 I welcome everyone to this, the 28th meeting of the Public Audit Committee in 2023. The first item on our agenda is for members of the committee to consider whether or not to agree to take agenda item 3 in private. Is the committee content to do that? We are agreed. Thank you very much. Our principal agenda item this morning is consideration, or further consideration, of the Auditor General for Scotland Accounts Commission report on adult mental health. I welcome everybody to the meeting this morning. We are very pleased to see you. The committee is taking evidence today in a round table format, and that will allow for a more free-wheeling session where we will be drawing on the experience of people and those they represent as well, both in the room, which I'll come to shortly, and online. For those of you that are online, which is the majority of you, if you want to come in at any point, if you could put request to speak in the chat box, that would be very helpful, that would assist us in making sure that you are brought in when you want to. Can I also ask you to keep on at all times your audio and camera? Your audio will be operated through the Parliament, so we'll turn on your mic for live audio when it's a point at which you want to speak. What I want to begin by doing, which is customary for the round table format, is for people to perhaps introduce themselves. We'll go round one by one, but we'll start with Joe Anderson, who is here with us in the committee room. Joe, do you want to tell us who you are and your organisation? Good morning, everyone. My name is Joe Anderson. I'm the director of influence and change at SamH. SamH is Scotland's mental health organisation. We deliver services across Scotland, and we're delighted to have been invited today. Thank you very much indeed. Can I turn to those who are joining us remotely and begin, maybe, Merriam, with you? Hi, good morning. I'm Merriam. I'm a project coordinator of International Women's Group. We are based in Glasgow, and we are providing counselling services to ethnic minorities. Thank you. Thanks, Merriam. That's very helpful. I'll now turn to Paula to introduce herself. Paula Fraser. Hi, I'm Paula Fraser, and I'm acting manager of voices of experience, or Vox Scotland, and we're a members-led mental health collective advocacy organisation. Thanks, Paula. Peter, do you want to introduce yourself next? Good morning. I'm Peter Kelly. I'm director of the poverty lands, which is the national anti-poverty network in Scotland. I'm very pleased to be here. Thanks, Peter. We're very pleased to have you here. Next, Dr Shari McDade. Shari. Good morning, everyone. I'm Shari McDade, and I'm the head of policy and public affairs for the Mental Health Foundation in Scotland. Sorry, just to introduce the organisation. I'm with the Mental Health Foundation. It's a UK-wide organisation with a dedicated presence in Scotland, and we focus on prevention of mental health problems. Thank you very much indeed, Shari. I'm now going to turn to Simon. Simon, if you want to introduce yourself. Thank you again. I'm Simon Portiff from the Royal Edinburgh Hospital Patients Council, and we're a collective advocacy organisation, obviously in Edinburgh, and I'm mainly here in support of Paula and Vox, where we're a Vox member. Thanks very much indeed, Simon. Last but by no means least, Kirsten, do you want to introduce yourself to us? Hi, everyone. I'm Kirsten Irkart. I'm the chief executive of Young Scots. We're actually a national youth charity supporting young people aged 11 to 26. We are a generalist youth support organisation, so we don't have a particular specialism in mental health, but support young people on a wide range of issues. I'm delighted to be here today. Thank you. Thank you very much indeed. We're very pleased that you are here. What we want to do is cover some of the ground that the Audit Scotland Accounts Commission reports covered. As I mentioned earlier on, if you want to come in, in particular, if you put RTS or request to speak in your chat box, that would be very helpful. Don't feel as though you are obliged to answer every one of the questions that we put. If you've got a particular hankering to come in, then we'll obviously take you, but there may be some areas that you don't have a particularly strong view on. What I want to do first of all is really go to a fundamental question that has been posed in the report, which is what the experience of people is, what the challenges are that people face when they are trying to access mental health services. I'm going to begin by inviting Joe, perhaps, to give us your take on that, and then I'll go to other members of the panel. Thank you. We were very welcoming of the report. We participated on a number of occasions, and we feel that it makes some strong recommendations that we do hope that the Scottish Government will take forward. Accessing mental health services was a key feature of the report, unsurprisingly. I think that, from what we hear when we talk to people, which we do every day, it's very challenging for individuals, often quite distressing, for people who are seeking help for their mental health. Confusing pathways, constantly having to repeat what is a deeply distressing situation that you have to account each time you meet a new health professional. Many messages about the length of time it might take to receive that support, or indeed that you might be deemed not unwell enough to receive that support. There's a lot going on in terms of messages that people are receiving as they're trying to access. People tend to, and we test on this quite often, people tend to use their GP as the main gateway to accessing support. Obviously, the report highlighted that. The last time we tested this, I think about 75 per cent of the population in Scotland said, that would be the first place I would go if I was feeling mentally unwell. What we also know from the work that we did in that survey was that people wait quite a long time to even reach out to their GP, and their mental health is worsening constantly. So it takes a long time for people to get to that point of asking for help, and then they are experiencing confusing pathways, long waits for treatment, so even after they might access that support in some way, shape or form, again that can be quite challenging. When the pandemic hit, we were most concerned about people who were already in receipt of mental health care and support, and what that meant for them during the pandemic, and in particular in the lockdowns. So we conducted some research with people who were in that situation, and six out of ten of the participants, and we tracked their situation over the course of the pandemic. Six out of ten participants reported challenges, seeking support from GPs and specialist services, lack of consistency in who was delivering that support, challenges with remote delivery, and long wait times to get to the specialist support. There's also a clear preference for face-to-face support among that population who already had some experience of mental health care and support. So there's a wide set of issues going on here around how difficult it can be for people when they've made the decision to seek help to then access it. Thanks, Jo. The expression in which the Auditor General used was slow and complicated. Do you think that sums it up quite well? Yes, it does. I think there are some good examples where there is progress being made, and maybe we'll come on to that in the discussion. Yes, absolutely. Graham, did you want to come in at this point? I did, yes. By the way, the other panellists, if you just put your hands up or whatever it is you need to do, doesn't all have to be Jo. But something that Jo said struck me as... I think this affects everyone. It's just people suffering mental health. Getting to see your GP now is more difficult, probably more difficult than it has ever been. If you have a mental health issue, and of course, as you all know, covers a broad range of... There is a broad range of mental health issues. Your first step is to get past a receptionist who you might have to phone up in order to see a GP, and if it's anything like my GP, you'll have to describe your condition. You might not want to, if you've got a mental health issue, you may just not want to tell somebody who's not a GP what that condition is. I just wonder if people think that is putting people off even seeking help, let alone getting help. I suppose the follow-up question to that would be, is the GP necessarily the best person to go to, or is there anywhere else you could go? I'm going to ask Jo to answer that, and then I'm going to bring in Peter on this general theme, and then other people might have a response to the GP gateway point which Graham has made. Jo, first of all. You're absolutely right, Graham. Describing the number of times you have to describe to somebody your situation and the receptionist is the first place. People have been telling us quite often, particularly during and post-pandemic, that it is difficult to even get to sit in front of a GP, and quite often they feel that there are other more prominent health problems that perhaps they don't want to put a burden on an audio-for-stretch system, so people face a reluctance, and that's a psychological thing that perhaps their situation is not as important as others, so they de-escalate on that basis. On the point about our GP's the only gateway to getting mental health support, it shouldn't be. We think that community-based direct referral supports should be widely available and have been calling for those kind of supports for some time. I'm going to bring Peter Kelly in, and after Peter I'll bring in Dr Sharon McDade, but Peter I'm going to turn to you next. It's kind of to pick up on some of the points that Joe's just made. In preparation for this session we did a snapshot survey with poverty lines members. We had around 60 responses on general issues around accessing adult mental health services. One of the things that struck us from the responses that we had was the increase in more focused approaches from community-based third sector organisations. We asked what the change in the representation of mental health issues for those organisations had been since before the pandemic to now, and around about 15 per cent were always dealing with mental health issues, so when individuals using their services presented, there was always a component of mental health in the reason for the presentation. We've now seen that 40 per cent of those organisations see people presenting with mental health issues every time. The organisations that we're working with have seen a significant increase in the representation of mental health issues. Some of them are specialist organisations working on mental health specifically. Many of them are not. Many of them are footbanks, advice organisations, and they're having to scale up, if you