Back to the Scottish Parliament Public Audit Committee Report
Archive Home

Business Bulletin 1999-2011

Minutes of Proceedings 1999-2011

Journal of Parliamentary Proceedings Sessions 1 & 2

Committees Sessions 1, 2 & 3

Annual reports

SP Paper 433 PAU/S3/10/R3

3rd Report, 2010 (Session 3)

Overview of mental health services

CONTENTS

Remit and membership

Report

Introduction
Committee Consideration
General Background

Barriers to improvement and challenges

Expenditure on Mental Health Services

Resource transfer
Voluntary organisations

Accessibility of Mental Health Services

National targets for mental health
Child and adolescent mental health services
Access to mental health services by people from black and minority ethnic groups
Access to mental health services by people from deaf and deafblind communities

Delivery of Mental Health Services

Single Outcome Agreements and joint delivery
Cross-board working
Antidepressant prescribing Services for an ageing population

Annexe A: Extracts from the minutes

Annexe B: Oral Evidence and associated written evidence

Please note that all oral evidence and associated written evidence is published electronically only, and can be accessed via the Public Audit Committee’s webpages, at:http://www.scottish.parliament.uk/s3/committees/publicAudit/index.htm

Remit and membership

Remit:

1. The remit of the Public Audit Committee is to consider and report on—

(a) any accounts laid before the Parliament;

(b) any report laid before or made to the Parliament by the Auditor General for Scotland; and

(c) any other document laid before the Parliament, or referred to it by the Parliamentary Bureau or by the Auditor General for Scotland, concerning financial control, accounting and auditing in relation to public expenditure.

(Standing Orders of the Scottish Parliament, Rule 6.7)

Membership:

Willie Coffey
Cathie Craigie
George Foulkes
Murdo Fraser (Deputy Convener)
Hugh Henry (Convener)
Bill Kidd
Anne McLaughlin
Nicol Stephen

Committee Clerking Team:

Clerk to the Committee
Jane Williams

Assistant Clerk
Jason Nairn

Committee Assistant
Jennifer Bell

Overview of mental health services

The Committee reports to the Parliament as follows—

Introduction

1. This report sets out the Committee’s findings in relation to the report entitled Overview of mental health services (the AGS report) published by the Auditor General for Scotland (AGS) and Accounts Commission on 14 May 2009.

Committee Consideration

Committee scrutiny of the report

2. The Committee first considered the AGS report at its meeting on 20 May 2009. It agreed to take oral evidence from a selection of health boards and their local authority partners. At its meeting on 7 October 2009, the Committee heard from—

Anne Hawkins, Director, Mental Health Partnership, NHS Greater Glasgow and Clyde;

Raymond Bell, Head of Mental Health, Glasgow City Council;

Peter MacLeod, Director of Social Work, Renfrewshire Council;

Dr Ken Proctor, Associate Medical Director, NHS Highland;

Harriet Dempster, Director of Social Work Services, Highland Council;

Colin Sloey, Director of North CHP, NHS Lanarkshire;

Bobby Miller, Manager, Younger Adults, Housing and Social Work Services, North Lanarkshire Council;

and

Mairi Brackenridge, Head of Adult and Justice Services, South Lanarkshire Council.

and on 13 January 2010 from—

Dr Kevin Woods, Director-General Health and Chief Executive of the NHS in Scotland, Graeme Dickson, Director of Primary and Community Care, Geoff Huggins, Head of Mental Health Division, Dr Denise Coia, Principal Medical Officer (Mental Health), and Ruth Glassborow, Programme Manager, Mental Health Collaborative, Scottish Government.

3. In addition to the oral evidence taken, the Committee also received written evidence from the above listed health boards and partner local authorities and took further written evidence from a number of voluntary organisations providing mental health services.

4. The Committee’s scrutiny focussed on the following main areas identified in the AGS Report—

  • general background;
  • expenditure on mental health services;
  • accessibility of mental health services; and
  • delivery of mental health services.

These issues are outlined in more detail below.

General Background 1

5. The AGS reported that mental health problems cause considerable poor health in Scotland and one-in-four people will experience mental health problems at some time. Severe and enduring mental illness, such as schizophrenia or bipolar disorder, affects over 40,000 people in Scotland.

6. Scotland has higher suicide rates than England and Wales, with Scotland having the highest rates in western Europe. People who are socially excluded, including people living in deprived areas, children in care, people with drug or alcohol problems, black and minority ethnic groups, homeless people and prisoners, have a higher risk of developing mental health problems.

7. It is estimated that there are at least 66,000 people in Scotland with dementia and this figure is likely to increase due to the ageing population.

Barriers to improvement and challenges

8. The health boards and their partner local authorities highlighted major barriers to improving mental health services in oral evidence to the Committee. During evidence, the following factors were identified as impacting on mental health services: multiple deprivation and alcohol misuse, the stigma of mental health and antidepressant use, and the focus on treating enduring mental illness rather than on preventative work. These areas explored in more detail below.

Multiple deprivation and alcohol misuse

9. Peter MacLeod of Renfrewshire Council highlighted the increasing demands that those with alcohol-related brain damage made on mental health services and explained the link between alcohol-related brain damage and deprivation. He emphasised the need for local authorities and NHS boards to work together to tackle the problem and address the gap in their services and the challenge of shifting towards community based care.2

10. Anne Hawkins of NHS Greater Glasgow and Clyde also highlighted the link between multiple deprivation and mental health, citing a study by Jill Morrison that showed that where there is social and educational deprivation there are higher levels of antidepressant prescribing.3 She explained that much of the work in tackling deprivation in Greater Glasgow and Clyde had been done through its community planning process.4

11. Commenting on the challenges faced in tackling deprivation in communities, Raymond Bell of Glasgow City Council stated that “we need to exert more leadership in community planning, with community planning partners, around the social determinants of mental health.” In particular, he emphasised the importance of early intervention in communities to prevent acute problems and allow people to build emotional resilience.5

Stigma of mental illness

12. A number of witnesses identified stigma as a barrier to improvement. Kevin Woods informed the Committee that the Scottish Government had been working to change the stigma surrounding mental health and a positive approach to mental health is central to its “Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011” (TAMFS).6 Dr Denise Coia said that the stigma attached to mental illness was a generational thing and that older doctors regarded it is something that people “had to get on with”. Younger doctors were much better at picking up depression, trauma and anxiety.7

Insufficient emphasis on early intervention and preventative work

13. A common theme emerging throughout the inquiry was that mental health services tend to have been targeted at treating severe and enduring mental health illness, rather than on preventative work and early intervention, on which more emphasis was required.

14. Peter MacLeod of Renfrewshire Council agreed about the impact of deprivation and alcohol on mental health and went on to argue that there should be an emphasis on wellbeing and that people, regardless of mental health issues, must be able to contribute to their community as fully as they can. His view was that “it is everyone’s job to promote the notion of wellbeing”. Mairi Brackenridge of South Lanarkshire Council acknowledged the need for a focus on wellbeing but felt that limited resources meant that its services focused on severe and enduring mental illness. She felt that more engagement with those alienated in deprived areas would allow them to take ownership of problems and would allow a more preventative agenda to be developed in the community.8

15. Geoff Huggins of the Scottish Government informed the Committee of the initiatives contained within TAMFS and its emphasis on early intervention. The policy recognised a role for early years and education and this prompted the implementation of the child and adolescent mental health services framework. He also highlighted the role that TAMFS had in promoting exercise and good general physical health and diet and the potential benefits it had for improving mental health.9

Suicide

16. To address high suicide rates, the Scottish Government has developed the choose life policy, put in place in 2002. This served to identify young males as an at-risk group. Following a review of services in 2006, the Scottish Government strengthened its interventions policy as there was “no strong evidence for many of the interventions being applied”, apart from antidepressant medication. Since the review, the Scottish Government has provided training for front-line staff of the NHS and community to better recognise those who are displaying potential suicidal behaviour. The Scottish Government has also compiled a suicide register in order to “track back case by case and develop an understanding of the particular factors relating to individual cases.”10

17. The Committee notes the view held by witnesses of the positive effects that early intervention and focus on wellbeing can have in promoting a preventative agenda in terms of mental illness, but is concerned that a lack of resources means that services are targeted at treating severe and enduring mental illness.

