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

Future vision

The third question asked respondents to consider their vision for the future.

Question 3: What do you want mental health services in Scotland to look like in 10 years' time?

Around 560 respondents commented at Question 3 and set out their vision for mental health services in Scotland in 10 years' time.

Overall, the most-frequently raised ideas reflected the central issues or concerns raised at earlier questions. They are summarised below under broad and frequently inter-connected themes.

Reduced stigma and discrimination

In 10 years' time Scotland will be a country where mental health is seen as everybody's business, and where it truly has parity with physical health in terms of how it is supported, delivered, and communicated about.

A focus on prevention will improve understanding of mental illness, support a reduction in stigma and address inequalities. A medical model will be a thing of the past and people will instead be aware of the importance of good mental health and how they can manage it themselves. This message will be understood and promoted throughout communities, including through our schools. Services will break down stigma at all levels, with practitioners examining their own practice to ensure people are encouraged to take part in their own care and there will be an emphasis on what people can do for themselves. People will feel empowered to choose and pursue paths to recovery that they feel are right for them. People and communities will be healthier and will help sustain each other.

Positive mental health will be recognised but where ill health does occur then more enlightened public attitudes will ensure that the experience is free from stigma. Accessing services will not come with a 'label' attached. Where an individual's mental health sits alongside other issues such as addiction this will be acknowledged and addressed. Services will be fully inclusive and affirming of all, but will be aware of the impact of multiple discrimination and intersectionality and will take this into account. Everyone will receive the same level of service, although services will be aware of the particular challenges some communities, such as the LGBTI community or older people, may face.

In 10 years' time, Scotland will not aim for less discrimination and fewer health inequalities, but will strive for no discrimination and no health inequalities.

Wellbeing and prevention

A common vision was that in 10 years' time, Scotland will have heeded the messages from the Christie Commission and the approach to mental health will focus on promoting wellbeing, prevention and early intervention. We will recognise the human cost of mental ill health, as well as the long-term social and economic consequences. Early intervention will be recognised as key to doing the best for individuals and communities, but also as cost-effective.

An early, responsive service will be seen as key and as offering the best chance of avoiding problems escalating, with potentially lifelong consequences. A public health-focused approach would help improve population mental health by building resilience within individuals and communities, and by helping ensure the support is there to allow people and places to fulfil their potential. There was a clear view that investment in the protection and promotion of mental wellbeing will improve quality of life, life expectancy, educational achievement, productivity and economic outcomes, and reduce violence, antisocial behaviour and crime.

Within 10 years' time there could have been a substantial shift in the focus of services, along with the resources that go with them, and the benefits could already be being realised. Critically, this shift could mean that wider society will collectively experience a mental health gain. Respondents felt there is considerable scope to develop more innovative approaches to good population-wide mental health including swift service access, new technologies, community asset building, social prescribing and peer support.

However, it was noted that while there are many reasons to support 'the earlier the better' approach, its full potential will only be realised if there is follow through and continuity of services for those who need it. The prevention focus will need to be a key theme running through all service development and work with individuals and should not be confined to initial intervention.

Tackling inequalities

Tackling the underlying root causes of inequalities was seen as key to delivering on the vision of a Scotland in which peoples' wellbeing is at the heart of policy-making and delivery. It was felt that progress will be seriously compromised if the problems which make people and communities more vulnerable to mental ill health are not addressed. Therefore, understanding and addressing inequality will be a key part of creating a mentally healthier society in 10 years' time.

The association between low socio-economic status and mental health disorder was seen to be well evidenced and should be a central consideration, particularly when considering the needs of children and young people. Early disadvantage and damage can have lasting effects on life chances and stifle potential. There will be both a human and economic cost of failing to act, and lack of progress here will not only undermine the realisation of the 10-year vision but will have repercussions for decades to come.

As a society we need to acknowledge the link between deprivation and the incidence of poor mental health. To address these challenges, there needs to be recognition that many of the barriers to wellbeing and recovery lie within society and not within the people who experience mental ill health. Both society as a whole and services need to work to remove these barriers so that disadvantaged individuals or groups have access to the support they need.

