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

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Data The need for improved community mental health data has been consistently highlighted, including in the Audit Scotland review of Adult Mental Health Services in 2023. We recognise the historic challenges to storing and accessing GP data, and the need for both new infrastructures and technologies associated with accessing consistent mental health data within general practice.

During the development of this report, we have sought to evidence the widely used statistic that a third of appointments in general practice, approximately 8,000,000 per year, have a mental health component. While this is a long understood and reported estimate of demand, there is no national empirical data available to underpin this.

We also understand that there is a desire for more robust and complex mental health data from general practice. This this will take time, needs to be underpinned by a shared understanding of what such data priorities should be. Crucially it is also dependent on resource, locally and nationally, to facilitate new data collection.

What we can evidence now

We therefore sought to consider how we could better use existing data on mental health to determine demand in general practice, who is accessing this support, and their experience of doing so. Mental health analysis has been drawn from the Health and Care Experience Survey relating to people who received care from their general practice or out of hours services for a mental health reason. These statistics^[4] published on 28 November 2024.

Improved access to general practice data

A programme of work is underway to improve access to primary care data through the implementation of a Primary Care Data and Intelligence Platform. This will make data available from all GP IT systems daily for statistical analysis and reporting and will include relevant and agreed data captured in relation to mental health. Controlled access to the data held in this platform will be made available on a use case basis on a “use case” basis to each Regional Board, Public Health Scotland, NES and National Services Scotland (NSS) by March 2026.

However, an examination of current data of conditions coded by GPs concluded that data input is too variable to draw meaningful conclusions, and that any new Platform would have to be accompanied by training and investment in data entry in practices.

Improving access to support from General Practice

We know that there are opportunities to improve access to mental health and wellbeing support from general practice. While general practice is often rightly the first port of call for people seeking support for mental health assessment and treatment, there are a variety of national tools and therapies, and community resources that people can be better connected to, to improve the package of care and support available to them.

General Practice to communities

We recognise that more could be done to strengthen the links with community-based support and advice, whether through signposting or in the context of more in-depth social prescribing interactions. We will therefore look to strengthen links between primary care and community-based support and services funded through the Mental Health and Wellbeing Communities Fund for Adults so that staff working in General Practice can maximise the potential of community resources. It is envisaged that this work will be transferrable and we will consider widening out to other third sector supports in future.

We know this is already working well in many places. We will engage with Third Sector Interfaces and projects themselves to gather best practice examples of advertising and promoting community-based supports. We will also engage with CLW services to explore their resources and practice to understand how they find out about and link people to support in their local areas.

We also recognise that there is much social prescribing activity within communities that is delivered through services outwith general practice. This activity also has a key role in creating good mental health in communities. Building on Scotland’s frontline experience in primary care and wider settings, we are exploring, through the development of a long-term Population Health Framework, a potential overarching, national approach to social prescribing to support better health in communities.

Some IJBs have created or are in the process of creating a single point of access to all mental health and wellbeing services in their locality. We will therefore ensure that work to strengthen pathways between general practice and communities both learns from, and can be adapted to take account of, such models.

We will also explore ways to improve links between the Mental Health and Wellbeing Communities Fund for Adults and the community supports for children and young people.

Primary Care resources toolkit

The Mental Health in Primary Care Resource Toolkit was developed to support staff working as part of a multi-disciplinary team in mental health and wellbeing in primary care services. It provides a directory of additional sources of help and support that staff can signpost people to, and was first published in July 2022. We committed to ensuring that the resource remained up to date. It has therefore been reviewed, updated and re-published alongside this report. It includes, for example, the Towards Transformation Leadership Framework resources for health practitioners supporting autistic people and people with learning disabilities.

We will actively promote the updated resource with key stakeholders and professional groups across primary care to raise awareness.

Increasing the use of digital therapies

We will increase the use of digital therapies in general practice, namely Silvercloud CCBT (requires referral), and Sleepio and Daylight (both unsupported/self-referral and for insomnia and anxiety respectively). We will look to increase the use of underutilised programmes, for example, programmes to support those with long-term conditions and children and young people. We will also undertake targeted work with health boards who have the potential to increase their use of digital therapies. This will increase the availability of support and treatment in general practice for those with mild to moderate mental health needs.

