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

Priorities

The framework described in the new Mental Health Strategy sets out the priorities that the Scottish Government thinks will deliver significant improvements in the mental health of the population of Scotland. It is organised around life stages:

• Start Well - ensuring that children and young people have good mental health, and that we act early when problems emerge;
• Live Well - supporting people to look after themselves to stay mentally and physically healthy, to get help quickly when they need it, and to reduce inequalities for people living with mental health problems;
• Age Well - ensuring that older people are able to access support for mental health problems to support them to live well for as long as possible at home.

The framework sets out 8 priorities 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.

The first question asked respondents whether the 8 priorities (as set out within Annex A of the Mental Health in Scotland - a 10 year vision paper) are the most important.

Question 1: The table in Annex A sets out 8 priorities for a new Mental Health Strategy that we think will transform mental health in Scotland over 10 years. Are these the most important priorities?

If no, what priorities do you think will deliver this transformation?

Responses by respondent type are set out in Table 2 below. The analysis presented in Table 2 excludes those respondents who did not answer the question: the corresponding table including such respondents is attached to this report as Annex 2.

Table 2: Question 1 - Responses by type of respondent

Type of respondent	Yes		No		Don't know		TOTAL
	N	%	N	%	N	%	N
Academic or research group	3	43	4	57	-	-	7
Health	24	73	8	24	1	3	33
Local authority	3	50	3	50	-	-	6
Multi-agency partnerships ( MAPs)	4	27	11	73	-	-	15
Network, forum or membership organisation	8	32	16	64	1	4	25
Other	2	50	2	50	-	-	4
Professional body or college	10	83	2	17	-	-	12
Public agency	5	63	2	25	1	13	8
Third sector	26	43	31	52	3	5	60
User and/or carer group	5	50	2	20	3	30	10
(Total Groups)	(90)	(50%)	(81)	(45%)	(9)	(5%)	(180)
Individuals	181	51%	127	36%	47	13%	355
TOTAL	271	51%	208	39%	56	10%	535

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).

Professional bodies or colleges, health respondents and public agencies were most likely to agree (83%, 73% and 63% respectively). Multi-agency partnerships, networks, forums or membership organisations and academics or research groups and third sector respondents were least likely to agree (27%, 32%, 43% and 43% respectively). However, it should be noted that the number of respondents within some respondent type groups is small and these findings should be seen as indicative rather than robust. The content of many of the further comments made also suggests that the quantitative results should be viewed with a degree of caution.

Around 410 respondents went on to make a further comment at Question 1 and/or made general comments which have informed the analysis presented in this chapter of the report. Of those commenting, around 110 had answered 'Yes' at Question 1, around 200 respondents had answered 'No' and around 90 respondents had either answered 'Don't know' or had not answered the question. However, irrespective of how they had answered Question 1, many of the further comments included both positives and negatives and could most accurately be described as 'mixed'. In terms of how respondents giving mixed comments had answered Question 1, some appeared to have taken a 'Yes, but…' approach, whilst others had taken a 'No, although...'.

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 proposal. A number of respondents commented on one or more of the proposed Priorities and some respondents identified additional Priorities (either in terms of themes or in terms of client groups). Each of these areas is covered in turn below.

General comments on the proposed Strategy

The value of a long-term Strategy

Either in their opening comments or directly under Question 1, a number of respondents welcomed the intention to introduce a new Mental Health Strategy for Scotland. Some of these respondents noted their particular support for the decision to shift from a 3-year to a 10-year strategy. Reasons given for supporting this longer time-frame included that it will provide for a more realistic timescale to demonstrate outcomes, particularly in terms of prevention. However, notes of caution included that:

• The longer-term approach makes it even more essential that the right direction is taken and any current weaknesses in the system are not consolidated.
• The funding commitment only extends to 5 years. The lack of detail around how the planned investment will be allocated was also noted.

Strengths and weaknesses of a life stage approach

Another area of frequent comment was the life-stage focus of the Strategy, with those highlighting this approach generally offering their support. In particular, it was suggested that this approach helps to map out the journey through life and identify access points, referral thresholds and criteria to/for services. However, one respondent suggested that the changing demographics in Scotland, along with a continuously evolving policy landscape, require continuous monitoring and responsiveness to changing needs and that the long-term nature of the Strategy may result in certain sections becoming obsolete or irrelevant.

Other comments included that some client groups, such as people with dementia or experiencing psychosis, would benefit from moving to ageless services and it was suggested that the overall message might be clearer if certain of the Priorities were not selectively applied to particular groups of people. For example, addressing physical health will be of benefit to people other than those with severe and enduring mental health problems. Equally, early interventions should be a priority across all age groups and circumstances and not just for mothers and children.

