Independent Oversight and Assurance Group on Tayside's Mental Health Services

Appendix 4: Scottish Government Final Submission to the Oversight Group on Trust and Respect National Recommendations 12 and 32

Recommendation:

Conduct a national review of the assurance and scrutiny of mental health services across Scotland, including the powers of Healthcare Improvement Scotland and the Mental Welfare Commission for Scotland (recommendation 12).

Intended outcome(s):

Improved understanding of how effective and comprehensive current scrutiny and governance arrangements of mental health services are.

Identification of areas where improvements are needed and how to do so most effectively.

Improved collective scrutiny of mental health services and cohesion between national scrutiny bodies.

Improved patient outcomes and staff safety.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The recommendation highlighted that there is limited external scrutiny and assurance of mental health services. This issue is born out of the lack of clarity around roles, remits and responsibilities of national scrutiny bodies, giving rise to a lack of leadership and oversight in mental health scrutiny and gaps in assurance.

The recommendation also highlights the limited powers of national scrutiny bodies to monitor and enforce the implementation of their recommendations. This may also be regarded as a symptom of a lack of legislative clarity in relation to scrutiny bodies, without clearly defined powers to follow up on their findings and recommendations.

Summary of Actions:

Mental Health Scrutiny and Assurance Review

We are in the process of commissioning a contractor to undertake a review of the scrutiny and assurance of mental health services. The aim of the review is to provide the Scottish Government with independent, robust information about how effective and comprehensive current scrutiny and governance of mental health services are. It will also highlight areas where improvements could be made to existing arrangements. We expect the contractors to commence their work in mid-October and to deliver a final report by the end of January 2023. Their findings and recommendations will be considered as part of the wider package of work and used to inform any future changes to policy in relation to mental health scrutiny and assurance. Where appropriate, we will also ensure the findings feed directly into the on-going work of the Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group.

Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group

We have been working with the Care Inspectorate, Healthcare Improvement Scotland and the Mental Welfare Commission to consider how to improve the collective scrutiny of these services. A Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group has been set up to provide scrutiny organisations the platform to share, discuss and act upon emerging themes and issues from their on-going scrutiny activity.

The Group will meet bimonthly and aims to ensure a cohesive approach across the organisations and reduce the burden on mental health and learning disability services. The Scottish Government will act as secretariat, working closely with members and the current Chair, Julie Paterson from MWC, to support delivery of the Group's aims.

Healthcare Improvement Scotland infection prevention and control inspections

We have funded Healthcare Improvement Scotland to develop and rollout intelligence-led and risk-based inspections of mental health settings, with a focus on infection prevention and control (IPC). HIS have spent the summer recruiting an inspection team and working with a short life working group to develop a bespoke inspection methodology. They have recently begun piloting their IPC inspections in clinical mental health settings. The Scottish Government will continue to support the delivery of these inspections, including follow-up with services regarding HIS' findings and recommendations. These inspections will contribute to improved coverage of mental health services from our external scrutiny partners.

Links to Scottish Mental Health Law Review and National Care Service

Alongside our response to recommendation 12, we regard these related pieces of work as forming part of a package of work around governance, assurance and scrutiny. It has been of the upmost importance that we are joined up with them, to ensure a cohesive approach to shaping future policy in this area.

We have been meeting regularly with the Scottish Mental Health Law Review secretariat, in relation to our overlapping work around scrutiny and assurance. Their findings and recommendations regarding accountability noted the need for greater co-ordination, clarity and focus among the different scrutiny bodies and explicitly mention the newly formed Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group as a possible 'nucleus for this formalised network we are recommending'.^[1]

The Scottish Mental Health Law Review reported that there was not widespread support for radical structural change to the existing scrutiny landscape for mental health. However, this will need to be considered in the context of possible changes to policy and legislation with the new National Care Service. We have therefore been working closely with National Care Service colleagues who have recently announced an Independent Review of Inspection Scrutiny and Regulation. Their review is closely linked to our own mental health scrutiny review and to ensure coordination and collaboration, we have requested that they have representation on our Research Advisory Group which will inform how the review will be carried out.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The scrutiny review to be undertaken will strengthen our understanding of current scrutiny and governance of mental health services, identifying areas where improvements are needed and how to do so most effectively.

