Adult secondary mental health services: consultation analysis

Appendix F: additional points

Additional points raised by respondents to consultation questions are captured below. In the main these were raised by a few respondents.

Question 11

Additional examples of things respondents felt were missing from the access standards included that they could:

• give greater consideration to how to improve access to emergency and out of hours services and support
• address psychological and emotional barriers to access, and understand the possible impact of trauma on people accessing services
• address the issue of a shortage of in-patient beds – it was noted that outcomes are poorer for those unable to be hospitalised locally, and adds to the distress of in-patients if it is difficult for them to see family or friends
• give greater consideration to location and building accessibility
• include explicit reference to the role of, and interface with, primary care and non-specialist services
• acknowledge the use of private diagnosis and titration services, and explain how these services may be integrated

Question 18

Additional examples of things respondents felt were missing from the assessment, care planning, treatment, and support standards included that:

• the standards could be improved by providing more detail on for example: regularity of contact a person may expect; how multidisciplinary teams should work together, including the core duties and responsibilities of each professional group and their relationship with the person
• it would be important that the links between discharge from in-patient setting to community are clear and flexible so that "continuous progress in mental wellbeing" can be the outcome of the interventions
• the assessment, care planning, treatment, and support standards could include an explicit link to the Equality Act 2010

Question 25

Additional examples of things respondents felt were anything missing from the moving between and out of services standards included that:

• greater consideration could be given to how specific groups of people in vulnerable circumstances are best supported to move between and out of services (for example, people with experience of homelessness, people who are not registered with a GP were mentioned in consultation responses). A related point was that the standards could be more explicit about how people with learning disabilities would be supported with transitions, and that this should take cognisance of existing good practice
• there were a couple of comments regarding care plans:
  • further clarity was required on the care plan for moving between services – a comment was that this is not reflective of practice as a care plan would change based on need and may not be detail the individual’s story
  • whether the care plan is relevant for moving between different services out with adult secondary services
  • how the sharing and updating of care plans (and transition plans) would be coordinated - for example, more information on roles and responsibilities may be required
• more explicit reference could be given to the role of families and carers in supporting transitions/discharge – as it is often a time of increased stress and may also mean a change to their caring/support role
• the adult secondary mental health standards could acknowledge any existing standards that services use, and also describe how different standards relate to each other (for example, Medication Assisted Treatment (MAT) standards: access, choice, support)
• more guidance on what ‘good transitions’ should look like

Question 27

Additional suggestions for how the moving between and out of services standards could go further to help ensure that services meet everyone’s needs, included that:

• consideration could be given to the development of a 'mental health' service map for people to help explain the stages, expectations and direction of their care journey – related point were that there could be additional narrative to explain why changing services and transitions might be challenging, and that people need to be informed as to what should happen at transitions, what the standards of care services should be expected to provide at these points, and what other forms of support are available at these points
• the procedures regarding discharge and moving through services in adult secondary mental health services are not fully accessible to those with a mental illness or who are experiencing mental ill-health – there needs to be shift in onus from the person seeking support and engaging with people in an accessible and simple way. It was suggested that the standards could consider how to remove barriers to access, including to avoid a situation where a person in need of support is removed from waiting lists for support
• there could be greater reference within the moving between and out of services standards to making people aware of, and connecting people to, local advocacy support
• the formulation of single written care plans also need to give due consideration to any workforce implications – including ensuring appropriate processes are in place to ensure the plan is shared seamlessly between services, and provides the advocacy support needed to underpin smooth transitions

Question 29

The following points were raised by respondents in relation to what a standard around substance use could contain, albeit not to any great extent:

• the adult secondary mental health services workforce may require a level of knowledge and understanding of substance use work (that is “addiction-informed”)
• adult secondary mental health services need to have adequate resources and staff in place to deliver a specific standard for people with lived and living experience of substance use – and high levels of staff turnover within services makes it more challenging to provide continuity of care
• the systems used by different services “do not talk to each other” and digital infrastructure improvements may be required to ensure deliverability
• there could be greater co-location of adult mental health and addiction services to help ensure deliverability of a specific standard for people with lived and living experience of substance use
• a mental health organisation noted “The inclusion of a specific standard around substance use would open up questions around whether there should be specific standards for other service users, for example, those with trauma, severe mental illness” – while another mental health organisation felt that “The standards should be general enough to cover substance use in the same way as they should be able to cover the full range of mental health conditions”

The Mental Welfare Commission for Scotland called for:

• “….a clear written policy/service delivery model reflecting national standards and guidance, outlining the expectations for the holistic, joined up care of people with a co-occurring mental health condition and problem substance use (if one does not already exist)
• audits should be undertaken to ensure that every person with a co-occurring mental health condition and problem substance use has a documented care plan with a care-coordinator identified
• protocols should be in place detailing agreed approaches for people who disengage with services and this includes people with co-occurring mental ill health and problem substance use
• Psychiatric Emergency Plans should be reviewed to ensure that sections that set protocols for the care and treatment of those individuals presenting intoxicated provide a mechanism for contemporaneous and subsequent engagement
• NHS Education for Scotland (NES) to consider with relevant stakeholders, and report on how educational and improvement programmes for professionals working in mental health, addiction services and social care might:
  • embed a trauma-informed approach to care and treatment of people with mental health conditions and problem substance use
  • address stigmatising attitudes within professionals towards people with mental health conditions and problem substance use

• the Scottish Government should monitor the delivery of the above recommendations and work with health and social care partnerships (and associated health boards/local authorities) and NES to support consistency and address any barriers to delivery over the next 12-months

“The first four recommendations lend themselves to the development of a standard whether as individual standards or subsumed within the first recommendation around a protocol. We note that the Scottish Government rapid review on the subject complements the MWC work and there is a shared view around a protocol - this would form the basis for a standard for services”.

Mental Welfare Commission for Scotland

Question 49

Other views provided on possible questions to include in the self-assessment tool included:

• which workforce planning models are used to estimate whole time equivalent staffing and skill mix required to meet the needs of the population
• which suite of routine outcome measures is used by services to evaluate outcomes for patients, including measures of stabilisation or wellbeing, in addition to measures of symptom reduction
• how people with lived experience are engaged to help inform and co-design services
• what more could be done to support the wellbeing of the mental health workforce
• are there ways to improve access to services
• waiting times data - is this data available to the public; and is data on why referrals have been rejected collected and available
• how often are staff are given refresher training on digital systems; and is there is a digital champion in each team to offer local tailored support
• there could be a question for all of the subsections of each standard relating to how success is measured, level of success in meeting the standard, any barriers, and lessons going forward

Question 50

Other suggestions for possible indicators included:

• number and length of stay of patients in other in-patient settings awaiting transfer to psychiatry wards
• wait time for best practice treatment after initial assessment
• how long did it take to get access to the appropriate level of care
• how many people who needed it got access to in-patient treatment
• how relevant/beneficial was the treatment received for your needs
• proportion of individuals deemed in crisis and length and type of response
• proportion of people who say that they would be happy if their loved one received care from this service
• the proportion of people electing or not electing to provide feedback on the service and support received, and steps taken to improve this
• uptake of wellbeing support among the mental health workforce
• the proportion of people who do not provide consent to share their care plan between services
• proportion of referrals that were re-referrals
• reasons for delay in discharge from in-patient settings
• indicators relating to staffing levels, including for staff in administrative roles

Question 51

A few additional points were raised as suggestions for how the Scottish Government could support services to reduce inequalities in the outcomes and experiences of people who use services, including in the measurement of the standards. This included that it is important: to involve people with lived experience in service design and improvement; and for services to adopt a human-rights based approach.