A further concern was that, while the Start Well stage is clearly set out, the Live Well and Age Well stages are conflated in the latter parts of the document. One respondent suggested there should be a fourth stage, Die Well. They suggested that the Strategy needs to ensure that people at the end of life, or living with a terminal illness, can access support for mental health problems to support them to die well.

There was also broad support for the overt focus on prevention and early intervention. However, there was a concern that the proposed approach is narrowly conceived and that the focus should be on the benefit of prevention and early intervention at any age and stage. It was suggested that the Strategy overall gives insufficient recognition to the prevention of mental ill health or to the need to respond to the worsening of an existing condition.

Scope for a more ambitious vision

Some respondents raised other issues or concerns about the overall focus or approach and/or the current draft document. A primary concern of 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 suggested that to deliver transformation, that transformation needs to be defined and this of itself should be a Priority. It was also suggested that the Strategy should set out a clear vision or statement of ambition and a set of core values. It was recommended that these should be developed in partnership with those with lived experience and that when further developing and/or finalising the Strategy, the Scottish Government should take an inclusive approach, which includes meaningful consultation with people from across the protected characteristics groups.

A specific suggestion was that a Commission of Enquiry be established to lead and inform the transformation needed to significantly improve the mental health and wellbeing of Scotland's population, and to reduce inequalities in mental health and wellbeing. It was proposed that this commission would bring together a range of people, including those with lived experience of mental health problems, to develop a longer-term vision and make recommendations for change, including legislative reforms.

Key components of a robust Strategy

In terms of what else should be set out within the Strategy document, suggestions included:

• The evidence base that has informed the Strategy.
• Further detail concerning the actions to be taken forward, along with the associated activities required. This should cover the 10-year Strategy period.
• A clear implementation/delivery plan. This should make clear which organisations will be delivering on the various actions contained in the Strategy.
• A reporting framework.
• Details of the budget and funding arrangements.
• Definitions of the terms used. It was noted that the national indicators and frameworks for mental health of adults, children and young people provide these definitions.

In terms of elements to be taken into account and which should inform the Strategy, the following issues were highlighted:

• The Mental Health Strategy needs to be aligned with other strategies, policy and legislation and the appropriate parallels and linkages made. Examples cited included the ongoing work to revise the Dementia Strategy, the Key to Life Strategy, the Criminal Justice Strategy, the National Clinical Strategy for Scotland, the soon-to-be-published Maternity Strategy, the Perinatal and Infant Mental Health Plan, Scotland's National Plan for Human Rights, and the National Outcomes for Health and Wellbeing. Reference was also made to the Self-directed Support and Health and Social Care legislation, the Children and Young People (Scotland) Act 2014, the Community Justice Act 2016, and the Child Poverty Bill. The need to demonstrate links with other transformation programmes was also highlighted. Suggestions included the Primary Care Transformation Fund, Urgent Care Transformation Fund, Mental Health Innovation Fund and Distress Brief Intervention Programme.
• The Strategy should recognise the good progress that has been made via the infrastructure created through the previous Strategy. It was recommended that the previous Strategy's 6 high-level priorities should remain and could be built on by introducing one or two more actions.
• There should be a clear outcomes-focused approach. Outcomes, like recovery, need to be a thread that runs throughout the Strategy and outcome-based measures need to be co-produced with people who use services. Restructuring the Priorities so that they focus on outcome first should be considered.
• The Strategy needs to take a needs-focused, evidence-led approach. Implementation science could be used to ensure interventions and approaches are implemented for maximum benefit.
• There is a lack of coherence and relationship between the early actions and the results and more work needs to be done to map out how outcomes will be delivered.

Delivering the Strategy

Other comments that focused on key requirements for the successful delivery of the Strategy included the need for:

• Sufficient resources and funding. Clarity was sought as to how the funding already committed over the next 5 years will be used to tackle a range of issues, including waiting times for accessing services and a lack of appropriate acute beds for mental health patients. The need for a sufficient level of funding to support appropriate staffing levels was highlighted. There was also a concern that the focus of investment will fail to contribute significantly to shifting the balance of care, and that the necessary funding should be available for third sector and independent provision.
• Workforce development and training and the availability of suitably skilled staff to deliver on the Strategy's commitments. For example, reference was made to current challenges in recruiting Mental Health Officers and to recruitment and retention issues in General Practice. In terms of the type of training required, it was suggested that early identification of mental health difficulties should be established as a core capacity of all health, social care and education professionals.

