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National Mental Health Services Assessment: Final Report
8. CONCLUSIONS AND RECOMMENDATIONS - AN OVERVIEW
THE ACT
8.1 The Mental Health (Care and Treatment) (Scotland) Act 2003 has been well received generally and it is a source of pride that Scotland is pioneering mental health legislation that enshrines recent developments concerning human rights. Extensive consultation by the Millan Committee with people who use the services and those who care for them, as well as with those who plan and provide services, helped to develop the principles behind the Act and this has ensured a degree of awareness about what is needed in addition to the changes in statutory procedures.
8.2 In many places training in the details of the Act has already begun, with considerable progress since we first started the Assessment. Although the Millan Report
4 was written in language accessible to most people, the new Act obviously had to be written in legal terms, causing difficulty for some with understanding. Publication of the Code of Practice will be very welcome, but there are perhaps overly optimistic beliefs that it will "explain everything". This is new territory, not just an amendment of the old Act.
8.3 The principles underlying the new Act provide the basis for a new style of service delivery that will have a major impact in improving the experience of users and carers and will link with many other initiatives underway and planned which are designed to progress better mental health and well-being and to improve health and social inclusion generally. This broader approach to mental health policy and practice in Scotland includes work on stigma, mental health promotion and achieving greater social inclusion for people with mental illness and complements the work being done to improve treatment and care services.
8.4 The conclusions and recommendations that follow capture what is needed to bring about early change and improvement in the organisation and delivery of mental health services, and to the well-being of services users and their carers. The key themes from the users and carers perspective, gathered from a wider list and brought to the fore during the assessment, are as follows:
There is a real need for out-of-hours and crisis services
There is insufficient support for those living in the community
There is a need for easier access to services in the community which should be local not centralised and remote
There is a need to continue the national and local work on tackling stigma
Mental health awareness training would help to promote a better understanding of mental illness and mental health issues for staff in a variety of agencies who come into contact with people who have a mental illness
Conclusion
8.5 The process of consultation and involvement has worked well and people are waiting for further training and guidance. The new Act is recognised as being part of a broader and more integrated policy, both nationally and locally and the Joint Local Implementation Plans should reflect this.
Recommendation
8.6 The Scottish Executive should continue with the current implementation process and provide central guidance to inform the priorities in local training action plans and Joint Local Implementation Plans, to be implemented by the agencies within set timescales.
ORGANISATIONAL CULTURE
8.7 Despite the positive response to the Act per se, in many places we encountered a sense of paralysis or inertia among staff and managers, with people talking about exhaustion and work-overload. Although the importance of the new Act was acknowledged, there was genuine bewilderment about how to cope with the added demands. Some people responded with anger, others with denial and the hope it would "all go away". Travelling round Scotland we found that this portrayal of helplessness was striking and reinforced what we were told about the effects of gaps in the workforce and other stresses.
8.8 We gained the impression that what we were finding was broader than the impact of the Act alone. As one person said
"the Act is a peg to hang things on". Or another
"this is the straw that will break the camel's back". There was cynicism about increased resources or increased support being made available.
8.9 While there was agreement that many policies had not been fully implemented, including the
Framework for Mental Health Services in Scotland,
2 this tended not to be accompanied by a sense of any personal or local responsibility (or funding) to start making a difference.
8.10 So why are mental health services within the health and social care sector, plus to a lesser extent the voluntary sector, under such strain? There appear to be six main reasons:
Perceived chronic under-funding, yet very apparent rising needs, demands and expectations from the public and politicians
A continuous change agenda and restructuring, which is seen as being in the way of getting on with the work rather than assisting the process
Increasing monitoring and accountability, which can be seen as bureaucratic and unhelpful, not ways of improving service quality
Lack of clarity about accountability, roles and responsibilities, which is seen by some as an attack on professionalism
Continuing negative feedback from people who use the services, which leads to low morale
The perception of increasing centralisation and control from the Scottish Executive and local senior management, despite rhetoric about devolved power
8.11 Although this overall picture is a source of major concern, we were partly reassured by meeting some people with energy and enthusiasm, who are planning and providing very good services; people who are entrepreneurial about accessing all funding streams and people who are working creatively across traditional service boundaries. In order to achieve this they have needed close partnership with users and carers. How to ensure that this approach becomes more mainstream is a significant challenge.
