Mental Health in Scotland - a 10-year vision: analysis of responses to the public engagement excercise

Executive Summary

Introduction

This summary presents the key messages from the analysis of responses to the Scottish Government's engagement exercise about a new Mental Health Strategy for Scotland.

The new Mental Health Strategy is intended to cover a 10-year period. The framework on which respondents were asked to comment sets out the priorities that the Scottish Government thinks will deliver significant improvements to the mental health of the population of Scotland. It is organised around life stages: Start Well; Live Well; and Age Well. The framework sets out 8 Priorities that the Scottish Government has identified for the next Strategy. These are:

1. Focus on prevention and early intervention for pregnant women and new mothers.

2. Focus on prevention and early intervention for infants, children and young people.

3. Introduce new models of supporting mental health in primary care.

4. Support people to manage their own mental health.

5. Improve access to mental health services and make them more efficient, effective and safe - which is also part of early intervention.

6. Improve the physical health of people with severe and enduring mental health problems to address premature mortality.

7. Focus on 'All of Me': Ensure parity between mental health and physical health.

8. Realise the human rights of people with mental health problems.

A total of 598 responses were available to inform the analysis. The majority of responses, 61%, were submitted by individual members of the public. The remaining 39% of responses were submitted by groups or organisations, including health organisations, local authorities, multi-agency partnerships, third sector organisations and service user or carer groups.

Many of the submissions made were both lengthy and detailed, and this analysis focuses on the most frequently raised themes and issues.

The Priorities

The first question asked if the 8 Priorities are the most important for transforming mental health in Scotland over the next 10 years. 51% of those who answered the question thought that the 8 Priorities are the most important. Of the remaining respondents, 39% disagreed and 10% did not know. Group respondents were relatively evenly divided (with 50% agreeing, 45% disagreeing and 5% not knowing), as were individual respondents (with 51% agreeing, 36% disagreeing and 13% saying they did not know).

General comments on the draft proposals

Although Question 1 focused on the 8 Priorities set out, a number of respondents raised more general or fundamental issues about the scope or focus of the current proposals. Many of these respondents offered support for the shift from a 3-year to a 10-year strategy, the life-stage focus of the strategy, and the overt focus on prevention and early intervention.

Some respondents raised issues or concerns about the overall focus of the current draft document. A primary concern for some respondents was that, while the 8 Priorities would help improve mental health services, they do not amount to transformation, and that the overall Strategy lacks ambition or vision. It was recommended that a vision and core set of values should be developed in partnership with those with lived experience.

In terms of elements to be taken into account and which should inform the Strategy, it was suggested that the Strategy needs to be aligned with other strategies, policy and legislation and the appropriate parallels and linkages made. It was also suggested that clear arrangements should be in place for monitoring and evaluation.

Themes and emphasis

In terms of the overall themes and emphasis running through the Strategy, it was suggested that there should be a much stronger focus on wellbeing. This would mean a shift in focus away from service provision to the emotional health and wellbeing of Scotland's communities, and would require a major revision of the current Strategy. It was also suggested that a whole system response, with a stronger emphasis on a collaborative, multi-agency approach, should be central.

Areas in which it was suggested that overall coverage is insufficient included the impact of socio-economic disadvantage, and the needs of the most marginalised and hardest to reach communities. Another area on which a number of respondents commented was the human rights-based approach. It was sometimes suggested that this needs to be more firmly embedded and should be 'threaded-through' the whole Strategy rather than be seen as one of the Priorities. On a connected point, a number of respondents commented on the extent to which the Strategy addresses equalities commitments. A clear statement recognising how experiencing inequality can contribute to, or cause, poor mental health was also proposed. Other areas which respondents suggested should be given greater focus included: addressing the needs of more vulnerable populations; the rural dimension; tackling stigma and discrimination; employment and employability; and the links with alcohol or substance misuse.

Other comments focused on key requirements for the successful delivery of the Strategy including the need for sufficient resources and funding. The need for a sufficient level of funding to support appropriate staffing levels was highlighted in particular, as were issues around workforce development and training.

Many comments focused on the types of approach or service which should be given greater prominence within the Strategy. Suggestions included rehabilitation and recovery. It was suggested that recovery needs to be at the core of mental health policy and practice, not seen as an added extra that can be bolted on. Person-centred approaches and trauma-informed approaches were seen as important, as was delivering a family-inclusive model of care. It was also seen as important to have mental health services which respond to the needs of those who do not fit current service approaches, including those with complex or unusual needs.

