Key messages
Overview of mental health services
Prepared for the Auditor General for Scotland and the Accounts Commission
May 2009
Auditor General for Scotland
Acknowledgements:

Audit Scotland would like to thank the members of the project advisory group for their input and advice throughout
the study.

We are also grateful to everyone who provided us with information and assisted us with this study, including the participants of our focus groups.

Thanks also to Alan Ross of Ross Consulting for carrying out the service user and carer focus groups.

Jillian Matthew managed the project with support from Christopher Spratt, Lynn Conway, John Simmons (consultant) and John Jackson (Scottish Development Centre for Mental Health),  under the general direction of Claire Sweeney.
The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and value for money in the spending of public funds. 

He is responsible for investigating whether public spending bodies achieve  the best possible value for money and adhere to the highest standards of  financial management. 

He is independent and not subject to the control of any member of the Scottish Government or the Parliament. 

The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General: 

•	directorates of the Scottish Government
•	government agencies, eg the Prison Service, Historic Scotland 
•	NHS bodies 
•	further education colleges 
•	Scottish Water 
•	NDPBs and others, eg Scottish Enterprise. 

The Accounts Commission
The Accounts Commission is a statutory, independent body which, through the audit process, assists local authorities in Scotland to achieve the highest standards of financial stewardship and the economic, efficient and effective use of their resources. The Commission has four main responsibilities:

•	securing the external audit, including the audit of Best Value and Community Planning
•	following up issues of concern identified through the audit, to ensure satisfactory resolutions
•	carrying out national performance studies to improve economy, efficiency and effectiveness in local government
•	issuing an annual direction to local authorities which sets out the range of performance information they are required to publish.

The Commission secures the audit of 32 councils and 41 joint boards (including police and fire and rescue services). Local authorities spend over £19 billion of public funds a year.

Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

Key messages
Background

1. It is estimated that there are up to 850,000 people with mental health problems at any one time in Scotland.1 Mental health problems can include a wide range of conditions with varying symptoms and severity, for example, depression, eating disorders, bipolar disorder and schizophrenia.

2. People with mental health problems may require different services depending on their condition. Services are provided by: the NHS, in hospital and community settings; councils through social work, education, leisure, housing and employment services; and voluntary and private organisations. The police and prison service also have an important role. It is essential that these agencies work in partnership to deliver effective, joined-up services for people with mental health needs. In addition to formal care, family and friends provide a considerable amount of unpaid care.

3. There have been significant developments over the last ten years in the way that mental health services are delivered, with a focus on shifting resources and care into the community and a move away from large, long-stay institutions. The Mental Health (Care and Treatment) (Scotland) Act 2003 has created a new legislative framework for Scotland, with a greater focus on advocacy and the rights of the individual. There is also a greater focus on recovery, which involves supporting people to be active in managing their own healthcare and to carry out everyday activities even with ongoing symptoms. There is strong support across all professional groups for recent policy developments.

The study

4. The report provides an overview of mental health services and is the first in a series of planned reports in this area. We carried out an overview to highlight areas for improvement and to identify priorities for future audit work.

5. We looked at mental health services provided by the NHS, councils, prisons, the police and the voluntary sector across Scotland for all ages. Our study examines the accessibility and availability of mental health services and how much is spent on them.

6. In this study, we:

•	analysed published data and research on mental health, using information relating to Scotland where available
•	reviewed documents and interviewed staff at the Scottish Government, special NHS boards, the Scottish Prison Service and the Association of Chief Police Officers in Scotland (ACPOS)
•	carried out detailed fieldwork in three areas across Scotland – Glasgow, Highland and Tayside – which included detailed interviews with councils and NHS boards and reviewing available local data2
•	held focus groups with, and interviewed staff from, various voluntary organisations
•	held focus groups with people who have used mental health services and their carers
•	make recommendations for the Scottish Government and local partners. Local partners include NHS boards, councils, the police, the prison service and the voluntary sector.
Key messages

1
Mental health problems cause considerable poor health in Scotland. Rates of suicide in Scotland are higher than in England and Wales. Mental health problems can affect anyone but people who are likely to be socially excluded, such as people living in deprived areas, are at higher risk.

