Mental health - distress framework for collaboration: multi-agency partnership approach

6. The Mental Health System

The mental health system is wide and varied and involves a range of services, with many key public services supporting those experiencing mental distress and their families. The detail below aims to describe the current service delivery landscape and some of the key roles central or aligned to this work.

Support, Care and Treatment Pathway

People’s needs for mental health care vary enormously. Some people may be able to manage their mental health conditions themselves, especially with support from family members, peer support groups, faith-based organisations, or community providers. Many others will need formal interventions to support their mental health conditions, typically offered through a range of daytime services.

The Support, Care and Treatment pathway demonstrates the different tiers of the mental health system, defined primarily based on the individual’s risk and need. The supports and services across the tiers are provided by a range of partners and this varies in different local systems. Boundaries between tiers can be blurred and people may require input from different tiers at different times or even from more than one tier at any point in time; their path between tiers may not be linear. The list of services under each tier is not exclusive to what may be available. The tiers provide a useful way of describing a complex interacting system.

Figure 1 text version:

A diagram visually representing the support, care and treatment pathway for mental health.

• Tier one which includes; Self Management; Self-care; Community supports; Third sector; Digital support; Digital mental health and wellbeing supports; Helplines e.g. Breathing Space; and Peer support
• Tier Two: Primary care and GPs; General mental health care; Helplines e.g. NHS 24 Mental Health Hub; Digital/online support and therapies
• Tier three which includes Specialist secondary mental health care and treatment; Community mental health team; Older adults community mental health team CAMHS; Psychological therapies teams Liaison/urgent care teams
• Tier four which includes Highly specialist services; Inpatient care; Forensic teams; Perinatal services; Eating disorder services

Tier One is targeted at people with low support needs, though they may have met the criteria for the other tiers, with the aim of prevention and early intervention, meaning services and support at this level usually support people to stay well and maintain a good level of wellbeing. The services and supports are generally delivered by local authorities and third sector organisations that have been designed or commissioned meet local needs and are directly accessible without requiring a referral. Tier One supports may also include digital supports that are available to members of the public without requiring a referral, such as mindfulness and wellness apps.

Tier Two provides early intervention and is aimed at people seeking further support with managing their health wellbeing or with improving their situation. The services and support in this tier are provided by a range of partners, including Primary Care, Local Authorities and Third Sector. Similar to the previous tier, individuals can usually access these services and supports directly. However, they may require a referral from Primary Care, NHS 24, or emergency services to access certain therapies and services, such as Computerised Cognitive Behavioural Therapy or Distress Brief Intervention.

The wider community-based support provided by Local Authorities, and HSCPs, around the socio-economic determinants of health, including employability, housing, and education are a critical underpinning of both tiers one and two. Social Work also plays a key role in providing advice, care, and support for those in need, such as supporting and protecting vulnerable people because of a mental disorder.

Tier Three are more specialist services which require a referral from Primary Care or another health and/or social care professional. The services and supports are usually based in the community and are aimed at people with more severe concerns and may need an assessment, diagnosis, treatment and/or recovery support. These services and supports are usually provided by the NHS though may also include Third Sector.

Tier Four is targeted at people who have high and/or complex support needs, and consists of very specialist care and treatment, often requiring inpatient or residential care. These services are usually provided by the NHS and require a referral from Primary care or another health and/or social care professional, though the independent and third sectors may also provide some of these services, such as private rehabilitation facilities.

Role of Key Services in Supporting Mental Health and Wellbeing

As outlined in the Mental Health and Wellbeing Workforce Action Plan, the delivery of mental health care is typically associated with the core mental health and wellbeing workforce such as psychiatrists, psychologists, mental health nurses, mental health pharmacists, peer support workers as well as allied health professionals and social work staff who provide mental health support just to name a few. They may work in Primary Care, Community Mental Health Teams, CAMHS, the independent sector, third sector or other specialist mental health services such as those for eating disorders. While not directly employed in providing mental health support, the wider mental health and wellbeing workforce also play an important role in promoting and supporting good mental health, for example community link workers.

In this section we highlight some of the services that also play a key role in supporting mental health and wellbeing in the community, however this list is not exhaustive so Health Boards and local partners are advised to consider other services or agencies that can support a multi-agency response to distress.

