“NEW HORIZONS - A JOINT ENDEAVOUR”

A FRAMEWORK FOR MENTAL HEALTH SERVICES IN GRAMPIAN

1.Introduction

On 19 September 1997 the Framework for Mental Health Services in Scotland, NHS MEL(1997)62, was launched by the Minister for Health and the Arts. This report is the culmination of extensive work across all stakeholders in Grampian, especially Users and Carers. It brings together progress to date in Grampian, identifies gaps in service and the resource implications of meeting these gaps into the next century. It also sets out clear actions for all Stakeholders in implementing the Framework.

The National Framework requires the development of a comprehensive local mental health service which addresses the full range of needs of all people with mental health problems. However, “individuals with severe and/or enduring mental health problems, including the small number who presents either a danger to themselves or others, should be the service’s first priority”.

2.Objectives

The objectives of the Review as outlined in NHS MEL (1997) 62 were as follows:

  • To understand and interpret the national guidelines/directives from the ME.
  • To identify existing NHS, social work and other resources available for mental health services.
  • To assess local needs for mental health services.
  • To undertake a service review of current services against the framework and local need, in particular identifying gaps and shortfalls, and develop these to confirm joint Health Board and Local Authority aims and priorities for mental health services in Grampian.
  • To draft a six year implementation plan to put into practice existing and new plans developed in response to the service review.

3.Timescales

Each of the six year implementation plans prepared jointly by each Council and Grampian Health Board was formally requested by the Scottish Office to be completed by 1 April 1998. There was a consensus from all parties that in order to meaningfully engage with Users and Carers this timescale was unrealistic. Support from Grampian Health Board Directors was sought and given for a suggested extension to 30 June 1998 being requested from the Scottish Office. However, a report on progress was submitted to the Scottish Office by 31 March 1998 and subsequently a further progress report was submitted on the 20 July 1998.

4.Background

In line with national policy, a major component of Grampian’s Health Improvement Programme is concerned with focusing resources on reducing the levels of morbidity associated with Scotland’s most prevalent diseases.

This means targeting effort and resources so that all relevant aspects of the Service’s work will be concerned with improving mental health, in order to respond appropriately to unmet need and the important status of mental health as a national clinical priority for the NHS.

5.MORBIDITY

The table below shows National and Grampian expected psychiatric morbidity in the adult population and service use based on Goldberg and Huxley (1992) and from the Mental Health Portfolio (SNAP-1997). These figures demonstrate the “Iceberg” of Morbidity.

National and Grampian Expected Psychiatric Morbidity and Service Use.

MEASURE / ANNUAL PREVALENCE (%)
(NATIONAL DATA) / GRAMPIAN PREVALENCE
Number of adults suffering from mental illness/distress / 25%-31.5% / 127,153
Number consulting primary care / 23% / 92,841
Number identified as having mental illness/distress / 10.2%-14% / 41,173
Number referred to mental health services / 1.7%-2.1% / 8,477
Number admitted to psychiatric hospital / 0.3%-0.6% / 1,211
GRAMPIAN POPULATION TOTAL (ADULTS AGED 18+) / 403,658

Source : National Data based on Goldberg and Huxley (1992)

Grampian Population - Registrar General’s 1997 estimate and population projection to 2004. (1996 base).

Prevalence of Dementia in Grampian

Age Group / Prevalence / 1997 Est. / 2004 Est. / % Difference
65-69 years old / 1.4% / 319 / 319 / 0
70-74 years old / 2.8% / 545 / 556 / 2.0
75-79 years old / 5.6% / 833 / 886 / 6.4
80-84 years old / 10.5% / 1025 / 1206 / 17.7
85-89 years old / 20.8% / 1171 / 1067 / -8.9
90+ years old / 38.6% / 996 / 1375 / 38.1
Total (65+) / 4889 / 5409 / 10.6

Source : A Joint Strategy and Action Plan for Dementia Services in Grampian; 1995

Grampian Population - Registrar General’s 1997 estimate and population projection to 2004 (1996 base).

There are likely to be around 250 people with dementia under 65 years old in Grampian as a whole, rising to around 274 by the year 2001.

Although the total numbers of people with dementia is projected to increase over the next 6 years the impact will be greatest in Aberdeenshire (with little increase in AberdeenCity) and in the oldest age groups; those with the weakest informal support networks.

Child & Adolescent Mental Health Mobidity

Just as there is an “iceberg” of morbidity for adults, a similar pattern exists for children and adolescents. However the diagnoses are different.

MEASURE / ANNUAL PREVALENCE (%)
(NATIONAL DATA) / ESTIMATED NUMBERS IN GRAMPIAN
Proportion suffering significant distress & curtailment of normal daily activities / 20% / 25400
Proportion suffering severe distress / 6 - 10% / 7620 - 12600
Referrals to Child & Adolescent Psychiatry / 0.6% / 700

Source : Needs Assessment Report : Children and Adolescents Mental Health Services, GHB 1998

Although large numbers of children may be affected over the course of a year, most of these problems will be transient and smaller proportions will require services from Primary Care and fewer still from Secondary Care.