like, in order to deal with the change in nature of the issues that people present with. On the challenges that people face in accessing services, they are similar to what Joe has just mentioned. The importance of GPs, almost all the respondents talked about the importance of GPs being the initial gateway into receiving help, and there are very well-known problems with them. Access and GP services, and then the issue of what happens to the onward referral to specialist services where those are made, not always receiving a service once a referral is made, was one of the issues that was mentioned. I think that the additional question is some of the practical dimensions of access and services that a number of organisations based in rural parts of Scotland where the very real problems of accessible transport to allow people to actually engage services was a very real one, and that was something that actually acted as a barrier to people receiving the help that they need. There's much more I can say on the role of the third sector, but I know that we'll pick that up later on, so I'll leave it there just now. Thanks, Peter, we will, and we will also focus on the unequal impact of these health issues as well. Dr McDade, I'm going to come to you, then after that I'm going to bring in Kirsten from Young Scot, but Shari first of all to you. Thank you, and just to acknowledge that we're in the foundation very happy to be partnering with the Poverty Alliance on a programme to build the capacity of their member organisations to be able to support people's mental health. That programme is just in its early stages, and it's funded by the Scottish Government, so to acknowledge that. And I think that links very much with what we hear in terms of where the gaps are in support. So I want to highlight particularly that there are two at-risk groups that maybe haven't been raised so far, though others may come in on these perspectives as well, and I appreciate that. And I'm drawing on our concerns around black and minoritised ethnic communities from a round table that we held with organisations representing those communities when we prepared our submission to the mental health strategy, and also on our experience in hearing a diverse experiences advisory panel, which is an advisory panel that's been set up in order to inform the Scottish Government on its mental health policy and which the Mental Health Foundation provides the secretariat for the diverse experience advisory panel. From both groups, we heard very much that for people in minority ethnic communities, that there are concerns around them, individuals there, knowing how to access services. So there are significant problems with trying to know where to go for help and how to navigate the system, but also that when they do come in contact with the system, often they are met with a very white ethnocentric service that doesn't properly recognise the way that their community talks about mental health, understands mental health and how it's appropriate within that community to try and respond. So that is something that, while it's mentioned in the mental health strategy and the delivery plan that was just published earlier this week, mentions culturally sensitive services, but we can't see any specific action in the delivery plan that is there to deliver culturally sensitive mental health services, and that's a significant concern. Another group that we are working with is lone parents, and lone parents are a very high-risk group for a number of reasons. One is that they experience isolation just from the process of being a lone parent, but also they're much more likely to be living in poverty, they're at higher risk of having low income. So what we have heard from, and I've connected with my colleague who's running our program called Small Talk, working with lone parent organisations, is that while we have a perinatal mental health service, it's a specialist mental health services, and it's basically orientated towards providing crisis service for individuals or service for lone parents who have severe mental health problems. But we don't have provision for new parents, new lone parents for mild and moderate mental health problems. That's a huge gap, and I think that that really needs urgent attention. Thank you, that's very helpful. I am going to bring Merriam in next, because I'm sure you will pick up some of those themes, and then I'll come back and bring in Kirsten Merriam. Thank you, because she mentioned ethnic minorities as I'm working with women ethnic minorities. So the Scottish Government has acknowledged the existence of mental health inequality amongst ethnic minorities. This disparities of primary attitudes to lack of culturally appropriate service. And also the language barrier, there is language barrier for ethnic minorities to access the mental health service. International Women's Group has been providing the service, counseling service to ethnic minorities women since 2014, but we weren't able to manage to provide the service to all of them. So we faced a big challenge of waiting list as well because of that, and during the pandemic we started to provide the service through the WhatsApp contact, which is video contact, and was Arabic and English. So the culturally sensitive and multilingual service should be provided within the NHS service and reduce the waiting list, which caused worse in the situation within the women ethnic minorities. So I wanted just to add the cultural service and multi-language to the service. Thank you very much. Mary May, are you saying that multilingual information is available or that there is a gap there? It is a gap. It's not provided, so because of that we had to take this action and start providing the service within the ethnic minorities. It's not existing, so they provide interpreters which we found that women weren't comfortable to speak to two people like interpreters and the councillor, so they prefer to find the language they are looking for to speak face to face to councillor. Thank you. One of the themes that's highlighted in the report is the alarming rise in mental health issues for young people. That's why we're particularly keen to get young Scott to give evidence to us this morning. So I'm going to turn to Cerson to give us your perspective and the perspective of young people at this stage about accessing the service and the challenges that young people especially have been facing with it. Thank you. We, together with some other youth organisations towards the end of last year, carried out some research with young people particularly around mental health and emotional wellbeing. We had about well over 1,000 young people participate all the way from age 8 up to 25. We did some survey insight with that older demographic 12 to 25 of which about 35 per cent were 18 plus. And almost half of those that participated reported that they did not feel good about their mental health and wellbeing. So just like you were saying, it is an issue that young people are dealing with. I think though what's interesting is some of the insight we had really echoes what Jo had said about access to services. GPs tend to be somewhere where the young people automatically think to as a first port or call. But actually there's kind of wider issues there. I think what young people are talking about is that kind of privacy trust and confidentiality for them in terms of how they might access services and some of the issues and barriers that Peter picked up in terms of actually physically being able to access services, transport, affordability, timing about when services are available for young people to access have all come up as issues for young people. I think a big part of that as well is young people's confidence in being able to know about where to access and how to access services as well. So it seems like there's, you know, young people generally they told us that they over about half said that they felt that they could find information about mental health should they need it but they felt less confident that it's actually given the correct information that they need. And there was also some things that came up there about school, you know, this idea of accessing support in school and education kind of settings that actually they're concerned about the kind of stigma that could be raised within that. Excuse me a school environment in terms of, you know, it might be cancer, you're missing a lesson and so there's a kind of stigma that arises potential around, you know, there are other learners about what they're seeking support for. So I think there's a wide range of issues face to face continues again like Jo was saying face to face is young people's preference in terms of accessing support. Digital is an important tool but they look for the same characteristics of a kind of online digital support so that kind of trust is not being judged that privacy and feeling of safety I think is a big part of that. I think also we may come on to talk about digital services but there is a big misconception that because young people spend a bit more of their time online that young people are able to then use these services, these digital spaces to access appropriate support but actually going on TikTok is not the same as using, you know, some kind of mental health support tool and knowing where to find it. There are some big misconceptions particularly of young people's ability to navigate digital tools and it seems like a bit of a catch-all solution for supporting young people when actually we are hearing that face to face trusted individuals trusted adults and that kind of familiar setting in space is how young people want to access and what we're hearing is that they possibly don't feel that confident at the moment to access those services so very similar themes that we're hearing from children and young people that are still being reflected in this adult space as well. That's very helpful and it's good to dispel some of the mythology about where digital exclusion lies. We've got a whole load of other areas of questions that we want to put to you so I'm going to turn now to Sharon Dowey who's the deputy convener to put some questions about where the demand is and what the response from the services are to that. Thank you. Good morning everybody. Could I ask you a bit more about the current demand for mental health services including where this demand is being felt the most among service providers and also how unmet need is being measured. So I don't know who wants to come in on that one first. Have you got anything for online? Paula, I don't know, do you want to come in on that question and I apologise, I know you wanted to come in on the previous passage of the discussion that we had so please reflect on that and if you've got any response to Sharon's question then please answer that as well if you can. I'll just start with the previous bit first if that's