The Scottish Government

« Previous | Contents | Next »

Listen

4 Shared objectives and actions for local delivery

4.1 The first question in the consultation paper was: What shared objectives and actions for local delivery should be made for 2008-11 that would be deliverable, measurable and valuable?

4.2 The responses to this question were detailed and varied. However, as mentioned in the previous chapter, respondents generally agreed with the three broad themes for action - promotion, prevention and support. Therefore, these three themes will be used as the basis for summarising responses. Where additional themes arose, these will be addressed at the end of this chapter.

Promotion

4.3 Respondents had a range of views on possible objectives and actions to promote and improve mental health and wellbeing. In general, these focused on:

• Individual lifestyle interventions
• Population interventions
• Structural interventions
• Interventions with children and families

Lifestyle interventions

4.4 Respondents agreed with the links made in the document between mental health and wellbeing and lifestyle issues. It was suggested that ongoing work to reduce tobacco, alcohol and drug use should continue. There was also a view that greater priority should be given to reducing alcohol problems in Scotland, and that this might include an increase in taxation on alcohol to reduce the prevalence of drinking among young people and stricter controls on licensing of pubs. There was also a suggestion that action was needed to raise awareness among the general public of the relationship between alcohol and mental health.

4.5 Respondents suggested that, on a local level, much more could be done to link mental wellbeing more explicitly to other health-related strategies, including strategies on physical activity, healthy eating and substance use.

4.6 Finally, there was a call for awareness-raising and increased action to reduce the risk of dementia through encouraging healthier lifestyles.

Population interventions

4.7 Respondents agreed that it was important to promote positive mental health and wellbeing through interventions targeted at the general population - in schools, workplaces and other community settings - and it was suggested that where they were available, existing networks such as Health Promoting Schools and Healthy Working Lives should be used for this purpose.

4.8 Respondents made general comments about how to promote mental health and wellbeing. For example:

• Foster hope in communities and families
• Undertake media campaigns to inform and educate the general public
• Strengthen the factors that promote positive mental health
• Tackle the cultural barriers to prevent people from being able to talk about their emotions.

4.9 They also made suggestions for more specific interventions and activities:

• Promote gardening and community allotment schemes, particularly in deprived areas of Scotland ("Local Councils and NHS Boards should fund at least one Community Allotment Health Project in their area.")
• Give people opportunities to participate in more cultural, social and artistic activities ("Identify, foster and protect the things that give people a 'lift' - musical entertainment, drama, games, sport, cinema." "School holiday programmes should be widened to include more cultural / art activities and evening classes.")
• Continue to tackle bullying in schools
• Develop emotional resilience among young men
• Use community development methods to encourage people to support each other.

4.10 Respondents were very much in support of the suggestion made in TAMFS that action needed to be taken to improve 'literacy' around mental health and wellbeing among service providers and the general public, and one respondent suggested that 'mental health literacy' should include 'dementia literacy.' This work should include all public sector staff, including social workers, medical staff, teachers, community learning and leisure staff, and staff in further and higher education. (However, note that there was also a request among some respondents to clarify what is meant in the document by 'mental health literacy'.)

4.11 Similarly, respondents agreed that 'emotional literacy' should be taught in schools to children of all ages, and that action was needed to educate the general public about coping skills and strategies.

Structural interventions

4.12 Respondents very much saw the promotion of mental health and well-being as "everyone's business." The point was made that activity needed to be undertaken at a local level to engage with organisations and agencies that previously would not have seen themselves as involved in the business of mental health improvement.

4.13 There was a strong feeling that local planning policies on transport, environment, economic development, housing, recreation, etc. needed to be 'proofed' for their impact on mental health and wellbeing. One respondent, representing a local authority, suggested that action at a local level in his area might involve the inclusion of actions on mental wellbeing in all council department service plans and strategic documents. Another respondent suggested that, to promote more positive mental health, it would make sense to tackle poverty and the lack of affordable housing first.

4.14 Respondents made specific suggestions about ways of improving local infrastructure to better promote mental wellbeing. Many of these suggestions were similar across sectors and across the urban-rural divide. However, respondents perceived that increased action was needed specifically to reduce isolation and social exclusion of people living in remote and rural areas, and of older and disabled people.

• Improve access to community services such as dial-a-bus and Shopmobility (for elderly and disabled people)
• Invest in and improve access to public transport, recreational / community leisure facilities, sport centres and cafes, particularly in remote and rural areas.
• Improve the physical environment of colleges and workplaces.
• Provide safe / comfortable street corners for young people to hang out on.

4.15 One individual commented there was a need to encourage communities to adapt to an older age profile in relation to housing, transport and community services.

