Mental health strategy 2017-2027: second progress report

3. Adult Mental Health Care

The principles that underpin our approach to children and young people’s mental health also ground the work we are doing to improve mental health support for the whole population. Central among these is partnership working to provide high quality, accessible mental health services for adults. Sustained change will only happen if we work in partnership with Local Authorities, NHS Boards, Integration Authorities and third sector partners. Consequently, we are taking actions to strengthen the collaboration between partners – such as the national Adult Mental Health Collaborative, and the support for networking in rural areas – and disseminate learning across different parts of Scotland that will enable the actions to drive effective change quickly.

As part of an approach to improving adult mental health services that brings together all services, we have developed a wider set of actions to address distress and trauma, whilst ensuring that improving and responding to mental health needs is also delivered across wider public services. This includes close working with partners in justice, addictions, homelessness, and other policy and service areas. It also requires a clear focus on prevention and early intervention, as well as ensuring that the development of existing services meets the emerging and growing needs of the population. Consequently, many of our actions support the development of new services, such as computerised cognitive behavioural therapy.

Proportion of mental health is included in the Quality Indicator Profile as a measure of whether mental health services are efficient.

Collaboration

In order to drive forward our ambitions for strengthened adult mental health services, we announced the establishment of an Adult Mental Health Collaborative in the 2019 Programme for Government. The Collaborative is a key part of our goal to better support adult mental health services through public services, the third sector and communities working together to improve support to people suffering from mental ill health. We will use the Annual Forum event at the end of November 2019 (Action 39) to start a conversation about what our Collaborative should look like.

We envisage that the new Collaborative will seek to build on the experience and learning gained from similar initiatives. It will create a learning system in which partners can connect and easily learn from each other, as well as recognised experts in areas where they want to make improvements. It will also support the application of improvement methodology to bridge the gap between what we know works and what we do in practice. 

Recognising the importance of working together across services, we are also taking forward the work of the National Distress Intervention Group to ensure that services from across our health, justice and social care system are brought together to focus on the needs of any person experiencing distress. That particularly includes those with multiple, complex needs. 

Self-help support (Action 25)

The Scottish Government has developed more accessible psychological self-help resources and supported a national rollout of computerised cognitive behavioural therapy (cCBT) with NHS 24 through Action 25 of the Strategy. NHS 24 has recently successfully procured Beating the Blues US, an updated version of the Beating the Blues cCBT product. This new product will be available to all NHS Boards, following successful national rollout of cCBT in 2018. It will provide improved technical and operational capabilities, while maintaining the quality of the clinical content. Further work is underway to support more widespread online access to Cognitive Behavioural Therapy. 

The 2018 Programme for Government also committed to strengthening the content of current self-help platforms provided through NHS Inform. This has included new self-help guides for anxiety and depression, and ongoing work to develop additional guides for bereavement, problem-solving, self-esteem, chronic pain and Post-Traumatic Stress Disorder.

Primary care transformation (Action 23)

Action 23 focuses on the transformation of mental health services in primary care through the testing and evaluation of the most effective and sustainable models of service delivery. To this end, the Scottish Government invested £110 million in the Primary Care Fund in 2018/19 to support implementation of the new GP contract and wider primary care reform. This includes the Primary Care Transformation Fund and the Primary Care Mental Health Fund (PCMHF). 

To date, £20 million has been invested via the PCMHF to encourage the development of new models of care to ensure that people with mental health problems get the right treatment, in the right place, at the right time. This includes £5.5 million in 2019/20. Primary Care Improvement Plans must demonstrate how this is being used to re-design primary care services to ensure that those who need mental health support can access it when they need it. As a result, Primary Care Improvement Plans will continue to be reviewed.

Furthermore, the Scottish School of Primary Care published its National Evaluation of New Models of Primary Care in Scotland report in Spring 2019. It tested and evaluated new models of delivering mental health services in a primary care setting, such as a listening service for service users, training service users on self-management, improved support for self-directed support for mental health service users, and wellbeing services for NHS staff and locating welfare rights advisors in GP practices. The Scottish Government also published its ten-year strategy, Primary care: national monitoring and evaluation strategy in March 2019, which will inform the evaluation of such models.

Unscheduled care (Actions 13, 14 and 15)

Unscheduled care is an example of an area where coordinated actions across Government are required.

As a result, Action 13 is being progressed as part of a broader project recommended by the Health and Justice Collaboration Board for a ‘National Distress Intervention Group’. The Group comprises multidisciplinary representation from across Scotland including Police Scotland, Board Chief Executives, the NHS’s Information Services Division, Emergency Medicine, Academia, Secondary Care Senior Management, Scottish Government, individuals with lived experience and Third Sector. The Group will focus on practical detailing and implementation of improvements, including improvements in access to mental health services.

The Scottish Government is working with NHS 24 to develop its unscheduled mental health services to complement locally-based services under Action 14 of the Strategy. NHS 24’s 111 phone line provides a Scotland-wide triage service for people or carers seeking urgent health advice out of hours. The 2018 Programme for Government committed to enhancing the handling of mental health calls to the 111 service, with more specially-trained staff and improved routing of mental health calls. The aim is to deliver a better journey for those accessing the service, reducing the need for onward referral by ensuring people get the right help at first point of contact. Work to build and grow the mental health ‘hub’ model within the 111 service began in February 2019. Evaluation has now been completed, highlighting a range of positive experiences from those calling the service. Work will continue to build on the findings of the evaluation, including additional recruitment to extend opening hours of the service to seven evenings a week, and increase the hours covered at weekends.

