 E dosech yn f призwg iawn ar y dweud y Ffbatwr. A wnaeth sy'n gwaith yna dweud i'r ffotografaeth neu'r ffotograff, mae'r fideisiau tydd wedi'i unigol ar gyfer y cyflawn i ddiolch. Fy gyd, mae'r Ffataith sy'n gwyfodol yn sydd. Mae'r ffataith tyddiad yw, mae'r gweithfell ar gyflawn i'r gweithfell mewn ddiogeliaeth. Mae'r gweithfell wedi'u gwbl iawn ar gyfer y gweithfell mewn ddiogelio mewn. Penny Curtis, head of mental health and protection of rights division of the Scottish Government. Lauren Murdoch, head of mental health unit and John Mitchell, principal medical officer both from the Scottish Government. Can I invite the minister to make an opening statement, please? Thank you very much, convener, and good morning. Scotland should be proud of its commitment to improving mental health. Its visibility and awareness have substantially arisen in the nation over the last decade. There is better public awareness of mental illness and the creation of access standards for mental health has raised the profile of service demand at health board level. Scotland was the first nation to introduce a waiting time target for calm services in the world and was the first country in the UK to introduce a waiting time target for psychological therapies. I think that this is an indication of how seriously we take this issue. We want to continue to drive improvements in mental health services and are committed to ensuring that children and young people of any age get access to high quality mental health services as quickly as possible. We have moved away from a pre-target position of not having a good picture of what was being delivered nationally and we now have clearer information about demand and capacity. As capacity and throughput have increased, we are seeing greater numbers starting therapy each quarter. This increase in demand has been driven by better awareness of mental health services and recognition of mental health problems and a reduction in stigma associated with mental health conditions. Demand is projected to rise as services become more accessible. In response, the additional funding we announced includes 54 million of funding for mental health improvement. This has been designed as a comprehensive package of support and offers a new approach to improvement of mental health services, working with boards across Scotland up until 2020. Calms is only a small part of how we support young people's mental health. We must focus on the things that evidence tells us is most effective in improving outcomes for children and young people. In the forthcoming mental health strategy, we will set out the Scottish Government's vision for mental health for the next 10 years. This is underpinned by the additional £150 million that we are investing in mental health to 2020. Having a 10-year timeframe is important and I want to ensure that we take this opportunity to focus on those things that will make a real difference in mental health and wellbeing. The new strategy will focus on themes including prevention and early intervention, responses in primary care settings, improving the physical health of those with mental health problems, and improving access to mental health services. It will be organised around life stages to support mental health throughout a person's life. Supporting progress in these areas will require new models in primary care to respond to mental health problems. We want to deliver changes that will support people to look after their own mental health alongside their physical health, treating them and understanding them in the same way. Alongside a continued focus on improving access to support and treatment for people with mental health problems, we want to make mental health services more efficient, effective and safe. We need to be able to show that what we do matters in the sense of clinical effect and personal experience. These services will also have a continued focus on realising the human rights of people with mental health problems. I will ensure that our new mental health strategy will take a rights-based approach. We are ambitious for improvement and believe that those priorities will deliver significant improvements in the mental health of the people of Scotland. I am happy to discuss this further with committee members this morning. Thank you very much, minister. Colin Smyth. I thank you very much, convener, and good morning to the panel. Can I just touch on that new strategy that you outlined there, minister? At last week's evidence session, Dr Alastair Cook of the Royal College of Psychiatrists said that the draft strategy lacked ambition. We heard people describe it as being more about a strategy for mental health services, which you touched on in your opening statement, rather than a comprehensive mental health strategy. Do you think that criticism is fair? Who did you consult prior to publishing the draft strategy? As the First Minister made clear in her reply to a question last week from Willie Rennie, we have taken very seriously the feedback received on what was the engagement paper rather than a draft strategy. What was published was a result of engagements that had taken place prior to that, and that document was in no way a draft strategy. It was a further engagement paper and drew a huge number of responses, 598 responses. We have been gathering views since, I think, we can go back to the national conversation that was started in August 2015 and lasted until March 2016, started by the cabinet secretary, and since then we have had a programme of events to gather people's views. As I said, there were 598 responses to that document and there have been 412 people have attended the various events, but Lauren, you can give further details of the events that have taken place. We have had public engagement events in Aberdeen, Dundee, Glasgow and Edinburgh. There was also an event run for us by Children in Scotland that consulted with 49 children. There was a Young Scot round table event and we have also had a workshop with COSLA. There has also been an event with the Alliance. There has been quite a number of events since we launched the engagement paper. Prior to that, in my role as the head of the mental health unit, I was meeting with organisations to talk through with them in order to develop the policy that led to the engagement paper. Since coming into post, I have met a huge number of organisations as well. I think that I have met all the organisations that you have taken evidence from in the past three sessions. It was not entirely clear who was actually spoken to specifically on. Prior to the discussion document being published, given the fact that it has met with quite a lot of widespread criticism that the evidence that we have had and evidence from Sam Mental Health Mental Welfare Commission, the Alliance Social Work, have all talked about the lack of ambition in the original document and the need for a transformative vision. If you are able to give an absolute commitment that when it does come to the final strategy, that will reframe what we are talking about in terms of mental health strategy, and it will be an absolutely transformative approach to mental health strategy, not just about mental health services. It certainly will not just be about mental health services. We want to make sure that it is visionary in what it wants to achieve over the next 10 years, but it also has to be practical and deliverable. While I want it to be visionary and ambitious, we also need to make sure that it is practical and deliverable. That is what we have been working on in developing the strategy, along with all the partners that we have talked about. Just in terms of your own role, Minister, I think that we very much