Adult secondary mental health services: consultation analysis

3 General comments on the standards

3.1 Introduction

Part one of the consultation asked seven questions which sought feedback on the standards overall. Everyone was invited to provide a response to these questions, however, this section was aimed at those who perhaps had less time to complete the full consultation.

3.2 Question 1

Table 3.1 provides the quantitative response to Question 1.

The feedback shows that a majority of all consultation respondents who answered Question 1 either agreed or strongly agreed (71%) that the standards will improve the experiences of people using secondary mental health services.

Base = 89 (individuals = 50 and organisations = 39)

Percentages may not total 100% due to rounding

3.3 Question 2

Table 3.2 provides the quantitative response to Question 2.

This shows that over half of all consultation respondents who answered Question 2 either agreed or strongly agreed (59%) that the standards will improve the outcomes of people using secondary mental health services. A relatively large proportion of respondents neither agreed nor disagreed (28%) with this statement.

Base = 90 (individuals = 50 and organisations = 40)

Percentages may not total 100% due to rounding

3.4 Question 3

Table 3.3 provides the quantitative response to Question 3.

This shows that three-quarters of all consultation respondents who answered Question 3 either agreed or strongly agreed (75%) that the standards clearly set out to individuals, their families, and carers what they can expect from a secondary mental health service.

Base = 90 (individuals = 50 and organisations = 40)

Percentages may not total 100% due to rounding

3.5 Question 4

The Scottish Government recognises that currently not everyone has the same experiences or outcomes when they engage with mental health services. They want these standards to help make sure that services meet everyone’s needs whoever you are and whatever your background.

Table 3.4 provides the quantitative response to Question 4.

This shows that just over half of all consultation respondents who answered Question 4 either agreed or strongly agreed (54%) that the standards will help do this. A relatively large proportion of respondents neither agreed nor disagreed (29%) with this statement.

Base = 90 (individuals = 50 and organisations = 40)

Percentages may not total 100% due to rounding

3.6 Question 5

Almost three-quarters (74%) of all consultation respondents answered Question 5 which asked whether respondents had any suggestions for how the standards could go further to help ensure that services meet everyone’s needs regardless of who they are or their background.

The main themes are presented below.

Theme 1: More detail on how the standards would be delivered, measured, and audited

Some respondents (all organisation sub-groups and individuals) called for further clarity, detail, consultation and/or guidance on how the standards would be delivered, measured, enforced, and independently audited. These respondents emphasised that organisations that provide adult secondary mental health services would need to have appropriate governance, policies, resources, and staff in place to establish the roles, responsibilities and lines of accountability required to deliver the standards.

Further, these respondents noted that services would need to have robust processes and procedures in place to: support a culture of service evaluation and improvement; provide evidence of progress and success; and highlight examples of best practice that could be shared nationally.

Common feedback from organisation respondents was that the Scottish Government could consider and provide further clarity on a range of issues, including:

• whether there would be a “central commitment to support the development of data collection and establishing baseline data” (NHS Greater Glasgow and Clyde) in order to help demonstrate whether the standards have been met
• the wealth of existing data (and sources) that is routinely captured and reported on within health and social care in Scotland – for example, it was noted that existing data-strands were not currently brought together as a composite, and that there could be more effective and efficient use of existing datasets to minimise duplication of effort in monitoring arrangements for the standards
• whether there may to scope to develop a “single mental health dataset” (Mental Welfare Commission for Scotland) – for example, in keeping with a suggestion around aligned datasets within the Scottish Mental Health Law Review (2022)
• how best to involve people with lived experience, their families and carers, and the workforce in monitoring and evaluation of the standards – while not placing undue burden on any of those involved

Theme 2: Format of the standards

Some respondents (all organisation sub-groups and individuals) highlighted a range of points to do with the format of the standards, as summarised below. It was considered important that the final standards for adult secondary mental health services should for example:

