Response 36033735

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Kevin O'Neill

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Lanarkshire Planning Partnerships North & South

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Questions

1. Our framework sets out 8 priorities for a new Mental Health Strategy that we think will transform mental health in Scotland over 10 years. Are these the most important priorities?

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If no, what priorities do you think will deliver this transformation?
Lanarkshire Partnership Response: Methods The Lanarkshire partnerships (North and South Lanarkshire Health and Social Care Partnerships including; NHS Lanarkshire, North Lanarkshire Council (NLC), South Lanarkshire Council (SLC), Voluntary Sector through Lanarkshire Recovery Network and Service Users and Carers) have come together to review the strategy and to prepare a joint response. There is "no health without mental health" and therefore this draft strategy is of interest beyond just mental health services and views were proactively gathered from a wider audience. A standard partnership e-mail was agreed and widely distributed. This was also targeted at key individuals and groups who were asked to give views on specific points relating to their areas of interest across life span, settings and high risk groups cutting across the prevention, promotion and care and treatment agenda. A single point of communication was created for all responses. Rather than having a single consultation event the draft strategy has been included on multiple agenda’s with focused discussion and specific comments gathered. Representatives from the partnerships also attended the national consultation events throughout September 2016. Service user views were gathered through a number of channels, but also, and specifically through working with Lanarkshire Links (Service User and Carer Involvement), who hosted a focus group. A specific response from Lanarkshire Links has been submitted to the Scottish Government direct) and is also included as appendix 1 of this feedback form. Lanarkshire Peri-Natal Mental Health colleagues have submitted their views through the national Peri-Natal Mental Health networks, this is included as appendix 2. Feedback Are these the most important priorities? A positive foundation: The national priorities in the proposed strategy were largely welcome. It was noted that the lack of detail made specific reflection difficult, however the partnership appreciates the Scottish Government’s intention not to be over prescriptive at this time. Therefore the feedback below focuses on the areas where further focus and/or detail is required.

2. The table in Annex A sets out a number of early actions that we think will support improvements for mental health.

Are there any other actions that you think we need to take to improve mental health in Scotland?
1.1 Vision: It’s felt that the next strategy should broaden the MH agenda from something that is done by MH community focused on improving services to a vision of a mentally healthier Scotland, where positive mental health is built into community planning, employment, education, law and all other policy areas. The strategy should set out how we go about creating mentally healthier communities, where everybody is looking to improve their mental health – not just those with mental health issues or problems. Where problems arise there need to be multiple options that promote self management, early intervention and low levels of support as the norm. Where services do need to be engaged the approach should be one of collaborative working towards maximising potential. In summary we think this reads like a short term workplan for the MH division that has a few laudable and achievable workstreams within it but doesn’t amount to a strategy - never mind a 10 year vision. We wish to see a Scotland where we all understand that there is no good health without good mental well-being, where we know how to support and improve our own and others’ mental well-being and act on that knowledge, and where our mental well-being contributes to a healthier, wealthier, fairer, smarter, greener and safer Scotland for all. A Scotland where we: • Promote well-being in the general population, both individually and collectively. • Raise efforts around the prevention of mental health problems, mental ill-health, distress and suicide. • Improve the quality of life, social inclusion, health equality, economic wellbeing and recovery of people who experience mental illness or have a learning disability. We will achieve this through high quality, locality based support and services where possible, specialist interventions and hospital based services where required, recognising that services need to be part of a wider social context involving, personal responsibility, family, carers, housing, employment, leisure and the voluntary sector 1.2 Context: Set the context for local delivery of the new strategy within partnership and integrated structures, which applies across prevention, promotion, and care and treatment. The integrated partnership approach recognises that significant effort is required to promote good health and well-being at individual, social, community, cultural, environmental and economic levels, to address the wider determinants of health and well-being across age ranges, settings and high risk groups. At an individual and local community level, building individual and community resilience , and social capital will contribute significantly to Scotland’s capacity to survive the wider determinants of health, respond to the changes and flourish. Support and facilitate local partnership to build on the long-standing culture of joint, integrated and partnership working, utilising our collective assets for collective impact. 