welcome the appointment of a dedicated mental health minister, but I suppose that the danger of that is that it becomes almost silo working, if you like, that you are actually taking mental health and you are focusing it on one department, one minister. Do you have the authority to be able to go to every other Scottish Government department and cut right across that and make sure that all those departments are contributing to the strategy? It is not just about the health service and mental health services, it is about education, it is about decent housing, it is about employment opportunities for people in deprived areas, for example. Do you have the authority to cut across those departments to make sure that the strategy that is going forward will have the full support from all those departments? You are absolutely right. One of the hallmarks of this Government has been the cross-cutting nature of it. Clearly, as you yourself say, it is definitely not silo working. We have to make sure that all the different policy areas that you outlined are involved in the strategy. I am working with Minister Jeane Freeman on reducing poverty. We are working with education in terms of the welfare reform and the disability delivery plan. We are working also in employability and in the justice system. That is very important, too. We have to make sure that we deliver a joined-up approach to mental health. Alex Rowley Building on Colin Smyth's point, Dr Cook from the Royal College of Psychiatrists recognised that it was a consultation paper, not a strategy, but he did still say, and I quote from the official report, there is a lack of ambition in the consultation document, which contains a series of actions, but no overarching aim or objective. Considering this is going to be a 10-year strategy, we have been waiting a year for this since the last one officially expired, albeit we have still been operating under its terms, that if the Government had an overarching aim or a big idea, it would have given a hint to that in this consultation document. In the same breath, he said, he went on to say, in reference to the additional funding of which you speak, that the new money that has been identified as coming into mental health services nowhere near matches the efficiency savings that are coming out. All of this in response to delays in treatment times, delays in access to treatment, that Lucy Mulva from the Alliance says is absolutely outrageous. Can you offer your reflections on the fact that actually we are not investing in mental health at all and we don't have ambition in this area? Well, you raised a number of points, Mr Cole-Hamilton. In terms of the vision for the strategy, we asked all the people that we've met and all the people who have contributed to the strategy what they think vision should be. I have to say there probably is an agreement on what a vision should be and some people didn't even have an idea themselves about what the vision should be, but the nearest to what we want to get to is one that the Scottish mental health partnership provided in their submission and they said, our vision is of a Scotland where wellbeing flourishes, where a focus on equality, prevention, support, human rights and recovery means good mental health for all, where people can get the right help at the right time, expect recovery and fully enjoy their rights free from discrimination and stigma and we will develop that through the new mental health strategy. In terms of your other questions, in terms of money, we have the extra 150 million over and above that which is spent in mental health already and that amount of money has increased by 38.9 per cent over the last 10 years. In terms of overall health budget and efficiency savings, yes every health board has to make efficiency savings but that is reinvested so there is extra money going in, we're making sure, I'm making sure and my colleagues are making sure that that money is directed to where it can make the best impact. Thank you for that. It troubles me though that if you say that stakeholders can't agree on a vision it sounds like the Scottish Government doesn't really have a clear idea what that vision should be and this is a 10-year strategy we are going to lock stakeholders into. I hope that we can amend it once people agree what that vision should be and I understand yes absolutely that there's new money coming in but that doesn't answer the question about the problem of money hemorrhaging out at the other end through the efficiencies that these organisations and these arms of the health sector are being forced to make. I welcomed your appointment, I really did. The First Minister was very gracious and said that in response to Liberal Democrat calls for a mental health minister you would be appointed and we absolutely applaud that and I've worked well with you in the past but you must be frustrated that without the tools necessary to effect meaningful change then people might look at your office as window dressing for a problem that the Scottish Government is unwilling to solve. Well I think you're absolutely wrong in terms of money hemorrhaging out of the health service. The health service budget is increasing overall and of course in order to keep that going we've got to make sure that the money is well spent and that the money that we go into is used to best effect and that is what we're doing. Efficiency savings means exactly that it's reinvested in the health service not hemorrhaging out to anywhere else. The words of Dr Cook from the Royal Society of Psychiatrists, new money has been identified as coming into mental health services, nowhere near matches the efficiency savings that are coming out. Perhaps someone in the health service would like to give another view. The efficiency savings obviously apply across the whole range of health services and I think the point that Dr Cook was making was something to do about parity of esteem and about the importance that mental health is considered a priority by organisations and the money that comes into mental health stays in mental health and efficiencies that are made in mental health remain in mental health. There are examples where efficiencies have been made and that actually there has been no detriment to patient care. In fact, actually things have been improved and an example of that, for example, is the efficiency of inpatient psychiatric bed use in Scotland and we know that from two censuses that we did in over a one-year period and we've made a significant reduction in our inpatient beds whilst at the same time managing to maintain enough availability for people that need them and reduce the amount of out of placement beds that we need for children and young people. But in answer to an FOI in the summer we discovered that tier four beds were inpatient in CAMHS we found that actually children were being turned away because there were insufficient staff to man to staff those beds so I understand the beds may be there but they're not always available are they? Well the mental welfare commission's report welcomed the big reduction that there had been in the number of children who were being admitted to general adult psychiatry beds rather than child and adolescent beds so we're going in the right direction and that's despite a reduction in the total number of psychiatric beds in Scotland. I think you would always want to make sure that patient safety was paramount before admitting children but I visited the Dudhope unit the other week and I met the staff and some patients and you know it seems to be working very well and that is what we want to see but as Dr Mitchell said we want to make sure that as far as possible we can treat young people