Adult secondary mental health services: consultation analysis

Appendix E: feedback on specific standards

Access

Standard 1.2: ‘If I seek support, I will be supported to get the help that is right for me regardless of where I first made contact’:

• it was considered important that when statements talk of people getting 'the help that is right for me' that this is defined by the person not the services. It was suggested that this standard could be reworded to 'If I seek support, I will be supported to get the help I believe is right for me, regardless of where I first made contact’
• there was felt to be a need to address a perception that all people with learning disabilities will automatically access learning disabilities specialist services – for example, people with mild to moderate learning disabilities may be more likely to benefit from access to general mental health services

Standard 1.4: ‘I will be provided with information on other available support such as online resources and community resources which will support me while I wait’:

• online resources may not be appropriate for everyone – people who are digitally excluded, with low levels of digital literacy, or who cannot access online support (for example, older people, young carers, refugees and asylum seekers) and people where English is not their first language (for example, people from an ethnic minority community, asylum seekers, gypsy/travellers)
• a more proactive approach may be required to ensure that people are supported while they wait for specific treatments and/or access to secondary mental health services. Signposting and information in and of itself was not considered sufficient.
• it was suggested that a commitment to connecting people with other available support would be stronger and incentivise secondary mental health services to invest in non-clinical roles such as community connectors and peer workers who can connect people with appropriate supports and also reduce reliance on secondary mental health services

Standard 1.6: ‘I will receive care and support in a timescale that reflects my needs’:

• it was suggested that this standard was open to interpretation – and that it would need to be defined to enable it to be measured and benchmarked

Standard 1.7: ‘Services will prioritise the referrals of those in most need and detail the criteria used to assess need and to prioritise’:

• consideration will need to be given to how Standards 1.6 and 1.7 relate to one another. There may be contrasting perceptions of need and priorities between patient and the service. Consideration needs to be given as to how these standards would be balanced, supporting a service to meet individuals needs and providing realistic expectations of service provision. The way in which service user views and professional experience and expertise are balanced will also be key in any data collection exercise

Standard 1.8: ‘Services will publish information in a clear and accessible format on who services are for, what is provided, and who can refer to these services. Information will include contact information, location of services, opening hours and how to contact out of hours/emergency care’:

• it was suggested that a commitment to 'publish information' does not necessarily reflect the diverse ways that people access healthcare information
• this statement could be strengthened with some notion of 'promote in meaningful and culturally relevant ways' or similar

Standard 1.9: ‘This information should be widely available and easily found. Information should be available in people’s preferred languages and in formats which are culturally sensitive and understands the possible impact of trauma on people accessing services’:

• to be consistent with the other standards it was suggested that phrasing should change from "should" to "will"
• this standard could further expand on accessible mental health resources to include easy reads, audio and video formats for those with learning disabilities
• the standard outlines an expectation within the standard that information should be available in “peoples preferred language" - however, consideration will need to be given to the resource available to create these materials

Standard 1.12: ‘Services must have systems to accurately measure waiting times for assessment and treatment, this information should be accessible to everyone. It must be recorded and regularly reported through Clinical and Care Governance structures’:

• the importance of the NHS and secondary mental health services having systems which correctly record the identities of LGBT+ people was considered important. For example, recording an individual's correct name and gender, in line with how they live their life (whether male, female or nonbinary)

Assessment, care planning, treatment, and support

Standard 2.2: ‘Alongside consideration of my needs, I will be asked what is important to me and this will inform my mental health assessment, care planning, treatment and support. If I want them to be, and it is appropriate, my carer and/or family should be involved’:

• this standard (and the standards more generally) could be more inclusive of kinship networks for LGBTI+ people

Standard 2.3: ‘I will have a copy of my care plan which will be regularly reviewed to ensure it reflects my needs’:

• there should be explicit reference to a written care plan

Standard 2.6: ‘I will have a choice in how I prefer to access care and support and whether I engage digitally or face to face. However I access support, the environment will be safe and will enable effective treatment’:

• while for the vast majority of people accessing services this is accurate for those who are assessed as lacking capacity (using relevant legal frameworks) then although their choice should be taken into account it may not be possible to act on it, this is particular true if there are risks present

Standard 2.7: ‘If I need support from multiple professionals and agencies, I will have a designated named person who will offer support in coordinating these’:

• it was suggested that the reference to a named person is changed to care coordinator or equivalent as named person has meanings under mental health legislation and under GIRFEC

Standard 2.9: ‘Services will ensure that teams have an adequate staffing skill mix to provide a wide range of assessments and therapeutic interventions based on needs in their community. This team should include psychiatry, nursing, psychology, social work and Allied Health Professionals as well as opportunity for peer support and other expertise as needed’:

• adequate staffing mix would need to be defined
• pharmacy could be added to the ‘team’ mix
• peer support is treated as an add-on which is not how many service users and services experience or think of peer support
• this standard may raise expectations of delivery of care which cannot currently be met, and it would be useful to see that acknowledged
• there should be a clear path to escalation where staff feel standards are not being met