The newly formed Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group has been set up to improve joint working between scrutiny bodies. The Group will provide opportunity for early, and where appropriate, coordinated intervention and support. It will provide clarity and ensure accountability to members about their roles in following up on issues identified to support robust delivery of mental health and learning disability services.

It will also seek to join up planned programmes of scrutiny, as appropriate, to ensure a cohesive approach across the organisations and reduce the burden on mental health and learning disability services. We will continue to provide support to the Group to organise meetings and ensure their findings are fed back into government, for example to the Quality and Safety Board and the Sharing Intelligence Group where appropriate.

The new IPC inspections led by HIS is one step to improving the scrutiny of mental health services. This work aims to bring parity between mental health and physical health settings, which currently have a robust inspection programme in place. It will look to improve the conditions of mental health settings and to contribute to the safety and wellbeing of patients and service users.

The ongoing collaborative working with MHLR and NCS aims to ensure a joined-up approach across government and related independent work to governance, assurance and scrutiny. Our cohesive approach to this policy area will allow for all relevant findings to be considered as part of a package of work and used to inform future policy in this area.

Evidence and Milestones:

Scrutiny and Assurance Review – to commence October 2022 and completed by end January 2023.

Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group - set up in September 2022, next meeting scheduled for 7 November 2022.

Infection prevention and control (IPC) inspections – recruitment of inspection team and development of inspection methodology took place over Summer 2022. Piloting of inspections to commence October 2022.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We have experienced some unfortunate delays with the scrutiny and assurance review due to capacity issues in the social research market. For this reason, we have not been able to complete this work stream in line with our original timeframe. We are very pleased that we are now close to appointing a suitable contractor to undertake this work at speed over the autumn and winter months. The final report will be delivered by January 2023.

This timeline will allow the review to draw on the findings of the Scottish Mental Health Law Review and the work of the recently announced Independent Review of Inspection Scrutiny and Regulation. This work will be crucial in meeting the outcome of improved understanding of how effective and comprehensive current scrutiny and governance of mental health services is and identification of areas where improvements are needed and how to do so most effectively. This will allow for positive, evidence-based changes to be made to strengthen the collective scrutiny of mental health services and cohesion between scrutiny bodies.

We have proactively driven forward work with national external scrutiny bodies over the summer 2022, drawing on the work of the MHLR and discussing the changes necessary to improve the collective scrutiny of mental health services.

This has culminated in the creation of Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group, which will provide a valuable forum for creating a more cohesive approach to mental health scrutiny. We will provide support to the Group and its Chair to ensure that it fulfils its vital role in helping to meet the outcome of improved cohesion between national scrutiny bodies.

After experiencing significant winter pressures due to the Omicron COVID variant, HIS have recruited an inspection team, developed a methodology and begun piloting these inspections. These inspections will help to fill a current gap in the scrutiny of mental health services that was made clear by the COVID-19 pandemic and bring parity between mental and physical health settings in relation to IPC inspection. These inspections will contribute to the safety of mental health settings for the people who use services.

We consider this package of work as taking both a short- and longer-term approach to strengthening mental health scrutiny. The formation of the new Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group and the rollout of the IPC inspections both seek to fill gaps and make meaningful improvements to current scrutiny arrangements in the short term. The mental health scrutiny review and links to wider work relating to the MHLR and NCS review will ensure that in the medium to long term, productive structural improvements are made to the system of scrutiny and assurance, that take into account the changing landscape of mental health service provision. We believe that the programme of work that we have developed strikes the right balance and satisfies the need for immediate pragmatic changes whilst also informing future structural improvements to external scrutiny.

RAG Status: Amber

Green – actions are complete and the intended outcomes have been achieved or actions are on track and the intended outcomes are very likely to be achieved in the timescales required.

Amber – actions are marked as complete, but have not achieved the intended outcome or actions are underway but are unlikely to achieve the outcomes in the timescales required – additional action required.

Red – actions are not underway and / or not on track and urgent remedial action is required to achieve the intended outcomes.

Any further action proposed:

As we have set out, we intend to bring together our mental health scrutiny review, the findings from the Mental Health Law Review and the Regulation Review being delivered by the National Care Service to inform what the future of scrutiny of mental health services looks like. Work on this will commence in early 2023 (once our review is completed) and we will set out a clear programme of work, with timeframes to ensure we deliver improved scrutiny of mental health services.

