Adult secondary mental health services: consultation analysis

6 Moving between and out of services

6.1 Introduction

Part four of consultation asked nine questions on the moving between and out of services standards.

6.2 Question 22

Table 6.1 provides the quantitative response to Question 22.

This shows that a majority of all consultation respondents who answered Question 22 either agreed or strongly agreed (70%) that the standards within the moving between and out of services theme will improve the experiences of people using secondary mental health services.

Base = 77 (individuals = 41 and organisations = 36)

Percentages may not total 100% due to rounding

6.3 Question 23

Table 6.2 provides the quantitative response to Question 23. This shows that around three-fifths of all consultation respondents who answered Question 23 either agreed or strongly agreed (61%) that the standards within this theme will improve the outcomes of people using secondary mental health services.

A relatively large proportion of respondents neither agreed nor disagreed (26%) with this statement.

Base = 77 (individuals = 41 and organisations = 36)

Percentages may not total 100% due to rounding

6.4 Question 24

Table 6.3 provides the quantitative response to Question 24.

This shows that just below three-quarters all consultation respondents who answered Question 24 either agreed or strongly agreed (72%) that the standards within the moving between and out of service theme clearly set out to individuals, their families, and carers what they can expect from a secondary mental health service.

Base = 77 (individuals = 41 and organisations = 36)

Percentages may not total 100% due to rounding

6.5 Question 25

Around half (49%) of all consultation respondents answered Question 25 which asked respondents whether they think there is anything missing from the moving between and out of services standards.

Theme 1: Key principles that underpin effective delivery of moving between and out of services standards

Some respondents (individuals and all organisation sub-groups) provided feedback that could be described as key principles to help underpin effective delivery of the moving between and out of services standards. These respondents considered it important that this set of principles were fully reflected within the final set of standards and wider commentary.

Some points raised relate to people with lived experience of accessing and using adult secondary mental health services, while others relate to services themselves, and are summarised below.

People with lived experience should:

• have access to consistency of care and treatment – to ensure that they do not have to constantly retell their experiences and only have to tell their story as few times as possible
• be able to move through a service at a consistent pace that suits them - and that access should not come to an end sooner than desired
• have access to ongoing care and support if it is needed again (that is access to support and services without a predetermined end date)
• be able to reengage with services if initially discharged but support is needed again - for example, planned and supported ‘step up and step down’ approaches
• have access to person centred and collaborative care
• be supported and empowered to make shared decisions about their move between and out of services

Services should:

• ensure open and strong lines of communication and improved information and record sharing, including between primary and secondary care services, social work, addiction services
• continue to move towards a more integrated and holistic approach to care and support - to ensure that people move easily and seamlessly between services
• be able to signpost and connect people to peer support networks and other community resources and assets as part of a more holistic approach to supporting people as they move between and out of services
• have efficient and effective organisational processes and practices in place to help keep people with lived experience informed at each stage of the process of moving between and out of services

Theme 2: Something missing from the moving between and out of services standards or the standards could be improved

A few respondents (individuals and all organisation sub-groups) suggested that something was missing from the moving between and out of services standards. This feedback reflects calls from respondents for more detail, specification, and/or greater clarity on these standards, as well as proposed changes to language, wording, and terminology. A few examples (see also Appendix F) include that:

• greater consideration could be given to the different processes, procedures, and IT systems that services currently use, and what action may be required to enable improved and timely information and data sharing between services (including between services in different Health Board areas)
• there were various comments regarding a person’s discharge from a service, including that:
  • there should be no unplanned discharges
  • there could be greater reference to people with lived experience feeling supported to transition out from services - ‘step down’ approaches
  • there could be recognition within the standards that people may choose to opt out of services at any time – it should be clear that people would not be penalised for disengagement during transition points
  • there could be a standard relating to discharge planning and letters, and ensuring the GPs are aware when a patient has been discharged