okay. Just to echo what Jo was saying Vox members took part in Audit Scotland's audit and we really also endorsed the recommendations that they've put in that report and so a lot of the themes coming up from that are about access to services and surprisingly and that's actually been our top priority of our members for a number of years unfortunately is the difficulty that they have in accessing services and obviously part of that is the long waiting list but also what was mentioned as well about the communication around how long a wait is going to be or when you're going to get an appointment or how you're going to get an appointment and the fact that people maybe will have a phone call and if they miss the phone call that's them off the waiting list or if they miss an appointment when they finally get an appointment if it's a phone call rather than a face-to-face and they miss that phone call people are saying that they're absolutely terrified that's them not going to have any access to that service anymore and that's what the experience of our members has been and they've reported that that's gotten worse since Covid and then just around also what Jo had mentioned about eligibility and this kind of idea of capacity so a lot of our members will report this idea of being told that either they don't qualify and are not eligible to have any support or service that they wanted access to because they're too well they're coping too well they're too able they're able to do this or they're able to do that or they're not crying or they're not too upset this sort of thing and so that they don't actually need access to the service they're being told or they have a few appointments for example with the CPN and then after those few appointments they're told well you're doing fine now you don't need this support and of course our members report that they understand that probably this is to do with a lack of resource and lack of enough workforce to be able to meet the demand the increasing demand but obviously for the person involved that means that they're back to square one they don't have the support they need so that then there's nothing to help them maintain wellness and then it ends up with them in a crisis situation again and this just repeats and repeats and obviously costs a lot more money than just having those three monthly for example appointments with their CPN or whoever it happens to be so that's one of the main things that our members continue to report and just on the kind of face-to-face part as well our members are talking all the time about their choice so it's sort of written maybe on their appointment sheet or whatever it is that they have the choice of having face-to-face or choosing virtual appointment and of course for some members that might be preferable maybe they would prefer that or it helps them to have a virtual appointment but for a lot of them they would prefer face-to-face and they may be not actually getting that choice and they don't feel that they've got agency and choice in the treatment that they're receiving like Kirstin was mentioning that face-to-face thing is so important for building up trust especially when it's a mental health issue that people are talking about and it's very difficult for them to do that necessarily online and it's also difficult for the clinician to pick up so well on what's going on with the person and be able to help them in that way so that was another thing that was really important and just on the kind of transport and accessing services in terms of transport a lot of our members in rural areas are reporting that it's extremely difficult to get an appointment because there's no staff in their area to give them a psychiatry appointment or a CPN appointment for example or psychologists and that they are willing to travel but then it's very difficult for them to actually afford that travel and it's not arrangements are not put in place for them to be able to have that transport so that they can actually attend appointments that they would like to attend elsewhere and I was just going to say in terms of the GP question earlier a lot of our members are reporting this same situation where it feels like the receptionist is the gatekeeper and that you have to get past them and prove why you need an appointment and of course that's very difficult to do and a bit humiliating really to have to talk about that with the receptionist and so we do hear about that as well going on to the other question about unmet need I mean obviously our members are in a variety of situations and so they're reporting not being able to access services in terms of we're hearing people having to wait in A&E and that there's not an inpatient mental health bed for them to go to we've been hearing that so that's one of the situations where there's demand on services but we're also hearing from our members that there are a two year waiting list for example for them to see a psychologist if they're wanting psychological therapy and that there are the waits particularly in rural areas but also in other areas for them to be able to see a psychiatrist and like I say this kind of ongoing situation with people feeling that they do need a community psychiatric nurse but they're not being the facility there to have that continue and that they maybe only have a few sessions and then told that they're well enough to cope without it unless it's an extremely serious mental health problem that they've got where they may have access to a cpn continuing if they've got a depot that they need to have I hope that answers the question sorry for going on oh that's great thank you if I could ask Joanne Dawson okay three things to say under the demand piece so I mean demand so the indicators are all there's quite a lot of data that tells us that demand is rising obviously the audit Scotland report highlighted some of those so the calls to the NHS 24 mental health hub has increased dramatically over the last period it's the same for our own mental health information service we're expecting to speak to around 7000 people this year it's almost double what we were doing pre-pandemic so people are reaching out to get information and support and signposting and the numbers are there the centre for mental health also did a report during the pandemic that suggested that the NHS will need two to three times its current capacity to adequately meet and treat the expected increase in mental health problems resulting from the pandemic now that was an England and Wales report but one can expect something similar for Scotland so all the indicators and the dashboard is flashing demand is increasing and you can see that in the numbers of people being referred to psychological therapies for example and of course the pandemic brought mental health and wellbeing into sharp focus for all of us and I was just talking to the gentleman outside the room about that as we were coming in so people are thinking about it more and people are thinking about their wellness or not and therefore one can imagine that that will just increase help seeking over time and quite frankly people should be able to just ask once and get help fast it's as simple as that however demand is on the increase we know there are some groups that we should be concerned for because the mental health tracker that was run through Scotland during Covid was telling us that and some of colleagues on the screen were describing some of those groups whose mental health and wellbeing particularly suffered during the pandemic so young people as Kirsten was mentioning and women as others were mentioning and people with pre-existing mental health problems should all be groups that we have concern for and we should be targeting support too and in terms of unmet need because people aren't able to get the support through the traditional routes unmet need will displace itself to other places like workplaces and schools and community groups and sports groups and all the other places that we live our lives and so therefore we expect that workplaces and other places are going to be needing to do a lot more on mental health and wellbeing in the future because people aren't being able to access the support through health services Can I just go back to your previous comments earlier you said about confusing pathways you said about GP being the main gateway and just in your response there you said about asking once and getting help fast do you think that we've got a robust enough system so that people know the pathways that they can go on and what I'm saying is that there's various funding out there for different groups see once a group gets funding to help with mental health are the GPs made aware of it or are the GPs made aware of all the help that's been funded by the Scottish Government so that they can then give that pathway quite clearly and even for us Merriam is the co-ordinator for the international women's group as well so again if a doctor was struggling to for somebody from an ethnic minority for a translator or to help them would they know to go to that group to help or I suspect the answer is no many years ago there was an attempt to gather up all this intelligence and I can't quite remember the name of the system but it was being populated by lots of these programmes and supports and interventions to make it available to GP so that they would be more knowledgeable about what was going on in their area and sadly it gets very tired very quickly because funding cycles mean that things go as quickly as they are set up so it's a real challenge what I would say and when we were talking earlier about primary care and that kind of gatekeeping one of the things that we think has been particularly a particularly positive introduction is community link workers in primary care so a dedicated team we have a SamH worker in every single GP practice in Aberdeen City and we are there as a support system for individuals where mental health may be a component of the reason why they're sat in their GP surgery but it may be other things too and the GP can send them down the corridor to us we've got the time to listen to work out what would be the best supports for that individual to support them to reach those community assets it's a great programme but we've got great concern about the future of that programme because the emergency budget cut the £38 million to the mental health budget and as a result there was a delay to the mental health and wellbeing primary care services progression which we think is a deep concern I would ask you more on that but I think those questions are later on in funding so I think we'll come back to it Dr Simon, I think it's next Oh, Simon's next, sorry Yeah, thanks I think our members would see a mismatch between the supply and the demand and that essentially you're spending money on the old paradigm, not the new convention with the rights of persons with disability paradigms so