1.Executive Summary and Implementation Plan

2.Aberdeenshire Response to the Mental Health Framework 

1. North
2. Central
3. South

 Appendix 1 - Membership of Strategic Planning Group

Appendix II - Map of Aberdeenshire

Appendix III - Mapping Exercise

1. 1.1 This report summarises the Aberdeenshire response to the Framework for Mental Health Services in Scotland, launched by the Scottish Office in September 1997. The Framework requires Local Authorities, Health Boards and NHS Trusts to develop an effective local Mental Health Strategy and a six year costed implementation plan to achieve a comprehensive local Mental Health Service.

1.2 This Mental Health Service should seek to address the full range of needs of all people with mental health problems and ensure that people with severe and/or enduring mental illness are a first priority. The Mental Health Strategy should provide a home based service wherever practicable, or in small facilities as close as possible to the individuals' home.

2.1 A Strategic Planning Group chaired by Aberdeenshire Council and comprised of representatives of service users, Council services, Health interests and service providers has co-ordinated the planning process.

2.2 The Locality Planning Groups, which are part of the Community Care infrastructure reviewed the mental health services in their areas and produced reports which form the basis for this Aberdeenshire Strategy.

3.1 Joint Commissioning of Health and Social Care Services in Mental Health

The cornerstone of the strategy for the future provision of Mental Health Services in Aberdeenshire is that they should be jointly commissioned by representatives of the main planning partners, service users and service providers. This joint commissioning team would be responsible for overseeing new expenditure and the reconfiguration of existing expenditure on Mental Health Services across Aberdeenshire. They would also be responsible for the evaluation of new and existing Mental Health Services to ensure appropriate outcomes for service users and the achievement of best value.

Priority areas are -

3.2 The development of appropriately resourced, Aberdeenshire based community mental health teams for adult service users.

3.3 The development of appropriately resourced, Aberdeenshire based community mental health services for children and adolescents.

3.4 The development of a range of locally accessible community based mental health services which will provide crisis care, respite care and supported accommodation for people who suffer from severe and enduring mental illness. The aim of these services will be to respond to the stated wishes of users and carers for them to receive services at home or in their own communities. This will be achieved by preventing inappropriate admission to hospital and facilitating early discharge.

3.5Seeking to establish a secure basis for the funding of Voluntary Organisations, which provide essential Mental Health Services.

3.6Facilitating the development of a range of opportunities to address the social isolation and exclusion experienced by mental health service users, such as education and employment opportunities, social and recreational activities.

3.7To review on an ongoing basis the identified needs of service users, particularly in relation to the level and location of specialist Secondary Care Services.

1.1 The Framework for Mental Health Services in Scotland was launched by the Scottish Office in September 1997, in response to the Select Committee's report into the closure of Psychiatric Hospitals in Scotland.

The Framework sets out the political and professional context within which Local Authorities, Health Boards and National Health Service Trusts should plan to deliver Mental Health Services.

The Framework requires the planning partners to adopt a functional approach and to provide services based on assessed individual need. It recommends starting with a blank sheet where nothing is sacrosanct and developing core services, which are locally delivered. These services must be planned and delivered in conjunction with service users, based on what is known to improve the quality of their lives and their mental health.

1.2 Since the Framework was launched, the Scottish Office has also produced a number of new initiatives.

1.2.1 The White Paper "Designed to Care", which sets out how the Health Service should seek to improve patient care and also deals with the alignment of Primary and Secondary Health Care.

1.2.2 The Green Paper "Working Together for a Healthier Scotland", which seeks to tackle inequalities in health by creating healthier communities. It recognises the social and economic factors, which influence the health of the population.

1.2.3. The "New Deal" and "Welfare to Work" initiatives also reflect the Government's intention to improve access to employment opportunities and thereby deal with aspects of social exclusion which can have a negative impact on health.

2.1 Aberdeenshire is a large, mainly rural, area covering 2,430 square miles with a population of 227,430. Unlike many other parts of Scotland, the population continues to grow which places increased demands on existing services such as Health, Social Care, Education and Housing.