Monitoring and evaluation

Issues raised concerning the evaluation and/or monitoring of the Strategy included that:

• Learning from the implementation of the previous Strategy should be used to help inform the development and delivery of the new Strategy. An evaluation of the successes, or otherwise, of the previous Strategy is required.
• An independent oversight group, which includes representatives of people with lived experience and carers as well as other key third sector partner organisations, should be established. It was proposed that such a group should be given the authority to seek information and answers from those who fund, commission and manage services.
• Clear arrangements should be in place for monitoring and evaluating, including which models are the most effective and sustainable. This includes in relation to primary care models. The introduction of National Key Performance Indicators ( KPIs) was one suggestion made. Older people from the LGBTI or black and minority ethnic groups should be included in any KPIs that are developed to measure strategy implementation.
• Measurement frameworks must capture health economic gains, making progress on addressing the social and economic determinants of mental health inequalities and, in particular, include effective measures of the impact of prevention activities.
• There may be opportunities to link with wider work to support measurement of progress towards outcomes in Local Outcome Improvement Plans.
• Elements which could lead to transformation should be measured rather than just those elements which lend themselves to being measured, such as waiting times.
• There is a need for caution in seeing measurement of outputs as denoting success. These are good as activity measures, but to be effective the outcomes should be captured on an individual, community and population basis.
• There should be an explicit commitment to greater data transparency and accountability. In particular, while many mental health statistics are published, basic information on aggregate levels of mental health spend are not readily available and improvements could also be made in reporting of rates of recovery and improvement.

Themes and emphasis

In terms of the overall themes and emphasis running through the Strategy, respondents raised a number of issues for consideration.

Co-production and valuing lived experience

A frequently-made suggestion was that the views of those with lived experience should be valued and a co-production approach taken - this was raised in relation to the development of the Strategy itself and regarding the development of services at a local level. It was noted that this level of influence was enshrined in The Public Bodies (Joint Working) Act (Scotland) 2014, and the Community Empowerment (Scotland) Act 2015.

It was suggested that an immediate priority should be the co-production of an ambitious and transformative vision for the future mental health of Scotland's people. This should be developed over the next few months with people who have lived experience, carers and other key third sector organisations.

Co-producing services with those with a lived experience of the mental health system was also considered essential to the human rights approach and as a commitment which should be threaded throughout the Strategy. It should include co-designing services and being part of governance and commissioning groups to ensure that services best meet the needs of people experiencing mental health problems. People with lived experience should also be involved in the evaluation process.

It was noted that this approach should be applied across all services and should be as inclusive as possible. This includes ensuring that children and young people are involved where appropriate. It was also suggested that the approach should be inclusive of carers, families and communities.

Human rights-based approach and tackling inequalities

Another area about which a number of respondents commented was the human rights-based approach. This needs to be more firmly embedded and should be 'threaded-through' the whole Strategy rather than being seen as one of the Priorities. It was noted that the Scottish Human Rights Commission and the Mental Welfare Commission recommended that the Strategy should be explicitly built around a rights-based approach and should utilise the human rights framework to shape its aims and mainstream human rights across its commitments.

Using the PANEL ^[3] principles was seen as allowing for a rights-based framework to shape the Strategy and for the Priorities already identified to be placed within this framework. It was also seen as allowing for any gaps in actions that would fully address the principles to be identified. However, it was suggested that it is difficult to see how the principles have been used to shape the proposed Priorities and that, in its current form, the Strategy does not embed a human rights approach.

One opportunity highlighted was around rethinking how international standards of human rights can be embedded and operationalised across mental health services. An approach to mental health and wellbeing where the person is at the core of decision-making because upholding of rights requires it was recommended.

On a connected point, a number of respondents commented on the extent to which the Strategy addresses equalities commitments. It was suggested that the PANEL approach be used to consider both the human rights impact of actions and to help ensure that the Strategy meets the diverse needs of Scotland's communities. It was also suggested that there should be an equality statement to ensure that no group, irrespective of equality characteristics, is disadvantaged in relation to accessing timely and appropriate support. A specific suggestion was that all aspects of the framework should have a strong gender focus. A clear statement recognising how experiencing inequality can contribute to, or cause, poor mental health was also proposed.

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. Given that the incidence of mental illness is often greater in areas of deprivation, improving socio-economic inequalities needs to be given appropriate consideration. In particular, it was suggested that there should be a greater focus on inequalities and the impact of poverty and other socio-economic disadvantages on children and young people. The barrier created by digital exclusion, including in relation to accessing psychological therapies such as computerised Cognitive Behavioural Therapy ( CBT) was also highlighted.