at home in the community rather than having to take the step of having them in mental health beds. Thank you convener and thank you for joining us this morning minister. I'm just mindful of the last several weeks we as a committee have heard lots of information from lots of bodies and organisations about mental health and that we haven't actually fed into the mental health consultation and I wonder how the minister would feel about this committee writing to her with some of the information that we've gathered and asking if that can be considered as part of the the 598 responses that you've received. Well I'm happy to discuss that with the committee obviously I want to publish the strategy this year but I don't know when you intend to publish your paper if the committee would wish I could consider holding off till January at the latest to publish the strategy if and take into account what you wish to put forward. I think that would be very helpful if you know we we are only finishing our evidence session today obviously we have a bit of time where we have to gather our thoughts and then the parliamentary officials have to assist us in drafting that report so it will be you know we need a bit of time on that but I think it would be remiss if we did not feed into that given the evidence that we've taken and it would be good to get some indication from the government whether they'd be well into give us that period of time we're not talking about months we're talking about maybe a week or so. So you definitely would have it by January would you? Yes. Well as long as you're not then going to criticise me for not publishing it in 2016 I'll certainly take that into account. Thank you. Thank you. Who is next? Richard no sorry Ivan I was going to come to next Ivan. Thanks container and thanks minister and panel for coming on to talk to us this morning. I would just want to explore a wee bit more around about the preventative agenda and I know you kind of mentioned some of that in your opening remarks but it's surely about where you see the focus shift and how you see the focus shift to tier one and tier two because a bit of what we've heard from witnesses and what I've also heard from constituents who are involved in this area is that a lot of the stuff that a lot of the cases that end up at tier three waiting list are issues that could perhaps have been addressed earlier with more resource and more focus and more training and a wider understanding of how to deal with that at that stage and he also that means that the individuals getting needs are going to addressed earlier but also it means that perhaps with the issues aren't as severe and I don't get worse over time because they're in a long queue for seeing some day at tier three so I don't if you just want to comment on that and how you see maybe resources shifting and what policies are would be to affect that okay so you've you've taken evidence on on what the the different tiers are and I think the strands that will the strand that will run through the whole of our strategy is starting well living well and aging well mentally so we want absolutely to to focus on the tiers one and two there has been as you say much focus on tiers three and then on tier four so it is right to say that sometimes children are are sent to tier three when in fact they don't necessarily need tier three intervention and that's why we want to build up the workforce in tiers one and two and also make sure that that the children parents and health professionals and schools and are more aware of what what to do with with children or young people who are beginning to show signs of mental distress and penny can give you some examples of that in more detail. Sure um could I maybe just start are you talking predominantly here about children and young people or more generally because the same would apply for both. Sure but mainly children and young people the people I've spoken to have talked about mental health first aid training programme for teachers and then organization stud sector that are working on play therapy and that kind of thing which seems to have an impact and also probably much more cost effective as well to do at that stage rather than later. There are already some quite good examples of where staff in schools for example have been upscaled in areas like mental health first aid as indeed have some pupils at schools in terms of helping their own peers as well. The kinds of changes we know we need to look at is actually partly driven by the impact that the waiting time standard has had within CAMHS because as the level of demand has increased year on year and we've seen sort of 10 to 20 percent increase in the number of children and young people who are actually starting treatment every year so that's not just referrals coming in that's actually children who are receiving some form of treatment when they're seen by CAMHS and part of what that's being driven by we know is unmet need that has already always existed in the system and that is being much better picked up by GPs by staff in schools and other children's services and is much more likely to be referred on but as a result of that increasing demand the CAMHS professionals are now very much having to concentrate on treating those children and young people which means there's less capacity actually for those CAMHS services to be doing some of the early intervention work working with other children's services so what we know we need to be doing in the next strategy is both looking at how those connections can happen better so the CAMHS service is involved in supporting other children's professionals, make good decisions about what would be most effective in terms of early intervention and prevention but also in terms of how other services are upskilled to deliver what the evidence base says is most effective for different problems emerging at different times as well as the things that you would see as a population based approach so the things that would go on in terms of the culture of a school being a nurturing school for example that just supports that good mental well-being and resilience for children and young people. Yeah I mean you just to explore that a bit further very briefly and I understand what you're saying in terms of the culture and environment but I suppose it's more specifically about individuals that have identified as an issue in dealing with them earlier and I think what I may be heard to say is that resources are driven to the tier three target and which of course in the medium of long term is inefficient because the resources the evidence I would imagine would show that they're much more effectively deployed further upstream. That's the downside of the target. I mean I'm 100% for targets but is there an issue here that we're maybe at the wrong target or not enough targets and I know there's a target review underway with Harry Burns but have you got any comment on that because maybe it would be more or helpful to have targets for tier one and tier two as well? Absolutely the target has been extremely helpful and a target is always something that is to drive improvement over a period of time and in CAMHS there was a very clear case for why that needed to happen in terms of the service being under capacity waiting times of a year and more being common. So it absolutely has that space and has driven some real improvements. There are always unintended consequences or consequences that you can accept for a point in time but what you also have to do is to track some of the other things that are happening that are important. So in CAMHS for example we have what's called the balance score card and that looks at activity across a range