18. The Committee notes measures put in place to address Scotland’s high suicide rates and encourages the Scottish Government to continue monitoring the effectiveness of such services.

Expenditure on Mental health services 11

19. The AGS reported that the NHS spent £928 million on mental health services in Scotland in 2007/08 and that this was likely to be an underestimate as there were limited data on the spend in the community. The total amount spent by local authorities on mental health services was unknown.

20. The AGS also reported that it was too early to assess the impact of changes to local authority funding of mental health services. Certain funds were no longer ring-fenced (eg, Mental Health Specific Grant, Choose Life, Changing Children’s Services Fund and Supporting People) and councils reported that they did expect to make changes to this previously ring-fenced funding and would review it as part of their single outcome agreements.

Resource transfer

21. NHS boards transfer money to councils to support community mental health services, which are mainly provided by social work departments and voluntary and private organisations. The AGS report highlighted the variation in the amount of money transferred between the NHS and councils across Scotland, suggesting that shifting the balance of care to community-based services is more developed in some areas of Scotland.12

22. In written evidence to the Committee, Dr Woods stated—

“Disparity in the level of transfer can be accounted for in part by the fact that, historically, resource transfer was linked to long-stay bed closure programmes for which different NHS Boards and local authorities had different starting positions. In some areas a relatively low level of resource transfer may indicate a lower level of activity for which transfers are made but this should be interpreted with caution given the different starting points referred to.”13

Board variations

23. The Committee was interested in the variation in resource transfer figures across NHS boards and, in particular, why there was such a difference in the figures between demographically similar areas Glasgow (£8.30 per head) and Lanarkshire (£35.33 per head). Colin Sloey of NHS Lanarkshire questioned whether the resource transfer model was still a relevant method and suggested that integrated service provision and joint resourcing be examined. He also highlighted that as many of the Lanarkshire beds had already been closed prior to the 1995 circular that created resource transfer, this affected how much Lanarkshire had to allocate to communities. He also informed the Committee that, in his view, Lanarkshire received “£21.5m below its fair share allocation” in terms of Arbuthnott14 and NHS Scotland national resource allocation funding.15 This was further emphasised by Mairi Brackenridge, who said “the fact that we started off with a low resource base meant that, even with "A Picture of Health", we were juggling a relatively limited pot of money to try to meet increasing demand.”16

24. Peter McLeod of Renfrewshire Council also argued that his area started with a deficit as many of their long-stay beds had been removed before resource transfer came into effect. He argued that when resource transfer was created, it was envisaged that funds would be transferred to local authorities, but figures transferred were static and did not take into account the fact that the cost of a patient’s care might increase over time. 17

25. Dr Woods informed the Committee that variations in resource transfer reflected local agreements between partners and it was up to them to agree how services should be developed.18 He further stated in written evidence that some NHS Boards had not transferred as much responsibility to local authorities as a result of local agreements about how services should be delivered.19

26. He disagreed that Glasgow was getting a better service than other areas due to the higher levels of resource transfer, and argued that the picture is more complex because it was recognised that boards had different starting points when the legislation guidance was issued in the 1990s. At that point Glasgow had a large institutional base. He added—

“Conclusions about the quality of the service cannot be based on the quantum of resource transfer. The numbers in the report reflect local agreements. Are those agreements right? That is the question that we are asking people to address. We are trying to equip them with the tools and the data to examine that question. That is how we are pursuing the issue.”20

27. The Committee was interested in how resource transfers took place over health board boundaries, specifically how resource transfer followed patients who had been placed at a national specialist hospital out with their home location when they return to that location. In order to demonstrate the system works, Dr Woods cited closure of the Royal Scottish National Hospital at Larbert—

“A specific sum of money was identified per patient for resource transfer which was then passed to the NHS Board which would assume health responsibility on discharge. These Boards would then liaise with their local authority partners to make the placement in their community. So, to quote the example of a Kilsyth resident as mentioned in the Committee hearing, NHS Forth Valley would transfer a specified sum to NHS Lanarkshire who would then agree a care plan with North Lanarkshire and transfer the appropriate resource. NHS Forth Valley had a project lead who played into all these discussions and ensured resolution of any problems taking account of individual patients’ needs.”21

28. Dr Coia emphasised that the focus should be on moving care from institutionalised NHS care to providing NHS care in the community—

“Therefore, the issue is not so much about resources; it is about shifting the balance of resources. Through the benchmarking, we track how much each board is shifting the balance into the community in terms of NHS spend…At present, the board is considering a fairly major redesign of its NHS community services to be able to work with local authority services…That process is going on, but we need to see the total system and not just the health services or social work services.”22

29. Dr Woods informed the Committee that a working group with membership from the Scottish Government, NHS Scotland and local government had been created to look at the clarity of current resource transfer arrangements and, “offer advice on ensuring that current resource transfer arrangements work efficiently and effectively, and to the greatest benefit of service users.” He added that an Integrated Resource Framework (IRF) is being developed and tested at four sites to encourage understanding and improve management of the pool of resources for health and social care.23

30. The Committee remains unconvinced by the explanations given for the variations in levels of resource transfer and recommends that levels of resource transfer be reviewed by the working group on resource transfer, due to report in June 2010.

31. The Committee would also welcome feedback from the four IRF test sites and would encourage roll-out across Scotland should the pilots produce positive results.

Value for money

32. In answer to questions about whether health boards have been securing value for money in the funds they transfer, Anne Hawkins stated that NHS Greater Glasgow and Clyde has been producing performance data looking at community services and bed usage and bench-marking staffing to see where it is getting the best service. Whilst NHS Greater Glasgow and Clyde pays more for some community services, she believed that patients had a better quality of life if they were cared for in the community rather than in long-stay institutions.24

33. Raymond Bell felt that resource transfer in Greater Glasgow and Clyde had offered value for money in that “it allowed us to deliver all the targets set in the planning assumptions on which our financial framework from 2001 was based”. He agreed that hospital closures had been beneficial and that funding needed to be more closely aligned with those who were providing the services. He agreed that local authorities, rather than health boards, should get more in the national allocation of resources.25

34. The Committee was concerned that it was hard to identify value for money in relation to resource transfer, as information from the AGS showed local authority spend is not tracked in the same way as NHS spend. It was concerned that there appeared to be inadequate central monitoring to ensure that funds were used for their intended purpose in the community and the removal of ring-fenced funds such as the changing children’s services fund meant that certain funding was no longer protected.26

35. The Scottish Government informed the Committee that it did not track local authority spend centrally as it was up to local partnerships to decide on how funds should be spent and each area had differing priorities. Geoff Huggins explained in oral evidence that the work could be quantified, but the services being developed to deliver the framework varied by area.27 He added that—

“we have been monitoring on-going delivery against the framework and have seen in practice that local government is continuing to support the investments that it had made after the ring fence. We are less bothered about the pounds and more concerned about ensuring that the service continues to be available.”28

36. Dr Woods added that the integrated resource framework and benchmarking project was designed to measure outcomes and monitor the performance of mental health services—

“we know that people are pursuing the policy objectives that have been set. We know a great deal about the relative performance of partnerships in relation to some of the important targets that we have set for readmissions, the use of antidepressants, the development of child and adolescent health services, and suicide, which we have discussed. We are monitoring in relation to policy objectives, rather than the detail of individual resource transfer agreements.”29

37. Dr Coia added—

“The indicators are for the overall population, so while services in the Highlands and Islands will be delivered differently from those in Glasgow, it is important that everyone's outcomes are equal, in terms of what happens to their mental health and its improvement.”30

38. The Committee understands that local partners are responsible for ensuring effective allocation of funds, but remains concerned that there is no central monitoring of funding.

