Mental Health Forum For Cowal

MENTAL HEALTH
“LOCAL” SERVICE PROVISION
THE WAY FORWARD

By
John Quick
A discussion paper submitted in partial fulfilment Of the requirements set out in the constitution of the
Cowal Mental Health Forum “Most of this document has been combined from other material already in publication”
“And is solely for the benefit of stimulating the debate on local services”

Introduction

This publication is the result of detailed research and is intended as a resource for health professionals
and lay volunteers interested in patient and public involvement. People who have mental health issues
or learning Difficulties tend to spend a lot of time in segregated places when, in general, services
should be helping them move more into places used by everyone, and to get involved in activities open
to everyone. Government policy encourages health and social care agencies to provide more support
in inclusive settings, and work towards supporting clients to make use of community and public
facilities. This is where most people want to live their lives:
Mental health improvement and population mental health work have advanced considerably in
Scotland since 2001 and Scotland is now recognised internationally for its work. There are areas of
excellence, but we need to build on these and do even more, especially to address inequalities and to
ensure that the mental health and wellbeing of Scotland’s people flourishes this work forms part of the
Scottish Government’s wider health and wellbeing ambitions for a Healthier Scotland and is integral to
addressing health and social inequalities. The future direction also adds to and complements a range
of policies, not just on health and wellbeing, but for achieving the wider strategic objectives of the
Scottish Government there is no health without good mental health, where we know how to support
and improve our own and others’ mental health and wellbeing and act on that knowledge.
There is continuing debate about what mental health and mental wellbeing mean, about the underlying
causes of mental health problems and about the best ways to maintain and improve mental health and
mental wellbeing. However, the general concepts of what we mean by mental health are becoming
clearer and we are now able to define and measure mental health as something positive.
Mental health problems generally refer to having difficulties with our mental health which affect how
we go about our everyday lives. Mental illness refers to clinically identifiable illnesses or conditions that
affect our cognitive functioning. Similar to mental health, mental illness can be described as a
continuum from high levels of mental illness to low levels of mental illness. There is a good evidence
base to show that mental health and wellbeing can be promoted, learned, strengthened, developed and
sustained and, equally, it can be eroded, undermined or put at risk. This is not just about individuals
or about how we behave: it can be undermined or supported by wider factors - our work environment,
our physical environment, by what we have available to us, our opportunities and by wider social,
health, economic, political or cultural factors. We need to enhance people’s mental health and
wellbeing, so that they are able to flourish. to reduce the occurrence of mental health problems and
mental illness and improve the quality of life of people living with on-going mental health problems or
illness The promotion of mental health is complementary to improved physical health, the prevention
of mental illness and physical illness, and to achieving improvements in the quality of life of people
experiencing mental and physical conditions and illnesses. This should include a focus on the
prevention of more common mental illnesses (such as depression and anxiety), on psychoses, and on
the interaction between mental illness and other health conditions such as heart disease, cancer and
diabetes and other long-term physical conditions. Support improvements in the quality of life, social
inclusion, health, equality and recovery of people who experience mental illness, to include further
work on addressing stigma and discrimination, recovery and on promoting equality of opportunity in
areas such as employment, housing, education, cultural, sporting and recreational activities. People
with a mental illness are among the most excluded in our society. (See also Commitment 1 of
Delivering for Mental Health.) Mental health can be improved, just as physical health can be.
Positive mental wellbeing can contribute to positive social, health and economic outcomes.
The Government’s National Programme for Improving Mental Health and Wellbeing (‘the National
Programme’) and its many partners have made significant strides since 2001 in mental health
improvement it must go further. To assist and reach those people, agencies and organisations that are
unsure about what the priorities should be, or uncertain if there is a good enough evidence base for
action, or are unclear how their particular area of work can make a positive contribution to this agenda
as part of work on improving health and wellbeing. Many of the key risk and protective factors for
mental health and mental wellbeing are similar. Those efforts must be made to promote and embed
the skills, attributes, belief, values and circumstances that increase resilience, self-efficacy, a sense of
mastery, coherence and control, individually and collectively. Increasing these attributes enables
people to realise their abilities and to flourish, contributing to greater optimism, hope and an ability to
cope with the challenges of life. Work in this arena must include the promotion of mental wellbeing
for people living with, and/or recovering from, both physical and mental illnesses and should address
the specific challenges faced by people who are subject to discrimination in its many forms (see the
Fair for All strands). Issues to address could include greater holistic support such as poor housing,
poor employment and educational opportunities, social fragmentation, poor social cohesion and lack
of social networks and support. Approaches should be ready to identify where things might go wrong
and to engage and support early and address multiple and complex needs, not just isolated issues,
within an ethos of promoting self-efficacy. For too long, people who experience mental illness,
whatever their age have been marginalised, discriminated against, excluded and denied the opportunity
to realise their potential. This is beginning to change in Scotland as evidenced by Well? What do you
think? Survey But much more needs to be done, especially in tackling deprivation and discrimination,
as those in adverse socio-economic circumstances and/or those subject to discrimination are more
likely to suffer from mental health problems and illnesses and more likely to experience stigmatising
behaviours and prejudice. Further work is required on addressing stigma, prejudice and
discrimination, especially for those who have a diagnosis under the general heading of psychoses.
Greater equality of opportunity is also required in areas such as employment, housing, education, and
cultural, recreational and sporting activities. Increasing access to mental health and mental illness
literacy can also help in enabling people to have the information, education and knowledge they need
to keep well and help to support behaviour change in a positive way. Improved mental health literacy
can also support, enable and encourage people to seek help earlier and access care, support and
treatment earlier, before problems get worse or a crisis arises. Recovery in the presence or absence of
the symptoms of mental illness is possible and will be individual to each person and their
circumstances. Belief in recovery is the way to tackling stigma and discrimination and improving
people’s quality of life, inclusion and opportunities. In developing improved mental health literacy, we
wish to see greater public understanding that it is possible to recover, symptom-free from mental
illness, and that it is also possible to live life fully and well with a long term mental illness. Valuing
people’s lived experience of living with mental illness is a key part of this agenda. Supporting self help,
for example, through resources such as Living Life To The Full www.livinglifetothefull.com and
other capacity building, training and self-help work aimed at individuals, groups and communities
Utilising and supporting a wide range of individual and local population-wide interventions and
supports, such as community referrals, social prescribing. Understanding and addressing comorbidity,
including substance misuse and mental health problems (see also Commitment 13 of
Delivering for Mental Health). Improving local capacity for suicide prevention, including
mainstreaming suicide prevention in social, community, public health, Health improvement and
mental health care arenas (see also Commitment 7 and Target 2 of Delivering for Mental Health).
Improvement of attitudes and behaviours within staff groups (in the NHS, local authorities and other
public services) to help support improvements in the quality of life, social development, social
inclusion, recovery and equality of opportunity for people experiencing mental illness and improve
access and use of public services and community resources.