This will be achieved primarily through promotional activity with relevant networks and professional groups in primary care. In addition we will also:

• Ask Big Health, the supplier of Sleepio and Daylight, to engage with all health board clusters across Scotland, with the aim of replicating Lothian’s success in increasing the use of the apps following similar engagement.
• Further promote the Mental Health in Primary Care Resource Toolkit with key networks. The resource includes a comprehensive chapter on both referral and self-referral digital therapies and sets out what is available and how to access.
• We will explore with health board pharmacy/prescribing support leads whether we can further increase the use of digital therapies, mainly Sleepio, by embedding information about the therapies into local formularies and prescribing tools.

We are mindful that not everyone will be able to benefit from digital therapies for a variety of reasons. These include digital exclusion and language barriers, therefore digital therapies should be a choice that complements other forms of support and treatment. However, promoting appropriate referrals and uptake will allow timely access to support for many people and free up GP time to provide more complex clinical support.

National Pathways to Support

The Scottish Government has increased investment in the NHS 24 Mental Health Hub by over £6 million since it was launched as 24 hour, 7 day a week service in 2020. The Mental Health Hub is staffed by specially trained Psychological Wellbeing Practitioners who are supported by Mental Health Nurses. It offers immediate expert advice and assessment for people who are experiencing distress, mental health crisis, or mental health emergency.

The Mental Health Hub is now well established, regularly responding to over 10,000 calls per month and offers a variety of care outcomes for individuals, including connecting them with other services when needed.

Held in Mind

We will work with NHS 24 to scope the feasibility of delivering a national ‘Held in Mind’ service. This would expand the offer of the NHS 24 Mental Health Hub to provide access to brief video enabled psychological interventions and therapies for people who may benefit from early treatments from applied psychologists, and other professionals appropriately trained in psychological practice. It could also provide a national referral route to evidence based digital therapies.

The Held in Mind expansion could improve early identification and timely access to early intervention and support to prevent mental health symptoms escalating by providing access to digital therapies and brief psychological treatments without the need for a referral from local GPs.

Out of Hours Support

Regardless of how good planned care is, there will always be a need for unscheduled care. It is vital that our whole system is designed to ensure that only those who require unplanned care are supported within unscheduled care settings. People seeking support during the out of hours period should be offered the same support as those seeking support in-hours. While not all forms of support will be available immediately out of hours, there has been, and continues to be significant improvements to mental health unscheduled care that can be aligned to support general practice during the out of hours period.

Psychiatric Emergency Plan Review

A review of the Psychiatric Emergency Plans (PEPs) is currently underway. This aims to improve consistency across all 14 Health Boards and ensure that the roles and responsibilities of all local agencies and service providers are clearly articulated and as consistent as possible, while still allowing for local flexibility.

The review will also look at safe transfer of care between agencies, safety and crisis planning, and information sharing guidance, among others, and is expected to be complete by the end of 2024. Following consultation, guidance and a national template will be developed and published in 2025.

Mental Health Unscheduled Care Resource Toolkit

A Mental Health Unscheduled Care resource has been developed for unscheduled care and out of hours staff. The resource brings together a range of national resources and tools that aims to support and improve people’s mental health and wellbeing. These additional sources of support can complement the support, assessment and treatment people are already receiving, or are waiting to receive. The resource has published alongside this report.

Safe Spaces

We have published a report^[5] which explores the feasibility of implementing additional safe spaces. The report recognises that Emergency Departments (ED) have been, and will continue to be, an important space and service for people experiencing crisis and acute emotional distress. At the same time, it notes the limitations of ED as an environment to support people in crisis and suggests that alternative safe spaces are needed in addition to ED to support people within the community, and as an alternative to ED as a place of safety.

