Under pressure: is it time for a rethink of Scotland’s mental health system?

“We think the worst of the mental health aspects of this crisis may still have to come,” says Billy Watson, chief executive of the Scottish Association for Mental Health (SAMH).

Months after restrictions were brought in to contain the spread of COVID-19, slowly but surely, these limits are being reduced. But the pressure on services to support mental wellbeing is only growing.

Watson tells Holyrood that while the curve of virus infection rates may be flattening, the same is not true for the mental health impacts of the pandemic lockdown.

“As the world, the economy and people generally move on from the ravages of the virus, and this period of intensity where we’re significantly worried for our health and our mortality, the curve that everybody’s been talking about trying to flatten during the virus period, we still think we’re climbing the curve on the upside in mental health,” he says.

“There needs to be a massive strategic rethink of how the care and treatment system in Scotland funds itself, delivers itself, meets the demand that was already there, and the demand that will be increasing upon it.”

The virus may have further exposed the issues in Scotland’s mental health system.

The Scottish Government’s mental health strategy started in 2017 – a “10-year vision” that claims it will “transform the mental wellbeing of people in Scotland and the mental health services they use”.

It sets out 40 actions and boasts that 19 were “complete or nearly complete” as of the last progress report in November 2019, including employing 268 additional mental health workers, £18.5m in funding to improve access to services and psychological therapies, a £4m investment to recruit 80 more Child and Adolescent Mental Health Services (CAMHS) staff, a programme board and taskforce to address children and young people’s mental health.

However, as Watson sees it: “We’re only three years into a 10-year plan but we think, almost regardless of COVID, that plan was creaking considerably and requires significant review. And, my goodness, ever more so now.

“If you look back to things like the Cabinet Secretary for Health, two years ago come next month, saying the CAMHS system that rejected nearly 8,000 young people a year was completely unacceptable, and little has changed in that two years despite the government assembling taskforces and programme boards, the situation on the ground has got worse. And then we’ve had the [COVID-19] crisis.”

At the beginning of the pandemic Watson says calls for help dropped, but now they are “rising at a rapid rate, which will take it back to previous levels and then beyond”.

“Our concern is, particularly in the care and treatment system pre-COVID, that mental health was already struggling badly. It was meeting very few of its mental health targets in Scotland,” he says.

“And this latent demand is about to hit us soon and we need to work hard with everyone, including government, to actually make sure there’s not a return to where we were, with an enhanced offer that needs to create a new, higher, benchmark than where we were pre-COVID.”

Watson says more specific targets are required when it comes to the increasing inequalities around health and mental health, “which we think the virus will exacerbate”, and that efforts around suicide prevention must be “redoubled”.

“The kind of ‘we’re all in this together’ sometimes it doesn’t feel like that for people at the highest SIMD [Scottish Index of Multiple Deprivation] categories, where their exposure to the virus and their exposure to mental health is now well-documented,” he says.

by Liam Kirkaldy

Society & Welfare

New mental health apps provided to NHS staff

“Whilst we think there needs to be a core universal service that potentially is better than what existed before, we also need some specific targets because the needs of those people in the inequalities groups are greater and different.”

Any strategy re-think must include more support for those with long-term mental health problems. Watson says there has been “a little bit of noise in the system” about how COVID-19 mental health campaigns have left out some people.

“There are people who have slightly deeper mental health problems who are frustrated in terms of their voice in all of this. So, the ability to have a routine, take exercise, all of those good public health messages around wellbeing are landing well, but there’s a constituency of people who maybe already have anxiety or depression who get a bit frustrated by those messages because they don’t feel included in them. They’re on a mental illness journey that needs some dedicated and specific support.

“Whilst we ratchet up the public mental health and mental wellbeing at work, we must never forget that there are vulnerable people who live with mental health problems or mental illness every day, and they potentially are suffering more than most of the moment.

“We cannot leave them behind. We must design a better system for them going forward.” 

While employment is “almost a singular action” in the current plan, Watson says it deserves far more attention than that.

“Now more than ever there’s a real appetite from employers, particularly those in the corporate sector – who in some respects have been in denial around mental health and wellbeing in the workplace – are now clamouring to make sure that they improve in the position that they have,” he says.

Those with ongoing mental health problems remain the largest number of people who are unemployed, “and therefore, into work programmes need to be more attuned to mental health”.

“The main programme for getting unemployed into work is Fair Start Scotland, and it’s pretty obvious that it hasn’t done much in the first couple of years to help people with mental health problems achieve sustained job outcomes – so that needs a review.”

With lockdown restrictions beginning to ease, employers are looking at how to transform their workplaces to adhere to government and scientific guidelines around social distancing.