Other areas which respondents suggested should be given greater focus included:

• Addressing the needs of more vulnerable populations. It was suggested that while the Strategy should emphasise universal approaches where appropriate, it must also demonstrate awareness of the needs of particular groups. A number of these particular groups were suggested as being additional priorities for the Strategy and further analysis is included later in this chapter.
• The rural dimension and in particular the needs of those living in remote or isolated communities.
• Tackling stigma and discrimination. There could be more emphasis on addressing stigma attached to mental health. There should be a greater emphasis on addressing these issues within a range of settings including general health settings, job centres, schools, local community groups and the police. It was also highlighted that the stigma experienced by people with mental health problems can be further compounded if they have an addiction problem. Additionally, it was reported that stigma continues to be a problem for people living with HIV, and that this can directly impact on health outcomes.
• Isolation and loneliness. There should be a focus on addressing the crippling impact of chronic loneliness and isolation experienced by people who have no family networks. It was noted that a sense of belonging is important and some people who are unwell over many years feel increasingly isolated and abandoned by society.
• Improving the response of the justice system to people with mental health needs. It was reported that the police, the prosecution service, the prison service and the courts have all expressed a wish to respond better to people with mental health needs, be they offenders, victims or witnesses.
• The links with alcohol or substance misuse. It was suggested that this is one of the most vulnerable populations experiencing significant mental health problems in Scotland. It was highlighted that alcohol is not only relevant to the Strategy as a preventable physical health problem but as a contributory cause and compounding factor in mental ill health. It was also suggested that action to reduce alcohol consumption will help to prevent mental health problems arising and/or reduce their severity. There was a call for the Strategy to consider how people can be actively engaged in treatment for both these manifestations of their ill health and be actively and adequately supported with what can be long-term and chronic ill health. There was a specific concern that links to drug and alcohol use and specific vulnerability from dual diagnosis appears to be missing. In relation to suicide, it was suggested that the Strategy would be improved by a far stronger emphasis on the role of alcohol in suicidal behaviour.

In addition to the suggestion that the Strategy should have a stronger focus on tackling inequality and discrimination, this was also proposed as an additional Priority. It was suggested that part of the current Priority 8 ("people with mental health problems experience less discrimination and fewer health inequalities, improved access to mental health services and improved employment"), would be better relocated under a separate Priority focused specifically on addressing discrimination and inequality. A suggested title for this Priority was "Ensure that equality for people with mental health problems is achieved and protected across all the protected characteristics and their intersections".

Suicide prevention

It was noted that there is a separate strategy for suicide prevention. Nevertheless, it was felt that suicide should be referenced within the Mental Health Strategy and, overall, must remain a key priority. It was noted that while suicide is not solely an issue of mental health, it is one the many different factors which can interact in complex ways to result in someone taking their own life. The commitment to a new and distinct Suicide Prevention Strategy was welcomed but it was suggested that there is merit in including a commitment to suicide prevention and actions to support a continuing reduction in suicide within the Mental Health Strategy. Issues raised about suicide prevention included:

• Evidence from elsewhere suggests that people with autism may be a particular 'at risk' group and this needs to be explored.
• The duty to share information to protect life should be articulated by Government to the leadership of all agencies involved in policing, health and social care. A mechanism should be developed which allows police, health and social care services to record information in relation to personal suicide risk and for this information to be capable of search by front-line staff.

Other areas to be emphasised or reviewed

Other areas suggested as warranting review included:

• 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.
• Overall, the Strategy appears to be very health-focused, and in particular NHS-focused, based on medical models, and uses medical-based language. There is much less emphasis on social models.
• Shifting the balance of healthcare priorities should be central but the language used in the Strategy might be described as oversimplifying this. For example, the use of the term 'primary care' belies the complexity of multi-agency input and may erroneously be interpreted as referring only to healthcare systems.
• To be successful, a whole system response will be required and a whole government health improvement approach would be part of this. The ambition of an all-of-government approach is missing from the vision statement.
• There should be a stronger emphasis on a collaborative, multi-agency approach. In particular, there is no specific mention of health and social care integration, which is surprising given the scale and importance of the reforms being introduced and the changes still to come. There is also insufficient recognition of the role of public health services, particularly with regards to prevention.
• The distinction needs to be made between mental illness (that requires specialist support services), mental distress (that can be addressed in general practice) and mental health (that is, fundamentally a community/societal issue).
• Many of the Strategy's broader aspirations overlap with the fields of public health, health improvement and primary care, suggesting unnecessary duplication and inefficiency.

