Mental Health Strategy for Scotland: 2012-2015

Key Change Area 3: Community, Inpatient and Crisis Services

A well functioning mental health system has a range of community, inpatient and crisis mental health services that support people with severe and enduring mental illness. There has been considerable redesign of mental health services across Scotland, continuing the long-term trend of moving from largely inpatient services to services where care and treatment is delivered mostly in the community. Within the broad direction of change towards developing more services based in the community, we know that there are wide variations in pace of change, delivery, and models of services.

As information about mental health services has been developed over the past few years, there is increasing scope to use data - across teams, services, local areas and internationally - to understand variation and use the information to plan and implement change. There are examples across Scotland of NHS Boards using such data to improve the quality of care and treatment, improve the efficiency and effectiveness of services, and to make strategic decisions about how services should be configured. We intend to develop our understanding of how service structure and design produce better outcomes.

Intensive Home Treatment Services and Crisis Prevention Approaches

Some mental health problems can be episodic in nature, with people experiencing stable periods with few symptoms, and periods of crisis with intense symptoms. A number of NHS Boards have developed home treatment services to care for people in their own homes during the acute phases of severe mental illness. Two reports, The Scottish Crisis Resolution/Home Treatment Network Service Mapping Report⁷⁶ and A Review of Crisis Resolution Home Treatment Services in Scotland⁷⁷, highlight the range of models that have been developed in Scotland but also indicate the difficulty in making comparisons across the models to understand which deliver the best outcomes.

Intensive Home Treatment Teams - Edinburgh CHP

Available 24/7, these multi-professional teams provide a rapid response, intensive specialist assessment, treatment and risk management in a community setting. They focus on people who might otherwise require hospital admission. They have had a significant impact in quality terms:

• A 32% decrease in admissions and readmissions allowing closure of 25 beds in December 2008 and 12 beds in the Summer of 2009. NHS Lothian now has the lowest number of acute beds per capita in Scotland: 13 per 100,000 population.
• Average length of stay reduced by 6 days.
• Average occupied bed days reduced from 89% to 77%.
• Service user feedback is routinely positive, with 87% of respondents reporting clinical improvement, 43% feeling recovered at discharge and 96% feeling safe during their episode of treatment. People value the level and quality of support, avoidance of hospital admission and improved recovery facilitated by home treatment.⁷⁸

The Mental Welfare Commission in their report Intensive Not Intrusive⁷⁹, into intensive home treatment services in Scotland found that individuals who had received a service, and also carers, valued the service highly. They found that most mental health services were able to demonstrate how intensive home treatment had reduced the use of inpatient beds, with many demonstrating fewer admissions and shorter spells in hospital where admission had been necessary. However, they also noted that intensive home treatment is not equally available across Scotland and made the recommendation that NHS Boards should monitor the uptake of intensive home treatment to ensure equality of access and to continue to evaluate services.

The Mental Health Pathway Efficiency and Productivity Report⁸⁰ also considered the role of crisis resolution and intensive home treatment teams. It concluded that while the overall evidence for the cost-effectiveness of the approach was mixed there were also likely to be significant quality and efficiency savings attached to preventing crisis occurring in the first place. As there is evidence that psychiatric crisis is often preceded by a social crisis, integrated, responsive health and social care services are vital.

Further work is needed to identify the key components of crisis prevention services, but the likely elements include:

Routine use of relapse and crisis contingency planning for individuals who have experienced more than one acute episode;

Integrated (cross heath and social care) and person-centred care planning;

Effective involvement of families, friends and carers; and

Timely responses by specialist services when an individual or their carers highlight the occurrence of early warning signs.

A further idea that is creating interest in Scotland is of a crisis safe house, safe haven or sanctuary. Crisis houses offer intensive short-term support to help resolve a crisis in a residential rather than hospital setting. There is no single model for a crisis house, but they are often run by third sector organisations and can provide a key location for undertaking peer to peer support. They also have a clear function and linkages to statutory services. We will be interested to see how this idea develops over the coming period and will take forward discussions with interested parties.

Commitment 23: We will identify a core data set that will allow effective comparison of the effectiveness of different models of crisis resolution/home treatment services across NHS Scotland. We will use this work to identify the key components of crisis prevention approaches and as a basis for a review of the standards for crisis services.

First Episode Psychosis

Early detection of psychosis and intervention for first episode psychosis provides better outcomes for individuals and financial savings for the NHS and wider public sector. Early intervention teams provide intensive support and treatment for people who have had a first episode of psychosis, and aim to reduce relapse and readmission rates, and improve clinical and social outcomes such as returning to employment, education and training. The Mental Health Pathway Efficiency and Productivity Report⁸¹ also identified potential savings from early intervention teams, and used benchmarking data on psychiatric bed usage by individuals aged 18-24 years in Scotland to illustrate where there might be scope for improvement in service delivery.

Commitment 24: We will identify the key components that need to be in place within every mental health service to enable early intervention services to respond to first episode psychosis and encourage adoption of first episode psychosis teams where that is a sensible option.

