Mental Health Scrutiny and Assurance Evidence Review

Executive summary

Mental Health Scrutiny and Assurance Review: Response can be found here: https://www.gov.scot/isbn/9781835219829

Executive summary

Scottish Mental Health Services have a duty to the communities they serve to maintain the quality and safety of patient care. David Strang’s (2020) Independent Review of Mental Health Services in Tayside noted that at a national level, there is currently limited scrutiny and oversight of mental health services in Scotland. He drew attention to organisations such as Healthcare Improvement Scotland (HIS) and Mental Welfare Commission (MWC), who currently have limited powers to monitor and enforce the recommendations they make. He recommended that the Scottish Government conduct a national review of the scrutiny and assurance of mental health services, including the powers of HIS and MWC. This review includes the Care Inspectorate (CI), due to their wider role in relation to mental health within care services and the relevance of their working relationships with HIS and MWC.

The aim of this review is significant and is to inform the Scottish Government’s considerations around the scrutiny and assurance of mental health services – predominantly secondary services - mapping current arrangements and possible improvements to strengthen these. Ultimately, this work will contribute to the future of scrutiny and assurance of mental health services in Scotland, ensuring they are safe, timely, effective, person-centred and delivered for service users in equitable ways.

Methods

There were three distinct phases of the project: Phase 1 - a rapid review of the literature to establish the existing evidence base; Phase 2 - a national survey to capture views from senior managers/clinicians, directors and chief executives; Phase 3 - a series of interviews, affording stakeholders opportunity to express their views on current practice, identify gaps and explore how best to strengthen scrutiny and assurance arrangements in the future. A written invitation to interview was extended to all potential participants. Appropriate representation was sought across 50% of the Scottish Health Boards ensuring contributions from North, South, East and West geographical areas, urban and rural locations, taking account of variation in size location and representative of Integration Joint Boards (IJB).

Existing evidence base

There is a growing body of evidence within the literature that outlines good practice at a local, national and international level. However, issues have been identified with current external scrutiny and local governance, namely: the inconsistent and varied use of measurement tools; lack of standardisation of measurement instruments used within mental healthcare systems; reporting and regulatory bodies’ lack of communication and sharing of intelligence and data. This review identified international evidence and national examples of good practice to learn from and inform external scrutiny and local governance arrangements. There appears to be a consensus towards approaches and recommendations that may provide a solution to the issues highlighted.

Such as:

• The provision of leadership in establishing agreement on a common set of mental health quality measures and the development of an overarching framework necessary to obtain and manage this information.
• The collection of measurement data and reporting in a variety of ways understandable by different audiences such as patients, other quality oversight bodies, policy makers and healthcare providers.
• For professionals and services to routinely use validated assessment instruments to monitor and evaluate patient outcomes including standardised performance indicators to improve the quality of care.
• The increased service user and patient involvement in all aspects of scrutiny and assurance services.

Capturing the stakeholder perspective

There are several different stakeholders involved in governance and assurance processes including people with lived experience who are in receipt of mental health care and treatment; those who deliver and manage health and social care services, and those who oversee and are responsible for the scrutiny of services. Information was captured from organisations representing these perspectives through the use of a national survey using a questionnaire and discussion through one to one and group interviews with stakeholder representatives. There were twenty-six responses to the survey and thirty participants were interviewed.

Findings from the questionnaire indicate that external scrutiny does capture key issues and involvement of people with lived experience improves the process. Collaboration and sharing intelligence between external scrutiny bodies is considered patchy and there is general agreement that there is scope for improvement. Follow up processes are a source of frustration, requiring further exploration of the powers associated with HIS and MWC, to ease implementation of recommendations.

Reflecting on discussions with stakeholders, there exists a question around whether scrutiny should be rights or process based, in order to establish the real value of mental health services and how well they function. Tensions exist between focussing on the individual or the organisation and its systems and processes. We suggest both can be of value, especially where there are different but complementary approaches, allowing different perspectives to be explored. The importance of investigations taking account of the wider context cannot be underplayed, and reviewers must endeavour to keep abreast of current practice, in order to understand and account for the current context. People with lived experience understand both systems and processes, having had first-hand experience of the services, yet their representation at the highest level is not always evident. Finite resources must be used wisely and a more cohesive approach across all scrutiny bodies is necessary in order to be more productive.