39. The Committee recommends that the Scottish Government considers making an attempt to track local authority spend, to ensure that public funds are being allocated appropriately.

Voluntary organisations

40. The AGS reported that some voluntary organisations had experienced reductions in funding for some projects and had received warnings from councils of future reductions.31

41. In Glasgow, Raymond Bell confirmed that the council had reduced funding to three voluntary organisation by £200,000 (one of which had found alternative means of funding). He went on to explain that the council had to make savings of approximately £380,000 from adult mental health services in Glasgow, and this would be done by a reduction in council staff and grant funding to the voluntary sector.32

42. Other local authorities confirmed that while funding might not be reduced, they would be asking voluntary organisations to make efficiency savings in the services that they provide – for example by providing support for more people within the same budget.

43. Harriet Dempster said that Highland Council had been asked to identify savings of £5 million from next year’s budget of £100 million. It intended to measure outcome indicators in voluntary organisations’ service level agreements in order to gauge value for money. If voluntary service providers were found not to be meeting outcome indicators, Highland Council would review services and consider bringing services in-house.33

44. Mairi Brackenridge informed the Committee that South Lanarkshire Council would look to prioritise funding for statutory or core services, although providers would be expected to look at delivering their services more efficiently. She went on to say—

“The work on building community infrastructure and supporting communities to do preventive work is one of the areas that could be most affected, because it is neither a statutory nor a core service”34

45. The Scottish Government emphasised the importance of the voluntary sector in providing mental health services and its strengths in being user led and innovative in the development and delivery of services.35

46. However, evidence from various voluntary organisations raised concerns that efficiency savings were, in effect, reductions in funding and that various local authorities had either frozen or given below inflation increases in funding.

47. In its written submission, SAMH offered the following—

“Our experience suggests that some local authorities are implementing necessary cuts in a short-sighted and possibly counterproductive manner and these cuts do not simply threaten the organisation: far more importantly, they affect the service users whom we support…SAMH has been under increasing pressure to deliver the same quality of services at a reduced cost…Where once we would have had some opportunity to negotiate, we are now being presented with required cuts in contract values.”36

48. Penumbra agreed, stating the following—

“An important point is that the voluntary sector receives a real cut in funding when local authorities seek to make efficiency savings. We do not have the economies of scale of a local authority and we are not given the opportunity to create efficiencies to re-invest in our services.”37

49. Community Care Providers Scotland added—

“It is the experience of many providers that funding decisions are not made on the basis of ‘meeting targets’, unless those targets are cost-related… evidence from the Care Commission indicates that voluntary sector social care services are of significantly higher quality than in-house provision.”38

50. The Committee recognises the value of mental health services provided by voluntary organisations and that the current financial constraints are already impacting on funding for local and national voluntary organisations. Looking ahead, this is likely to become an even more serious issue.

51. The Committee recommends that the Scottish Government ensures that local authorities monitor the impact of current spending constraints on voluntary sector organisations (in terms of the quality of services provided and their ability to meet demand). The Committee further recommends that the results of this monitoring are reported back to the Scottish Government.

52. In turn the Committee requests that the Scottish Government updates the Public Audit and Health and Sport Committees, by December 2010, on the outcome of this monitoring and on the steps taken at local and national level to protect mental health services delivered by the voluntary sector.

Accessibility of Mental Health Services

Background

53. The AGS report found there was limited information on mental health staffing, vacancy levels and caseloads. Available data showed that there were high vacancy rates for certain professional groups and particular problems in recruiting staff in some areas. This affected the availability of services and could lead to long waiting times for services.

54. The AGS also found that basic management information on waiting times was needed for agencies to plan and manage mental health services more effectively. The AGS found evidence of children and adolescents waiting a long time to access services in some areas and this was likely to reflect the picture across Scotland.

55. The AGS report found that people who were likely to be socially excluded find it more difficult to access mental health services than the rest of the population. People from minority ethnic groups, those with sensory impairment, homeless people, prisoners and people with drug and alcohol problems found it harder than most people to access the mental health services they needed.

National targets for mental health

56. There are four national health improvement, efficiency, access and treatment (HEAT) targets for mental health services, focussing on the need to reduce psychiatric readmissions, to stop the rate of antidepressant prescribing from increasing, to reduce the suicide rate and to achieve agreed improvements in the early diagnosis and management of patients with dementia.

57. Dr Ken Proctor stated that in NHS Highland, a major redesign of psychology services was under way which would be encouraging health boards to look at the accessibility of services.39 He added that NHS Highland had achieved the re-admissions target, but that targets were a driver rather than an end in themselves. They had taken steps to make services more accessible and enhance them and as a consequence the board had met its targets.40

58. When asked about whether there was a problem in getting GPs to accept responsibility for meeting targets, Dr Proctor advised that the new general medical services (GMS) contract created an incentive for GPs to change the way they delivered services. In north Highland GPs would only receive payment if they followed a set of pre-agreed actions, including the “Patient Health Questionnaire” which required them to ask specific questions to monitor an individual’s progress.41

59. Mairi Brackenridge also stated that targets were an important driver, but sometimes too much focus was placed on the target. She highlighted the importance of more joint targeting so that those providing health, social work, housing and education played an equal part in the resilience agenda, ensuring that people got access to a wide range of support at an earlier stage. Harriet Dempster echoed this, adding that setting targets centrally discouraged discussions about what was important in local areas. She added that because of the concordat between local authorities and the Scottish Government42, the Scottish Government sometimes had a hands-off approach to local government.43

60. Anne Hawkins highlighted that HEAT targets were driven centrally, but NHS boards had an opportunity to influence them. NHS Greater Glasgow and Clyde had local access targets for its community mental health teams, which were agreed with social work colleagues and managed jointly. Targets for community mental health teams, emergency referrals, same-day or 24 hour response were listed in its written submission.44 She felt that targets could drive improvements in the way that services were delivered. She also referred to the mental health collaborative and the seven helpful habits for effective CAMHS, which provide an outline for efficient and effective services.45

61. Colin Sloey referred to NHS Lanarkshire’s capacity planning system, which allows it to track referral rates and consider triage46 and admission procedures. The system allows the board to identify gaps and consider the efficiency and effectiveness of its service. As a result the board has increased CAMHS staff from 4.2 WTE staff per 100,000 of the population to 8.8 WTE staff per 100,000, cutting waiting times from 72 days to 46 days.47

62. The Committee recognises the efforts of boards to meet targets and recommends that boards and local authorities continue to monitor the accessibility of services.