Workforce Education and Training

Generalist Staff

Most mental health and wellbeing demand in primary care is dealt with by generalist staff, particularly GPs as a first contact-point who can facilitate continuity, address complexity and multimorbidity, and provide leadership for the rest of the multidisciplinary general practice team. It is vital that other generalist staff, including non-clinical roles, have non-specialist skills, knowledge and confidence to be able to help people they support and care for. An individual’s interaction with such staff can shape the quality of a person’s experience and influence how they engage with healthcare. There are opportunities to improve the ways in which staff are equipped to deal with people’s mental health and distress, recognising the increased risk of physical and mental health difficulties in people affected by trauma and the opportunities to reduce barriers to engagement in services for improved outcomes. It is also important that whole teams are given appropriate training opportunities to foster MDT working and practices that are ‘trauma-informed’, at the very least, if not ‘trauma-skilled’ or ‘trauma-enhanced’, by embedding principles and learning from the National Trauma Transformation Programme into their policies (e.g. for registration and missed appointments) and ways of working. Such changes in turn can help to address a lack of engagement with services by individuals and specific challenges like ‘missingness’ (repeated missed appointments).

The Scottish Government will publish its Transforming Roles Paper 6 – The Role of the General Practice Nurse – 2025 (GPN) in early 2025. This will set out a refreshed General Practice Nurse role for long-term condition management and proactive health promotion, and as highly adaptable clinical leaders. To support implementation of Paper 6, NES will produce an accompanying GPN Knowledge and Skills Framework, and will undertake a training needs analysis to shape this. We will work with NES to help ensure that GPNs have access to resources and training opportunities to feel confident in dealing with mental health and distress.

General practice administrative staff have a unique role and opportunity, as they are usually the first contact a person has with their GP practice. It is important to acknowledge significant developments in recent years to strengthen and support practice administration roles which led to their 2023 Competency Framework. NES is developing a Menu for Learning aligned to that framework which they will integrate into a dedicated TURAS section and update quarterly. This will include guiding staff to the ‘informed level’ on the ‘Mental health improvement, and prevention of self-harm and suicide’ knowledge and skills framework and the National Trauma Transformation Programme. NES will also deliver a series of ‘masterclasses’ for receptionists from early 2025 which will include care navigation, de-escalation, health inequalities, patient access/rights, and general practice coding.

It is also important that practices help patients to understand why a receptionist may ask for more information when they contact a practice: the Right Care Right Place Receptionist Campaign resources are useful for this. Receptionists do not make clinical judgements and can helpfully make people aware of other national or community services or resources that might benefit them. Reception staff often deal with patients who are distressed and anxious, so they need to be supported to have the skills to recognise why a patient may be behaving in a certain way and how to respond appropriately.

Mental Health Nursing

Mental Health nurses will continue to play a vital role in providing mental health support, assessment and treatment in general practice.

The Ministerial Taskforce on Nursing and Midwifery is looking to specifically promote and enhance the value and contribution of the nursing and midwifery professions in Scotland. It will also identify the key activity that will support the two professions in the context of their shared, as well as their distinct challenges, in building a sustainable, attractive, fair, flexible, respected and empowered workforce for the future. A report of recommended actions will be published in early 2025.

The review of mental health nursing will build on the recommendations from the Taskforce. It will consider key themes such as voice, leadership and professionalism; workforce skills, education and research; the mental health nursing contribution to mental health promotion, prevention, and service provision; and the mental health nursing role in ensuring the quality and safety of patient care in all care settings, including primary care. A report of recommended actions will be published in Spring 2025.

Digital education and training

To support uptake of digital therapies, we are exploring:

• The development of advice/guidance for referrers on conversations with people that will ensure suitability and maximise engagement with digital psychological therapies and interventions.
• Working with NES to scope the development of learning materials ‘Introducing digital psychological therapies and interventions in 2025-26.
• Working with NES ways to raise awareness of the benefits of digital psychological therapies and interventions across the public services, including primary care for example through SWAY, webinars etc.
• Signposting to learning resources introducing digital psychological therapies and interventions, including self-referrals for staff across public services including primary care.

To support the digital literacy and skills of the health and social care workforce, we have recently launched ‘Thriving in a Digital Age Pathways’. Developed by NES on behalf of Scottish Government and COSLA, the pathways are intended to build understanding of the role of digital in health and social care. There are four pathways (Explore, Embed, Drive, and Shape) which are aligned to levels of responsibility.

Children and young people

NES has several training offers supporting the delivery of evidence based psychological therapies and interventions for children, young people and their families, that are highly suitable for delivery within general practice and community settings.