To note, we will not hesitate to take early action once the findings of our review have been published. However, the approach set out above will ensure these three connected pieces of work inform the future of mental health scrutiny in Scotland.

As discussed with the Oversight Group we will develop a 12-month programme of work with the Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group set up by the Scottish Government before the end of 2022. We are also working with Group to ensure there is public visibility of the group, of its work and impact. This will be reflected in the final version of the TOR.

Recommendation:

Develop national guidelines for responding to substance use on inpatient wards (Recommendation 32)

Intended outcome(s):

National approach to responding to substance use on inpatient wards.

Improved patient and staff safety

Improved health outcomes for substance users

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

At present, there are no national guidelines for responding to substance use on mental health in-patient wards. This can lead to patients receiving different levels of support and care depending on which health board they visit or area they reside in. It can also leave staff feeling unsafe and unsure on the correct procedures to follow when responding to substance use.

Summary of Actions:

We established a short life working group (SLWG) to develop the guidelines comprising of mental health and nursing leads, alongside representatives from the Mental Welfare Commission and Police Scotland. We have also received input from people with lived and living experience, which includes service users and clinicians.

The SLWG has developed draft national guidelines which will be shared with Ministers for approval in Mid-October, before we move into a phased implementation in the coming months. This will involve the guidelines being tested in two Board areas for four weeks to ensure they are fit for purpose and to address any potential 'teething' problems.

We will use the learning from this testing phase to support Scotland wide implementation in early 2023.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The guidelines have been developed in line with a person-centred approach. They not only ensure the patient is receiving the correct care and advice but also that staff feel confident and empowered to respond to instances of substance use on in-patient wards.

Evidence and Milestones:

The next section sets out planned activity to support the implementation of the guidance.

The document will be formatted to comply with Scottish Government guidelines and an easy read version will be developed for online use

Implementation Phase

Sign off – October 2022

Officials will shortly begin the sign off and implementation process. This will involve gaining sign off from Ministers, alongside ensuring the Chief Medical Officer and Deputy Chief Medical Officer are sighted on the guidance.

Once the Ministers have confirmed they are content with the guidance and proposed next steps, we will proceed with implementation.

Testing guidance – November 2022

The first phase of implementation will involve testing the guidance at 2 test sites, ideally one urban and one rural. The duration of this trial will be approximately 4 weeks.

Feedback will then be collated via a short survey from the trial and any feedback or recommendations implemented.

If the document requires changes, this will be shared with the Minister for Mental Health and Wellbeing and the Minister for Drug Policy for awareness and sign off.

Communications – November to December 2022

To support the official launch, officials will engage with drug colleagues, other relevant officials, Public Health Scotland and other external stakeholders in order to develop communication materials to support the messaging of the guidelines, such as posters for display on the wards.

Implementation – January to March 2023

A letter from Ministers to NHS boards will be drafted to accompany the guidelines, explaining the rationale behind the guidelines and that they will become national practice. Officials will also share the Guidance and accompanying materials with any relevant internal and external networks to increase to help support awareness raising activity.

The guidelines will also be published on scot.gov for public access.

Proposed Timeline

October: Share with Ministers

November: Testing in two areas

December: Updated guidance if required

January to March: National implementation

Communication of guidelines to stakeholders

October: Share with Tayside Oversight Group

November:

December: Draft letter / Letter to health boards

January to March: Published on Scot.gov

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

RAG Status: Green

Green – actions are complete and the intended outcomes have been achieved or actions are on track and the intended outcomes are very likely to be achieved in the timescales required.

Amber – actions are marked as complete, but have not achieved the intended outcome or actions are underway but are unlikely to achieve the outcomes in the timescales required – additional action required.

Red – actions are not underway and / or not on track and urgent remedial action is required to achieve the intended outcomes.

Any further action proposed:

On-going engagement with Boards through the Scottish Government's board engagement function, to understand how the guidance is working in practice throughout 2023.

On-going work with the national Drugs Mission to ensure learning generated from the guidance informs the development of future guidance regarding substance use within health settings.