2.2 There are ten main towns, which range in size from 4,100 to 19,000.

2.3 The economy relies heavily upon the traditional industries of fishing and farming. Tourism is of increasing importance and a significant number of people commute to Aberdeen for employment.

2.4 Existing Mental Health Services

2.4.1.Primary Care (General Practitioner, Community Nursing, Care Management Services) - These services, which are based in local Communities continue to deal with the majority of people with mental health problems - 80%.

2.4.2 Secondary Care (Consultant led specialist services) - Royal Cornhill Hospital in Aberdeen City provides the majority of services to the acutely mentally ill and those with severe and enduring mental illness

Some in-patient services are also provided by Angus and Moray Health Care Trusts.

In Scotland, approximately 80% of the monies spent on Mental Health Services is committed to in-patient care, although this deals with only 20% of those people with psychiatric problems. The Aberdeenshire situation reflects a higher percentage spend on Aberdeen situated inpatient care.

2.4.3 Community Mental Health Services (Community Mental Health Teams, Social Care Services, Specialist Residential and Nursing Home Services) - These have been developed over a number of years through joint working initiatives by Social Work and Health staff.

Mental Health Teams which are staffed by Social Workers and Community Psychiatric Nurses who are based at Royal Cornhill Hospital provide an outreach service to Aberdeenshire.

Community Mental Health Teams such as the Old Age Psychiatry Team North Aberdeenshire, and the Dementia Teams in Central and South Aberdeenshire are locally based with similar types of staffing. These teams have been successful in assisting service users to stay in their own home areas, rather than being admitted to hospital in Aberdeen which can be up to 60 miles away.

A range of self help groups, employment initiatives, drop-in facilities and supported accommodation projects have been developed through Mental Illness Specific Grants and Resource Transfer. These Community Mental Health resources are highly regarded by service users. However, their development remains patchy across Aberdeenshire and those that do exist cannot meet the demand for their services. The location of existing services is shown on the maps in Appendix III (1-7).

It is anticipated that some specialist services will continue to be provided on a Grampian wide basis in Aberdeen e.g. Forensic Services.

3.1 A Strategic Planning Group has been convened, and is comprised of representatives from service users, Aberdeenshire Council's Social Work and Housing Service, Grampian Health Board, Grampian Healthcare Trust,General Practice, the independent sector providers and the Local Health Council. A list of members of the Group is included in Appendix I. The Group agreed that the following tasks were a first priority -

(a)Assessment of local need in terms of epidemiological data and qualitative data from people who receive services and their carers and from professionals working at a local level.

(b)Gathering information on the scope and activity of existing services.

(c)Estimating the resources available and their existing distribution.

 Due to the size and nature of Aberdeenshire, Community Care Planning takes place at a local level by three Locality Planning Groups, one each for North, Central and South Aberdeenshire. As can be seen in Appendix II, each of these covers a large geographical area. The Locality Planning Groups undertook the work identified above as a priority by the Strategic Planning Group.

3.2 Locality Planning Groups

The Locality Planning Groups are comprised of representatives from Aberdeenshire Council's Social Work and Housing Service, Grampian Health Care Trust, G.P. Facilitators, Education and the voluntary sector who meet regularly, to plan and co-ordinate local services. The Locality Planning Groups commissioned a number of short term working groups which involved services users and carers, to gather the information required for the service profiles outlined in the Framework document. These groups identified existing services, identified gaps in service and suggested ways of filling the gaps.

The Locality Planning Groups have each produced a comprehensive report which has been summarised for this report. A copy of the full report is available from the Convenor of the Strategic Planning Group (see Appendix I).

3.3 Local Health Council

The Local Health Council employed a Project Worker to assist the Locality Planning Groups in gathering information from service users. A questionnaire was developed and sent out to service users. The Project Worker attended discussions and focus groups and interviewed individuals. Three reports were produced and these have been incorporated into the Locality Planning Group Reports.