of indicators that gives that more balanced picture of a whole service and I think that is something in how we're using data in the new mental health strategy as well that we'll be looking right across the system at those things that are most important. You'd have the same profile as the tier three waiting time target and we might drive resources to the right place. I think we need to be careful because obviously tier three and four are very much medical interventions from medical professional psychologists or psychiatrists. What we would envisage with tier one and two is very much lower level intervention, basic counselling that is offered in many schools now, that kind of early intervention and prevention. You know all teachers for example are you know responsible for literacy, numeracy and wellbeing so it's making sure that you know more teachers and other professionals have mental health first aid for example and that use is made of counselling service that is often provided by the third sector through iJBs and into schools or through the GP practice. I mean I think we need to use data in a very smart way and I think you're absolutely right we need to get a handle on what we're doing and whether it's making a difference or not really at all levels from population right up into specialist services so we're going through an exercise about thinking about how we collect that data in a way that's not a burden to services but actually evidence is meaningful change and as the minister said in her opening statement both in terms of clinical outcomes but also personal outcomes for people and aren't just measures about specialist services that are across a much broader range thinking across to the health and wellbeing indicators, the care standards and thinking about a total population approach to pre-health. Have you said that many schools have access to counselling? What percentage of schools do have access to counselling and have that on tap if they need it? I'm not sure I have the figure to hand in terms of schools but I know in my constituency for example both local authorities that I cover have counsellors available to secondary schools. Now what we want to do is make sure that people working in nurseries and primary schools maybe have this mental health first aid so that they know to be able to recognise where children are beginning to show signs of mental distress. When you said earlier that many schools have access to that service can you can ask your officials to provide the committee with that information at some point? That would be very good to have that. Last week on the CAMHS issue as a parent if my son or daughter was referred to CAMHS and was rejected, I would want to know why and if I found that the rest of my children were rejected as well having gone through that process I would want to know why. So as a corporate parent what is the Scottish Government doing to check on the 20 per cent or almost 6,000 young people whose referrals are rejected? Is there West Lothian Council called for a review of those rejected referrals? Would you support that review to find out what's actually going on to those children? I don't want to build in any unnecessary delays into children getting access to services and we've already put £54 million into a package of support for mental health services for both children and adults to make sure that children and adults get the appropriate support that they require. So much of the 4.8 of the money allocated has been awarded to Health Improvement Scotland to establish a mental health access improvement support team and that's working with boards to improve access to mental health services. We've also increased the workforce in mental health services and also put money into training to upskill those already working in the service but in terms of rejections I'll hand over to John. Can I ask whether you support a review of the rejected referrals to find out what's going on? As West Lothian Council called for? What I said to you in my initial remark on answering this question was I don't want to introduce any unnecessary delay into the system. If you have a review it might introduce a delay and I think we're beyond that stage. All specialist services have admission criteria and all specialist services will receive referrals from time to time to decline them. Whether that's said, children and adolescent mental health or general psychiatry or in due to physical medical and specialties, the referer is given an explanation about why the specialist service is not necessarily the best place to meet the need of the person being referred and it's really up to them to explain to an individual why our referrals have not been accepted in what alternatives are available. Is there any problem in the system as to why almost 6,000 children are being referred in the first place if what they appear to be being referred inappropriately? I think that for every specialist service there are always referrals that are inappropriate and that's common to every specialty in medicine. It's almost 20 per cent though. I think that you would find the same in general psychiatry. I think that it goes back to the question that Ivan Key asked about appropriate referral. It may not be necessary for someone to require a tier 3 level intervention and that's why there's a referral back to tiers 1 and 2. I just wanted to ask a supplementary about eligibility. We spoke to a couple of people giving evidence about the age of eligibility and that varies across the country. Is there any thoughts about standardising that? There's some evidence, I know, from being a pharmacist that physiologically your brain probably isn't adult until you're about 25. The impact of these illnesses at a time when you're fulfilling your educational potential or forming relationships or getting into work can be really quite devastating so I think there's quite a good case for a very specialist service for children and adolescents but adolescents probably older than is currently covered. What are your thoughts around that? We are aware that there are discrepancies between among health boards as to when you're referred on to adult services. Some are at 16 and very rigid and some are 18 and not so rigid. I think the main priority is to make sure that the transition between children and adolescent mental health services is smooth to adult services and we've seen good practice of that but John is a medical specialist. I think the transition period is always a period of risk and concern and the difficulty of having a separate child service from adolescent service from an older adult service is that it creates two transitions rather than one. The one place where I think your argument is best applied is to do with early intervention in psychosis and certainly early intervention in psychosis services that exist in Scotland exist across a broader age range from adolescence right into young adulthood completely for the reasons that you've said about the developing brain, about the social position of a child becoming an adult and having to think about living on their own and employment in relationships. I think that we certainly do support in the engagement document for the work to try and improve early intervention in psychosis services for that age range. Did you want to come back in, Mary? No, that's my time. Minister, can I move on to waiting times? You actually said in your introduction that we were the first to introduce a target for mental health but if you look at the most recent figures and performance against waiting time target for carms it shows that only seven out of 14 health ports met their target. Across Scotland as a whole 77.6% of people were seen within 18 