1.3 Build, integrate and widen: The consultation document aspires to set out the terms of a new Mental Health Strategy for Scotland, taking us forward into the next 10 year period. From this perspective, the focus on only a very small number of new priorities, serves only to restrict our potential and does not allow for any review and/or consolidation of work that has already been undertaken since the progressive Delivering for Mental Health (2006) and Towards a Mentally Flourishing Scotland (2009) were published. Significantly, the document does not acknowledge the changing organisational frameworks and evolving partnerships that are being created as an outcome of Health and Social Care Integration and, as such, makes no reference to expectations about the wider infrastructure provision that would be required to accommodate the continued and progressive development of services, as detailed in the strategy and, at the same time, meet the development needs of staff. 1.4 Local Authority and Voluntary Sector contribution requires greater recognition within the document, in the context of partnership working. 1.5 Integrating the prevention, promotion care and treatment agenda is largely welcome and replicates the approach being taken in Lanarkshire. However, the overwhelming initial feedback is that the strategy needs to give greater focus to the prevention and promotion agenda, recognising that the infrastructure created through Towards a Mentally Flourishing Scotland has laid the foundation and given the strategic focus required to support local direction and good progress has been made. It is recommended that the 6 high level priorities, children and young people, later life, communities, work place, preventing common mental health problems including suicide and self-harm and improving the quality of life for people with mental health problems, which were contained within TAMFS remain with a view to building on these previous commitments by introducing one or two more actions under those commitments. Greater focus needs to be given to promoting mentally healthy communities with community asset building underpinning the approach. 1.6 Making it Happen: It would be helpful if the strategy contained more specifics about HOW to achieve the objectives, and for there to be a way of compelling/ facilitating local Health Boards/ Health and Social Care Partnerships to implement and report actions rather than these being guidelines which are optional and risk creating postcode lottery. 1.7 Synchronising the mental health policy and programmes: the strategy should set out to synchronise the mental health and well-being elements and show the linkage across the range of current transformation programmes which currently are at risk of disconnect, such as the Primary Care Transformation Fund, Urgent Care Transformation Fund, Mental Health Innovation Fund and Distress Brief Intervention Programme. 1.8 The needs of specific populations (Older Adults, Learning Disability, Forensic Services, as well as general adult mental health). Consideration needs to be given to the different population groups this strategy covers and how inputs and outcomes might need to be different. There needs to be an acknowledged distinction with respect to ageing and the complexities arising within this context increase awareness and help ensure equality across lifespan when implementing strategies. The priorities all seem admirable but need to ensure that what is done is adequately resourced and some of the strategies don’t unintentionally discriminate against people with additional difficulties. I think there also has to be clarity regarding the links between other documents, e.g. some of the mental health recommendations in the “Keys to Life” (although there will be many other examples). Where strategies/ recommendations/ guidance for different client groups diverge, there needs to be clarity over which strategy/ recommendation/ guidance should be followed in that instance. There needs to be some thought given to ensuring there is no contradictory guidance in differing strategies. 1.9 Embedding the strategy within the tiered/ blended model 0 (wider community prevention) to tier 4 (specialist services) will help demonstrate how the integrated strategy comes together. This promotes a whole systems approach to mental health improvement - prevention, promotion, care and treatment. 1.10 Shifting the balance of care: A Mental Health Strategy for the next 10 years should set the tone and direction for services. The outcomes, as stated are reasonable but the strategy fails to acknowledge the desirability of a continued shift in the balance of care from institutionally based models towards those in the community. We propose changing to an outcome that over the period of the strategy there is an expectation that the proportion of care delivered in community settings as opposed to hospitals will increase and that resources currently tied up in hospital care should be released to support improved community support and treatment. We should indeed capitalise on the knowledge and experience of systems that have successfully rebalanced services through redesign. It is strongly recommended that the strategy needs to set a direction to support further movement away from institutional care towards more person-centred and integrated community services. The question for services should be how far and how quickly can they achieve a further shift in the balance of care, not how we (or whether we can) determine the correct balance. 1.11 Primary Care focus is welcome but needs to be seen in the context a wider locality response. Shifting the balance of care towards community has driven the mental health and Learning Disability modernisation programme over the past 15 years in Lanarkshire. It recognises the opportunity for partners to work together to tackle health inequalities, enhance anticipatory and preventative care, shift resources to community settings and provide a wide variety of services at local level. The importance of the locality model is further enhanced via the opportunities provided via the integration agenda, with a focus on efficiency and effectiveness, improved access, manage demand, reduce unnecessary referrals to specialist services, provide lower tier interventions, collaborate to meet the co-morbid needs of individuals and provide improved person centred community care services. 