Social inclusion, Sections 25 – 31 of the Mental Health (Care and Treatment) (Scotland) Act 2003
The emphasis on social development, wellbeing of people with illness. Supporting improved
employment and vocational outcomes for people experiencing mental illness, including improved
retention rates of people experiencing mental illness in the workforce, increased employment
opportunities, the implementation of workplace ‘mental health’ policies that include retention,
support and adjustments at work, promotion of mental health and mental wellbeing, prevention of
mental ill health, and proactive disability awareness on mental illness. An emphasis given to self care
and support for self care, complementary to the recovery message, with work on supporting people’s
capabilities and assets and on supporting self belief and change, and addressing self stigma. Further
emphasis given to recovery, with a focus on work out with services, encompassing relationships,
social networks, community, identity, employment, learning and support and addressing prejudice
and discrimination. Local co-ordination as a part of overall public health, wellbeing and health
improvement work, regeneration and social inclusion, working on the key determinants of health and
mental health in key settings such as the workplace, communities and schools, across the age ranges.
Making linkages to other key public health and health improvement agendas – especially alcohol,
drugs, smoking, obesity (physical activity and diet) and sexual health. Making linkages to
Delivering for Mental Health targets and commitments, including the health promotion agenda for
people experiencing mental illness, suicide prevention, equalities and inclusion. Making linkages to
supporting improved outcomes for those experiencing physical illness, disability and long-term
physical conditions. Improving the capacity and capability of practitioners and key stakeholders in
awareness, understanding, behaviours and action. Building on promoting mental wellbeing, mental
health literacy (e.g. Mental Health First Aid), suicide prevention, recovery, stigma and
discrimination. Increasing public awareness, knowledge, understanding and action. This paper aims
to support and stimulate discussions on the future of mental health improvement across Scotland.
The proposals set out here aim to help create the conditions and circumstances for making significant
advances in the promotion of mental health and achieve a discernible difference in addressing
inequalities in mental health.
(Taken from a number of sources)
John Quick (Chairperson Cowal Mental Health Forum)