weeks. Are you happy with this performance? Do you think that it could be improved on and what you're doing to ensure that it is improved on and what you're doing to ensure that the other seven health boards get a finger out? Well I'm absolutely not happy and I keep a very close eye on the statistics when they come out but not only that this extra 150 million is being used to help boards to meet their targets. So for example in the first tranche four health boards some quite close to meeting their targets or meeting their targets and two further away from their targets are working with Health Improvement Scotland to see how they can reconfigure their services to make sure that they start to meet their targets and we're seeing some initial evidence that that is working. John can or someone else can give the exact statistics but Forth Valley for example is one of the health boards which I think you had someone here from Forth Valley. I think I speak to board chairs and chief executives on a regular basis and all the boards have a keen eye on their mental health waiting times so it is very much in the forefront of their minds and the money that the extra money that we have allocated to us is being used to to help that improvement so it's possible that we'll see a further dip in waiting times as boards reconfigure their services but other boards are making big strides. Tayside for example have taken measures to make sure that they meet their targets and as I say every board is offered these services of Health Improvement Scotland to help them reconfigure their services employ more staff and retrain staff if necessary to bring them up to meet their targets so I'm not happy about the situation but I am quietly confident that we are moving very much in the right direction to make sure that all boards will meet their targets. So we've got more money than into mental health. We've got a dedicated minister like yourself who I respect highly. We have a situation that we can now move this forward in the new strategy that will come out in January. So now that you are the minister are you going to be driving these health boards to improve on a daily basis or a weekly basis including your officials to ensure that they can deliver more and I'm sure Penny will tell me yes. Sorry Mrs Kirk. Well my answer is yes but Penny will tell you how we're doing. What it might be helpful to do is just to set out a little bit more detail picking up what the minister said about the improvement package that ministers have put in place because what we recognised through the data we were seeing and from the engagement that we had with the clinical and managerial leads in each of the health boards is that there were different things happening in each of those boards. Some had made reasonably good progress towards meeting the targets but others were really struggling with particular very individual things within those boards and sitting in the Scottish Government and looking at the national data or even the health board data it's actually very hard to understand exactly what is happening under those headline figures. So what we recognised in what we had to do to support boards to improve was to be able to do something that was quite bespoke for each area that allowed us to have much more engagement with each of those boards in a way that was genuinely collaborative so instead of sitting with a very hard hat kind of performance management look which clearly the minister would also be doing and demanding that chief executives are taking improvement in those mental health services seriously what actually needed to happen in addition was work very very closely that went in and worked with the board to understand where the local barriers were. Quite often it was around fairly simple things around actually having access to good analytical support, good systems improvement or around particular issues where they were struggling with redesign so that's the work that healthcare improvement Scotland has been doing but has also been very closely tied to the work and the investment that NHS Education Scotland has done to make sure that the right workforce supply is going on going in and going in in a sensible way that meets boards needs and is doing that strategically but we recognise there were also issues that there wasn't enough capacity in the system which is why there's also money that has gone out to the boards and the health and social care partnerships to support investment in more staff to deliver more therapies or more services in CAMHS. In response is computer wave brief. Basically a new strategy came out in January what work are you going to do you know Scottish Government or any Government minister gets blamed for other organisations when they fail what work are you going to do to ensure that when the new strategy comes out all the boards are going to work to work that strategy so that you don't fail. Well I think you know in terms of meeting targets the work is ongoing at the moment it's not necessarily going to change very significantly as a result of the strategy what we've already started hasn't waited for the new mental health strategy in terms of meeting waiting times so that work will be ongoing as I say health improvement Scotland and healthcare Scotland will be working will be working health education Scotland will be working with the boards to redesign their services where necessary to start meeting the targets using best practice from other boards health improvement Scotland is involved in the redesign and education Scotland are involved in terms of making sure that they have as Penny said got the right workforce in place to start meeting their targets so it is a case of as I say if you're redesigning a service that may cause hiccups in the system initially but hopefully it will lead to and I'm confident it will lead to better meeting of the targets by health boards all health boards thank you very much you said it won't change too much because of the strategy I hope it does change because of the strategy because that's why we need a strategy that works but that's in terms of the redesign of services as I say that's already going on thank you Kavina and good morning just an observation really unusually that there is a huge degree of cross-party support for mental health it's an area of great consensus and if this strategy isn't right if this strategy isn't ambitious enough that will be squandered so I just hope you accept that the stakes are very high here my second question is about a rights-based approach which I think it was Lucy Mulver talked about last week and the Minister mentioned it in her opening statement as a general principle that is entirely clearly a good thing but how do we achieve that in practice how do we enforce someone's rights okay I agree with you on the first observation about given that we that the profile of mental health has been raised not just by my appointment but the fact that all parties are taking a very keen interest on mental health I think the stakes are high and I recognise that I'm not going to satisfy everybody with the strategy when it does come out but I hope that everybody recognises the importance of the vision and the direction of travel and we will have a governance we will put in place a governance a strategy reference group to make sure that that we're going in the right direction so while it's a 10-year strategy we'll make sure that there are outcomes that have to be achieved along along that route in terms of the strategy a rights-based approach is will be embedded in the threat in the strategy and the strategy will focus on the delivery of rights through the panel principles which is participation accountability