Scottish Government

National Mental Health Services Assessment
Locality Report

HIGHLAND

December 2003

Introduction

The remit for the National Assessment means that the focus in the locality reports is on what needs to be done locally to deliver the new provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003. With that in mind the many examples of good care seen across Scotland are not covered in the individual reports. This should not be taken as a negative.

Every effort has been made to achieve consistency in each report. There are however variations in those cases where the local arrangements vary sufficiently to warrant some variety in the presentation of findings. For example not all information was available for or from each area in the same format or with the same coverage and where this is the case it is stated.

The wide-ranging nature of the responsibilities that the Act places on local authorities means that it was virtually impossible to assess the services provided by them or the voluntary sector in a short timescale, although there are examples of services across Scotland in the Final Report. In no way should this be seen as devaluing the local authority contribution or minimising the additional demands placed on the Councils.

The findings arising from the visits and review of existing information can only represent a snapshot in time and in many cases the local situation will now be different. However, the purpose is to provide a shared, validated information base to start from and to plan for the successful and timely implementation of the new legislation. The reports should not be used in the form of league tables or as negative criticism.

These reports will now inform the local planning process and will be useful reference documents in the preparation of the joint local implementation plans announced in the Department's letter of 19 November 2003 (see Annex A).

Some general principles:-

• The Mental Health (Care and Treatment) (Scotland) Act 2003 applies to all age groups, although the greatest number will be adults of working age.

• Where the reports refer to Adult Mental Health Services this covers services and support for those aged 16/18 to 64. Where possible we have been more accurate, but this is the standard definition used by the Information and Statistics Division of the Common Services Agency and the local authorities.

• The year of the data source is stated in each case and represents the latest available.

• Regard was given to the wide range of archive, published and other material throughout the entire Assessment process for ongoing context, progress and other relevant considerations.

• References to the organisation of local authority Mental Health Officer (MHO) services or Responsible Medical Officer services should not be taken as implying or suggesting any preferred structure.

Locality

1. Highland is a large geographical area of about 10,000 square miles some of which is quite isolated making transport an important issue. The population of 208,100 includes 132,800 adults and 35,200 older people. Inverness is the main centre, but the inner Moray Firth area has a reasonably sized population as do the towns of Wick, Thurso, Aviemore and Fort William. Although levels of deprivation and morbidity are lower than the national average in Scotland, there is a high level of alcohol misuse among the population.

2. Mental health services are provided by NHS Highland and the coterminous Highland Council, in partnership with a broad range of voluntary sector services and not-for-profit care providers.

3. In 2001 the old Craig Dunain Hospital was closed and hospital services moved to new accommodation (providing a much improved care environment) built on an existing learning disability site, Craig Phadrig, to jointly become New Craigs. The choice of location was strongly influenced by the service user group.

4. Use of the Mental Health (Scotland) Act 1984

5. The level of emergency detentions under the current mental health act is higher than average, with only 2 other areas in Scotland making greater use of sections 24 and 25. Despite this, a survey in October 2003 showed that 21 people in Highland were admitted on a compulsory basis in October, around 15% of the whole acute admission population, which is a lower figure than in the other parts of Scotland where information was able to be obtained.

6. Table A - Detentions in Highlands under the Mental Health (Scotland) Act 1984 in 2001-02/2002-03¹

   	Actual No of Detentions	No per 100,000 In Highlands	Average No Per 100,000 People In Scotland
   Sections 24 and 25 2	204/198	98/95	85/90
   Section 26 3	116/119	56/57	51/56
   Section 18 4	50/50	24/24	21/23

   Table B - average number of detentions 1994-2002, related to population size and used to estimate the potential number of hearings.⁵

   Local authority	Population size	% of Scottish detentions over eight years	Estimated Tribunal hearings under the 2003 Act
   Highland Council	208,100	5.50%	166

7. As at July 2003 there were 3 patients from the Highlands currently resident in The State Hospital with no-one waiting to transfer back to the local area. The right to appeal against the level of security, which will be implemented in 2006, is unlikely to add significantly to local burdens. Highland is involved in the planning for a Northern Regional forensic psychiatric unit and service which will offer wider care options in the future.