3.4 General Practitioner's Views

The General Practitioner and the Primary Care Team are often the first contact for people with mental health problems and it was vital to have their views and thoughts incorporated into the information gathering exercise. A G.P. Facilitator (Community Care) is a member of the Strategic Planning Group and the Local Health Council Project Worker sent a questionnaire to G.P. Practices and the results have been included in her report. In addition, G.P. Facilitators attend the Locality Planning Groups in Central and South Aberdeenshire. Work is ongoing to engage a G.P. Facilitator in North Aberdeenshire.

3.5 Seminars

An Aberdeenshire Seminar took place in March 1998 attended by 60 people including service users and GPs. This was facilitated by the Director of the Scottish Development Centre for Mental Health Services. The findings from the Seminar have been incorporated into this Report.

A Grampian-Wide Seminar also took place in March 1998, again facilitated by the Director of the Scottish Development Centre for Mental Health Services.

3.6 Common Issues Group

A Common Issues Group was convened by Grampian Health Board to consider specialist services across the Grampian area. Officers from Aberdeenshire, Aberdeen City and Moray Council met staff from Grampian Health Care Trust, Moray Health Services Trust and Grampian Health Board to discuss common issues, including Forensic Services, long stay Hospital provision, eating disorders, Clinical Psychology, Rehabilitation Services, Community Mental Health Teams and Advocacy. The outcome of these discussions has been incorporated within this report.

3.7 Planning for the Future

Future plans are based on statistical information and on data gathered during the initial consultation exercise. Care arrangements will be based on the needs of individuals and their carers and will involve risk assessments for people with severe and enduring mental illness. The Care Programme Approach can be used to ensure that the needs of those most at risk are met and reviewed on a regular basis.

4.1 The Joint Community Care Plan 1998-2001 estimates the following numbers of adults based on prevalence rates within the population.

4.2 Indicators of deprivation, such as the Jarman Underprivileged Area Score, rates of unemployment and lone parent statistics indicate that Peterhead, Fraserburgh, Banff and Huntly areas are most likely to be affected by poor health. These can be seen on the maps in Appendix III (1-7)

4.3 Hospital Consultant out-patient statistics for adult psychiatry indicate that the following areas had the highest number of attendances in Aberdeenshire.

1996/97

Statistical and epidemiological information is available in large quantities and detailed study is ongoing to identify patterns and indicators relevant to Aberdeenshire.

4.4 Joint Health and Social Care assessment and outcome measurement systems do not presently exist in Aberdeenshire. The development of a joint core assessment and evaluation system will be a pre-requisite for effective joint working in the future.

4.5 Services Users' views are that they:

*prefer to be in the community rather than hospital

*want access to locally based services

*want support at home to live an independent life

*want meaningful employment and social activities

*want access to respite and crisis services

*want health services available when needed, particularly in times of crisis

*want information readily available

5.1 Service shortfalls across Aberdeenshire

A significant number of service shortfalls were identified by all three Locality Planning Groups and their development will form the basis of core health and social care services across Aberdeenshire.

(a)Community Mental Health Teams (Adults)

Although these exist to some extent, some are Aberdeen hospital based teams which visit patients in the community. Others models of teams are locally based specialist teams such as the Dementia and Old Age Psychiatry Teams.

The services provided by these different teams would be enhanced if they were based in the areas that they serve and were aligned with Primary Care Teams and the emerging Local Health Care co-operatives. This would avoid duplication of work, reduce unnecessary travel for both users and staff and assist the development of a seamless service between Health and Social Care.

The teams should be comprised of Social Work and Healthcare staff including Occupational Therapists and Homemakers. Consultant Psychiatrists and Clinical Psychologists should have regular input to the team's work.

(b) Community Child and Adolescent Psychiatric Services.

The existing Psychiatric Service is based at the Children's Hospital in Aberdeen. Significant levels of resources are committed by Health, Social Work and Education services to tackle a small number of children and adolescents who exhibit disturbed and disturbing behaviour. These resources and services are not strategically co-ordinated. Further work is required to develop joint working practices and a model of service delivery which will deliver effective locally based services at best value.