Standard 2.11: ‘Services will ensure that the mental health care and support is provided in a community setting wherever possible. If people need in-patient care, this will be for the shortest necessary time and planning for returning to the community will begin as soon as they are admitted with an estimated date for discharge’:

• there could be reference to the return to the community at times where assessed as appropriate, being to an alternative care/home setting. Similarly, for people who are transferred from assessment units to Hospital Based Complex Care wards the current wording of may not be the best fit
• this standard could include additional text: “Services will ensure that mental health care and support is provided in a community setting wherever possible and appropriate
• If people need in-patient care, this will be for the shortest necessary time and planning for returning to the community will begin as soon as they are admitted”
• in terms of discharge, it may be inappropriate to return people back to their own home and they may have to go into supported accommodation. This can sometimes be difficult for people and their families. The term ‘community’ should be expanded upon to reflect this reality in order to support understanding and expectation
• the statement imposes services' preference for community care on service users – some people are discharged before they are ready, or without their input into the process. Service user choice about the better setting for them at any given time and contribution to decision-making would be important

Standard 2.12: ‘When planning and delivering services, consideration of the wider determinants of health which can increase the risk of inequality will be addressed so that care and support can be person-centred and responsive. This will include consideration of inequalities related to cultural, ethnic and other protected characteristics’:

• Local Government plays a central role in supporting the social determinants of mental health by providing a wide range of services such as employment, education, housing, leisure and green space. These do not usually sit within secondary mental health provision – questions raised included what this standard refers to in practice, and how this can be made clearer to achieve its intended aim
• this standard could benefit from the inclusion of sustainable care when planning, using triple bottom line principles, so that care does not limit its future provision through unsustainable practice, nor does it have adverse environmental, or social impacts

Standards 2.13: ‘Services will routinely measure and report care and treatment outcomes. This should include understanding both responsiveness of interventions and service users and carer experience. This should routinely be reported through clinical and care governance’:

• further clarity was required on which services are expected to contribute to the collection of this data and what organisation will these services be providing this information to – it was proposed that: any data requests connect to existing data being provided; any new data requests should consider current workforce capacity; and consider the jointly published Scottish Government and COSLA Health and Social Care Data Strategy (2023) which aims to promote the consistent use of data across health, social work and social care

Standard 2.14: ‘Services will use demographic data, engagement intelligence, national prevalence rates and data on wider determinants of health to identify groups with poorer mental health and direct resources accordingly’:

• would this data be from GP systems too? – this would be welcomed but would need the current work round data sharing processes to be accelerated
• it was suggested that it may not be appropriate to include this standard within adult secondary mental health services as individuals will already have been clinically assessed – it was suggested that this standard seems to link more closely to prevention, where this data would be useful in identifying groups who are at increased risk

Moving between and out of services

Standard 3.1: ‘I will have one written care plan which is jointly created by me and the professionals supporting me. If I move between different services, this will include clear information which supports my move’:

• there should be explicit mention that the information will be translated and culturally competent

Standard 3.2: ‘With my permission, this plan will be shared as I move between services so that I have to tell my story as few times as possible’:

• this standard should also acknowledge that there are times when it is essential that a person is asked to share their story again. Whilst the number of times should be reduced, there will still be occasions when this is necessary. The reasons should be explained to the person by the clinician involved in their care
• any sharing of personal data must be accompanied by adequate legal safeguards

Standard 3.3: ‘If I need to move between or out of services, I will be supported to prepare for this move. If I need someone to help me, that support will be available to me at a time and pace I need, for example, advocacy’:

• could be strengthened to reflect the range of services that may help an individual during transition

Standard 3.4: ‘If I am discharged from mental health services, I will understand how to get care and support if I need this again, this will be easy for me’:

• there could be greater acknowledgement that discharge should ideally be a collaborative decision between the person with lived experience and the service, and involve discharge/recovery action planning
• language used in the statements could be more ‘recovery oriented’ – for example, it may be better to consider an alternative way to express ‘if I am discharged’ while at the same time acknowledging that some people may never be discharged from services
• a standard around discharge should also set out clear expectations for post-discharge follow up within a specified time frame
• what would be considered ‘easy’ in terms of re-accessing services – suggestions included providing a phone number to re-refer to a service as opposed to requiring a GP referral
• does the reference 'easy for me' refer to it being easy to understand how to get care and support or easy to get care and support as these are different concepts
• people should not be placed back on the waiting list upon re-referral
• this standard could reflect the duty on health boards under section 28 of Carers (Scotland) Act 2016 to involve unpaid carers in discharge discussions and plans. The discharge process needs to be fully explained to unpaid carers Unpaid carers also need to be aware of where to get further help, not only for themselves, but for the person they care for

Standard 3.5: ‘All mental health and care services will work together to reduce delays in transitions of care, whether from inpatient to community or between services, there must be joint processes in place to enable seamless transitions’:

• this standard could benefit from defining what services are included in the intended scope
• this standard could recognise that the ability to ‘reduce delays’ would depend on several factors including demand and workforce capacity
• the statement was also said to be too vague, and further clarity was required on the ‘joint processes’ referred to in this standard
• there is a need to expand in-reach support, especially in the transition from inpatient to community transitions