Quality of Community Services

To underpin the work to understand variation across services and particular models of service provision, we need to further develop indicators of quality across community services. Information on reducing readmissions to inpatient services provides part of the picture as it is dependent on having effective community services and discharge planning in place.

Commitment 25: As part of the work to understand the balance between community and inpatient services, and the wider work on developing mental health benchmarking information, we will develop an indicator or indicators of quality in community services.

Inpatient Services

As community services have developed, the number of psychiatric beds has reduced across Scotland. There is considerable variation in how beds are used across Scotland, in terms of the primary diagnosis of patients, the numbers of admissions and the average length of stay. There has also been recent development of specialist services e.g. significant investment in the forensic inpatient estate.

We want to better understand the use of acute, Intensive Psychiatric Inpatient Units and crisis services. We also want to consider the balance of services between the overall general inpatient provision and specialist provision, including where there is pressure to develop additional specialist provision. In undertaking this work we are clear that it is intended to support future local and regional decisions on redesign to improve outcomes and efficiency and that any decisions on local restructuring will be made by NHS Boards.

The National Forensic Network is supported by the Scottish Government with the aim of developing protocols to assist in patient movement throughout the secure estate, maximising the use of the forensic estate and creating sustainable services for specific patient populations with specialist needs. The Forensic Network has developed standards for low security and community services and will work with other local services to continue to improve standards and equity of access to specialist interventions.

Commitment 26: We will undertake an audit of who is in hospital on a given day and for what reason to give a better understanding of how the inpatient estate is being used and the degree to which that differs across Scotland.

Patient Safety

As well as understanding the balance between community and inpatient services and how they can deliver the best outcomes, we want to ensure that services are safe. We have introduced the Scottish Patient Safety Programme in Mental Health (SPSP-MH) The SPSP-MH will be a four year programme with an overall aim of reducing the harm experienced by individuals in receipt of care from mental health services. It will start with a focus on adult psychiatric inpatient units and forensic inpatient units, including admission and discharge processes.

Whilst there is clear evidence that harm is experienced by people using mental health services, there is currently no method in place within Scotland, other than for suicide, for reliably measuring the levels of that harm occurring. Therefore work will progress as part of the first phase to develop an approach to reliably measuring levels of harm in mental health services. Similarly, initial scoping into the subject area revealed limited evidence about what interventions will reduce harm in mental health. Therefore the programme will start with an initial one year phase of testing interventions and development of a future approach.

Commitment 27: Healthcare Improvement Scotland will work with NHS Boards to deliver the Scottish Patient Safety Programme - Mental Health.

Health Improvement for People with Severe and Enduring Mental Illness

As explained above, people with mental disorders have a much higher mortality than the general population, dying on average more than 10 years earlier. The Scottish Government made a commitment to take forward work on the physical health of people with mental illness in Delivering for Mental Health. We said:

Commitment 5: We will improve the physical health of those with severe and enduring mental illness by ensuring that every such patient where possible and appropriate has a physical health assessment at least once every 15 months.⁸²

We produced guidance on how NHS Boards could ensure good work between primary and secondary care in providing good quality physical health services to people with severe and enduring mental illness, to build on the QOF (Quality and Outcomes Framework used by GP practices) points, and to ensure that we got full value from them⁸³. The guidance made seven main recommendations with the key themes focusing on awareness raising, removal of barriers to accessing services, and the requirement to evidence improvement over time. It created a framework for local services to develop their local approaches.

NHS Greater Glasgow and Clyde works with primary care through the Primary Care Interface Group. The Interface Group took forward work to ensure that there was good recording of diagnosis in GP mental health registers and the matching process increased the percentage of people recorded on GP registers with a secondary care diagnosis of psychosis from 68% to 90%. GPs welcomed having access to better information which continues to be updated regularly. This increased the number of physical health reviews being taken forward, and we tracked performance on this across Scotland as one of the areas we focused on in twice yearly NHS Board area visits in 2008 and 2009.

This work to improve physical health is also supported by work in secondary care settings. Physical health improvement is built into the Scottish Recovery Indicator, ensuring practice in mental health services relates to the factors which can help recovery⁸⁴. Service providers are asked how they support people's physical health care. Service users are asked how the service takes account of their physical health needs. Similarly, the Releasing Time to Care inpatient programme, which is designed to increase the amount of time that professional nursing staff spend in therapeutic activity with patients, encourages a focus on physical health⁸⁵. Early work from the Releasing Time to Care work is showing increases in some areas in activity such as walking groups, exercise induction and preparation for sleep.

Various health improvement activities that are effective in the general population can be appropriate for those with severe and enduring mental health issues. We do know there are real barriers and challenges for this work but surveys and feedback show that it is important to service users. To gain maximum benefit, individuals are likely to require additional education and support to participate, sustain involvement in, and benefit from, health improvement activities. A combination of motivational and behaviour change interventions, alongside appropriate pharmacological treatments, appear to provide the best results in terms of both health gain and adherence to health improving activities.

