue of public awareness, and will continue to promote better understanding and help to eliminate stigma. Progress has also been made in improving public awareness, for example through the introduction to Scotland of the innovative Australian training programme Mental Health First Aid, which will be evaluated this year. That initiative is all about approaching and understanding mental ill health in the same way as for physical ill health.

5.1.6 Most people, with the appropriate medical, social and family support can and do recover from mental health problems, however those most likely to be detained under the new Act may need longer term contact with psychiatric services. It is especially important that these people gain from the greater emphasis on positive mental health and from a greater public understanding of mental illness.

5.2 SUICIDE PREVENTION

5.2.1 Many service users, their carers, wider families and voluntary and statutory organisations are acutely aware of the potential stress and difficulties that make suicide an option for many people at some points in their lives.

5.2.2 Undoubtedly those with mental health problems who are likely to be at risk of suicide may at some stage become subject to the conditions of the new Act, if it is thought they suffer from a mental disorder. The aim always is to provide support, care and treatment well in advance to help promote good mental health, promote recovery and reduce (and hopefully remove) the risk of suicide wherever possible.

5.2.3 During this Review, it was shown that access to services in times of crisis is of course a high priority for service users and carers and this issue is discussed in more detail in the separate sections on liaison psychiatry and crisis services.

5.2.4 In the UK approximately a quarter of all suicides (1,500) involve those who had already been in contact with mental health services. ⁴⁷

5.2.5 Not everyone who commits suicide has had a mental illness. Nevertheless those with serious mental health problems are perhaps more likely to have suicidal thoughts and are therefore more likely to attempt suicide and harm themselves. A recent UK survey, those with a diagnosis of psychotic illness were over ten times more likely to attempt suicide.

5.2.6 There were nearly 900 suicides and undetermined deaths in Scotland in 2002, with a ratio for men to women of more than 2:1, and this gender pattern continues to increase ⁴⁷. The rate in Scotland is higher than the UK as a whole and the reasons for this are complex. With this background, the Scottish Executive in December 2002 launched ' Choose Life ⁴⁷,' a national strategy and action plan for preventing suicide in Scotland. An additional 12 million is being spent over 2003-06 to support the first phase of local and national action in implementing the objectives of Choose Life.

5.2.7 One of 7 priority groups identified for action under this initiative covers those with mental health problems. This covers those in contact with mental health services, those with a severe mental illness, usually with a diagnosis of psychotic illness and those with severe depression or severe anxiety disorders.

5.2.8 There are a range of issues to be addressed in helping prevent suicide of those already in contact with mental health services including:

5.2.9 The Review Team is of the view that while there has been investment and progress at a national level there is no room for complacency. Efforts need to be consolidated and lessons learnt taken further. The issues are complex and it is critical to have a long-term integrated approach to the prevention and reduction of suicide.

5.3 INFORMATION

5.3.1 Information and its management are core components of planning, delivering and managing health and social services, including those delivered by the voluntary sector. The new Act places significant new demands on services and the availability of quality information will be an important contributor to successful implementation.

5.3.2 The day to day responsibilities of administering the legal requirements of the new Act will lie with health and social work administrators, responsible medical officers (RMOs) and mental health officers and The Mental Welfare Commission for Scotland will continue to have a central role.

5.3.3 The main new development will be the operation of the new Tribunal system, which is not discussed in detail in this report. NHS Boards and social work departments will need to contribute to monitoring the implementation of the new Act and make early decisions about how, where and why resources are being spent and used.

5.3.4 The Scottish Executive Health Department will monitor the implementation and impact of the new Act and will need information for that role and for advising Ministers and others on progress.

5.3.5 It is clear that Scotland's mental health services are generally data rich, yet information poor. Within the overall mental health system a lot of data is collected both at a local and national level but sometimes it is not used to best effect or seen as being of value to practitioners. Some information that would be useful in planning and monitoring of services is not being collected or appears to be inaccurate and contradictory, depending on which source is used.

5.3.6 Basic details about bed numbers proved difficult to access, including those for intensive psychiatric care, adult acute admission or longer stay. National data streams do not discriminate at a level below the general psychiatric specialty and often it was necessary to phone wards direct to get the data needed for this review. The sheer complexity and size of local authority and voluntary sector provision is such that the Review Team learnt not to attempt a comprehensive list. This is not to disparage the determination and success of some staff and managers to draw up directories of care - in some places fairly detailed local information was available. However, across Scotland this is not systematically collected and updated.

5.3.7 Information will be needed on the number of consultant psychiatrists (and their specialty) and the number of mental health officers. The Royal College of Psychiatrists could not initially provide data on the former with any degree of accuracy and on more than one occasion NHS Trusts suggested that the only people with accurate information would be the pay office. Systems have now been put in place to rectify this and the Royal College of Psychiatrists will shortly be able to make baseline data available that will be regularly updated. Information supplied by local authorities regarding the number of MHOs practising in mental health differed somewhat when compared with the Scottish Development Centre's survey in June 2003 ⁴⁸, although this seemed to be due mainly to different definitions of what constituted working within a mental health field.

5.3.8 This significant lack of available and consistent information is acknowledged throughout the service and appears to be taken for granted; it is as if no-one expects accurate data. However, better information is available for and from the acute sector and all others concerned must work to improve the information available for mental health services.

5.3.9 With this in mind, the Improving Mental Health Information Programme ⁴⁹ is already making significant strides in developing better quality mental health information, by working with the agencies and others on information culture, sites and systems. This work must continue as a high priority. Some specific additional data analysis has been undertaken on behalf of this Review.

