 I welcome everyone to the 29th meeting of the Public Audit Committee in 2023. The first item for the committee's consideration is whether or not to take agenda item 3 in private. Are we all agreed? We are agreed, thank you very much. Our main agenda item this morning is further consideration by the committee of the Auditor General for Scotland and Accounts Committee. I welcome everyone to the meeting this morning of the committee. It is a round table format which is intended to promote discussion amongst participants, not just questions from the committee and answers from those taking part. I hope that we can have a fairly free-flowing discussion this morning to elicit the evidence that will be useful to us in informing the recommendations and conclusions that we may well draw. Can I say to those people who are joining us remotely, you are very welcome, can I say to you that if you want to come in at any point, if you put in the chat request to speak RTS or indicate there that you want to come in, we will try and bring you in. To those who are in the committee room with us, if you indicate to yourself or to the clerks that you want to come in, we will do our best to bring you in. To those in the room and those remotely, you do not feel obliged that you need to answer every question. We will bring people in who feel as though they want to make a contribution to the areas of questioning that we have. Can I also say to those people who are joining us remotely that if you keep your camera and audio switched on at all times, we will bring your audio on when you are going to make a contribution? Can I start by asking those witnesses who are joining us to introduce themselves to us, beginning with the people in the room and I will turn first of all to Chris Williams. Chris Williams, I am a general practitioner. My clinical work is in the Highlands and I am deputy chair of the Royal College of GPs Scotland. I am Derek Fru. I am the chief superintendent within the partnerships, preventions and community wellbeing division in Police Scotland and responsibility for oversight of mental health. I am Stephen Low. I am the policy officer for Unison Scotland. We are the largest union in the NHS and local government and involved in a lot of other areas in the third sector and housing and so on. Can I turn to people who are joining us online, beginning with Mike Burns? Morning, folks. I am Mike Burns. I am the CEO of Penumbra. Do you want to introduce yourself? Good to see you. I am Brian and I am the founder of Chris's Health Association. We are not sure, and I am pleased. Thanks, Anne. Christiana. Hi, I am Chris in the Mellam and I am the chief executive of the National Association of Linkwalkers. We are a professional membership body and the collective voice for Linkwalkers in the UK. Thank you. Finally, Pavan, to you. Hi, I am Pavan Sready. I am a general adult consultant psychiatrist based in Glasgow. I am the vice chair for the Royal College of Psychiatrists in Scotland. Thank you very much indeed. I am going to ask the first question to get us going. That is one of the striking things that is evident in the report. It is just the impact that the Covid-19 pandemic has had on adult mental health. It is also the cost of living crisis on the overall state of mental health. From your perspective, we are particularly interested to understand what differences you have seen as a result of those factors as far as demand on the services that you provide is concerned. I am going to start Chris with you if that is okay, if you want to kick us off. I would look back to some, I guess, very difficult, very strange times when we saw a massive shift in how we were interacting as a society and there was very clear messages coming from our government, coming from our health advice around about how we needed to instantly and rapidly change how we interacted as individuals, as organisations with fear about an infection that was a new infection where we did not have effective treatment or vaccines for and where knowledge was being acquired very quickly but small amounts of information were needed to be extrapolated up into emergency measures. Right from the start of the pandemic, we saw messaging being communicated out across society and some immediate changes in terms of access to services that we would previously have always taken for granted. In general practice, for example, people were always used to being able to walk up to the reception desk or to be able to get to ask for an appointment for things without being always questioned around what it was about. For general practice for mental health, that is particularly important in that people do not always feel able to say to a member of a reception staff or somebody who they are not yet comfortable with about aspects of mental health, especially if there is stigma involved. Of course, mental health and physical health do not have clear boundaries. From the start of the pandemic, we have seen something build in terms of the accumulative effect and it is interesting when you hear academics who are versed in dealing with disasters about the length of an aftermath, how long an effect lasts so we have been seeing things building up in terms of people's ability to interact, in terms of their experiences using all of our public services as well as their interactions with friends, relatives and other forms of support. The cost of living crisis is that. Does that have any impact on people's mental health and the demands that are placed on the health service? I think that if you are someone who can rely on knowing that money comes in and money goes out and that your basic needs are met for, life is a lot more comfortable. Being able to cope with everyday challenges is straightforward. When the numbers in front of you are changing, you have no control, that must be massively impactful for a huge number of individuals and families. I am going to ask Parvan whether you have a perspective on this from the psychiatrist's point of view. I was going to say it from the psychiatrist's chair but I probably shouldn't say that. Parvan. Thank you. I agree with a lot of what Dr Williams has said and we have seen quite a consistent increase in demand for mental health services over the past three years since the onset of the pandemic and subsequently the impact of the cost of living crisis. There has been a very specific increase for certain conditions, for example, for assessments for people with neurodivergent disorders, autism, ADHD, in some cases up to 700% to 1,000% increase in referrals. But what we've also seen is probably the greatest impact of the pandemic, the lockdowns and the cost of living crisis being felt by people with preexisting mental health conditions and sometimes that's lost in figures around referral rates and demand. People with significant severe and enduring mental health problems were greatly affected by loss of social supports, loss of family networks, reduction in service provision over the period and the shift to remote working, which had a disproportionate effect on a lot of those people. That also spiraled out in terms of impact on access to medical services, having poor physical health from premorbid level and the cost of living crisis has hit them particularly worse than most of the people. Among the most vulnerable people in our society, people with long-term severe mental health conditions and who already struggled from a financial perspective and the additional stress associated with the cost of living crisis has had a huge impact. What that translates to on the ground is an increased need for support for people with preexisting mental health conditions or severe mental health disorders alongside an increase in use of services. So we've got the highest rate of detention under the Mental Health Act as per the Mental Health Commission data at any point at all. I think that's a reflective of the disproportionate effect that this has had. Thank you, that's helpful. We got evidence on that last week, very distinctive evidence on that final point last week. I think, Christina, you wanted to come in as well from the link workers point of view. Yes, absolutely. So I think that what we are seeing is that our members are having to hold people for longer because the more statutory services are stretched, the more they are having to hold people. So some of the cases are becoming a bit more complex than you would expect them to take on in terms of mental health. Some people that were a bit resourceful and able to cope due to the pandemic were actually seeing people that were not usual suspects actually coming forward and needing support as well. And we haven't quite managed to rebuild communities. So some of the community supports that were available to people before the pandemic because of the pandemic, particularly the elderly they were asked to shield and those with long-term conditions. Some of those groups have not managed to start again. So there is a need to rebuild communities. And what we're also then finding, if you look at the mass law hierarchy of needs, most people are on survival mode because of the cost of living crisis. So before you can even build their resilience or helping them to cope with the situation, you need to deal with that basic level of feeling safe and having money before you can move to anything about managing your resilience in terms of mental health. Thank you very much indeed. I'm going to invite either Anne or Mike. I don't know whether either of you have got a perspective on this from the point of view of community-based, charity-based intervention. What's happened to demand on your services? Maybe begin with Mike and then go to Anne next. What's happened to the services that Penumbra mental health provides over the course of the last four years? Thank you, Richard. I mean, it's without a doubt that the accumulative effect of Covid and the cost of living crisis is having a major impact on people's mental health and wellbeing. We only have to look at the increased numbers of people that we ourselves as an organisation work with. I mean, a considerable increase in the number of people that we engage with. I mean, last year, for instance, 12,649 people in mental health interventions. But again, if we look at the impact of suicide ideation or suicide itself and how that impacts disproportionately on our most deprived areas across Scotland and the impact of poverty on people's mental health, then if you put those things together, the anecdotal evidence coming from people who walk through our doors is that, yes, it is having a big impact on their mental wellbeing. Thank you, Mike. Ann, do you want to add anything to that? I agree with what everyone is saying. I think that there's more than the financial impact. I think that the social anxiety, the shame that people are feeling because of the financial impact and the difficulties that people are facing. I don't know what the answer is. I think that everyone is doing their best to find that answer. But we are seeing much, much more people, many more people with very, very high levels of anxiety leading to depression as well and suicide ideation. It's the hopelessness that the pandemic has left. And when Christina brought up about the autism on the isolation from the pandemic and the aftermath of the pandemic and the access to GPs and everything else, people are feeling less and less valued and more and more worthless. I don't know if that's relevant to this, but that's how I'm feeling and that's what I'm seeing on the Christmas house. It's passing the hot potato and people should be working together, but they're not on the holistic side of things. I read that in the report. The quicker we get this done and get the holistic therapies in Richard Jude being on Christmas