1.12 Focus on ‘All of Me’: ensure parity between mental health and physical health is extremely welcome that there is an aspiration to reduce the disparity between mental and physical health outcomes, albeit in circumscribed areas. The comments above are equally relevant to this suggested priority area. In addition, the extension and roll out of the Anticipatory Care Planning documentation and processes to include all aspects of mental health conditions, capacity and proxy information would be of great benefit to all. The focus on recovery must build on work undertaken to date and further consider how the concept of recovery can be defined, understood and hold relevance across diverse individual experiences of mental ill health and mental distress. Early Action 4 describes improving access to Mental Health services for people living with other long term conditions. This should also include better ‘Mental Health’ support within long term conditions and wider ‘physical health’ services promoting wellbeing and coping with the adjustment and stresses of living with a long term conditions, in addition to better access to specialised MH services designed to assess and intervene with mental illness. Mental Health falls on a spectrum, and All of Me must acknowledge this rather than just improve identification and onwards referral. 1.13 Distress Brief Intervention Lanarkshire is the host pilot site for overseeing the National Programme of Distress Brief Interventions. Both staff training support and an evaluation process are explicitly included in the programme. While distress can be experienced across a continuum of severity and degree, this programme is a valuable starting point to providing a recognisable structured and supportive response to people experiencing emotional distress. 1.14 Health inequalities are the unfair and avoidable differences in people’s health across social groups and between different population groups. They represent thousands of unnecessary premature deaths every year in Scotland, and for men in the most deprived areas nearly 24 fewer years spent in ‘good health’. As well as understanding what determines our mental health, we need to understand how these same determinants can cause health inequalities. National data also shows that when you compare the most deprived areas of Scotland with the least deprived there is; higher level of Common Mental Health Problems, (GHQ) (21% versus 10%) , Higher levels of GP consultations for anxiety (62 per 1,000 versus 28 per 1000) and Higher level of mental health problems in children as indicated via conduct disorder: (4-12 years 34% versus 13%; S2 - 28% versus 20% and S4 - 30% versus 19% respectively) . To do this, NHS Health Scotland has developed a ‘theory of causation’ for health inequalities. The MH strategy needs to include specific reference to efforts grew the evidence base around what works most effectively to; undo the fundamental causes (engaging and influencing national government) and using the partnerships sphere of influence and assets to prevent the harmful wider environmental influences and mitigate (make less harmful) the negative impact on individuals. Through national support and performance measures, postcode should be gathered as standard in all service contact data and analysed using Scottish Index of Multiple Deprivation to demonstrate that we are reaching our most deprived communities via deprivation quintiles. 1.15 Financial Insecurity: National and local data consistently shows that financial insecurity is one of the greatest risks to mental health and well-being. We are in the midst of an economic down-turn and significant welfare reforms, which is impacting on individuals, communities and services. This requires priority focus within the strategy making recommendations that national support are in place to ensure agencies understand their duties, impact on communities and services are monitored and service make every effort to identify financial insecurity, provide supportive information and support people to access benefit, welfare, debt and employment advice. See the Director of Public Health Annual Report (Published 2010) for further information http://www.nhslanarkshire.org.uk/Services/PublicHealth/directors-annual-report-2009-10/Documents/Public%20Health%202009-10.pdf 1.16 Prevention and early intervention The Christie Commission report suggested that around 40% of our spending is currently accounted for by interventions that could have been avoided by prioritising a preventative approach Christie suggest the focus needs to shift (from meeting the cost of dealing with health or social problems after they have developed) to prevention and early intervention. The recently published framework for public mental health titled ‘Good Mental Health All’ , should be strongly endorsed within the strategy and promoted as powerful framework for local partnerships to develop and co-ordinate collective population mental health respecting that clearly one stage of life and setting leads and impacts on another, with a continued focus on: o Mentally Healthy Infants, Children and Young People o Mentally Healthy Later Life o Mentally Healthy Environments and Communities o Mentally Healthy Employment and Working Life o Reducing the Prevalence of Suicide, Self-harm, Distress and Common Mental Health Problems o Improving the Quality of Life of those Experiencing Mental Health Problems, including the promotion of recovery, stigma reduction and physical health improvement. The commitment to update the Mental Health Improvement Outcome Framework is of real value and continued support to maintain the National Mental Health Improvement Network would support sharing of practice and knowledge into action. 