Child and adolescent mental health services

63. Ken Proctor stated that there were “currently no national access targets for psychology or for child and adolescent mental health services” (CAMHS) and that the issue would not be helped by employing more psychologists but by changing the thinking of psychologists who tended to take a more traditional view of the service. He believed that a tiered service based on the access requirements of the individual and an 18-week psychology target would improve services, rather than the GP or psychiatrist referring patients to a psychologist.48

64. Bobby Miller of North Lanarkshire Council agreed that funding for CAMHS was a problem in Lanarkshire and outlined the work the Council had been doing with emotional resilience as part of curriculum development in secondary schools. He also highlighted the time it had invested in early intervention in social work and agreed that the emphasis should be on wellbeing. Staff in his area had also been trained to help young people who self-harm.49

65. Witnesses from the health boards and local authorities agreed that early intervention was an important factor in identifying and treating children and adolescents with mental health problems.

Early intervention in nought to five years

66. Dr Denise Coia of the Scottish Government informed the Committee of the work it had undertaken in those aged nought to five years born into families with alcohol or drug problems or comorbid50 mental illnesses—

“There is a lot of evidence that putting in place significant parenting interventions in that age group prevents problems further upstream... Some really good schemes have started up in Scotland... It comes back to the issue of early intervention and focusing programmes downstream.”51

67. When asked if more money was being spent on early intervention in this age-group, where the evidence base shows that a difference can be made, Dr Coia informed the Committee that the Scottish Government was still looking at the evidence to see which interventions gave the best outcomes. Dr Woods went on to say that the Scottish Government had been developing some important policy in that area and highlighted the joint work involving the Scottish Government, local authorities and other partners in CAMHS.52

68. In a further written note to the Committee on specific initiatives that are in place to promote early intervention in children through improving parenting and early years education, Dr Woods stated that—

“while there are wide health benefits from early intervention, the strategy is not particularly aimed at making an impact on serious mental illness later in life. There is not an evidence base for such an impact.”

69. Dr Woods stated that the Early Years Framework53 aimed to ensure that children got the best start in life by addressing inequalities in health, education and future employment opportunities. The initiative will be delivered through Community Planning Partnerships (CPPs), which have been asked to give it high priority when developing their Single Outcome Agreements. The methodology which will enable delivery will be provided by the Getting it Right for Every Child (GIRFEC) programme. GIRFEC is a child-centred approach to children’s services aimed to encourage joint delivery of services between education, social work, health, police and the third sector to ensure that the child and family only deals with one team. This ensures consistency of approach and sharing of information between partners and focuses on the needs of the child. A guide to implementing the GIRFEC approach is to be produced in Spring 2010.

70. One of the main focuses of the Early Years Framework is parenting and Dr Woods stated in written evidence that the Scottish Government had invested in a number of programmes to improve evidence-based parenting interventions and had started a new marketing campaign designed to highlight the importance of parenting in the first three years of a child’s life: Play Talk Read Marketing Campaign.

71. The Scottish Government is developing a core set of skills that those who work with children, young people and families should all exhibit to deliver the policy of transforming the outcomes for children and families. It has reviewed community nursing services, invested £4 million in a programme designed to encourage play for vulnerable five to thirteen year olds and a concordat commitment to expand pre-school education ensures that funding for this is included in each local authority’s annual local government finance settlement.

72. The Health and Wellbeing in Schools Project54 has shown an increase in the number of school nurses by 17% from 2007 to 2009. Dr Woods said—

“Mental Health Advisors in the demonstration sites are taking a whole school approach to develop children and young people’s participation in addressing their own health and emotional wellbeing... The work of the demonstration sites will be evaluated to ensure transfer of information nationally.” 55

73. The Committee notes the need to continually improve the evidence base on the impact of early intervention in relation to child and adolescent mental health. It recommends that the impact of early intervention be monitored and used to inform policy development and that investment is targeted where the evidence suggests that a particular policy would result in positive outcomes.

74. The Committee would welcome a progress report from the Scottish Government, in six months, on its evaluation of the early intervention based initiatives and would welcome sight of the GIRFEC guide to implementation when it becomes available.

75. The Committee noted that there was an increase in prescribing of CMS stimulants and drugs used for Attention Deficit Hyperactivity Disorder (ADHD) between 1997-98 and 2007-08. 56 The Committee believes that there should be close monitoring of the levels of prescribing of these drugs for children with ADHD.

Access to mental health services by people from black and minority ethnic groups

76. The Committee was interested to know the extent to which mental health services are accessible to people from black and minority ethnic groups.

77. Evidence from Glasgow Council showed that percentage uptake of services did not reflect the population mix. Anne Hawkins and Raymond Bell highlighted a number of targeted approaches which have been taken in the Glasgow area to improve the accessibility of services. Ms Hawkins also told the Committee that NHS Greater Glasgow and Clyde had started work with Glasgow Anti-Racist Alliance’s researcher on how training in primary care and emergency services could be enhanced. She said that a positive indicator of service use was that 40 per cent of people using advocacy services were from minority ethnic communities and drew the Committee’s attention to the work sponsored by NHS Scotland encouraging regions to network on minority ethnic issues.57

78. Dr Proctor advised the Committee that NHS Highland had a translation service, but in crisis situations it could be difficult as the board did not have the infrastructure found in larger health board areas. Bobby Miller informed the Committee that only 1.3 per cent of the population in North Lanarkshire was from a minority ethnic background. North Lanarkshire Council was carrying out an equality impact of its services and was working jointly with South Lanarkshire Council to develop links in relation to minority ethnic groups.58

79. Raymond Bell indicated that Glasgow Council would increasingly work to ensure that all services were accessible to all communities rather than relying on targeting of specific groups. For example, Glasgow Council was currently reviewing its crisis services to make them more accessible and to meet its responsibilities under equalities legislation.59

80. Geoff Huggins of the Scottish Government outlined some of the approaches NHS Health Scotland was taking to make mental health services more accessible to people from black and minority ethnic communities. He said—

“there is a question of reach and the degree to which we effectively engage with BME communities…The second set of issues concerns the degree to which particular approaches and particular interventions that we offer are sufficiently culturally sensitive. In addition to the general programme that NHS Health Scotland has taken forward, we have developed two local approaches, one of which is in Lothian. That work is supporting particular primary care areas or GP practices to identify ways in which they can reach out and engage with particular communities so that we can use that as a learning process and, in time, become better at it.”60

81. Mr Huggins went on to say that the Government would use the experience of other countries in addressing issues relating to mental health services to those from black and minority ethnic groups. He added that the European Union expert group on mental health would inform the Scottish Government’s plans.61

82. The Committee notes the various activities being undertaken in different areas to promote greater accessibility and recommends that their impact be monitored with a view to identifying good practice. The Committee would welcome an update from the Scottish Government, in six months, on its progress towards identifying any such good practice.

Access to mental health services by people from deaf and deafblind communities

83. Witnesses from various boards and local authorities described some of the initiatives in place to make services more accessible for deaf and deafblind communities.