(c) Social care services

Shortfalls exist in respite care, rehabilitation and supported accommodation provision, the development of which has been patchy across Aberdeenshire.

(d)Other services

Shortfalls exist in employment training and assistance into work, further and continuing education opportunities for service users, day activities and social opportunities. The lack of information about available resources and services is consistently raised by service users and carers.

(e)Security of Funding

The Voluntary Sector are significant providers of mental health services in Aberdeenshire. Organisations such as NSF provide drop-in centres, befriending and advocacy services. They are funded through a combination of the Mental Illness Specific Grant, Resource Transfer and their own fund raising efforts. Uncertainty about the future of the Mental Illness Specific Grant and alternative funding arrangements does not assist them to recruit and retain high calibre staff.

5.2 Specific Service Shortfalls by Local Authorities Areas -

(a) North Aberdeenshire -

(i) Banff and Buchan

*development of 24 hour staffed rehabilitation and respite facility in Banff

*Psychogeriatric beds in Fraserburgh

*small residential dementia unit in Portsoy

*further development of residential accommodation in Fraserburgh to increase staffing to 24 hours

*development of home detoxification service for drugs and alcohol

(ii) Buchan

*small residential dementia units in Old Deer and Peterhead

*development of home detoxification service for drugs and alcohol

*development of a 24 hour staffed mental health resource in Peterhead

(b) Central Aberdeenshire

(i) Formartine

*development of flexible resource in Ellon offering respite, rehabilitation, crisis accommodation, day services and outreach

*dementia day hospital places in Turriff

*small group residential provision in Oldmeldrum for people with dementia

*locally based detoxification services for drugs and alcohol

(ii) Garioch

*development of flexible resource in Inverurie offering respite, rehabilitation, crisis accommodation, day services and outreach

*locally based detoxification services for drugs and alcohol

(c) South Aberdeenshire

(i) Kincardine & Mearns

*day hospital and rehabilitation facilities

*development of specialist residential/EMI units for older people

*locally based detoxification and rehabilitation service for drugs and alcohol

(ii) Marr

*development of flexible resource in Huntly offering respite, rehabilitation, crisis accommodation, day services and outreach

*day hospital and rehabilitation facilities

*development of specialist residential/EMI units for older people

*locally based detoxification and rehabilitation service for drugs and alcohol

7 EXISTING FINANCIAL RESOURCES COMMITTED TO MENTAL HEALTH SERVICES

7.1 Social Work

(i) Within the Social Work Budget for 1998/99 the gross amount allocated specifically to Mental Health services is as follows:-

(ii) Aberdeenshire currently contributes 30% of the staffing costs of the Royal Cornhill Hospital Social Work Teams. For 1997/98, this amounted to £155,338

(iii) Much of the social work involving mental health issues is hidden within other areas, such as work with children and families, older people and people with learning disabilities. Using estimates of the percentages of these other groups who have mental health difficulties, it could be calculated that approximately £13 million or one third of the total social work budget is related in some way to mental health.

7.2 Grampian Health Board

Figures awaited

7.3 Grampian Health Care Trust

Figures awaited

Please refer to Executive Summary.

The need was identified for:

*local, community based services and support

*an expansion of existing community based mental health teams with dedicated health and social work staff as well as PAMS and clinical psychology

*co-terminosity of boundaries between health and social work

*some acute inpatient beds

*local day hospital facilities and 24 hour staffed respite, rehabilitation and residential provision for the small numbers who have more severe and enduring illnesses.