Preface:
Mental Health ‐ A Priority:

Care in the community is a priority for health, social work and housing agencies and
mental health is a continuing national priority for the National Health Service in Scotland
(NHSiS). A comprehensive local mental health service should seek to address the full range
of needs of all people with mental health problems. Health, social work and housing agencies are required to agree a clear strategy among themselves and with primary care and the independent sector who are their partners in the planning and delivery of mental health services.
This is to ensure:
• multi-agency assessment and agreement on the need for mental health services;
• provision of integrated community-based services, with a range of accommodation
from in-patient provision to ordinary living, to meet that agreed need;
• clarification of what services are to be provided by whom, in what setting, for what
type of mental health problem and who is to pay for which service;
• clear recognition of the skills and contributions of the agencies and disciplines
involved; and
• identification of mechanisms to monitor and review the provision of services and to
ensure the best outcomes and the most efficient use of existing resources.
This emphasis on collaboration is to improve the quality of life for those affected by mental
health problems by providing a full range of local services to meet their health, social, housing, educational and other needs.

Care in the Community

Care in the community seeks to:
• promote privacy, dignity, independence and choice;
• provide support for community-based living;
• provide, as far as possible and practical, professional care and support at home, or in a
homely setting;
• provide services which are sensitive to the individual’s needs for health, social care
and housing and cause as little disruption to the service user and their family and friends.

This requires:

effective joint working among all the disciplines and agencies involved, including
primary care and the voluntary and private sectors;
• the close involvement of people who use the service, their relatives, carers and
advocates at all stages;
• that properly resourced replacement facilities and services are in place before any
service is discontinued or hospital unit is closed;
• that changes in the balance of care are pursued with commitment but also with
sensible caution;
• that no person should be discharged from NHS long-stay care without an agreed care
plan, support and accommodation in place, available and properly resourced;
• recognition that some people with a serious mental illness will need admission to inpatient
services, possibly with repeated re-admission, and that some may also require long-term asylum;

A FRAMEWORK FOR MENTAL HEALTH SERVICES IN SCOTLAND:

Originally published in 1997, this document continues to grow and expand to reflect current thinking on the best way to provide mental health services in Scotland. Visit the Framework website at www.show.scot.nhs.uk/publications/mental_health_services The Framework is a “living” document and remains relevant to latest thinking and policy advances by additions when and where necessary of new sections or expanded entries to the text e.g.:

Additional service profile on services for women with postnatal depression (March 1999);

An expanded core service element chapter on psychological interventions (talking treatments) (October 2001);

Additional guidance on services for those with an eating disorder (October 2001); and

Additional service profile on Perinatal Mental Illness/Postnatal Depression Hospital Admission and Support Services (March 2004).

Additional service profile on The Planning, Organisation and Delivery of Joined Up Services for those with Dementia and their Carers (November 2004).

Introduction

The emphasis of this Framework is on the needs that have to be met and process and service elements that have to be present to meet those needs. It should be used by service commissioners to establish the extent to which local services encompass these elements and are therefore able to meet identified needs. It should be used as a performance monitoring tool to guide the commissioning activity of health boards, GPs and local authorities. It should also help in the identification of opportunities for joint commissioning.
Local agencies must work together to deliver comprehensive mental health services
which meet the needs of their resident population.
The Framework has been prepared in accordance with Government objectives and policies to provide clarity and a sense of direction.

Process elements

In assessing the needs of a population for a comprehensive community based mental health service, and in reshaping the existing service, there are some aspects of these processes which will have a critical impact on the success of the venture. These relate as much to the ‘how’ of what is done as to the ‘what’. If they are not attended to, the development may be hindered. Delay may occur in the development of the infrastructure necessary to maintain services of the desired quality and avoid waste of resources in duplication.

These process elements are: the interface between primary care, secondary care and social work;

involving people who receive services and those who care for them;

joint commissioning; ∙ effective leadership and management;

quality assurance;

information systems;

staff supervision, development and training; and measurement of outcomes.