house, you know the way that we work. People can walk in our doors and that's imperative and that gives people hope immediately. So I totally agree, but I know that there's more depth in why we're seeing the figures rising in the mental health. And it's not just, as Christina called them, usual suspects. People that have never been affected before are now affected by poor mental health, social anxiety, shame, desperation. God help them, God love them, average is the only based. So that's all I want to see. Thank you, Ann. We will bring you in during the cost of this morning for that direct front-line experience. It's really valuable to us. I've got now one very particular question I want to put, which I think I'm just going to ask Paavan and Chris maybe to respond. If anyone else wants to chip in, that's fine. But one of the things that struck us in the report is that despite this huge increase in demand, the number of psychiatry appointments appears to have decreased. I wonder whether you could shed any light for us on the reasons for that. I'll ask Paavan and Chris if you want to come in. If you don't want to come in, that's fine. Paavan, may I start with you on that question? Certainly. I think the simplest explanation is that's a reflection of the workforce crisis that we're facing. We just do not have the staff that we need to provide the basic services we need, let alone the high quality services we want to provide. So it's a finite number of consultations, appointments, amount of work that each individual clinician can undertake. And what we've got is a reduction in the number of psychiatrists over the last five years rather than an increase to match the increase in demand. And it's not just psychiatrists. Mental health nursing, we can see, is at the highest level they have ever been. And that spirals out across almost every component of the mental health system. So the reality is we just do not have enough staff. And the reduction in the total appointments simply reflects the contraction of the workforce, whereas actually what we need is an increase. And that has been one of our biggest concerns. So the Royal College of Psychiatrists in Scotland has just published a State of the Nation report highlighting the needs of the workforce, but also some of the challenges in proposing solutions across all the tiers of the psychiatry workforce, of the medical workforce that we represent. And the issues extend all the way from constant psychiatrists, where we have vacancy rates in general psychiatry of almost 30%, which is three times the official figure of about 9%, which tends to be underrepresentation because a lot of those posts are filled with locums that might not necessarily have the relevant qualifications. If you have a vacancy rate of 30%, one in three posts is sitting empty, you can get a sense of how that translates into capacity within services. Thank you, that's very helpful. Workforce planning is something that is a recurring thing that the committee has to address. Chris, I'm going to bring you in. Yeah, so I suppose I'm very keen to illustrate some of the changes in how our services operate across primary and secondary care. So, going into the pandemic, we had a viable technological solution in the form of near me video consulting was coming across NHS Scotland. It had been proven as a concept that clinicians and patients alike could use it. Now, as it turns out, it's not so well, it's not so beneficial in some sectors, and I would say in terms of mental health, conditions and services, I think that face-to-face still has a predominant benefit. We see that as well in general practice. So, in terms of number of consultations, that's one metric. It doesn't fully reflect need and if you've got services that are limited in their capacity to deliver consultations and you've got referrals still going in, you've still got need, then we see other forms of activity, so we see waiting lists increase, we see referrals being bounced back or rejected, and sometimes our psychiatry specialist services are under so much strain that people being asked to triage these referrals, to look at these referrals, will sometimes find reasons to try and hold the dam, to try and knock things back to general practice, and we see a lot of referrals that aren't being progressed, and again as a reflection of this limited workforce capacity in the specialist service. In general practice, I would also just flag up, we're still counting our general practice workforce in head count rather than whole-time equivalent, so there's a real hidden problem there. This is something we've tried to tease out of the Scottish Government when they've been sitting in front of us, Chris, as well. I was going to bring this up later, but I'm going to bring it up now because it seems to me to be something that relates to what you said, Chris. That is one of the things that strikes us that's contained in the report is Exhibit 3, which has got a graph which shows huge variation from health board to health board in the number of face-to-face appointments versus telephone or video appointments. It's not just about remote communities being more reliant on video and telephone. There are stark contrasts, for example, 86 per cent of psychological therapy appointments are face-to-face, just 14 per cent telephone or remote, whereas NHS Lanarkshire, for example, a similar population demographic, I guess, has got just 32 per cent face-to-face and over two thirds are video and telephone links. Can you explain that variation? I can't fully explain it, but I can offer some insight. In primary care, for example, there are many places with very limited premises that you can't house all the members of staff, especially where we've been trying to transform primary care and bring in an expanded multidisciplinary team. There are some differences in terms of preference and it would be interesting to map that activity against patient preference or clinician preference, but patient preference and the patient experience predominantly. Even with our current information technologies, we aren't doing a good job of mapping who has a preference to take an appointment as a phone call or a video call. For some people, video conferencing works really well and they can interact with services without missing large amounts of their time in employment or giving up some of their caring responsibilities, but I think that variation does need to be understood and looked into. I'm going to move on to Graeme Shortley, who's got a question about the role of the police, but before I do that, Christine, I think you wanted to come in on this area as well before we move off it. I just wanted to come in, because it's very important to us that we make sure that we're not over-medicalising and life-issued. I think that there is a thing about do we have the right numbers to be able to meet needs, but again, it's how many of that needs. It's about mental health that is caused by social determinants of health that then needs different approaches. I think if the round table agrees with me that we've all got mental health, we've all got physical health, we've all got emotional health, is about the state that they are in. That's all we're talking about here. For some people, it's poor. They don't have an illness yet. They don't have a mental illness yet. I think it's reflecting the needs, so I'm just focusing on reflecting the needs and then the number of what sort of woes we then need as opposed to the numbers. If we get things right, we don't expect lots of people to be developing mental illness in the first place if it can be prevented from deteriorating to that stage. Thanks, Christina. That's very helpful. I'm going to now ask Graeme to kick us off on a couple of areas. Graeme. Thanks very much, convener. Before I speak about the police, Derek, I'll be speaking to you about that, obviously. I just want to go back on something that Chris said, and I raised this in our session last week. It's about the difficulty that people are now facing, and you mentioned this earlier, of actually getting to see a GP. It has become much more difficult, and you have to almost get past the receptionist, whereas before, you used to be able to just phone up and ask for an appointment, and you'd be given an appointment. People are having to explain what's wrong with them to somebody who's not a GP, and I think, and I don't know if you'd agree with me, I think that must put people off, and particularly people with mental health. They may just not want to discuss it, and so it will put people off, and if it's putting people off, then we're going to miss people. I just wonder what you think of that. So, I don't know that it fully puts people, there's a lot of people that doesn't put off, I think it drives frustration and I think it drives negative experience. At the moment, general practice and our GP workforce faces a real difficult time. There are other parts of the system that are mentioned, the waiting lists, where they're long waiting lists, so people keep returning to us with problems that we've already referred them to any replacements that they can't yet have, so we're still dealing with their issues of needing pain-killing medicines and dealing with other problems that rack up. We have a limited GP workforce and some of the changes that are introduced in recent times are to bring in other types of workforce, pharmacists, physiotherapists, and they can deal with some specific issues. But I say that this combination then of our GP's needing to train more students, needing to supervise more GP trainees, needing to offer input to this rapidly expanding team. So we find our GP's very stretched and we're there at this constant demand and much of it driven by genuine need. And it's very difficult to be a GP in that position where you can see the amount of contacts we have on a daily basis where we try and meet, where we try and I suppose we've needed these systems that we describe as triage where we have to try and understand who out of a huge volume of people contacting a practice who needs to be absolutely at the top of the list to see and it's not always those who are shouting the loudest. And in amongst all this reaction, all this reactive work there's a very clear danger that some of the planned care that we would be delivering some of the proactive work and I guess mental health especially falls into that area where we would in previous times have sought out patients who we know of vulnerable, who we know we haven't seen in a while who we would be wary if they dropped off our radar and it comes back to some of the issues that were raised I think by back Katrina, Christina in particular around about some people out there and we might ordinarily on coping in their normal role in society and there's such pressures at the moment over the last while that there's so many people turning to general practice to ask to be seen and we know that there's lots of people where the preference is I'd like to speak to my GP and I would like to not have to explain myself about it but it's an operational issue that we don't have a GP capacity to meet that demand I'll move on from that because we could spend ages just on this one subject but I do want to chat about the police if I can Derek because it's been a big concern of mine for quite a while now having spoken to police in my own patch myself and the convener represent Central Scotland so that includes Lanarkshire and speaking to police in Lanarkshire they're telling me and I think that the police are nationwide are saying the same thing the amount of time that officers are spending just dealing with mental health cases can be as high as I found this an astonishing figure and this was given to me locally 80% cases dealing with mental