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

Other actions to improve mental health

The table in Annex A of the public engagement document set out a number of Early Actions, supporting the Priorities that seek to support improvement for mental health in Scotland over the life of the Strategy.

Question 2: Are there any other actions that you think we need to take to improve mental health in Scotland?

Almost all respondents (around 560 out of 598 respondents) commented on other actions needed to improve mental health in Scotland. These comments tended to be structured around the 8 Priorities and the analysis presented below deals with each Priority in turn.

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

Early Action:

Perinatal mental health - improve the recognition and treatment of mental health problems in the perinatal period. This will initially be done through the introduction of a network of specialised staff working together, which is formally known as a Managed Clinical Network.

Perinatal mental health - focus interventions on the most vulnerable mothers who are at the highest risk.

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. One suggestion was that the Priority could be reworded to refer to new parents and it was also suggested that there must be a whole family approach, recognising the impact of perinatal mental illnesses on babies and other family members.

Other suggestions focused on how vulnerability could be defined to ensure resources were prioritised most effectively and included highlighting:

• Individuals who may experience poverty, adversity or maltreatment in their own childhoods.
• New parents with a perinatal mental illness.
• Mothers who themselves were care leavers or looked after children.
• Those with addiction issues or poor physical health.

It was also suggested that, in order to support early identification and treatment, the provision of care and support needs to take into account the whole spectrum of wellbeing such as lifestyle, physical and mental health, employment, and socio-economic circumstances. This more holistic focus was considered better placed to mitigate future risks by identifying where early intervention would be most beneficial. One respondent suggested the screening of expectant mothers for early identification of mental health vulnerability and that this could be achieved through existing primary care systems. It was also suggested that staff should be trained in the early identification of domestic abuse and that this would allow trauma-informed perinatal interventions which can link effectively to agencies that can protect women at risk.

It was noted that the onus for perinatal health appeared to be placed on health services, but suggested that success will depend on the inclusion of 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. The existing expertise of many third sector organisations, and in particular their position within and experience and knowledge of particular communities, was seen as a key asset. The role of other services, including education services and social care was also noted.

The establishment of a Managed Clinical Network ( MCN) was frequently welcomed as providing a vehicle for local and national coordination and as helping to ensure services are consistent and of a high quality. MCNs were seen as offering a number of advantages including:

• Supporting evidence-based practice.
• Supporting the establishment of client pathways with rapid access to services when needed.
• Providing leadership.
• Fostering multi-agency collaboration.

Specific suggestions included a commitment to establishing a national MCN for perinatal mental health to ensure consistent implementation of the national clinical guideline, SIGN 127. It was also suggested that any MCN for Perinatal Care should be expanded to include Infant Mental Health.

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

Early Action:

In 2016-17, develop a range of evidence-based programmes targeted to promote good mental health, support key vulnerable populations of infants, and children and young people. These programmes will be delivered by children's services during 2017-20.

By 2018-19, support the work above by better assessing which early intervention programmes are proven to work for different vulnerable populations.

By 2019-20 have completed the national roll-out of targeted parenting programmes for parents of 3- and 4-year olds with conduct disorder.

Psychosis - by 2017-18, have improved the recognition and treatment of first episode psychosis through early intervention services.

Develop further actions to support health and wellbeing of children and young people, recognising the link between mental and physical health through our Children and Young People's Health and Wellbeing strategy.

Utilise our universal services such as the new health visiting pathways to support good mental health, prevention and early intervention.

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 should consider the unmet need which can result from these issues and, in particular, the prevalence of early-stage, undiagnosed depression.

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. Taking such an approach was seen as having the potential to reach and support a broader range of vulnerable families, and as having the potential to prevent issues from occurring in the first place.

