Mental health in primary and community care: report - December 2024

Existing Investment

The Scottish Government has, and continues to provide, substantial investment to increase mental health and wellbeing capacity in general practice, alongside continued investment in the general practice workforce and generalist MDTs. We remain committed to increasing the number of GPs who provide a key role in mental health diagnosis and treatment. We offer a range of recruitment and retention initiatives so that becoming a GP remains an attractive career choice.^[2] This allows more direct support, assessment, and treatment to take place in these settings. This has resulted in newer models of primary care mental health and wellbeing staff embedded within or attached to practices.

These have significantly increased the ability to offer easier access, more inclusivity, continuity, and earlier intervention. However, we recognise that this increase isn’t reflected equally across the country, and some Integrated Joint Boards (IJBs) used the investment to recruit mental health workers in other sectors, or invested in non-mental health related priorities as directed, regulated or permitted by funding rules.

Enhanced Mental Health Outcomes Framework

We have directly allocated £120 million to NHS Boards and Integration Joint Boards (IJBs) for the Enhanced Mental Health Outcomes Framework in 2024-25.

The Framework builds on previous years’ allocations and aims to enable continued investment across a range of mental health services, including primary care, in line with the aims of the Mental Health and Wellbeing Strategy and associated specifications and standards.

The Framework focuses on embedding increased capacity around CAMHS (Child and Adolescent Mental Health Services), the delivery of psychological therapies, eating disorder care, primary care, and neurodevelopmental services, as well as ongoing innovation and service reform. It also brings together several other funding streams previously administered separately including:

• The Action 15 workforce commitment
• Perinatal and infant mental health
• School nursing services
• Annual health checks for people with learning disabilities

We acknowledge that the public sector funding landscape is challenging. This has been echoed by Boards and IJBs who have highlighted challenges with maintaining the existing levels of workforce. We recognise that they are well placed to identify how they can be more efficient and effective within available resources to suit their local populations.

Our intention is that the increased flexibility of the Enhanced Mental Health Outcomes Framework, combined with increased access to frontline spend, will help us work towards a more sustainable and improved system.

Action 15

Action 15 of the Mental Health Strategy 2017-27 outlined our commitment to fund 800 additional mental health workers in key settings within five years, including A&Es, GP practices, police station custody suite and prisons – ensuring local provision and support is at the heart of our plans.

An additional 958.9 whole time equivalent (WTE) mental health roles in A&Es, GP practices, police station custody suites, prisons, and community settings, were recruited under Action 15 of the Mental Health Strategy 2017-27. This ensures that local provision and support is at the heart of our plans. This exceeds the original commitment of 800 mental health workers. At the end of the Action 15 commitment in April 2022, 356 WTE of those posts were recruited within general practice settings to increase capacity to provide support, assessment and treatment and respond to the range and complexity of presentations. This allowed for a diverse range of practitioners to become part of the general practice team, including Mental Health Nurses, Occupational Therapists (OTs), and Peer Support Workers.

We have made over £144 million available since 2018-19 to 2023-24 to deliver the Action 15 commitment. Baselining this funding within Health Board’s core budgets from 2025-26 allows health boards the opportunity to provide greater stability and to improve longer term, sustainable financial planning.

Primary Care Improvement Plans

The 2018 General Medical Services Contract in Scotland^[3] for General Practice (“the GP Contract”) and associated Memorandum of Understanding (MoU) set out the six priority service areas that Integration Authorities (IAs), in partnership with NHS Health Boards and GPs, would focus on for service redesign and expansion of the Multi-Disciplinary Teams (MDTs). The Primary Care Improvement Fund (PCIF) supports the implementation of the Primary Care Improvement Plans (PCIPs) in which IAs set out how they would deliver the GP Contract and MoU. In 2024-25, we are investing over £190 million in support of the implementation of PCIPs.

PCIPs reflect local priorities based on population healthcare needs, taking account of existing service delivery, available workforce and available resources and working in collaboration with local partners. The Scottish Government publishes annual progress reports on PCIP and MDT implementation, including WTE figures for workforce in post as part of PCIPs. These figures include three staff groups key to mental health support: Mental Health Workers, Occupational Therapists (OTs), and Community Link Workers (CLWs).

OTs provide a valuable role by taking a holistic, practical and early intervention approach to improving an individual’s physical and mental health, regardless of age and diagnosis. They aim to improve an individual’s ability to carry out everyday tasks and promote independence, including supporting people who may have challenges at work or those who require adjustments to return to work. We will explore opportunities to maximise their role with the Scottish Occupational Therapy in Primary Care Network, which is taking forward several work streams in collaboration with a range of national partners.

CLWs in general practice work with people to improve their health and wellbeing by offering support in relation to issues such as poverty, loneliness and isolation, housing, debt, and abuse. CLWs will often work with someone over many sessions, using a social prescribing approach to clarify what matters to them. CLWs then help them come up with a plan to address aspects of their lives that have a negative impact on their health and wellbeing. A high proportion of CLW caseloads will involve mental health and wellbeing concerns, and CLWs often work with people who have been unable to access specialist care and support. We have started to review CLW policy, including future funding arrangements, to ensure CLW capacity can be sustained and aligned with greatest need.

The Primary Care Phased Investment Programme (PCPIP) has been established to help improve implementation of two regulated services areas within the GP contract. It aims to develop a culture of continuous improvement across primary care settings and build evidence to understand the national context for GP contract implementation to inform long term Scottish Government investment.