1.17 Life span approach: Generally the framework and priorities outlined in the strategy are to be welcomed. In particular the life course perspective ensures that all stages of life are considered in relation to mental health. The structure of the document in terms of the life stages and many felt the eight priorities are logical and will support the development of a clear operational plan for implementation at the local level. The focus on prevention is positive but would be strengthened with explicit mention of primary prevention and some statement challenging the concept that poor mental health, especially for minority populations, is inevitable and somehow acceptable. 1.18 Transitional Age range (16-25) would benefit from particular focus recognising the long-standing challenges of providing effective and engaging supports for this group. 1.19 Suicide Prevention activity should continue to receive national support and be strongly linked to the new strategy. 1.20 Focus on prevention and early intervention for infants, children and young people: Improvements in partnership working should be undertaken within the context of a review of current service delivery from and access to CAMHS services to determine inter-professional links at the present time. There is reference in this section to ‘conduct disorders’. While categorisation and diagnosis of mental health conditions can provide some coherence to the treatment of specific symptoms, as we know from research on stigma in mental health, diagnostic labels can also create implicit assumptions which serve both to pathologise and marginalise individuals and groups. This can be particularly damaging for children and young people, especially in cases where there is also a focus on parenting style. Details of the delivery plan for this type of programme, including staffing would be helpful. The reference to early recognition and intervention of first episode psychosis is greatly welcomed and must include young people with a learning disability and the provision of links into schools. It was felt that there is not enough of a focus on the interface between Mental Health and Education, and that links could be made more explicit and worked linked to Curriculum for Excellence and Closing the Attainment Gap. Toxic Stress: Advances in biology are providing deeper insights into how early experiences are built into the body with lasting effects on learning, behavior, and health. Numerous evaluations of interventions for young children facing adversity have demonstrated multiple, positive effects but they have been highly variable and difficult to sustain or scale. New research on plasticity and critical periods in development, increasing understanding of how gene-environment interaction affects variation in stress susceptibility and resilience, and the emerging availability of measures of toxic stress effects that are sensitive to intervention provide much-needed fuel for science-informed innovation in the early childhood arena. This growing knowledge base suggests 4 shifts in thinking about policy and practice: (1) early experiences affect lifelong health, not just learning; (2) healthy brain development requires protection from toxic stress, not just enrichment; (3) achieving breakthrough outcomes for young children facing adversity requires supporting the adults who care for them to transform their own lives; (4) more effective interventions are needed in the prenatal period and first 3 years after birth for the most disadvantaged children and families. The time has come to leverage 21st-century science to catalyse the design, testing, and scaling of more powerful approaches for reducing lifelong disease by mitigating the effects of early adversity. 1.21 The gendered implications of the strategy as currently written need to be addressed. Priorities one and two which are the only ones to identify specific segments of the population and are focused on prevention, identifies pregnant women, new mothers, children, and young people as key target groups. Whilst this ties the prevention element of this strategy to the early years agenda as a consistent theme of Scottish Government policy, with is positive, there is no explicit mention of men anywhere within the prevention priorities. This is despite the fact that we know in terms of suicide, men in Scotland, and younger men in particular, experience higher rates of suicide than any other section of the population. It is not acceptable to be aware of this inequality and not address it in a high level strategy such as this. Whilst this may be included in the Suicide Prevention Strategy due for publication in 2017, it would do no harm to enshrine this topic within this strategy also. 1.22 Equality monitoring information We know that Lesbian, Gay, Bisexual, and Transgender (LGBT) populations are adversely affected by disproportionately high levels of poor mental health yet there is no reflection of this within the strategy. The evidence base shows that these poor outcomes are further compounded by other aspects of identity which are protected characteristics such as coming from a BME background, living with a disability, or identifying as bisexual. Equality monitoring should be collected as standard for anyone accessing a mental health service and this data used to monitor whether the inequalities experienced by certain sections of the population are being addressed and whether this leads to mental health outcomes improving over time at a population level generally and within clearly identified minority populations. With regards measures of success. A baseline marker would be for all mental health services to collect as standard, equality monitoring information from all patients/clients/service users at the point of first assessment. 