*a crisis response service to reduce the need for inappropriate hospital admission

*a comprehensive local child and adolescent psychiatric service

*education and training for the general public and a range of staff on mental health issues

*a forum for collaboration to ensure maximum results and no duplication as services develop

*NHS psychogeriatric beds in Fraserburgh

*small residential dementia units in Old Deer, Portsoy and Peterhead

*resources for local detoxification for those who misuse alcohol and drugs

*continue to offer hospital beds for those in the acute stages of illness

*offer services that are as local as possible

*all services should be focused around locally based multidisciplinary community mental health teams

*offer, where necessary, locally based intensive 24 hour staffed respite, rehabilitation and residential provision

*offer day supports to those, who in the past would have required day hospital provision

*further develop crisis response services, particularly those that avoid unnecessary hospital admission

*underpin with more secure funding: specialist home support; day services, befriending (counselling), information

*ensure better education of the general public and all care providers in mental health issues

*staff dedicated to the overall development and co-ordination of all mental health services within the area, ensuring early involvement with the Primary Care Co-operatives

*expansion of community mental health teams, especially to ensure aggressive outreach and crisis response services that avoid inappropriate hospital admission.

*development of local 24 hour staffed rehabilitation and respite facility in Banff

*further development of residential accommodation in Fraserburgh to increase staffing to 24 hours

*additional funding to The Arches for outreach worker for young people with schizophrenia

*reconfiguration of day provision in Fraserburgh and Peterhead to maximise service to those in most need

*development of home detoxification service (for drugs and alcohol)

*NHS psychogeriatric beds in Fraserburgh

*Dementia Day Hospital places in Turriff, with a reconfiguration throughout the area

*residential dementia unit at St Drostans

*local child and adolescent psychiatric service

*development of a challenging behaviour/rehabilitation unit for people with a dual diagnosis

*further consideration of staffed residential resources for the elderly functionally ill

*review and further development of residential services in Banff and Fraserburgh

*development of 24 hour staffed mental health resource in Peterhead

*development of services for children and adolescents

*developments in all areas as a result of reviewing progress and success with various models to date

*under development of services locally

*wish of users and carers for community based services including many of those currently provided in hospital

*development of integrated services in the major centres, with priority to Huntly, Inverurie and Ellon, which could offer respite rehabilitation and crisis accommodation, day services and outreach staff in a flexible manner

*need to develop multi disciplinary working including co-terminosity of boundaries between Mental Health Teams and Community Services and a community base for Community Mental Health Teams

*Need for further dedicated staffing including CPN, SW/MHO, Clinical psychology and PAMS

*need to develop a 'whole person' approach including meeting needs for education, leisure, social inclusion, housing and an employment service which works across all user groups

*need to increase funding for community based services and secure longer term funding for valued Voluntary Sector provision

*need for a range of supported accommodation

*development of 'Foyer' type services in locations throughout Aberdeenshire

*development of the range of services available for people with dementia particularly minority group services, non institutional respite, housing models of care and a small group residential provision in Oldmeldrum

*development of a community based multi disciplinary team aligned to the Dementia Team to meet the needs of older people with functional illnesses

*need for localised services for older people with functional illnesses including respite crisis and residential accommodation and day services

*development of a multi agency assessment service and joint funding arrangements to provide a flexible service provision for children and young people with mental health problems

*development of multi disciplinary working for people with learning disabilities and mental health problems

*development of a drugs service

*need for a specialist alcohol CPN

*creation of locality based detoxification services

*services that are localised

*respite, rehabilitation, crisis and residential accommodation provided in a flexible manner

*day service provision which can meet the needs of a range of user groups including those with severe and enduring illnesses

*an employment service targeted at those with mental health problems and other groups. Involvement of other agencies and public education to ensure a 'whole person' approach to meeting the needs of people with mental health problems

*crisis services which are community based

*development of locally based community mental health teams with increased dedicated staffing

*provision of joint training to a range of providers

*increase in funding for the development of new services and security of funding for current provision

*advocacy for users and support to carers

*commissioning manager, care managers and development of joint commissioning team. Locally based community mental health teams with boundaries aligned to community provision and increased dedicated staffing

*resources in Huntly, Inverurie and Ellon which offer respite, rehabilitation and crisis accommodation, day services and outreach provision by flexible use of facilities and staffing

*Aberdeenshire wide employment service for all user groups

*ongoing public education programme developed by Health Education

*locally based multi disciplinary team to meet needs of older people with functional illnesses

*pilot project for multi agency assessment of children and young people with Mental Health problems