• comprise clear and concise statements – use plain English and incorporate graphics and visuals to aid readability and to make sure language is accessible for all. The Royal College of General Practitioners Scotland also suggested that consideration could be given to a ‘patient-friendly version’ of the standards
• be easily understood and measured – for example, the Mental Welfare Commission for Scotland note that “With a total of 50 standards, that are split into what I can expect and how services will support me, this may be too many and confusing for both individuals with lived experience to apply, and services to measure”. Wider feedback included that there needs to be clear definitions provided of terms used (for example, ‘adult’ ,‘person-centred’, ‘trauma-informed’, ‘better outcomes’)
• be specific and sufficiently defined to ensure a shared understanding among both the workforce and people looking to access services – it was suggested that the standards could be ‘less high-level’ by describing ‘what’ type of service should be delivered and ‘what’ needs to be in place to implement the standards
• be capable of measurement – it was suggested that amendments to phrasing or wording in some of the standards and more detail on appropriate metrics would make it easier for services to measure whether the standards have been met
• not be open or subject to interpretation in any way, nor should they have the potential to cause confusion or be considered contradictory
• provide clarity on the timescales for implementation - not least because services were said to be “starting from a very significant capacity shortfall” (Royal College of General Practitioners Scotland)
• create realistic expectations – it was suggested that the standards and commentary could acknowledge that Health Boards vary in Scotland in terms of size, resources, and service offering. “Whilst consistency of outcomes is necessary, consideration should be given throughout the standards to ensuring they do not create the expectation that care provision will be identical across Scotland” (COSLA). Local variation is important to ensure services can deliver for their communities - whilst retaining consistency in quality and outcomes variation should not be construed as a “postcode lottery” but a “legitimate difference due to differing demographics, culture and delivery landscape” (Social Work Scotland)

Theme 3: Wider factors and their impact on deliverability

The rationale for, and aspirations of, the adult secondary mental health standards were acknowledged within some consultation responses, as was their focus on reducing inequality in mental health (for example, health improvement and mental health organisations). The development of national quality standards were viewed as a ‘welcome development’ in this regard.

Some respondents (all organisation sub-groups and individuals) emphasised that the deliverability and achievement of the standards would depend on, or be influenced by, a range of factors – the feedback highlighted that these factors should be acknowledged sufficiently within the standards and within the wider commentary.

Factors raised by these respondents included:

• the demand for services – service demand was said to be greater than current staff capacity. It was also considered important to set the standards within the context of the COVID-19 pandemic which was said to have negatively impacted the mental health and wellbeing of many people and that increased demand has placed ‘unprecedented pressure’ on adult secondary mental health services and its workforce. The current cost of living crisis may also make the situation worse
• that ‘existing gaps in service provision’ may make it harder to achieve the standards due to insufficient resource and capacity
• workforce capacity constraints – a range of workforce challenges were identified, including staff recruitment and retention. As well as wider factors such as workforce wellbeing, morale, and burnout
• more financial resources, an increase in the number and diversity of frontline workers, and the provision of other support (for example, workforce development, digital infrastructure/support) would be required to help service providers operationalise the standards and to achieve meaningful change for people accessing and using these services
• there was also recognition of workforce challenges across the healthcare ecosystem, with wider feedback that more needs to be done to ensure the mental health workforce feel supported and valued, and to increase the number of people with lived experienced within the workforce
• wider social determinants of health – there was recognition that many factors influence a person’s mental health, and respondents noted that many of these are largely out with the control or influence of adult secondary mental health services. It was suggested that the standards should define clearly “what areas of mental health should be addressed by secondary care services” (individual)

The following quote is reflective of points raised:

“Overall AHSCP is supportive of these standards but with recognition that these can only be met with adequate, ongoing resource. With resource as it currently stands the standards will be hard to meet.

Support is required to meet and maintain standards and we have concerns that the standards could be subjective, and may create unrealistic expectations, leading to complaints about Mental Health Services not meeting the standards. To meet these standards additional resources are required to increase capacity to meet the ever increasing demand for mental health support. Services know where there are gaps but these can't be met due to resource and capacity.

Adequate implementation, training, enforcement and monitoring on a national basis is required to meet these standards. Staff need to have continual opportunities and training which at the moment is difficult due to pressures on services. The standards need to be part of a continuous improvement model and evaluation which is meaningful”.

Angus Health and Social Care Partnership

Theme 4: Key principles to enhance deliverability of the standards

A few Health Boards, HSCPs and services and mental health organisations emphasised points they considered essential to help enhance the deliverability and achievement of the standards, and to improve the experiences and outcomes for people with lived experience. The feedback was that these points should be acknowledged sufficiently within the standards and within the wider commentary.