To take this vision forward, the Strategy needs to make tackling inequalities a clear priority. In so doing, it will provide the framework within which local partnerships can take this work forward. As part of this work, there will need to be a focus on ensuring that services are accessible to all, including those with complex needs. It was also hoped that in 10 years' time, person-centred services will be the norm. This will include recognising that some people, for example people from the LGBTI community, older people, people with a learning disability or people living in rural communities, may not have been well-served by a 'one size fits all' approach.

Whole systems working

The development of a whole systems or holistic approach to mental health, acknowledging and incorporating social factors, employment, environment and physical wellbeing was considered essential. Action focused on addressing the underlying determinants of poor population mental health is required. This includes addressing the effects of poverty and disadvantage, social isolation, lack of employment and skills and financial exclusion. However, to be truly successful, it will be important for policy, and the actions which stem from this policy, to recognise that many of these challenges are inter-connected.

It was felt that a more holistic approach to mental health, if founded on promoting wellbeing and otherwise taking an expansive and public health-focused approach to prevention, should help reduce the need for more specialist services. The whole systems approach will be intrinsically person-centred, flexible, effective at promoting recovery and will have moved away from overly-medicalised models of care towards person-centred and individualised support. The consideration of mental health in its widest context will mean that communities as a whole will be healthier, more cohesive and more supportive of each other.

To achieve this whole systems approach, respondents felt that there was a requirement to:

• Articulate what it will look like and map out the services and information that will be required for this vision to be achieved.
• Consider how a broad range of services can work together, with each playing their own distinct role and making their own contribution towards promoting wellbeing.
• Improve on the ways in which services work across organisational and geographical boundaries, with the clear aim of improving outcomes for those using the services.
• Ensure that support is both easily accessible and readily available and that accessing that support is seen as part of the everyday.

It was suggested that one of the specific benefits of this approach will be a more cohesive and comprehensive package of services being available to people with severe mental health conditions who are also experiencing other significant challenges. It was also seen as the right approach to ensuring the necessary supports are available to families and carers.

Integrated and equitable services

Partnerships between organisations were seen as providing the framework within which the whole systems way of working can sit, with 'behind the scenes' structures and processes supporting a joined-up, community-focused approach which then feeds into a better patient, service user and carer experience. To be truly effective, the services involved will extend well beyond health and specialist mental health services. A wide range of other services, agencies and groups - including education, social care, the third sector, housing and employment services - will also have a central role to play.

Easy and timely access to services remains a priority - a flexible, needs-led package of services should be available and there should be no discrimination of access. There will be a tiered approach to care, with a range of prevention and early intervention initiatives, and access to the right service at the right time. A particular emphasis was placed on rapid access for both medical and non-medical treatments for common mental health issues. The resources will be available to enable such access.

In 10 years' time it was hoped that where someone lives will not affect their easy access to this package of fit-for-purpose services. Current regional variations will be reduced, including in relation to services for people with complex needs and/or severe mental health problems. The system will be more equitable, both in terms of what is available and the outcomes achieved.

The ongoing work around integration of services, although recognised as being at a relatively early stage at present, should help ensure that someone who needs support will have a smooth journey through the system. In particular, the assessment, referral and transition stages will be as seamless as possible. There will need to be coordinated and clear pathways between hospital, primary or community-based services, particularly where a client is transitioning between one service and another. However, these moves will not be service-driven and according to a linear, predetermined process but will be based on each individual's needs. This approach will be applied consistently and will not be prejudiced by the type or complexity of someone's needs, their personal characteristics or their personal circumstances. Health and Social Care Partnerships will have a key role in ensuring the consistent application of these principles across Scotland.

Self-management

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

The self-management approach will make clear the link between physical and mental health and will recognise the impact on mental health of having long-term or multiple health conditions. It will also not sit in isolation and will be delivered in the knowledge that there is a risk of individuals becoming disengaged or isolated. The provision of self-management via self-directed care may be a means of mitigating this risk.

The promotion of self-management as part of the wider health and social care system will be evidence of a continued commitment to the Recovery Model and will send a clear message that supporting people to manage their own mental health has system-wide backing.