Types of approach or service

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. This was seen as requiring there to be changes to the way mental health services are designed, commissioned and delivered. It was suggested that recovery can mean different outcomes for different people so what it means and how it will be measured needs to be defined. It was suggested that the role of recovery within child and adolescent mental health should be considered further. Also, the lack of focus on people who are 'stuck in services' was raised and it was suggested that the Strategy should look to addressing the needs of this group.
• Person-centred approaches. The increasing emphasis across the whole of health and social care on a personalisation approach was noted, and it was recommended that the Strategy should support further movement away from institutional care towards more person-centred and integrated community services. Particular reference was made to enabling people to access psychological therapies.
• Trauma-informed approaches. It was suggested that public services need to become trauma-informed and that this should include seeking to understand and nurture those with self-harming behaviours including substance misuse and dangerous risk-taking.
• Delivering a family inclusive model of care. It was suggested that the Strategy be reviewed to ensure its suitability for supporting families as a whole, rather than individuals within the household. It was felt this would recognise the family dynamics and interplay between family members, with consequences for mental wellbeing for all. It was also reported that preventative and early intervention strategies for young people are most effective when the family or primary carers are included at all stages. It was suggested that initiatives which support family and primary carers early, before requiring specialist CAMHS, will be essential to the successful delivery of the Strategy.
• Mental health services which respond to the needs of those who do not fit current service approaches. For example, people with complex or unusual needs, including people with acquired brain injury, a personality disorder, or women and young people needing secure care. Developing an adequate response to these small but highly vulnerable populations often needs to be at a regional or national level, and requires a greater degree of co-ordination and strategic direction than often appears to be available at the moment.
• Generalist or primary care and the provision of services through GP surgeries in particular. It was suggested that the overall balance between specialist and generalist care needs to be reconsidered and the important role generalist care plays recognised. It was suggested that the current imbalance also extends to the funding regime for generalist services.
• Acute and crisis services. Reference was made to strengthening emergency out-of-hours psychiatric care and to the need for new approaches to support children and young people in crisis, as opposed to simply expanding CAMHS. It was also suggested there should be a focus on developing local partnerships to improve the response to and reduce the number of critical incidents involving people in metal health crisis.
• Specialist mental health care, including that within integrated health and social care services and the investment required to support this role.
• Community engagement and capacity building. Specific reference was made to the development of confidence, social skills and resilience to enable people to fulfil their potential and engage actively in their communities.
• Awareness raising and public education. Particular reference was made to educating children and young people about mental health issues. It was suggested that there is scope to share information about the body of work that is already under way.
• Advocacy. It was noted that people affected by mental health problems experience obstacles to their full, meaningful and effective participation in decisions that affect them. It was further noted that this extends not just to their own care, treatment and support, but more widely into decision-making around the design, delivery and financing of health services and support. It was suggested that supported decision-making should be incorporated into the Strategy and that advocacy for people with mental health problems is an area that could be better supported and resourced.
• Promotion of physical activity. It was suggested that the Strategy should stress the importance of physical activity for maintaining and improving mental health. It was also suggested that the value of physical activity as an opportunity for preventative spending should be highlighted.
• Employment and employability. It was felt that the Strategy could do more to recognise stresses and other conditions in the workplace which can precipitate or exacerbate mental health issues. It was also felt there should be more coverage around getting people back to work and the positive role that work plays for maintaining people's mental health. It was suggested that the Strategy should also place an onus on Government to provide employers with the tools to support colleagues with mental health conditions.

Other areas suggested as warranting further priority included preventing mental ill health through education, access to greenspace and tackling obesity.

Key agencies or sectors

The need to consider the role and contribution of various types of organisation was also highlighted, including that of:

• The third sector. Examples cited included specialist mental health services, substance misuse services, and employability organisations. It was suggested that third sector organisations have a particularly key role to play in the field of prevention and that this work needs to be acknowledged, harnessed, supported and developed. It was also suggested that there should be greater emphasis on the role that community-led health organisations have to play.
• Integration Authorities. In was noted that, with the advent of health and social care integration, mental health services are increasingly coming under the auspices of Integration Authorities and that this presents significant opportunities for developing a more joined-up approach. However, it was suggested that much of the Strategy fails to take account of the role of the Integrated Joint Boards ( IJBs) in setting local priorities.
• Community Planning Partnerships. Specific reference was made to their ongoing role in improving early-years services.
• Non-mental health specialist statutory and public services. In particular, it was suggested that local authorities have a major role to play in preventing mental ill health and improving mental health, through their provision of a wide range of services which influence the determinants of mental health. Examples cited included Social Work Services, Criminal Justice Services, housing, education, community safety and employability services.

Groups to be prioritised

This section sets out some of the groups or types of people which respondents suggested should be given a higher priority or which are not but should be included within the Strategy.

Families and carers, including kinship carers

It was suggested that the identification, involvement and support for carers and young carers of people with mental health problems should be given much greater coverage. The difficulties carers and young carers face when trying to be seen as equal partners in mental health care was also highlighted.

It was suggested that the Strategy should be developed and considered in the context of the Carers (Scotland) Act 2016. There was a call for any carer who is caring for someone being treated under the Mental Health Act to have a specific right to independent advocacy. It was also noted that the Strategy currently contains no mention of specialist support to carers and young carers to help them manage their own mental health.

People with learning disabilities or autism

It was proposed that the Strategy should be informed by the specific experiences of mental health and mental healthcare inequalities experienced by people with learning disabilities and people with autism.