5.3.10 A major cause for concern is inconsistent financial data (discussed in Chapter 7). It is vital that better information is used to ensure that best value for money is gained from the services, and that service planners and managers can use the information to inform and enhance their decision-making. Better information leads to better decisions and of course better care.

5.4 MEDICAL RECORDS ADMINISTRATION

5.4.1 Medical records administration staff provide a pivotal role in ensuring the proper administration and legislative compliance of all related paperwork. They are the central information base for interested parties and for enquiries relating to detentions.

5.4.2 In some cases they are undervalued in consideration of the contribution they make and the pool of knowledge they represent. They are essential to the smooth operation of the issues and protections attaching to the detention procedures under specific legislation.

Overview

5.4.3 The Medical Records staff perform a range of duties on behalf of Managers, including: processing completed papers from wards, courts etc; accuracy checks and ensuring process completions within set time limits; informing relevant parties in those cases where papers are void; complying with the legislative requirements and informing relevant bodies of detention/continuation arrangements; ensuring all receive proper and timely notification and completed paperwork and ensuring 'Consent to Treatment' and 'Second Opinion' forms are sent to the responsible medical officers and are completed within the set time scales.

5.4.4 On behalf of the responsible medical officers the Medical Records staff will remind of all requirements due for detained patients at appropriate times and will alert of any outstanding issues/requirements.

5.4.5 Otherwise the Medical Records staff will routinely; provide sector general managers with regular reports on outstanding issues for detained patients; liaise with the Mental Welfare Commission for Scotland, Central Legal Office and courts on any matters arising; provide statistical and patient identifiable information as required; and provide guidance and advice to relevant parties on issues surrounding the relevant legislation.

5.4.6 Medical secretaries will also ensure that consultants receive all relevant papers within the appropriate time periods; where consultants are unavailable, will ensure the papers are re-routed to the covering RMO; and will make sure Medical Records staff are aware of all covering arrangements.

5.4.7 Local areas will have to ensure there is very close liaison between hospital Medical Records Officers/Departments and the lead contacts in the local authorities who are responsible for monitoring mental health officer activity. Local protocols should exist between all local authorities and their health service colleagues to ensure timely, efficient systems for referrals, reminders of deadlines for reports, applications and renewals. This is an area that the National Service Standards for mental health officer services should address.

5.4.8 There is a wealth of knowledge held by the current administrators within the NHS and local authorities, who also have invaluable experience in learning to deal with groups/individuals that other staff may find daunting. This experience is crucial for a successful transition to the new arrangements and should be utilised accordingly.

5.5 THE VOLUNTARY SECTOR

5.5.1 The term 'voluntary sector' is used to distinguish services from those directly provided by the 'statutory' bodies (health services and local authorities) although often a considerable amount of funding comes from these sources. One frequent source of confusion is with the term 'volunteer.' The voluntary sector employs a range of paid and trained staff. The private sector also provides care services.

5.5.2 Around a third of all social care staff in Scotland are employed through the voluntary sector and in the region of 40% of local authority spend on mental health services is on services provided by the voluntary sector.

5.5.3 Partnership for Care ³⁴ states that:

The mental health voluntary sector

5.5.4 The contribution currently made by the voluntary sector is wide ranging and extensive and their potential role should not be underestimated by any of the statutory organisations. They should be recognised, and in many cases are, as a full partner in the planning organisation and delivery of mental health services and should be recognised for the contribution they make also to innovative thinking and policy direction.

5.5.5 Some services are small, while other much larger organisations employ a salaried workforce. Some employ hundreds of staff, deliver a range of services, and have multi-million pound turnovers. The term 'voluntary' therefore is a misnomer and 'not for profit' perhaps better describes their position.

5.5.6 Voluntary organisations are subject to the same regulations as others in respect of employment law, health and safety legislation, accounting procedures and reporting. They have to meet quality and care standards and ensure staff training.

5.5.7 Like other sectors, voluntary sector staff are drawn from a variety of backgrounds and experience in fields such as nursing, social work/social care, psychology, occupational therapy and speech and language therapy. Others have experience and qualifications in diverse fields outside health and social care for example in the arts, education, community development, horticulture, information technology, law and business.

5.5.8 Some voluntary organisations combine two or more functions - being a lobbying group and a direct provider of services. For example, the Scottish Association for Mental Health (SAMH) is a membership organisation which campaigns, provides information and services for people across the whole spectrum of mental health. There are diagnosis specific groups such as the Manic Depression Fellowship Scotland (MDF Scotland), Depression Alliance, National Schizophrenia Fellowship and Alzheimer Scotland - Action on Dementia.

5.5.9 Some organisations, including Penumbra, Barony Housing Association and the Richmond Fellowship Scotland, concentrate more on the provision of care, especially in supported accommodation and day care. Increasingly the voluntary sector is moving to complement the statutory sector especially with the developing focus on Well-Being and Recovery.

5.5.10 These large and well-known organisations are only a small part of a larger network of services. Around the country there are many local Mental Health Associations that are well established and highly regarded within their areas both with service users and mental health providers. They provide a local focus for many different organisations including other voluntary groups. One of the fastest rising groups of voluntary organisations is those providing advocacy services. These are discussed separately.

What is unique about the voluntary sector?