In terms of particular groups who may be vulnerable and which services should target the following were amongst those suggested:

• Looked after or accommodated children. It was suggested that it is vital that a person-centred approach is taken when the needs of care experienced young people are being considered. It was noted that the Strategy contains no specific recognition of the duties and responsibilities held as corporate parents, as enshrined in the Children and Young People (Scotland) Act 2014.
• Parents of children with learning disabilities or autism. It was noted that amongst infants, children and young people, the highest rates of mental ill health occur in those with learning disabilities and those with autism. It was suggested that rather than generic programmes, specifically designed interventions are required.
• Young carers. There should be specific reference to advocacy and support for carers, aligned to the Carers' Act, when a family member requires mental health support. In particular, adult mental health services should be in a place to identify how adult patients' disorders are impacting on their ability to parent. Also, the impact on children of a parent or carer being in prison should be taken into account.
• LGBTI children and young people. It was suggested that there should be work to ensure that CAMHS practitioners understand LGBTI young peoples' experiences of inequality and are equipped to address these experiences where relevant in treatment.
• Those undergoing periods of transition and particularly the teenage years. It was suggested that not enough attention has been given to adolescence, despite this being an important stage of the life course and it was noted that many long-term mental health problems emerge during the adolescent years.

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.

In terms of defining and designing the services required, comments included that:

• An assets and solutions based approach should be favoured. Such an approach helps develop life skills and fosters self-confidence.
• Taking the views of children and young people into account when developing interventions should be the norm rather than the exception.
• There should be a review of the counselling and other support that is available in schools and there is also much existing good practice which could be drawn on.
• Whilst early intervention programmes should be supported, the focus on the provision of quality, effective and accessible mental health services should not be lost. Unmet need remains a huge issue and capacity building in specialist services needs to continue while also building capacity in the wider CAMHS systems. Refining models of service delivery to make sure that urgent access is available when required should be supported more widely.
• The fundamental importance of attachment should be recognised. The Strategy must be underpinned by robust scientific evidence about the importance of attachment relationships for long-term mental wellbeing. In particular, the mental health of babies should be prioritised by expanding access to community-based perinatal mental health support that helps mothers form a secure attachment with their babies.
• There should be a focus on trauma-informed approaches and working with people, including young people, who have experienced trauma or bereavement should be central. In particular, there should be a focus on Adverse Childhood Experiences.

The roll out of a national parenting programme for parents and children of 3- and 4-year olds with conduct disorder was welcomed, although some respondents expressed significant concern about the terminology being used. In particular, it was suggested that the term 'conduct disorder' could be perceived as out of step with the accepted child development model and that the use of the term 'behavioural issues' or 'attachment issues' would be more accurate. A small number of respondents questioned the ability to diagnose this condition in children under 4 years.

Improved recognition and treatment of first episode psychosis was also seen as positive and a number of suggestions were made as to how this could be achieved. They included:

• The establishment of a specific Integrated Care Pathway.
• Clear adherence to SIGN guidelines.
• More generally it was felt that quick and effective diagnosis and treatment should also continue as a clear priority.

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

Universal services, particularly education, were seen as ideally placed to support good mental health, prevention and early intervention. It was suggested that alignment should be made with the Getting It Right For Every Child ( GIRFEC) agenda and SHANARRI ^[4] indicators already embedded in the Curriculum for Excellence. Schools were seen to have a unique relationship with parents and an ability to empower young people and to strengthen the links to attainment. Suggested actions included:

• The provision of schools-based counselling.
• Training teachers in child development or mental health.
• Improving information and pathways been the child, the school, the parents and professionals.

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

Early Action:

By 2018-19 have tested and evaluated the most effective and sustainable models of supporting mental health in primary care. These models will be rolled out in 2019-20.

By 2019-20 we will have completed an evaluation of the Distress Brief Intervention and be in a position to recommend next steps.

There was a frequent view that 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. A small number of respondents offered examples of where a multi-agency single point of access to services had been established and had proved successful. The need for compatible, safe and effective information exchange to support collaborative working was also recognised.