It was suggested that the overall balance between specialist and general care needs to be reconsidered, and the important role that general care plays should be recognised. Acute and crisis services, and specialist mental health care, were also seen as needing further focus and investment.

Groups or approaches requiring additional focus or priority

Some respondents highlighted particular groups of people to whom they felt the draft document does not give sufficient focus. They included: families and carers; people with severe and enduring mental ill health; people with learning disabilities or autism; children and young people with mental health problems; people experiencing or at risk of homelessness; LGBTI people; and young LGBTI people in particular.

Respondents also identified a range of groups of people or types of issue or approach which they felt should be an additional priority within the Strategy. A number of the groups identified were focused on children and young people and included: care experienced children and young people; young people needing secure care; children or young people in the youth justice system; deaf children and young people; children and young people with learning disabilities; and older young people. Other groups suggested included: people going through transitions; people with sight loss; people with disfigurements; people with dementia; older people; people with eating disorders; prisoners and those in the criminal justice system; refugees and asylum seekers; and students.

The need to consider the role and contribution of various types of organisation was also highlighted, including that of: the third sector; Integration Authorities; Community Planning Partnerships; and non-mental health specialist statutory and public services.

Themes or types of service which respondents identified as possible priorities included: co-production and valuing lived experience; suicide prevention; addressing discrimination and inequality; developing inclusive, connected and resilient communities, which can support good mental health; preventing mental ill health through education; building and maintaining wellbeing; recovery-focused mental health services; the role of employment; access to greenspace; tackling obesity; developing and expanding the provision of crisis care; and a review of the use of medications.

Specific comments on the priorities and actions

Priority 1: Focus on prevention and early intervention for pregnant women and new mothers.

Raising awareness of perinatal mental health and working closely with mothers was seen as a significant way of intervening early, reducing vulnerabilities and supporting the child protection agenda. The focus on the early recognition and treatment of perinatal mental health, particularly for those most vulnerable, was widely endorsed, although some respondents suggested that there could be a greater emphasis on the inclusion of work with fathers and other family members.

It was noted that the onus for perinatal mental health appeared to be placed on health services, but suggested that success will depend on the inclusion and integration of the work of a number of key agencies. Frequent reference was made to the third sector as continuing to have a key role to play.

Priority 2: Focus on prevention and early intervention for infants, children and young people.

There was strong support for evidence-based programmes to promote good mental health, and that these should again target vulnerable groups. It was noted that a range of issues which can affect a child or young person's mental health, such as being bullied, difficulties at school, or unmanaged grief or loss, need to be recognised. It was suggested that the Strategy needs to consider the unmet need which can result from these issues. However, there was also a frequently-expressed view that such programmes should also focus on wider physical and mental health determinants such as deprivation, employment, social connectedness, and environment.

When taking this work forward, it was suggested that community involvement will be imperative and that communities need to take responsibility for children and young people. It was noted that schools have a particularly important part to play in the promotion of good mental health and that the Strategy needs to recognise this.

Although a clear link was seen between mental and physical health, many of those commenting thought these principles should be extended to consider a whole person response to supporting wellbeing. Resilience, self-worth and optimism were seen to equip children and young people to be socially connected, confident and to decrease the impact of any inequalities, and it was thought these should be promoted. Co-production of services with children and young people and their communities was considered to be of value to the individuals involved, and was seen as having a positive role to play in challenging stigma.

Priority 3: Introduce new models of supporting mental health in primary care.

There was a frequent view that, in order to support mental health in the community, wider determinants of mental and physical wellbeing needed to be considered. This included the impact of factors such as poverty, employment and social inclusion on health outcomes and recovery.

In order to address these challenges, it was felt that service responses need to extend beyond primary care, other health services and other statutory services. The wide range of private, independent and third sector partners was noted, and it was highlighted that delivering primary care does not preclude collaboration with the third sector or with non-mental health focused statutory services. It was suggested that the independent, private and third sectors should also be supported to introduce new models of care.

This shifting of the balance of care was seen as key to accessing the extensive pool of resources embedded in the heart of communities and, by extension, to addressing inequalities effectively.

Priority 4: Support people to manage their own mental health.

The focus on self-management and self-help resources was welcomed, as was the emphasis on building emotional resilience, confidence and coping strategies rather than just psychological self-help. The ability to manage day-to-day living, retain employment and access social and leisure activities was considered important in reducing vulnerability, with the third sector seen as having a key role in achieving this. The value of diet, exercise and positive relationships was also noted, alongside the provision of a range of alternatives such as mindfulness, yoga and exercise.