The particular needs and requirements of children and young people with learning disabilities or autism were also highlighted. It was noted that children with learning disabilities have a much higher risk of mental distress than those without, and that those from disadvantaged backgrounds can be particularly affected. There can be particular problems around inappropriate care settings or no suitable provision being available in Scotland. The Strategy should recognise these challenges.

People with severe and enduring mental ill health

It was noted that people with severe and enduring mental health issues have complex needs which include multi-morbidity issues. It was also noted that previous strategies have included numerous measures to improve the lives of people affected by severe and enduring mental health issues and that there is still much work to be done and this needs to be reflected across all areas of the Strategy.

LGBTI people, and young LGBTI people in particular

There should be a focus on reducing discrimination and inequality and improving practioners' awareness of their impact on the LGBTI community. It was also noted that trans people in particular can have very difficult life circumstances and need trans friendly mental health services. It was also noted that older LGBTI people can have specific mental health needs.

Care experienced children and young people

This particular group of young people was identified as having complex needs and often marginalised status. It was reported that looked after and care experienced young people have much poorer mental health outcomes than other young people. and that they have often faced trauma and neglect which will have a lasting impact on their mental health and wellbeing. It was suggested that looked after children's emotional and mental health needs cannot be understood and responded to without reference to the developmental impact of attachment and trauma.

It was suggested that a recognition of the duties and responsibilities held as corporate parents, as enshrined in the Children and Young People (Scotland) Act 2014, would strengthen the Strategy.

In terms of the support required, it was suggested that greater and more consistent attention should be given to the mental health of children and young people throughout their care journey. However, it was also noted that a 'one size fits all' intervention, based simply on the experience of being looked after, is unlikely to be of benefit and that it will be important to listen to what care experienced young people say about mental health services.

A specific concern was for looked after children who may have serious mental health needs that remain unmet due to a change in their place of residence resulting in discontinuation of a service, or increased waiting times to start receiving a service.

Young people needing secure care

This group of young people was also identified as being a Priority, including because children and young people within care or secure settings are often unable to access CAMHS. It was also noted that currently young people are unable to access inpatient NHS facilities in Scotland and young people in secure care are transferred to England for forensic mental health inpatient care.

It was suggested that for many of the young people on the borderline between the mental health and secure care services, having their mental health needs addressed is the point at which the balance between the NHS mental health threshold for admission and secure care's admission criteria comes into play. The importance of the referral pathway being supported by appropriate mental health assessments was highlighted and seen as ensuring the young person is placed in the most appropriate placement. The need to develop and measure outcomes in order to support efficient and effective service provision and redesign of services was also highlighted.

Children or young people in the youth justice system

Research highlighting that young people involved in violent offending are significantly more likely to be victims of crime and adult harassment, have self-harming and para-suicidal behaviour, problematic health risk behaviours and weak bonds with both parent carer and the school was referenced. It was suggested that working with these young people will require long-term intensive support.

Deaf children and young people

Research highlighting the importance of being aware of young deaf people's vulnerability to mental health issues was referenced. It was reported that while deafness itself does not cause mental health problems, the communication barriers and language delays that deaf children and young people may experience increases how likely they are to be affected by mental ill health. It was noted that there is currently no specialist mental health service for deaf children in Scotland, despite such services being available and well established in other parts of the UK.

Older young people

It was recommended that there should be a focus on the transition from CAMHS to adult services to ensure that vulnerable young people have a seamless transition from one to the other, along the same principles as a through-care model.

More generally, it was noted that there is no focus on older young people but the life stage from 18 to 25 is vital in setting up life skills, making new social connections and learning about becoming an adult. A specific concern was that in some deprived areas, including more remote rural areas, these young people can easily 'fall-out' of the system, particularly if they leave school at 16.

It was also noted that in the current economic climate, many young people experience a prolonged transition into adulthood, with many not leaving the parental home until well beyond the minimum adult age of 16. It was also highlighted that those experiencing disadvantages, such as being care experienced or having caring responsibilities, can take longer to reach a settled, independent adulthood than others. For these reasons it was suggested that the definition of 'young person' in any initiatives funded under the Strategy be extended to 25 years as a minimum.

People experiencing or at risk of homelessness

It was noted that people experiencing or at risk of homelessness or living in unsuitable housing circumstances experience high levels of mental ill health. It was also reported that there is a high rate of both attempted and completed suicide and serious self-harming behaviour in the homeless population and that homelessness is both a cause and consequence of mental ill health.

People going through transitions

There was concern that people undergoing transitions in their lives, including moving from one priority group to another, could be missed. Particular transitions identified included becoming a parent or retirement.