Regarding primary care teams themselves, it was suggested these should be extended to include link workers but also psychological services, community psychiatric nurses and allied health professionals. Primary care services in turn would require rapid access to specialist assessment when indicated, particularly where early interventions have not worked. The need for effective pathways was noted specifically in relation to CAMHS and in relation to memory clinics or teams for those with dementia or cognitive issues. The creation of multi-disciplinary primary care teams was also seen as beneficial in increasing the capacity of general practice.

It was expected that within the Strategy reference would be made to Health and Social Care legislation and the autonomous role of the Integrated Joint Boards ( IJBs). It was noted that IJBs are responsible for setting out a local framework, to lead service redesign, and to support Community Planning Partners ( CPPs) to improve mental health. It was felt that CPPs were well placed to take local action on the broad socio-economic determinants of mental health.

Other approaches or models that were highlighted by respondents as positive included:

• A person-centred approach, with services shaped by individual needs rather than clients having to 'fit in' to pre-determined structures. Person-centeredness was seen to support a human rights-based approach to mental health care where individuals can achieve the outcomes that matters to them.
• The use of social prescribing as a means of actively promoting overall physical and mental wellbeing and accessing wider support services available within the community. A small number of respondents suggested an impact assessment on both the benefits and the cost-effectiveness of what they considered a valuable approach.

In terms of particular issues to be taken into account when developing services, the following were amongst the issues highlighted:

• For children and young people, primary care workers have a crucial role to play as they will often be the first point of contact that a child will have in relation to their mental health. It is crucial that they are trained in responding to the specific needs of children and young people.
• Adults with learning disabilities have the highest rates of mental ill health of any group in the population. However, they also experience significant barriers to accessing good quality health and other care across all tiers of the system. This point is particularly important for primary care, given that this is where the majority of health care takes place.
• The importance of primary care within custodial settings should be recognised.

The evaluation of Distress Brief Intervention ( DBI), providing assistance with difficult emotions and situations and subsequently developing a 'distress plan', was supported. It was seen as important to acknowledge that DBI was a limited contact only and, if implemented, should be considered a single component of a wider tiered approach to care. If the evaluation of the pilots was successful, it was suggested that roll out be prompt and that the 'place' of DBI intervention in the wider care system be made clear.

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

Early Action:

By 2017-18, develop more accessible psychological self-help resources.

By 2018-19 have increased the number of link workers and peer support workers in primary care providing information to support self-management and to support people with mental health challenges to access and stay in employment.

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.

A number of respondents highlighted issues that would need to be considered if the activity around supporting people to manage their own health is to be successful. These included:

• A recognition that services need to consider how they can enable and support individuals to take action independently rather than being seen as the care recipient.
• Self-Directed Support Legislation ( SDS) offers genuine self-management with individual control, support and choice. Steps should be taken to improve access to SDS for those with a mental health condition.
• Peer support workers and link workers could be seen as a valuable extension of primary care, providing support to engage with community resources and tackle social exclusion and promote self-management. However, a number of respondents, particularly those with lived experience, queried the relationship with carers who themselves required both recognition and support.
• The Strategy must make the distinction between the generalist link workers and specialist Dementia Link Workers who support people with a diagnosis of dementia in line with the Post Diagnostic Support guarantee and HEAT Target.
• The Strategy does not fully appreciate the complex capacity issues that prevent people from managing their own mental health now. Self-management would not always be appropriate and support must be realistic and based on ability; people experiencing substance misuse or people with a learning disability were two groups identified as possibly requiring additional support. Also, it should be made clear that children and young people can benefit from support to manage their mental health.

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

Early Action:

By 2017 publish a new mental health outcomes framework.

Continue to support the Scottish Patient Safety Programme in Mental Health.

By 2019-20 have delivered a programme of work on improving access to mental health services to increase capacity and address waiting times issues in CAMHS and psychological therapies.

By 2017-18 have improved access to psychological therapies by rolling out computerised Cognitive Behavioural Therapy nationally.

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. One suggestion was that the framework may also benefit from alignment to the National Care Standards (designed to apply across health and social care) as well as other relevant national targets and indicators. It was also noted that there is no mention of training and awareness raising.

The continued support of the Scottish Patient Safety Programme in Mental Health was widely endorsed.