Standard 3.6: ‘Services will ensure that if people’s move out of inpatient care or between services are delayed, this will be recorded with the reason for the delay made clear. Services will report this through Clinical and Care Governance processes’:

• what would be done with the data collected on delays
• would the data be reviewed to identify common themes and inform action to reduce or eliminate delays
• it would be important to further embed lived experience into any evaluation process to help improve service transition
• clarity on the expected role of the Scottish Government in the reporting process

Standard 3.7: ‘Services will provide co-produced written care plans for transitions between services or discharge from services, detailing how to reengage’:

• what format would the care plan take, which professionals would be involved, who would have ownership of the care plan, how would information be shared (respecting the person’s wishes and privacy), and who would be able to access the care plan
• where does decision-making rest in instances where a person is moving between services and may not wish to share their care plan with the receiving service, even although this may be in their best interests
• people should have power over their own care – this is key to preventing discrimination, or people feeling stigmatised - care plans should be outcome focused and reflect the needs and preferences of people using the services. Care plans could use advance statements to ensure the will and preferences of the individual are supported
• whether co-production would centre mainly around the person with lived experience’s own opinion and needs
• people should be given the option of how they contribute to these plans. If non-digital methods are used (for example, a handwritten care plan) then efforts should be made to digitise these so that they are available out of hours and are not lost
• that this standard could be extended further to include transition into the community from inpatient services
• barriers such as intersectional stigma and its impact when creating collaborative care plans would need to be considered and addressed
• creation of an agreed care plan must also have relevant scrutiny and accountability processes in place to ensure that person centred appropriate care is delivered
• care plans should be provided in an accessible and clear format, including in different formats and languages (and funding for translation services) – this should also be emailed/mailed to individuals so they can share it themselves as they move forward

Workforce

Standard 4.1: ‘I will be confident that the staff who work with me have the right skills and experience to care for and support me’:

• standard is vague and ill-defined. Service users often feel that even if staff are properly trained, their treatment still may not be appropriate. Suggest that this section refers to skills as both vocational/academic skills and the interpersonal skills required to work in mental health services
• should be amended to state they ‘will have the right training, knowledge, skills, experience and ongoing support for their professional development’

Standard 4.3: ‘Services will support the wellbeing of the workforce’:

• the next stage of these standards should demonstrate how services will support the wellbeing of the workforce

Standard 4.4: ‘Services will ensure that all staff who work with me will be trained in trauma informed practice and approaches and will have completed equalities and diversity awareness training’:

• available training can be mixed in quality. Training should be standardised, and the standard more explicit about the nature and quality of training
• should include a more comprehensive requirement of staff training that includes risk assessment/suicide prevention training / physical healthcare. Explicitly naming and cherry-picking trauma might result in the exclusion of other training that is equally important to delivery within a particular service

Standard 4.6: ‘Services will ensure that staffing levels are safe and adequate and are compliant with the health and care staffing legislation’:

• several secondary care mental health services do not currently have safe and adequate staffing levels. This section would benefit from a specific point not just about ‘services’ but the staff within them, and what they could/should do to highlight concerns about staffing or their own wellbeing
• further clarification on this standard and more information on the practical steps about how these staffing levels will be ensured. Currently adults are rejected from specialist referrals as they do not meet the criteria for support. If the assessment criteria becomes more rigid in an effort to adhere to staffing levels legislation then there is a risk of structural discrimination, resulting in a lack of treatment and service users slipping through the cracks despite a need for a service
• this is important but not always achievable. Raising patient expectations can then lead to increased dissatisfaction and risk of complaint from patients and burnout among staff. The government either needs to fund services adequately or accept that such standards are unhelpful
• It will currently be difficult to achieve this standard in some areas, despite legislative requirements, given national and significant staffing level deficits

Standard 4.8: ‘Clinical supervision and reflective practice will be incorporated into all services as routine practice.’:

• reflective practice and clinical supervision is not routine for some staff groups. More guidance should be given for staff to embed this into their work. Low staffing levels also impact the ability to achieve this

Standard 4.9: ‘Leadership of services will create a collaborative culture which empowers and enables the workforce to support the implementation of these standards’:

• should read "Leadership of services will create a collaborative culture which empowers, enables, and holds accountable the workforce to support the implementation of these standards." It would make staff at all levels accountable to actually implement the standards rather than paying lip service to them

Governance and accountability

Standard 5.3: ‘I will be signposted to independent advocacy services for support, and given the opportunity to share my experience confidentially and or be supported to make a formal complaint’:

• it was suggested that this may be difficult to uphold as most advocacy services have limited resources and prioritise referrals for people who are subject to a compulsory treatment order
• standard should be expanded to clarify if there is a guarantee of anonymity in these processes

Standard 5.5: ‘Services will ensure that processes are in place to learn from feedback and complaints and will use this to improve services.’:

• add “and made public with relevant changes to the service” as a means for ensuring accountability

Standard 5.8: ‘Services will work together with scrutiny bodies to provide assurance that standards are met and improve quality of care where necessary’:

• this could be extended to involve people with lived experience