8. The Act puts pressure on many services, but in terms of individual professionals the main additional demands will fall on Mental Health Officers and consultant psychiatrists (the pressures on administration and advocacy services will be discussed in the Final Report).

9. A major issue is the workforce vacancy levels in all disciplines, which is having a significant impact on the ability to deliver services in both the outlying rural areas and the city. General practitioner vacancies compound the gaps in secondary health care and social workers and service users stressed that as a consequence access to out-of-hours and crisis support is often lacking. There is large scale planning taking place about out-of-hours services as a whole, in relation to the changes to the GP contract next year, and social services need to be included at all levels.

10. There are 13.5 WTE consultant psychiatrist posts in Highland with a vacancy rate of around 22%. Some of the positions are being filled by locum doctors. Within these figures, 2 vacancies are in general adult psychiatry, one in old age psychiatry (due to maternity leave) and 1.5 vacant learning disability consultant posts. Some consultants cover more than one specialty (for example general psychiatry, forensic services or general psychiatry and older adults) so it is difficult to quantify the number of general psychiatry sessions. At full establishment Highland meets the level of provision suggested to local planners and commissioners by the Royal College of Psychiatrists. Any local planning or calculation must necessarily include travel time to outlying clinics, and the potential for overnight stays by staff.

11. Consultant psychiatrists discussed the difficulties in recruiting to posts over recent years and saw little hope of this situation improving, within what is a national problem. However, given the serious problem various options and possible solutions are being considered, with a major focus on recruitment and retention. For example, consultants are working to identify possible changes to roles and responsibilities within a service redesign process. The introduction of the Adults With Incapacity (Scotland) Act 2000 has compounded the sense of becoming 'overwhelmed' and the perception of ability to respond to a further change in practice after more legislation involving mental health and learning disability is understandably causing concern.

12. Currently there are 24 doctors approved under Section 20 of the 1984 Act, including 4 GPs, in addition to consultants, specialist registrars and staff grade psychiatrists. The new GP contract will have an impact on the work GPs undertake and continuing discussion with psychiatric colleagues is important.

13. There is an unusually high number of approved Mental Health Officers (MHOs) working for Highland Council and it was reported that 48 out of the 50 had carried out duties under the current Mental Health Act in 2002-2003. This means 23 MHOs per 100,000 of the population (comparing favourably to the national average of 11.5 per 100,000). At present only about 26% are located in mental health settings.

14. It was explained locally that the high number was to ensure there would be a relatively quick response across the area and that in practice fewer than stated will have been active in the last year. The majority of the MHOs (60%) are clustered in Inverness, Dingwall and Nairn. With the enhanced MHO role under the 2003 Act, which will include care planning, the MHOs not working in mental health may need updated training in mental health casework as well as the provisions of the Act.

15. There is currently no agreement by Highland Council to pay their MHOs enhanced rates, although a recent review supporting this is being considered with the proviso that there is at least a minimum level of detentions each year and that refresher training is completed.

16. Table C - Mental Health Officers approved by Highland Council

    Local Authority	No of MHOs	Practising MHOs	MHOs in mental health	Additional payment
    Highland Council	50	48	13	No

    Hospital Services for Adults

17. Mental health facilities within the area consist of:

Three acute adult admission wards

• New Craigs Hospital (72 beds)

One intensive psychiatric care unit

• New Craigs Hospital (12 beds)

Two rehabilitation units

• 11 beds at New Craigs Hospital

• 20 community based beds

1. This is a higher number of beds than that suggested by the Royal College of Psychiatrists for services where there are no additional sub-specialty day and community services. The maximum proposed number (50 per 100,000 adult population) would be 66. ⁶ The local situation may partly reflect the lack of intensive support opportunities elsewhere in the region.

2. While it is accepted by the Project Team that there are too many acute beds for direct clinical need, the beds have been used to full occupancy. There are insufficient numbers of skilled community staff in rural areas and the large distances people travel in an emergency to get to the hospital means that it is virtually impossible to send them home on the same day.