7. The most common mental health problem is depression with anxiety, and 108 women per 1,000 and 68 men per 1,000 report this condition.3
 
8. Dementia is more common in older people but can also affect younger adults. Alzheimer Scotland estimates that in 2008, up to 66,000 people in Scotland had dementia, and that up to 1,600 of these people were under the age of 65. Due to the ageing population, the number of people with dementia is expected to rise by 75 per cent to 114,000 by 2031.4 

9. Data from GP registers in 2007/08 show that there are 43,135 people in Scotland recorded as having severe and enduring mental illness, such as schizophrenia or bipolar disorder. Figures on individual conditions are not available from GP registers, although in 2004 NHS boards identified over 12,000 individuals with schizophrenia who were in contact with their services.5 

10. Children and adolescents can have particular mental health problems, such as attention deficit hyperactivity disorder, behavioural problems, anxiety problems and mood disorders.6 In 2004, the level of identified mental health problems in children aged 5-16 years was estimated at just over eight per cent of the population (over 55,000 children).7 

11. Rates of suicide in Scotland are among the highest in Western Europe and higher than those in England and Wales, at 18.7 per 100,000 population compared to 10.2 in England and Wales.8 In 2007, there were 838 deaths from suicide in Scotland. Not all people who take their own lives have a diagnosis of mental illness or have been in contact with services.

12. Mental health problems can affect anyone but some people have a higher risk of developing them, including people living in deprived areas, people with drug or alcohol problems and people with physical illnesses.9 

2
Staffing levels are affecting the availability of mental health services and there can be long waits for services for children and adolescents. Better information is needed about socially excluded people to identify unmet need and ensure resources are targeted on those most in need of support.

13. There are gaps in staffing information such as caseloads and vacancy levels for some staff groups. This information is needed to plan and target resources effectively.

14. The numbers of staff working in mental health services varies across Scotland, including mental health officers, psychologists and psychiatrists. The reason for the variation is not known but is likely to be due in part to differences in how services are delivered locally. Available information shows high vacancy rates in some areas for consultant psychiatrists. Shortages of mental health officers and staff working in child and adolescent mental health services have also been identified.10  Staff shortages can affect the availability of services and lead to long waiting times.

15. Mental health services for children, adolescents and older people vary considerably across Scotland and there are gaps in the provision of specialist care, such as psychological therapies. Waiting times for access to services for children and adolescents are too long in some areas. The Scottish Government is developing a health target on delivering faster access to mental health services for children and adolescents from 2009/10.

16. Better information is needed about socially excluded people to help plan and deliver services. Although NHS boards and councils in our fieldwork sites consult with service users and carers, this is not always carried out routinely or consistently for all groups of people using mental health services. Information is needed about the make-up of the local population to help identify any unmet need and ensure that services are appropriately targeted and sensitively delivered. However, we found little evidence of local equality and diversity monitoring within mental health services. 

3
There have been significant developments in the way that mental health services are delivered, with a focus on shifting resources from hospitals to the community. Community services have developed in the last ten years but there is insufficient information about how well resources are being used and what difference they are making to assess how well they are working.

17. The number of psychiatry beds in hospitals varies across Scotland, from 0.96 beds per 1,000 population in NHS Grampian to 1.39 beds per 1,000 population in NHS Greater Glasgow and Clyde. Bed occupancy levels also vary and more work is needed to identify the number of beds needed, given that this is an expensive resource.

18. Over the last ten years, there has been a gradual reduction in hospital care and an increase in community services for people with mental health problems. Between 1997/98 and 2006/07, the total number of psychiatric inpatient beds reduced by around a third, from 9,076 to 6,114 beds. This suggests that more people are being treated in the community instead of in hospital but there are no detailed figures for the number of people receiving treatment in the community.

