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Chapter 2 Mental health

Introduction

Significant efforts to improve people's mental health have been made in Scotland and the Scottish Executive has made a commitment to ensure that people who experience mental ill-health are not stigmatised or discriminated against. It is important that they are enabled to make a full contribution to life in Scotland and are encouraged to use their abilities and talents like anyone else.

Improving mental health is a complex task and involves addressing not only the needs of people who may have or who are in danger of developing major problems or illnesses, but also involves efforts to improve, support and sustain the mental health and well-being of the whole population.

The contribution that good mental health can make to a country's overall health was made clear in the WHOMental Health Declaration for Europe ( 1) launched in Helsinki in January 2005, in the presence of Health Ministers and their representatives from over 50 European countries. Scotland's Deputy Minister for Health was also present. Later in 2005, the European Commission published its Green Paper on Mental Health ( 2).

Both these documents make it clear that attention needs to be paid nationally and locally to:

• improving and promoting the mental health of populations
• working to prevent mental health problems and illnesses developing
• ensuring that, when illnesses and problems do occur, there is a good system of local community access to care, treatment and support to aid people's recovery.

They highlight the importance of having appropriate, modern and supportive national legislation that protects the rights of people experiencing mental health problems and safeguards high quality treatment and support.

Progress in Scotland in 2005

During 2005, good progress was made on population mental health, ill-health prevention, improving care and treatment, and implementing modern legislation.

New legislation

A highly significant contribution to ensuring progress in mental health was the staged introduction of the Mental Health (Care and Treatment) (Scotland) Act 2003. This brings positive changes to the lives of people using mental health care and learning disability services and to their carers, including:

• a clear set of guiding principles
• new treatment orders to be tailored to people's personal needs
• fairer and safer procedures
• new powers of protection for people's rights
• the ability to make advance statements about how people would like to be treated if and when they become too unwell to make their own decisions
• rights of access to independent advocacy
• a duty on local authorities to promote the well-being and social development of all people who have a mental illness or learning disability.

The impact of each aspect of the Act will be evaluated and a programme of research into its operation has been put in place. This will demonstrate whether the aims are being met and whether and how the law and its operation may need to change in the future. It will also help to gather new evidence and insights into mental health care and treatment in Scotland.

A large part of the preparation for the Act was carried out by local health and local authority services and their voluntary sector partners. Much of the focus has been on modernising and improving services across the country. This will continue and has been given additional impetus by the publication of Delivering for Health ( 3) which sets out a programme intended to accelerate improvements across aspects of the health service over the next few years.

Scotland has maintained a strong focus on children and young people's mental health. Substantial work followed the launch in 2005 of the Children and Young People's Action Framework for Mental Health. The next two years will see significant investment being made in supporting improvements to children and young people's mental health services and in creating an environment where young people can have ambition and confidence in their own abilities and where they can contribute, learn and achieve.

Prevention of mental ill-health

Good progress has been made in the area of prevention of ill-health. One notable achievement has been the Doing Well by People with Depression programme. A major component of this is aimed at enabling local services, particularly in primary care, to recognise and respond to depression and to improve local care and treatment. This includes a wide range of appropriate interventions such as drug therapy, self help and self care resources and social supports.

This programme fits well with Delivering for Health's emphasis on preventive care, support for self care and anticipating where services are needed most. Earlier studies in public mental health have shown that there is a particular need for local prevention of depression in the more deprived areas of Scotland, with more emphasis on recognising problems earlier and supporting people's recovery. The Doing Well programme has provided a sound basis for this.

It is supported by the expansion of the Breathing Space advice and support line, an important part of prevention and response. This free service, which receives over 3,000 calls per month, helps to support people experiencing depression and emotional and mental health problems and guides them to local services. It is particularly aimed at men, who are less likely than women to access NHS or other services for health problems, especially about mental or emotional health. An independent evaluation of Breathing Space was carried out in 2005 and the findings will be used in the development of the service.

Another important area has been suicide prevention (defined as deaths by intentional self harm and those of undetermined intent), following the launch of the Choose Life Strategy and Action Plan in 2002. In that year, the number of suicides in Scotland was 899 (17.6 per 100,000). In 2005, the number was 763 (15.0 per 100,000). There was a marked decrease in male suicides in the 15-24 and 25-34 age groups. (These are European age-standardised rates. Suicide statistics in Scotland are based on small numbers, rates are subject to annual fluctuations and figures need to be monitored over a five year period to assess any trends.) Steady progress is being made and the results of an independent evaluation of the first phase of Choose Life will be published in 2006.