A focus on employment was welcomed as having a role in improving aspiration and sustaining positive health. It was also suggested that the benefits of volunteering as a preventative measure should be highlighted. It was suggested that volunteering is evidenced to improve mental health and wellbeing, and employability. In particular, it was suggested that buddying and peer support models could be referenced, although these should not be promoted as a 'quick fix' for pressures on primary care. More generally, it was noted that self-management should not be seen as a way to reduce access to support or services, or used as a cost cutting exercise.

Priority 5: Improve access to mental health services and make them more efficient, effective and safe - which is also part of early intervention.

It was suggested that the focus of Priority 5 should be on providing an effective and safe service, and that it will be important to maintain quality and governance whilst improving the speed of access to services. It was noted that, without a focus on ensuring quality, there is a risk that whilst patients may be seen more quickly, the treatment provided may be less effective.

Many of those who commented felt that priority should be given to ensuring timely and accessible services throughout the wider health and social care system, acknowledging the valuable role of them all. A number of respondents also commented that a true partnership approach which embraces social care, children's services and the third sector, could provide a more comprehensive range of support, would help prevent crisis and escalation, and would support positive outcomes.

The development of a mental health outcomes framework was welcomed as providing open and accessible public reporting of mental health outcomes data. It was seen as valuable for monitoring progress against clear targets and developing evidence-based interventions.

Priority 6: Improve the physical health of people with severe and enduring mental health problems to address premature mortality.

There was a view that physical health should be embedded throughout the Strategy. Many respondents commented on the interrelationship between the physical and mental health of individuals with severe and enduring mental health problems, including noting that to treat conditions in isolation presented a risk of an incomplete picture and conditions being ignored (or not explored adequately).

The remodelling of primary care was seen as an opportunity to integrate services and create more holistic approaches to the care of individuals with severe and enduring mental health problems, incorporating both physical and mental wellbeing. Partnership was seen as being of particular importance in relation to those with additional vulnerabilities such as older age, learning disability, autism or substance misuse.

Priority 7: Focus on 'All of Me': Ensure parity between mental health and physical health.

Priority 7 was described as 'critical and visionary' and it was suggested that it is essential that mental health is seen as being as significant and requiring of investment as physical health. Other points raised about Priority 7 included that the Strategy needs to more clearly set out that physical and mental health are not just issues that sit alongside each other, but are closely interconnected. It was also suggested that this Priority should include a clear preventative focus, with GPs encouraged to ensure early intervention takes place and health and wellbeing issues are addressed before they worsen.

A number of respondents identified actions or opportunities which would help realise the ambition of parity between mental health and physical health care, with inequalities reduced and mental health being seen as part of everyday life. They included that the integration of health and social care would provide an opportunity to establish better links between services through strategic commissioning, but that the contribution that other sectors - such as housing, leisure and employment - can make should also be recognised and exploited.

It was also suggested that increasing financial security through employment has the potential to promote inclusion, decrease stigma, increase self-worth and open up opportunities. It was felt that employment and welfare programmes should be designed to take account of mental health conditions and offer people the greatest chance of success.

Priority 8: Realise the human rights of people with mental health problems.

There was a broad consensus that realising the human rights of people with mental health problems is essential to the delivery of quality mental health care. This Priority was seen as providing a clear focus on recovery, choice, uniqueness and dignity, and as key to improving the quality and experience of health and social care. Success was seen as not being about simple adherence to legislation, but as requiring a substantial shift in both organisational culture and workforce development.

It was suggested that joined-up thinking across Government departments and strategies would help maximise impact in this important area. In particular, the Strategy should explicitly align itself with the Scottish National Action Plan for Human Rights, and there should be explicit reference to the United Nations Convention on the Rights of the Child ( UNCRC).

Future vision

Respondents were also asked to outline their vision of what mental health services in Scotland should like in 10 years' time. Overall, the most frequently raised ideas reflected the central issues or concerns raised at earlier questions. They are summarised below under broad and frequently inter-connected themes.

Reduced stigma and discrimination: In 10 years' time, Scotland will be a country where mental health is seen as everybody's business. A focus on prevention will improve understanding of mental illness, support a reduction in stigma and address inequalities. People will instead be aware of the importance of good mental health and how they can manage it themselves. This message will be understood and promoted throughout communities, including through our schools. Positive mental health will be recognised but, where ill health does occur, then more enlightened public attitudes will ensure that the experience is free from stigma.