8.12 People who use the services often say that one of the worst problems is being treated with disdain and restraint (both overt and covert) rather than dignity and respect and this is one of the essential cultural issues that must change. There is a growing number of staff who completely agree and whose practice demonstrates commitment to a service user focus, even though they may be part of a group that is frequently denigrated by service users and carers. Part of the challenge is for people with like minds, whether users, carers or staff, to work together without compromising the radical momentum of the service user and carer movement.
Conclusion
8.13 There are major staff morale, attitudinal and cultural problems which, unless attended to consistently, will inhibit full implementation of the underlying principles of the new Act.
Recommendations
8.14 People who use the services and those who care for them should work together with staff who share the same values, to jointly bring about change and ensure that the principles behind the Act are adhered to.
8.15 Front-line staff should lead on bringing about the changes required by the Act, using it as a development opportunity for the service, those working in it and those receiving care.
8.16 The senior managers in local authorities and NHS Boards should devolve more authority, responsibility and accountability (including budgets) to front-line staff, with a clear objective to work closely with the voluntary sector and service users and carers.
8.17 The Scottish Executive should focus on the implementation of existing policies in mental health services and the implementation of the Act and avoid creating additional policies at this point in time.
INFORMATION
8.18 Throughout the visiting and review process we were considerably hampered by lack of accessible information and financial data as described in Chapters 5 and 7. Although this had been anticipated, the extent of the problem had not. Better information for managing services locally, regionally and nationally has been sought for many years. Why is it not available?
Lack of consistency and standardisation of terminology and methods of collecting data
A continuing focus by ISD on the collection of inpatient and consultant-centred data, despite the change in emphasis of the service to multidisciplinary provision in the community
The complexities of data linkage across health and social services
A hope that "new software" will solve everything - and waiting for it to be provided
Insufficient information fed back in time for it to make any difference to the people who have to fill in forms, who therefore see this as a bureaucratic burden without direct benefit
Lack of investment and resources in equipment and training, plus recognition of the time involved in providing data
8.19 Our sense of frustration and exasperation about not finding information was in contrast to the help we received from people throughout the services (and from the General Registry Office also) who undertook specific pieces of work for us, especially the ISD sponsored
Improving Mental Health Information Programme. Better data is now being collected and information shared in the monthly bulletin that can be accessed at
http://www.isdscotland.org/imhip. A Mental Health Information Strategy for Scotland is being developed, which will take this work forward.
Conclusion
8.20 There are serious and major problems in accessing adequate data about mental health services. However, there are a number of significant developments that with consistent application should improve this.
Recommendations
8.21 The Scottish Executive should continue with its current work on developing a Mental Health Information Strategy and ensure that it is locally adopted, resourced and fully implemented in the medium term (3 years).
8.22 The work of the
Improving Mental Health Information Programme should continue and expand so that it can become an expert resource for local services as well as providing national data.
8.23 Staff and managers across agencies should agree on the minimum set of data to be recorded to help improve service delivery and quality and ensure that this is collected.
8.24 Information that informs decision-making should be made available in time for it to be relevant to all stakeholders.
INEQUITY
8.25 The quality and quantity of available services for people with mental health problems differs across Scotland. Some services are very good and some use innovative ways of delivering care. Nevertheless some services are below what would be expected were they adhering to the template within the
Framework for Mental Health Services in Scotland.
2 The deficit in the provision of good quality care has several causes, one of which may be a lack of managers with the range of skills required in this complex area. Resources (usually funding) may not have been adequately accessed or applied to service improvement, nor staff supported in professional development. The challenges to senior management in the health and social services is immense and our comment is not about blaming individuals, but a reflection on a system that does not provide enough personal support or training for managers.