Interventions with children and families

4.16 As mentioned in Chapter 3, respondents strongly supported the TAMFS proposals to increase early years interventions as a way of promoting and improving mental health and wellbeing in Scotland. One individual (representing a local authority) pointed out that the focus on early years was in line with the conclusions drawn in the report, Mental health promotion: Building an economic case (Friedli & Parsonage 2007, mentioned in Chapter 3) recently published by the Northern Ireland Association Mental Health.

4.17 The point was made that the mental wellbeing of a child is often inextricably linked to the mental health and wellbeing of parents. Therefore, it was important that action in this area focus on families - both parents and children together. Respondents felt that such interventions should "start at as early an age as possible - it's crucial to identify and address problems in infancy, if possible." However, there were some concerns about whether local areas had the infrastructure and services on the ground to support this.

4.18 Respondents highlighted that there were likely to be special needs among children with long-term physical health conditions, looked-after and accommodated children, children whose parents have drug / alcohol problems, children who have been victims of abuse and children whose parents have a mental illness.

4.19 There were also suggestions for some specific interventions, including making a primary mental health link worker available in every school, and improving access to youth leadership programmes.

Other points

4.20 Respondents made a large number of additional suggestions in response to the question about shared objectives and action for local delivery. A few of these are listed below (in no particular order of priority), to illustrate the range of comments received.

• "Need to find the '5 fruit and veg message' for mental health" - move the focus from mental illness / crisis intervention to wellbeing and prevention.
• People have a responsibility to take ownership of their own mental health and wellbeing. It's important to realise that people are the experts in relation to their own lives and experiences.
• Equip and support the voluntary sector to deliver the promotion agenda.

Prevention

4.21 Respondents agreed that local action should be undertaken to prevent mental health problems, mental illness and suicide, and the view was frequently expressed that service provision needed to shift its focus more towards early intervention rather than crisis management. Respondents also agreed with many of the suggested actions listed in the TAMFS paper, Section 9.2, although one individual questioned the extent it was possible to prevent psychosis (Section 9.2, point 2).

4.22 Once again, there was a range of views expressed on the subject of promotion. However, comments can generally be grouped according to three main themes:

• Mental health needs of people with physical illness or long-term conditions
• Primary / community care interventions
• Preventing self-harm and suicide

Mental health needs of people with physical illness and long-term conditions including sensory impairments

4.23 Respondents welcomed the suggestion that there was a need to better address the mental health and wellbeing needs of people with physical illnesses and long-term conditions, such as diabetes, epilepsy and dementia. One respondent called for increased funding for services to prevent mental health problems among older adults, including those with dementia, and concerns were voiced that the focus on early years interventions in the TAMFS document should not be at the expense of services for older people.

4.24 The point was made that, for some conditions, such as diabetes, it would make sense to support mental health and wellbeing through established Managed Clinical Networks.

4.25 Respondents also highlighted the particular challenges of identifying and addressing the mental health needs of deafblind people, people with communication support needs, and people with complex and multiple needs related to sensory impairment and learning disabilities. All of these groups experience poorer mental health compared to the general population, and the needs of these individuals often go undetected by services. Respondents requested much greater emphasis on identifying and meeting the needs of these groups in the TAMFS action plan.

4.26 Another respondent suggested developing 'wellbeing centres' (along the lines of the Thistle Foundation in Edinburgh) as one way of addressing long-term physical health conditions along with mental health and wellbeing.

Primary / community care interventions

4.27 Respondents very much agreed with the proposals for action set out in TAMFS in relation to primary care interventions for people with mild to moderate mental health problems.

4.28 In particular, there was strong support for the use of 'social prescribing' and 'anticipatory care' approaches, and one respondent went so far as to suggest that targets should be set locally by Community Health Partnerships to encourage social prescribing. Another called for a reduction in the practice of "prescribing anti-depressants as a first resort." However, other respondents argued that targets for reducing anti-depressant prescribing were unhelpful.

4.29 However, the point was made that it is important for GPs to have up-to-date information about what is available in their areas and what is effective. Some respondents were clearly concerned that the infrastructure to support social prescribing was not available in their areas. It is also worth noting that at least one individual expressed a lack of certainty about the effectiveness of 'social prescribing' and 'Keep Well' approaches, and a second individual, citing a study by Bream (2006), suggested there was insufficient evidence of the effectiveness of primary care prevention approaches targeted at deprived populations. ²

4.30 Other suggestions related to primary care or community care interventions included:

• Making available a mental health and wellbeing person in each GP surgery
• Giving priority to the identification of mental health problems in new mothers (ante-natally and post-natally)
• Increasing the levels of formal drug and alcohol screening in primary care
• Improving the accessibility of psychological therapies (including "health coaching" / life coaching), alternative therapies and self-help groups for people with mild to moderate mental health problems (However one respondent questioned the effectiveness and appropriateness of cognitive behavioural therapy for older adults.)
• Promoting the use of garden projects, volunteering and outdoor recreational activities within social prescribing approaches.