As part of our 2018 Programme for Government, NHS 24 has also been trialling improvements to the NHS 24 Breathing Space service by introducing web-chat with an NHS 24 adviser. The additional staff to manage the service are now in post, with training completed. Work is ongoing to identify capacity requirements to increase the availability of web-chat, alongside an evaluation of the service. Findings from the evaluation will be used to inform the roll out of a test of change in the coming months.

One of the key settings outlined by Action 15 of the Mental Health Strategy is Accident and Emergency (A&E) departments. Good progress with the recruitment of additional mental health workers is being made with this commitment. Not all Integration Authorities have an A&E department in their area, however, for those who do, recruitment or the planning of recruitment for this setting has begun. The most common role being recruited for in A&E departments are Registered Mental Health Nurses. This is being linked to the work on access to services through Action 13, as discussed above.

Better mental health in the justice system (Action 10)

A governance group has been established which meets quarterly to discuss the development and progress of the enhanced mental health pathway as part of the Justice strategy. In addition, an Expert Group has been established to take forward the recommendations made to the Scottish Prison Service (SPS), the Scottish Government and the NHS following the Expert Review of Mental Health and Wellbeing Support by HM Chief Inspector of Prisons for Scotland. Work on the recommendations is progressing well, and actions to date include:

• agreement to scope a single data sharing agreement for the Justice pathway (from point of arrest to release from prison);
• implementation of a Standard Operating Procedure by HMP and YOI Polmont to provides a robust system to support a young person’s transition from secure care, to SPS care and strengthens processes for information sharing in these cases; and
• commitment by the Scottish Prison Service to develop a new health and wellbeing strategy, with a draft to be ready by April 2020.

Building on Success: Review of the Delivery of Forensic Mental Health Services in Scotland

A rights-based approach, with people with lived experience at the centre, is being taken by a review of the delivery of forensic mental health services in Scotland. This review follows developments in recent years that include a decline in the number of patients detained in high security, the development of medium secure services elsewhere, the introduction of excessive security appeals for patients detained in medium security, and a continuing move towards services in the community. In light of these changes and new developments this review offers an opportunity to make sure that not only do services reflect the key priorities for our health services and that practice is joined up across health, communities and throughout the criminal justice system, but also that forensic mental health services deliver the right help at the right time so that people receiving services fully enjoy their rights.

Access to services by people in rural areas (Action 12)

Action 12 outlines the Scottish Government’s commitment to supporting the development of the National Rural Mental Health Forum. The Forum was established in 2017 with Scottish Government funding. It helps and encourages people in rural areas to maintain good mental health and wellbeing. The Forum also develops connections between communities across rural Scotland to reflect the unique challenges presented by rural isolation.

The Forum is jointly funded by the Scottish Government’s Rural Economy and Mental Health Directorates and will receive £50,000 for 2019/20. Since it was established in 2017, membership has grown from 16 organisations to over 110. For 2019/20, the Forum will focus on delivering activity such as the following:

• addressing the specific impact of Brexit on rural businesses/employers;
• increasing the evidence base of workplace mental health issues and experience in rural areas, with the aim of informing policy;
• developing and sustaining relationships with COSLA, Community Health Partnerships and Community Planning to promote benefits of connecting to the National Rural Mental Health Forum (NRMHF);
• at least two national anti-stigma campaigns with NRMHF and all partners; and
• links made with all Integration Authorities to discuss local plans.

Action 38 of the Mental Health Strategy committed to developing a Quality Indicator Profile for Mental Health (QIPMH). The QIPMH collates a range of indicators on individual care and treatment as well as service response, and has been designed as a tool for monitoring and improving service quality. In February 2019, Information Services Division published the first report of the QIPMH, which presented data on eight quality indicators.

The QIPMH is complemented by the Population Mental Health Framework. The Framework is a set of indicators reflecting four main themes: childhood determinants of a mentally healthy life, the impact of mental ill health, population mental health and wellbeing, and health inequalities and parity of esteem. Data for these indicators have recently been updated with the latest available data. Data from both sources is used to illustrate this and future Annual Reports to Parliament.

The Mental Health and Learning Disability Inpatient Bed Census and the Mental Health, Addiction and Learning Disability Patients: Out of NHS Scotland Placement Census continue to provide annual information on mental health, addiction and learning disability services and who uses these services. The most recent Censuses were published in October 2018.

Inpatient beds 

We are continuing with our work to further improve prevention and early intervention of mental health problems while supporting the increase in the treatment of people at home, or in a home-like setting. 

Data on psychiatric inpatient beds comes from the annual National Inpatient Bed Census and from Information Services Division of NHS National Services Scotland. We have seen successes in the reduction in the bed occupancy rate across Scotland and a marked reduction in the average length of stay. This is indicative of the successes in developing new models of care within community settings, allowing people to receive the support they require in settings more suitable for their needs. 

There still remain instances where individuals require specialist support which can only be provided in an inpatient setting, however, the number of psychiatric inpatient admissions has declined further in the last year. As this work progresses, we will continue to work with key partners to address health inequalities, which are evident in statistics, to help build a fairer and more inclusive Scotland.