It was also noted that other populations can be hidden by their transitory nature. Groups referred to (and who are sometimes referenced further above or below) included prison populations, looked after young people, gypsy travellers, refugees and people with first episode psychosis.

People with sight loss

It was reported that people in the UK with sight loss are more likely to experience mental ill health than the general population. It was suggested that people with sight loss need access to emotional support and/or counselling and that being offered information, advice and the appropriate support at the point of diagnosis and being given dedicated time and ongoing support to help gain confidence and achieve a sense of wellbeing is key.

The question was posed as to how accessible the consultation was for a hard to reach population, such as those with sight loss.

People with disfigurements

It was reported that people with disfigurement are more likely to develop mental health problems because of their visible difference and suggested that the NHS needs to provide people with the psychosocial care they need to reduce these health inequalities.

People with dementia

It was reported that one study of older people found depression nearly doubled the risk of developing dementia and suggested that the links between mental health and dementia should be addressed in the Strategy.

The broader issue of where policy development for dementia sits was also highlighted. It was noted that dementia has its own national strategy and that the interim publication of the new Dementia Strategy gives primary care a greater role in diagnosis and support for people with dementia. It was suggested that new thinking around where the focus should be within health services for the delivery of support for people with dementia would be welcome.

Older people

Although the document states that it is organised around three stages of Start Well, Live Well and Age Well, it was suggested there is little in the Priorities or the proposed actions which specifically addresses the needs of older people.

It was felt important to recognise the spectrum of mental health conditions that an older person may be living with, and that this extends beyond dementia. It was suggested that social isolation due to a lack of physical mobility, and sometimes the consequent inability to access the necessary support services, will disproportionately affect those in the older age groups. It was also suggested that the fact that people are living longer does not diminish the range of conditions they may be living with, nor the requirement for tailored, effective support to be available to those over 65.

Some of the particular challenges highlighted included the way in which both formal and informal support is available to individuals when they start receiving social care services, particularly within a care home setting. It was also noted that there are challenges around effectively supporting older people with enduring mental health conditions and it is important to recognise the particular factors relating to older people and social care which may prompt or exacerbate mental health conditions.

People with eating disorders

People with eating disorders were reported as having a high mortality rate, including being much more likely to commit suicide than people without an eating disorder. It was also reported that the duration of untreated eating disorder is critical and that early access to high quality, evidence-based treatment options is vital.

An ongoing need for innovative models of care and research into effective treatments was highlighted. There was a call for better provision of specialist services for young people with eating disorders, with most young people to be treated within the community. However, it was also noted that care needs to be provided across the full age range and not just for children and young people. Provision of effective support and information at a primary care level was seen as essential to facilitating this. The need for enhanced support to parents and carers was also highlighted.

Prisoners and those in the criminal justice system

It was noted that people who enter the criminal justice system disproportionately come from disadvantaged communities and have high levels of poor health, particularly alcohol, drug and mental health problems. It was also reported that there is a high proportion of people in prisons and community justice service with a learning disability. It was suggested that ensuring access to mental health services in police custody, courts, prison and through-care into the community is key to improving health.

With particular reference to the HEAT standard for the delivery of psychological therapies with 18 weeks of referral, it was noted that this does not apply to those within the prison population and it was suggested that there is insufficient resource allocated to the delivery of psychological interventions within prisons. It was also suggested that patients who are treated within forensic outpatient services are a vulnerable group and require greater consideration for improved outcomes.

People who use drugs

Other suggestions included that consideration needs to be given to dual diagnosis between mental health and addictions regarding emerging drug trends, including new psychoactive substances.

Refugees and asylum seekers

It was reported that studies have highlighted mental health as one of the biggest health issues for asylum seekers and refugees in Scotland. It was suggested that the Scottish Government should recognise and respond to the rights and experiences of refugees and asylum seekers in all mental health policy areas and strategy.

Students

The particular pressures which students can come under and the potential for this to affect their mental health was highlighted. It was suggested that accessible mental health support which is responsive to the needs of the often mobile student population should be available across Scotland.

The existing 8 Priorities

The analysis presented below summarises comments made on each of the 8 Priorities set out in the draft proposals, including why each is important and/or any suggested changes to how the Priority is focused or defined. Comments about how these Priorities should be taken forward are then covered under Question 2.

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

Points raised about Priority 1 included:

• There is a need for clarity over who would be responsible for ensuring consistent prevention and early intervention. It was suggested that Managed Clinical Networks ( MCNs) are not seen as being answerable to a specific body and thus are subject to variable quality. An MCN may not be needed: rather, the development of an agreed national pathway may offer consistency and may help develop a tiered model of intervention.
• The way the Strategy is worded, the focus seems to be on "routine" perinatal health service contact and there is limited mention of the work being done by Social Work Services or third or voluntary sector organisations.
• This Priority needs to consider those who have a long-term mental illness and become pregnant.
• This Priority should be rephrased to be more inclusive of the diverse gender identities of those who give birth in Scotland. The specific suggestion was 'Focus on prevention and early intervention during and soon after pregnancy'.