4.31 Although there was overall support for greater action in this area at a local level, it is important to note that one respondent had a question about the role of community nurses in meeting the aims and objectives set out in TAMFS document.

A number of the nurses we consulted raised questions about the links between the new community nurse model being tested in four health boards and the needs identified in the discussion document to focus on early years' interventions and the opportunities to expand community-based mental health improvement. [We] would be interested to see how this vision for population mental health is to be mapped on anticipated changes to health visitor, school nurse and district nurse roles. (Representative of NHS professional group)

Preventing suicide and self-harm

4.32 Respondents highlighted a need for ongoing work to prevent suicide and self-harm in Scotland, and there was a call for "more defined action in relation to suicide prevention" than that which is set out in Section 9.3 of the TAMFS document. It was also suggested that action to prevent self-harm should be separated from action to prevent suicide, and there was a call to develop a more strategic approach to the prevention of self-harm.

4.33 Respondents argued that suicide prevention activity needed to be targeted at communities, neighbourhoods and whole populations. As one individual said, "Training and awareness-raising in relation to suicide is not just about meeting Commitment 7."³ One respondent suggested that action on a local level could involve the delivery of suicideTalks in local communities, poster campaigns in bars and pubs and direct work with young people in schools.

4.34 Respondents also highlighted a need for a much greater focus on preventing suicide among people who misuse drugs and / or alcohol. The point was made that published suicide statistics do not accurately represent the scale of the problem among this population because the statistics do not include non-fatal overdoses, or 'near-misses.'

4.35 Respondents suggested the following actions could take place at a local level in relation to preventing suicide and self-harm:

• Improve access to cognitive behavioural therapy and art therapy
• Develop better joint-working between NHS and voluntary sector agencies to support those at risk of suicide
• Offer support to young people who self-harm at school or in college
• Identify and support children affected by parental substance misuse - many of whom are known to self-harm and / or have suicidal thoughts
• Improve multi-agency training for health and social care staff in relation to self-harm and suicide
• Target young men, older people and farming / rural communities.

4.36 Finally, there was a suggestion by some respondents that post-vention support needs to be more widely available to friends / family of people who have attempted or completed suicide, and there was a request for advice in taking forward work in this area.

Support

4.37 Respondents strongly agreed with the need to support improvements in quality of life, social inclusion, equality and recovery among people who experience mental illness. Suggestions were made for a range of actions and many of these reflect those listed in the TAMFS document in Section 9.4.

4.38 Before going on to look at these suggestions in detail, it is worth mentioning that, in general, respondents strongly supported the concept of "recovery." However, it should be noted that two individuals highlighted that the term "recovery" can be misleading and cause confusion. It was suggested that the term implies to many people that, "You will get better and be illness free, and therefore not require support services." This may not be so for some people with mental illness, and will not be so for people with dementia.

4.39 The main themes arising in respondents' comments about support related to:

• Training and employment
• Supporting recovery
• Giving people options
• Providing people with a safety net
• Giving people a voice

4.40 Some respondents also stressed the need to improve the quality and consistency of services in their areas.

Training and employment

4.41 About half of respondents highlighted the importance of meaningful employment in promoting recovery for people experiencing mental illness. Employment was also seen to be the key to recovery for people with co-morbid mental health and substance misuse problems.

4.42 Service users and carers echoed these sentiments, and provided personal examples from their own lives of how the move into work helped their process of recovery. One respondent, a GP, confirmed that he had seen similar positive results from an initiative in his area which involved placing people with severe and enduring mental illness into part-time employment.

4.43 A large proportion of respondents argued that public sector employers had a duty in this respect - not only to support people back into jobs as part of the process of recovering from mental illness, but also to create environments that were conducive to positive mental health and wellbeing among their employees. Respondents felt that local authorities and NHS agencies should be "exemplar employers."

4.44 However, there was a feeling that some employers (including further and higher educational institutions) may need advice, guidance and training to put in place policies and procedures that supported mental health and wellbeing in the workplace. Respondents felt that there would be benefit in working with local businesses to foster relationships and create opportunities for employment for people recovering from mental illness, and it was suggested that more could be done at a local level to recognise 'good-practice' employers.

4.45 Finally, in relation to employment and training to support recovery, there was a call from service user groups for information and advice to recovering service users wanting to set up their own businesses, and training for those wishing to become befrienders.

Supporting recovery

4.46 In addition to employment and training, respondents suggested a wide variety of other interventions and initiatives to support recovery among people experiencing mental illness at a local level. Respondents clearly saw the need for care and support to extend beyond clinical and psychological services to include social supports. At the same time, however, the point was made that good-quality acute services would still be needed, but a number of respondents (service users, carers and one GP) expressed concern that service users still often had the experience of being discharged from psychiatric hospital into the community with little or no support.

