The independent inquiry into mental health services in Tayside, which was commissioned by NHS Tayside, was announced by the Cabinet Secretary for Health and Sport in June 2018, following a debate in the Scottish Parliament.
The inquiry’s interim report, which was released this morning, sets out what David Strang, the independent chair of the inquiry, has heard so far from a range of partners. The interim report is an important milestone in the work of the inquiry. The final report will provide further analysis and recommendations.
The inquiry is guided by the five principles that were agreed in the Scottish Parliament debate, which are that the inquiry must be open and transparent; be truly independent; include and involve staff from NHS Tayside, its partners and third sector providers; include and involve patients, families and carers; and include a public call for evidence, to ensure that everyone’s voice is heard.
As David Strang said:
“It is important to recognise that this report identifies only the issues which have been raised in the evidence submitted to the Inquiry. Investigation and detailed analysis will be required before any conclusions can be drawn or recommendations made by the Inquiry.”
A wide range of individuals and groups have contributed to the work of the inquiry so far. Following the announcement of the inquiry, a group was established to represent patients, families, carers and third sector organisations, to enable stakeholders to engage with the inquiry and to ensure a high level of transparency in its work. The stakeholder participation group is co-ordinated and chaired by Health and Social Care Alliance Scotland.
In addition, an employee participation group was established. The EPG is chaired by a representative from Unison and consists of representatives from all national health service-recognised trade unions, professional bodies and employee relations representatives.
More than 200 submissions of written evidence were received by post or email or in person, and between September and November 2018 the alliance held focus groups across the NHS Tayside area to capture the voices of people with lived experience of mental health services in Tayside. That significant piece of community research produced a range of valuable recommendations.
The EPG conducted an online staff survey during November and December 2018 and held focus group meetings for all those employed to work in NHS Tayside mental health services. 53 per cent of all staff who were surveyed responded: a total of 524 individual returns. The EPG submitted its report as evidence to the inquiry in April 2019.
More than 70 oral evidence sessions were held in Angus, Dundee and Perth and Kinross, with families, patients, carers, NHS employees, other health professionals and third sector organisations. Oral and written evidence was also submitted from other organisations such as Police Scotland, university student welfare teams, the Dundee fairness commission, the Dundee drug commission and third sector organisations. Additional meetings were held with a range of healthcare professionals and clinicians such as consultant psychiatrists, psychologists, general practitioners, allied health professionals, staff at the Carseview centre, student nurses and trainee GPs. The team also met integration joint board representatives and key personnel from local authorities. That enabled the inquiry to gather views on mental health provision in Tayside.
I would like to record my thanks to David Strang and his team for the work that they have done, and my thanks to the range of individuals and organisations that have taken the time to contribute to his considerations. I also thank the staff and families whom I had the privilege to meet in January when I visited the inquiry, for giving me their insights.
The interim report outlines six key themes on which improvement is required: patient access to mental health services, patient sense of safety, quality of care, organisational learning, leadership, and governance. The narrative presented in the report raises significant concern.
David Strang has not sought to provide recommendations at this stage, but I must make it clear to the chamber that the Scottish Government will not wait to receive recommendations before we act.
For that reason, yesterday, along with the chief executive of NHS Scotland, I met the chief executive and chair of NHS Tayside and their senior team, as well as representatives of the integration joint boards of Perth and Kinross, Dundee and Angus. During that meeting, I set out my clear and specific expectations of them: specifically, that the pace of change needs to be faster and the quality and safety of their services need to improve further. They are in agreement with those expectations and have welcomed the interim findings of the inquiry.
To support them in their efforts to accelerate the pace of change and improvement, the Scottish Government will augment their local team, to ensure that they can deliver on those expectations. In the coming days, my officials will meet the senior leadership team to assess the additional resources that will be required, which is likely to include additional clinical input, programme management support and community and staff engagement resources. That support has been welcomed by the local leadership, who have met it with strong commitment to delivery.
In his interim report, David Strang makes one specific point that refers to halting service redesign until a “comprehensive review” of the mental health service strategy has been undertaken, and I have sought specific assurance about the risks associated with that work. To better assess that point, I have asked the local leadership team to urgently review the risks and impact of the redesign programme, placing it fully in the context of their transformation programme.
I am clear that any redesign of services must consider the needs of all service users, and the Scottish Government is keen to ensure that the voices of people with lived experience are at the forefront.
I also committed to ensuring that the learning from the inquiry informs our national approach. The interim report raises significant issues about quality and safety. For that reason, I will give further consideration to our national approach to the quality and safety of mental health services. We need to bring coherence to our arrangements for quality planning, quality improvement and quality assurance for mental health. Arrangements are varied, and I am keen to ensure that the issues raised in Tayside are not present elsewhere.