The Framework is in two parts:

the Framework itself which sets out the essential features of a local mental health
strategy; and a matrix summarising the elements a comprehensive service should provide in order to meet the needs of people with mental health problems, and examples of possible service responses
The Scope of the Framework
The Framework considers the service needs of people with severe and/or enduring
mental health problems, including those with dementia. It does not address the needs of people with for example learning disabilities or substance misuse or alcohol problems unless these individuals also have a mental health problem.
Service Principles and ValuesA local multi‐agency mental health service should reflect local needs and value the
individual, no matter how severe his or her disability, as a full citizen with rights and
responsibilities. Self determination should be promoted by:
• involving people who use services during the assessment process and thereafter;
• working with individuals so that they can shape and influence the development of
their individual programme of care;
• recognising the importance of purposeful employment in promoting self‐esteem,
independence, social interaction and a structured day;
• providing independent advocacy support where required or requested;
• providing a comprehensive range of services and accommodation based on
individual needs;
• addressing the special needs of women;
• ensuring that culturally acceptable services are provided to minorities and ethnic
groups;
• ensuring consultation and participation in the development of relevant strategies
and services; and
• taking account of the needs and views of those who care for the person with a
mental health problem during the individual assessment process, in the
construction of individual care programmes and in the development of relevant
strategies and services.
Public Education and Awareness
There is a need to influence the broader community and promote the concept of community care in general by:
• providing education to overcome stigma and to promote positive attitudes to mental health;
• openly addressing anxieties about public safety; and
• adopting a positive and open approach to media interest.

Staff Development and Training
All the staff involved in the delivery of mental health services should:

be consulted and involved in the development of the local strategy;

be equipped and enabled to achieve its purpose, share its values and feel rewarded by furthering it;

be assisted in coping with change and adapting their skills to the provision of care in community based settings;

receive clinical, management and personal support, education, training, and access to research findings;

be given training which includes input from service user groups.

Joint training is crucial to the development of mutual understanding, language, goals and respect.
The staff development and training arrangements of individual agencies should
therefore be supplemented on a multi‐disciplinary and inter‐agency basis, including both
managers and primary and secondary care staff. The allocation of training resources should
reflect the priority given to mental health and promote the development of services which
improve the health and social functioning of the people who use the service.
Appropriate mental health awareness training should be provided to others who will come into contact with people with mental health problems, for example receptionists, housing officers, accident and emergency staff, the police, employers etc. Stakeholders In addition to health boards, social work, housing and education departments, The following agencies and groups should normally be invited to take part in the development of the strategy:
• people who receive mental health services;
• family and friends who care for them;
• NHS trusts ‐ including clinical staff and managers;
• providers of primary care, especially GPs;
• local health councils;
• voluntary sector agencies, including housing associations, advocacy organisations and
specialist employment services;
• other housing agencies, including Scottish Homes;
• education services;
• Government Employment Service and local enterprise agencies;
• criminal justice agencies; and
• private providers.

Multi‐Agency Agreement on Local Needs

A comprehensive local mental health service should:
• meet the assessed needs of those individuals who have mental health problems;
• be based on an analysis of the aggregated needs of the local population served;
• be based, as far as possible, on evidence of good practice and effectiveness,
recognising the varying levels of need in different communities;
• be quality driven and fit for purpose;
• give priority to those with severe and/or enduring mental health problems;
• integrate primary care, which is where the majority of people with mental health
problems have their care managed and provided, with secondary health care, social work
and housing services;
• use resources effectively ensuring that there is no duplication of provision; and
• promote mental health and engage actively in health promotion, including action
to de‐stigmatise mental illness.

Such a service should ensure :

• an early recognition of, and appropriate response to, those with a serious mental illness;
• the provision of a 24‐hour, 7 day a week crisis response with access to community and
appropriate in‐patient facilities;
• the provision of an integrated range of community, day and in‐patient services;
• continuity of care so that team, organisational or geographic boundaries do not cause
problems for people who receive the service;
• co‐ordinated and timely management of the requirements of the mental health
legislation, including Leave of Absence and Community Care Order arrangements;
• the availability of interlinked and effective Care Management, Care Programme

Approach and multi‐agency after‐care arrangements;
• access to choice, for example of care and key worker, and second consultant opinion
(arranged through the GP) when requested;
• an appropriate number of staff, sufficiently trained to deliver services of the quality
agreed with the commissioner;
• clearly defined roles and support for staff without specialist training and volunteers
who provide important befriending, socialising and other services;
• access to culturally acceptable services for black and ethnic communities; and
• training, education and support for those who care for people with mental health
problems.