19. There is a lack of information on community mental health services. Community mental health teams (CMHTs) bring together staff from councils and NHS boards to deliver care in the community and to provide a link with psychiatric wards to smooth the transition during admission and discharge from hospital. Limited information on CMHT activity is available from the Information Services Division but not all NHS boards provide the information; where it is provided it is collected differently, levels of accuracy vary and not all boards are able to break down the information by different age groups, which makes comparisons difficult.11 

20. Better information needs to be available to examine the use of resources and what works best for service users, including:

•	numbers of people receiving treatment
•	details of what treatment is being provided, to whom and for how long
•	outcomes for people being treated
•	size of mental health staff caseloads
•	staffing levels and vacancies
•	the amount of joint funding by the NHS, councils and other partners.12
4
Strong partnership working is essential to plan and deliver effective services. NHS boards and councils use different information systems and this limits their ability to plan and deliver joined-up, responsive services. Services out of hours and at times of crisis are not well developed in all areas. Local partnerships are using Single Outcome Agreements (SOAs) to improve services but it is too early to assess their impact.

21. People with mental health problems often get care and support from more than one professional or organisation. NHS boards and councils use different information systems and collect information in different ways. This limits the scope to routinely manage and evaluate services and the care given to service users, and to share information across organisations. Some records about service users are still paper-based. 

22. People may also need access to care outwith normal working hours if they need urgent treatment. This means that staff and organisations providing services need to easily share information about individuals but this does not always happen.

23. Crisis services differ across Scotland in how they are provided and when they are available, and not all services provide out-of-hours care. Often the first point of contact for people needing out-of-hours care is NHS 24 or hospital accident and emergency departments whose staff do not necessarily have the skills to deal with mental health problems. Service users and carers we spoke to confirmed this was a problem for them. ACPOS has also raised concerns about getting people who have been detained under the Mental Health Act to a place of safety, particularly in remote and rural areas, and poor access to psychiatric services to have someone assessed.13, 14

24. National standards were issued in 2006 to encourage the development of crisis response and crisis services across Scotland.15 The Scottish Government is monitoring whether the quality standards on crisis services have been implemented across Scotland and is due to report on this during 2009.

25. There can be problems in the transition between services, for example moving from adolescent to adult services or for prisoners being released into the community. Some specialist services are available within children and adolescent services but not within adult services, such as services for autistic spectrum disorder. Some areas have no specialist community mental health services for older people. This means that there is a lack of continuity of care for some younger and older people.

26. As part of the concordat between the Scottish Government and councils, Single Outcome Agreements (SOAs) were introduced across Scotland from April 2008. SOAs set out how each council and its partners, including the local NHS board, will address their priorities and improve services for the local population. However, detailed management information on services, quality and cost is still needed to underpin work on outcomes to assess how well needs are being met.

27. There are currently four NHS targets for mental health which many partnerships are using as part of their SOA. These measures are to reduce the number of hospital readmissions, reduce the rate of antidepressant prescribing, reduce the suicide rate and achieve agreed improvements in the early diagnosis and management of people with dementia. However, these targets are not clear measures of improvement or fully supported by robust data and it is not clear yet whether the NHS will achieve them.

5The wider costs of mental health problems are over £8 billion a year. The NHS spent £928 million on mental health services in Scotland. The total amount spent by councils on mental health services is unknown.

28. The wider economic and social costs of mental health problems in Scotland are estimated at around
£8.6 billion a year.16 This includes costs to the economy of people not being able to work. Unpaid carers provide a significant amount of care and it is estimated that in Scotland this would cost £376 million if undertaken as paid work by a third party.

29. It is difficult to calculate the exact amount spent on mental health services but from available national data we estimate that in 2007/08 the NHS spent £928 million on mental health services (nine per cent of its total expenditure). This figure includes costs associated with the State Hospital (£39 million) and prescribing medicines in the community (£95.2 million) (Exhibit 1).

30. The amount that NHS boards spent on mental health services in cash terms (including resources transferred to councils and excluding the State Hospital costs) increased from £641.2 million in 2002/03 to £888.7 million in 2007/08. The average NHS spend on mental health services per head of population for Scotland is £173. This varies by NHS board, from £55 per head of population in NHS Shetland to £220 in NHS Greater Glasgow and Clyde. Levels of mental health problems tend to be higher in more deprived areas but spending does not always appear to be related to levels of need.