Therefore, I will create and chair a quality and safety board for mental health. The board will consider the arrangements for quality planning, improvement and assurance and will be informed by the work of the independent inquiry. It will focus on issues such as coherent multi-agency planning to ensure that quality and safety is at the heart of our approach to mental health services. It will create the right conditions to develop and spread excellence, as we know that many areas already have high-quality services in place, and we want those approaches to be replicated around the country, so that people can access high-quality services when they need them, wherever they are.
It will also involve the examination of our quality assurance arrangements. We will bring together all the agencies that are currently involved in providing assurance on mental health services, which will ensure that we have clarity and certainty that the correct arrangements are in place to assess the quality and effectiveness of services.
Issues of safety and patient care will be included, such as the use of restraint, administration of medicines, use of risk assessments and wider-ranging issues as agreed by the group.
We know that work is already under way on many issues of safety. For example, the Scottish patient safety programme for mental health has led to reductions in self-harm, seclusion, violence, aggression and restraint in a number of areas. Collaboration and innovation from staff, service users and carers and the use of quality improvement and improvement science has been essential to achieving those improvements over the past six years. We will build on that work and ensure that it is given greater national profile and prominence.
The Scottish Government has a rights-based approach to mental health services and I will ensure that that ethos is embedded in the new group.
I am clear that alternatives to physical restraint should always be considered first. Alternatives might include nursing interventions, medical, psychological or other treatments, and/or modifications of observation policy, care regimes, the person’s activities or even buildings. Appropriate and personalised risk assessments play an important part in identifying alternatives that are suitable for each individual, and assessment should be a dynamic, on-going process by clinicians in collaboration with patients. Only after assessment by fully trained and qualified staff should restraint be used by such staff, and it should be a last resort.
I recently wrote to seek reassurance from all health boards that they have the appropriate policies and training in place for all staff who might be involved in any sort of restrictive practice. I have asked specific questions about the reporting, recording and clinical review of incidences of restrictive practice. I have also made it clear that training records of all staff who are involved in such interventions must be maintained and that training must be kept up to date.
I will provide further information on the membership of the group and the terms of reference in due course. I am absolutely clear that the safety of our patients and the quality of the services that they receive is paramount.
I welcome the interim report from the independent inquiry in Tayside and restate the commitment of this Government to improving the quality and safety of mental health services for the people of Scotland. It is absolutely vital that people feel safe when they engage with our mental health services, whether they are using them or delivering them. We must ensure that there is a high level of confidence in our mental health services and that people know that they can receive the right help when they need it.
That is why I have given the interim report the serious consideration that it deserves and why I stand fully behind the work of the independent inquiry and alongside the people who deliver those crucial services. Importantly, when the inquiry has concluded its work, I will ensure that the lessons learned and the inquiry’s recommendations will be shared widely around Scotland.
Before we move on, I gently remind members that the timings that are given in the
Business Bulletin are only indicative and that business runs on. I thank those who sent me notes of apology for being late.
We move on to questions on the issues raised in the minister’s statement, for which I will allow around 20 minutes.
I thank David Strang and his team for their work, as well as everyone who has informed the inquiry or given evidence.
The basis of the report is to examine end-to-end mental health services, which means from the first point of contact with the health service to the best possible outcome for the patient.
For example, in the interim report, GPs raised serious concerns about the referral process. There were also concerns around ambiguous child and adolescent mental health services thresholds. That highlights that we need a whole-system approach to the design and delivery of services. Will all future actions take that into consideration?
The minister has assured us that the Scottish Government will not wait to take action. When will she report back on the meeting with the senior leadership team? When will she report on progress?
The minister has described the interim report as a milestone moment, but the milestone moment will not come until patients in Tayside see better mental health services.
I will take Annie Wells’s questions in order. I apologise if I miss anything; there were a lot of questions.
Long waits for support and treatment are unacceptable. This Government is investing £54 million to help boards improve their performance against waiting times. The Government expects those who need help to get help at the time that they need it.
NHS Tayside has stated that its policy is that if patients have to wait to be seen, they should be advised of the likely waiting time. The Scottish Government has committed to providing funding for 800 additional mental health workers in key settings, which includes GP practices.
With regard to the meeting with senior leadership, I apologise if I was not clear in my statement; I thought that I had covered the fact that my meeting with the senior leadership of NHS Tayside and the integration joint boards was to set out my plans for a response to the interim report and my expectations of how they will accept that report and respond to it.
Annie Wells raised the difference in the CAMHS thresholds in NHS Tayside. The board assures me that it plans to raise the age threshold for children to 18, to bring it in line with most of the other health boards across the country.