health cases and I've heard locally that we've had incidents where there are entire shifts of officers in A&E sitting with people and not able to deal with other cases that seems to me to be a ludicrous situation and not a good use of resources so I'll ask you to comment on that initially and then we can move on I've heard those anecdotal stories as well so that's not a unique story and I think HMICS we've recently done a review we've also provided similar evidence on that in terms of police officers going to the hospital or 80% when we look at our stats we're getting better at understanding that 80% figure probably covers a wider number of incidents so for example concern for people missing persons, assistant member of the public comes under quite a wide range of descriptors that get that 80% figure but there's no doubt there's a huge element of that 80% figure are individuals who are suffering from mental health there's no doubt about that we do often go to hospital and there is that demand issue and it's no fault of theirs that they have a capacity issue when we take them there we then from our perspective and people maybe say that the police are being risk averse but I suppose our view is that we're investing in the vulnerability and the safety and protection of an individual and I think that goes back to when we became Police Scotland in that unique point in the legislation that actually writes in our legislative purpose is to improve the safety and wellbeing of individuals and we didn't probably have that in our purpose before we became Police Scotland we've always done it, it's a police service regardless in terms of supporting people with vulnerabilities but what does that wellbeing mean that wellbeing we're probably still wrestling a wee bit in terms of we need to define that in terms of our service provision but if we define that in terms of our service provision what does that mean for our partners because there's that unscheduled care element and I think Police Scotland are not and hopefully people will be supportive of this are not taking the position that they have done down south whether certain areas have said we are stepping back and we're not going to do that well we think we've got a different legislative purpose but we do have to work with partners to work out where that that kind of line stops because we have to remove ourselves at some point we have to go back to what I would call traditional core policing requirements but the reality is mental health is now a core policing requirement so what was traditional before needs to be redefined as mental health always going to have an impact on policing yes is policing always going to step up in Scotland anyway is policing always going to step up and make a commitment to deal with the most vulnerable in society yes it's how we get the care services from statutory and non statutory partners that fill the gap when an individual isn't admitted to a hospital what do we do? Do we walk away and do we leave them vulnerable because what we heard is evidence provided already post Covid people have lost their networks of support some people just don't have that family support and we find ourselves often filling that gap not through choice but because we're invested in the vulnerability of that individual okay officers on the ground will tell you I'm sure they've told you as they'll tell any of us that the police are risk averse and that's not criticism by the way that's just the reality and you mentioned the situation down south ultimately this comes down to what is the best way of dealing with people who have mental health problems people who need help and so the question is I suppose are the police the best people to deal with that answer sometimes yes often no and so they've looked at they have looked at this down south they've got a system called right care right person in humberside humberside police took this up and they believe it's saved I'll just quote the figures 1400 officers officer hour hours on average every month have been saved by adopting a different approach if you look at that across the whole of England that could be up to a million police hours a year so that if you just take that a good thing from a resources point of view if we deal with things differently so I don't think we should completely rule out what they're doing in England we should perhaps look at it and see if we can learn from it because what we don't want is police Scotland to be tied up dealing with cases that really is not your job so I completely agree just to probably take on from the last comments is it the police's job to fill that gap we don't feel it is just to be blunt we don't feel it is but the commitment we've made is that without having a proper plan and engagement and consultation with partners we won't take that approach that England and Wales are doing without understanding the right place kind of model so we at HMICS have commented on it as well we will absolutely look at that and we'll review that we've actually got a workshop coming up in the 22nd of November with partners to try and help us work towards what a new model is going to look like for Police Scotland and we can only do that through collaboration we realise that with the funding envelope that Police Scotland's got and the reducing police numbers based on that we need to come up with a model not only for mental health but look at efficiencies across the board but we are looking at that so that step in the 22nd of November is really important because we can't design that service without professionals from other bodies we have to listen to lived experience there's the advisory group the HMICS use we're going to look to see how going forward we'll listen to lived experience and we'll use our service design team to come up with new approaches and new models but based on not just stopping and pulling back because we think that is not what the public and certainly people with vulnerabilities require we do have good practice going across Scotland it's very hard to get a consistent approach because there's different health boards different third sector so to try and get a model that works everywhere is quite challenging there is really good learning coming out of central Scotland area in fourth valley round about a risk assess process what you talked about has been risk averse because we do obviously think about what happens and we'd be subject to a perk investigation as you know so we're looking at the work that's been done in fourth valley with police, partners, perk a proper clinical risk assessment that allows us to take an individual to a hospital and based on that assessment we can then move back but that's through partnership so we're looking at that, can that be scaled up looking at geographical areas where we can pilot that that's great sorry just to alert you to the fact that Mike, Paven and Chris also want to come in on this question oh do they? yes it's not a dialogue it's around table well it is it's good to know that other people want to come in on this because it's really important but I was just going to say that I think that's really encouraging what Derek said that we have this project I suppose you could call it in fourth valley I think I'd like to know a little bit more about that and the discussion is coming up on November 22nd 22nd I think that's great if we're looking at it if we can get to a system where even if police are called out that you can then contact somebody else and they can take on the case that would be good so I don't know, convener, who you want to bring in well I'm going to bring them in in that order I think I'm going to invite Mike first of all if you want to come in then I'll go to you Paven and then I'll bring in Chris in the committee room so Mike first of all thank you Richard and just to pick up on what Graham was saying there a social worker of 30 plus years experience having delivered services and homelessness addictions and mental health I have nothing but admiration for the way Police Scotland excuse me I'm full of a cold for the way Police Scotland work with the most vulnerable and those within crisis here in Scotland some examples in relation to how we're trying to plug that gap here in Scotland to my knowledge there are only services multiagency services working alongside NHS Lodion and NHS Tayside the crisis centre in Edinburgh and the Hope Centre in Dundee which are attempts to try and address some of the issues that have been highlighted thereby Police Scotland in delivering what we would call a physical walk-in mental health crisis service so there are some areas of good work out there but there are few in far between thanks Mike Pavan thank you I recall a lot of what Derek had said and also what Mike had said in terms of the very different context in Scotland in terms of working relationships with Police Scotland which is far more collaborative and I would have real grave concern about any move towards the unilateral approach which was adopted by the Met to withdraw and then look at what needs to be put in place I think that puts people at real risk and these are some of the most vulnerable people we are going to be part of the collaborative approach that Derek described in terms of working through to find what the right model for us in Scotland is and I think there are elements of learning from experience down south but I also wanted to highlight that there are actually lots of examples of very good practice Derek, Mike mentioned a couple another example is the mental health assessment unit which acts as a diversion from A&E so officers don't need to be stuck in A&E for five, six, eight hours if you have a mental health difficulty a mental health crisis you go straight into the mental health assessment unit where you're seen by a specialist rather than having to go through the generic process but all of these things need funded and I think that is the real challenge so the Humber example the difference is in Humber the investment in mental health services as a proportion of overall health spend is about 13% that is almost exactly the double the exact double of what some of the other board areas in Scotland spend where it's an average of 6.57% and you get what you pay for ultimately that is the challenge we need dedicated investment in all components of the service specialist services where there is a statutory role for someone who is presenting in crisis where there might be a risk to themselves or to others all the way through to multiagency examples in the way that Mike described or in other third sector partners and we haven't seen that joined up process of looking at making long term investment decisions not year by year decisions but long term investment decisions especially in terms of third sector supports and commission services that allow for that collaborative shift away from the police acting as a first responder in a lot of these circumstances Thanks Pavan I'm going to bring in Stephen because we've not heard from Stephen yet and then I'll bring Christian for a brief comment before we move on No it's just so that the point that this is failure that a lot of this is failure demand is made I mean a lot of our people are quite upfront about the fact that they are not they don't have the capacity or the numbers or the range to get into to help people before it reaches the kind of crisis point that does involve the police indeed they are only getting involved with people after incidents and behaviours that have involved the police and really if you want to reduce the demand on police you there's a strong strong case for interventions downstream so to speak in services like housing in services like the various psychological therapies and so on that people have been saying we shouldn't have