Finally, it was suggested that consideration be given to viewing Priorities 1 and 2 as a continuum. It was felt that this approach could support an increased focus on the subsequent outcomes for children, and help ensure the best support is available to the most vulnerable families.

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

Points raised about Priority 2 included:

• There should be an explicit reference to the United Nations Convention on the Rights of the Child ( UNCRC). In particular, reference should be made to Article 12 - the right for young people to express their views on matters affecting them.
• This Priority could include and begin with the promotion of good mental health. There is a need to work with children and young people on awareness of their own mental health. This can help in developing coping skills and in building their own emotional resilience.
• The partnership approach between CAMHS and partners needs to be expanded to detail the types of partnership working that will take place.
• There should be more of a focus on early intervention and prevention for older children and adolescents. It was suggested that schools should be a route in for teenagers and that there should be school-based counselling programmes.
• There is a pressing need for additional specialist services for children and young people, including for those with severe mental health problems. There should be a commitment to a 2-week treatment target for young people with first episode psychosis.
• There may be a link between mental health issues and increased susceptibility to radicalisation, particularly in young people. This should be given consideration.
• Scrutiny and improvement bodies would be able to contribute to an evidence-base about which early intervention programmes are leading to positive outcomes.
• The use of the term 'bad behaviours' in regard to 3- to 4-year olds is not helpful.
• The Strategy should specifically address the steps that need to be taken to cover the transition from CAMHS to adult services.

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

Points raised about Priority 3 included:

• This Priority should be widened to be focused on all forms of community-based support for mental health and wellbeing and not just the statutory primary care sector. This should include the development of new models.
• This Priority is not clear enough either in intent or in deliverables. Given much research into new models has already taken place, some of these should be described in the Strategy.
• New models should form part of a tiered model of support whereby an individual can access the required levels of support and intervention depending on their mental health and wellbeing.
• This Priority also needs to incorporate a preventative focus and any new models should build in the routine recognition of the needs of people who are at high risk of mental health problems.

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

Points raised about Priority 4 included:

• There should be a proactive approach to promotion of self-management.
• It should be clarified that the Strategy does not mean to imply that self-management online will be substituted for access to mental health services, where a mental health issue exists.
• An assessment should be made as to whether more accessible resources are being developed or if existing resources should be better advertised or visible.
• There needs to be much more support to third sector organisations working on self-management of conditions. There is insufficient focus given to non-clinical services and Asset Based Community Development approaches.

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

Points raised about Priority 5 included:

• The focus should be given to providing an effective and safe service. Listing efficiency first places too much emphasis on reducing spending on mental health.
• It will be important to maintain quality and governance whilst improving the speed of access to services. Without a focus on ensuring quality, there is a risk that whilst patients may be seen quicker, the treatment provided may be less effective.
• People seek support from a range of places, and a variety of organisations and sectors deliver relevant services. Understanding how and when people seek help could help realise this Priority. In particular, there is a need to address the gap between people identifying themselves as having an issue and actually seeking help.
• It is difficult for children and young people to access specialist support when they need it. The Strategy needs to consider how the increasing need for these specialist services can be met.

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

Points raised about Priority 6 included:

• There is a need for increased and equitable access to psychological treatments for this group.
• People with psychiatric disability in the community will often need long-term care packages tailored to their need. The Strategy needs to acknowledge this, including a need for adequate skilling and resourcing of social care and third sector services to allow people to be cared for in the community.

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. However, an alternative perspective was that this Priority is not sufficiently ambitious and that the Government should aim to end the mortality and morbidity gaps experienced by people with long-term mental health conditions.

Other points raised about Priority 7 included:

• 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. Mental ill health and physical ill health are inexorably linked. Groups for whom there is a particularly strong link included people with learning disabilities.
• The Scottish Government should work with people with serious mental illness to develop a Strategy centred on taking a rights-based approach to physical health.
• 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. More generally, there needs to be a focus on making every opportunity count.
• Success will be dependent on parity of funding.

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

Points raised about Priority 8 included:

• This Priority should be reframed as 'Enact the human rights of people with mental health problems.'
• 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.
• There should be explicit reference to the UNCRC. An important right for children and young people is Article 12, the right of a child or young person to have (their) views heard in decisions affecting them.
• Some of the language used in the Strategy is not helpful from a human rights perspective, for example 'conduct disorder'.
• It would be helpful for the Scottish Government to set out timescales for the review of the legislation and to provide detail on the scope and approach of the review, as early as possible.