Many of those who commented felt that priority should be placed on 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. It was also suggested that some value could be found in developing a partnership workforce model, based on wider population need and weighted for deprivation.

The role of psychological therapies was seen to be of value at all levels of care from self-management to clinical intervention. Other points raised about psychological therapies included:

• From area to area, there is inconsistent provision of clinical psychology services for some specific groups. These groups included people with severe and enduring mental illness and individuals with a learning disability.
• Current waiting times can be long. Suggested solutions included additional staffing, the strengthening of multi-agency collaboration and lower level interventions.
• People reaching the age of 65 with mental health problems appear to become ineligible for therapeutic interventions from a mental health budget. This is not in the best interests of the person, or in the long-term care and cost implications for the NHS.

With reference to the capacity within CAMHS, suggested solutions included extending partnership working with other services, a greater emphasis on prevention, reviewing access criteria and working with schools and communities to raise levels of awareness.

The roll out of computerised Cognitive Behavioural Therapy ( CBT) was supported as an option alongside a range of additional face-to-face supports such as guided self-help or self-management resources or Dialectical Behavioural Therapy. The evidence base for computerised CBT was widely accepted but it was suggested that barriers may exist for older people unfamiliar with technology, those with learning disabilities or in rural areas with poor internet access.

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

Early Actions:

By 2019, have evaluated the effectiveness of the Scottish Association for Mental Health's programme to increase the physical activity levels of people living with mental and/or physical health issues.

Ensure that prevention programmes - e.g. smoking cessation, alcohol, screening for preventable conditions - are accessible to people with mental health problems. This will ensure that our public health strategy delivers health improvements for people living with mental health problems.

By 2018-19, have improved responses to, and monitoring of, physical health issues associated with the psychiatric medications clozapine and lithium.

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 unitary 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.

It was also noted that individuals with complex needs often presented with multiple health conditions and were at higher risk of poorer social, educational, health and employment outcomes. An integrated approach was seen to proactively mitigate these risks. In particular it was suggested this is crucially important for people with learning disabilities who die 20-25 years earlier than the general population and often from avoidable causes. It was suggested that different approaches will be required as the pattern of physical health problems and causes of death in people with learning disabilities and people with autism differs from the general population.

Social isolation, poor access to support and living within deprived areas were considered key determinants of health behaviours such as smoking, excessive alcohol consumption and lack of exercise. A number of interventions were proposed including:

• The application of health psychology models in relation to positive behaviour change.
• Regular monitoring by key workers of those at most risk to prevent relapse and assist recovery. One respondent noted that those with the highest risk of health problems are likely be those with the most significant mental health issues and this relationship needs to be understood.

The commitment to ensuring that prevention programmes are accessible to people with mental health problems, including the screening for preventable conditions, was broadly welcomed. This was also the case for the evaluation of the Scottish Association of Mental Health's physical activity programme, appreciating the learning that could be taken from it.

In line with the stated preference for a more holistic approach, it was suggested that it may be beneficial to broaden the monitoring of physical health issues in relation to clozapine and lithium to include all antipsychotic drugs, given the known risks associated with them.

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

Early Action:

We will develop mentally and physically healthy work places linked to the 'See Me' programme to eliminate stigma and discrimination.

We will ensure that our employment and welfare programmes are designed to take account of mental health conditions.

We will develop more effective alignment with wider population health improvement e.g. alcohol, diet, activity.

We will increase our focus on improving access to our mental health services for people living with other long-term conditions.

We will continue to improve the focus on recovery through supporting the work of the Scottish Recovery Network.