I think our members might think you're spending too much on the biomedical model, the psychological stuff not enough on the social side of the sort of what works for mental health and I think maybe learning the mental health foundation would cause task shifting that I think what we hear is that a lot of people don't necessarily think mental health is a problem with them it might be it has a wider significance and there might be worth spending more money on stuff that sports families stuff that sports communities I think Peter Kelly mentioned community based solutions instead of I think what you might be doing is empowering professional groups very well, the psychiatry and psychology are very well empowered but I don't know if you are empowering people to mutilate and support their own mental health so I think a shift towards much more social funding maybe what our members would like to see thank you I'll go on to your next question I think Sharon I'll just go on to another question if I could ask now about the impact of the Covid-19 pandemic and the cost of living crisis on demand for mental health services and how this is affecting service delivery and if I could ask Dr Shari McDade to come in on that thank you and I just wanted to follow up with what Simon Porter was saying around this idea of task we call it task sharing and we are running a project in Dundee that is bringing together variety of agencies with NHS CAM services to schools and all the agencies and community supports that are working with children in order to try to get faster support for children that are on waiting lists in CAMS but faster, more appropriate support where many of the children may not need CAMS it might be just as Simon was talking about that it's a lot of circumstances in a family situation that are giving rise to children having perhaps a behavioral issue that needs some type of support so very supportive of the idea of looking better at the resources in the community and how we can invest in communities but also how we can bring those resources together and also would really agree with Simon that oftentimes what we see and what people tell us that helps them in their mental health journey is for example peer support is spending time and being given the opportunities to connect with other people in a similar situation that's what we're working on very much with our loan parents project small talk is very much around bringing loan parents together and often young loan parents that they don't feel they comfortable going into even the regular new mother groups that may not have so many young mothers in them and then we also are supporting that kind of work with the alliance for health conditions in terms of again advising them on how they can bring people with long term health conditions together to support each other it's not a replacement for clinical services it's not meant to be a replacement for very important clinical services that people need but so much of the levels of mental distress that are around the vast quantity of it is in mild to moderate mental health difficulties and for those kinds of situations it is possible that peer support can play a very important role with regard to your question around the pandemic and the cost of living crisis of course our pandemic study I won't at the top of my head be able to quote exact statistics apologies for that but I can get further information to you but in terms of the pandemic certainly our pandemic study showed a rise in levels of distress during the period of the pandemic and what we saw then towards the end of the pandemic was that those levels of distress had not come down to pre-pandemic levels and I think that's probably reflected in the kinds of statistics that SAMH was reporting around levels of demand for services and we have done a bit of polling of the population around their the cost of living crisis and we've asked people about that we found that people are reporting that the increasing cost of living is negatively affecting their mental health and that doesn't surprise us because we know that financial stress is a very clear risk factor it's a very clear risk factor for poor mental health and if I just can say one thing about young people that I wanted to draw in relation to young people from our study our huge sample studies of young people in universities and young people in colleges there was a quite clear link between lower levels of mental wellbeing among the students and food insecurity and we often don't think about that or maybe it's not spoken up enough about young people there are lots of things in young people's lives that might be negatively affecting their mental health but we often forget that reality is that many young people today are struggling to have enough money to put to eat and to have adequate shelter and that financial stress is going to be a further exacerbating young people's mental health Thanks for that lots of points to consider could I ask Peter Kelly to come in now? Thank you I think it's well understood that poverty is both a cause of mental health problems and a consequence so I think at a time of acute financial crisis really that we've been through since the start of the pandemic where we know that people who are already on low incomes suffered most during the pandemic and then moving into the period of the cost of living crisis which we're still very much in we shouldn't be surprised that that translates into increased demand across a whole range of services related to mental health I suppose a couple of areas or a couple of points just to make in that context we did some research within the Scottish Women's Budget Group into women's experience of the cost of living crisis and one of the very clear messages coming out of that was the mental health impacts of for women in particular having to manage poverty as that report said being very much responsible for often being responsible for care within a family and trying to juggle that at a time of acute financial crisis the other related issue I think is debt so we have seen increasing levels of debt one of the poverty lines members who responded to our survey noted that from the period between 2018 to now a third of their clients debt advice agency a third of their clients were reporting suicidal ideation when they presented now half of their clients are reporting suicidal ideation I think that one statistic from that one organisation is really quite compelling about the impact that our current context is having on individuals mental health the other part of your question was around what happens to that demand and I think as Simon and Shari and others have said the importance of voluntary sector community organisations in providing alternatives to primary care to address mental health issues early is really important and I know we will talk about funding those services are very much under stress but what our members told us their response to this current context has been they've done various things so around about almost 70 per cent had increased training to staff and volunteers around mental health very often that was around mental health first aid but looking to as I said earlier to skill up their staff and their volunteers to be better able to support the people that they're working with around about a fifth had recruited specialist staff who were providing specialist services to enable them to better able respond to these areas I think this is the tip of the iceberg and really organisations are undoubtedly struggling to respond to the demand that's there and I know as I said we'll go on to talk about funding issues later thank you okay thank you very much Peter for that and the other contributors I have to say unfortunately due to time limitations we clearly aren't going to be able to take everybody who wants to come in on every question so I shall try and exercise some egalitarian principles and make sure that everybody gets a reasonably equal amount of time so I apologise to those who wanted to come in on that question but I'm going to move things along and invite Colin Beattie to put some questions to you thank you I got one or two subjects and covering the theme initiatives to increase in-person and remote access to support obviously there's been initiatives across Scotland to increase in-person and remote access NHS 2411 mental health hub distressed brief intervention programme or perhaps two of the main ones what I'd be interested in asking is there seems to be a wide variability in terms of primary care health services third sector services pier sport services the joining up is not perhaps what you would want to see it could be better and I'd be interested in the the witnesses feelings on that their views on that and Jo maybe we can start with Hugh since you're here so a few things to say it's true that there are some great interventions and supports out there and the system doesn't necessarily connect up so that people know how to get to these or how to refer on to these and that would be a welcome improvement if we could make that in the system I think that would help a lot of people but it also comes down to the funding cycles that exist that I'm sure we'll come on to talk about later but how these supports are literally on annuals funding cycles and it's very difficult particularly in the third sector to plan over time for setting up something that is robust enough to exist beyond the end of a year so that's a real challenge for us. On the DBI point that you mentioned DBI is I think it would be our view in Scotland it is particularly effective in de-escalating distress for many thousands of people since its inception we are one of the delivery partners and we deliver it across multiple locations in Scotland and it was extended to include young people which again I think was a real benefit of the programme expanding to recognise that there are lots of people that would benefit from such a service but we know that the dedicated funding for that is going and that there will then be you know it will be down to local commissioning and procurement processes to determine the future kind of DBI provision Thankfully the national pathway remains in receded dedicated funding until March 26 which is good news which means anybody coming through the 111 number will still be able to get into the DBI service but we have concerns about what might happen and local commissioning on such a service and we absolutely believe that we should retain the core elements of the service as it was set up at our slight fear is that we might end up with DBI lite versions or drawing it in with other services and commission jointly and we think that might be well that should be a concern for all of us I suppose when we're talking about variability we're talking about availability of the service and the quality of the service some of which comes back to funding I guess can I bring Paula Fraser in? Hi, yeah