8.26 Another highly significant factor leading to inequity is inadequate funding for the major task of ensuring that all inpatient provision (including that provided in old or out-worn buildings) is fit-for-purpose. This has to be done at the same time as the proportion of the budget spent on hospitals goes down in favour of developing an adequate range of local community care options. Some responsibility for this must lie with Chief Executives of NHS Boards who have to choose between funding mental health or other pressing priorities. The Chief Executives of local authorities do not make prioritisation decisions, these are for the elected council members, who set budgets, (both capital and revenue) according to their priorities and local authorities.
8.27 For people with mental health problems living in some parts of Scotland this may unfortunately mean one or more of the following:
Lack of 24-hour and crisis support
Minimal community care
Excessive stays in hospital
Inappropriate admission to a hospital far from home
Poor hospital environment, including décor, facilities, privacy and separate provision for younger people and mothers and babies
Lack of day activities and opportunities
Lack of advocacy and other support
No access to psychological approaches and interventions
8.28 These services are all
essential components of good mental health care. Local service providers, together with those who use the services and those who care for them, should decide how these requirements can be met. When the numbers of people requiring some specialised aspect of inpatient care are low (meaning that providing a local service would have a disproportionate effect on the overall allocation of resources) services should be planned and provided through managed care networks and regional consortia.
8.29 The high cost, low volume specialist services that will have to be provided at a regional level include:
Inpatient child and adolescent services
Hospital provision for mothers with post-natal depression and their babies if appropriate
Regional forensic psychiatric units and services
8.30 We also found that many Intensive Psychiatric Care Units serve multiple purposes in unsuitable accommodation. There continues to be a debate about how to balance the available resources (skills and finance) against the demand for a range of services to be provided locally when numbers are very small. Providing intensive care facilities for adolescents and people with a learning disability is a particular problem.
8.31 The provision of privacy and security for women seems to be a problem in some areas, especially when the layout and size of wards makes it difficult to find easy solutions. It is clear that many women find being cared for in a mixed-sex environment threatening, especially if they come from a Muslim community or if they have been sexually abused and we were disappointed that this is still a problem several years after finance was made available to services for this purpose.
8.32 An issue that was raised in the Interim Report was the large numbers of people who are admitted to hospital outside their local area, because beds are not available locally. We saw this as a bed management problem rather than the total number of admission beds in Scotland. It needs to be addressed.
Conclusion
8.33 Mental health services in Scotland have some way to go before every citizen has access to the same level of high quality service, including services mentioned within the provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003.
Recommendations
8.34 Flexible and responsive 24-hour support services should be developed locally and planning should involve service users.
8.35 By the time the Act is implemented in 2005, everyone with a serious mental health problem should have their assessed community needs met by a multidisciplinary and interagency team, which should include the voluntary sector.
Any admission to hospital remote from the local area for reasons other than planned regional service provision, because the local facility has no spare capacity, should be monitored and analysed by regional planning groups, with the aim of improving national bed management.
8.37 The accommodation where care is delivered should provide a good environment. When necessary, people should have planned and timely access to gender and age-appropriate facilities and specialist services, including mother and baby units, as required by the Act.
8.38 Day activities and therapeutic opportunities should be available both in the hospital and community, including psychological and social interventions.
8.39 The Scottish Parliament should continue its interest in the welfare of people with mental health problems following the implementation of the Act.
WORKFORCE
8.40 One of the most obvious impacts of the Act is the need for experienced staff to contribute more time to assuring the rights and meeting the needs of people who are detained, or who are subject to the provisions of a community-based Compulsory Treatment Order. This will include presenting comprehensive plans of care to the Mental Health Act Tribunal on the basis of meeting assessed needs, rather than fitting in with what current services happen to be able to provide. This is what the Millan
4 principle of
Reciprocity demands.
8.41 Although the implementation of the Act will involve many people from different care settings, the major implications in the short-term are for responsible medical officers and mental health officers who have leading roles in meeting statutory requirements. Quite simply, there are not enough of them.