5.5.11 The powers of the statutory agencies to make major decisions about service users, including detention under the Act, sometimes makes it harder for service users to develop a trusting relationship with those bodies. To some, the voluntary sector may seem more approachable and better equipped and more flexible to respond to service users' needs and views.

5.5.12 An additional advantage is the sector's capacity to respond quickly to identified and emerging needs innovatively and have access to alternative finance streams (e.g. Enterprise funds, European funds) that can bring additional resources into a voluntary/statutory organisation partnership. However the paradox is that such multiplicity of short-term contracts, not always linked to inflation or the need for additional training, can put considerable pressure on these services.

5.5.13 The " see me…" anti-stigma campaign ⁶ was assisted through an alliance of five voluntary organisations working together to highlight the importance of tackling the commonly found social exclusion experienced by many mental health service users. Many mental health voluntary organisations work with carers, the Benefits Agency, education providers, employers and communities as well as with service users to inform, increase awareness and integrate support within the social inclusion agenda.

5.5.14 The Review Team found some examples where there was a lack of acknowledgement of the important role the voluntary sector plays and some confusion about the different role of unpaid volunteers. Better understandings and better working together should be a priority for all concerned. At a time of major service change and development voluntary organisations have the opportunity to contribute on a more equal footing in partnership with NHSScotland and the local authorities.

5.6 PSYCHOLOGICAL INTERVENTIONS/THERAPIES

5.6.1 The new Mental Health (Care and Treatment) (Scotland) Act 2003 goes much further than before in stating that the full range of appropriate care and treatment options must be available to patients who are detained under the Act. This will apply to medication and psychological treatments as well as a range of care and support services. Psychological approaches are implied or explicit in the new legislation and Section 329 states:

Definition

5.6.2 Psychological 'therapies', 'interventions' or 'approaches' are interchangeable terms with considerable overlap and are often described more simply as 'talking treatments'. The term 'intervention' is most commonly used to describe care based on cognitive behavioural therapy for specific problems, for example psychosocial interventions for people with schizophrenia, for which guidelines have been developed by the Scottish Intercollegiate Guidelines Network (SIGN) ⁵⁰.

5.6.3 Providing such services calls on a broad range of skills and competencies based on identified psychological concepts and theory which have been acquired through training and maintained through supervision. Services should be provided at different levels of specialisation, by a wide range of skilled and trained professionals, in a tiered approach where the level of skill matches the level of identified need. Services may be provided by clinical and counselling psychologists, psychotherapists (medical and non-medical), psychiatrists, mental health nurses, occupational therapists and other allied health professionals, social workers, voluntary organisation workers and counsellors, all working within a variety of services and settings.

5.6.4 Psychological approaches include work not just with individuals, but also with families or with groups of people. Self-help groups with peer support are increasingly being developed by service users to share knowledge and learn how to manage their condition.

5.6.5 Although psychological approaches are appropriate in helping a wide range of mental health problems this section will focus on services for people with more severe problems who may be directly affected by the Act.

Severe and enduring mental illness

5.6.6 It is known that psychological factors predict emotional adjustment, recovery and staying well following an episode of psychosis and that preventative work may reduce or remove the need for hospital admission ⁵¹ and may lessen the likelihood of a serious breakdown ⁵².

5.6.7 Acute admission for a severe illness can be traumatic and the experience of post-traumatic symptoms, depression and suicidal thinking is linked to the way an individual perceives the illness in terms of shame, entrapment and humiliation, including the extent to which compulsory measures were necessary ⁵³. This has been recognised by the National Institute for Clinical Excellence (2002) ⁵⁴ which published good practice guidelines about the psychological needs of individuals following involuntary procedures such as rapid tranquillisation.

5.6.8 Decisions about treatment must always include assessment of a person's psychological needs and strengths within a social context and this is of particular importance when a Compulsory Treatment Order is being considered. In situations where conventional pharmacological treatment has failed or is not appropriate (as in some people with a personality disorder) then specific, evidence-based psychological therapy is of prime importance. Traditionally people with a psychotic illness ⁵⁵, major personality disorder ^56,57 or a learning disability ⁵⁸ were not usually offered such treatments - it is now known that such approaches can be of added benefit. Drug treatments and psychological approaches are not in conflict and a holistic approach will ensure that all factors are borne in mind when drawing up the Plan of Care with the service user.

5.6.9 The guidance on psychological interventions in the Framework for Mental Health Services² gave agencies baseline to use as a planning and audit tool for the delivery of services, which can inform what will be needed to comply with the expectations set out in the new legislation.

5.6.10 The national overview of treatment for schizophrenia, carried out by the Clinical Standards Board for Scotland ⁵⁹ reported on performance against 6 of 11 standards. The report states that "most service users do not have their need for psychological interventions assessed" and "access for people with schizophrenia to clinical psychology services is variable." A recommendation was made that "assessments of need for psychological interventions are undertaken by a clinical psychologist, and that NHS Trusts develop guidelines to be used for the provision of psychological interventions for people with schizophrenia." It also recommended that the skills and composition of multidisciplinary teams are reviewed. The recent workforce planning survey of psychology services ⁶⁰ acknowledged that the need and demand for psychological approaches could not be met by the present workforce and that service redesign was necessary to develop a skill mix that reflected client need and that training and supervision should take place on a multidisciplinary basis.