I remember most of our members have severe and enduring mental illnesses and they've reported that for example phoning NHS 111 is not actually going to be helpful for them in getting the help that they need it seems to be more of a kind of having a talk through and then a signposting kind of service and then their signposted on to something that maybe isn't actually available or that they can't get access to and in terms of the variability I think we hear about that a lot like's been mentioned before about peer support and about community link workers and how valuable those services are and wellbeing hubs and that sort of thing they're completely varied across the country and whether you can have access to them or whether you can take part and attend a local wellbeing hub or have peer support is something that just seems to vary from place to place and it's something that our members are continually asking for and wanting and obviously you've seen in the Scott review that that was one of the recommendations about the wellbeing hubs and people having access to that and the peer support and so I do think that's an issue and I think maybe have been mentioned in the report the Audit Scotland report was about you know how it's not necessarily always obviously there will be specialist clinical support needed for people at times but it's not necessarily always about the kind of high level of specialist training that somebody has but actually about the attitude and the time that they take for somebody so actually being empathetic and being able to listen so some of our members have reported that you know they've got a brilliant GP who does still have the time to be able to talk to them and they have those regular appointments and that's what keeps them well or it might be that it's a community link worker or it might be that it's a peer support worker but it's not necessarily about always about seeing a psychiatrist or a psychologist but it's about that maintaining a kind of trusted empathetic attitude from somebody who they're able to connect with and that's not available for everyone across the country when they need it and in terms of crisis support people are saying crisis support is something that you really really need at the weekends and during the night and that's something that they're not being able to get access to when they need it and our members report that continually and that seems to have gotten worse again through the Covid pandemic and afterwards Thank you, maybe I can bring Kirsty Orkerton Yeah I mean I suppose I don't have a huge amount of insight particularly from young people in relation to kind of crisis support I think just to add to some of the points that Paula were just making about kind of timing of access to services that is something that young people have flagged with us that quite through the survey work we've done that actually those services are sometimes during business hours when they're at school or in employment but also for potentially kind of younger people and accessing some digital support you know quite often they don't have access to devices you know if they're living with a parent or carer they might not restrict their access at certain times of the day when they need it most and so there's a whole range of issues impact young people being able to access those services I think again we've mentioned things like kind of transport and accessibility I think some of the work that we do I mean you'll be aware of things like the under 22 feet bus transport initiative that we work in partnership with and it's about thinking about you know transport is always a barrier to accessing services and it's something that young people in particular have issues with accessing and so there's initiatives that we look to do to make sure that it's not just about the particular kind of mental health challenge but it's the looking at the bigger picture of the world of a young person and what are the things that make accessing kind of services and support possible I think going back to just some of the points that were made earlier about about access as well that you know some of this is about it's not always about that acute crisis access you know that kind of post Covid cost of living crisis we're hearing from young people about you know that kind of secondary mental health they're witnessing their parents and carers going through really challenging times and that's having access you know we've got a stat from a survey that we did in December over 70% of young people are concerned about the financial pressures on their parents carers and the associated stress and impacts of their mental and physical health we've got young people we talk about the triggering aspect that a 16 year old saying that they're worried because they're embarrassed about not having enough money for lunch they're worried about their parents not being able to put food on the table young people saying that they don't want to go and continue their studies because they want to go out and work to contribute towards a household and things so this kind of secondary impact on young people is really kind of heavily heavily felt I think also to add to that just quickly that you know during Covid lots of services closed for young people cost of living crisis we're seeing swimming pools, leisure centres all of these things that should support young people to live their lives and have fun and do the things that they should be able to do that support their emotional, physical, wellbeing and mental health and that access to that is being decimated across communities across Scotland and I think it is something we have to pay attention to what are the things the preventative measures that we're putting in place to support young people well not just young people everybody's wellbeing and I think that it's a whole system approach that we have to look at supporting young people's mental health so thanks Thank you. Just to move on to a certainly different aspect what are the advantages and disadvantages of in-person versus remote access for support and to what extent do people have a choice in the type of support that they receive I'll ask Salon Porter to come in on that I was going to quickly say about the intersectoral partnership working that I understood the other question but I think the advocacy view on this is that there is a power dynamic between the NHS and IJBs and local authorities in a kind of a pecking order so I suppose these are the reasons that we see sitting in the sidelines about partnership working between third sector and public sector there's a sort of an assumption of pecking order that the NHS, the professional that's the serious safe good stuff and social care is kind of like the keen amateurs and well intentioned but we don't really know what we're doing so we do see there's sort of an epistemic injustice aspect of an undervaluin of social care in your funding I guess wondering if the national care service could help equalise that because I think the NHS in a way is disproportionately powerful and it sucks it's like it exerts a gravitational pull of resource and attention that I don't think the patients think it warrants and I missed your question there about do people have choice but no there's coercion the mental health system at our end of it relies on coercion which is a human rights violation so obviously by definition most or many people in the psychiatric hospitals do not have a choice to be there and do not have a choice about the treatment they are receiving and their voices basically irrelevant what they want matters but it doesn't really matter at all so yes there is no choice in this system for many of its most disabled users thank you maybe I could ask Miriam to comment on the advantages and disadvantages of in-person and remote access oh hi yeah there is disadvantages in accessing so as I mentioned is language barrier as well is an issue and ethnic minorities women so they don't have any information who to approach as we mentioned earlier like the only way they think to contact is their GP so they don't have more information who to contact in that issue also as I mentioned earlier like they don't find they don't feel comfortable to use interpreters they prefer to speak like directly about their their issues to the councillor also disadvantages for as a community group we don't have enough resources to provide all the their needs like we are very limited in resources so it's just few hours and we have like quite a big list waiting list as well to see all this like needed women need the service so this is some of disadvantages although IWG is trying to provide other activities for women to ease like isolation for example we provide yoga and zumba exercise so to bring them in and try to reduce in that way some mental health issues this is some advantages that we are able to provide to with our limited resources also like we provide English classes while they are waiting for the college places so they are ethnic minorities their language is not English so we have to take this in consideration so we provide English class so they learn English which we can come to address some language barrier also we provide dropping to come in and meet other and talk so we also we are providing some of advantages that we were able to secure some funds to to reduce some mental health issues thinking about cost of living so we provided some vouchers to women to families like to reduce some mental health in thinking a lot about their financial issue and this where we are able to provide so hopefully I answer the question Perhaps one last person I would ask is Dr Sharia McDade on this question Yes, well I think Simon has raised the very important point about it being a person's choice so while the evidence that I am aware of from a few years ago about the effectiveness of online versus in person usually shows that they are about equivalent in fact what we see around effectiveness is that online effectiveness isn't really less than in person however that very much depends on as Paula was pointing out the quality of the relationship that's able to be built between the therapist and the individual seeking help and we know that all the evidence is that the quality of that relationship is key to whether you get any therapeutic benefit and so I think it is quite important that the digital option is the person's choice on the other hand I think I have seen evidence that having that choice means that people who may never have come forward for mental health support previously do come forward for that support and again even if we think about parents of young children I've heard that for parents of young children the fact that they don't have to try to organise with their infant to get out the door to be able to get support but that they could actually have that support from their home might be the difference between them being able to get help and