Mental Health Scrutiny and Assurance Evidence Review

Discussion

A wealth of information was gathered through the process of reviewing Scottish mental health scrutiny and assurance services, much of which is supported by the existing evidence base.

Network Approach

A network approach to scrutiny and assurance was introduced to Scotland in 2010, involving HIS, MWC and CI. Since then, two groups have been created, the SIHCG in 2013 designed to share intelligence across scrutiny bodies in relation to health and social care, and the NSACG introduced in 2022 to coordinate activity on mental health and intellectual disability. Respondents in both survey and interviews described the current landscape as complex and cluttered, due to the existence of multiple bodies and groups. The sharing of information across bodies was viewed as problematic and roles were not always clearly defined. This is similar to the situation identified by the Crerar review (Scottish Government, 2007), which described scrutiny bodies as overly complex, costly and lacked clarity in their position.

Although scrutiny bodies were viewed as having many strengths, especially in the volume of their work and their ability to notice key issues, they felt restricted in part by limited resources and by the lack of regulatory power to enforce change when they felt it was required.

The combination of elements described above led to the consideration of adopting a modified approach, informed by available literature and views of respondents. A rapid review of the literature enabled comparisons of approach with other countries. Australia and Ireland favoured a framework model whereas England and New Zealand both had a single regulatory body; each approach with their own strengths. The overarching framework in Australia was designed because of limited connection and data exchange between their regulatory bodies, leading to the creation of a mental health information strategy which was described as a world leading approach some years ago (Brown and Pirkis, 2009) and anecdotal evidence suggests this continues to be the case. Similar issues of disconnect and challenges with data sharing were apparent in our Scottish system and the solution, which Australia have now tried and tested with success, is attractive. The Australian model is similar to what Scotland currently has in place but provides structure within a busy landscape, it is likely that it would be relatively straightforward to replicate. Respondents of both survey and interviews strongly advocated for an overarching framework or body to provide consistency. There seemed little appetite for a single regulatory system, which could provide an alternative solution. It was thought that the complexity of the task made it too onerous a challenge for a single body and multiple bodies with their unique remit - but shared focus on mental health – could be more effective.

Leadership and Oversight

It became apparent throughout the research process that overall leadership was an issue requiring attention. Issues such as this occasionally emerged discretely i.e., from what was not said - indicated by neutral responses in the survey - as well as opinion voiced through interview. Respondents seemed somewhat dissatisfied with the current situation but were hesitant to make suggestions for change. In keeping with the recommendations proposed by Strang (2020) that one service should be responsible for ensuring scrutiny activity accountability, a pragmatic solution is suggested. The recommendation is that MWC adopt the lead position for the recently created NSACG coordination group, to provide oversight and ensure accountability of scrutiny for mental health and learning disability, rather than maintain the current arrangement with a rotational lead. The rationale for this is the entire remit of the MWC is on mental health and learning disability, whereas HIS and CI have a limited proportion of their work plan assigned to focus on mental health. Links with the existing SIHCG require to be considered as part of this process. It is hoped that the impact of new leadership will result in improved communication and coordination of effort across scrutiny bodies.

The assumption is that ultimate responsibility for mental health and learning disability scrutiny and assurance of NHS provided services will still rest with Scottish Government and the NSACG – or alternative group – will be accountable to Scottish Government. This is similar to the Care Quality Commission model in England (Care Quality Commission, 2021) in that it has oversight of scrutiny and assurance and is accountable to the government. The independence of any resultant activity of the NSACG - or alternative group with collective oversight - will need to be made clear, because each scrutiny body is independent from one another and each have their own different reporting/accountability structures. Any future model would need to recognise and respect each organisations’ independence and their own governance arrangements.

Meaningful Involvement of People with Lived Experience

Findings from the recent Scottish Mental Health Law Review (2022) noted that external scrutiny bodies are essential for the improvement of mental health services. Their position allows them to influence cultural shift. One of the key findings from the survey and interviews was the desire for the voice of people with lived experience to be stronger, perhaps indicating a need for further cultural shift. A proportion of respondents noted people with lived experience were involved and included in all aspects of scrutiny, commonly in instances where they were paid employees. Others felt there was a distinct lack of people with lived experience involvement, and their contribution was restricted to certain stages of the process. Coia and Glassborow (2009) formerly commented on people with lived experience involvement in mental health scrutiny in Scotland as a ’tick box exercise’, but there has been significant advancement in thinking since then especially within HIS, MWC and CI. Support for the inclusion of people with lived experience at Senior/Board levels in scrutiny organisations was welcomed and is recommended.