Personality disorder

5.6.11 Patients with a diagnosis of personality disorder have been disabled by their diagnosis and by the lack of specific treatment interventions available. This is surprising when one considers that figures suggest 11% ⁶¹ of the adult population may have a personality disorder, accounting for approximately 300,000 adults in Scotland. In 1998 personality disorder accounted for 2% of the 32,000 psychiatric admissions in Scotland. Although this is a condition five times more common than schizophrenia it is currently neglected therapeutically. Patients suffering from these conditions are variously referred to as having 'behavioural disorders', or 'mild to moderate mental health problems' or can also be included under the umbrella term 'severe and enduring mental health problems'. ³⁰

5.6.12 The MacLean Committee for Serious Violent and Sexual Offenders ³⁰ noted the recommendations of the Ashworth Inquiry ⁶², which described key features in providing services for people with personality disorders. These in turn were very similar to the recommendations of a 2003 report from the National Institute for Mental Health, England (NIMHE). ⁶³

5.6.13 For best outcomes, interventions should be well structured, coherent, focused, long term and well integrated. The services should also devote effort to achieving ownership of the task by the service user and develop a clear treatment alliance between therapist and patient.

5.6.14 Discussions have started in Scotland about a needs assessment of such services, with the Mental Health Division of the Scottish Executive Health Department and NHS Health Scotland.

Learning disability

5.6.15 Learning disability is classified as a mental disorder in the Act and people with a learning disability must also have access to psychological interventions as appropriate. In view of the current work on needs assessment this will not be discussed in this report.

Current services

5.6.16 In many areas training of clinical staff in some form of psychological intervention is either taking place or is at a planning stage. However, this encouraging position is not happening systematically based on assessed service or client need and individual staff interest has sometimes been the main reason for undergoing training. Up to 50% of newly trained staff may not be applying the training in everyday practice and services are not always being reshaped to allow this to happen. The result is a patchwork of provision that is not always fully integrated into mainstream services and lacks ongoing support and supervision.

Pilot projects

5.6.17 In 2000 and 2001 the Scottish Executive Health Department supported Psychological Interventions Projects in four areas (Ayrshire and Arran, Dumfries and Galloway, Forth Valley and Greater Glasgow). The projects had input from the Scottish Development Centre and the Glasgow Institute of Psychosocial Interventions (GIPSI). This work was restricted to interventions provided by psychologists and therefore was not inclusive of the broader multidisciplinary provision of psychological interventions. Difficulties were found in the development of service links and a need for short, medium and long- term strategies to address delays in access. A lack of systematic supervision was discovered in all areas and the projects also found problems with data collection systems and identification of entry points. It was stressed that training must follow an assessment of service and user needs.

5.7 ETHNIC MINORITIES

5.7.1 The term 'ethnic minorities' covers diverse communities and includes different cultures, religion, colour and different socio-economic background.

5.7.2 According to the 2001 Census ¹² there are about 102,000 people (around 2% of the population) in Scotland who regard themselves as being part of a black and minority ethnic group, the highest percentage being of Pakistani origin. Most live in large cities, (for example making up 5.5% of the Glasgow population). There are some demographic differences common to many groups which may impact on future care delivery, although the issues are always complex.

5.7.3 Perhaps most striking is the age structure:

• 56% of all ethnic minority communities are under the age of 30, compared with 36% of the white community

• 7% of all ethnic minority communities are aged over 60, compared with 21% of the white community.

5.7.4 Being in any minority is not necessarily a disadvantage. For some people, perhaps especially older people, being part of a small community may mean a clear identity and culture and a considerable support network. There is a danger of cultural stereotyping, where members of a particular community are seen not to require help from outside their community for cultural reasons and appropriate services are therefore not developed with their needs in mind. The reverse also applies where people do not seek help. This could suggest that any needs assessment based on overt demand is likely to underestimate requirements.

5.7.5 The central task is to ensure equality of assessment, and a service response that overcomes these limiting factors and eliminates unconscious or other racism. The Race Relations (Amendment) Act 2000 (RRAA) was in part a response to the Macpherson report ⁶⁴ into the death of Stephen Lawrence. The report concluded that all UK institutions were affected by institutional racism - "the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people".

5.7.6 An extreme example was reported in 2002 by The Mental Welfare Commission. ⁶⁵ Following a Deficiency in Care Inquiry the Commission reported significant and serious shortcomings in the treatment and care of a patient (born in India in 1926, a Punjabi speaker, with very limited English). The Mental Welfare Commission adopted racial and cultural issues as the special focus for the visiting programme during 2003-04.

5.7.7 All NHS organisations now have a statutory duty to work to eliminate unlawful racial discrimination. The NHSScotland Fair for All ⁶⁶ initiative obliges all NHS Boards and Trusts to produce Race Equality Schemes and Fair for All Action Plans. The National Resource Centre for Ethnic Minority Health (NRCEMH) was set up in order to support this work and is based within NHS Health Scotland (previously The Health Education Board for Scotland and the Public Health Institute of Scotland).

5.7.8 A review of progress was undertaken jointly by NRCEMH and the Commission for Racial Equality (CRE) in 2003. The Fair Enough? Report ⁶¹ described clear commitment and leadership, but noted local difficulties translating policies into action so that although there were examples of good practice there were definite gaps and weaknesses.