Carers and families

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

The impact on families and carers will be better understood, allowing the right support to be made available in the right places. This will include recognising that becoming a carer of someone with a mental health issue can be a challenge and be both physically and emotionally demanding. Aligned to the Strategy commitment, there will be an expectation that the human rights of carers, as with service users, are fully met at every point in the mental health and social care pathway. These rights should include support to maintain resilience and wellbeing throughout the entire caring process. This in turn will feed into achieving better outcomes for all.

Meaningful carer and family involvement and support will be enabled by additional resources and investment. Carers and families will have access to appropriate information and will be in regular communication with mental health professionals.

Employment

The importance of accessing and staying in employment was highlighted. Employment was seen to offer a means of financial security, self-confidence and as key to addressing some of the inequalities associated with a higher likelihood of having mental health problems.

In 10 years' time, the importance of good quality employment opportunities being available will be recognised and there will be a focus on enabling people to both access and retain employment. Employability support will be seen as an inherent part of the package of community-based provision, alongside access to information, social support and physical healthcare.

There will be initiatives for individuals to learn skills to enable them to gain and retain employment and people will be able to take on part time work without being penalised through the benefits-regime. The critical role employers have to play in providing support to employees will be understood, including in terms of promoting wellbeing and good mental health. There will be programmes to support and advise employers.

The approach will also recognise that many people with mental health problems are not able to work and many are in retirement, and the value of alternative meaningful activities will be recognised and promoted. For example, the role that volunteering can play in empowering individuals will be promoted.

Outcome-focused evaluation

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

This will be particularly important given the shift to a whole system but person-centred approach. Outcome-focused performance reporting will be seen as the norm, and this will include improved monitoring and evaluation of personal outcomes. There will be systematic gathering of qualitative data from service users and carers and the views of those using services will be central to the process. This will include children and young people, families and carers and the wider community. The information generated will be used to inform ongoing and evidence-based review of practice. Services will be developed and improved based on this evidence-based assessment.

Co-production and lived experience

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

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

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

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

Summary findings

This engagement exercise generated a considerable level of interest, with responses received from many individual members of the public and a diverse range of groups and organisations. A number of key themes emerged from the analysis of the responses. They included aspects of the proposed approach which were particularly supported, as well as a range of areas which respondents felt required further consideration. A number of additional priorities were also proposed.

Elements of the proposed Strategy which received particular support included the shift from a 3-year to a 10-year strategy, the life-stage focus of the strategy, and the overt focus on prevention and early intervention. However, there were other areas which respondents felt should be being given a greater focus and which respondents felt could help transform mental health in Scotland over the next 10 years. These included taking a co-production approach to both strategy and service development and genuinely valuing the views and input of those with lived experience.

Other areas identified as requiring greater focus included:

• Developing a truly transformational approach, with an ambitious strategic vision supported by a clear plan of action and a robust, outcomes-focused monitoring and evaluation framework.
• Strengthening the links between the Mental Health Strategy, and other relevant strategies, policy and legislation.

• The impact of social and economic disadvantage and how tackling this can contribute to better mental health and wellbeing. The Strategy should also place greater emphasis on overall wellbeing.

• The development of a whole systems approach to care, with an emphasis on integration and multi-agency working and placing even greater focus and expectations on approaches to prevention and early intervention.

Many respondents identified groups of people who they felt should receive greater consideration. A focus was often placed on those individuals and groups whose needs are complex or distinct, and who thus are at risk of discrimination or inequity. Examples included: individuals with severe and enduring mental ill health; children and young people with mental health issues and particularly those in contact with the care system; people from the LGBTI community; older people with multiple issues; and those with learning disabilities or autism. There were also significant calls for the Strategy to include a much greater emphasis on the needs of families and carers.

The vision of many respondents for the future centred around a Scotland in which mental health is everybody's business and where the focus on prevention and wellbeing will improve understanding and support a reduction in stigma. Addressing inequalities will be key, releasing potential and improving life chances. Co-production with those with lived experience, their carers and families will be at the centre of decision making. A whole systems approach to care will be underpinned by integrated approaches, while services will be person-centred, and accessible and will support self-management. There will be clear and tangible evidence that individual and collective outcomes have improved and that the allocation of resources is evidenced based.