31. Mental health services are increasingly being provided in the community although the majority of money is still spent on hospital services. However, there is variation across Scotland in the balance of spend on specialist mental health services provided in hospitals, the community and the amount of resources transferred to councils (Exhibit 2).

32. NHS boards transfer money to councils to support community mental health services. These services are mainly provided by social work departments or commissioned from the voluntary and private sectors. In the absence of more detailed data, the amount of money that NHS boards transfer to councils is a proxy indicator for the progress in shifting care from hospitals to the community. In Scotland in 2007/08, an average of ten per cent of NHS expenditure on mental health was transferred to councils (£90.3 million). In mainland NHS boards, this ranges from £2.72 per head of population in NHS Fife to £35.33 per head of population in NHS Greater Glasgow and Clyde.

33. It is more difficult to quantify how much is spent by councils to support people with mental health problems. Only the amount spent on adults with mental health problems is shown separately in council budgets (£141.9 million). Services provided to children and older people with mental health needs are not separately identified within the general social work budgets for children and families and for older people, but this is likely to be a significant amount.

34. It is too early to assess the impact of funding changes for councils on mental health services. The councils in our fieldwork have made no major changes to the levels of funding ring-fenced before the concordat (Mental Health Specific Grant, Supporting People, Changing Children’s Services Fund and Choose Life). These funds are currently under review and some councils in our fieldwork reported that they expect to make changes in the second year of SOAs.

Key recommendations

The Scottish Government and local partners should:

•		ensure that they work together to deliver services for people with mental health problems which are joined up and that appropriate services are provided on the basis of need
•		collect information about services in the community to enable better planning and development of services.
Local partners should:

•		work together to identify and address any gaps in services, including services for children and adolescents and the availability of psychological therapies
•		continue to monitor and develop the move from hospital to community services, ensuring that the resources to support this change are transferred as necessary
•		ensure that data on waiting times for mental health services are collected and reported routinely. Action should be taken to address services with long waiting times
•		use the Audit Scotland checklist detailed in Appendix 3 of the main report to help improve the delivery and impact of mental health services through a joined-up, consistent approach.

1	The World Health Report 2001 – Mental Health: New Understanding, New Hope, World Health Organisation, 2001.
2	NHS Greater Glasgow and Clyde, Glasgow City Council and Renfrewshire Council; NHS Tayside and Dundee City Council; NHS Highland and
Highland Council.
3	Psychiatric morbidity among adults living in private households, Office of National Statistics, 2000. This was a UK-wide survey.
4	Dementia factsheet, Alzheimer Scotland, 2008.
5	A review of schizophrenia services in Scotland, NHS Quality Improvement Scotland, 2004.
6	Needs Assessment Report on Child and Adolescent Mental Health, Public Health Institute of Scotland, 2003. 
7	The mental health of children and adolescents in Great Britain, Office of National Statistics, 2004.
8	The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Lessons for Mental Health Care in Scotland, University of Manchester, June 2008.
9	National Service Framework for Mental Health: Modern Standards and Service Models, Department of Health, London, September 1999.
10	Mental health officers staffing, Scottish Government, 2008 and Getting the Right Workforce, Getting the Workforce Right: A strategic review of the child and adolescent mental health workforce, Scottish Executive, 2005.
11	Information Services Division (ISD) is part of NHS National Services Scotland. It collects and analyses information across the NHS in Scotland.
12	A shared approach: Developing adult mental health services, Accounts Commission for Scotland, 1999.
13	A place of safety is defined under the Mental Health Act as ‘a hospital; premises which are used for the purpose of providing a care home service; or any other suitable place (other than a police station) the occupier of which is willing temporarily to receive mentally disordered persons’.
14	Medical Services for People in Police Custody, Her Majesty’s Inspectorate of Constabulary for Scotland, October 2008.
15	Delivering for Health: Delivering for Mental Health National Standards for Crisis Services, Scottish Executive Health Department, November 2006.
16	What’s it Worth? The Social and Economic Costs of Mental Health Problems in Scotland, Scottish Association for Mental Health, December 2006.

Overview of mental health services 
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