A Service Framework

Increased emphasis is being placed on maximising the effectiveness of use of existing
resources to ensure the flexible provision of a full range of mental health and social work
services in the community. This results in a need for health, social work, housing, education,
employment, voluntary and other agencies to work jointly in the provision of complementary
services for people with mental health problems. In so doing, their planning assumption
should be that, wherever practicable and possible, the local service will be provided as a
home‐based service or in small facilities as close as possible to an individual’s home.

Process Elements

In assessing the needs of a population for a comprehensive community based mental
health service, and in reshaping the existing service, there are certain aspects of these
processes which will have a critical impact on the success of the venture. These relate as
much to the ‘how’ of what is done as to the ‘what’. If these are not attended to, the
development may be hindered. Delay may occur in the development of the infrastructure
necessary to maintain services of the desired quality and avoid waste of resources in
duplication. These process elements are:
• the interface between primary care, secondary care and social work;
• involving people who receive services and those who care for them;
• joint commissioning;
• effective leadership and management;
• quality assurance;
• information systems;
• staff supervision, development and training; and
• measurement of outcomes.

Core Service Elements

A local mental health service must similarly provide a range of care to meet the
mental and physical needs of individuals with mental health problems. Clearly, not all
individuals will have needs in all the categories, but all elements should be provided in an
overall service. Each is equally important; if needs are left unaddressed the effectiveness of
the whole service will be affected. This must be monitored by the joint commissioning body.
These core service elements are:
• information and access to services;
• individual planning of services;
• services to promote personal well‐being and social development;
• services for ordinary living and long‐term support;
• services offering psychological therapies, including clinical psychology; and
• services offering physical methods of treatment

Clinical risk management

TO ADMIT OR NOT TO ADMIT?

One of the most frequent decisions being grappled with on a daily basis across all mental health services is whether or not a person needs a hospital admission. The decision becomes more acute, in its own right, when faced with 100%+ bed occupancy rates. Difficult decisions are having to be made on a basis of greatest need, because the resources are not available to admit all the people who meet a looser set of criteria. Whilst the ultimate decision most frequently lies with the doctors (or in some cases the crisis team as gatekeeper to admission and discharge), the issue of potential hospital admission is being considered on a daily basis by all workers involved in delivering mental health services (statutory and voluntary sectors); and indeed, by service users and their carers, when involved in the decision‐making process. The factors that ultimately determine whether someone is admitted or not, are many and varied, and too complex to be fully covered in this publication. As well as need, there is also the consideration of what local alternatives are available e.g. are there the right kind of resources to sustain someone outside of hospital who would otherwise occupy a hospital bed? The final decision will, more often than not, turn on issues of risk (to self and/or others). What alternatives are there to offer in the local area?, what is the assessment of the risks, whilst simultaneously being asked to consider the positive potentials and resources available to manage the situation. There can be no substitute for developing adequate alternative resources, but in the meantime, the many people who have to make the difficult decisions should be offered the tools to aid and support the decisions they make.