5.7.9 People from different ethnic groups should have their cultural and religious practices respected and provided for wherever possible. Some within black and minority ethnic communities, particularly women, only access services at the point of crisis due to lack of confidence and trust in the service. In some cases a mental health practitioner can lack the appropriate knowledge and language skills to communicate with a distressed individual and in this regard the development and support needs of interpreters and advocates must be acknowledged. There are 13 main areas where care could be improved. Understandably many apply to all care groups:

• Dietary requirements

• Spiritual care

• Interpreting and translating

• Advocacy

• Same sex facilities (and staff where possible) for women - taking into account the needs of children

• Suicide prevention

• Outreach, drop-in and community based services

• Culturally appropriate information, including on the new Act

• Psychological and self-help therapies

• Funding initiatives with the black and minority ethnic volunteer sector

• Unmet needs of refugees and asylum seekers

• Service users, carer involvement and activities

• Workforce development

5.7.10 In some cases the provision of interpretation and advocacy services may be complex because of family connections in small, close communities and ensuring truly independent services may prove difficult. The same can apply to remote island communities. A basic principle should remain one of choice. Some people may prefer to move away from their local area for treatment so as to enhance confidentiality. Wherever possible such requests should be respected and facilitated.

5.7.11 Improving the mainstreaming of ethnic community issues should focus on the patients their families, and also on the staff. Ethnic minorities contribute significantly to the workforce in the health and social services.

5.7.12 The Review Team noted that the National Resource Centre for Ethnic Minorities has received funding to conduct a stock take of mental health services across Scotland for individuals from black and ethnic minority communities and a final national report will be produced this year (2004) and will incorporate 15 NHS Board locality reports. Once available these should be read alongside the National Assessment published locality reports.

5.8 ASYLUM SEEKERS

5.8.1 Asylum seekers are of course entitled to have access to NHS care and support on exactly the same basis as UK residents. This entitlement continues through any appeal stage.

5.8.2 The remit of this Review includes consideration of demographic factors. One significant development that had not been anticipated fully is the increase in the number of asylum seekers in Scotland, many of whom have survived severe physical and psychological trauma and need considerable help. Asylum seekers are among the most poor and vulnerable care groups. Their weekly funding is about 70% of UK income support; they cannot claim other benefits and are not permitted to work. Difficulties in accessing health care services were highlighted as one of the main emerging health issues for asylum seekers and refugees in Fair for All.⁶⁷

5.8.3 Most of those 'dispersed' to Scotland live in Glasgow, where there are about 10,000 asylum seekers. About 80% of those granted refugee status have remained in Glasgow. Neither group was included in the ethnic census data.

5.8.4 Glasgow has developed a designated service for assessing needs and assisting this group. In the last 4 years nearly 800 people were referred for specialist mental health help from 55 countries of origin and 33 languages (78% needing an interpreter). Over an 18 month period 46 people were admitted to psychiatric inpatient facilities, some more than once. The most common diagnoses were post-traumatic stress disorder and depression, although 5% suffered major psychotic illnesses.

5.8.5 Gender issues are especially important in all contact and support for asylum seekers and refugees due to the high incidence of sexual assault and rape that has taken place. The sensitivity and expertise of people working in sexual assault clinics provides an essential contribution to the support networks needed. A Scottish Executive report on sexual abuse services is due to report this year.

5.9 ADVOCACY

5.9.1 The Mental Health (Care and Treatment) (Scotland) Act 2003 includes the requirement for local authorities and NHS Boards to collaborate to ensure independent advocacy services are available for people with mental disorder. ⁶⁸ Many current advocacy services are not wholly independent of provider organisations bringing the potential for a conflict of interest.

5.9.2 The Scottish Independent Advocacy Alliance, initially funded by the Scottish Executive, provides an umbrella agency for advocacy and offers support and training to individual projects and assists in developing services.

5.9.3 The Advocacy Safeguards Agency is funded by the Scottish Executive to ensure that good quality independent advocacy is available to anyone in Scotland who needs it.

Current services

5.9.4 Although advocacy services are developing for adults aged between 18 and 65 years who have mental health problems and for people with a learning disability there is a general lack of advocacy provision for older people, people with dementia, young people and children, people with a physical disability and those from ethnic minorities. 'Hidden' need also arises for other groups, including homeless people and ex-prisoners.

5.9.5 People with mental disorder are among the most vulnerable, especially so when communication difficulties are a factor. The Act provides the right of access to independent advocacy services and they are crucial in ensuring that people can make their voice heard. In addition, advocacy services work with commissioning bodies to develop services and are involved with the evaluation of existing services and in offering suggested solutions to difficulties encountered in the work.

Funding and spending

5.9.6 Advocacy services are primarily funded by the NHS and local authorities, although there is significant variation in statutory funding across the country (table 3) and a significant proportion of funding (18%) comes from other sources such as the Scottish Executive, charities, trusts and community funds. About 70% of the total advocacy spend is on independent or sole focus services. The Advocacy Safeguards Agency notes that while the increase in statutory agency spend has increased by 36% in the last year, and there has been an increase of 61% in spend on independent services, there remain many gaps in service.

Table 3 - Statutory advocacy spend per head of population, NHS and local authorities, 2003/04

5.9.7 A further 1,405,763 is received from other sources.

5.9.8 Given that the Act gives the right of access to independent advocacy, there may need to be significant increases in services to meet the anticipated needs. People with mental disorder benefit from the services of an advocate in several ways. This might be to assist with representation at a Tribunal or other specific situations. Other people may require assistance in representing their views in the longer term due to ongoing difficulties getting their point across. Group or collective advocacy might be appropriate for people with mutual concerns. Advocacy services are organised so that these differing situations can be addressed with professional, volunteer, citizen, collective and self advocacy services available.