  • services should ensure that if a person’s move out of in-patient care or between services is delayed, this would be recorded with the reason for the delay made clear
  • delays between services should be acknowledged and reported on – but there was considered to be a lack of clarity on needs to be done about the delays (for example, what constitutes a delay and do I get to choose if the delay is in line with receiving person centred care?)
• there should be standard for those moving from Child and Adolescent Mental Health Services into Adult Mental Health Services, and a standard for those moving from Adult Mental Health Services into Older Adults Mental Health Services

A few Health Boards, HSCPs and services felt that the standards could be improved and further clarified, as outlined below:

“This section is very brief and does little justice to the collaborative approach which most clinicians would take in relation to transitions of care. The content is written in a tone which suggests that clients will simply be ‘informed’ of decisions made about them, by other people/services. This wording does not support the implementation of person-centred care and does little to inform or reassure potential clients about what they can expect from services. It also offers little guidance to services on what good transitions should look like (that is, who should be supported to be involved in informed decision-making, how best to collaborate/share decision-making)”.

NHS Greater Glasgow and Clyde

“Acknowledgment from services that the stakeholders involved in a person’s care may all have different standards and timescales, and the mental health standards should acknowledge and relate to other relevant standards, for example MAT standards”.

Angus Health and Social Care Partnership

“Clarity is required on a Care Plan moving between services. This is not reflective of practice as a Care Plan would change based on need and may not be detail the individual’s story”.

East Ayrshire Health and Social Care Partnership

Theme 3: A repeat of the key themes

A few respondents reiterated comments made to previous questions (see Section 2.5 – Key themes), and in the main the feedback relates to how services could realistically deliver the moving between and out of services standards.

6.6 Question 26

The Scottish Government recognise 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 6.4 provides the quantitative response to Question 26.

This shows that over half of all consultation respondents who answered Question 26 either agreed or strongly agreed (56%) that the moving between and out of services standards will help do this. A relatively large proportion of respondents neither agreed nor disagreed (31%) with the statement.

Base = 72 (individuals = 39 and organisations = 33)

Percentages may not total 100% due to rounding

6.7 Question 27

Just over half (53%) of all consultation respondents answered Question 27 which asked respondents whether they had any suggestions for how the moving between and out of services standards could go further to help ensure that services meet everyone’s needs.

Theme 1: A repeat of the key themes

Some respondents (individuals and all organisation sub-groups) reiterated previous points as suggestions for how the moving between and out of services standards could go further to help ensure that services meet everyone’s needs (Section 2.5).

Theme 2: Further clarification required

A few respondents called for further elaboration or clarification regarding specific standards. Some examples are provided in Appendix E.

Additional points

Please refer to Appendix F.

6.8 Question 28

The Scottish Government understand that substance use and mental health difficulties can be co-occurring. They want to ensure that people with both a mental wellbeing concern and substance use receive access to treatment that is tailored to their needs.

Table 6.5 provides the quantitative response to Question 28. This shows that over four-fifths of all consultation respondents who answered Question 28 either agreed or strongly agreed (82%) that the Scottish Government should include a specific standard on support for those with substance use issues within these standards.

Base = 71 (individuals = 39 and organisations = 32)

Percentages may not total 100% due to rounding

6.9 Question 29

A total of 61% of all consultation respondents answered Question 29 which asked respondents what a standard around substance use could contain. Most of these respondents expressed strong support that the moving between and out of services standards should include a specific standard on support for people with lived and living experience of substance use.

Theme 1: Alignment with existing strategies, plans and standards

Some respondents (Health Boards, HSCPs and services, mental health and other organisations) recommended that the adult secondary mental health standards should align with existing strategies, plans, and standards, including:

• National Drugs Mission Plan: 2022-2026 – which sets out the actions needed to reduce deaths and improve lives impacted by drugs, and more specifically Outcome 3 ‘People at most risk have access to treatment and recovery’, and Outcome 4 ‘People receive high quality treatment and recovery services’
• MAT Standards - which define what is needed for the consistent delivery of safe and accessible drug treatment and support in Scotland - and more specifically to MAT Standard 9 – Mental Health: “All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery. People have the right to ask for support with mental health problems and to engage in mental health treatment while being supported as part of their drug treatment and care”

It was also proposed that the standards should take account of other national strategies, polices, guidelines and report recommendations that consider the co-occurring nature of substance use and mental health difficulties.