These have a particular focus on prevention and early intervention, for mild to moderate mental health symptoms in children and young people. They include the training of Clinical Associates in Applied Psychology (specialist mental health professionals who work in a range of areas involving children, young people, and their families), as well as a suite of training offers for the multidisciplinary, wider children’s services workforce. These are delivered within community-based settings, related to Parenting and Infant Mental Health (including the Psychology of Parenting Programme) and Training in Psychological Skills- Early Intervention for Children).

Through this suite of offers, staff can be trained to develop the competencies required across different practice types to deliver evidence based psychological therapies and interventions to support the mental health and wellbeing needs of children and young people.

Principles to Underpin Practice

Time Space Compassion

The Suicide Prevention Scotland delivery plan (2024-26) outlines a commitment to work with primary care colleagues to embed the principles of Time Space Compassion and good practice in suicide prevention across primary care settings.

Initial scoping work by Suicide Prevention Scotland highlights potential areas for collaboration to improve access to mental health support in primary care, in line with the General Practice Access Principles and Realistic Medicine.

A key priority is to promote best practice in assessing, managing and reducing recurrence of self-harm and suicide risk. This builds on early work underway with mental health and unscheduled care teams in several boards and with national partners, including HIS and NES, to develop a national package of resources that supports teams to make the shift from risk assessment to personalised risk management practices. It is anticipated this pack will focus on supporting improvements in risk formulation skills, person centred practice and processes, family and loved one involvement, and taking a trauma informed and inclusive approach. This is aligned with the latest evidence and national clinical guidelines. Taking this work into primary care is expected to involve gathering and sharing information on how primary care services are already approaching personalised risk management and using this learning to adapt and test the national resource pack in primary care settings.

Running in parallel to the Time Space Compassion suicide prevention work, Self-Harm Network Scotland have a small practice development team. They work with teams and communities to develop their capacity and capability to support people affected by self-harm, typically using bespoke learning resources. There is the potential for targeted development work within primary care settings, or with community-based partnerships.

We will continue to use the Time Space Compassion practice story publication (here is an existing example from an acute care setting) as a vehicle to share improvement and emerging good practice in primary care. We will ensure this aligns with the priorities and ongoing work of the Improvement Service and HIS Primary Care Improvement Collaborative.

Some other areas of improvement we will seek to support include:

• Improving awareness and use of evidence-based practice for patient safety and safer services in primary care, available through the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) toolkit
• Sharing good practice around effective referrals, including use of peer and community support
• Trauma, self-harm and suicide informed reception and triage skills, behaviours and practices
• Improved/increased awareness and uptake of learning and development for GPs and primary care-based staff on both self-harm and suicide prevention

The Future of Mental Health and Wellbeing in Primary and Community Care Reform

Work on the future state of mental health services, including community mental health services

In addition to continuing to promote a mental health and wellbeing MDT approach across Scotland, we know there is a need to define a well-balanced mental health system. This includes supporting a shift towards more community-based support, care, and treatment.

We are considering what work is needed to ensure nationally consistent healthcare delivery and to define the future state of mental health services. As part of a wider programme of reform, we are considering the development of service specifications, or a target operating model for mental health services. A target operating model would describe a high-level national framework for mental health services, which would support local planning and commissioning decisions and be driven by existing good practice and success within the mental health system.

Target operating models and similar approaches have been used in other areas. These include the Prison Healthcare Target Operating Model published last year, and the Community Mental Health Framework for Adults and Older Adults which sets out a structure for providing integrated community-based mental health care.

Primary Care Reform Route map

The Scottish Government is developing a Route Map to further enhance the sustainability of primary care. The Route Map will set out both how the primary care system operates currently and how it will operate in the context of wider reforms. These wider reforms include the development of the National Care Service, reform of Acute NHS Services through the National Clinical Framework, and the Population Health Framework.

The Route Map will cover key enablers to realise our collective vision for primary care: workforce, finance and funding mechanisms, ‘governance, contracts and planning’, ‘infrastructure, data and digital’, ‘policy, frameworks and standards’ and ‘improvement and learning’, and it will recognise the necessary diversity of arrangements across the independent contractor landscape. Cross-cutting themes are being considered throughout the development of the Route Map, including the remote and rural perspective, alongside health inequalities and person–centeredness.

We will ensure that mental health, especially in general practice, will be a key consideration in the work on primary care reform.