NHS 24 Mental Health Hub

The NHS 24 Mental Health Hub (the Hub) is available 24/7 on 111 for anyone in Scotland who is in need of emotional support, is in a state of despair or is feeling distressed or suicidal.

The Hub is staffed by Psychological Wellbeing Practitioners (PWPs) who are specially trained advisers who work in mental health and are supported by Mental Health Nurses. If a person has an urgent mental health need, the PWPs will help them get the right care in the right place.

Through the development of the Enhanced Mental Health Pathway, the Scottish Ambulance Service and Police Scotland’s contact centres can safely pass callers with a mental health need to the Hub, provided the caller consents and only where no immediate risk has been identified. The Enhanced Mental Health Pathway not only ensures that the person is getting the right help, but that resources are deployed appropriately, thereby reducing unnecessary demand on emergency services.

Third Sector

Third sector organisations (which include charities, social enterprises, and voluntary groups) provide many essential services that support a person’s mental health and wellbeing and play a vital role in reaching marginalised communities. The services provided by third sector organisations are typically focused on prevention and early intervention, meaning that they are vital in preventing mental health issues from escalating to a crisis point or even from occurring in the first place.

Third sector organisations also provide the relevant knowledge, services, and supports that address wider social factors that may be contributing to a person’s distress or crisis. This is why it is crucial that they are involved in the design and implementation of local distress pathways.

Social Workers

Social workers bring a social ecological perspective to the concept of mental health. They work in partnership with colleagues from health, police, the third sector, and others, to provide an effective, holistic service for individuals, families, and communities. Social workers empower people who use services and protect and promote individual Human Rights, as per the Human Rights Act 1998.

Social workers play a significant role in supporting people living with mental illness. Their involvement enables those with complex needs and trauma experiences, including those with forensic mental health involvement, to live as independently as possible in the community. When working with someone experiencing mental illness, the role of the social worker is to try and understand the person’s illness in their personal and social context, balancing the rights and needs of the person and others. They work with the individual, family and/or carers to provide support and education regarding the individual’s mental illness. Social workers may be part of an integrated team, working alongside colleagues in health, and/or working across a wide range of services that include people with mental ill health; for example, working with people with dual diagnoses in substance use or learning disability services.

Social workers across all teams and age groups will work with people who experience mental distress, but who may not have a formal diagnosis of mental illness.

Mental Health Officers

Mental Health Officers (MHOs) are specially trained social workers who, following a period of specialist training, undertake this statutory role. The training of MHOs needs to reflect the high standard of expertise, legal knowledge and autonomy required to undertake the role.

MHOs have a unique role in supporting and protecting people who are vulnerable because of a mental disorder. At times when a person requires care, treatment and/or detention under the Mental Health (Care & Treatment) (Scotland) Act, the local authority must ensure that an MHO is appointed to work with the individual.

Generally speaking, the MHO’s role includes:

• Protecting the individual’s health, safety, welfare, finances, and property
• Safeguarding the individual’s rights and freedom
• Public protection where this concerns mentally ill offenders
• Letting the Mental Welfare Commission and the individual’s Named Person know if the person has been detained or where an application is being made for the individual to be placed on a Compulsory Treatment Order.

Although MHOs work alongside medical and legal professionals, they work and carry out their responsibilities independently.

MHOs also have specific statutory responsibilities for reporting to the courts in relation to certain parts of the Adults with Incapacity (Scotland) Act 2000, such as applications for Intervention or Guardianship Orders.

Police Scotland

Police officers are often the first point of contact during a crisis in the community or at home, and they play a vital role in supporting communities, individuals in distress/crisis, and victims of crime. At times their attendance at mental health incidents can be vital. While Police Scotland have a specific duty to improve the safety and well-being of persons, they should only be deployed when a policing response is appropriate and necessary.

The Mental Health Unscheduled Care Network has been working on providing police officers with access to effective and efficient transfer of care, allowing individuals in distress to get the right care, in the right place, at the right time.