5.9.9 It is estimated that there will be 3,000 Mental Health Tribunals per year. ⁷³ In August 2003, 1,921 people were subject to long-term detention under the 1984 Act and in 2002-03 there were 2,795 short-term detentions. ⁷⁴ All of these people could request the services of an advocate and will be informed of this by their mental health officer. In addition, there were about 25,000 admissions to psychiatric hospitals in 2002 ⁷⁵ and this number of people could also request a service. People receiving outpatient services might further add to these totals. It was not possible to get information about how many people actually used the services and this is important data to collect.

5.9.10 It is very difficult to estimate future demand and the likely requirements for additional advocates. There will almost certainly be an increased demand. Work on identifying gaps and planning new and increased services is very much work in progress for local commissioners in conjunction with the Advocacy Safeguards Agency and the Scottish Independent Advocacy Alliance. However, given the finite workforce available, recruitment of both paid and unpaid advocates is expected to be problematic. There is a risk that the statutory requirement for mental health advocacy might divert available human resources away from other forms of advocacy. The training of new workers will also place demands on the limited resources of the Scottish Independent Advocacy Alliance and other training sources.

5.9.11 Given the complexity of the new legislation and the significant involvement of advocates, among the challenges for advocacy will be consideration of the roles of paid and unpaid advocates. Training about the Act will be vital along with an appreciation of mental illness and how this might manifest itself. It is important for an advocate to be able to understand and represent the interests of the client even when, or especially when, the person is acutely unwell and perhaps expressing unusual ideas.

5.9.12 Advocacy organisations may need to consider the level to which the service can and should 'professionalise' and develop a career structure. This would help to address a common complaint that health and local authority professionals do not give due regard to independent advocacy and would bring a sounder footing to the process. For some service users, however, this could have the disadvantage of making it appear that advocates had joined the formal caregivers.

5.9.13 Advocacy services do not have the capacity to provide a service to everyone who might request it. Planning partners within each NHS Board area are required to submit the next 3 year advocacy plan in February 2004 to the Executive and these plans will need to reflect the new requirements.

5.10 ACCOMMODATION

5.10.1 The transfer of Housing Benefit funding to local authorities under the Supporting People initiative means that more people who are vulnerable can receive support to retain their tenancies and stay in their own homes and this will include significant numbers of people who have mental health problems. (Certain aspects of employment-related support are also eligible under Supporting People funding - see the separate Employment section of this chapter).

5.10.2 Closure of large numbers of psychiatric hospital beds for people with long term illness and the expansion of community based services has allowed finance to transfer from NHS Boards to local authorities through the resource transfer arrangements. This has contributed to the costs of care and support provided by the local authorities directly or commissioned from other providers,

5.10.3 In most cases 3 year service contracts are agreed between the local authority and supported housing providers, although commonly voluntary sector providers agree ongoing funding on a year to year funding. Some contracts will not include an increase for inflation. In such cases the provider will be placed under increasing financial pressure to keep pace with salary costs, new investment in equipment, training and other pressures.

5.10.4 The 2001 voluntary sector workforce survey showed that there were around 37,000 social care staff ⁷⁶ in Scotland. The survey did not define the proportion who were working with the adult mentally ill, nor those employed in supported accommodation. However, the findings did confirm that around 15,000 staff had qualifications in social work, registered nursing, occupational therapy, or community education. There are concerns within the voluntary sector about their long-term ability to attract and retain experienced and trained personnel to their services given increasing competition over salary levels.

5.10.5 Information from the statutory to voluntary sector is not always wholly exchanged or explained, with the potential for leading in some cases to an unsafe position caused by the failure to provide essential basic facts. This point of view was expressed more than once by voluntary sector providers.

5.10.6 It is essential that voluntary sector providers of care and support become more integrated in the overall mental health teams, and be better valued for the role and contribution they make to sustaining people in their own homes and communities.

Regulation of housing support

5.10.7 From April 2002 all registered supported accommodation, support services, day care services, residential homes and nursing homes fell under the quality, registration and inspection processes of the new Scottish Commission for the Regulation of Care (Care Commission). From October 2003 all housing support services were also required to be registered and inspected by the Care Commission. Care at home services came under the Commission's responsibility from December 2003.

Support models

5.10.8 Models of supporting people in community housing were described in the Scottish Development Centre for Mental Health (SDCMH) briefing paper ⁷⁷ under five main headings:

Table 4 - Models of supporting people in community housing

5.10.9 Strathdee and Thornicroft ⁷⁸ estimated the number of supported living places that would be required for every 250,000 population, shown in table 5 below:

Table 5 - Number of supported living places required per 250,000 population

5.10.10 In many cases local authority staff raised concerns about the lack of adequate and affordable housing stock in their area to allow supported accommodation to be developed. One solution now being employed in parts of the country is to include a Senior Housing Officer on the local strategic mental health planning forum, with some positive results in greater access to housing.