the police involvement to the extent that we have because we shouldn't have as many people in crisis as we have and there are ways to prevent that if we're serious about it that's helpful Chris I was going to make that point we do have some very good examples of multiagency working but also the one element we haven't flagged up some people have insight that they have a mental health problem that they need help there are of course others that don't have insight where their friends or relatives may be flagging up concerns either to health services or to the police and I guess especially if there's any suspicion of a threat of violence or other situations where the police have specific skills and capacity resources that they can offer and with an aging population I think we are seeing more and more vulnerable people where carers or relatives live far away and there are concerns about well-being so I think that's all been really useful and I thank everyone for contributing to that I should say that the MET system my understanding of the metropolitan police system is that they only respond to 999 mental health calls where there's an immediate threat to life of course I'm not sure how you're meant to judge that over the phone that seems to me to be a rather blunt system so I think if we can just improve the way we deal with things I don't know convener if we've got time to ask the panellists about the model that's used in Trieste I don't know if you want me to If anyone's got any views about that which is highlighted in the report from the Auditor General the Accounts Commission then would be interested to get their views it's about a more community-based organisation a walk-in maybe and that's something you would have a perspective on Anyway, Graham It is mentioned in the report so this is Trieste in Italy where they've set up a new way of dealing with mental health and it operates through a network of mental health centres 24 hours a day you don't need an appointment you just walk in so not only has it improved the way mental health is dealt with in that area it's also cheaper than what was there before now that's not why you do it but it's just ended up that way so I don't know but don't comment if you've not read this section or if you don't know about it but if you have read the section about it I think both Ann and Mike have indicated that they want to come in and I think because Christine wanted to come in on a previous point so if Ann and Mike might be the ideal candidates to tell us about their insights into this approach beginning with Ann Trieste I've known about for as long as it's taken for to recover from the death of my son between Trieste and Pieta system in Ireland and the Matri foundation I've based Chrissie's house on that anyone can access and crisis mental health service at any time 24 hours a day, 7 days a week, 365 days a year and I'm very very proud that we've got a very very high success rate in Chrissie's house we're not a big player we don't advertise, we can't advertise Dr Pavan Dew mentioned funding we don't get funding we're self funded which limits us and how much we can expand I set this up with my vision my background is social science that's my education obviously I've got bought on since I started Chrissie's house but it's a very very successful model the problem in our country as opposed to Italy there's something in Brazil as well at our crew is red tape and this frightened as you say risk a verse we're all tied up in red tape but I think in fairness and to crisis and I understand the crisis that they'll live in has no longer working that's what I'm hearing whether I'm right you can correct me if I'm wrong because if the red tape have made it they have to be a health and social care thing that they'll live in centre down institutions so they can get it properly because they regulations so we get tied up with regulations and in Chrissie's house I'm glad to see that we are independent and we do work on a person centred basis on the person's needs and when we can influence outside agencies as in housing our social work channels we do recognise as a status we're not recognised like a status of a service so we don't have the teeth that other people have hopefully that will come in time once we've proven the success of Chrissie's house and how successful we are so yes the TRIES system is absolutely what we need what everyone needs is people to access when they're in crisis we're not in crisis in two days we don't organise crisis it happens when it happens and they have to be attended to so that's all I'll say on it I hope that answers what you think that's a very very good service thank you Mike, I'm going to bring you in next and then I've got Christina and Pavane but Mike to you next thank you Richard just to answer Graham's question somebody that's studied the TRIES model for a number of years Graham the earlier intervention in crisis will always be more cost effective we know that all the research is there you don't need to be over Einstein to work that one out and the point that Anne makes is really good we do have some difficulties in this country around registration and the role of the caring spectra in relation to how we develop these models in Scotland and certainly that's something that would encourage the committee to look at and talk to those people with lived experience about the really positive outcomes a model such as the TRIES model has been able to achieve for them thanks Mike, Christina I think I do agree with what most people have said apart from the Italian sort of like model so I think we are chasing we've got a crisis model which is the reason the police are having to deal with people that have got a mental health crisis and all the systems so all the public sector have got a crisis model and most of the cases they are seeing is a cry for help and I think we don't need to change behaviour so I wonder what needs to come up from here is to recognise that behaviour change is something that we need to do because this is the reason why the thought sector is probably not as recognised as the way that it should be recognised and the reason why even the community link workers are not sustainable despite delivering fantastic services the GPs, the community sector the patients actually saying this saved my life yet in Glasgow they are about to slash the number of link workers by a third so I think there has to be an acknowledgement here what are we talking about when we talk about mental health are we talking about mental health in terms of poor mental health are we serious about preventing people from operating or what and we have got a massive example in Highlands custody link worker the work with the police that is under the community justice partnership programme we've got examples here we've got link workers that they can refer from the GPs but of course it has to be looking at the pathway and looking at what is the need from what the need is we can then design pathways and look at step down models to then address that so I don't think we need to speak with the link workers to find out what they are already doing how they are working with the criminal justice system what the need is like and then how do we increase capacity from there but we can't do that if we don't recognise that we are not an optional addition as a workforce Thanks Christina that's a point forcefully made I've got Pavane to come in and then I'm going to turn to Colin to put some questions Pavane on the TRIES model perhaps Thank you We're very aware of the TRIES model and I've studied it, I've been involved in looking at it in detail in the evaluation for where it decayed and it's been around for about three times that long and the TRIES model is also what guided the shift to community mental health in Scotland it's not new, we've worked on that for the last 20, 30 years unfortunately it's a job half done so we made the shift we shut their silence we put into the community and then we kind of lost interest I would also disagree with the point Christina made that the public sector model is a crisis model I would disagree with that wholeheartedly our model is very much a model of looking after people in the long term people with severe and enduring mental illnesses and I'm making the distinction between poor mental health and a severe and enduring mental illness I'm talking about people with bipolar disorder psychosis, severe OCD severe eating disorders which are in some cases lifelong conditions which have a huge impact I've seen people for the last 20 years that have been working as a psychiatrist and I'll see them for the next 20 years while I continue to work as a psychiatrist these are long term relationships that we build with people the challenge has been that we've made investment in the community we've started that process and we've lost sight of it there needs to be a focus on prevention absolutely but not at the cost of investing in services, in specialist services as well it's not neither our model and it's a bit like saying we'll invest in smoking cessation but we don't need to worry about cancer services these are generational shifts and prevention takes place across multiple levels there's prevention of a crisis which is prevention which is what specialist mental health services provide all the way through to looking at housing and employment and educational resources which is primary prevention and sometimes these conversations get simplified into an all or nothing position that somehow if we invest early we invest in prevention we're not going to have mental illness and that's not the case I guess the point I'm trying to make is it's a very good system but it requires going back to what I said that long term strategic vision and a commitment that is not measured in one year, two year, five year cycles but a 10 to 15 year cycle thank you that's a very clear point of view before we finish this section I'm going to give a last word to Derek before I bring Colin in Derek I appreciate it, I'll keep it really brief it's probably just to close in on what Dr Parvin just said that strategic vision and that 10 to 15 year vision of a 24 hour service is what will reduce your policing demand because until there is mental health services that are available 24-7 the police will continue to fill that gap so that I would just wholeheartedly endorse what's been said thank you and thanks for being succinct Colin, over to you I'd like to look at some aspects of access to support and I'll start with GP so Chris will put you on the rack first my experience as an MSP is we do get people coming in for mental health issues to a greater or lesser extent and usually we pass the information back to their surgery and we get zero feedback for confidentiality reasons often the same person is back in a month later with still the same problem so we never know what's happened anecdotally although we don't hear in majority cases anecdotally we hear as long as they're not a danger to others they're not fussed but for example someone who has a belief that they're being under police surveillance or MI5 or whatever they're very distressed because they truly believe that so it seems that nothing's being done in respect to that so I'm asking about the role of the GPs what support you need to better support mental health needs of patients but where is the break there so I would say that I would start by speaking generally and saying that all GP practices their access arrangements and we're continually changing how to try and understand where there is need and need to try and deal with that so above and beyond the demand sometimes we're hampered by old telephony systems for example where there's a limit to how many people can contact the practice at one time and so sometimes we see