1.23 Lanarkshire Peri-Natal Mental Health colleagues have welcomed the high profile focus and have submitted their views through the national Peri-Natal Mental Health networks. If this area of work is taken forward as a priority it would be fundamental that any network of staff is adequately resourced to meet demand, offers flexible referral processes and includes access to follow-up community based support. There is also more work to be undertaken around the social and cultural expectations of women who are experiencing pregnancy in addition to those who have recently given birth, and/or have other children. Social/cultural stigma and self stigma for women and their partners in relation to their emotional and psychological reactions to pregnancy and the perinatal period may not always match with the anticipated roles and expectations of others. These subtle difficulties can lead to a increased stresses, relational tensions and more significant mental health problems, and new mothers may be cautious about seeking help for fear of judgment, shaming or service responses. The recent Mental Welfare Commission investigation into the care and treatment of Ms OP recommends the development of a National Managed Clinical Network to establish standards, pathways, staff competencies and equitable access to advice and care for all pregnant and postnatal women with or at risk of mental ill health (MWC, 2016). 1.24 Increasing the use of technology enable care to enhance, facilitate and support mental health and well-being through self-management, should be supported through the strategy. 1.25 Delivering person centred health and social care should be supported with reference to the NHS Quality Strategy with a focus on Personal Experience, Staff Experience and Co-production. 1.26 Valuing the lived experience should underpin the strategy through the involvement of service users and carers in the planning, development and evaluation of services; facilitating the gathering and sharing of the lived experience, further enhancing access to peer support and wellness recovery action planning recognising people as experts by experience. Service user views were gathered through a number of channels, but also, and specifically through working with Lanarkshire Links (Service User and Carer Involvement), who hosted a focus group. A specific response from Lanarkshire Links has been submitted to the Scottish Government direct). 1.27 Self Directed Support for people with mental health problems is implemented in a significantly inconsistent way across Scotland. The new strategy could support co-ordination of evidence and understanding to further progress this agenda. It may be helpful to undertake a review of the extent to which the use of self directed services has been used effectively to accommodate the support needs of people with long term mental health problems; to access mental health and support services more flexibly and responsively, and how this could be extended. For some people with long term mental health conditions, only small budgets are required in order to sustain positive mental health and promote individual potential. This can create both financial and resourcing difficulties for Service Providers, and it may be that different approaches to investing in this type of support would be beneficial. 1.28 Delivering safe and effective services should be an objective of the strategy, supported by the Scottish Patient Safety Programme. 1.29 Improve Access to mental health services and make them more efficient and safe: More flexible and responsive access to all mental health services would be available across the lifespan, removing the barriers currently created in transition stages, such as between CAMHS and Adults, and Adults and Older Adult provisioning. More integrated service provision would be considered as the quality standard. More discussion and planning regarding the statutory and the support services being provided Out of Hours is also required in order to improve the continuity and safety of integrated services. Computerised access to psychological therapies can be effective for some adults, but can also act as a barrier, if no infrastructure or support is available for those who may not have a straightforward route in to access or utilise this type of approach. Other options to assist access for adults, older adults and young people, may also need to be scoped in conjunction with recognised third sector organisations, through the Health and Social Care commissioning strategy. Lessons can be learned from the introduction of IAPT by NHS England, the implementation of which has demonstrated mixed results, doubling the number of people with anxiety and depressions accessing ‘treatment’ between 2011 – 2015 but with a ‘recovery rate’ of 45.4% over the same period (The Health Foundation, June 2015). The factors relating to the lower than 50% recovery rate are not clear and neither is the data for sustained recovery over the longer term. In relation to the provision of a ‘safe’ mental health service, accurate triaging processes, together with regular staff support, training and development are also essential elements. 1.30 Embedding a Human Rights Based Approach underpinned by the PANEL principles (Participation, Accountability, Non-Discrimination, Empowerment and Legality.) should be supported through the strategy with objective of improving people’s experience in health and social care settings. o Additional Specific Comments offered by North Lanarkshire Council Social Work Colleagues: Realise the human rights of people with mental health problems While the consultation document, and this priority in particular, makes reference to areas of social policy and legislature, changes to which are currently in process, it would be preferable if human rights was seen less as a priority in relation to individual areas, than as a set of fundamental principles, which are embedded in the strategy as a whole. This said, we would welcome an initial short term review of incapacity legislation which recognises more recent changes to other primary legislation, including ECHR rulings and current practice in the field of mental health. We would anticipate this would offer a more flexible and responsive judicial process, whilst retaining appropriate judicial