We called for this inquiry and our thoughts are with the patients and families who are affected. I pay tribute to everyone who has taken part in the inquiry.
I am surprised that there are no immediate recommendations. Can the minister provide a further update on the timeline for when she expects David Strang to make his recommendations? As risk to patient safety is an urgent concern, does she agree that NHS Tayside should be moved back up to the highest level of escalation and placed under special measures? Can she confirm whether the quality and safety board for mental health, which she announced moments ago, will report to Parliament? Will it carry out a national review of mental health services? That is what Scottish Labour and campaigners have been calling for.
The safety of those who use and deliver our mental health services is paramount. NHS Tayside has outlined to me the work that it is undertaking within its quality improvement programme on a range of activities that are aimed at improving the care and safety of patients. I agree that that is extremely important. Central to that is the on-going feedback from staff, patients and carers. Current improvement activity in NHS Tayside is focused on improving observation practice, which is a Healthcare Improvement Scotland national priority.
David Strang’s inquiry is independent. I have no influence—and nor should I—over when that inquiry will report and what its recommendations will be. Mr Strang will provide us with details of when he will come forward with his final recommendations. This is an interim report.
I echo Monica Lennon’s thanks to those who have been involved in the inquiry. I met service users and their families and staff who are involved in the inquiry. Their words have stayed with me. It is important that we thank them for their contribution to the evidence that we have had today from Mr Strang’s report.
There is a need for transformation to a whole-system approach to mental health by all public services including GPs and other primary care workers. That needs to be done in partnership with people who use the services and their families, the mental health workforce, and delivery partners across the public and third sectors. Multidisciplinary and multi-agency working is key to that transformation and will ensure the delivery of a whole-health model of care for individuals who are accessing services. As I announced today, the new quality and safety board for mental health, which I will chair, will look at creating the right conditions to develop and spread excellence across Scotland.
The interim report states:
“Patients report telling staff they were suicidal but the risk was not taken seriously until they made a serious attempt to take their own life.”
I do not believe that that situation is specific only to NHS Tayside. Therefore, what investigation will take place into the on-going service redesign in other health boards across the country? If the Government is truly going to regain the confidence of families with the establishment of the quality and safety board for mental health, why will the board not be chaired independently?
I am disturbed by Mr Briggs’s assertion at the start of his question about patients reporting that they feel suicidal that he thinks that it is widespread that mental health and healthcare professionals ignore people when they are in distress. That is certainly not my experience from working in the NHS for many years. Every interaction that mental health professionals, GPs and other healthcare professionals have with people who are presenting in distress or with mental health problems involves risk assessment. It does not have to be a formal risk assessment. I accept what Mr Strang has put in his report. I am not refuting that, but I refute the assertion that Mr Briggs is making about mental health services across the country.
Where people do not feel welcome or represented, it can be hard for them to open up about mental health problems or to believe that they will be listened to. Differences in ethnicity, sexuality or gender identity, for example, should not be barriers to receiving high-quality services to treat mental health problems. Our aim is for mental health services and professionals to be welcoming to all and to respond to the mental health needs of individuals in a person-centred, safe, effective and respectful way.
Up to 2019-20, we are investing £54 million to help boards improve access to mental health services. Our programme for government also sets out a £250 million package of measures to support positive mental health and prevent ill health. That funding aims to ensure that high-quality mental services are accessible to everyone.
My thoughts are with every family affected by the issues that are raised in the report. The minister said that safety is paramount. There are huge patient safety issues in the report, but there were no actions in her statement today that will guarantee patient safety over the next weeks and months until the final report is published. I reiterate Monica Lennon’s call for the minister to re-escalate NHS Tayside to level 5 so that the board gets the supervision and support that it needs to guarantee patient safety.
Also, David Strang was very clear that the changes in the service redesign should be halted until there is a comprehensive review. Will the minister instruct NHS Tayside to halt those changes until the final report is published?
I am aware of Jenny Marra’s interest in the issue, certainly during my time in Parliament. I address the issue of Mr Strang’s recommendation in my report. I have asked the board to report back to me shortly on the risks of progressing service redesign and on the risks of not progressing it.
Jenny Marra has asked me a question, which I have tried to answer.
NHS Tayside has been responding to the recommendations that came out of the HIS report and the inquiry following the BBC programme, and it has been using those to improve the quality of its care. Some improvements have already been made but, as I have said, the pace of change is not as I would expect. That is why we will look to provide additional outside support, in the form of programme management and clinical assistance, to ensure that changes can be made more speedily.
The inquiry’s report revealed that GP referrals to mental health services are frequently rejected on the basis that the patient in question did not meet the required criteria, despite GPs not having been informed of what the criteria are. What steps will the minister take to ensure that clear referral guidelines are communicated to GPs as a matter of urgency?