A number of themes emerged through the stakeholder interviews, namely:

• the complex landscape of multiple scrutiny bodies and a need to improve the collective leadership and accountability;
• uncertainty as to whether the focus of scrutiny activity is on people or services and some examples of disconnect with what is happening ‘on the ground’;
• a need for improved joint working and communication between scrutiny bodies;
• the issues caused by a lack of power held by scrutiny bodies, as well as limited resources;
• a role for the meaningful involvement of people with lived experience and the prominence of their voice within reporting;
• the important role of internal governance in improving quality and safety, including creating opportunities for learning and follow-up on scrutiny recommendations;
• the improvements needed regarding measurement and data availability, access and sharing.

Conclusions

The wealth of data gathered from the rapid literature review, questionnaires and interviews has served to provide a real sense of strengths and areas for improvement that exist in current systems and processes. The literature highlighted areas of good practice that facilitated strong scrutiny and assurance, including: national standards of care; regular inspection of services; regular reporting of service performance to local and national government and publicly available performance indicators and benchmarking. The survey with stakeholders produced mixed results. A shared passion and desire for success was evident from all respondents, and an eagerness to achieve more and provide a better service for the people of Scotland was at the heart of each conversation. There were however clear differences of opinion in relation to how successful current practices are, and strong views on the need for change and improvement. In particular, there were calls for more external scrutiny of CAMHS, Intellectual Disability and Community mental health services.

A list of recommendations is enclosed with suggested solutions to issues raised with regard to current systems and processes.

Recommendations

1. Ensure a managed overarching framework that leads to a cohesive and coordinated approach to external scrutiny is implemented. This could be achieved through adjustment of the existing role of the Mental Health and Learning Disability National Scrutiny and Assurance Coordination Group (NSACG) or creation of a new group. A clear remit for external scrutiny dedicated to mental health and learning disability is required.

2. If the NSACG were to function in the capacity described above, rather than create a new group, it should review and strengthen the role and remit in order to optimise efficiency and minimise duplication of work. Consider and enhance collaboration between NSACG and SIHCG. Position MWC as permanent chair, replacing the existing rotating chair, due to their extensive focus on mental health and learning disability. This should be done recognising and respecting each organisations’ independence and their own governance arrangements. The NSACG will require the authority to support accountability of NHS Health Boards, which may require legislation.

3. Review and improve the way in which inspections/visits are scheduled collectively, to minimise duplication of work for both scrutiny bodies and Health Boards/IJBs. Co-ordinate joint and co-produced themed visits, with an agreed joint methodology to maximise resources.

4. Scrutiny bodies to support the full implementation of the new Mental Health Quality Standards and utilise the standards as a common framework to support the coordination of scrutiny activity.

5. Improve public awareness and increase the visibility of all scrutiny bodies and their individual and collective roles, remits and responsibilities. Methods through which this could be achieved should feature on the workplan of the NSACG.

6. Review and strengthen the role and responsibilities of people with lived experience within scrutiny bodies, with a view to introducing roles at Board/senior level in order to ensure greater involvement and focus on people with lived experience. Influence at senior level is more likely to ensure the people with lived experience voice is respected and suggestions from people with lived experience in reports are safeguarded.

7. Ensure employees of scrutiny bodies have the opportunity and accept responsibility for keeping themselves abreast of changes in practice and appreciate current context to maintain credibility. Also, to give greater consideration to the wider context when undertaking inspections/reviews and reflect this more strongly in final reports, to give a greater focus on systemic issues.

8. Increase support from scrutiny bodies in the follow up of recommendations arising from reports, for example, through offering suggestions and sharing examples of good practice. Encourage the exploration of existing evidence captured in the literature; learning from tried and tested methods is both logical and pragmatic.

9. Review and improve existing data sharing mechanisms that exist at NES (Azure) with a view to implementation, as opposed to creating or purchasing new systems in order to expedite sharing of intelligence. Safety and security of data sharing is of critical importance.

10. Improve the equity of scrutiny across the lifespan, with a renewed focus on Community, Intellectual Disability (ID) and Child and Adolescent Mental Health Services (CAMHS).

11. Refocus on how and what is measured across the lifespan extending to use of softer outcomes, such as wellbeing and quality of care.

12. Explore any additional powers aligned to MWC in order to enable recommendations to be enacted in a timeous manner.

13. Provide awareness training for staff in Health Boards/IJBs in governance and assurance related issues.

14. Implement a two-strand approach to scrutiny, involving a regular cycle of reviews in addition to risk-based and intelligence led inspections. It is recognised that this recommendation may have resource implications for scrutiny bodies.

15. Continue good practice of engaging in rigorous review through thorough internal and external governance processes for mental health and Intellectual Disability services.