non-discrimination and equality empowerment and legality and making sure that we make the provisions in mental health legislation meaningful to to everybody I think rights will be intrinsic to the actions in the strategy and making sure that particularly people with enduring mental health problems are empowered to have a say in their in their treatment and that we make sure that we encourage more people to have make use of advocacy and have a written statement of their treatment when they can which they can work on when when they're well but John you're involved in this area I was just going to give examples I suppose about our participation is really about how people are involved in their own care plans and we've worked on anticipatory care plans and advanced statements the accountability is about the measuring outcomes measuring data showing that what we do matters for people non-discrimination and equality is is through parity of esteem looking at premature mortality and trying to face that and empowerment and legality we have the Milan principles that really our current legislation sits upon and guided clinical decision making in terms of protecting people's rights when their ability to make consent for decisions is impaired thank you convener and good morning to the panel one of the aspects of the strategy in improving mental health services in the community is actually the role of link workers within GP surgeries can I ask when will all 250 actually be in position I think none of us are the policy leads for that so if it's okay we'll write to the committee with some further information about that we had some evidence last week on this specific issue and that's why I wanted to know if if you minister were involved and aware of this that actually the fairer Scotland action plan suggests that only 40 will be in position by 2018 and I don't think that's good enough and I think if we're really going to make a huge difference these 250 should be recruited and trained now could I ask that you go away and look at this and make sure that we can actually look at how we're going to recruit these people early on so they're across Scotland because I think just 40 by 2018 is completely unacceptable if the funding's in place then we should be recruiting these people now so I'd ask maybe that firstly you comment on that and that we can look at how we can transform services with these link workers that way well we certainly can't take it away and get back to you on it but I would say that you know why we do look to recruit link workers to every practice that doesn't mean that there isn't already someone with training in mental health already available in the GP practice and there are more than likely is someone already available and it's making sure that GPs and other people in the practice are aware of all the services that are available in their communities as well as as the CAMH services. Sure but as the minister responsible do you think these 250 link workers which you know was in your manifesto which we're all signed up to delivering when do you think they should be in place by then? Well I can't as I said we'll get back to you on when we expect that to happen. Is it unnecessarily? Is CAMHS actually and what is it? Well do it now quickly. Okay very quickly reflecting on Richard Lyle's question and the response from the minister it strikes me that the reason that half of our health boards have failed to meet their CAMHS target is not for want of a government minister breathing down their neck and saying you must work harder but rather the fact that a profound and crushing lack of investment. I'd like to ask specifically about autism because this week three families have come to see me all of whom with children with autism at various stages in the CAMHS process. None of them have had a diagnosis within six months many have had to wait more than a year and with that delay comes a failure to connect into other services they don't they can't get benefits they can't get DLA and there is that massive uncertainty about what life will hold for that family. Listen so what what can we do to disaggregate autism from the CAMHS system to make sure that these families get the care and treatment that they need as quickly as possible? Well I'm not sure it necessarily needs to be disaggregated on the number of psychiatrists who have a specialism in learning disability has doubled in recent years but I accept your point that people have to wait too long in some cases for a diagnosis but every local authority has to have an autism strategy in place and many of them work with the third sector organisations in the autism field to make sure that families get the support that they need but I'm not happy with the situation as it is at the moment in some areas but I think autism as well as mental health in general has had now has a much higher profile we have some cities for example my own in Aberdeen working towards being an autism friendly city and obviously I work closely with the minister for early years and childcare on this issue on this particular issue. Thank you. My first question was specifically on perinatal services. Alison, could we come to that at the end because if can you do the health inequality? Okay. Minister you'll be aware that evidence on health inequalities and mental health indicate that there are marked differences in relation to those who do and don't experience mental health problems but also that people with long-term mental health problems typically have poorer physical health and a lower life expectancy than the general population so I'd be interested if the minister could advise the committee. Will a new strategy aim to close the life expectancy gap and how will it achieve this and also how will the new strategy respond to these inequalities through preventative measures? I think like you Alison I think it's unacceptable that people with enduring mental health problems have a shorter life expectancy up to 20 years and that is one factor that will be key in our strategy. It has to change and that the strategy will focus on proving the physical healthcare of people with mental health problems and there are things that we can do to make sure that when people present with mental health problems their physical health is looked at as well and that's where you know I talk a lot when I'm out and about about the parity of esteem that looking at the whole person and not just necessarily their mental health in one silo and their physical health in another silo so we would expect people who are dealing with the mental health problems of individuals to also look at their physical health in terms of support for smoking cessation, alcohol and drugs problems, obesity problems so it's incumbent on all of us in the healthcare sector to make sure that everybody's the total person is looked at and that the healthcare is provided for those so we will for example be focusing smoking cessation on people with mental health problems. We've made huge strides in smoking cessation and now we've got to drill down to look at specific groups and those with mental health are obviously one area. The other thing is that we've given Sam H a million pounds to focus on improving the physical health of those with endearing mental health problems and obviously the CME campaign has been a huge part of everything that we do in the mental health area and one of the great success stories in reducing stigma around people with mental health problems. I appreciate the minister's response. Can you advise what action the Scottish Government is taking in other policy areas to improve people's mental health? I mean we know that housing has an impact as does education you know