Chamber and committees

Cabinet Secretary for Health and Social Care submission of 10 February 2022

PE1871/I - Full review of mental health services

Further to the submission that the Scottish Government provided on 8 July 2021, I am writing to the Committee with additional information as requested.

I would like to start by conveying my sincere condolences to Ms McKeown, the petitioner. Every suicide is a tragedy, felt by family, friends, colleagues and the wider community. I understand Ms McKeown’s passion and drive to ensure that we have a mental health system that is responsive to all. The Scottish Government fully supports and shares this ambition. I am also sympathetic to Ms McKeown’s specific ask for a full review of mental health services – however, I believe that work already committed to by this Government, across multiple levels of need, will amount to the transformational change that the petitioner is calling for.

The petition covers a range of issues, from the referrals mechanism for mental health services, to suicide prevention. The Committee requested additional information on several of these topics.

I hope it is helpful if I outline the wide range of work that the Scottish Government is taking forward to ensure we have a mental health system where the right help is available, in the right place, at the right time. This is especially critical given that we know the mental health impacts of the pandemic will continue to emerge and evolve over time. The help and support available must be similarly flexible and innovative to respond appropriately.

Improving the Mental Health System

Although transforming mental health services is a fundamentally important focus for this Government, our work focuses just as much on supporting and creating the conditions for everyone to have good mental wellbeing.

In 2020 we published our Mental Health Transition and Recovery Plan, which set out how we intend to support Mental Health through the pandemic and beyond. In financial year 2021-22, this is supported by our £120 million Mental Health Recovery and Renewal Fund – the single largest additional investment in mental health in the history of devolution.

The Scottish budget, published on 9 December, continues record levels of investment to match our ambition, with direct funding for mental health in 2022-23 of over £290 million – a 6% increase on this year, and a 139% increase on 2020-21.

By the end of this Parliament, we have pledged to increase direct mental health funding by 25%, and ensure that 10% of all front-line NHS spend goes to mental health, with 1% directed specifically to children and young people.

Details of how we are using this funding to support a whole-system approach - including ensuring that people receive the support they need at the earliest possible opportunity - are set out below.

How the System Works Together

Primary and Community Care Teams have a pivotal role to play in supporting mental health. As frontline practitioners, GPs and their teams are often the first port of call for people seeking professional help for mental health issues. However, the range and complexity of mental health presentations in primary care do not all fit existing pathways of care. That is why, on 12 January 2022, I set out plans to ensure that every GP Practice will have access to a mental health and wellbeing service, funding 1,000 additional dedicated staff who can help grow community mental health resilience and direct social prescribing by 2026.

These multi-agency Mental Health and Wellbeing in Primary Care Services will provide assessment, advice, support and some levels of treatment for people who require a mental health, distress or wellbeing response. The Services will be designed according to local need, based on a set of national principles underpinning service delivery; and could include Occupational Therapists, Mental Health Nurses, Psychologists and Enhanced Practitioners.

These teams would connect to the range of community assets within local areas, linking to other forms of support such as physical activities, addiction services, family support and peer networks. It will be a requirement for all funded roles to directly support wellbeing and social prescribing, and for each practice to have dedicated link worker resource to support wellbeing.

This commitment has the potential to achieve real, and positive, transformational change and will be supported by significant investment, increasing year on year to 2026 and reaching an expected £40 million per year by 2024-25. Funding of £1.5 million has already been allocated this year from the Mental Health Recovery and Renewal fund to support the establishment of local planning groups, enabling the development of long term plans for the implementation of these Services.

We recognise the importance of social determinants such as poverty for suicide and mental health more generally. The pandemic has exacerbated pre-existing structural inequality in society, putting some communities disproportionately at risk and having more adverse impacts on the mental health of some parts of the population. The Mental Health Transition and Recovery Plan, and our Communities Mental Health and Wellbeing Fund for adults, have a particular focus on addressing these issues.

Care, Quality & Standards

We want to ensure that individuals, their families and carers know what they can expect from mental health services, and will develop a set of standards for adult secondary mental health services this year. The standards will provide an opportunity to build a collective understanding of performance and enable effective benchmarking to drive improvements in quality of care. As well as helping reduce the scope of unwanted variation of quality of care, whilst also contributing to improving experiences and outcomes of patients. We expect the standards will also provide a basis for continual improvement though enabling greater scrutiny and assurance of services against the standards.

We are working with partners, including people with lived experience of adult mental health services, to develop the standards. The Mental Health and Wellbeing Standards Working Group is supporting their development and delivery. The Group consists of people with lived and living experience of using services and their carers, the mental health and social care workforce and organisations who commission mental health services. This partnership approach will enable a broad range of expertise to inform the standards and ensure they are comprehensive and impactful.