Types of support people receive

5.10.11 Most people who receive support to live in a home of their own (whether single or shared tenancy) are generally happy with the services they receive. Service users understandably attach great importance to security of tenure, a place to call their own home, to being listened to and to having access to help if and when required. Individually and collectively these components are key to maintaining positive health. The Scottish Development Centre for Mental Health refers to the work of Carling ⁷⁹ and 3 guiding principles for supporting people in housing:

• Choice - location, neighbourhood, convenience, space, privacy, accessibility to networks and services

• Integration - the opportunity to live in non-segregated stable housing with the necessary support provided

• Normalisation - the avoidance of approaches that accentuate differences from typical community practices and acceptable patterns of lifestyle

5.10.12 Voluntary sector providers have said to the Review Team that for any provider to deliver on all 3 principles means going beyond the traditional 'medical model' of diagnosing and treating illnesses and ensuring a whole person approach to care. Supported housing providers regularly commented on a group of service users whose needs assessments were out of date and as a result the existing care packages no longer met needs. This absence or regular review of needs applies especially for the 'graduate' long-term population.

5.10.13 The Scottish Association for Mental Health, one of the voluntary sector housing providers, notes a growing difficulty in accessing services for people in crisis situations, although they found that those on the Care Programme Approach (CPA) usually experience better responses.

Benefits Issues for Users

5.10.14 Supporting people in the community through the Benefits system has recently undergone significant change. The introduction of Supporting People in early 2003 was to replace Transitional Housing Benefits. While this was expected to increase the availability of housing support, this has yet to be fully achieved.

5.10.15 Many existing supported housing projects have or are in the process of transferring to unregistered status with the Care Commission. A key feature of this will require transferring tenancy of a property from the service provider to the resident. The people most affected by this are often the most vulnerable, marginalised and at risk of social exclusion.

5.10.16 The effect of these changes has placed many potential tenants on their local mainstream housing list, rather than being in a home run and provided through a housing support provider. While these moves toward greater autonomy and independence are positive, the paradox is that vulnerable users will now have to negotiate with a variety of agencies, potentially the Department for Works and Pensions, Housing Benefits offices, Council Tax benefits sections, and separate utility providers. The housing support providers previously dealt with all such issues.

5.10.17 People who need furniture and housing equipment now need to submit applications for Community Care Grants. Previously housing support providers were able to secure value for money and other savings through bulk purchase and discount arrangements.

5.11 EMPLOYMENT

5.11.1 Employment policy is complex, involving many initiatives to drive the agenda forward for the population as a whole. There are particular issues facing people with a mental illness, who have historically been marginalised from the work force. Evaluative research to discover which employment interventions actually work best is hard to find in this country. American studies found that interventions based on supported employment models were significantly more effective than vocational training in achieving the desired outcomes of sustained open employment. ⁸⁰

5.11.2 Section 26 of the new Act places a duty on local authorities to provide support into employment for people with mental health problems. The actions required will have an impact on health, social work, employment, enterprise, education and social inclusion agendas. Surveys confirm that people with mental health problems want a range of employment services and opportunities. Up to 90% have said they would like employment of some kind ⁸¹, but not everyone wants to be employed in the competitive mainstream setting. Some people may not be capable of joining or rejoining the workforce and a range of opportunities including sheltered, supported and voluntary settings may be attractive alternatives to ensure occupational activity.

5.11.3 In broad terms studies indicate that as well as financial reward, work offers added status, purpose and opportunities for relationships, ⁸² yet there is a paradox reflected in the rising incidence of work related stress disorders.

Numbers and costs⁸³

5.11.4 The number of people with a physical disability gaining work has steadily increased over the last ten years, but there has been very little increase in the proportion of working adults with acknowledged mental health problems. A recent report ⁸⁴ estimated that 43% (117,000) of unemployed people in Scotland have a mental illness.

5.11.5 People with a mental illness who receive Incapacity Benefit comprise around 35% of the current 2.7 million registered in the UK and are 3 times more likely to be unemployed than all other disabled people. People with psychotic disorders are even less likely to be in employment.

5.11.6 For some people state benefits can act as a disincentive to work and this issue is being tackled through initiatives such Disabled Persons Tax Credit and Pathways to Work Green Paper ⁸⁵. However, fear of losing benefits may for some remain a significant barrier to returning to work.

5.11.7 In addition to the personal costs for people with mental health problems who cannot work, there is the economic cost for the country of the inactivity of such a large group of people. In Scotland the estimated cost ⁸⁶ is around 1 billion.

Policy background

5.11.8 The Disability Discrimination Act 1999 (DDA) aims to tackle a wide range of discrimination against people with disabilities and prohibits discrimination against any person with any disability who either applies for a job or is already in employment. There is little evidence yet of the impact of the DDA on mental health service users in relation to employment.

5.11.9 Helping people with disabilities, including those with mental health problems to return or start work is an important factor in recovery. This is supported through a range of policy statements and practical initiatives, including the Welfare to Work Task Force, New Deal for Disabled People and Pathways to Work . The National Programme for Improving Mental Health and Well-Being ⁸⁷ has a key priority to improve mental health and well-being in employment and working life. This will raise the profile and support that mental health service users can expect to receive from employment initiatives.

5.11.10 The Framework for Mental Health Services in Scotland² includes a section on 'Services to promote personal well-being and social development', offering service elements relevant to employment and these should form a service matrix for strategic planning.

5.11.11 Finally, the Mental Health and Employment Policy for Scotland ⁸⁸ addresses closing the exclusion gap, tackling discrimination, improving the mental health of the working population and solving labour force shortages.

Service funding and availability

5.11.12 There is no obvious single secure source of funding for the various specialist employment services that target people with mental health problems. Historically many services operate with an unstable mix of funding sources with many receiving grants from the European Social Fund (ESF) Objective 3 and the New Futures Fund. The imminent termination of this type of funding will not help existing projects and some may close down.