surges of people trying to contact the practice all at once and I guess the Monday morning scramble for appointments is one example so we try and introduce other ways of people getting in touch so digital ways where people can send in a form so all the time we're trying to find ways to allow patients to come into the system where we've got I highlighted earlier where we've got a limited GP workforce and especially where that workforce is needing to attend to other tasks in terms of educational tasks other supervision of other clinicians other members of the team we can really become stretched and on the back of that as you've picked up on continuity is a big thing in general practice when we are able to afford continuity which doesn't always need to be the same GP it can be different clinicians different members of the team but where I should say the evidence is around the continuity on general practitioners rather than studies on the other members of the team but where someone feels that they are known where they are listened to where their issues are understood even if we can't fix all those issues they can have a better sense of a better sense that they're doing okay and I absolutely accept what you're saying about some of the frustrations that people will voice when they feel they aren't able to access a system sometimes through no fault of their own but again I would highlight that there are a lot of people across primary care and especially in terms of GPs who want patients to have a straightforward route and especially for those who have need to be seen in a timely way there's a wide range of mental health issues it's not just one particular issue for people the process is described as Sloan complicated to get support what happens when people are not eligible for specialist services but still have mental health challenges and I'll throw that open obviously to everybody I think Pavan wanted to come in on the point about the role of GPs and you might have a view on this as well and then if other people indicate thank you the point I'll make links into both the questions that are being discussed I guess one of the first things I was going to say in terms of some of the challenges in the interface between primary and secondary care is the capacity for communication but also for expertise for mental health expertise to be available within the primary care setting that is a real challenge because our primary and secondary care services tend to work with quite distinct boundaries and that can be a real challenge when someone doesn't neatly fit within those boundaries some of the work that has been undertaken around expanding the provision of mental health and well-being services in primary care would have gone a long way in addressing some of those challenges the initial challenge described about how you get access to specialist services, how do you get access to advice to determine what would be the best service and how do you get access to advice to determine what might be alternatives if they don't meet the threshold for specialist services there are really good models for example down south in Cambridgeshire a model that has been in place for several years and the aspiration here in Scotland was that we would expand quite significantly the provision of mental health specialist and third sector mental health provision within the primary care setting with the expansion of multi-discipline teams with input from psychiatrists from psychologists but also from link workers and third sector partners all of that has been on hold since the cut to the budget which was announced in the emergency review in December last year and that is the challenge this is a much needed resource it's a resource that can be provided we've got very good idea of how it could be provided but it does need new investment and that is what the 32 million which was earmark for it would have delivered, would have addressed a lot of those challenges which also would have addressed the challenges of well what are the alternatives if they don't meet the threshold for specialist mental health services the other point I also wanted to make is that when we talk about someone being rejected by specialist mental health service it's not simply about gate keeping it's not simply about keeping people out it can also be that actually specialist mental health service within the model of care that is provided within a psychiatric service it is also because that might not be helpful to that individual and that they should be alternatives the challenge of course is those alternatives don't exist and that's why it becomes a problem but sometimes a bad alternative is not a good substitute for no alternative I think it's also important to highlight that and keep that in mind one or two of the points you made there between primary healthcare and moving into secondary who does the triage how does it work who decides on the priority for that particular case in practice it's based on the information provided in the referral and that triage and that decision is made within the secondary care service so that is on the basis of what the secondary care service provides to the adult community mental health team we would look at the information provided in the referral by the GP we would look at whether the individual's needs are best met within the secondary care service sometimes if we can identify an alternative service we would signpost the individual to that alternative service but that triage process is undertaken by clinicians within the secondary care service OK Colin I don't know if there's anybody I'll bring them in before you go on to your next question if that's OK and I'm conscious that Unison's got a lot of mental health nurses amongst its membership and you might have a view on this I'll come to you in a second but first of all remotely I've got both Christina and Mike want to come in on these points so I'm going to bring Christina I'll bring you in first Yeah so I think that the thing is that the referral and the way we describe mental health is all kind of like links so you've got those, you've got mental illnesses like Pavan has listed and those whose mental health is as a result of all the issues that don't need a clinical treatment and a non-clinical approach like the link walkers walk so we need to figure that out and just making sure people are not bouncing around the system and the especially services they need to be aware of what link walkers do and what they're not able to do so that we're then very clear because that is what we are finding is where people go feet into any box and they're just bouncing around the system the referral is coming back to the GP whereas there might be community-based link walkers that are basing the community or those that are basing primary care that can pick that up so I think we need to discuss and have a look at what the evidence is saying and what the data is saying and take a personalised approach we need to take a personalised approach to mental health some people will respond better to a non-clinical approach some people will respond better to a clinical approach but policing everyone into one list might mean that people might be waiting in the list inappropriately and we're not able to identify what step-down model that they might need You're talking there I was just thinking what's the extent to which people are actually aware of the different types of support that exists and I'm thinking here quite clearly the role of community link workers how aware are people in general of this Well they're not very so I gave every verse to the alternative pathway to primary care you know that health and sport select committee and it's because we haven't got a universal access in primary care and I know that that's a challenge we need to have universal access to community link workers across all GP practices in Scotland because most of the mental health works happens in primary care and community care that's what the evidence does suggest so not being able to meet that then means it's quite very difficult to do a universal campaign but now the current First Minister when he was the health secretary I said to him we needed a national campaign he needed a national campaign to raise awareness of the support that can be provided by community link workers but we need capacity when people don't value that we are not an optional addition then how it's not sustainable I mean lots of link workers in Glasgow right now they don't know if their job is guaranteed so those sort of approach is sort of like a setback we bring in an additional workforce and we promise the public and now they're getting used to that we take that away so that is wrong I think we really need to think about what is it that we're doing here are we serious with mental health are we really really serious about helping people to live well in good health or are we just sticking boxes because if we're not serious with the link workers and what they bring it's just to let down to patients Thanks Christina I'm going to go back to the question that Colin put around the description in the report of access being slow and complicated and I'm going to bring in Mike and then I'll come to Stephen I think Anne wants to come in in this area too but Mike remotely if you want to give us your view on that that would be really helpful Thank you Richard on your question one of the best examples we've had here in Scotland over the last two or three years has been the DBI programme the brief intervention programme into working with people who are in various states of distress and anything up to suicidal ideation and if we look at the outcomes that we've achieved in relation to that and the recent evaluation it's how valuable it has been in diverting people away from clinical services or statutory mental health wards or indeed the role that the police played that's been highlighted here earlier One of the difficulties we have is that however the Scottish Government will no longer provide dedicated funding for DBI as of March 24 and this will be expected to be reflected in health and social care budgets and as the report itself points out in point 24 this could result in varying quality and availability of DBI services across Scotland so again going back to what Pavane said about triest if you start a model and you build a model that's proving to be really really good and successful think long and hard about how we take that forward thanks Mike Steven and then Ann remotely To take Colin's final question how aware are people of what's out there I don't wish to be harsh on doctors here but people don't always need doctors but we are wired to think that you must see the doctor if you've not seen the doctor if you've not seen anybody and there are a whole load of other alternatives that have been out there for a while but progressed there's much more online access to information and even attempts at therapy there's NHS 24 in the breathing space programme quite a lot I could say about how they operate but nonetheless they are there there are things there and we need to get away from if we are going to create a sustainable set of mental health services we need to get away from the idea that everybody must always see a doctor even I suspect initially I mean maybe you need a doctor to go down the social prescribing route of the link workers that Christina is arguing for but you don't always need a doctor to deal with everything there are other areas out there and I don't think it's been I think you need a cultural shift there quite how you develop that I'm not sure but we do need more of an effort to get these other clinical professionals and people with expertise involved and available for people I could talk about staffing but I suspect we'll get to