Improving the Referrals Process

In February 2020, we published our National Child and Adolescent Mental Health Service (CAMHS) Specification, which sets out the levels of service that children, young people and families can expect from CAMHS across Scotland. As part of this year’s additional investment through the Mental Health Recovery and Renewal Fund, we have provided £40 million for to NHS Boards to improve CAMHS. Specifically, we have provided £16.4 million funding to support NHS Boards to implement the CAMHS Specification.

The Specification includes a clear expectation that services should have appropriate re-engagement policies in place. Children and young people whose referral is not accepted are sensitively and appropriately signposted to a more suitable service within their community.

Additionally, we have provided £15 million of extra funding to local authorities to deliver locally-based mental health and wellbeing support for 5-24 year olds in their communities. These services offer an alternative to CAMHS for children and young people, where appropriate, by providing support for emotional distress delivered in a community setting. Further information is provided below.

Distress Response

Distress Brief Intervention (DBI) is a ground-breaking, award winning programme which provides a fast, personalised and compassionate response to people in emotional distress who don’t need a clinical intervention. Since it launched in 2016 in four pilot areas it has expanded into many new areas and we are committed to ensuring that it will be available in all parts of Scotland by 2024.

DBI is available to people 16 years and over and we are testing how it can support children aged 14/15. Core funding for DBI in the current financial year is just under £4.1m.

The DBI has two levels: Level 1 is provided by trained front-line staff (Police Scotland, Scottish Ambulance Service, Accident and Emergency and Primary Care) and involves a compassionate response and offer of referral (where individuals are assessed as appropriate) with confidence, clarity and guarantee of support within 24 hours. Level 2 is provided by trained third sector staff who contact the person within 24 hours of referral and provide compassionate community-based problem solving support, wellness and distress management planning, supported connections and signposting for a period of up to 14 days – connecting people to the supports that help them over time.

As part of our wider response to the pandemic, in 2020 we opened up a national pathway to DBI via NHS24. Since launch in 2016 the DBI programme has provided support to over 23,000 people, including over 6,000 via the NHS24 pathway.

Suicide Prevention

Suicide prevention is a key priority for this Government. In August 2018, we published the Suicide Prevention Action Plan "Every Life Matters" and set up a National Suicide Prevention Leadership Group (NSPLG) - to harness the expertise, insight and contributions from Scotland’s key suicide prevention partners, academic community, public sector organisations, clinicians - and most importantly people with lived experience.

Since 2018, many aspects of the Action Plan have been successfully delivered including: establishing a new social movement and awareness-raising campaign ‘United to Prevent Suicide’; producing workforce learning resources to support suicide prevention; developing a local action planning toolkit, and launching a pilot bereavement support service for individuals who have been bereaved by suicide. The pilot suicide bereavement service is currently running in NHS Ayrshire & Arran and NHS Highland, and is designed to provide early advice and assistance to bereaved families, and is also intended to help reduce suicide, as evidence shows that up to 10% of people bereaved by suicide may go on to attempt to take their own lives. This includes practical support, and advice on financial issues and the Crown Office and Procurator Fiscal (COPFS) investigation process. At the heart of the service is assessing the needs of families, ensuring safety plans are in place, and connecting families to local organisations which can provide further assistance and support to meet their needs. The Scottish Government is providing £510,000 for the pilot, which will run initially for two years, with a view to national expansion. The Scottish Government is also investing in suicide bereavement support in workplaces, to ensure compassionate support is available to staff who have been affected by the suicide death of a colleague.

The Action Plan also included a focus to improve suicidal crisis support, and that work is now moving to implementation stage following National Suicide Prevention Leadership Group (NSPLG)’s publication of ‘Time, Space, Compassion - Three simple words, one big difference: Recommendations for improvements in suicidal crisis response’ in October 2021. A Suicidal Crisis Support Action Group has been established which is an independent, time limited group led by the Scottish Government to agree and advise on activity to implement the recommendations with the aim of enabling improvements in suicidal crisis support right across Scotland.

The group is currently working to draw together lived experience, expertise and evidence from a wide range of sources to advise on the most effective actions and approach to support change and remove barriers. The NSPLG recommendations deliberately do not recommend a particular model of crisis support. Instead, it sets out an approach which sees suicidal crisis response as a human reaction, not a service model, and sets out the principles of Time, Space, Compassion as the basis of improvement in support people in suicidal crisis – across a range of settings, from statutory services to communities. The Suicidal Crisis Support Action Group has recently commenced and will be working over the next 18 months to deliver on these recommendations.

Reviewing deaths by suicide also forms part of the Action Plan, and good progress is being made to set up pilot reviews in 3 local authorities areas over the coming months. These reviews will provide valuable information about the factors and circumstances leading to a suicide to inform national and local suicide prevention efforts. The Government is also committed to preventing suicide deaths in custody and has accepted in principle all of the recommendations in the Independent Review of the Response to Deaths in Prison Custody, published in November 2021.