oversight. Thereafter, a fuller consideration of what a progressive legal framework in mental health requires in a modern day Scotland, would take place. We would welcome the opportunity to be in a position to support the expansion of access to Independent Advocacy and Interpreting Services. In addition, we would support the Mental Welfare Commission statement emphasising the need for the current role of the Mental Health Officer to be properly resourced and supported nationally, in order that the important safeguards in mental health and capacity law are upheld. In addition to the priorities described in the Consultation document therefore, we considered the following areas of work to be equally important: i) Considerations of accommodation and self directed support options for older adults with co-occurring mental and physical health problems, which provide realistic alternatives to institutionalised permanent care settings. ii) Development of explicit person centred, anticipatory and preventative approaches to promote easier access to services and to better inform treatment and support responses, such as Anticipatory Care Pathways that include information about mental health status and capacity. iii) Mental health of offenders: improvements in pre/post-release planning for individuals serving custodial sentences, who also experience mental health difficulties; renewed direction for Local Authorities, Crown Office and Procurator Fiscal Service to consider diversion from prosecution options in order to provide credible and robust alternatives to the criminal justice system; take up of the Mental Health Treatment requirement option in Community Payback Orders (CPO) has only been used in 0.5% of all CPOs imposed and increased take up could also reduce the use of custodial options. iv) Focus on a lifespan approach to service delivery and open access to treatment and support, where the focus is on person rather than problem or diagnosis or age. 1.31 Reducing physical health inequalities for people with a mental health problem should be an explicit and measurable objective of the 10 year strategy, with a focus on identifying ‘what works’. While prevention programmes such as those mentioned in the Consultation document (for example, smoking cessation, alcohol harm reduction and screening mechanisms) have been in place for several years, their effectiveness among people with mental ill health remains low. This is possibly on account of the multi-factorial vulnerability factors influencing the use of cigarettes and the lack of direct targeting on the wider social, emotional and psychological factors that may serve to promote or maintain their use, through NHS Health Improvement policies and local protocols for community based mental health services (ASH, 2015). Similarly, the damaging effects of alcohol are not explainable solely by over-consumption but also by the combination of socio-economic and relational pressures, poor diet and deprivation of positive experiences and relationships (Rehm et al., 2009). Embedding Health Improvement Programmes, in a co-ordinated way within community based services, supported by organisational systems and/or structures, and the role of co-production in community capacity building approaches may be required, to better understand and effect change in individual life circumstances, from where people live to the influences and deprivations which drive and maintain the use of alcohol, cigarettes or other psycho-active substances which together can perpetuate health inequalities and poverty of life experiences. 1.32 Greater focus on the needs of people experiencing the greatest inequalities with systems to record and demonstrate that people in our most deprived communities are accessing and benefiting from the range of supports that are available is required. This includes building capacity, skills, knowledge and confidence in those working with high risk populations. Groups that could benefit from particular focus are: o People who are homeless o Veterans o Looked after and accommodated young people o People who are unemployed or living with financial insecurity o People living with long-term conditions o People in prison o Black and minority ethnic communities o People involved in the justice system 1.33 Support for families and carers (including kinship carers) should receive significant focus in the next strategy, recognising that the success of a community based strategy relies heavily on the role of family and carers. 1.34 The Live Well section should make clear that this applies throughout the entire lifespan, including into old age, however the specific issues faced by older people could be more explicit as this population has featured very little in previous mental health strategies. 1.35 Loneliness is recognised as significant public health issue; supported by evidence, impacting on poor mental health, poor physical health, pre-mature death and poorer recovery rates. The strategy could have reducing loneliness as key theme running through all strands and a specific outcome. 1.36 A joined up assertive approach to the legal issues including early signposting and referral for assessment of capacity and general cognitive functioning would facilitate more appropriate community based supports, the promotion of Powers of Attorney, Advance Statements and Advance Directives reducing significantly later hospital admission and subsequent delayed discharged resulting from late assessment of capacity and the need to progress applications for welfare and financial guardianship which in itself is a lengthy process. The role and responsibilities of General Practitioners in this area cannot be underestimated. 