not get help and for those for communities and for people who have still a high sense of stigma around seeking help we think that perhaps for example for men where or older people where there's still some levels of stigma around seeking help for mental health that having the digital option could be really important for enabling people to access support that they otherwise might not go near thank you just from my last question or subject we've already talked a little bit about NHS 2411 mental health hub and the distress brief intervention programme so we've heard some feedback on that but what's the impact on that on the programmes of the withdrawal of dedicated funding for these initiatives and maybe I can ask Peter Kelly to comment I have to say that that's not an area that we've sought information from our members so it's not an area that would be confident given your response on those particular funding streams there might be others on the call who are better able to say what that impact would be okay thanks Peter I was just about to go to Joe I think what our concern is at the moment you removed dedicated funding you then opened up the opportunity for 32 different versions of what is essentially already proven to be a very effective programme of supporting somebody who is in a distressed situation so our concern is how do you retain the effectiveness of that programme that has been piloted over the last period to do a national roll out and removing the dedicated funding suggests that it might then be open to interpretation we've seen it happen on other programmes like individual placement and support which is an employability programme which supports people with severe and injury mental health problems into sustained work it is the single most effective programme to do that and it's been proven time and time again to be so the minute it gets into the procurement system it becomes a light version of itself and therefore you lose the fidelity of the programme Thank you Paula Fraser do you have a comment on that? I think you're on mute Sorry I don't know if I know particularly about the impact that reduced funding has had I just know from what members have reported that it has become more difficult for them to access services and even those who would maybe have depended on phoning NHS 24 for example during the night if they can't access other crisis services and reported maybe not being able to actually get through to somebody or not really getting the help that they need when they need to but I don't know whether that's a direct impact of reduced funding and in terms of distressed brief intervention for most of our members because of what enduring, severe and enduring mental health conditions they have that wouldn't necessarily be an appropriate way to go but I can totally understand that it's really helpful for other people and I can see what Jo's saying about keeping it consistent if it's not dedicated to funding Finally I'll ask Shari McDade whether she's got any views on this Sorry I just wanted to just add one more piece about online mental health, digital mental health which is that the evidence around its effectiveness is that it's better when it's guided by a professional so it's important to bear that in mind that there's maybe some views that it's possible to replace the clinical support or the support of a mental health professional with digital but that actually what is proven to be effective is where there is a therapist involved it might enable the therapist to see more people than if there was all face to face but having a therapist involved in the online is really the best approach Thank you Okay thanks and I think Jo you mentioned earlier on the Aberdeen example has been something that's under threat because of funding issues and if you or any of the other panellists have got other examples of that kind of initiative which might be at risk if you could give us a note in writing that would be really really helpful and I'm going to have to move it on and invite Willie Coffey to put some questions Thanks very much and hello everybody I wonder if I could take us back to talking a little bit about how we reduce mental health inequalities there's been some discussion earlier on the Auditor General's paper that I'm sure you've read points to certain groups within society and inequalities basically reflect the inequalities in society that we're seeing I suppose that's obvious I mean people that are living in their deprivation circumstances issues that affect young people LGBT people people with learning disabilities and we're hearing today of course that affects ethnic minorities the funding that's been allocated to the mental health directorate over recent years has gone up significantly from 2020 it was £130 million a year now it's nearly £300 million a year so where's this money going is it not being spent and targeted correctly and appropriately in your opinion and what more do we need to do to do that I wonder if I could just start with Dr McDade but I'd really appreciate it if we could hear a short brief perspective on this from each of our panellists if that's possible Sure and I'll be as brief as I can when you're talking about trying to reduce mental health inequalities and this is something that the foundation feels is a very big priority the reality is that many of the reasons why there are mental health inequalities lie outside the mental health services and therefore until we really have a whole society approach to addressing mental health we will see those inequalities persist and one of the concerns that we have in the foundation is that the mental health strategy delivery plan which was just published is still relatively vague on how government departments beyond the mental health directorate beyond the NHS mental health services will be involved in taking action on mental health so we think that one of the best ways to reduce mental health inequalities is to require that every government decision is assessed for its impact on mental health and that would mean that decisions around social security, around transport, around housing around investment in community spaces and in government that those decisions would be assessed for their mental health impact and I think that if that was taking place and we would find that the circumstances within which people are trying to have good mental health would change and be more balanced so that individuals who are at higher risk would have a better chance Thanks very much for that joke Could you offer a perspective on the money this funding has been increasing are we targeting correctly properly and so on? I would wholeheartedly agree with everything that Shari just said about the cross-government opportunity the delivery plan itself that was published earlier this week is vague on that and there are I think something like 80 something national policies that are listed at the back of that delivery plan but no sense of how we're going to make that a reality so we would urge that great attention is paid to how we implement that over the course of the delivery plan and in terms of funds I noticed in your question you were talking about the community's mental health and wellbeing fund as a particular example of a recent kind of innovation regarding mental health directorate spending and as much as it's welcome it's on an annual basis so it's limited in terms of its effectiveness in that regard and it's critical about in fact we know nothing about the outcomes for those individuals who have been the recipients of something through now I'm not saying that there wasn't some benefit to those individuals but we don't know so we know how many people might have received support in some way but we don't know the outcomes for them and that's the kind of data transparent data that we need going forward in terms of being able to assess mental health spending so that the research and outcomes in a wee while I think but I wonder if I could just ask Miriam something you said earlier Miriam you said there isn't even multi-lingual information in a number of circumstances for people from minority ethnic communities to use to help them to direct towards these services is that actually the case? I mean I'm astounded at that convener if we don't even provide information that people need a little bit more about that please Yeah as I said from our like experience working with ethnic minorities women so we found out that they don't have this information they don't have information so the only way they know is to contact the GP to refer them so there was no big language services provided for them so because of that we tried to provide services that help them like councillor who speaks both languages Arabic and English and we found like a high demand for this service although as I said we were like when we started we had only two hours a week to provide service and now we were able to secure this service for six hours a week as they found out that they prefer to speak to the same person who speaks both languages and we unfortunately were able to provide this service to English speakers and Arabic speakers only we weren't able to find like or we were able to have all that fun to find like councillors who speaks more languages actually and also there is like a challenge we are facing that we don't have like more fun to continue this project we have only two years because we were funded by the big lottery community fund mental health project and now it's not they are not providing this kind of project anymore so we don't know what's going to happen in the next so this is where we were able to provide only like Arabic and English councillers so hopefully, hopefully in the future if the NHS can provide this kind of or get more support to community groups to provide this kind of services. Thanks very much for that Mariam that's something that we're keen to follow up on I wonder if you're still there I know you have to leave about half ten but could you give us a little perspective on these issues and why these inequalities exist particularly for young people we've seen this in the report that young people often report much higher levels of anxiety stress and mental health related issues and you've described a few circumstances but could you just give us a little flavour of what we need to do more to effectively target spend the areas that we need to reduce the inequalities that we're all talking about today I absolutely appreciate spend has gone up around mental health I think that it's such an all-encompassing issue that it could be a challenge to think about where that funding is diverted to at the moment and I think that what we've also got to take into consideration is the intersectionality of so many of these things that we've identified and I think that that then is a challenge in itself in terms of how you're providing that effective support to all people but particularly to young