There was broad agreement that parity should exist between mental health and physical health care, with inequalities reduced and mental health being seen as part of everyday life. A number of respondents identified actions or opportunities which would help realise that ambition. 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 of other sectors - such as housing, leisure and employment - should also be recognised and exploited.
• Increasing financial security through employment has the potential to promote inclusion, decrease stigma, increase self-worth and open up opportunities. A number of respondents queried whether employability should have an even greater focus in the Strategy given its essential role in wellbeing and the ability to reduce involvement in the health care system.
• Employment and welfare programmes should be designed to take account of mental health conditions and offer people the greatest chance of success. The capacity to make reasonable adjustments based on individual circumstances and the specific nature of mental health issues should be built in. Mental health services and primary care should embed models to support employment into their practice, supporting early employment with the provision of training and support on the job.
• Potential employers should be supported to undertake mental health awareness training and understand the nature of recovery. Collaboration across the mental health and employability fields would help achieve this.
• Improved joint working with the welfare system would help address problems such as the effect of hospital admissions on benefits and the effects of welfare sanctions on recovery.
• Parity should extend to ensuring the Curriculum for Excellence and what is taught around mental health and wellbeing has the same emphasis as physical wellbeing.

Other comments focused specifically on the people with multiple or complex needs and included:

• Specific action will be needed to address the challenges faced by individuals with severe and enduring mental health problems, learning disabilities or autism. They are more likely to experience stigma, discrimination and subsequent inequalities and services will need to take this into account.
• Given that multi-morbidity increases with age, efforts should be made to ensure that parity of mental and physical health is emphasised across the lifespan to include older people.
• Improving access to mental health services for people living with other long-term conditions will also be important. In particular, ensuring that people living with long-term conditions, such as dementia, are not compartmentalised is to be welcomed.
• Where complex or multiple issues exist, it was suggested an explicit pathway be put in place and clear standards of care articulated. It was noted that people often required long-term, holistic packages of care in the community and that, to support this approach, service integration, workforce training and the management of transitions should be prioritised.

Continued support for the Scottish Recovery Network was welcomed. The organisation was noted as having achieved a great deal and that it had provided valuable tools (such as the Wellness Recovery Action Plan) to help support an individual's strengths and assets and right to recovery.

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

Early Action:

By April 2017 we will begin a review of learning disability, autism and dementia in the definition of "mental disorder" in the mental health legislation.

By April 2017 we will have started a review of how deaths of patients in hospital for mental health care and treatment are investigated.

In 2016-18 we will be conducting a review of the incapacity legislation.

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.

Other changes or actions which respondents identified as being needed to realise the human rights aspirations of the new Mental Health Strategy included:

• Policy and legislation will need to recognise the specific barriers to accessing good quality health and other care which some people face. These groups include people with learning disabilities or autism.
• The increased use and consistency of advance statements, detailing individual preferences in the event that they cannot make their own decisions.
• The provision of advocacy and its role in assisting individuals to understand their rights in relation to legislation. To aid them in making healthcare decisions, people should be provided with enough information and support in an accessible format. More widely, more needs to be done around educating people about their rights.
• Recognition of the role and rights of the carer in terms of information and involvement.
• Mental Health Officers using their role as both a supporter and safe guarder of individuals' human rights.

There was support for the proposed review of learning disability, autism and dementia in the definition of mental disorder in legislation. Comments included that the review should help provide greater clarity for policy development, supporting equality and improving how a number of services work together to best effect.

The review of deaths of patients in hospital was also seen as offering essential learning. However, a number of those who commented suggested the review should not limit itself to deaths in hospital. It was suggested that the remit should be expanded to include deaths and serious incidents in all settings. It was felt that this expansion would inform practice, and ensure uniform and transparent approaches to investigation across the entire health and social care system. A number of respondents suggested it would be beneficial to clarify how the review of patient deaths in hospital will contribute to the outcomes outlined in Priority 8.

Similarly, a review of the Adults with Incapacity (Scotland) Act 2000 legislation was welcomed, with the assessment of capacity viewed as a fundamental component of mental health care. It was suggested that outcome measures be established to support this assessment.

It was also suggested that the review of incapacity legislation was necessary
and should be set within the context of wider legislation and strategy. Examples
of the legislation to be taken into account included the Mental Health (Care and Treatment) (Scotland) Act 2003, and the Children and Young People (Scotland)
Act 2014.