The points raised by these respondents included, for example:

• whole-person whole-system approaches
• continuity of care/relational care and compassionate care
• early intervention and prevention
• equal and non-discriminatory access to services (for example, addressing inequality of access to mental health services among older people and people from cultural or ethnically diverse backgrounds)
• an intersectional approach to implementation of the standards (for example, LGBT+ inclusivity)
• that recognition of the ‘Rights, Will and Preference’ of a person with lived experience should apply across all of the standards
• the valuable role of third sector mental health services which act as a bridge between those with particular conditions, combinations of conditions or protected characteristics
• the role of community resources and supports, including peer networks, advocacy and other specialist support, in helping people to stay well
• ongoing and meaningful engagement and involvement of people with lived experience, their families, and carers

3.7 Question 6

Three-quarters (75%) of all consultation respondents answered Question 6 which asked respondents whether there are any other areas of mental health services in which these think these standards could apply outside of adult secondary services.

Table 4.5 provides the quantitative response to Question 6.

This shows that a vast majority of consultation respondents who answered Question 6 (82%) reported that there are other areas of mental health services where these standards could apply, outside of adult secondary services.

Base = 76 (individuals = 45 and organisations = 31)

Tables may not total 100% due to rounding

Theme 1: The standards could apply to anyone regardless of age

Some respondents (individuals, health improvement, mental health, and organisations who support specific target groups) suggested that the adult secondary services standards could be applicable to anyone who needed access to secondary mental health services regardless of age.

More specifically, there was reference to the standards applicability to children, adolescents, and older adults (and associated services).

Theme 2: The standards could apply to other parts of the healthcare system

Some respondents (all organisation sub-groups and individuals) considered it important that the standards were not developed and implemented in isolation from the wider healthcare ecosystem, and that they could be broadened out from adult secondary services to help ensure joined-up and collaborative care.

The following quote is reflective of points raised.

“In broad terms the generic principles described are relevant to all mental health services”.

Scottish Mental Health Pharmacy Strategy Group

Suggestions included applicability of the standards to: primary care; tertiary care; community health; third sector mental health services; in-patient care; crisis support; forensic services; and social care/independent sector.

The standards were also considered applicable to other services where there are transitions. For example, the following services were mentioned in consultation responses:

• alcohol and drug recovery
• attention autism and deficit hyperactivity disorder (ADHD)
• eating disorders
• gynaecology
• learning difficulties
• neurology
• perinatal
• specialist trauma
• young-onset dementia

The following quote is reflective of points raised:

“Alcohol and Drug Recovery Services, Services for people with Eating Disorders, Learning Disability Services, or Specialist Trauma Services. Including these additional services would promote consistency of high quality service provision. This will also ensure consistency of care for people with complex presentations and who require the support of multiple services”.

NHS Greater Glasgow and Clyde

It was suggested that it may be helpful for the Scottish Government to develop a “suite of related standards to improve mental health and psychological care” (NHS Greater Glasgow and Clyde Older People's Psychology Service).

A few respondents noted that the standards were comprehensive and have the potential to “significantly improve the quality of mental health service provision and its consistency across Scotland” (for example, NHS Greater Glasgow and Clyde, NHS Greater Glasgow and Clyde Older People's Psychology Service).

There was also feedback that the standards complement and cross-over with other existing and developing standards (for example, the Health and Social Care Standards, the Child and Adolescent Mental Health Services (CAMHS) service specification, the neurodevelopmental service specification, and a specification for phycological therapies), and that “Consideration should be given to consolidating mental health standards to ensure they are effective in supporting implementation” (COSLA).

3.8 Question 7

Over three-quarters (76%) of all consultation respondents answered Question 7 which asked respondents to share any of their thinking on the answers provided to Question 1 to Question 6, and to provide views on the standards overall. The main themes are presented below.

Theme 1: A repeat of the key themes

Many respondents (individuals and all organisation sub-groups) reiterated points raised to previous consultation questions - see Section 2.5 (Key themes).

Theme 2: Key principles that underpin delivery and measurement of the standards

Some respondents (all organisation sub-groups) highlighted aspects that they considered important in the delivery of the standards and/or in how they would be measured. This included:

• continuity and consistency of care
• trauma-informed care and practice
• clear and effective referral and service pathways
• reducing stigma in accessing mental health services
• the role of people with lived experience and their families and carers
• more national data and measurement to understand if the standards have been met and to enable benchmarking
• capturing and sharing lessons learned