people I fully agree with Dr McDade's view on that whole system approach to a person, to a young person because actually quite often mental health poor mental health is a result of circumstances of a young person's living situation their relationships, their life their experiences and I think that like I mentioned before I feel that a lot of focus is rightly so on the kind of I suppose the kind of fixing the problem maybe the kind of sticking plaster but what are we doing kind of further upstream internally and effectively intervention for people, for young people in particular I think the world that we live in at the moment can feel like a quite heavy place for everybody but particularly for young people they've had their education disrupted during Covid key milestones in their lives were missed for a lot of young people on that social interaction and the things that make people people I think that quite often when young people talk about getting support face to face it's maybe not physically face to face but it's that human connection it's the social isolation and loneliness and all these things that young people are experiencing you just have to turn on the news at the moment and it is a very stark reality for lots of young people but not only that when you think about something like climate anxiety quite often we look to young people to come up with the solutions and they're the ones that are bearing the brunt of thinking that they have to deal with this in the future so you put all that together and we're not painting a very optimistic future for young people the Carnegie report that came out this week about the wellbeing index and the kind of difference in those over 55 and young people in terms of their wellbeing is quite a stark reminder that all of us that are young people are challenged in the current environment and I think that yes there absolutely needs to be resource allocated to mental health provision but actually it's about what's that whole system approach to young people's lives about the things that they can access the opportunities they can take part of the type of education that they have so I think it's wider than mental health support services about all the infrastructure that sits around a young person which I think needs that attention and just on Jo's point as well the kind of annual funding cycle of some of these things as well it's huge in me and it's coming from a third sex organisation who provides mental health information for young people the year to year kind of cycle that makes it very challenging for us to do any long term planning I think also I would just say as I always would it's really important we keep having these conversations involve them in this that we're not making decisions on their behalf that we're young people are at the table when we're talking about what solutions might be kind of moving forwards Thanks so much for that Custin convener is there anybody else on line wanting to? I think both Simon and Peter indicated they want to come in on this question so we'll go to Simon next Yes there's quite a big Polish community in Edinburgh quite a lot of Polish members and it's interesting what they say to ask about why they don't access NHS services because often they will pay to fly to Poland and pay to get treatment in Poland that they could get free in Scotland but they're not doing that and I guess we asked why why don't you and there are trust issues with the NHS they don't I guess we're all brought up to worship and adore the NHS and I guess other communities don't necessarily have that ingrained in them and they don't trust where data goes what the data sharing they are concerned about health and government sharing information that there's that issue but there's quality issues this is hard to hear and I think people don't you know NHS morale is low and they don't want to hear basically the Polish people say that our health service is better than yours okay we have to pay but what you get we wouldn't put up for that and I appreciate people who don't want to hear that but that's what Polish people say to us so just about what to spend things on just assuming that more and more NHS is going to bring in BME communities I'm not sure that's correct Thanks Simon Peter Thanks, I'll try to be brief I think I echo much of what Shari has already said the answers to how we reduce mental health inequalities lie outside, largely lie outside of the mental health system so I think one thing that we do need to do in terms of policy within Scottish Government and other parts of the policy making framework in Scotland is make sure that there's alignment so is there alignment between our efforts to reduce child poverty we have a very well developed child poverty strategy with regular delivery plans but are they really as closely aligned to issues around mental health and reducing mental health inequalities do they take good enough cognisance of mental health issues in some way to go there yet again we have priorities around developing a well being economy that absolutely has to be fundamental to addressing mental health inequalities so when we look at the way that our labour market operates issues around security of contract around stability of work around the hours that people have these all contribute to where effective in reducing mental health inequalities so I think taking that into account when we're developing our approaches in these areas will help reduce those inequalities and one further area that I think is really important is around housing and we know that Edinburgh has just declared a housing emergency we know the stress the impact the insecure accommodation has on people if we're to address mental health inequalities if we're to address the stress that comes through homelessness then that's one area that we need to prioritise I think thanks very much for that Peter thank you I'll hand over thank you in the time remaining I'm going to invite Graham Simpson to lead us through a discussion on an area that the committee is keen to get your views on can I also say though that we would very much welcome any written submissions that you want to make to the committee if you feel as though we haven't covered some of the ground that you wanted to we've really been up against the clock this morning there's been a lot of rich evidence presented to us which we will certainly be keen to look at in more detail and reach some conclusions about but if you have anything that we haven't got to that you could submit to us in writing we would really appreciate that and we'd hand over to Graham yeah thanks convener I just want to come back on something that Kirsten said while you're still with us Kirsten I know you've got to shoot off but you said that the world feels like a heavy place for everyone and there's a danger do you not think of giving the impression that we've got a nation of stressed out young people who are struggling with life and well that's not the case I mean there are some young people who struggle but not everyone's in that place we don't want to give that impression do we no absolutely not and apologies if that's how it came across it's absolutely not my intention to do that I think there's as an organisation that supports young people to do amazing things and to participate and they're sharing their voices and views and we've actually got a generation of young people who are very kind of socially aware and socially active and are very kind and considerate and caring about others and we have a brilliant generation of young people in Scotland I think the opportunities but I think we have to pay attention to that don't we we have to, whilst it's not true of everybody it is true of some young people and they are being exposed to a wide range of a very changing environment a changing environment that they are living in and I think that we can only see as a positive that young people are motivated to seek support for their mental health and emotional wellbeing they are thinking about the types of services that they can access but we absolutely have a fantastic generation of young people lots of good opportunities, lots of prospects they are active in shaping that I mean everything that I've talked about today has come from young people telling us kind of what their views are that they would like to see things change and be better for them in future generations so I absolutely agree with you I'm all about positivity and opportunities for young people but I think it's also for those that need that support we should have an adequate system that does support them so yes apologies if I gave a bit of a doom and gloom view of the world of young people I'm glad you've injected some positivity there and I'll let you go I know you've got to shoot off but thanks for that I really appreciate that so I want to I think I'm just going to ask Joe about this because I know we're up against the clock and Joe you mentioned earlier about outcomes and the report does state that the Scottish Government doesn't measure the quality of services or outcomes for people who receive mental health care which seems to me to be a huge oversight so I just wonder if you have any views on you know if you're accepting that that should be rectified how should it be rectified and what kind of things should we be measuring I mean I think that we've been saying this for a long time along with many others who were on the on the screen that it is crucial for us to understand the effective use of mental health the mental health budget we need to know what works for people and it can be done because it's being done in England right now so there is it used to be called IAPT and it's now called NHS England's Talking Therapies for Anxiety and Depression programme and we've studied this and written quite a lot about it there is routinely published individual outcomes data that's readily available it includes data on recovery and lots of other things as well and so it is a good example of what can be done I'm not saying it's the only example but it just demonstrates that it's possible and the fact that we can only measure things by waiting time targets on a quarterly basis it's just not good enough and we absolutely must get to a position where we understand the effectiveness of an intervention on an individual we do it in our organisations because we have other funders who expect it of us so it can be done there are examples in Scotland even of various organisations doing their own thing but as you say we haven't got that nation wide I'm actually seeing somebody nodding who's that pull the phraser I think no you weren't nodding you were nodding I was nodding just in agreement yes it does seem ridiculous that we don't collect that information and that data and have that evidence about how things are working and where they're working for people and that would be very welcome if we were able to do that so I think if I can go back