8.42 With the current vacancies and problems in recruitment and retention, plus the delay in training new staff, the only solution is to determine what are the core tasks that can only be carried out by these scarce staff members, so that their time can be freed up. This change in roles and responsibilities and the reallocation by discussion and agreement of other responsibilities to the rest of the workforce is what is meant by the "redesign" of services. This is an agenda that has been emerging from a number of sources and the legal requirements of the Act mean that such change is no longer optional.
8.43 Another significant development need is in the provision of advocacy services, which must expand considerably, with major training implications.
Conclusion
8.44 Workforce gaps are probably the most difficult issue to address in the short-term (one year), but this must be done in order to fulfil the obligations of the Act from 2005. This will mean major changes to personal roles, responsibilities and job plans. It will also have an impact on the strategic and structural issues involved in redesign initiatives such as the move to Community Health Partnerships.
Recommendations
8.45 At a national level, work should be carried out to clarify issues about roles, responsibilities and pay scales between different disciplines, organisations and levels of seniority and experience. This must involve the staff-side as well as senior management and should be compatible with ongoing human resource development strategies and life-long learning strategies.
8.46 Locally, there is no time to wait for a national directive, so interim compromises and solutions should be found, in order to ensure the legal rights of people using the services are met. It is essential that this interim work and experience informs and shapes the national guidance and regulations.
8.47 The National Mental Health Workforce Group should lead on these issues.
FINANCE
8.48 The comments in Chapter 7 were mainly about insufficient financial information being available. During the visits we also developed concerns about the lack of knowledge about how to get access to funding.
8.49 At the beginning, some concerns were expressed by the Scottish Executive that we would arrive back with an enormous wish-list. Despite giving people open opportunities to express such wishes, little was forthcoming (even at very senior levels) except in the most general way and it was often about things that did not cost money, such as better communication.
8.50 People said they were worn out asking and not getting, so did not ask any more. This 'poverty of aspiration' is part of the cultural problems mentioned at the beginning of this Overview. This applies mainly to the statutory sector, where people providing services in the front line are not experienced in presenting properly set out and costed business cases to managers. If managers do not have that kind of information in support, how can they argue for increased resources?
8.51 In contrast, the voluntary sector has vast experience in securing funding from a variety of sources - that is how it survives. Despite the fact that there is considerable opportunity cost in the time spent applying for money and there are negative aspects in short-term funding, there is an expertise and resilience that should be learnt by workers in the statutory sector.
8.52 These observations relate to relatively large sums of money. Yet resource allocation problems can arise when even small amounts of money are refused. There are groups of service users and carers who have asked for relatively small amounts of money that could make a difference to their quality of life, for example for support groups, creative projects and for disseminating information. The money required is nowhere near the size to merit formal grant application (nor is there the knowledge to do so). We found that when attention was brought to this at high levels there was a degree of surprise and money was rapidly forthcoming. Until budgets are devolved to local levels, with flexibility and a priority to resource and support such initiatives there will continue to be problems.
8.53 Behind all the financial concerns two things stand out: the lack of ring-fencing of money and insufficient investment in mental health services generally.
Conclusions
8.54 There is insufficient standardisation and clarity about the funding of mental health services and how the money can be tracked into services at a local level.
8.55 There is insufficient expertise within the statutory sector at a care delivery level about how to develop a business case and obtain resources to fund it.
8.56 There is a perceived under-funding of mental health services. Until it is clear exactly what is being spent, how well and to what effect, an unanswerable case for an increase is difficult to make. The need for resources will become greater in order to implement the new Act.
Recommendations
8.57 The Scottish Executive, NHSScotland and local authorities should ensure that there is a standardised and transparent system for recording financial data that contains not only national data, but regional and local spend.
8.58 A system should be developed whereby money spent can be tracked to local service provision and accounted for within the monitoring systems
8.59 Staff as well as managers should take responsibility for understanding financial issues in relation to improving outcomes, including the concept of opportunity cost.
8.60 Robust business cases should be put forward for increasing resources within the statutory sector and voluntary sector.
8.61 NHS Boards and local authorities should give increased priority to mental health service resource allocation especially in relation to the pressures and commitments associated with the new Act.
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