84. Bobby Miller stated that North Lanarkshire Council purchased support for deafblind people but faced a challenge in letting people know what services were on offer. The council relied on voluntary organisations to do this.62

85. For deaf people, North Lanarkshire was “rolling out communication opportunities for people to come in and have direct access to assistance through the use of British Sign Language”. This had been welcomed by the community. The council was also looking to tailor services to individuals’ needs rather than having “block services that people fit into”63

86. Peter MacLeod informed the Committee that Renfrewshire Council had a dedicated social work service for people who were deaf and deafblind and had a broad range of staff who could use sign language, including business support staff and qualified social workers.64

87. Colin Sloey referred to the work of the Scottish Parliament’s Health and Sport Committee on access by deafblind people to mental health services, and the feasibility study being carried out for the Minister for Public Health on developing a residential centre in Scotland. The nearest such service was in Manchester. The group undertaking the study has “identified the need for a relationship between specialist residential care and the community infrastructure in order better to support people who are deaf and deafblind and who have mental health problems.” The group is also encouraging boards to have more BSL trained staff.65

88. The Committee notes the feasibility study on a Scottish residential centre for deafblind people with mental health issues commissioned by the Minister for Public Health and would welcome an update from the Scottish Government, in six months, on the progress of the feasibility study.

Delivery of Mental Health Services

89. The AGS reported that people with mental health problems often receive services from more than one agency. The report emphasised that strong partnership working was therefore essential in planning and delivering effective mental health services. Different information systems were used in mental health services by NHS boards and councils and this limited their ability to deliver joined-up, responsive services. Services out-of-hours and at times of crisis were not well developed in all areas.

90. The report found that there were currently few outcome measures for mental health. It noted that outcome agreements (SOAs) were now being used to measure improvements provided by councils and their partners but as yet they did not focus on outcomes for mental health.

Single Outcome Agreements and joint delivery

91. SOAs were introduced in April 2008 and set out how councils and partners would work together to improve services. They are designed to encourage a focus on outcomes rather than measurements. The AGS reported that whilst all SOAs mentioned mental health services, there was little in the way of real outcome measures for mental health.66

92. The AGS reported that people with mental health problems received care from a number of different providers, but services were not sufficiently integrated to provide adequately joined up services. The AGS recommends a more integrated approach, which would be facilitated by NHS boards and councils having shared electronic records and streamlined admission, referral and patient monitoring systems.67

93. In its written submission, NHS Greater Glasgow and Clyde said that SOAs “are not underpinned by a robust enough infrastructure of joint national priorities, or money following delivery, and in practice have led to a less transparent ‘below the line’ loss of funding to mental health, from previously ring fenced funding sources.”68

94. Anne Hawkins elaborated by saying that because grant funds were no longer ring-fenced, it was more difficult to track where money was being spent. She stated that health managers and staff were given the opportunity to feed into the SOAs and the concordat, “but the process was carried out very rapidly, and the opportunities to contribute were limited.”69 Written evidence to the Committee indicated that some areas have included HEAT targets within the SOA.

95. Peter MacLeod stated that SOAs represented a way for partners to work together and take joint responsibility for areas such as prescribing and self-harm, traditionally seen as health service or social-work specific problems. He added—

“further refinement is required. With single outcome agreements, we need and aspire to describe and measure outcomes rather than outputs from services.”70

96. Dr Coia informed the Committee that the Scottish Government was keen to ensure that outcome measurements were not just clinical outputs, but could also allow measurement of other areas, such as social care, employment and whether people had houses and relationships. This required effective joint cooperation between NHS Boards, local authorities and other agencies. She said—

“The work has been trying to ensure that we can measure those outcomes and put them into a structure that we can measure. In the report that we will produce in March, we now have the measurements attached to the outcomes and agreements…Community care outcomes that are much broader than that have been developed jointly between health and social work. They are at a much higher level. We are doing work at the moment to fit our practical outcomes that can be measured on the ground into that community care outcome structure.” 71

97. Geoff Huggins added that targets were identified that required action across the system and cited the in-patient readmission target as an example of this. He said that effective joint working had shown a significant improvement—

“with regard to the readmission target, for example, performance has improved by 20 per cent over three years; indeed, in five or six boards, it has improved by more than 25 per cent. Performance across partnerships has certainly altered significantly.”72

98. Geoff Huggins advised that there had been much input from voluntary organisations in creating measurable outcomes and that the quality outcomes framework had ensured that GPs had also been contributing through the quality outcomes framework in diagnosing and treating dementia.73

99. The committee recommends that the Scottish Government encourages CPPs to ensure that Mental Health outcomes are included as part of SOAs and highlights the need for better underpinning information on cost, quality and activity.

Cross-board working

100. In evidence to the Committee, boards and partner local authorities gave examples of how mental health services could be provided across boards.

101. Mairi Brackenridge informed the Committee that there was some cross-board working in the South Lanarkshire area, particularly for vulnerable asylum seekers and women in forced marriages. South Lanarkshire Council relied on the expertise and knowledge built up in bigger cities like Glasgow, due to the small number of people affected in smaller areas like South Lanarkshire.74

102. Much cross-board working occurs between Argyll and Bute and Greater Glasgow and Clyde NHS Board. There is a network for eating disorders in the North in which NHS Highland works with NHS Grampian. NHS Highland is looking for more opportunities for cross-board working as it cannot always provide the services itself.75

103. On children who self-harm, Mairi Brackenridge informed the Committee that North and South Lanarkshire councils were working in partnership with health services to target vulnerable young people; in particular they have delivered suicide prevention training for those working with accommodated young people, including foster parents. The training enables early identification of those at risk and access to appropriate support.76

104. The Committee notes the evidence it received from boards that shows that they continue to share information on providing services to vulnerable people, particularly where this provides opportunities for boards to benefit from the more extensive experience and expertise of other boards.

105. The Committee would appreciate an update from the Scottish Government Health Directorate on how it is monitoring and encouraging more cross board working across health boards.

Antidepressant prescribing

Increases and variations in antidepressant prescribing

106. The AGS reported that antidepressant prescribing had quadrupled between the periods 1993-94 to 2007-08 (based on the defined daily dose (DDD) per 1,000 population per day) and that unless levels of prescribing remained static or reduced the NHS would not meet its HEAT target77 for stopping the rate of antidepressant prescribing from increasing.

107. The target had been set as proxy to improve care for people with depression as reducing antidepressant prescribing should lead to an increase in the number of people receiving other non-drug treatments such as psychological therapies. However the target did not take account of initial prescribing levels in each NHS board. It was also unclear what the correct rate of prescribing should be and whether reducing the rate of prescribing was always appropriate. Patients might require antidepressants and psychological therapies rather than one or the other.78

108. The Scottish Government explained, in written evidence, that since setting this target there had been a growing consensus that most of the increase in DDDs of antidepressants is caused by a relatively small group of people taking their medicines for a longer period (in that regard the Scottish Government highlighted the work undertaken by Moore et al (2009)79).