1.37 Psychological Capacity v Cognitive Capacity: A specific comment from psychological therapies asked the question “Is this the opportunity to begin to better explore the distinction between psychological capacity and cognitive capacity. The latter is relatively well understood and has legislation and guidelines attached. Psychological distress alters capacity to make decisions in a different way, and while we must be cautious to promote the rights and restrict the choices of those who are distressed by applying the AWI legislation, we must do better at recognising that those who are distressed may not be making ‘choices’ without skilled supports to assist with the containment of challenging psychological processes and emotions. A pathway to guide access to these supports, without activating restrictive legislation such as AWI, would be helpful.” 1.38 Allied Health Professionals: The cradle to the grave idea is welcomed. It fits well with new AHP ALIP Strategy which is due at the end of 2016 and many of the same themes can be mapped within the 2 documents. A concern was raised that the does not accounts for the hardest to reach groups - with multiple functional issue that often prevent or hinder engagement from early intervention to mediation compliance, and just not sure that the severe and enduring end of the spectrum will be served as well as they could . I liked the notion that physical health of those with mental health issues are being highlighted and pushed up the agenda to try to reduce this inequality poorer mortality rates for patients (up to 15- 20 years). While I welcome the idea of link workers - I was disappointed to note that they were being tasked with VR support to access and stay in employment and that AHP and in particular the significant OT contribution was not highlighted or noted within VR. 1.39 Co-morbidity (substance misuse and mental health problems): Improving co-ordination and collaboration for people experiencing both substance misuse and mental health problems continues to require specific focus due to lack of progress in some aspects. The SG could lead the way by showing improved connection between policy and strategy and consider a joint and integrated approach to Mental Health and Substance Misuse Policy, facilitating improved local connections. 1.40 Gaps in existing services: A focus on the relationship between mental health and trauma, substance misuse and development disorders is welcome. It is suggested that while some specialist services are required much of the solution requires a generic approach to addressing these issues such is the prevalence. Through the duration of the next strategy we would like to see these implemented through national support embedded with the performance review framework. Ensuring an appropriate response to gender based violence within mental health services was also highlighted. 1.41 Stigma : A continued focus on reducing stigma is required supported by embedding the Rights Based Approach as is the continued support of See Me. However, there is gap in the current national programmes in relation to dementia. The National Dementia Strategy identified the taboo of dementia as one of the five key challenges. A national programme to support addressing this would be welcome. 1.42 Recovery: The continued support of the Scottish Recovery Network is very welcome. Creating the expectation and possible trajectory, that the Scottish Recovery Indicator should be completed by local inpatient and community mental health services would support translation of information, training and policy into direct client experience. At every stage we should look to effect first level change that benefits individuals, through accessible services and opportunities which facilitate recovery (SRN). But also effect second level change aimed at creating the conditions within community that maintains recovery including improving public attitudes (see me), increasing access, reducing barriers and supporting connections. 1.43 Community Asset Building – As you will know the assets approach has received a strong positive focus through the Christie Commission report and Chief Medical Officer support. Some national support to progress and evaluate this at a local level would be welcome. The assets based approach is strongly supported by both the adult and children’s indicators and links very closely with the recovery approach i.e. is about strengths and in particular, resilience or what enables individuals and communities to survive, adapt and/or flourish, notwithstanding adversity. Social prescribing (SP) (sometimes called community referral) is a mechanism for linking people with non-medical sources of support within the community. The ‘see me’ pledge can form an important part of the Social Prescribing Programme with specific pathways developed to improve access to benefit, welfare and debt advice, biblio-therapy (through libraries) employment, access to green space, leisure, learning, arts and culture and volunteering opportunities. National support to help embed these programmes across Scotland would be welcome. In addition, resources such as community libraries, developed as community hubs where people are able to access a range of information, people and services/groups etc., regardless of age or ethnicity, could begin to set a scene for a more society based approach to valuing mental health and give us the best chance of nourishing wellbeing, 1.44 Self-management & Self Care: The development of community based, accessible, psychological self-help resources for common mental health problems, designed in a way that is sufficiently flexible for people of all age groups with a range of difficulties, and including those from diverse backgrounds is fundamental to the promotion of early intervention and prevention strategies. Peer Support workers are available in the Lanarkshire area although demand is currently outstripping the resource we have and is not available in the evenings or at weekends. A combination of Link Workers and Peer Support Workers would be welcomed, if this would make it more possible for support to be sustained and the workers themselves to be supported in their role. The notion of “developing more accessible psychological self-help resources” is useful. Can this be addressed at a national level, with Boards working collaboratively, perhaps through NES? 1.45 Green Space; was highlighted in many responses as an area that has developed significantly since the last strategy and would benefit from inclusion in the next strategy in the same way social prescribing featured in the last strategy “further enhance understanding of the role of green space in promoting a mentally healthy Scotland”. 