POSITIVE RISK TAKING

‘Positive risk‐taking’ is perhaps one of the most difficult concepts to put into practice within a context of a ‘blame culture’. Risk‐taking is not negligent abdication of clinical responsibility. It is about making good quality clinical decisions to support and sustain a course of actions that will lead to positive benefits and gains for the individual service user. Seen in this way, positive risk‐taking should be seen as the first choice focus of clinical interventions. Its basis within the expressed personal wishes of the service user, certainly offers the best starting point for a collaborative working relationship. ‘Positive risk‐taking’ is not just about ideas; it also has to be about targeting resources and agreed decisions between all people involved in the network of care and support. And offer them the opportunity to enquire into, and identify, the resources and the positive risks that may be possible. It also requires a collaborative plan to be agreed and reviewed in order to proceed with the desired course of action. Risk is more usually seen in the context of behaviour patterns that have the potential for harmful outcomes. However, an essential aspect of our daily lives involves the weighing up of potential benefits from exercising one choice of action over another. This is positive risk‐taking, and involves each of us in exercising degrees of autonomy over how we make use of the resources and options that are open to us, and accessing the desired and necessary support that is available to help us achieve our desired aims. Considering the potential for positive risk‐taking should be an essential element of risk assessment. Ultimately, risk management will be dependent on the availability of resources. In addition to the availability of resources within the mental health services, it is vitally important to investigate what resources are available to, or through, the service user, their significant carers and other social supports, as well as the wider community. A focus on a person’s own coping mechanisms, and previous achievements, will greatly help the task of engaging a workingrelationship. It is one of the most likely elements on which to develop trust; and will thus offer a strong foundation for good quality and effective risk management. It is the positive potentials, and stated priorities of the service user themselves, that will guide towards more likely directions for successful collaborative interventions. Positive risk‐taking should always be considered as an effective counter‐balance to the more usual negative and coercive approaches adopted towards risk in mental health. The process of assessment, and thinking through the formulation of the assessment information, will necessarily trigger thoughts about the potential actions and reactions in the context of known local resources. Practitioners who identify risks carry responsibilities to take actions with a view to ensuring the risk is reduced and/or managed effectively. In this way the processes of risk assessment and risk management, whilst being distinct functions in themselves, become part of the same integrated and continuous process. Assessment is seen as the identification and description of the risks; and management is a clear statement of plans, actions and responsibilities, linked to the intended outcome of minimising and/or managing the risks. The service context in which multi‐agency and multi‐disciplinary working should exist is the Care Programme Approach. This is the forum for sharing information, and collectively deciding and changing management plans. All those involved in the discussions and decisions should be indicated by the previous ‘Network of Support’. The involvement and agreement of service user and/or carer will be essential at this stage the decisions made within the Care Programme Approach should be collective decisions. However, they should outline the individual responsibilities for putting the plans into actions i.e. who will do what, and when. This should also document the responsibilities of the service user and/or carers, where appropriate. A reasonable expectation would be the completion of the whole format early in the care and support of an individual who is referred to a part of the area mental health services. This would be within days for the specialist acute services, and weeks for the longer‐term support services (e.g. assertive outreach, community mental health team). More specific standards should be determined by the local area service, to correspond to other locally agreed service standards. Where risk status changes, the whole assessment and management plan will need to be repeated/up‐dated i.e. when there is a significant increase or decrease in the potential for the primary risks. There is no one single way in which this format can be used, other than the way that is agreed for consistency within an area based mental health service. The management and organisation of care has a direct impact on health outcomes. Service users should get the right care and treatment at the right time. In Delivering for Health, Integrated Care Pathways (ICPs) for schizophrenia, bi‐polar disorder, depression, dementia and personality disorder. NHS Quality Improvement Scotland (NHS QIS) is taking this work forward in conjunction with clinicians, social care professionals, service users and others An ICP sets out the process of assessment, care and treatment for service users with similar diagnoses or symptoms. It lets service users know what they should expect from services. It should set expectations for the local management and organisation of care and act as a point of comparison for treatment and care provided. A good ICP will look beyond treating the disorder and will focus on the full range of needs and capabilities of the individual. In addition to the condition specific ICPs, NHS QIS is looking at the generic elements of an ICP, in particular risk management and patient safety.

Findings

A journey of care may also include an admission and discharge from hospital. This element of the work will be informed by the acute in‐patient forums which are developing so that service users,
carers and staff can influence the shape of their local service. The introduction of crisis response services is a major step in the redesign of existing mental health services and will enable people experiencing mental health difficulties to be treated in community settings and with the minimum of disruption to their lives. In Delivering for Health the Government is committed to developing standards for crisis services in Scotland. This work has been taken forward by the Mental Health Foundation and the Scottish Association for Mental Health in conjunction with the service. These
standards are important in enabling services to manage and care for people better in the community, the emphasis should be on safety but at the same time ensuring access to services which meet the individual’s (and their family’s) needs. Shifting the balance of care from hospital to the community is a key challenge within Delivering for Health in particular, by ensuring that local crisis services are functioning effectively. To be effective crisis services must deliver several important functions. They will require to have rapid, same day response times, provide intensive specialist input of assessment, treatment and risk management including that for self‐harm, in a community setting and focus on those people who might otherwise require admission to hospital financial solutions must be found that will help to drive forward improvements in the care and delivery of mental health services across Scotland. financial support is needed to deliver the targets and commitments.

Summary

improvement of services, the strongest message I have heard was that service users and carers still had experiences of the mental health system that did not match their expectations and
the commitments of public and other bodies. This is not a new problem, but it is disappointing that more progress has not been made. We need to address this issue more directly, not simply restate existing principles or develop new ones. Change is possible, but we need better levers to
produce change and clarity about the changes that we expect to see. By addressing cultures and behaviours in our services we will improve the experience of all those who work in the system and those who come into contact with it. Local services work best so funding is needed.