This morning, Gilly Murray, who is the niece of David Ramsay, who, very sadly, took his own life after being failed by the services at Carseview, tweeted:
“I have been and am going through hell and none of this benefits me or my family. David is still dead.”
What support will the minister give to the families who were left behind when patients in Tayside took their lives? Also, given the concerns about the use of restraint, and the disbelief among staff that a crisis situation exists, what comfort will she extend to patients in Tayside who are in crisis today to assure them that they will be taken seriously?
My sympathies and my thoughts are with any family in Scotland bereaved through suicide—and especially those in Tayside, for whom today’s publication of the report will have stirred up emotion. It is not that they do not feel such pain every day, but I imagine that today will have been especially difficult for them.
I think that Mr Cole-Hamilton also asked me about physical restraint. As I have said, the Scottish Government is absolutely clear that alternatives to that should be considered first. Physical restraint should be used only as a last resort and for the shortest possible time to ensure safety. As I mentioned in my statement, I have written to all health boards to seek assurances that they have in place policies that cover all forms of restrictive practice, and that staff receive guidance on the appropriate use of such restraint.
Counselling and other support services for bereaved relatives are currently available in Dundee. Part of the suicide prevention leadership group’s work looks at support that can be given to all who are touched by bereavement through suicide, which is very important.
It is important to understand that all health issues are connected. There are clear links between an individual’s physical health and their mental health, as well as the quality of their life and the overall quality of their health outcomes. As part of its mental health strategy, the Scottish Government has committed to providing funding for 800 additional mental health workers to improve access in key settings, including GP practices. It is investing significantly in such development work, and funding will rise to £35 million in 2021-22 and beyond.
I think that the minister would agree that, in delivering patient safety, it is important that we look after the needs of our healthcare professionals and ensure that they have support in place in what is a very stressful environment. As part of the final report, will consideration be given to the health of our healthcare professionals?
The report by David Strang is an independent report, so I cannot predict or influence what will be in the final report.
The inquiry team has ensured that there is a separate workstream for staff—it has been led by an official from Unison, with representatives from all the major trade unions and professional bodies—so that staff who are employed by NHS Tayside and work in mental health services could be open about their concerns and have their voices heard in such a way that they felt safe and supported.
It is crucial not only that NHS Tayside as an employer ensures that its staff are safe and supported in their work through its duty of care as an employer but that staff-side organisations, trade unions and professional bodies play a pastoral role to ensure that staff are supported and feel safe at work and that, if they do not, staff can raise the matter in such a way that they feel reassured.
What action is the Scottish Government taking to reduce the stigma of mental ill health and suicide to ensure that people who are at risk of suicide feel able to ask for help?
I thank Tom Arthur for asking that extremely important question. We want a Scotland where people can get the right help at the right time, expect recovery and fully enjoy their rights free from discrimination and stigma. Action 3 of the suicide prevention action plan commits the Scottish Government to working with the national suicide prevention leadership group and partners to encourage a co-ordinated approach to public awareness campaigns that maximises impact.
The Scottish Government provides funding to see me, which is Scotland’s national programme to end mental health stigma and discrimination, and it has quickly established an international reputation for being groundbreaking in its scope, ambition and delivery. It has put the issue of mental health stigma firmly in the public arena and it is working to challenge stigma and discrimination at their roots, where people experience them at work, in health and social care, in education, at home or in our communities.
The minister mentioned patient restraint both in her statement and in reply to an earlier question. Will she outline the training that staff receive on restraint? How confident is she that only fully trained and qualified staff exercise restraint? Is a record kept of each and every time an individual is restrained?
I used to train people in physical restraint, so I could give Mr Stewart a demonstration if he likes.
There are accredited training courses that are provided by accredited trainers. When I had my meeting yesterday with NHS Tayside, I was informed that, at that point, the training records of 95 per cent of its staff were up to date. It is vital that staff are appropriately trained so that it is safe for the patient who is being restrained and safe for the staff who are carrying out the restraint. As I said, restraint should be used only as a last resort and after other considerations have been made in trying to manage a very difficult situation.
As I said in my statement, I have written out to all the health boards to set out my expectations of training records and to ensure that they are keeping records as they should.
We have the Datix system in the NHS and all physical restraint should be recorded in that. The Datix records are then approved by management. Any incidence of injury will also be reported to management and there will be an injury review. Any incidence of serious injury will be reported to the Mental Welfare Commission for Scotland. In addition, any incidence of restraint will be recorded in the patient’s clinical notes.
What steps will the Scottish Government and the Convention of Scottish Local Authorities take to implement the work of Dr Dame Denise Coia and the children and young people’s mental health task force?