Edinburgh Shadow Health and Social Care Partnership
Joint Strategic Needs Assessment
Topic Paper 7.2
MENTAL HEALTH
1. OVERVIEW OF CURRENT AND FORECASTED NEEDS:
Over one in four people (over 120,000 people) in Edinburgh experience a mental
health problem. Anxiety and depression are the most common mental health
problems, but others include schizophrenia, personality disorders, eating disorders
and dementia.1
Risk Factors
Mental ill health is not evenly distributed across society and is more common in socio
economically deprived areas23. In 2009-13 the suicide rate was three times higher in
the most deprived tenth of the population. As well as being more likely to have a
mental health problem, people in the more deprived groups suffer ill-health for
longer. About half of people with mental health problems are no longer affected after
18 months but poorer people, the long-term sick and the unemployed are more likely
to still be affected than the general population4. Within Scotland around 43% of
social welfare benefits or disability pensions are to people with mental disorders5.
Being old is also a risk factor for poor mental health with depression affecting one in
five older people living in the community and two in five living in care homes6.
Dementia is far more prevalent in people over 60 with the incidence increasing
further with age.
Estimates of Future Demand
In terms of predictors of future prevalence of mental ill-health, there is some
evidence that mental health problems increase during periods of economic
recession, low growth and insecurity. There is also some evidence that the welfare
reforms are having a significant negative effect on people who receive benefits.
According to a survey by SAMH, 98% of people surveyed said the welfare reforms
had increased anxiety and stress and staff carried out six suicide interventions
directly related to the welfare reforms7. However the epidemiology of prevalence of
mental ill health and economic recession is being reviewed. Meanwhile the
1
SPICe briefing, Metal Health in Scotland, May 2014
SPICe briefing, Mental Health in Scotland, May 2014
3
Scoltand’s Mental Health, October 2012, NHS Health Scotland
4
Better or Worse: A longitudinal study of the mental health of adults in Great Britain, National Statistics, 2003
5
SPICe briefing,. Mental Health in Scotland, May 2014
6
Adults In Later Life with Mental Health Problems, Mental Health Foundation quoting Psychiatry in the Elderly,
3rd edition, Oxford University Press, 2002
7
Worried Sick: experiences of poverty and mental health across Scotland. SAMH March 2014
2
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conservative planning assumption is that numbers increase by an average of 1.4% in
line with the annual increase in the adult population.
As old age is a risk factor for mental ill-health, an ageing population means that the
numbers of older people with mental ill-health can be expected to increase.
2. PROFILE OF ACTIVITY
The vast majority of people with mental health problems receive informal support in
the community. City of Edinburgh Council and NHS Lothian currently invest
£12,364,535 in mental health and well being services to shift the balance of care
from hospital to the community. The distribution of the investment is illustrated
below:
Just about half of the investment is in accommodation and support services where
people receive intensive levels of support to enable them to be discharged from
psychiatric hospital and to prevent readmission. Of this investment in
accommodation and support services 4% is provided internally and 96% is
purchased from third sector organisations. Currently there are 357 people supported
in this manner.
The remainder of the investment is in preventative community services. These
services were the focus of the 2014 Review of Mental Health and Wellbeing Services
in Edinburgh. Feedback from people who used these services included their
perception that these supports prevented them from needing more intensive levels of
support in the community or in hospital. Currently around six thousand people make
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use of these services. Of this investment 2% is provided internally and 98% is
purchased from Third Sector providers. At the moment it is not possible to
determine the comparative investment of preventative services in the community.
As part of the review, the services were mapped across the four localities as shown
below.
It should be noted that there are a number of universal services that are used by
adults with mental health issues which are not included in this map. A future
exercise will be to identify these across the four localities. The majority of mental
health and well being services are located centrally and provide city wide services.
Analysis of the post code information shows that the services have been successful
in attracting service users from all over the city. However there is an unequal
distribution of mental health and wellbeing services across the city with a particular
gap in the South West locality. In terms of locality inequalities, the North East has
twice the rate of people admitted to acute adult services at the Royal Edinburgh than
North West.
When community services are not sufficient to meet people’s needs there are 88
specialised acute psychiatric beds for adults and 55 longer term rehabilitation
psychiatric beds.
Mental Health Officer Services and uses of the Mental Health Act
Within the Mental Health Officer (MHO) service there are a number of continuing
demands. In terms of the use of Guardianship under the Adults with Incapacity Act
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(2000), Edinburgh makes comparatively fewer applications than other local
authorities. This figure, however, is misleading in terms of MHO activity because