that later Thanks that's a really helpful perspective to bring in I'm going to turn to Ann for your view on this what happens to people that fall through the cracks First of all I would like to go back to what Parven said about the people with the long-term mental illness and we also picked up on the bad alternatives there are bad alternatives because quite often in the government we're using a lot of peer support workers and there's very very good link workers there's also people that think that aren't your psychologists there's a place for people everyone and people need to know their limitations people need to know their limitations now we're a non-medical centre non-clinical we talk about clinical here my people they're psychotherapists they're at masters level that work in here we also know that we need we need clinical services we need medication in some points but we need to get to the trauma that's caused people to have the long-term mental health illness that they have it's not always just chemical imbalance something may have caused it but a lot of trauma needs to be done we need to be a lot more trauma informed on the best practice of DBI on the best practice of DBI on the best practice of DBI Mike it's wonderful that you brought that up because DBI is a short term and it's a short term but now like our services like ourselves are finding we have the flies holding up the ceiling because we've got nowhere else to send them we're getting them when other people are getting paid to do a job that they're not doing you know and the waiting list I know it comes in longer the waiting list to see a specialist or to see the specialist service I've got three psychologists working here to see a specialist service that if somebody presents to me in a psychotic you know presented in some psychotic form and I can't get them to see someone that day what am I supposed to do they're psychotic, they're a danger to themselves and maybe a danger to other people you know I'm very lucky in Lanarkshire that the police are where he is the police often will bring people in that have been dismissed after being on a train line the police have taken to the hospital brought them back in but they're deemed fit they're deemed they've got capacity a lot of people know the right things to say everybody has to get this joined up you know this joined up service and respect everybody else's input if we respect each other's input and know the need and know that there is no particular hierarchy there isn't a particular hierarchy and I understand that everybody thinks their moral is the best moral but as somebody say that there has to be a shift at other people like peer support workers link workers, psychiatry we all have to work together we're all saying we're working together but we're not we're not but very often I'm probably a Michael know this as CEO in Parambra we're fighting fires all the time so it's very unusual for me to be sitting in a meeting in a meeting because I don't take time to sit in meetings because I'm busy working with what we're working with on a daily basis if I gave you our figures you would probably think well that's a small amount compared to the statutory services but it's not a small amount for the size of your organisation but I want our organisation to get bigger and bigger but we can only do that because people actually start to work together in respect what each other do I don't know if that takes away from the point and it is a bit long-winded but I get really upset when people think they can work with bipolar or I would never touch any of doing eating disorder in Erexia because I don't have the team to work with that so I know that that's not for us it's not about getting numbers here it's about getting the best of the people and that's why I try to model as near as I can to the dress model because I've lost my son to suicide and we should also take note and stop ticking boxes and do the work and do the job and I know we're all sitting here because we are doing it but I'm pretty passionate about it and I get I get passionate when I'm speaking and I'm no making an apology for it there's too many variables when we're dealing with people's mental or wellness that goes for local local council areas personalities that are dealing people that are if compared to compassion fatigue we need to get this all on a level an awareness of the link workers awareness of what people can do and what people are here to do not tick the boxes to do it that's what I'll say thanks thank you Colin on the back of what I'm saying there it's probably worth highlighting that from the report there's a huge variability on primary care mental health services third sector services and peer support across Scotland I don't know what extent that arises from a greater or lesser knowledge and awareness of the different forms of support that exist but I'd be interested in hearing any comments on that anything that could be done better or how do we join this up and it's highlighted that not everything is joined up how do we fix that Chris I think wants to have a go answering that question it's a big one and I think a lot of the interfaces that are there don't aren't always reviewed in the way in the continuous feedback loop that we need so coming back to you asked about the referral process and so in Scotland we've got an electronic way of passing up things that are non-emergency if you have physical health problems then there's a category of urgence of suspicion of cancer that where you are on a very sort of fast waiting list that option doesn't exist in mental health but that the system does allow information to be structured in terms of how we pass it on but how that information is then received and reviewed so for example in my local area that the referrals are reviewed by a team who consider which service is available locally and they give very prompt feedback to me as a referer and it's that feedback that sort of supports the referring behaviour and drives things makes sure that I'm putting the right amount of level of detail in and balancing that with the speed of passing things along the line so although we're two separate teams because there's adequate communication that the system functions functions well I referred to mentioned earlier that there are systems which are under such pressure or where the where the feedback is simply a rejection of our referral and we mentioned there's some conditions so ADHD for example where we've seen such a change such a massive rise in demand that the specialist services there need to try and again identify who are at the most of need or who the service can provide for so in response to referral we'll send back a counter request asking would your patient be wishing to take medication what will they hope from having a diagnosis and so where the specialist service will try and check the referral but while we've got stresses I think feedbacks that the key to overcoming that we are really up against the clock and so I'm going to apologise to a couple of people that did want to come in on this point but I'm going to need to move things on because we've got some really quite important areas yet to be covered and I'm going to invite Willie into leaders off on the next section thank you very much, convener what a really important discussion we're having and to hear Anne speaking in the way she has done Richard is really quite an important thing for this committee to have heard it's one of the most moving contributions I've heard for my long experiences in MSP in the Parliament so thanks for doing that Richard, while the committee announced an extra million quid for the community link worker health and social care partnership in Glasgow so that's a wee bit of good news coming in at Christiana we'll probably be delighted to hear and no doubt there'll be a clamour from other health boards to get something similar so that's quite good I just wanted to ask the panellists some views on how we can improve these services and I'm thinking in particular about the order to general's comments the cluttered landscape and the structures that we have integrated joint boards health and social care partnerships we often don't have compatible systems to share information and so on anyone who has a view on this I'd really be obliged to give a few thoughts on how we might improve this situation so questions on the governance architecture and whether it works and fits together well or not I think Chris is indicating that he wants to come in first of all and if other people have a view just let us know you don't have to have a view either of course Chris I'll speak first on behalf of my psychiatry colleagues and I know that they were very fearful about some of the reorganisation proposals with the national care service about having these clinical staff in a governance structure that's based around social care for example and Pavan might want to pick up on that but in terms of information sharing we frequently hear a desire that people within a system don't want to be repeating their story that clinicians that other administrative parts of the team can access the information and at the same time they find these information governance barriers that are set up with very good intention and it sets the actual operationalisation and the legal fears around that as well that our information technology systems aren't good enough yet for us to easily be able to have that role based access that we need for information sharing Pavan wants to come in and also Mike and Christina so Pavan maybe you first of all Thank you that's really helpful and governance has been a real challenge and the moot integration has unfortunately meant nothing but fragmentation for mental health more than anything else there's been duplication of governance structures lack of coordination and planning due to a lack of clarity about responsibility between IJBs, HSCPs and boards and in most cases it has felt that mental health has come as an afterthought and that is exactly how it's felt within the national care service the reference to mental health was a paragraph it has continued to be an afterthought in all the planning most of the reference has been to social care rather than thinking about mental health in a much broader holistic sense and it also seems to not recognize the link between physical health and mental health it seems to treat it as two way separate distinct things rather than something that is part and parcel of an individual this almost like will separate the physical health put it in one section will separate the mental health put it in another section and expect all of that to automatically come together so I think that has been my experience personally of being a clinician on the ground we've got huge amounts of red tape due to duplication of governance structures across the board areas across IJBs and we don't know what the national care service is going to bring in and the points that Chris has made around communication is a huge challenge that we all use different communication systems and if anything that fragmentation is worsening and a lot of that certainly my sense our sense has been that it comes to not recognizing the importance of mental health services and mental health as something that needs to be a priority in terms of planning in terms of structures that it seems to be something that gets pushed into the background and moved or fit in after other decisions have been made and that is our grave concern about the national care service everything we've seen so far has reiterated that concern that mental health does seem to be an afterthought that it seems to be focused on the care provision and that mental health support care and treatment comes as an afterthought to be fit in on either