lack of you know a decent environment to have exercise in for example. I think all that feeds into making sure that people's resilience and growing up with the capacity to deal with those problems is important so all the other ministers feed into that in terms of making sure that there is good mental health for all and that does include things like the fairer Scotland action plan and you know feeding in making sure that people live in good housing and get the right education and that yes we have places to walk and get fresh here and stuff like that. My question was relating to the finance around the strategy. The minister has already mentioned £150 million. Is that set in stone or is there potential for other services needing to be developed that more money could be found? Well obviously everybody would like more money to be found but it's not there on a tree to be plucked. I think it's important to remember that this is an additional £150 million on what is already spent in the mental health service which is about 11-12% of the total health budget. I think it's about as we've spoken about already reconfiguring services to make sure that that money is used widely and used to make sure that we're meeting the demands of the population. Because the First Minister in the chamber has suggested to a number of colleagues from across parties that this £150 million isn't capped that in fact additional projects which would need funding money could be found. I was just wondering in terms of your work in this area whether or not you believe that that can be the case and that can be brought forward relatively quickly because we've met with a lot of organisations who have suggested that projects might not be included in this strategy but in the future might make a huge difference to help improve mental health in Scotland. Penny, I haven't heard of any new money of you. Thank you. I wanted to ask particularly about mental health legislation. I know that in the last term of the Parliament there was an agreement to consider going forward how learning disabilities are regarded in law. I think there was a particular issue that was going to be looked at going forward and I wondered if you could update us on that. I also heard that last week when we had evidence from the mental welfare commission, the chap giving evidence talked about when the Scottish Parliament did the first mental health act that was world leading and that we were now probably behind the rest of the world in terms of our approach to mental health law and I wondered if there was any consideration being given to a general review bringing into account the more modern view of human rights standards and disability law. To answer your second part of your question first, I think the legislation that went through in last year's mental health act will build on the work that was done in the 2003 act and make sure that rights are embedded in everything that we do but I will ask Penny to expand on that and on your first part. The review around learning disability is the one that the minister at the time who was Mr Hepburn made when the 2015 act went through and that was a long-standing commitment to review the definition of mental disorder within the mental health legislation and what the minister did was to carry out a review. We have asked a number of organisations to scope that review and we were very clear that what we wanted in that was to scope what that review should be covering and how it should be done in a way that really was very inclusive. That process is now pretty much concluded so we will now be looking at the outcome of that and offering ministers advice about the next steps. That will be happening over the next few months. Within the mental health strategy, we would have that as part of the context. As the ministers described, the mental health legislation in Scotland is part of quite a complex set of legislation that has built up over time. It is not just around mental health but gets into issues around adults within capacity, for example. As that has built up over time, in practice issues start to emerge where it is perhaps not working as well as we might like it. What we have committed to do at this stage is to look at some of the initial things that are not working and how those can be made better. A wholesale review of the mental health and capacity legislation is not something that any sensible Government would undertake lightly. However, over a 10-year strategy, it is absolutely right that the ability to revisit how Scottish legislation is operating within the context and experience of what is happening across the world is helpful. Thank you, convener, and I need you to clear an interest here because I am going to ask you a question about perinatal mental health, which is an area very close to my own heart. I have worked in the area for over a decade before the election. The number one ask in the Royal College of Psychiatries manifesto this year was that we improve the health of mothers and babies across Scotland. Last week, NHS England announced a £40 million investment into perinatal mental health services with a further £20 million next year for mother and baby units specifically. I am wondering if the minister can advise the committee on what investment is being made currently into perinatal mental health services in Scotland and how they see those services developing over the next few years? Focus on perinatal mental health is absolutely key to our programme of starting well and living well. In terms of starting well, focus on pregnant mother's mental health and the health of the newborn baby is absolutely key. Along with the new mental health strategy, you will know that there is currently a review of maternity and neonatal services, and perinatal mental health will be a key part of that review. I have also recently agreed that £170,000 should be spent on setting up a perinatal managed clinical network, and that will happen in the next few years so that there will be collaboration among those in the field to make sure that what they are doing is the right focus and the right way forward. I thank the minister for that answer. I was not aware that a managed clinical network was being set up and that was going to be my next question because I know that the services have been calling for quite some time, so I am pleased to hear that news. I may be behind the curve, but I understood that the application to establish a managed clinical network was unsuccessful at a meeting of the national specialist services committee. I just wondered why that was the case and what alternative routes the minister was going to. John, I will tell you why. The application went to the national services committee. Although the committee all agreed that it was an important area, it had anxieties about the funding being available for the board's top-slicing money to fund that. We took the issue to the minister to ask if we could fund this centrally. The minister just last week has confirmed that. We have let the relevant stakeholders know quickly so that they are aware of that. We still have to take the business case, the proposal, back to the national services committee, because it is national services Scotland who would manage the PEN&ATO managed clinical network, so they need to be able to set up the machinery to be able to do that. However, the problem was the funding that we have now resolved. A couple of things. Just before we finish, the drug and alcohol budget was cut significantly this year. Earlier, the minister said that there is no tree from which to pluck money. It appears that the boards and the integrated joint boards have had to find a tree from which to pluck money to fill