Section 1 Context
Mental health and policy in Scotland
Mental health problems can affect anyone. Mental health conditions vary in symptoms and severity. Depression and anxiety is most common, but many people live with severe and enduring mental illness, such as schizophrenia. Dementia is more common in older people and numbers are increasing. Developments in mental health services mean more people now receive treatment in the community.
Scotland has a rich policy and legislative framework underpinning for mental health services and the promotion of mental well-being. Underpinning the policy and legislative agenda is a recognition that mental health problems are more liable to arise among those who are socioeconomically disadvantaged, socially excluded and/ or victim to discrimination or abuse. Policy to tackle inequality in Scotland is set out in Equally well (3), the report of the Ministerial Task Force on Health Inequalities.
Central to the development of mental health services in Scotland is Delivering for mental health (1), which sets specific targets for service delivery and calls for whole-system change to enable services to provide recovery-orientated and person-centred care and to support people to manage their own care and carry out everyday activities.
The "refresh" of Delivering for mental health currently taking place will build on the original policy statement to focus on:
- increasing access to psychological therapies
- improving access to child and adolescent mental health services
- rolling out integrated care pathways and the National Benchmarking Project
- promoting improved service user experiences.
The Scottish Government is committed through Towards a mentally flourishing Scotland (4) to ensuring appropriate services are in place to promote good mental health and to embed mental health improvement in all NHS activity. The healthcare quality strategy for NHSScotland (2) aims to deliver services around individual preferences and requirements with a focus on supporting people to manage their own conditions, increasing the effectiveness of care and treatment and making patient experiences and outcomes integral to services.
This three-year action plan reflects the focus of these key policy initiatives and others, such as Scotland's national dementia strategy (5), Co-ordinated, integrated and fit for purpose: the delivery framework for adult rehabilitation in Scotland (6) and a range of initiatives being carried out in Scotland on developing child and adolescent mental health services.
Allied health professionals in mental health
Mental health care is changing, with an emphasis on shifting the balance of care from hospital to community and the promotion of recovery-focused and strengths-based approaches. This has led to new ways of working for the mental health workforce.
There is currently no detailed analysis of the AHP workforce in mental health, although the Scottish Government is performing a scoping exercise to identify workforce characteristics in partnership with NHS Education for Scotland ( NES). This is expected to report in Autumn 2010.
The whole AHP workforce in Scotland has increased from 8,277.2 whole-time equivalents ( WTE) in 2004 to 9,242.8 WTE in 2008 (an 11.7% rise) (7). Key workforce issues for AHPs in Scotland include a need for more detailed workforce data, challenges in capacity-building and succession planning in small professions and issues in remote and rural NHS boards (7).
All AHPs, regardless of profession or their area of work, have an important contribution to make in promoting mental health and well-being and preventing mental health problems in the populations they serve. That contribution is both valuable, and valued.
Some, however - those referred to in this action plan as " AHPs in mental health" - have, by virtue of their pre-registration preparation or the focus of their practice, a particular locus in providing mental health services. These AHPs work in core mental health services and are: those providing arts therapies; dietitians; occupational therapists; physiotherapists; and speech and language therapists (see Table 1). It is fully acknowledged, however, that other AHPs, such as podiatrists, also make a valuable contribution to mental health services through promoting positive mental health and providing direct services.
Table 1. AHPs in mental health
(art therapy/art psychotherapy* / dance movement psychotherapy** / dramatherapy / music therapy)
Postgraduate qualified psychological therapists who engage with arts activities aimed at promoting creative expression and understanding in the context of a therapeutic relationship. Practitioners combine knowledge of their relevant art form (art, dance-movement, drama, music) with knowledge and practice of psychotherapeutic techniques which both contain and give meaning to service user experiences and communication. Working with therapists who have expertise in the use of creative media offers service users opportunities to explore verbal and non-verbal material at different levels.
Translating the science of nutrition into practical information about food. Working with people to promote nutritional well-being, prevent food-related problems and treat disease.
Emphasising the relationship between occupation, mental health and well-being. Working with service users and carers to develop and maintain a personally satisfying routine of everyday activities that creates a sense of purpose and direction to life. Typically, looking at service users' self-care, leisure and work activities and the individual's hopes and aspirations.
Using physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status.