or rather than thinking specifically about mental health services needs and that is a real challenge it's a real challenge to have that heard and that contributes to the fragmentation and the lack of joint up working integration that we've touched on at various points all through this discussion particularly on this point of governance Mike, I'm going to turn to you next for your thoughts and then Christina I'll come to you and then to Stephen in the room here but Mike first of all Thank you Richard I would wholeheartedly agree with everyone that Pavane said there and I don't know what shape or structure the NCS will take but until we have that in front of us it's concerning that mental health will be the poorer for being lost within a structure that will be dominated by possibly older people services and that's a big big concern I have the privilege of co-chairing the biggest test of change in social care in Scotland in the city of Aberdeen GCC what we've managed to do there is put mental health on an equal standing alongside older people's care learning difficulties in personal care and our whole drive is to move away from a time and task model to one focused on outcomes for individuals and that has to be the direction of travel for everything we do in mental health and in social care and as a real concern that unless we focus on outcomes for people we will continue to focus on the services that we can deliver as opposed to the services that we need to deliver Thanks that's really well put Mike Christina to you before I bring in Stephen Christina Health care is holistic isn't it it's about joining everything up and I think that the link blockers are in a unique position because we're community people who've managed to be some GP practices and some of the clinical teams so we find ourselves it's been a very strong link between the community and the clinical services which then means there is an opportunity to do holistic healthcare and do the biopsychosocial work which we've always wanted to do and the continuity of care not lost now the challenge is we need to be able to follow the entire person's journey and that is what is not being enabled even with the funding commitment in terms of the link blockers just paying for the we're not looking at a digital infrastructure and the information governance and that then helps us to check what we're doing so I think the PRSB which is the professional standards body they managed to produce an information standards which they said all the four nations it's relevant all the four nations I think that's something we need to look at and see how can we strengthen our systems because with the work that our members do the traditional way and the clinical systems is not enabling us to capture all the information that we need to capture and then that then helps us to capture some of the social data and what's being done in the community and that should help to also then drive data driven informed commissioning arrangements as well Thanks for that Stephen Would the inadequacies of the National Care Scotland Bill were restricted to mental health however that's for another day but we should remember that when that bill was proposed the minister would talk about a system combining social work social care and community health as if this was a seamless continuity and of course it isn't it's just obvious from the discussion here today about how many mental health services or services that contribute to improving mental health are inextricably linked with local government for example and things like social care and housing it's not something that can be easily or should be either easily separated from everything else or indeed just lumped in with everything else you need to have a dynamic and then the Care Service Bill is in itself an attempt to deal with inadequacies that are perceived in a bill that was put through in 2014 the Joint Working Bill and that in itself was about the 15th older people in Meme I remember have go at integrating health and social care and what I think we should have learned from all this is it's not actually structures that matter you get better delivery based on relationships on the ground and you need to allow them or you need to work on improving them I don't have a big answer for a a centralised imposed model that would work and I'm not sure what we need to get these services working together is not frankly legislative action as such it's improving services on the ground and improving communications on the ground and frankly improving the resources on the ground it's not a structural change that we need particularly Willie back to you Thanks very much for that really important contributions again they're just my final question Richard in the interest of time the Auditor General's report was fairly critical of the Government's ability to measure performance and quality of mental health outcomes and so on but everyone around the table has contributed some great ideas and great local experiences of good practice here, there and everywhere so what are your views about how the Government can better do this so that we can report on outcomes because it's really important so should we collect various experiences around Scotland and somehow gather that together I would really appreciate your views on how we should tackle this start with you again Dr Williams so we used to in Scotland have a system known as QWF the quality outcomes framework which was a way of GPs and their teams coding specific information in patient notes and it was a system of its time and we abolished it in Scotland for good reason it had become box ticking it was causing burden and at the time we hoped that GP quality clusters would take over and as Stephen was describing a sort of a bottom up approach to teams and good practice would develop new better ways of coding not just coding activity but we would capture a mental health review for example so we dropped off recording mental health reviews in general practice for some conditions and that doesn't mean that that activity is not happening means we can't track it but as you've mentioned actual clinical outcomes are probably the preference that we would like and patient experience as well and for the foreseeable future our workforce doesn't have the capacity as mentioned in the term firefighting we are reacting to demand we are not yet in the space where we are able to be proactive I don't see us reaching that space within the next couple of years to be frank I do think we'd need further modernisation of primary care I do think general practices clinical systems are able to capture the sort of data on outcomes but our teams need the time to work together so that the primary care mental health workers for example know how to use these clinical systems to their best so that the next generations of these clinical systems can come in and can be harnessed so to Willie's point about how we capture outcomes whether the kind of performs measurement systems are adequate or not I think Parvan you want you to come in on this or bring you in next and then after you I'll turn to you Christina Thank you I quickly say I agree with both the points that Chris has made which is in terms of systems and workforce capacity the two of the biggest issues in terms of having the appropriate and adequate IT system and infrastructure to support recording of information and data and having the workforce capacity most of our time as clinicians recording data rather than seeing patients but we need the systems to manage that but another big challenge I suppose is about prioritisation one of the most telling things for me in terms of the audit Scotland report is that in the section about improving services the first thing it talks about is psychological therapy targets psychological therapies account for less than 10% of total mental health service activity but there is this overwhelming focus on just that one single metric because it's easy to measure actually what we don't know is how long someone might need to wait when they're in a crisis how long they might need to wait if they need admission to hospital bed how many people have died while they're waiting for admission to hospital bed we have no idea about any of those metrics but there is this overwhelming focus on psychological therapy targets to the exclusion of all of the clinical priorities now I'm not necessarily saying that focusing on psychological therapy targets is not a good thing but that's queuing of priorities that is so dangerous and I use the word dangerous not likely because it does affect priorities it does affect the focus and that is the concern so if we really want to understand what is happening in our services we need a suite of measures we need a very broad based approach to measuring how services are performing not focus on one thing and get stuck on that secondly we need patient reported outcomes we need to hear from the people that we are serving how they're benefiting from them and that is completely absent we focus on activity and expect that to be a measure of everything being wonderful and that is again a challenge I think that's the second bit the third bit is the government has done the work I was involved in developing the work around the indicators almost six, seven years ago there were a very broad suite of indicators that were developed and the report itself highlights that they still remain experimental that there's been no investment in the infrastructure needed to measure that and that is the challenge that I face as a clinician do I spend my time filling boxes ticking boxes on a system or do I use that to see patients and I know what I would much rather do when patients really need care I would much rather be seeing patients than spending lots of time on IT systems and that is the challenge because the underlying administrative and IT infrastructure to record this information just doesn't exist and that is then left to individual areas to find different systems and they need to prioritize where they spend their money Thanks Pavan in the interest of time I'm going to ask Christina to make a very brief intervention at this point so I'll bring you in and then I'm going to invite Sharon Dowey to put some final questions to you Yes, I think as the report highlighted I'd like to add that in share mental health improvement and well-being services they use a tool for their community link worker service but again like all the colleagues have said we're talking about complexity here we need to have some minimum datasets that we use to capture the link worker information but we also need to use a suite of tools which I think that there was a team within the Scottish government that were looking at some evaluation tool and I'd like that work to be restarted and I would very much like to engage in that Thank you and thanks for being so brief Sharon, over to you for the remaining minutes that we've got left to get some more evidence on the record for us I'd like to ask a wee bit about recruitment and retention and if I could get some reasons for the high vacancy and turnover rates on the mental health workforce also we bet on the reliance of local workers and that the impact that this is having on service provision Stephen, do you want to kick this one off? Recruitment and retention it's a matter of if you want to deal with the recruitment and retention crisis that you've got practically everywhere in this workforce you need to pay staff more money and improve staffing levels now I'm not saying that's the sole thing that needs done but I'm suggesting that you're going to solve it without doing that really isn't he saying anything serious at all I mean if you look at breathing space which is a good thing and I'm widely applauded and all the rest