Conduct disorder and mixed conduct and emotional disorder constitute about a third of all referrals, although hyperkinetic and hyperkinetic conduct disorders are an increasing proportion of referrals and a major contributor to the increase in numbers of children seen by the service. Child protection issues arise in about 20% of cases nationally but are more common in Grampian. There is a significant involvement of families in the care and management of children with mental health problems.

6.Context/Historical Development of Mental Health services in Grampian

Since the early 1970’s, throughout the UK, it has been Government policy to create services that are much more local, sensitive in nature and scale and person centred than those developed in the past. Local Councils now plan and arrange the essential services that are required to enable people to remain part of local communities, in close association with other publicly funded agencies within the context of the NHS and Community Care Act.

The role of the NHS is now seen as both a commissioner and provider of high quality health services, that are responsive to the needs and wishes of individuals and which promote the health of the whole community.

Since the 1980s, it has been recognised that social care and health care needed to be planned, organised and delivered as if they were one service. To this end we have had policies that have offered guidance on joint planning structures, and promoted jointly financed initiatives, joint working between practitioners, and most recently joint commissioning and joint approaches to assessment and discharge planning.

As a direct result of this close working, in 1995, Grampian Health Board and Grampian Regional Council agreed a joint Mental Health Strategy “Services for People in Grampian 1994-2001” and a “Joint Strategy and Action Plan for Dementia Services in Grampian 1994-2000”. The principles, philosophy and values within these documents continue to be the basis upon which the provisions of mental health services are planned.

It is acknowledged both locally and nationally that Grampian has one of the most progressive mental health services in Scotland. Alternative services have been created which have allowed a number of people to live more independent, better quality lives within their own homes and communities. This has resulted in a reduction in the number of people requiring care in hospital settings.

During that period there has been significant investment within Community Mental Health Teams, each of which have been aligned with General Practice. A number of Old Age Psychiatry and Dementia Teams have also been established to cover each part of Grampian. Alternative Residential and Respite Services have been developed in conjunction with Independent Sector Care Providers and a range of Day Care Services and Drop-In Centres commissioned by Local Authorities. An Out of Hours Crisis Intervention Service has been funded in order to provide a service to those people requiring urgent CPN support outwith normal “office hours”.

Grampian has also fully implemented the Care Programme Approach and following a recent survey by the Accounts Commission has been acknowledged as leading many aspects of its development nationally.

However, recognising that needs change over time and that practice should continually be reviewed the “Framework” process has enabled consideration to be given as to what further improvements in mental health services are possible within the next six years in Grampian.

7.PHILOSOPHY AND PRINCIPLES OF CARE

The following philosophy and principles of care should guide and underpin all future policy and service developments within Grampian.

The primary aim is to define a strategy which reflects and responds to the needs of people suffering from mental health problems. Recognising this person-centred approach the philosophy and principles have been divided into those which are person-centred and those which relate to the nature of the services required to achieve such a person-centred approach.

  • People with mental health problems have ordinary human needs and should be afforded dignity, offered the maximum possible choice and be involved in decisions affecting themselves.
  • Given the varying rural and urban nature of Grampian, there should be no discrimination in terms of accessibility to services based on where people live.
  • There should be equal access to services on the basis of equal need, whenever that need arises.
  • Positive attitudes to mental health should be promoted and a sympathetic understanding given to those suffering from mental health problems.
  • Services should, as far as possible, be based within a person’s normal environment and domestic surroundings unless there are compelling reasons for them to be elsewhere. Continuity of social networks, personal relationships, employment etc. should be maintained wherever possible.
  • Recognition should be given to and provision made for the needs of carers.
  • A person should be involved in the management of their care wherever possible, including their discharge, based on informed choices where clinically appropriate.

8.Process

It was agreed by Grampian Health Board and the three Local Authorities that the Review Process would be undertaken separately by Council Level Working Groups led by Aberdeen, Aberdeenshire and Moray Councils. Each Working Group was chaired by a Senior Social Work Department Official and comprised representatives of Councils, General Practice, Grampian Health Board, NHS Trusts, Users, Carers, Independent Sector and Grampian Local Health Council. All 3 Councils also held conferences.

A Small Senior Officer Group (Membership attached as Annex 1) chaired by Grampian Health Board was also established involving all three Local Authorities, Provider Trusts, General Practice and the Local Health Council to consider a number of issues common to each of the three Councils eg Forensic Services, Long Stay Population, Advocacy, Psychogeriatric Services, Acute Rehabilitation Services, Community Mental Health Teams, Primary Care, Care Programme Approach, Clinical Psychology and Neuropsychiatry. Child and Adolescent Psychiatry Services were considered as a separate Needs Assessment because of particular problems. The results of that review have been incorporated into this document. A very successful “Grampian” Conference was also held on 26 March 1998 to bring together all stakeholders with an interest in these issues. As a result of these discussions The Common Service Responses to Identified Mental Health Need as agreed by the “Common Issues” Group have now been incorporated in this Report.

Senior Clinical and Management Representatives from Grampian Healthcare and Moray Health Services have been involved in the appropriate Council Level and Common Issues Group. Copies of all three draft Strategies have been circulated to Grampian Healthcare Trust, Moray Health Services and Aberdeen Royal Hospitals NHS Trust for comment.