Wellbeing and prevention: In 10 years' time, Scotland's approach to mental health will focus on promoting wellbeing, prevention and early intervention. An early, responsive service will be seen as key and as offering the best chance of avoiding problems escalating, with potentially lifelong consequences. There will have been a substantial shift in the focus of services, along with the resources that go with them, and wider society will collectively experience a mental health gain.

Tackling inequalities: Understanding and addressing inequality will be a key part of creating a mentally healthier society in 10 years' time. Early disadvantage and damage can have lasting effects on life chances and stifle potential. There needs to be recognition that many of the barriers to wellbeing and recovery lie within society and not within the people who experience mental ill health. Both society as a whole and services need to work to remove these barriers so that disadvantaged individuals or groups have access to the support they need.

Whole systems working: In 10 years' time, we will have a whole systems approach which will be intrinsically person-centred, flexible, effective at promoting recovery and will have moved away from overly-medicalised models of care towards person-centred and individualised support. The consideration of mental health in its widest context will mean that communities as a whole will be healthier, more cohesive and more supportive of each other. This more holistic approach to mental health, if founded on promoting wellbeing and otherwise taking an expansive and public health-focused approach to prevention, will mean that the need for more specialist services may have been reduced.

Integrated and equitable services: Partnerships between organisations will be seen as providing the framework within which a whole systems way of working can sit, with 'behind the scenes' structures and processes supporting a joined-up, community-focused approach which then feeds into a better patient, service user and carer experience. The services involved will extend well beyond health and specialist mental health services. A wide range of other services, agencies and groups - including education, social care, the third sector, housing and employment services - will also have a central role to play. There will be a tiered approach to care, with a range of prevention and early intervention initiatives, and access to the right service at the right time. In 10 years' time, where someone lives will not affect their easy access to this package of fit-for-purpose services.

Self-management: In 10 years' time, self-management will be seen as an integral component of a tiered approach to care and this will support people to better understand and manage their own mental illness. This will include equipping people with the tools that support them in increasing their own self-awareness, managing their mental health challenges and remaining connected to society. A proactive approach to the promotion of self-management will be in place which will include options such as guided self-help, online support and peer mentoring.

Carers and families: A Scotland in which the vital role played by carers and families is recognised, and they are supported accordingly, was a key part of many people's 10-year vision. Mental health services will work alongside service users and carers with 'no decision about me without me' being the norm. Carers and families will be seen as key partners, and equal contributors, and this in turn will strengthen the partnership approach.

The impact on families and carers will be better understood, allowing the right support to be made available in the right places. This will include recognising that becoming a carer of someone with a mental health issue can be a challenge and be both physically and emotionally demanding.

Employment: In 10 years' time, the importance of good quality employment opportunities being available will be recognised and there will be a focus on enabling people to both access and retain employment. Employability support will be seen as an inherent part of the package of community-based provision, alongside access to information, social support and physical healthcare. The critical role employers have to play in providing support to employees will be understood, including in terms of promoting wellbeing and good mental health. There will be programmes to support and advise employers.

Outcome-focused evaluation: Considering what is working well and less well will be a central and ongoing process and will be focused on the outcomes being delivered. There will have been a clear move from measuring outputs such as service volume or hours of support delivered, to measuring outcomes which contribute towards achieving recovery.

Co-production and lived experience: The vital importance of involving and listening to those with lived experience has been a common theme running through many of the responses to this public engagement exercise. Although many respondents did set out their vision for what mental health services in Scotland should look like in 10 years' time, there was a common view that the important people, if not the most important people, to be involved in developing this vision are those with lived experience.

This focus on the importance of co-production extended to the Strategy itself, but also to the planning and delivery of services. The approach should be inclusive and ensure that everyone has the opportunity to have their voice heard, including children and young people. People will not only have a right to be involved but will have been made aware of that right.

In 10 years' time the idea of 'service user involvement' will have been replaced by the user-led participation model, with the involvement of the majority of people with lived experience. Services will reflect and act upon the views and experiences of both those using the service, as well as their families and carers. This will not only support informed service and resource decisions, but will also help in moving towards models of skilled user-led peer support. To reap the full benefits of this culture shift, outcome measures will focus on indicators of wellbeing and the development of these measures will be strongly informed and influenced by people with lived experience of mental ill health.

For many, co-production was seen as driving the person-centred approach where people feel empowered to choose and pursue paths to recovery which are right for them. This was at the heart of many respondents' vision of what mental health services in Scotland will look like in 10 years' time but was also seen as key to enhanced wellbeing across Scotland's communities.