Shared Resources and Joint Working

There was general agreement that scrutiny should maintain two strands of work; regular cycles of routine reviews/inspections in addition to risk-based and intelligence led visits. Respondents identified the breadth and depth of scrutiny activity these approaches created and subsequent benefit they provided. The main concern related to levels of activity with stretched resources and fears of errors or omissions. Having to prioritise areas of scrutiny based on resources rather than outcomes has been raised as a concern for a number of years (Flynn, Burgess and Crowley, 2015). Potential solutions to this resource problem were offered through discussion at interview. The suggestion was a more coordinated, collaborative approach with increased joint working and joint inspections between scrutiny bodies, resulting in less duplication of activity. This should free up some time to focus on follow up activity and increase the likelihood of recommendations being implemented. Comparable findings from the SMHLR review (SMHLR, 2022) suggested joint working is vital to address current gaps in service provision. Consideration should perhaps be given to how this might also apply to Community, CAMHS and Intellectual Disability services to enable greater equity of scrutiny across the lifespan.

Powers The issue of follow up activity and the ability to implement recommended changes presented different challenges for Health Boards/IJBs and scrutiny bodies. The accuracy with which the reports reflected the situation and context, and the resultant recommendations and associated timeframes for change sometimes presented difficulties for Health Boards/IJBs, because they were neither in a position where they were able to make the changes, nor did they know how to go about it. The required change was sometimes delayed as a consequence. Scrutiny bodies on the other hand were keen to ensure recommendations were taken forward timeously and some had no statutory power to enforce change. Campbell (2017) noted persistent difficulties in modern day scrutiny frustrations in improving standards and enforcing legislation. Survey respondents note enforcement of regulation is both powerful and necessary to ensure the safety of individuals receiving care. They also note each scrutiny body requires using the powers they hold to enable change. Therefore, the powers aligned to scrutiny bodies should be reviewed – with a particular focus on MWC - to ensure they have the ability to enforce the implementation of their recommendations by service providers where circumstances require this.

Data Measurement and Sharing

Mental health and learning disability services have engaged in debate for decades in relation to what are the best and most accurate and appropriate outcome measurements for this type of service. Different standards have been developed, audited and measured by health and social care professionals over the years, some of which are tangible measures, often described as ‘hard data’, for example waiting times, assessments, treatments, delayed discharges and so on. Other measures focus on ‘soft data’ such as satisfaction of services. Respondents from the survey and interviews suggested this might be the right time to review what we measure and attempt to capture wider perspectives. Exploring patient perception and experiences of the care they receive is considered central to this process (Schroder, Agrim and Lundqvist, 2013).

The data gathered from inspections can often be sensitive and personal therefore use of appropriate mechanisms for sharing this information across differing scrutiny bodies (where necessary) is vital. The recent COVID pandemic has escalated the programme of online activity and necessitated the creation of secure systems where sensitive data can be shared. Given the network model scrutiny services currently work within, it is important to find a secure system that facilitates improved sharing of intelligence and expedites the process. Lora et al. (2017) have stressed the importance of using relevant data to inform quality. One of the special Health Boards has identified a system that will enable safe sharing of data; it is therefore part of the recommendations.

Learning and Development

A gap that emerged through the review relates to staff awareness of scrutiny and assurance processes. Scrutiny bodies and Health Board/IJB representatives must ensure they encompass the challenges of all stakeholders to understand the importance of steps taken to create the best possible service, are fully aware of scrutiny and assurance processes and can contribute to good practice. The SMHLR (2022) advocated external scrutiny bodies are essential for the improvement of mental health services, critically impacting a cultural shift in the awareness and increase of human rights of which these scrutiny bodies should be experts in. A collaborative approach to learning and development would have the greatest impact.