referrals made under this legislation will involve assessments and attendance at
case conferences even if this does not result in an application for Guardianship
being made. Nationally there has been a 58% increase in the use of Guardianships
over the last four years and recent legal judgements strongly suggest there will be an
increased use of legislation.
Regarding the usages of the Mental Health (Care and Treatment) (Scotland) Act
(2003) the Mental Welfare Commission overview for 13-14 shows that within City of
Edinburgh all types of episode of compulsory treatment rose in 2013-14, with the
number of people being detained on a Short Term Detention order being at its
highest point since the Act came into force (see Table 1 below).
Table 1 – Short Term Detentions annual figures 2009/10 to 2013/14 in Edinburgh
and Scotland
Count of Short Term Detentions
Rate per 100k of 16+ population
09/1
0
City of
Edinburgh
Scotland
370
3354
10/1
1
419
3461
11/1
2
406
3543
12/1
3
421
3576
13/1
4
470
3665
09/1
0
78
65
10/1
1
86
66
11/1
2
84
66
12/1
3
85
68
13/1
4
97
69
Figures from Mental Welfare Commission for Scotland, Chief Social work officer end of year report, 2013/14
Use of Compulsory Treatment Orders in Edinburgh is also higher than the national
average with an NRAC adjusted rate of 26 per 100,000 of population compared with
a national figure of 22 per 100,000 of population (see Table 2 below). Furthermore
there has been increase in the number of community Compulsory Treatment Orders
in Edinburgh over the past 5 years from just over 3 per 100,000 of population in
2009-10 to just under 5 per 100,000 in 2013-14. This is against a national average
which has remained static at 2 per 100,000 of population in the same period.
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Table 2 Compulsory Treatment Orders granted in Edinburgh and Scotland in a year
Count of Compulsory Treatment
Orders
09/1
0
Edinburgh
Community
Hospital
Total
Edinburgh
Scotland
Community
Hospital
Total Scotland
10/1
1
11/1
2
12/1
3
Rate per 100k of 16+ population
13/1
4
09/1
0
10/1
1
11/1
2
12/1
3
13/1
4
13
95
13
101
16
90
18
83
21
105
3
20
3
21
3
19
4
17
4
22
108
117
106
101
126
23
24
22
20
26
118
967
1085
118
954
1064
122
997
1119
122
1000
1122
125
1048
1173
2
19
21
2
18
20
2
19
17
2
19
21
2
20
22
Figures from Mental Welfare Commission for Scotland, Chief Social work officer end of year report, 2013/14
Table 3 - Average length of Psychiatric stay
2007/08 2008/09 2009/10 2010/11
80.7
NHS Lothian
62.7
68.3
68.2
80.5
Scotland
88.7
81.0
67.0
2011/12
71.7
65.2
Figures from ISD Scotland, national Benchmarking project/Mental Health dashboard
In summary, Edinburgh has a higher rate of Short Term Detention (STD) orders and
Compulsory Treatment Orders (CTO) than the Scottish average, with the latter
having a large increased rate in 2013/14 which was not mirrored in the rest of
Scotland. Lothian has a higher than average length of hospital stay (see Table 3
above). Although it is not possible to determine comparative investment in
preventative services it may be that these higher rates reflect lower spend on
preventative services. The latest published figures on community spend as a
percentage total of general psychiatric services and mental health officers per
100,000 population show lower investment in these areas in Lothian than the
Scottish average (see Tables 4 and 5 below). This may be impacting on the higher
use of STDs/ CTOs and longer hospital stays.
Table 5 – Community Spend as a percentage of total spend for General Psychiatric
Services
NHS Lothian
Scotland
08/09
28
33
09/10
28
33
10/11
30
34
11/12
31
35
Figures from ISD Scotland, national Benchmarking project/Mental Health dashboard
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Table 6 – Mental health officers per 100k population (GROS mid year estimates
2011)
NHS Lothian
Scotland
08/09
11.5
12.4
09/10
11
12.7
10/11 11/12
11.3
10.8
13.2
12.1
Figures from ISD Scotland, national Benchmarking project/Mental Health dashboard
3. EXISTING PLANNING GROUPS:
Edinburgh Mental Health Forum. The primary function of the Forum is to ensure that
the Joint Strategic Plan, A Sense of Belonging, is implemented in Edinburgh.
Service user and carer representation has ensured their voices have had a say in all
aspects of the redesign of services. Full membership of the forum includes NHS
Lothian, Royal Edinburgh and Associated services, Edinburgh Community Health
Partnership, Health and Social Care (City of Edinburgh Council), Services for
Communities (City of Edinburgh Council), Independent Advocacy Services,
Voluntary Sector Services Forum, Service Users Forum, Carers’ Forums.
The majority of all the mental health and wellbeing services have service user and
carer representation on their management boards. This has provided valuable
information about how these services should be delivered to best met need.
4. EXISTING STRATEGIC PLANS:
The current joint strategic plan is A Sense of Belonging which runs until 2016.
In Edinburgh, in consultation with stakeholders, we are developing a commissioning
plan to support the implementation of the strategy.
5. CURRENT PRIORITIES:
Redesign of mental health and well being services: We want to move to a new
locality based way of developing services based on alliance contracting. This will
increase partnership working in meeting the prevention agenda. The plan is to move
to a local partnership model that will deliver on key principles. These principles
are informed by the Joint Improvement Team Health and Social Care Integration –
Locality Planning Conversations Report (June 2014) as well as conversations with
stakeholder groups and outcomes outlined in the joint mental health strategy ‘A
sense of Belonging’ and the ‘Alcohol and Drug Strategy’.
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The Local Partnership Models will;