While it is important to ensure that workers can wash and sanitise their hands, and are kept two metres apart from their colleagues, there should also be a focus on supporting the mental health of employees.

Scottish Trade Union Congress assistant general secretary of operations, Yvonne Stewart, tells Holyrood each employer should complete “a risk assessment based on the hierarchy of control measures” before inviting workers back into their workplaces.

“Your first control measure is always going to be: does the activity needs to take place at all? So, we’re asking employers to look very carefully at the activities that they’re engaging in, is it essential?

“The broad principles would be social distancing, hygiene measures and personal protective equipment, and then also asking employers to look at the mental health impacts and the welfare of their employees, as they’re going back.”

Stewart says employers should be openly communicating with their workers that they understand that the pandemic and return to work “places people under the extraordinary stress”.

“Reminding your employees that this is an extraordinary period, that lots of people are anxious, that there are people in the workplace they can talk to or formal employee counselling services that could be used, that are made available,” she adds.

For workers in health and social care, the frontline during the COVID-19 crisis, the Scottish Government has facilitated a virtual wellbeing centre, bringing together resources, support and advice.

The National Wellbeing Hub was created by trauma specialists, including psychological therapist Gill Moreton, a clinician at NHS Lothian’s trauma service the Rivers Centre, in partnership with Glasgow trauma service the Anchor Centre, and includes access to apps and online programmes Sleepio, Daylight and Silvercloud.

Moreton stresses that health and social care workers will react to the pandemic in different ways, while some may experience worsening mental health, other people might be OK.

“It’s not an accident that people are OK, even if they’re working in high-risk roles where they have exposure to potentially traumatic material and events,” she tells Holyrood.

“There’s usually a bunch of factors, from being able to detach, having a very strong supportive team around them, feeling prepared and equipped in terms of training, feeling competent and seeing that they are doing an important job.

“The challenge with COVID is that this is affecting all of us, everywhere, so you can’t entirely detach because you’re also worried about your loved ones.

“What’s particularly tricky about the pandemic is that it places additional demand on health and social care staff in terms of the level or the volume of work, the emotional content of the work, that ability to hold your professional boundary, at the same time as reducing the things that you would normally do to look after yourself.”

But she says: “When we talk about ‘the tsunami or the tidal wave’ of mental health problems that are just waiting for health and social care staff... we need to be careful that we don’t have a narrative that suggests that it’s inevitable or people are doomed.

“Because there’s also the potential for people – and we’ve certainly had this when people talk to us, when we were making the site – to feel pride, to feel sort of energised and grateful that they’re getting a chance to do something that matters for their fellow citizens at a time like this.

“People have transformed services and done remarkable things, whether that’s care home staff moving in to live with residents to try and protect them, or whether that’s kitting out wards of ICU units in tiny amounts of time.

Moreton adds:

“It’s just about making sure that we allow for the possibility for people to be tired and drained, but not injured.”

One service that has transformed how it operates during the virus is NHS24’s 111 Mental Health Hub, which has only been up and running for a little over a year.

Since lockdown began the service has received almost 5,000 calls, with the hub’s team resolving 3,000 of these calls over the phone, 1,500 people referred for further consultation to doctors and community psychiatric nurses, and about 400 calls referred to emergency services.

Additional demand and £2.6m in government funding have seen the hub bring forward plans to expand its offering from a 6pm to 2am phone service to 24-hours. This was due to happen later in the year but may be offered from this month.

NHS24 director of service delivery Stephanie Phillips tells Holyrood: “Our callers are dealing with a range of mental health and wellbeing issues ... And we anticipate that many more people will experience increased anxiety and other mental health concerns as we transition out of lockdown.”

As well as investing more money into mental health services, SAMH’s Watson praised the government’s quick decision-making during the pandemic. “I think the Scottish Government, on mental health, were pretty agile and pretty decisive during this – and I think they need to maintain that kind of way of being. They’ve gone to the organisations, particularly the third sector, who can get it done and get it done quickly.”

He gives the example of the Distress Brief Intervention (DBI) programme, which the Scottish Government had trialled over the last two years at four locations. “It’s been going fantastically well and makes a huge difference to people who are at risk of being in crisis,” he says.

DBI was due to be rolled out across Scotland by 2022, but Watson says the government has agreed to roll it out nationally, now: “So, something that was going to take two years to do, it’s being done in six weeks.”

Coming out of lockdown, Watson hopes the government will continue to work in this way. “We don’t want them to default to where they were before, which was largely slower, more bureaucratic and quite centrally driven,” he says.

“They genuinely have reached out across sectors and said, strategically, as partners of self-esteem, how can we tackle this together? I hope that’s a new cultural norm for how we’re going to work across sectors and with government. If they maintain that level of agility, I’m pretty hopeful.”