*specialist drugs service

*specialist alcohol CPN

*community based detoxification service

*non-institutional respite for older people with dementia or functional illnesses

*joint training developed for range of service providers

*small scale residential unit for people with dementia in Oldmeldrum 2000

*locally based services for older people with functional illnesses including developing current day services and residential accommodation and provision of new services

*multi disciplinary working developed in relation to people with learning disabilities and mental health problems

*development of a range of accommodation

*Foyer type services

*development of provision for minority groups who have dementia e.g. those with learning disability, younger people

*review of progress

*identifying existing provision

*identifying gaps in provision

*proposing developments in provision

*consultation workshops (care elements)

*working group (services profiles)

*social work staff questionnaire

*carers survey (dementia)

*consultation seminars (dementia - 1997)

*interviews with service users (ongoing)

*meetings with GPs (ongoing)

*Local Health Council user and carer survey

There is a need for -

*information for users and carers

*quicker and easier access to services

*earlier intervention

*local, community based services

*more specialist staff in health and social work

*education and training for non specialist staff

*better communication between professionals and agencies

*outreach services by specialist agencies

*day hospital and rehabilitation facilities

*respite, residential and supported accommodation

*home support services

*day activities, social and support services

*training and employment opportunities

*crisis intervention and response services

*more secure funding for mental health projects

*consideration of rural transport issues

*community mental health teams - multi disciplinary, community based, aligned to Primary Health Care

*Psychological, Psychotherapeutic and Counselling services

*crisis prevention and intervention services

*community support teams - providing range of domiciliary and other support services under direction of CMHT  

*"drop in" centres - local resource centres with (visiting) day hospital facilities, therapeutic and recreational activities, social contact and support services

*training, pre-employment and employment provision

*respite and permanent accommodation with appropriate support services

*mental health awareness campaign

Community dementia team - enhanced staffing to include PAM services

*elderly functionally ill team - multi disciplinary, community based - aligned with CDT

*local day hospital/day care provision

*local respite, including "Home from Home" type

*specialist residential/EMI units

*range of services for younger people with dementia and carers

*mental health education in schools

*development of joint agency, multi disciplinary approaches - education, social work, health

*enhanced child and adolescent psychiatry services, with outpatient clinics

*therapeutic day care (7 day) with educational facilities

*inpatient beds with some secure provision

*enhanced PAMs team

*increase in clinical psychology and availability of psychological therapies and counselling

*treatment, self help and support services for eating disorders

*rehabilitation and care services for those with brain injury

*development of joint agency, multi disciplinary approaches

*enhanced PAMs services

*outreach mental health services to day centres, residential units

*small units with 24 hour care, treatment, and day activities for those with more severe, enduring problems

*"drop in" facility - access to health care, support services, assistance with accommodation

*temporary accommodation with assessment of longer term needs

*range of accommodation with appropriate support

*co-ordinated, joint agency approach to homeless, housing, tenancy problems

*outreach services from specialist agencies

*detoxification and rehabilitation services - residential, day and home based treatment

*local services for - needle exchange, methadone programme, drug prescribing

*self help and support groups

*counselling and support services for carers and families

*supported accommodation for those with long term care needs, e.g. Kosakow's syndrome

*diversion programme (from prosecution)

*post sentence risk assessment

*greater use of deferred sentence with action plans for support

*through care programme - Criminal Justice Service with Forensic Unit

*development of home-based support and other community services (through Care Management)

*Community mental health teams

*community dementia and elderly functionally ill teams

*increase in clinical psychology services

*child and family psychiatry - increased staffing, outpatient clinics

*"drop in" facilities - local "resource centres" with day activities

*outreach services from specialist agencies in substance and alcohol misuse

People want mental health services that are -

*delivered locally

*seamless (with easy access)

*responsive to changing needs

 There is a need for development in all aspects of service provision in Aberdeenshire South with,

*multi disciplinary mental health teams

*domiciliary support services

*social and recreational provision

*training and employment opportunities

*support for carers

The aim is to help people to lead fulfilling lives in the community