Through the programme, Healthcare Improvement Scotland (HIS) is providing bespoke quality improvement (QI) and monitoring and evaluation support. HIS is working with four demonstrator sites covering a diverse range of settings (NHS Borders, NHS Shetland, NHS Ayrshire and Arran, and Edinburgh City Health and Social Care Partnership) to more fully implement two regulated MDT services areas within the GP Contract - pharmacotherapy and Community Treatment and Care (CTAC) services. The programme also aims to gather evidence to understand the impact of implementation for people, the workforce and the wider system.

While the QI support will focus on Pharmacotherapy and CTAC services, the evaluation will consider all the MDT services, including CLW and MH Workers, so it will include findings and best practice relevant to increasing the mental health and wellbeing workforce capacity when budgets permit that to happen. The programme will provide a final report in December 2025, with learning shared throughout. In addition, HIS has established a national ‘Primary Care Improvement Collaborative’ which offers support for teams outwith the PCPIP demonstrator sites. This aims to implement quality improvement approaches, including work to improve access to general practice, which is important for mental health and wellbeing.

Mental Health and Wellbeing Supports in Communities Funds

Third sector organisations (which include charities, social enterprises, and voluntary groups) play a key role in promoting mental health and wellbeing, preventing mental ill health and providing invaluable support in many ways. This ranges from prevention to recovery, through local grass roots groups to national organisations.

Their knowledge of local issues, connections with people and partners, and their ability to innovate and adapt to changing situations are why third sector organisations form such an integral part of a whole system approach to supporting mental health and wellbeing. This was evidenced during the pandemic and led to the establishment of the Communities Mental Health and Wellbeing Fund for Adults. This fund is managed locally by Third Sector Interfaces in collaboration with other local partners, including local authorities and Health and Social Care Partnerships.

The Mental Health and Wellbeing Strategy emphasises the vital roles that local authorities, community planning partnerships, communities, and third sector organisations play in developing resilience, providing social infrastructure and supporting mental health and wellbeing nationally and in local communities.

For these reasons, we have prioritised funding in community settings to ensure availability, of support for adults, children and young people. Two funding streams are in place to support local approaches specifically aimed at improving mental health and wellbeing in adults and children and young people, with a particular focus on prevention and early intervention.

The Communities Mental Health and Wellbeing Fund for Adults was launched in 2021 and supports grassroots community groups to deliver programmes for adults which build resilience and tackle social isolation, loneliness and mental health inequalities. In the first three years of the fund, more than 4,800 grants were made to a wide range of grassroots community interventions. These include initiatives based around peer support, physical activity, arts and crafts activities, social interaction and befriending. Year 4 of the fund launched in September 2024.

The Communities Fund for Children and Young People’s Community Mental Health and Wellbeing Supports began in 2020 to provide easily accessible support for those who did not meet the eligibility criteria for CAMHS. The £15 million per annum funding delivers community-based mental health and wellbeing support for five to 24-year-olds and their families. Support already delivered includes mentoring, art-based therapies, digital services, whole-family support, counselling, and sport or physical activities. More than 300 supports and services are available across the country, with local authorities reporting that over 58,000 people access them in the first half of 2023.

We have invested over £130 million since 2020 in community-based mental health support, through these two funding streams. We recognise the need to ensure that these community supports are accessible from general practice which is why this report contains an action to explore options to strengthen links between general practice and community-based support and services funded through the Adult Communities Fund.

The Autistic Adult Support Fund

The Autistic Adult Support Fund (AASF) is supporting autistic adults across Scotland by providing one-to-one services, peer group support and training sessions, as well as through developing and then sharing resources. This year, 15 organisations have received £1 million of funding. Diagnosis is not required to access this support.

Enhanced Psychological Practice Programme (EPP)

The 2020 Short-Life Working Group on Mental Health in Primary Care report recommended having a diverse range of professions within general practice settings, working alongside GPs, to ensure that the range and complexity of mental health and wellbeing presentations could be supported.

Since 2021 Enhanced Psychological Practice Programme (EPP), managed by NHS Education for Scotland (NES,) has already begun to demonstrate the improvements associated with introducing new training within primary care and in some instances, general practice. There are two courses: one which focuses on learners working with adults (EPP-A), and a course targeted at learners working with children, young people and their families (EPP-CYP). The EPP-CYP course has a central focus on training learners in the most effective evidence-based interventions to support the prevention of and early intervention for the most common mental health problems in childhood. The adult programme has been successful in bringing additional capacity to support work with adults with common mental health problems such as depression and anxiety.

Four new and distinct national job descriptions covering trainees and qualified staff in both children and young people and adult services, were approved by the Scottish Terms and Conditions Committee Job Evaluation Sub-Group in October 2024. These new job roles, which have been given the title Psychological Intervention Assistant (PIA), will help to underpin the educational programme. There are already examples of how people trained through the programme have been deployed in primary care settings. We will work with partners to consider how to ensure the most effective use of the training programme and new PIAs roles within primary care.

Further improvements We have invested in general practice and communities because we value these services and the vital support they provide. We acknowledge there is a need to grow the capacity of the primary care mental health workforce, in recognition that a significant proportion of mental health workload sits in primary care, especially within general practice. We will prioritise further investment to support this ambition when budgets permit and what we can do now is take forward actions to achieve smaller scale change to improve access to care within communities.