Speech and language therapists
Providing detailed assessments of communication skills, difficulties and needs to inform multidisciplinary diagnosis. Developing directly and indirectly delivered programmes for individuals to reduce the mental health impact of communication impairment. Advising and supporting others to deliver communication accessible services throughout the length of the care pathway. Assessing eating, drinking and swallowing difficulties and developing programmes to overcome or minimise their impact.
* Art therapy/art psychotherapy are synonymous protected titles
** Dance movement psychotherapy is proposed to join the arts therapies part of the Health Professions Council.
The above definitions are provided in agreement with the professional bodies: detail of each profession's contribution can be accessed via the web links at Appendix 3.
" I feel that I now have the information and knowledge that I need to make healthy choices and changes to my diet. "
Service user : Experience of dietetic services
Like other mental health practitioners, AHPs in mental health treat individuals of all ages in a range of clinical settings. Their skills and expertise, provided within team approaches to service delivery, help people recover from, or manage, their mental health problems.
Rehabilitation skills are core to the services provided by all AHPs in mental health - indeed, this can be considered the main contribution of AHPs to mental health services. Their rehabilitation orientation enables them to focus beyond symptoms to:
- promote psychosocial function and social inclusion
- support emotional, spiritual and physical well-being
- respect diversity and choice and the absolute right of the individual to self-determine
- focus on what a person can do, rather than what he or she cannot (a strengths-based focus)
- work collaboratively with service users and carers.
Numbers employed and skill mixes vary across the professions, with occupational therapists currently being by far the largest single discipline. Occupational therapists and arts therapists are specifically trained in the field of mental health on registration and have a long tradition of working in mental health, while others are newer to the field. They work as part of multidisciplinary and multiagency teams, sometimes in small teams, sometimes as sole practitioners, and sometimes on a sessional basis. Some mental health services, however, have little or no AHP resource.
To maintain current roles and to extend AHPs' contribution, sharing their expertise and increasing their availability, there is a need to consider:
- where AHPs make the greatest impact
- which professional has the appropriate competencies and is therefore best placed to provide interventions.
One way forward is for AHP services to outline their core contribution as either "direct service provision" (the highest proportion of AHP contributions in the current workforce are delivered through direct service provision), a "partnership-working" role or as providing a "consultancy" function. Table 2 illustrates these three different ways AHPs in mental health can work.
Table 2. The ways AHPs work
Direct service provision
AHPs working directly with service users and the families, individually or with a group, offering specialist professional assessment and intervention. All AHPs should operate at this level, which represents the greatest proportion of the AHP contribution.
EXAMPLES: occupational therapist and physiotherapist in a community mental health team; art therapist in a forensic medium secure unit.
AHPs working in partnership with others, combining the skills of the respective partners/teams to the benefit of service users. Most AHPs operate at this level but there will be differences in the volume of partnership-working among professions.
EXAMPLES: social skills group with a speech and language therapist and a member of nursing staff; AHPs working with voluntary sector support staff.
AHPs working in a consultancy capacity, offering advice, supervision and training for staff, service users and/or carers.
EXAMPLES: care home staff developing activities with occupational therapist and music therapist supervision; dietitians setting up nutrition links in an acute setting; dramatherapist offering group supervision to colleagues.
Realising the potential of the entire AHP workforce
As Table 2 shows, the AHP workforce has the capability not only to provide services directly, but also to work in partnership with other disciplines and to provide consultancy services. But there are questions around the capacity of the AHP workforce to meet ongoing service demand. Increasingly, therefore, AHPs will need to consider effective ways of building the capacity of the workforce. This will include:
- skilling-up the AHP support worker workforce in clearly identified areas to ensure that service user and carer needs continue to be met, particularly in relation to direct service provision
- more effective use of partnership working and consultancy methodologies to avoid the pitfalls of professional dependency among service users and promote the chances of individuals appropriately exiting the mental health system to pursue independent lives.
The forthcoming report on the AHP workforce in mental health, arising from the Scottish Government and NES scoping exercise referenced above, will underpin future work to progress this agenda.
" Going to the rock climbing group helps me to tell my story - and there is a happy ending ... I know that I am not at the end yet because I still suffer from mental ill health but I know that I am on the right track. If I didn't have the rock climbing group, I don't know where I would be at this moment in time. It's done so much for me. My hope for the future is to be mentally well enough to go back to college and get myself a good career. The rock climbing group I see as a major part of that ... it is not so much a physical exercise - it's the psychological benefit that you get from it, the positive you take away ... I plan to carry that on in all aspects of my life until I do get well enough [and] can take on the world on my own. "