Improving care and treatment

One example of the positive changes introduced by the Mental Health Act is the provision of perinatal services and purpose-built accommodation for women with mental health problems in pregnancy and post-natally. A facility has been established in Glasgow and a second is due to open in Lothian in 2006. Other parts of the country are making their own arrangements to provide perinatal services, including sharing or planning to share these facilities.

Population mental health

Mental health is a term that carries a variety of meanings for people, most often associated with illness or problems, but this is changing. In Scotland, and elsewhere, there is a shift from a predominant concern with mental illness to an interest in the wider aspects of mental health and well-being for the whole population, sometimes known as public or population mental health.

Part of this involves challenging people's knowledge and beliefs about mental health and mental illness (Figures 2.1 and 2.2). The award winning anti-stigma campaigning work by see me... ( 4) continues ( www.seemescotland.org) and in 2005 an innovative campaign started to engage and challenge attitudes and behaviour amongst children and young people. The campaign features a character known as Cloud Boy. The last frame of each short story about Cloud Boy has the caption 'I'm a person... just like you' ( 5) ( www.justlikeme.org).

Figure 2.1: I'm a person... just like you

The data in Figure 2.2 show small but important reductions in the prevalence of negative attitudes to people with mental health problems.

Figure 2.2: Changes in attitude 2002-2004

Source: Well? What do you think? The National Scottish Survey of Public Attitudes to Mental Health, Mental Well-being and Mental Health Problems commissioned by Scottish Executive in 2002 and 2004.

The Scottish Recovery Network was launched in 2005. This is designed to help challenge people's negative assumptions about mental illness and promote the recovery that people can and do make from major mental illnesses. A programme of training, evidence gathering of new models of care to support recovery and capturing people's recovery stories from all over Scotland has begun. This illustrates the importance of supporting people whose lives are challenged by mental illness and of giving them, their carers, family, friends and work colleagues hope for the future and an understanding of the important role they can play. In the same way as physical problems and illnesses, mental health problems and illness are part of the human condition.

The importance of positive mental health and well-being is increasingly becoming recognised, bringing new opportunities and challenges for public health. It is important to understand how people feel and think, and how resilience, control, optimism, confidence, self esteem and the ability to form and sustain satisfying relationships can affect positively health and well-being. There is a need to understand more about how to help support and improve mental health, emotional and cognitive attributes, skills and abilities in order to lead healthier and more satisfying lives.

The way people feel and think affects their abilities to take control over important aspects of their lives such as:

• their choice of food
• whether or not to exercise
• use of tobacco
• use of alcohol
• use of illegal drugs
• home and family life (especially important in the early years)
• life at work and in the wider community
• participation in sports, the arts, culture and recreation.

Work on these wider dimensions of population mental health will continue across Scottish Executive Departments and national and local agencies through the National Programme for Improving Mental Health and Well-being. As all health improvement work and addressing health inequalities requires a mental health component, the first national set of core indicators to measure Scotland's mental health and well-being is being developed by NHS Health Scotland. These will show the current position and what needs to be done to carry on the challenge of improving Scotland's mental health.

Mental Health Delivery Plan

For many years mental health has been perceived to be the "Cinderella" service amongst the three clinical priorities. Delivering for Health has provided the opportunity for the Executive to address this imbalance. We therefore agreed that a Mental Health Delivery Plan would be produced by the end of December 2006. We are now progressing this work, building on the good work that has already been achieved.

The purpose of the Plan and its subsequent implementation is to address the need for change in the way in which services are delivered, how they are delivered, where and by whom. The changes that we want to occur will take place across the board - in community settings, in hospitals and in specialist services. A big emphasis will be the need to work towards shifting the balance of care away from hospitals and into the community. This in turn means that there will be the need to work with service users and carers alongside those working in the statutory and voluntary sectors in order to drive change forward and ensure success and sustainability. This requires support at a local level and Chief Executives of all organisations involved will have a major role in ensuring the providing leadership at all levels in order to ensure successful delivery of these changes.

Much of what will be done will build on the good work that already exists. We will build on the work of the National Programme for Improving Mental Health and Well-Being and the new mental health legislation, ensuring that patients and their carers are at the forefront of service delivery. We will need to work with the NHS, Local Authorities and Voluntary Organisations to ensure that better integration of services takes place and that in turn this offers more choice, more accessible and more effective services for users. We need to ensure that we develop a culture across society and within services that not only embraces change but also respects the rights of individuals, as well as ensuring equality and respecting diversity. This applies to users and carers but equally applies to staff delivering services.

Change on this scale takes time and concentrated effort from all involved. During the implementation phase of the plan, dedicated change professionals will work alongside users and providers to embed new practices and make changes that will result in improvements to current services that will be sustained for the longer term.

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