Commitment 21 of Towards a Mentally Flourishing Scotland was that NHS Health Scotland would review the evidence base for health improvement activities for those with severe and enduring mental illness and work with NHS Education for Scotland to build knowledge and skills in the workforce⁸⁶. The review demonstrated that those with severe and enduring mental health problems can gain health improvement benefits from participation in health improvement activities (smoking cessation, weight management and physical activity)⁸⁷. These are evidenced to be successful as long as the activity is tailored to the individual, and the professionals involved have increased knowledge and awareness of issues surrounding the individual's mental and physical health, are aware of the benefit and impact of combination therapies, and ensure the most appropriate support mechanisms are in place.

Clozapine is the 'gold standard' antipsychotic for the patients with treatment resistant schizophrenia. Unfortunately it is associated with a range of side-effects, some of which can have a profound effect on a patient's on-going physical health. Work has been undertaken to develop NHS Scotland Clozapine Physical Health Monitoring Standards and these Standards will be taken forward through awareness raising, the development of appropriate prompts and the use of local clinical audits.

Commitment 28: We will continue to work with NHS Boards and other partners to support a range of health improvement approaches for people with severe and enduring mental illness, and we will work with the Royal College of Psychiatrists in Scotland and other partners to develop a national standard for monitoring the physical health of people being treated with clozapine.

Employability

We know that being in the right work is good for a person's health and improves their quality of life and wellbeing. This is also true for people with a mental or physical health condition. Remaining in, or returning to work quickly, aids recovery and more people gain health benefits from being in work than are negatively affected by it⁸⁸. However, people with mental illness are less likely to be engaged in work than the general population or those with other health conditions with one review identifying that 79% of people with serious, long-term mental health problems are not in employment⁸⁹. Improving and increasing access to employment for those with mental illness is challenging, but necessary and achievable.

We have already seen success in the use of recovery-orientated practice and person centred practice in services with the development of the Scottish Recovery Indicator⁹⁰. This approach has been well supported by Rights, Relationships and Recovery focused on nursing practice⁹¹. Employability is also embedded and integrated into the work that enables service users to develop personalised wellness recovery action plans⁹². These approaches demonstrate how services, service users and those who support them can orientate themselves towards work.

A key component of this change process is to reinforce this message of the importance of employment in promoting and maintaining health and for community mental health teams to more effectively incorporate vocational information and activity into care plans. This is a cultural as well as a technical challenge. NHS Lothian and NHS Lanarkshire are training occupational therapists to be aligned with community mental health teams to lead this role. In other places this role may be taken on by a dedicated support worker. NHS Tayside and NHS Fife are developing an electronic resource in partnership with work agencies to help staff signpost to resources. A community of practice has also already been established⁹³ and employability training made available to health professionals through NHS NES⁹⁴. AHPs in mental health are being encouraged to lead the way in promoting timely access to effective vocational support for service users through informed signposting and implementation of evidence-based models of practice.

There is an evidence base that shows that, with the right kind of help, people with serious mental health problems can successfully get and keep work. This applies irrespective of individual characteristics such as clinical history or previous employment. A Cochrane systematic review found that those with severe mental illness who received supported employment were two or three times more likely to be in competitive employment at 12 months⁹⁵. The evidence demonstrates that 'place then train' models are much more effective than traditional approaches such as vocational training and sheltered work in successfully getting people into work⁹⁶. A 12 month study on the impact of supported employment for those with mental health issues also found that those who entered work used significantly less mental health services⁹⁷.

"Place then train" focuses on competitive employment as a primary goal and is open to all those who want to work. It has demonstrated strong employment-related outcomes for individuals with long term mental health problems and has an evidence base that extends outside the US where it originated, across to Europe and the UK. The most well-established method of 'place then train' in mental health is Individual Placement and Support (IPS). IPS has been shown to be more effective the more closely it follows these eight principles:

1. It aims to get people into competitive employment

2. It is open to all those who want to work

3. It tries to find jobs consistent with people's preferences

4. It works quickly

5. It brings employment specialists into clinical teams

6. Employment specialists develop relationships with employers based upon a person's work preferences

7. It provides time unlimited, individualised support for the person and their employer

8. Benefits counselling is included.⁹⁸

There are already good examples of the "place then train" model being implemented in Scotland⁹⁹. The WORKS is an NHS Lothian vocational rehabilitation service for people living in Edinburgh that supports people with mental health conditions to stay in work, return to work, or gain work for the first time. It provides ongoing practical and emotional support that can include on-the-job support to manage a mental health condition, advice about informing employers about a mental health condition and other tailored support for as long is required. It also offers employers advice around good working practices, including disability discrimination legislation and reasonable adjustment.

Commitment 29: We will promote the evidence base for what works in employability for those with mental illness by publishing a guidance document which sets out the evidence base, identifies practice that is already in place and working, and develops data and monitoring systems. Change will require redesign both within health systems and the wider employability system to refocus practice on more effective approaches and to realise mental health care savings.