the gap in the drug and alcohol budget. Do you think that that was the right approach? What impact will that cut have on mental health? In terms of the alcohol and drug partnerships and meeting our targets in relation to alcohol and drugs, those are being met. The funding of alcohol and drugs partnership was something that the cabinet secretary wrote to health boards about and made it clear that they should find the money from their own resources to make sure that alcohol and drugs partnerships were funded. Where were they to find that from? From their own resources. The alcohol and drugs partnerships, as I said, are working well. They are meeting their targets. The boards were told in a letter from the cabinet secretary that they had to make sure that the alcohol and drugs partnerships were adequately funded. If you were asked to find additional money for mental health services from your budget to the same extent, would you be able to find that money? That is the thread that has run through all the evidence from my staff and colleagues today, is that reconfiguring services to meet the new demands and to make sure that the money is used wisely is something that is going on all the time. The Audit Scotland report absolutely shows that we are meeting our targets on critical care drug and alcohol treatment, but the cut to alcohol and drug partnership funding in our communities can be measured in Edinburgh alone as £1.3 million a year. There is no way that we are going to meet our targets on-going if we are going to have to absorb that kind of cut. That reconfiguration is going to be measured out in lives. Well, as I say, the targets are being met at the moment. It is not just about medicalised treatment, it is about in alcohol and drug partnerships. On the ground, I have, as Minister for Mental Health, visited a number of the partnerships, including those in Edinburgh and the work that is doing is meeting the needs of their communities. But this year, they will lose £1.3 million. You visited the Edinburgh partnerships. I have, as well, one of the things which they have told me was that someone who has an alcohol or drug dependency issue cannot access mental health services. What are you doing to change that? That is very much about cross-working and alcohol and drugs partnerships. We will have access to those working in the mental health field. Penny, do you want to take this over? One of the key things that we are looking to shift in the mental health strategy is recognising that this is probably the first major strategy in health and social care since integration of health and social care partnerships. What we will be looking to do is to empower the health and social care partnerships to be using their accountability and responsibilities to work across those boundaries. Being very clear about where the flexibility exists in how money goes to them, but also in their responsibility for delivering things. Alcohol and drugs and mental health are a really good example of why integration was put in place and where the opportunities are. So, if the responsibility is sitting with that local area to be meeting their needs, it is them that delivers it. If there is a gap between those services, they are responsible for fixing it. We are looking very much to be making that accountability very clear, but also providing the flexibility for local areas to meet that within their own contexts. I hear what you have to say about empowering them, but in terms of their current situation, they cannot actually refer someone. I have not seen any moves to change that. Is that likely to change then? Is that what you are trying to say? I was going to say that substance abuse services are mental health services and all of them have consultant psychiatrists, junior psychiatrists, psychologists, mental health nurses and social workers inside the multidisciplinary teams that manage substance abuse problems. Mental health expertise is available in substance misuse services, but certainly the relationship with general mental health services, there are sometimes barriers that should exist between these services and services have tried to develop comorbidity arrangements in the local areas to try and ensure that those links are made. It is the same to happen this year. Can we expect a further cut in the budget and the money tree to be asked to be shaken again? I think that we are waiting for the budget next week, because the week after. I haven't got any side of the budget. Have you been in scrapping and fighting on behalf of the service that you manage and saying that we won't accept a cut like that again this year? The budget will be delivered next week or the week after. NHS Scotland last week, in a submission, gave us a claim that three out of four people with a significant mental health problem weren't getting the treatment that they needed. That evidence that we have found was not referring to Scotland. That was disappointing the way in which that evidence was presented, or it may be just the way in which I and some of my colleagues interpreted that evidence. However, do we know the figures for Scotland? For those people with a significant mental illness, do we know how many of them are being treated and are not being treated? Would that figure be way off the mark? It is very difficult in mental health to try and work out prevalence and incidences, because mental health is the spectrum from mental wellbeing to mental illness. You seem to be doing it elsewhere, so how are we doing it? The best information that we have is from the Scottish Health Survey. We know that about 16 per cent of the population at any time has got a mental health disorder, but those would include minor disorders that primary care would manage, as well as more serious mental disorders. Is there a terminology called a significant mental illness? That is how they described it in the piece of research. The figure that they said of a significant mental illness is that 25 per cent, we would not necessarily recognise that number. The population prevalence of severe mental illness in Scotland, for example schizophrenia, is 1 per cent of the population. Only a third of those people are in on-going treatment with services. It is very difficult to identify what the population needs and then give an estimate about how much that is being delivered at a primary care level or at a secondary care level. For example, in England or Scandinavia, they seem to be applying a methodology where they can assess that. Is that a standard methodology for assessment or not? It is similar to the proxy measures. As I say, we know in Scotland from our own questionnaire studies that about 15 per cent of the population would meet a level of symptom announcement that would suggest that they had a mental health problem. We think probably in terms of psychological therapies. NHS Education Scotland early on, when we started the process, thought about a third of the population of Scotland that required psychological therapies. We are accessing that. We have improved our performance against that. However, psychological therapies themselves are such a spectrum of treatment that we are comparing apples with oranges. It is difficult to say exactly for the breadth of all mental health problems exactly what the penetration of services response is. Is there comparative data that is internationally recognised? Not with any more precision than I have explained. Could you, therefore, on the basis of the data that you have, write to the committee and advise on what that would be and do some comparative analysis? Certainly. Thank you very much. The committee will now move into private session. Thank you very much for the attendance today.