3. Table D - Hospital bed numbers Highland and Scotland⁷

   Hospital Beds	Highland Actual beds				Highland Number per 100,000				Scotland Number per 100,000
   	2000	2001	2002	2003	2000	2001	2002	2003	2000	2001	2002	2003
   All psychiatric specialties	261	258	257	259	125	123	123	117	161	153	145	141
   All adults under 65 years	140	140	140	123	67	67	67	64	74	70	66	64
   Older people	119	115	116	108	57	55	56	52	83	79	74	73
   Child Services	2	2	2	1	*	*	*	*	*	*	*	*

   Adult beds include acute admission, rehabilitation and continuing care. Slight discrepancies are due to the rounding up of figures. Information for 2003 is provisional. * rate per 100,000 is too small to provide meaningful data.

4. Local figures show an average of 7 one-day admissions a month to acute beds, from July 2000 to March 2003. In addition there were 69 admissions without overnight stays. The rationale about long distances is not the only explanation - a surprisingly high number come from the Inverness area. Since the opening of the Braeside Day Centre, which accepts referrals from GPs, there have been considerably fewer brief admissions.

5. Although the number of adult admission beds is high the overall number of psychiatric beds for adults meets the Scottish average. There are relatively few beds for older people with only two other mainland NHS board areas having less per 100,000.

6. In 2000-01 there were 37 discharges from New Craigs who lived elsewhere (all ages) and in the converse, 29 local people were admitted to other parts of Scotland. The following year was similar; 37 people treated from outside Highland and 29 people sent elsewhere. Some of the out-of-area admissions will be due to the pressure on beds elsewhere in Scotland and some will be from the influx of tourists in summer.

7. In July 2003 there were eighteen people whose discharge was delayed; five of these were adults, and the remaining were older people.

8. The emergency readmission rate (within 28 days) was used by the Accounts Commission ⁸ as a possible indicator of inadequate community care. The rate rose considerably in 1999, but this is partly explained in the statistics gathered for patients transferring from the old hospital to the new facilities who technically had to be admitted again. The last available figure was below the Scottish average of 7.27%

9. Table E - Hospital admissions in Highland for people aged 16/18-64⁹

   Adults 16/18 - 64	1998	1999	2000	2001	2002(p)
   First Admission (i)	208	135	75	14	177(p)
   Readmissions Within One Year (ii)	567	752	846	895	675(p)
   Readmission Rate Within 28 Days (iii)	8.06%	11.43%	10.13%	6.76%	N/A

   (i) First ever recorded admission to psychiatric inpatient care

   (ii) All readmissions following a break in in-patient care

   (iii)Emergency readmissions/discharges x 100

   (p)Provisional data from ISD SMR04 returns refer to year 2002 only.

10. Child and adolescent services in the region have been improved with an investment of 320,000 for primary care mental health workers who link in to the Department of Child and Family Psychiatry . There is now an additional half-time consultant supported by one H grade and 2 G grade community psychiatric nurses and together they provide a 7 day service for the region. This is a good example of consultant cover being supported by specialist nurses crossing the interface of primary and secondary care. Age-appropriate admission services for adolescents are required by the Act and it is evident that small numbers of inpatient units will have to be part of a managed clinical network across Scotland. The development of good local services such as this will contribute to the network.

11. The Highland Users Group (HUG) noted in their 2002 report ¹⁰ that "Video conferencing has been useful for some people in remote areas who have little access to psychology. This could be expanded where appropriate." The principle of reciprocity means that people should have access to the full range of treatments if under a Compulsory Treatment Order and this may now be community-based. The suggestion of increasing tele-conferencing is a good idea, although not acceptable to many who prefer face-to-face interactions.

12. Community Services for Adults

13. Community based services are as follows:

Five community mental health teams (each with sub-divisions)

• Caithness

• Lochaber

• East Highlands

• Nairn

• Inverness

Four day hospitals:

• East Highlands

• Inverness

• Nairn

• One travelling day hospital in East Caithness

Nine drop-in centres

1. The development of better out of hours support within communities would assist GPs to help their patients safely at a local level. There is an excellent example of a primary care based CMHT in Nairn, which has a visiting psychiatrist; this has consistently been shown to reduce the admission rate. Some areas have no CMHT cover however, while others also lack some primary care staff, including GPs, because of vacancies. These difficulties are compounded by the wide geographical area. Some creative solutions were offered involving the voluntary sector and local respite places and these options should be taken further in discussion with service users and carers.