For example, the following documents are referenced in consultation submissions across all organisation sub-groups: Quality Principles: Standard Expectations of Care and Support in Drug and Alcohol Services, Independent Forensic Mental Health Review: final report, Drug Deaths Taskforce response: cross government approach, Scotland’s Suicide Prevention Strategy, National Institute for Health and Care Excellence (NICE) guidelines).

Here, it was suggested that read across “would support multidisciplinary approaches and a holistic understanding of how best to support an individual” (Social Work Scotland).

Theme 2: Wider factors considered important to ensure consistent access

Aligned to Theme 1, some respondents (individuals and all organisation sub-groups) described a range of factors they considered important in order to help ensure consistent access to adult secondary mental health and the provision of high-quality care across Scotland for people with lived and living experience of substance use. These factors are summarised below, and include:

• clear guidance on what a person with lived and living experience of substance use when they access support (in different settings)
• person-centred, trauma-informed, holistic, and joined-up care
• integrated multi-agency planning and working - including clear protocols, interfaces, pathways of referral, communication, and information sharing
• tackling stigma
• informed choice about care and treatment
• access to support out with traditional office hours
• no unplanned discharges
• support to reengage with services
• harm reduction
• retention
• independent advocacy
• positive relationships and social connection
• continuity of care – and a named worker as a main point of contact with services

Some of the points outlined above are reflected in the following organisation quote:

“… any substance use standard included within the secondary Mental Health quality standards, should reflect a person-centred, trauma informed approach while also considering the impact of stigma on accessing treatment. The Cross Government Action Plan on drug deaths recognises, and aims to address, stigma as a barrier preventing access to treatment. As there is long-standing research on the impact stigma has on those with mental health conditions, it would be beneficial to include a standard aiming to tackle this”. Social Work Scotland

Theme 3: Why a specific standard for people with lived and living experience of substance use was important

A few respondents also acknowledged that substance use and mental health difficulties can be co-occurring, and there was explicit reference to the importance of “dual diagnosis” (AHP Mental Health National Leads Group), reducing “siloed care” (Royal College of General Practitioners Scotland), and recognition of “comorbidities” in mental health (CMHT Larkfield, East Dunbartonshire, Greater Glasgow and Clyde) – that is, more than one disorder in the same person.

There was also feedback, including from a few mental health organisations that set out that they often hear from people with living experience of substance use that they were denied access to mental health services until they were fully drug and/or alcohol free. This point is reflected in the organisation quote:

“A standard would contain the right for people living with substance use to have access to mental health services that are truly trauma informed and responsive. This would require a change in mindset and understanding that substance use is very often a way for people to deal with trauma and poor wellbeing as well as a factor in continued trauma and poor wellbeing”.

Scottish Recovery Network

The Mental Welfare Commission for Scotland pointed to its own report (September 2022) – which identified the need for a standard on a clear protocol at service level for those with these difficulties outlining the way that addictions and general adult secondary care services ought to work together (see Appendix F for more detail).

Additional points

Please refer to Appendix F for more detail.

6.10 Question 30

Almost half (48%) of all consultation respondents answered Question 30 which asked respondents to share any of their thinking on the answers provided to Questions 22 to 29, and their views on the moving between and out of services standards overall.

From a review of the qualitative responses to Question 30, the only new theme that emerged was that the moving between and out of services standards be mindful of existing workstreams, including:

• COSLA mentioned the development of the shared Health and Social Care Record which aims to make information sharing less resource intensive for those working in the service and reduce the number of times a person needs to repeat their story to professionals
• COSLA also mentioned the Improvement Service is supporting the development of a digital platform which aims to streamline all data collected by local authorities