be based on trust and parity of respect between partners

ensure the principles and values of recovery and person centred care
underpin the culture , development and delivery of services

ensure services are co-produced with local communities, service users and
carers, and third sector partners

services will have a renewed focus on early intervention and prevention

services will be psychologically minded in their approach to support
engagement

promote physical and mental health wellness

improve access and delivery across the care pathway

deliver a continuity of care across services by improved care coordinationnavigation, and are flexible and responsive to individual need

promote and deliver services that are personalised – Self Directed Support

ensure individual and service outcomes are clear and measurable

contribute to the development and implementation of strategic plans

be held to account for the delivery of local priorities
In relation to the redesign of our in-house care and support service, we will be
shifting to a reablement model to provide early intervention-prevent hospital
admission and to support and facilitate avoidable delays in hospital.
Wayfinder Project: This is a Knowledge Transfer Partnership between NHS
Lothian, City of Edinburgh Council and Queen Margaret University to develop
evidence based pathway redesign of adult mental health services. This will result in
the development of new services to support the redesign of the Royal Edinburgh
Hospital.
Delayed Discharges: Delayed discharge within acute mental health wards is a
major priority. In the adult under 65 service, currently 25% of inpatients are either
waiting for accommodation and support or waiting for an alternative NHS resource.
There are, for example, ten to twelve people waiting for a place in the inpatient
rehabilitation service. In the last 12 months the overall occupancy has ranged from
104% to 82 %. It normally rises again in summer (particularly August).
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6. FUTURE USE OF RESOURCES
NHS Lothian is within the bottom quartile in funding community mental health
services in Scotland. The problem of delayed discharge is caused in part by lack of
appropriate community services to support people. As is the recent 60% increase
over the year in detention rates. There is a need for more investment in the
community to prevent people from needing hospital beds.
The recent review of mental health and wellbeing services identified the following
key gaps and issues in service provision.
•
There is capacity for much greater joint working across third sector
organisations. This is partially a result of the way that services are currently
commissioned.
•
Although all services are moving toward a more personalised method of
service delivery, some services are more developed than others.
•
There is capacity for much greater use of peer support and peer working.
•
The accommodation situation for mental health and well being services may
not be sustainable.
•
There is a significant barrier to these services offering a fully personalised
service as they do not have the capacity to manage an individual budget for a
service user.
•
Use of these lower level services prevents the need to use more intensive and
expensive services.
Chapter authors: John Armstrong, Pathway Manager Mental Health, City of
Edinburgh Council and Linda Irvine, Strategic Planning Manager for Mental Health,
NHS Lothian.
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