2. There are many good examples of voluntary sector provision although difficulties with short-term funding and no uplift for inflation means that some services are being 'cut' in real terms to manage the widening gap in finance from year to year.

3. There is a Patients' Council at New Craigs Hospital, and the Highland Users Group (HUG) is a well-established and highly regarded example of user involvement in Scotland. At present, access to independent advocacy is insufficient to meet current demands and therefore further investment will be required prior to the introduction of the new Act. Funding to increase access to individual advocacy has been slow to cascade, and while advocacy groups are well aware of the unmet need, expanding existing services will take time and planning. An Advocacy Plan was developed by Highland's joint agencies and submitted to the Scottish Executive for approval. Following this, the Joint Committee for Action in Community Care agreed to invest 200,000 on advocacy services, although none of this money was ring-fenced for mental health service users or carers. Additional funding has now been released to the local authorities for advocacy as part of preparation to implement the Act.

4. Priorities of service Users and Carers in Highland

5. Users

• Adequate and consistent funding for the voluntary sector.

• Escorts for the journey to hospital.

• Structured activities in the community: help with motivation support and other activities that will help people keep well at home.

• Help with problem-solving opportunities for people living with illness and coming to terms with it.

• Out of hours services.

• Challenge stigma, provide mental health awareness training and change attitudes.

• Support for the rest of the family and for carers.

1. Carers

Caithness

• A place of safety as an alternative to the police station when people are in crisis.

• Easier transfer to hospital - waits of 18 hours in police cells are not acceptable.

• Talking treatments.

• Supported accommodation.

Inverness

• More stimulation in the wards. Nurses seem to spend hours in the nursing station.

• More monitoring of patients -health, diet clothing.

• More involvement from the dietician to avoid the massive weight gain that occurs with some medication.

• Better and quicker access to psychologists.

• More investment to help users with tasks such as cooking and shopping when people are discharged home.

1. Given the geography of the area and the dispersed population transport is a big issue, especially for emergency admissions that may require access to ambulance services. In such instances nursing staff from New Craigs are required to escort patients, often involving long periods and requiring staff to be away from the wards. Public transport to enable people to attend drop-in centres, attend out-patients or generally get involved in social activities is limited. The new Act puts additional responsibility on the local authority to address transport issues.

2. Another important theme raised by users was inadequate access to housing stock and this has hindered the development of supported accommodation projects. To help address this, a housing officer from Highland Council is now part of the mental health strategic planning process.

3. Comments

4. Key issues that will challenge Highland when implementing the new legislation:

• Out-of-hours services, especially in rural and remote areas, need to be developed. While Inverness had a good example of CPN triage gaps were clearly evident elsewhere and may well be contributing to unnecessary admissions to hospital.

• Vacancy rates in many disciplines require a continuing major focus on recruitment, retention and service redesign. When consultants develop their roles to meet the requirements of the Act other disciplines must be available to take on new duties, especially nursing staff and allied health professionals.

• Independent advocacy needs to be extended for users and carers.

• Despite relatively high numbers, MHOs are not readily accessible in remote parts of the region and this needs to be taken into account in the action plan for implementation.

• Users require better access to training, employment, recreation and daytime activities. There are some excellent examples; however some areas lack any such investments.

• There needs to be access to hospital services for children and adolescents and mothers with babies.

Visiting Team

Footnotes

1 Mental Welfare Commission Annual Report 2001-02/2002-03

2 Sections 24 and 25 are emergency sections lasting 72 hours

3 Section 26 is a 28 day order that can be used when an emergency section has expired

4 Section 18 is a long term order, 6 months in the first instance with the agreement of the Sheriff Court.

5 Scottish Executive Implementation Team, based on the scoping exercise undertaken by the Royal College of Psychiatry

6 Model consultant job descriptions and recommended norms. OP55 October 2002. Royal College of Psychiatrists. London

7 ISD

8 A shared approach: Developing adult mental health services. Accounts Commission for Scotland 1999

9 ISD provisional data from SMR04 returns

10 Current issues in mental health in the Highlands 2002