109. The Scottish Government however also noted that the limits of the current DDD data means that “we do not know whether the difference in DDD levels is due to more people receiving antidepressants and/or prescribing at a higher dose and/or prescribing for a longer duration”.80 The Scottish Government also acknowledged in written evidence that “information regarding the number of people on antidepressants is not currently collected so we do not know whether the number of people taking antidepressants has increased”.81

110. The Scottish Government highlighted a study by Jill Morrison on the factors associated with prescribing which found there was a large variation (4.6-fold difference) in the levels of antidepressant prescribing across 983 Scottish practices.82

111. That study concluded that some of the explanations for the variation in prescribing appeared to be non-clinical in nature, for example, significantly higher prescribing than expected was associated with limiting long-term illness, deprivation, urban location and a greater proportion of female GPs in the practices. Significantly lower prescribing than expected was associated with single-handed practices, higher than average practice list size, a lighter proportion of GP partners born outside the UK, practice location in remote rural areas a high proportion of patients from minority ethnic groups in the practice and higher mean GP age. These factors explained approximately half of the variation in prescribing levels across Scotland.83

112. The factors associated with antidepressant prescribing were also commented upon in oral evidence by Dr Coia who surmised that older doctors may regard mental illness as something that people “had to get on with” whilst younger doctors were much better at picking up depression, trauma and anxiety, and the reason female GPs may identify depression more is probably that everybody who is depressed goes to a female GP.84

113. The Committee is concerned that the reasons for the increase in antidepressant prescribing remain unclear and without justification. This was evidenced by the wide ranging explanations and observations provided to the Committee on the possible causes of this increase and reasons for variation in prescribing patterns. As a result the Committee has concerns with some of the non clinical observations given as reasons for the variation in prescribing levels across Scotland.

114. The Committee believes that understanding the causes of the increases and reasons for variation in prescribing patterns of antidepressants is essential to effective monitoring and target setting (and on which the Committee also comments at paragraph 126).

115. The Committee therefore recommends that further detailed research is undertaken to determine the reasons for the increase in prescribing, the causes of depression and the effectiveness of preventative measures.

HEAT Targets and monitoring

116. The Committee also questioned shifting policy to non-drug based treatment when figures did not record how many people were on antidepressants.

117. Dr Woods explained that the HEAT target was initially put in place to reduce the rate of increase—

“we have been trying with the target on antidepressant prescribing to reduce the rate of increase and, for a number of quarters, we achieved that. However, in the past couple of quarters, we have seen a slight upturn and we think that that is a consequence of prescribers adopting what is now regarded as best prescribing practice.”

“we have tried to examine the appropriateness of prescribing and work with boards to expand the availability of psychological therapies as alternatives, where appropriate, for the management of individual patients.”85

118. He added—

“We did not necessarily have all the data that we would have liked to have. The data that we have are still not a measure of the incidence and prevalence of anxiety and depression; they are a measure of the consumption of a particular range of drugs. We have been trying to use that information as a way of provoking analysis and wider change, which we believe will improve the quality of service.”86

119. Geoff Huggins informed the Committee of a study by the University of Aberdeen which showed that in 98 per cent of cases, people were receiving medication appropriately. He also added that in areas where psychological therapies were being offered, it was not having a significant impact on patterns of anti-depressant prescribing. He said—

“There are questions about the short-term and long-term impacts of different policies. Both in Scotland and in England, through the improving access to psychological therapies programme, there has been a growth in the use of therapies, but we have questions. Increasingly, we see such illnesses as ones that remit and return rather than as one-off illnesses. That raises questions about the longer-term prognosis in respect of the need for antidepressants, therapies and other approaches, such as exercise and other social interventions.”

“The target was accompanied almost immediately by the offering of additional points to GPs for case finding—GPs were offered an additional 20 points towards the quality and outcomes framework for identifying cases of depression, so we might have expected to have seen a rise in the number of cases that were identified when we launched the target. That is also significant. There is a range of factors. We worked the available information systems hard to develop a better understanding so that we could move to the next stage of our policy, which is to focus increasingly on the therapies agenda.”87

120. The Committee questioned the appropriateness of the target to reduce anti-depressant prescribing, given that this may be the most appropriate type of treatment for some patients. Geoff Huggins confirmed that the Scottish Government was not against prescribing drugs as treatment and that its priority was supporting the most effective treatment.88

121. Dr Woods added in written evidence, “this target has driven considerable work to improve evidence based prescribing of antidepressants and improved access to non-drug treatments”89.

Scotland compared to other nations

122. The Committee also questioned antidepressant prescribing monitoring trends in Scotland compared to the rest of Europe. Ruth Glassborow confirmed that trends in other countries, including the other UK jurisdictions, were similar to Scotland in that anti-depressant prescribing was on the increase. Geoff Huggins and Dr Coia informed the Committee that the quality of information that Scotland tracks was better than some other countries.90

123. In written evidence, Dr Woods confirmed that the whole of the United Kingdom had similar procedures for tracking anti-depressant prescribing. General practitioners can track how many people have been issued with anti-depressants, but this cannot be collated nationally. Scotland can track this data nationally from a third of GP practices and the Scottish Government will be analysing this information in Summer 2010. The UK cannot track data on the number of people who are dispensed antidepressants, but will be able to do so when there is a CHI (Community Health Index – unique patient identifier) on every prescription. Scotland now has around 80 per cent coverage compared to Northern Ireland’s 90 per cent coverage.91

124. All four jurisdictions in the UK record the number of prescriptions dispensed yearly (prescribed items) and the total amount of antidepressants prescribed (DDD – defined daily dosage) but as these figures cannot be broken down to show how many people are on antidepressants, it becomes difficult to explain variations in these figures. For example, Scotland shows lower levels of prescriptions than Wales but a higher DDD. Dr Woods explained that prescribed items figures did not distinguish between prescriptions dosed monthly and three monthly. In reality it would be the same amount, but prescriptions issued monthly would show as three items and the three monthly prescription as one item.

125. Dr Woods informed the Committee that it was hard to do international comparisons of antidepressant prescribing trends as recognition levels of depression varied by country, which ultimately affected the level of antidepressants prescribed. He states that Scotland has a high focus on detecting depression, so it will also have a higher treatment rate compared to those countries that have lower levels of detection. The Scottish Government provided evidence that rises in antidepressant prescribing have occurred in many countries.92

126. The Committee is concerned that the HEAT target on reducing the increase in antidepressant prescribing may be too simplistic. It notes the University of Aberdeen study results which identified that, in around 98 percent of cases, people on a prescription are receiving the medication appropriately. The Committee feels that no explanation has been given as to how this HEAT target can therefore be appropriately achieved and recommends that the Scottish Government reviews the target, in light of the results of this study.

127. The Committee has concerns about the quality of data available and believes it should be more patient focussed, rather than prescription focussed. The Committee therefore recommends that the Scottish Government should urgently look at improving the way that antidepressant prescribing is monitored including:

  • determining how many people are being prescribed antidepressants; at what dose level, and over what duration; and
  • the effectiveness of alternatives to prescribing antidepressants.

128. The Committee notes that the Scottish Government is analysing information on anti-depressant prescribing and will conclude this work in summer 2010. The Committee would like to receive an update on this work.

Services for an ageing population

129. The AGS reported that there were gaps in services for older people, particularly in psychology and crisis services.93 The Committee was interested in how services would be developed to respond to an ageing population, particularly dementia services.