Mr Gregor Henderson, Director, Scottish Development Centre for Mental Health Services and Professor Mary Marshall, Dementia Services Development Centre were commissioned to support both the Grampian Conference and other aspects of the Framework process.

9.Views of Users/Carers

Grampian Health Board funded the appointment of 1.5WTE Project Workers by Grampian Local Health Council specifically to obtain the views of users and carers on existing services and/or gaps in provision in Aberdeen, Aberdeenshire and Moray.

The detailed reports from this exercise have been used to both inform the preparation of each of the three Council area Strategies and the Common Service Responses to Identified Mental Health Need section. Specifically the main issues raised were as follows:

  • Information is difficult for users to access, particularly in the early stages of their illness.
  • There is a lack of communication between professionals and service users and in particular a need for greater user involvement in the planning of new services.
  • Continued development of respite care is required.
  • Employment services and training are not user led.
  • Advocacy services are required specifically for people with mental health problems.
  • Users prefer to be in the community rather than hospital.

10.Primary Care

A GP Facilitator was a Member of each Council Level Working and “Common Issues” Group and as such were able to contribute on an ongoing basis to the development of Strategy. In addition, each GP Facilitator was commissioned to obtain the views of Primary Care colleagues, in order that their views might also be reflected during these discussions. The key points highlighted are:

  • Access to services should be equitable throughout Grampian.
  • Services need to be responsive to local needs.
  • CPN services should be further developed, particularly in their role with those people with severe and enduring mental illness and crisis intervention.
  • Psychology services require to be developed.
  • Social Work services are seen as an area where new relationships and partnerships should be developed leading to seamless Primary Care with better care planning and tailored care packages.
  • Child and Adolescent Psychiatry should be further developed.

The Grampian GP Sub-Committee supports the service objectives as outlined in Section 14.

11.Grampian Conference

A Grampian Conference was held on 26 March 1998 to discuss a range of “Common Issues” and agree appropriate service solutions. The event confirmed the need to continue to shift resources in the following areas:

  • from service led to needs led
  • from hospital bases to community bases
  • from secondary to primary care
  • from health to social care

A key theme at the Conference was that there should be increased emphasis on the following improvements particularly from the users’ perspective eg

  • Access to services must improve in terms of speed of response and a more appropriate geographical spread.
  • More comprehensive information made available on the roles of specific services.
  • Improved links with employment and housing.
  • To involve users in decisions about their own care and in the proposed patterns of service delivery.

12.Locality Groups

A number of issues have similarly been raised within Locality Groups in Grampian consisting of users, specialist mental health, primary and social care staff. These include:

  • Any new resources should be focused on areas of greatest need and highest deprivation.
  • Community mental health teams should be re-aligned to community bases or locality settings.
  • Further expansion of crisis response services is required, particularly in rural Grampian.
  • Assertive rehabilitation services should be established.
  • Resources for mental health promotion should be increased.
  • There should be an ongoing shift in resources from institutional care to community care, via resource transfer.

13.Council Area Strategies

Copies of the three Council Area Strategies are attached to this report. A summary of the key features/issues from each document is listed below.

13a)Aberdeenshire

Aberdeenshire is a large, mainly rural, area covering 2,430 square miles with a population of 227,430. Unlike many other parts of Scotland, the population continues to grow which places increased demands on existing services such as Health, Social Care, Education and Housing. The cornerstone of the strategy for the future provision of Mental Health Services in Aberdeenshire is that they should be jointly commissioned, appropriately resourced and Aberdeenshire based. This strategy will be greatly facilitated by support from the Mental Health Development Fund for both a Joint Commissioning Manager and two Senior Care Managers.

Priority areas are -

  • The development of appropriately resourced, Aberdeenshire based community mental health teams for adult service users.
  • The development of appropriately resourced, Aberdeenshire based community mental health services for children and adolescents.
  • The development of a range of locally accessible community based mental health services which will provide crisis care, respite care and supported accommodation for people who suffer from severe and enduring mental illness. The aim of these services will be to respond to the stated wishes of users and carers for them to receive services at home or in their own communities. This will be achieved by preventing inappropriate admission to hospital and facilitating early discharge.
  • Facilitating the development of a range of opportunities to address the social isolation and exclusion experienced by mental health service users, such as education and employment opportunities, social and recreational activities.
  • To review on an ongoing basis the identified needs of service users, particularly in relation to the level and location of specialist Secondary Care Services.
  • Seeking to establish a secure basis for the funding of Voluntary Organisations which provide essential Mental Health Services.

13b)Aberdeen

The City of Aberdeen has a population of 219,000. Aberdeen is a compact city and mental health services are organised on a centralised basis from RoyalCornhillHospital. It is hoped in the future to move the balance of services from hospital to community, from health to social care and from centralised services to local community settings.

AberdeenCity has a good base of Adult Mental Health Services with the existing multi-disciplinary mental health teams. There is a clear need however to review the staffing structure of these teams in terms of deprivation indices and consider whether and which areas of the city should be prioritised in terms of additional resources.