to Joe you mentioned this model in NHS England why do you think we're not doing something similar does NHS Scotland why are they not doing it has anyone asked them to? I don't know Sam H has written a number of times in response to consultations about is a good example and it's worth looking at I know that people from the IAC programme have been in Scotland talking on this so I think it's entirely possible that's possibly a question for Government I know we'll have the Government at some point I've got a separate question and it's a question that is in the report and it's down to the spending on medicines this isn't necessarily a question for you Joe I'm just looking at you because you're in the room but it could be for anyone so the spending on medicines to deal with mental health and the spending has gone down that's because the cost of drugs has gone down and actually the number of items being dispensed has gone up so I just wonder whether whether anyone has a view on whether that is appropriate that we are prescribing more and more drugs are the better ways of dealing with mental health is it too easy to prescribe drugs and I do see someone nodding that is Simon so you may want to comment on that Simon I'm just comprising my yes there definitely is too much emphasis on medication and an unchallenged assumption that just keep taking the tablets works that it's as simple as that either get professional help or just keep taking the tablets and that is an old that these are very old fashioned ideas hold to them so about the lack of evidence it is very interesting that such an evidence led discipline medicine it's all meant to be evidence like why can't they provide the evidence for this and I suppose one possibility is because they know the evidence would not support that it is effective I remember Colin McHife from the welfare commission saying there is no evidence hospital inpatient treatment detention coercion there is no actual evidence that it works we do it everyone assumes we must do it that's the answer for mental health the severe end but there is an interesting question why can't they provide evidence that it is efficacious yeah Simon I mean you need if you're going to do something whatever it is you're doing you need to know that it's working and why it works or why it doesn't work your build here is the voice of experience so tell us your experience they would say that coercion detention are necessary evils but I think the people I represent they just say it's evil it isn't necessary if this is a civilised society that I think Scotland is we can come up with better solutions that a lot of the mental health system is backed up by this element of coercion that we would argue patients argue that's what creates the stigma if you lock somebody up for something that tends to mean it gets stigmatised so the solution is take the coercive element out and that is what UNCRPD would say you should do our one in terms of data that you should be monitoring the Scott review recommended that we will at least try and work to the reduction of coercion so could you put in costed for the things you don't get your money unless you are actually reducing coercion because I think what history teaches us what tends to happen with every new mental health act is that the it ratchets up the use of coercion ratchets up year after year detentions go up year after year they all start with the let's be least restrictive and they all end up with let's keep locking people up and institutionalising them so could you create a mechanism whereas you get money if you reduce coercion but if it just keeps going up sorry but we're not going to pay for that anymore Thanks Simon this coercion it's obviously a big deal for you you've mentioned it quite a few times does anyone else want to come in I'm going to look at a screen with lots of faces on and Paula and Dr McDade are interested in coming in Right Paula you were mentioned first Yes so I can totally understand a lot of what Simon's saying and we do hear that from members of ours and obviously we're really keen to see that there is a reduction in coercion that's been recommended by the Scott review and in terms of medication we've got a really varying wealth of experience in our members where many members will really talk about how much the medication that they are on has really helped them alongside for example having community psychiatric nurse appointments that are regular with somebody that they trust and I think that's quite important a lot of it is because the medication is working alongside that is helping them as well but of course we've had lots of very bad experiences where people feel that all they've been offered is medication or a higher dose of a medication particularly with things like depression and nothing else alongside it that is actually helping them and that's all that's being offered so I mean I don't know obviously I know a lot of the increase in medication you hear reports around the increase in antidepressants being prescribed and I would have assumed that that's to do with the lack of resource or workforce to be able to give other therapies and other treatments or help and medications that can resort that the GP has to go to because there's not that other help but yeah there's a kind of balance of there's really important for some of our members that they have access to the medication that really helps to keep them well but you really need that other support and how important it is to in terms of money and where the money is spent from what we hear a lot of money is spent on locum psychiatrist for example I mean a lot of money that could otherwise be spent a lot more wisely and I hope that the workforce plan is going to do something to help with that so that you actually can recruit and retain staff your psychiatrist or CPNs within the areas that they're needed rather than using locums and that that money that's left then can actually be used elsewhere to help for example what I mentioned earlier in terms of community resources, community well-being hubs and things like that that help to keep people well Dr McDaid So I really was requesting to speak in relation to your question about young people and whether we were overstating the extent of the distress there and if I can use this opportunity to comment on that if you don't mind when we did our thriving learner studies and we did two studies one study was of 17,000 university students in Scotland and one study was of 2,000 students in colleges in Scotland in colleges we found two thirds of college students had low mental well-being and over half reported symptoms of moderate to severe depression two thirds with low mental well-being and over half with moderate to severe depression and we did gathered that information for college students nearly three quarters reported low well-being and about a third reported moderate to severe or severe symptoms of depression so I do think we need to squarely think Can I come in there Dr McDaid? What question were you asking them because if you phrase a question are you do you get stressed about things most people will say yes it depends what you ask so what question were you asking So I can get you the detail of the questions but I can say that the questions we were asking were quite standard questions for how to measure well-being and how to measure symptoms of depression so we weren't just asking students whether they feel stressed about questions that are considered reliable for gathering that information so I think we have to acknowledge that there are levels of distress in the young people of Scotland what I think is so impressive maybe is the levels of resilience you know that you know we don't see you know every three quarters of college students seeking mental health support so clearly some are managing to cope without seeking mental health support but I think it behooves us to recognize the extent of the difficulty and that's the best way that we can move forward in terms of responding and particularly for young people for whom they have their whole life ahead of them so if we respond early at this point in their lives there's a much better chance of better outcomes in the remainder of their life okay okay thank you I got a note to say that Peter Kelly wanted to come in one final time so we've just got a couple of minutes left Peter if you want to come in I think it was probably on some of the broader issues that were raised in that last section but over to you Peter thank you it was really just to come back on the question of increasing medication I'm not going to comment on that specifically but I think what's very clear from the grassroots community organisations that responded to our call for evidence was that social isolation is one of the big factors that drives problems in mental health and stigma associated with the experience of poverty and the experience of mental health also one of the key drivers and I think where community based responses are in a very good position to support people with that relatively low level of mental distress we've seen for example members of ours the SPFL trust working with the community grassroots community football clubs and trust associated with football clubs they've been a real driving force in tackling social isolation often particularly for men but not only for men and addressing mental health through that means so I think just very finely if we're to think about alternatives we need to support our community and voluntary sector more effectively and questions around funding have been raised again and again in this session about the duration of funding the stability of funding and I just repeat that need for that longer more sustained funding for third sector organisations Peter on that very clear note can I thank you very much and can I thank all of our witnesses this morning it's been a very fruitful session and as I said earlier on I think the evidence that we've taken from all of you so can I thank Kirsten who's no longer here but also Simon, Shari, Peter, Paula and Merriam who joined us online thank you very much for your contributions this morning and to Joe who joined us in the committee room thank you very much indeed as well for the evidence that you've given us we've got future sessions where we'll speak to some of those agencies and organisations that are on the front line providing the services and then we will also speak to those who've got some responsibility for the oversight of the implementation and delivery of these services before we expect to have a session with the accountable officer in the Scottish Government about the state of adult mental health services so thank you very much indeed for helping to inform our work and hopefully getting some important messages out to a wider audience as well so thank you very much indeed now I'm going to draw the public part of this morning's session of the committee to a close