Service patterns

5.11.13 There is a diverse range of opportunities and although this is a very positive development the complexity means that understanding and co-ordinating such services is difficult. At a local level services are often patchy and the full range of options is rarely available. There is general consensus that an employment spectrum is required which means that people should have access to advice and brokerage; preparation for work; vocational and pre-vocational training; sheltered employment and transitional employment; and preventive strategies/work retention.

Preparation for work

5.11.14 Within the health service (often located in old larger psychiatric institutions) occupational therapy centres, day hospitals, and industrial therapy units combine to offer service users structure and meaning to their week, and some work preparation skills.

5.11.15 Within health and social work the role of occupational therapists should be considered core to identifying the employment needs of service users, although some of these services would be better delivered by the voluntary sector or the many other providers of employment in the community.

5.11.16 As the emphasis on community prevention and recovery gathers momentum, many of these services have been redesigned or re-commissioned. Within the community, day centres and drop-in centres are valued by people with mental health problems. The majority are provided by the voluntary sector and advice, encouragement and active brokerage into work are features of such services.

5.11.17 There are 6 Clubhouse centres in Scotland, where service users determine the running of the projects as members of a club. Members participate in a variety of activities, usually within the Clubhouse and education and training courses build confidence and raise awareness of opportunities. Members can move on to Transitional Employment Placements - part-time entry level jobs negotiated by the Clubhouse with local employers. Clubhouse staff work alongside the member for as long as is necessary.

5.11.18 Voluntary work has great potential as a step on a 'ladder of opportunity'. A surprisingly high proportion of people with mental health problems are involved in voluntary work at some point in their lives.

Vocational and pre-vocational training

5.11.19 Service user groups have noted that training is of little use if the likelihood of getting a job at the end of it is minimal ⁸⁹, and the extent to which training actually leads to employment is not clear and should be monitored if that is the specific objective.

Sheltered employment and transitional employment

5.11.20 There is a wide range of sheltered workshops and sheltered employment factories give opportunities to people with a range of different disabilities. The proportion of places taken up by people with mental health problems is not currently known. 'Social firms' and 'social enterprises' are the best-known service models within a transitional employment market that has been evolving and growing over recent years. The aim is to increase job readiness while recognising that some service users will not wish or will not be capable of moving on to mainstream employment. Virtually all social firm initiatives have been taken forward by the voluntary sector.

Preventive strategies/work retention

5.11.21 Early intervention and counselling services could minimise mental health problems and reduce the incidence of work related stress. Durie ⁸⁴ argues that " the overwhelming need is to stop people losing their jobs as a result of mental health problems, spending long periods inactive then needing significant help to overcome barriers to employment. Investment in job retention would eventually release resources to reallocate to supporting new labour market entrants and people with severe and enduring problems."

5.12 TRANSPORT

5.12.1 There can be major difficulties in remote areas when people are dependent on public transport, often relying on benefit support. In a town or city, access to drop-in support and leisure or work opportunities may be difficult, but is possible. People with mental health problems who live in rural and island communities have little opportunity to travel to such services (even if they are available). How are they to reach help or get to hospital? How does a solitary staff member get from one island to another in time to respond to urgent calls for help?

5.12.2 Solutions centre mainly on time-tabling, co-ordination, ingenuity and community spirit reflected through volunteer rotas from car owners, including those with mental health problems themselves. The Review Team was impressed that one service had the flexibility to provide a bicycle for someone with long-term mental health problems.

5.12.3 Under the new Act ⁹⁰ a clear duty has been placed on local authorities. The exact provisions are set out below:

5.12.4 Mental health patients, like other service users, will sometimes need transported to hospital by ambulance because their state of health rules out alternatives. The Review Team heard concerns about the Scottish Ambulance Service (not about the ambulance staff), where delays were seen as being attributable to a too rigid reliance on protocols.

5.12.5 At the extreme end the Review Team was told about a few people, who would otherwise have agreed to an informal admission, being detained under the Mental Health Act in order to get the required escorts to allow transport from the Air Ambulance Service rather than wait for routine transport. This practice is unacceptable and illegal.

5.12.6 In remote places there will be infrequent need for such transport for people who are mentally ill and therefore little local experience in dealing with such situations. The stigma of mental illness includes for some a fear that the person concerned will be or become violent and it is appropriate that due caution be taken, especially in a small aircraft with access to the cockpit. However this needs to be done on an informed basis and we welcomed the fact that the Scottish Ambulance Service has recently issued guidance on Emergencies in Mental Health ⁹¹ to establish routine procedures.

5.12.7 It will be important that ambulance staff are given appropriate awareness training about the new Act, alongside relevant mental health training.

5.12.8 The Remote and Rural Areas Resource Initiative (RARARI) multi-agency report ⁹², 2003, has 10 recommendations based on getting the right balance between respecting an individual's rights and needs and the responsibility to ensure the safety of others.

5.12.9 A key recommendation from the RARARI report is that "When psychiatric patients are to be admitted to hospital, the need for transport and/or escort must be assessed separately from the need for detention under the Mental Health Act section, and clearly documented."

5.12.10 All delays cannot be attributed to the ambulance service. Finding NHS escorts can be a time-limiting factor (as can the weather). The collection of systematic data about the process and outcome of ambulance transfers will lead to better informed discussion and resolution of some of the tensions that may arise.

5.12.11 When there is a delay in getting transport to hospital, there is a need for a safe place for the patient to wait in to reduce or remove any risk to self or others.

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