130. Colin Sloey emphasised the need for a balance between ensuring that people are kept healthier for longer as they age, and the importance of a single, efficient, joined-up service for older people, rather than local authority and health board versions of the same service. In North and South Lanarkshire, consideration is being given to how services will be provided when the General Register Office benchmark date of 2031 is reached.94

131. Colin Sloey went on to say that the new GMS contract has a target for the early identification of dementia so that patients get the earliest possible access to services. He also highlighted the need for considering some of the causal and preventative measures required and for individuals in communities to change their behaviour in, for example, alcohol consumption. He warned that current service delivery models for those with dementia would not be sustainable as the population ages.95

132. Bobby Miller agreed with Colin Sloey on early intervention, but emphasised the need to think about how to use existing resources for those who cannot self-support or those without social or family support to help them. North Lanarkshire’s model is to move away from building-based services as much as possible toward more home-based services for older people with dementia.96

133. Harriet Dempster warned that risk-averse behaviour can mean that professionals are worried about the risks associated with sustaining people in the home. She stated

“we are still struggling with this in Highland because of our rurality—that jettisons people into buildings when their welfare could be sustained and promoted at home.” 97

134. Peter Macleod agreed and suggested that community capacity-building would help to ensure that the needs of people with dementia were met. He described a project in Renfrewshire, called Reaching older adults, involving retired people who volunteered to help older people who might be more vulnerable than themselves. Dr Proctor spoke of a similar service in Highland called O4O—older people for older people. Peter Macleod added that a national dialogue on service provision was required to ensure that social care and NHS staff could work together to meet the needs of patients with dementia.98

135. Raymond Bell highlighted the challenge in balancing an individual’s choice of how their care is managed and ensuring “that there is proper intervention from the state to protect people when they are at risk.”99

136. Dr Proctor stated that the HEAT target for dementia meant that practices were actively seeking to assess people early. This remains a challenge in remote and rural areas, but NHS Highland had set up a specialist clinic in Inverness. He also spoke of a knowledge transfer partnership with Stirling University, which looks at information services for older people and highlighted an Australian model that NHS Highland might consider. 100

137. Geoff Huggins added that due to the ageing population, the figure for those having dementia would increase rapidly in the next 10, 20 and 30 years. The Scottish Government would need to look at how services would be delivered to address this and it would do so in its dementia strategy, due to be delivered by April 2010.101

138. The Committee notes the ageing population will result in a rapid increase in the numbers of people with dementia over the coming decades and therefore welcomes that a dementia strategy is being developed. The Committee asks that the Auditor General for Scotland consider reporting on this strategy as part of his future work programme.

Elderly people with mental health issues not related to dementia

139. The Committee was also interested in how services would be provided for older people with mental health issues not related to dementia.

140. Mairi Brackenridge stated that “Community capacity building is important, but when people in the community are all ageing together, that presents different challenges, which we must consider.” She went on to say that older people continue to make a contribution to the community and that a large amount of depression may be caused by feeling they cannot make the contribution they did previously. South Lanarkshire Council has initiatives to make sure that older people’s needs are taken into account in service design.

141. She added that public services with limited resources faced the challenge of competing priorities for funding.102

142. Geoff Huggins of the Scottish Government confirmed that due to the ageing population, new issues were emerging—

“We face new problems in relation to older adults. Only in recent years has a significant number of older psychiatric patients—people with mental illness—been in the system. The number of people with schizophrenia who are now entering their 60s and 70s is growing.”103

Staffing issues related to the elderly and mental health

143. The AGS reported that staff vacancies in some areas limit services for older people. There was also the issue of an ageing workforce as well as population. 104

144. Dr Proctor informed the Committee that there was a national shortage of consultant psychiatrists with an interest in care of older people and that NHS Highland had been trying to attract more.105

145. Colin Sloey stated that the percentage of consultant psychiatrist vacancies in NHS Lanarkshire had dropped from 22 per cent to 13 per cent, but there was still a gap in provision. The board is trying to make substantive appointments or fill vacancies with locum appointments.106

146. Geoff Huggins informed the Committee that the Scottish Government had increased the number of psychiatrists with a subspecialism in older adult psychiatry, to cope with the number of older people with mental health issues not related to dementia.107

147. In written evidence, Dr Woods confirmed—

“Figures provided by NHS Information Statistics Division show that in 1999 there were 43 older adult psychiatric consultants in Scotland; there are now 67. An increase of over 55% in 10 years. The proportion of consultants specialising in older adult psychiatric services in relation to the total number of psychiatric specialists currently stands at 11%.”108

148. In terms of an ageing workforce, Geoff Huggins said that mental health nurses had increased by 10 per cent in the past two years and that mental health doctors had increased from 460 to 560 in the past five or six years. These were new entrants and so the workforce was actually relatively young.109

149. Graeme Dickson reminded the Committee of Lord Sutherland’s report which recommended that forward planning was required to consider how services would be provided for older people. He informed the Committee of eight work streams that would be taken forward by local government and NHS to look at how services would be provided. 110

150. The Committee asks that the Scottish Government reports back to it the on the progress of the eight work streams being taken forward by local government and the NHS on service for older people and to be updated on these activities in due course.

ANNEXE A – EXTRACTS FROM The minutes

10th Meeting, 2009 (Session 3) Wednesday 20 May 2009

Section 23 report: The Committee received a briefing from the Auditor General for Scotland on his report entitled "Overview of mental health services".

Consideration of approach (in private): The Committee considered its approach to the Auditor General for Scotland's report entitled "Overview of mental health services". The Committee agreed to consider an approach paper at a later meeting.

15th Meeting, 2009 (Session 3) Wednesday 7 October 2009

Section 23 report - Overview of mental health services: The Committee took evidence on the Auditor General for Scotland's report entitled "Overview of mental health services" in round table format from—

Anne Hawkins, Director, Mental Health Partnership, NHS Greater Glasgow and Clyde;
Raymond Bell, Head of Mental Health, Glasgow City Council;
Peter MacLeod, Director of Social Work, Renfrewshire Council;
Dr Ken Proctor, Associate Medical Director, NHS Highland;
Harriet Dempster, Director of Social Work Services, Highland Council;
Colin Sloey, Director of North CHP, NHS Lanarkshire;
Bobby Miller, Manager, Younger Adults, Housing and Social Work Services, North Lanarkshire Council;
Mairi Brackenridge, Head of Adult and Justice Services, South Lanarkshire Council.

Consideration of evidence (in private): The Committee considered the evidence received at agenda item 2 and agreed to consider a paper from Audit Scotland on resource transfer between NHS boards and councils and to seek further written evidence from relevant voluntary organisations in relation to the inquiry.

1st Meeting, 2010 (Session 3) Wednesday 13 January 2010

Section 23 report - Overview of mental health services: The Committee took evidence on the Auditor General for Scotland's report entitled "Overview of mental health services" from—

Dr Kevin Woods, Director-General Health and Chief Executive of the NHS in Scotland,
Graeme Dickson, Director of Primary and Community Care,
Geoff Huggins, Head of Mental Health Division,
Dr Denise Coia, Principal Medical Officer (Mental Health), and
Ruth Glassborow, Programme Manager, Mental Health Collaborative, Scottish Government.

Consideration of evidence - Overview of mental health services (in private): The Committee considered the evidence received at agenda item 2. The Committee agreed to write to the Accountable Officer with some additional questions and to consider a draft report at a future meeting.

6th Meeting, 2010 (Session 3) Wednesday 24 March 2010

Section 23 report - Overview of mental health services (in private): The Committee agreed to defer consideration of a draft report on the Auditor General for Scotland's report entitled "Overview of mental health services" to a later meeting.

7th Meeting, 2010 (Session 3) Wednesday 14 April 2010

Section 23 report - Overview of mental health services (in private): The Committee considered a draft report on the Auditor General for Scotland's report entitled "Overview of mental health services" and agreed to consider this report further at its next meeting.

8th Meeting, 2010 (Session 3) Wednesday 28 April 2010

Section 23 report - Overview of mental health services (in private): The Committee considered a draft report on the Auditor General for Scotland's report entitled "Overview of mental health services". The Committee agreed to consider a revised report at its next meeting.