The Scottish Ambulance Service

The Scottish Ambulance Service (SAS) is a national, mobile health service, delivering services locally and in people’s home within every community in Scotland, 24 hours a day, 365 days of the year. They support people with mental ill-health who are in crisis and those in emotional distress, though they are normally contacted and/or deployed in an emergency when an individual may need urgent care and/or conveyance to the emergency department. SAS work alongside many other partners including police Scotland, NHS 24 and local health services.

In 2021 three Mental Health Paramedic Response Units (MHPRU) were commissioned, they are staffed with paramedics who have additional training in mental health and work alongside local mental health clinicians often within mental health assessment units. The current locations of the MHPRUs are Dundee, Glasgow and Inverness.

As with Police Scotland, the Mental Health Unscheduled Care Network has been working on providing SAS’ ambulance staff with access to effective and efficient transfer of care, allowing individuals in distress to get the right care, in the right place, at the right time.

Intersectionality

Mental wellbeing, mental health and mental illness are linked to a combination of factors covering biology (e.g. genetics, health, and neurodiversity), psychology (e.g. thoughts, emotions, and beliefs) and social factors (e.g. culture, poverty, and discrimination). Many people experiencing mental health conditions also require help accessing other health services and/or key social services such as housing, employment, education, and welfare. Effective community-based mental health support, care and treatment includes consistency and co-ordination, as well as a careful mix of services and support that are responsive to the person’s needs.

Some of the services or agencies that may not sit under the mental health umbrella but may be involved in supporting the individual are listed below.

Adult support and protection

All adults at risk of harm have the right to be safe and protected. Harm means all harm, including self-harm and neglect. The Adult Support and Protection (Scotland) Act 2007 (ASP) requires councils and a range of public bodies to work together to support and protect adults who are unable to safeguard themselves, their property and their rights. The intervention of particular health professionals or emergency services is not at the exclusion of protective pathways via social work and/or the local authorities.

In 2021/22 there were an estimated 41,569 ASP referrals in Scotland where an adult is known or believed to be at risk (albeit an adult can be referred multiple times by different agencies). In 2021/22, the largest source of ASP referrals came from Police Scotland (28%)^[1]. Adults at risk of harm experience a wide range of underlying conditions including:

• substance misuse
• mental health problems
• learning disabilities
• physical disabilities, and
• infirmity due to old age.

In 2021/22, ‘mental health problem’ remained the top client category for people subject to ASP referrals (19%), despite dropping around 1% from the previous year^[2].

From the Care Inspectorate’s Triennial review of initial case reviews and significant case reviews for adults, 2019-2022, published in 2023, we also know that the circumstances of those affected by mental health and substance misuse were most frequently considered in reviews. Significantly, most adults subject to a review were either not known to ASP services or were but were not being supported/protected by a protection or risk management plan.

The intersection between risk of harm and people affected by mental health underscores the need to take a multi-agency, partnership approach to efficiently and effectively identifying adults at risk and working together to support and protect them.

Substance Use Services

Although there is a lack of systematically gathered data on the exact prevalence of co-occurring substance use and mental health concerns in Scotland, the overall evidence shows that co-occurring substance use and mental health concerns are a common issue^[3].

Concerning drug use specifically, in 2023, 80% of people presenting for MAT were screened for mental health problems by substance use services. Of those screened 68% presented with mild, moderate or severe mental health problems. Of those screened, 38% were already receiving treatment for their mental health problems^[4].

The lack of integration between mental health and substance use services is identified as a key barrier to accessing adequate treatment and support. It is also considered a barrier to effective service delivery as the lack of a consistent, joined-up approach results in failures to diagnose or recognise the needs of people with co-occurring substance use and mental health concerns, as well as having negative effects on treatment outcomes.

Housing and Homelessness Services

A 2018 Scottish Government study linking homelessness and datasets for the first time at a national level found that of those who had experienced homelessness at some point, around 30% had evidence of a mental health problem at some point during the study period (with no evidence of drug or alcohol-related conditions at any point). This was higher than in the control groups. Another 19% had evidence of drug and/or alcohol interactions, which was also higher than in the control groups. Of this 19%, 94% also had evidence of mental health issues.

Individuals experiencing mental health distress who are also experiencing or are at risk of homelessness will need a coordinated, responsive approach to their care to ensure their needs are met.