4.47 Service users and carers, and respondents from across all sectors suggested that the following types of services helped support recovery:

• Good quality housing and housing support services
• Befriending and peer support services
• Advice and education regarding healthy eating
• Occupational therapy in hospital and in the community - yoga, painting, woodwork, musical activities, exercise, supper clubs
• Comfortable, homely, relaxing environment in hospital
• Alternative / holistic therapies

4.48 Service users and carers, as well as other respondents, agreed strongly there was a need to take action to improve staff attitudes and behaviours towards people with mental health problems, people with drug and alcohol problems and people with communication support needs.

4.49 There was also a suggestion that local areas may wish to consider the development of 'Individual Health and Wellness Accounts' (like 'Individual Learning Accounts'). This would involve making direct payments to people on lower incomes who could then use the payments to access supports such as exercise, relaxation or sport, which are currently only available to those on higher incomes.

Giving people options

4.50 There was a feeling among respondents that action needed to be taken to provide people with a greater range of options for support, particularly options other than medication. One respondent suggested that people should be provided with a 'menu' of "mainstreamed and innovative support services" to take into account their needs and preferences. This increased range of services should include greater availability of out-of-hours and drop-in services.

Providing people with a safety net

4.51 Respondents felt that safety nets needed to be available to those who were most vulnerable - including prisoners upon release and older homeless people with mental health problems. Service users and carers also highlighted a need for better response times from services when people were in crisis.

Giving people a voice

4.52 Respondents felt that action was needed to give a greater voice to people who were subject to inequality and discrimination. Respondents wanted:

• Improved interactions between deafblind people and professionals - e.g., through the provision of guides / communicators, increased awareness, and the establishment of a national guide / communicator service.
• Increased support for service user networks - to allow service users to voice their views collectively or individually.
• Greater availability of advocacy services.

Other points

4.53 Finally, respondents felt it was important not to overlook the needs of carers, including carers of people with drug and alcohol problems, and it was suggested that action was needed at a local level in this area. There was a specific request from service users and carers for increased respite provision for carers, including at Christmas.

Targeting

4.54 Another of the major themes that arose in the consultation responses was in relation to the issue of targeting. Section 6 of the TAMFS paper made suggestions for groups that could be targeted, and nearly half of respondents made some comment in relation to this section.

4.55 In general, respondents agreed with the points made about targeting, and agreed with all six of the illustrative target groups for local and national action (listed in para 6.1).

4.56 However, one respondent suggested that the focus of Section 6 was too broad. ( "Currently almost all of the population is included.") This individual felt it would be helpful to prioritise some key groups to provide the intensity of effort required to make a difference.

4.57 Another respondent seemed to be arguing for the opposite approach. This individual suggested that, rather than attempting to target too many groups, any future strategy should target national and local action in three broad areas:

• Population at large (through provision of skills for life in education / workplace)
• At-risk groups (people without access to key assets or resources)
• People with long-term conditions (including people with physical and / or mental illness, and those who experience discrimination).

4.58 This person made the point that promotion, prevention and support would be required for all of these groups at different levels, and that local planning committees should decide what the priorities for targeting are in their areas.

4.59 However, most of the respondents who had comments on the subject of targeting either made suggestions for additional groups to be targeted, or - as was more often the case - they were requesting that particular groups should be mentioned explicitly. (It should be noted that many of groups proposed by respondents for targeting would have been encompassed within the groups listed in para 6.1.) Such groups included:

• Older adults, including those with dementia
• Refugees and asylum seekers
• Black and ethnic minorities
• Lesbian, gay, bi-sexual and transgender people
• Armed forces veterans
• Homeless people
• People involved in prostitution
• People with learning disabilities
• People with epilepsy and other long-term physical health conditions
• People with sensory impairments and / or communication support needs, particularly those with complex and multiple needs
• All children identified by agencies as requiring particular support

4.60 As has already been mentioned elsewhere in this chapter, respondents were particularly concerned that the emphasis on children and young people in the TAMFS document should not exclude action to promote the mental health and wellbeing of older people.

4.61 Three additional groups which, perhaps, did not obviously fall into any of the categories listed in para 6.1 included:

• People living in rural and remote areas of Scotland
• Men (In particular, efforts were needed to address the stigma associated with men acknowledging they have a need for some form of help.)
• Unpaid carers (including carers of people with long-term physical and mental health problems and / or dementia).

4.62 In relation to TAMFS para 6.1, point 5, one respondent expressed the view that "people without access to key assets or resources" was not explicit enough. This individual suggested that such a statement should be more directly linked to the Scottish Government discussion paper, Taking forward the Government economic strategy: A discussion paper on tackling poverty, inequality and deprivation in Scotland (February 2008). ⁴

« Previous | Contents | Next »