1.46 Preventative and nurturing: mindfulness was highlighted in many responses as an area that has developed significantly since the last strategy and would benefit from inclusion in the next strategy in the same way social prescribing featured in the last strategy “further enhance understanding of the role of mindfulness in promoting a mentally healthy Scotland”. It was proposed by one mindfulness practitioner that we should adopt as a national vision the perspective of mental wellbeing as a positive set of traits to be nurtured for life, rather than the present deficit model of a problem which affects a set of individuals who, when they despair, seek and get help. Related to this, and in line with the general desire for workplaces to be places where employees and others feel well and nurtured, we should formally adopt the wider measurement of societal success of GNH (Gross National Happiness) or the similar versions created by Oxfam (the Humankind Index) in place of or in addition to the current use of GDP and GNP, and similar evidence-based practices being practiced regularly each day in schools at all levels, from nursery through to sixth year at secondary. It should be considered as essential as we now regard cleaning our teeth twice a day. 2.1 A taking stock exercise: where are we now in relation to the strategic, clinical and operational work that have already been undertaken and completed from the previous mental health strategies? Are the performance targets currently in place effective both from a qualitative and a quantitative perspective? Where do we want to go with what has already been accomplished? What are the priorities that naturally flow from this work? What infrastructure is required to make further progress across integrated services and to embed community capacity building? 2.2 Building in clear evaluation and review processes across the timeframe, for the range of priorities set is also fundamental. Many of the anticipated outcome listed read more like process out puts as opposed to clinical, personal or experiential outcomes. A 10 year strategy provides real opportunity to begin to establish base-line and then monitor, evaluate and learn. By gathering useful information now, then this should support longer-term review and planning into the next 10 year strategy and the next one after that. Can we collect some useful information/ data with confidence and commitment that we will continue to collect it over the duration of future strategies? The commitment to update of the Mental Health Improvement Outcome Framework is of real value. Emphasis on outcomes needs to be bolstered by qualitative research looking at views of services users and providers 2.3 Investment in workforce support and development which recognises staff as an asset and the qualities, skills, knowledge and experience they bring as fundamental to the delivery of an effective, compassionate and resilient infrastructure in any mental health service. 2.4 The results are positive; however outcomes must be fully integrated into the strategy. We would suggest an integrated health and care system that supports mental health wellbeing at every point of delivery, and where screening, signposting, and onwards referral is smooth and consistent. This would entail moving away from the notion that only Mental Health services ‘treat’ mental health issues. Mental Health services currently mostly assess and intervene with mental illness. Much more could be done to promote mental wellbeing from a public health perspective and throughout all services. All Of Me principle is a good way to do this, but the current proposal does not seem to clearly state what this should actually mean for either the ethos of the principle or where responsibility will lie. 2.5 There should also be more of a specific interpretation of psychological models and interventions in the context of issues specific to ageing, with consideration of the differentiation between psychological and cognitive capacity. 2.6 Learning disability requires an increase focus in the strategy including cross referencing, recognising the co-morbid relationships including the specific needs for families and carers.

3. The table in Annex A sets out some of the results we expect to see.

What do you want mental health services in Scotland to look like in 10 years' time?
3.1 A Scotland where a step has been made towards understanding mental health and wellbeing as a social philosophy, where all aspects of society and all organisations from town planning, to housing, to public and third sector bodies have a role to play in the anticipation of mental ill health and distress, and including the different ways in which individuals need to be connected to networks of support. As such, a strategically driven approach to increasing organisational connectedness across all sectors in the delivery and resourcing of mental health and wellbeing services/approaches is required. Additional References: ASH Scotland (June 2015). Smoking and mental health: a neglected epidemic. http://www.ashscotland.org.uk/media/6671/ASHScotlandSmokingandmentalhealth.pdf Mental Welfare Commission for Scotland (September 2016). Investigation into the care and treatment of Ms OP by NHS Board C. Edinburgh: The Mental Welfare Commission. The Health Foundation (June 2015). IAPT and targets: what has been achieved, and where next? http://www.health.org.uk/blog/iapt-and-targets-what-has-been-achieved-and-where-next Rehm, J., Mathers, C., Popova, S., Thavornsharoensap, M. and Patra, J. (2009). Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders, Volume 373, No. 9682, p2223–2233, The Lancet, Elsevier Limited