9th Meeting, 2010 (Session 3) Wednesday 12 May 2010

Section 23 report - Overview of mental health services (in private): The Committee considered a draft report on the Auditor General for Scotland's report entitled "Overview of mental health services". The Committee agreed the report, subject to revisions, and the arrangements for its publication.

ANNEXE B - ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

Please note that all oral evidence and associated written evidence is published electronically only, and can be accessed via the Public Audit Committee’s webpages, at: http://www.scottish.parliament.uk/s3/committees/publicAudit/index.htm

10th Meeting, 2009 (Session 3) Wednesday 20 May 2009

ORAL EVIDENCE

Robert Black, Auditor General for Scotland

15th Meeting, 2009 (Session 3) Wednesday 7 October 2009

WRITTEN EVIDENCE

NHS Greater Glasgow and Clyde
NHS Highland
NHS Lanarkshire
Glasgow City Council
Renfrewshire Council
Renfrewshire Council Supplementary
Highland Council
North Lanarkshire Council
South Lanarkshire Council

ORAL EVIDENCE

Anne Hawkins, Director, Mental Health Partnership, NHS Greater Glasgow and Clyde;
Raymond Bell, Head of Mental Health, Glasgow City Council;
Peter MacLeod, Director of Social Work, Renfrewshire Council;
Dr Ken Proctor, Associate Medical Director, NHS Highland;
Harriet Dempster, Director of Social Work Services, Highland Council;
Colin Sloey, Director of North CHP, NHS Lanarkshire;
Bobby Miller, Manager, Younger Adults, Housing and Social Work Services, North Lanarkshire Council;
Mairi Brackenridge, Head of Adult and Justice Services, South Lanarkshire Council.

1st Meeting, 2010 (Session 3), Wednesday 13 January 2010

WRITTEN EVIDENCE

Community Care Providers Scotland
NSF Scotland
Penumbra
SAMH
Dr Kevin Woods, Director General Health, Scottish Government - 7 December 2009

ORAL EVIDENCE

Dr Kevin Woods, Director-General Health and Chief Executive of the NHS in Scotland,
Graeme Dickson, Director of Primary and Community Care,
Geoff Huggins, Head of Mental Health Division,
Dr Denise Coia, Principal Medical Officer (Mental Health), and
Ruth Glassborow, Programme Manager, Mental Health Collaborative, Scottish Government.

SUPPLEMENTARY WRITTEN EVIDENCE

Dr Kevin Woods, Director General Health, Scottish Government - 22 February 2010
Audit Scotland


Footnotes:

1 Information taken from Audit Scotland. (2009) Overview of mental health services, (p6-8).

2 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1232.

3 Morrison, Jill et al. (February 2009) Factors influencing variations in prescribing of antidepressants by general practices in Scotland. British Journal of General Practice.

4 Scottish Parliament Public Audit Committee. Official Report, 4 November 2009, Col 1232.

5 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1235.

6 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1419.

7 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1449

8 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1233 -1234.

9 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1420.

10 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1420-1422.

11 Information taken from Audit Scotland. (2009) Overview of mental health services, (p29).

12 Audit Scotland. (2009) Overview of mental health services, (p31.)

13 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 7 December 2009.

14 Sir John Peebles Arbuthnott chaired the National Review of Resource Allocation in December 1997, the principal task of which was to conduct an independent review of the way in which NHS money is allocated annually to the 14 Scottish NHS Boards. The resulting mechanism, known as the Arbuthnott Formula, assesses key indicators of population, inequality and deprivation of the areas covered by each of the boards to allocate money.

15 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1259-1261.

16 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1262.

17 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1258-1259.

18 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1431-1432.

19 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

20 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1432.

21 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

22 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1433.

23 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 7 December 2009.

24 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1258.

25 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1263-1264.

26 Audit Scotland. (2009) Overview of mental health services, (p28-33)

27 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1428.

28 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1427.

29 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1438.

30 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1437.

31 Audit Scotland. (2009) Overview of mental health services, (p33)

32 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1265-1266.

33 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1267.

34 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1268

35 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1446.

36 SAMH. Written submission to the Public Audit Committee.

37 Penumbra. Written submission to the Public Audit Committee.

38 Community Care Providers Scotland. Written submission to the Public Audit Committee.

39 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1236.

40 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1239.

41 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1240.

42 Following agreement of a concordat between the Scottish Government and COSLA in November 2007, Single Outcome Agreements (SOAs) were introduced to set out how each council and its partners would address their priorities and improve services for the local population.

43 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1237.

44 NHS Greater Glasgow and Clyde. Written submission to the Public Audit Committee.

45 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1238.

46 Triage is a process of prioritising patients based on the severity of their condition.

47 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1238-1239.

48 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1236.

49 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1236.

50 Comorbidity refers to the presence of more than one diagnosis occurring in an individual at the same time.

51 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1423

52 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1422 - 1423.

53 The Early Years Framework was launched on 10 December 2008 by the Scottish Government and COSLA, signifying the Scottish Government and COSLA's commitment to the earliest years of life being crucial to a child's development

54 The Health and Wellbeing in Schools Project was launched as a two year project by the Scottish Government to increase health care capacity in schools, in response to the recommendations of the ministerial task force on health inequalities.

55 Information in paragraphs 66 to 70 is taken from Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

56 Audit Scotland, Supplementary written evidence, 17 June 2009

57 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1242-1243.

58 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1245.

59 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1242.

60 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1452.

61 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1453.

62 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1245.

63 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1246-1247.

64 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1245-1246.

65 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1247.

66 Audit Scotland. (2009) Overview of mental health services, (p 24).

67 Audit Scotland. (2009) Overview of mental health services, (p 21) citing Mental Health Project Final Report: National Benchmarking Project, Scottish Government, December 2007.

68 NHS Greater Glasgow and Clyde. Written submission to the Public Audit Committee.

69 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1250-1251.

70 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1249.

71 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1443.

72 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1446.

73 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1444-1445.

74 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1248.

75 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1249.

76 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1248.

77 The full description of the target is: to reduce the annual rate of increase of defined daily dose of antidepressants per head of population to zero by 2009/10, and to put in place the required support frame work to achieve a ten percent reduction in future years.

78 Audit Scotland. (2009) Overview of mental health services, (p25).

79 Moore et al (2009), Explaining the rise in antidepressant prescribing, a descriptive study using the general practice research database, British Medial Journal, 2009:339:b3999

80 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

81 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 7 December 2009.

82 Morrison, Jill et al. (February 2009) Factors influencing variations in prescribing of antidepressants by general practices in Scotland. British Journal of General Practice.

83 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 7 December 2009.

84 Scottish Public Audit Committee. Official Report, 13 January 2010, Col 1449

85 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1447.

86 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1448.

87 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1449.

88 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1450.

89 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

90 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1451.

91 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

92 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

93 Audit Scotland. (2009) Overview of mental health services, (p14).

94 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1251.

95 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1252.

96 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1252.

97 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1253.

98 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1252-1254.

99 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1254.

100 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1254.

101 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1453.

102 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1255-1256.

103 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1453.

104 Audit Scotland. (2009) Overview of mental health services, (p14).

105 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1256-1257.

106 Scottish Parliament Public Audit Committee. Official Report, 7 October 2009, Col 1257.

107 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1454.

108 Scottish Government. Letter from Dr Kevin Woods, Director General Health to the Public Audit Committee dated 22 February 2010.

109 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1453.

110 Scottish Parliament Public Audit Committee. Official Report, 13 January 2010, Col 1454.