Beyond the Action Plan, through the £120m Recovery and Renewal Fund, the Government has increased its investment in local suicide prevention activities with six new implementation roles to support local suicide prevention planning, delivery and evaluation. Our new Communities Mental Health and Wellbeing Fund, described in more detail below, also provides £15m for 2021/22 to invest in community support for adults to support initiatives that tackle priority issues and at risk groups in line with local needs. Suicide prevention, social isolation and loneliness, prevention and early intervention are all key priorities for the fund.

Looking to the future, the Scottish Government and COSLA will publish a new Suicide Prevention Strategy in September 2022, accompanied by an initial Action Plan. This Strategy will build on the learning from the current Action Plan, and will be outcomes-focussed. The development of the strategy is being directed by the voices of people with lived experience as well as data and evidence of what works. The Government has also committed to doubling the annual funding for suicide prevention by the end of this Parliamentary term, from £1.4m per annum to £2.8m per annum.

Community Mental Health and Wellbeing Support for Adults

The Scottish Government supports and greatly appreciates the valuable work that community groups and organisations do to support the mental health and wellbeing of our communities, in particular the important role that small, grass roots, community groups play. We want to build on the excellent examples of good practice we have seen emerge throughout the pandemic, and on 15 October 2021 we announced a £15 million Fund to support adult mental health and wellbeing in communities across Scotland. This funding is expected to be in place for two years.

The funding reflects the importance that the Scottish Government places on promoting good mental health and early intervention for those in distress, ensuring that individuals can access a range of different types of support to match their needs.

The Fund supports the development of an integrated culture of mental wellbeing and prevention within local communities and across Scotland, building on and developing capacity within community organisations and grass roots groups and supporting the mental health and wellbeing of individuals.

The Fund focuses on:

• Tackling issues within the Mental Health Transition and Recovery Plan such as suicide prevention, social isolation and loneliness and prevention and early intervention;
• Addressing the mental health inequalities exacerbated by the pandemic and the needs of a range of ‘at risk’ groups such as women (particularly young women, and women and young women affected by gender based sexual violence); people with a long term health condition or disability; people who are or have been on the highest risk (previously shielding) list; people from a Minority Ethnic background; refugees and those with no recourse to public funds; people facing socio-economic disadvantage; people experiencing severe and multiple disadvantage; people with diagnosed mental illness; people affected by psychological trauma (including adverse childhood experiences); people who have experienced bereavement or loss; people disadvantaged by geographical location (particularly remote and rural areas); older people; and Lesbian, Gay, Bisexual and Transgender and Intersex (LGBTI) communities
• Supporting small grass roots community groups and organisations to deliver such activities, thus providing opportunities for people to connect and revitalise communities, to build trusted relationships within communities; and
• Building on communities’ own efforts throughout the Covid-19 pandemic and examples of good practice and innovation which emerged.

Community Mental Health and Wellbeing Support for Children & Young People

Children and young people have told us that they need more support for mental and emotional distress, and for their wellbeing and resilience, delivered in a community setting. 

The Scottish Government is committed to improving access to community mental health and wellbeing support. Last year, a new fund was established to provide Local Authorities with an additional £15 Million per annum to deliver new and enhanced supports and services for children and young people aged 5-24.

There are now over 230 new and enhanced services in place which provide support for mental and emotional distress, alongside preventative support for wellbeing and resilience. Services are based on a Framework developed through two years of engagement with stakeholders, and in response to recommendations from the Children & Young People’s Mental Health Taskforce, Youth Commission, Audit Scotland report on Children and Young People’s Mental Health and the Audit of Rejected Referrals.

We are committed to continuing to expand community based support, and will double the budget for these services for children and young people to £30 million per annum within this Parliamentary term.

Lived Experience Panel

Finally, we are committed to ensuring that all of this work is taken forward with lived experience at its heart.

We are currently working with the Health and Social Care Alliance and Mental Health Foundation to set up a Lived Experience Panel to advise and inform mental health policy. Membership for the Lived Experience Panel will be open to individuals with lived experience of mental health problems, disadvantages, and/or discrimination that puts them at risk of developing a mental health problem. The recruitment is planned for Spring 2022 and the panel is due to have its first meeting in April 2022.

Conclusion

I hope that this summary of our ongoing work reassures the Committee that this Government is committed to transformational change for mental health. We want to see a whole system which responds appropriately whenever anyone asks for help – whether that involves clinical services, or community support. Embedded within this must be a focus on reducing stigma, suicide prevention, and on involving the voices of lived experience. We will also continue our focus on addressing the social determinants of mental health, and on prevention and earlier intervention. This is our opportunity to ensure that issues do not escalate into mental ill-health wherever possible.

I once again wish to offer my sincere condolences to Ms McKeown, and commend her for her work to bring this fundamentally important issue to the Committee.