of it they're sitting with a 20% vacancy rate at the moment if you look at NHS 24's web page for recruitment they're not trying to recruit they don't advertise vacancies for banned six nurses they advertise recruitment fares for banned six nurses that's how short staff they are now part of this is money it's just straight money if you look at nurses in particular historically they looked at themselves in terms of their pay should be similar to police officers and teachers and they don't perceive that now so that's part of the problem the other thing is a lack of flexibility again to look at NHS 24 that's the obvious one I mean it is essentially an out of our service however the jobs they're advertising are talking about five weekends out of eight six weekends out of eight eight weekends out of eight and strangely enough they're struggling to recruit so what you need is better staffing so that there's more flexibility and that ties into local workers and bank workers skilled staff are going there because they get to choose their own shifts because there isn't enough flexibility in what the NHS is offering them so fundamentally you need to resource the system to allow that level of flexibility and resource assessment off that it seems an attractive option to people there's more to it but that's I'm going to bring in again we are quite tight for time so I'm going to bring in Mike who we've not heard from for a while just on this question of the vacancy turnover rates and just the whole picture of staffing Mike we have a major issue here of CCPS we're trying to establish a fair pay for fair work campaign across the third sector we have a lot of very experienced, very skilled very highly qualified people working in mental health services in the third sector but if you tell them they're only worth the minimum wage then retaining them and recruiting them is always going to be difficult and the campaign at the moment is to try and look at a minimum wage of around £13 just £1 above the now agreed national minimum wage by the minimum wage foundation so it's no rocket science you know we have to invest in the services that we want to deliver and we have to invest in the services that will deliver better outcomes for the people that we want to support or need to support thanks I've got Carvan and Christina want to come in on this point and I've got another question to put Carvan Thank you it is hugely complex and what I would also want to offer is to share the Royal College of Psychiatrists report on recruitment and retention challenges with the committee and I can send that subsequently but there's several reasons from a medical workforce perspective that we think have contributed to this so we've seen high rates of turnover and that's leaving and that's to do with burnout I don't use the word crisis lightly it feels like we're in a death spiral so the more staff who leave it places a greater burden on the staff who remain and that has a huge impact on the burnout of that workforce so that's one challenge but there's also a very specific question about locums and the reason I highlighted that the current vacancy rate is 30% is because the official figures only measure the vacant posts that is posts that we haven't been able to recruit usually for months if not years at a time 20% of our consultant workforce is currently made up of locums and there are real challenges with having locums but not least that a large proportion of the locums do not have the appropriate or necessary qualifications a CCT which is what is required to be a specialist secondly consultants do a lot more than just see patients we do that but we provide training we provide input into learning from mistakes and improving services, undertaking critical incident reviews, we undertake teaching we undertake supervision of other staff within the team and if you want to expand the range of professionals within the team you need that supervisory capacity and the support for training and teaching all of that goes away when we have a locum do not undertake any of those functions so what you then have is a critical loss to system capacity to improve but also to change which is what is needed and that is partly what I mean by being in a debt spiral because the numbers have become so low that it has become almost virtually impossible to provide a safe service let alone a good quality service in large parts of the country and that is an emergency that we really need to sit up and look at thanks Paavan Kristina vacancy and turnover rates I think for our workforce the good news is that we do not have a shortage of people that is wanting to do this work the challenge that we have has to do with retention and that has to do with the capacity so for example Public Health Scotland published that we have got just a little on the registered patients across GP practices in Scotland now the way we equate that there should be at least one link walk up to 10,000 so that should be about 5901 at the moment we have just got about 300 so we are not able to meet the demand because this work is about giving people time now the other thing is the lack of value we are not feeling valued at the announcement that the Glasgow crisis link walk up crisis is about to be resolved but then our members they can get a mortgage you see so it's all temporary contracts now if you are seeing a vacancy for something that is not even stable I mean you don't want to apply and that's not very good now I had a look at the health and social care staff in Scotland at 2019 that is on the consultation about to be reall 2024 can you imagine we are not even listed there so what am I doing on this panel so we need to be listed there because we are part of the health and social care workforce this is about making people feel valued and making the profession attractive as well as providing support I mean I have been speaking with NHS education Scotland they need to provide education packages for us, CPD for us provide training opportunities so that we make sure that it is truly more than four right, thank you for that and I know we are short on time so Dr Paven if there is any further information you want to give and write then that would be helpful next question is if I can get comments on the effectiveness of the new mental health workforce roles including any views on the recently published mental health and wellbeing workforce action plan and also if you have went through the workforce action plan if it gives you a sense in how we are actually going to achieve it and that's the thing there are lots of good things that it's very much in favour of good things and against bad things the workforce plan is it reads very well we were very pleased that there's an attention on workforce planning the question is will the means be provided to deliver it that's the question it's less about the specifics of the plan it's about the determination to pursue it because frankly we see a lot a grant statement is made but is the effort and the resources going to deliver it that's the question it's not a question about the plan as such thank you anybody else want to come in on the workforce action plan Chris? again I mentioned before primary care reform there is willingness to change how we set up the primary care mental health workers I think are a very useful addition to our services that our patients can use and are very accessible but I do wonder that our primary care improvement plans that we have across Scotland don't have the sufficient resource to really take advantage of that primary care mental health worker so those people who are based in primary care with the line management through primary care thanks Chris we've got Pavane wants to come in on this workforce action plan and then we're going to turn then to the final question so Pavane on the workforce action plan thank you I'll try my best to be succinct I completely agree with the point Stephen made so the plan is not lacking in ambition we support almost all ambitions within it but unfortunately I think what it's lacking in is the detail about how those ambitions are likely to be achieved in the time frames for that and more importantly the investment that's required to put it in context it takes at a minimum 15 to 16 years to train a consultant psychiatrist so if we want to address the 30% gap in the consultant workforce in 15 years time we need to make those decisions now and that goes back to that longer term strategic need and planning and investment and sticking with it for multiple cycles and unfortunately we are not seeing that in the workforce plan we are not seeing that longer term need for investment and any commitments to that in the plan as it currently exists okay last question thank you last question and the mental health strategy excuse me 2017 to 2027 action 15 of the strategy was to increase the workforce to give access to dedicated mental health professionals to all ANEs all GP practices every police station custody suite into prisons over the next five years increasing additional investment to 35 million for 800 additional mental health workers in those key settings so I suppose maybe specifically for Derek and for Dr Chris if I could ask what access you have to mental health so I would say that the usage of those acts at session 15 that those monies is opaque from a general practice perspective we feel that there are many areas where that resource has not made its way through having said that if workers are now aligned with the police services I would say that that there is huge benefit from that and I wouldn't want to see any slow down in that side of things but my fear would be that some of those monies have been subsumed into some of the secondary care services or where it wasn't specifically intended to be targeted and I'll answer this as best as my corporate knowledge will allow me to do we have had action 15 funding it's been piloted in a very pocket it's not widespread across all custody areas in Police Scotland as far as I'm aware and my concern will be that it's probably just come back to the conversation today it will be a moment in time funding it won't be sustainable funding I think the last word this morning I think Christina is going to go to you on this question so I'm delighted to invite you to make your final contribution thank you so much I think we need to have universal access to link workers so that report it did highlight that some GP practices do not have link workers I wonder Chris would you not like more of us you see we are there to look after the patient's holistic wellbeing so I don't really buy 800 is about a variety a sheet of workforce I need a Scottish Government we need a Scottish Government to commit to how many community link workers are they going to recruit and demonstrating that we truly want to demedicalise life issues in Scotland thank you very much well on that note can I thank all of our panellists this morning for the contribution that you've made thank you for the time that you've given up and it's two hours you won't get back I'm afraid but I also appreciate the fact that you will have all prepared before coming along here to give your evidence and so can I thank you very much on behalf of the committee for the really top quality evidence that you have given us this morning which is very illuminating informative and at times very moving so can I thank you all and just a reminder as Sharon alluded to if you do want to make any written submission if there are areas that we haven't got to maybe that you would have liked to have commented on then by all means put anything down in writing and we'd be delighted to accept it but with that can I thank you again for your attendance and I'll now draw the public part of this morning's committee to a close thank you