mental health in scotland a 10 year vision consultation ......srn: mental health in scotland – a...

SRN: Mental Health in Scotland – a 10 year vision 1

The Scottish Recovery Network (SRN) welcomes the opportunity to respond to the

consultation on ‘Mental Health in Scotland – a 10 year vision’.

SRN works to achieve a Scotland where mental health recovery is a reality for all. We believe

that people with experience of mental health problems and those around them should

expect recovery and that recovery values and principles are a foundation from which to

build a fairer, inclusive and flourishing Scotland.

Since it was established in 2004, SRN has been involved in a range of activities which:

Promote greater knowledge and awareness of recovery.

Support the empowerment of individuals to participate in decision making and

manage their own mental health and wellbeing

Influence policy and practice to ensure that it is recovery focused.

SRN is primarily funded by the Scottish Government but located in the third sector. This

allows us to maintain independence from Government and to act as a facilitator and bridge

builder. This approach has been broadly welcomed and in the last 12 years recovery has

moved from the edges to the mainstream of thinking in mental health in Scotland and

elsewhere. There is now a clear and strong commitment to recovery in national policy and a

good level of understanding of and familiarity with the language of recovery amongst policy-

makers and practitioners.

SRN was involved in the development and implementation of the previous Mental Health

Strategy and believe that the learning from the implementation of the strategy should help

inform the development and delivery of a new vision for mental health in Scotland.

The challenge for the next ten years is translating this commitment into practice. To do this

we believe there needs to be changes in the way we design, commission and deliver mental

health services so that recovery underpins all that we do. Recovery needs to be at the core

of mental health policy and practice not an added extra that can be bolted on. It is not

something that should be seen as being ‘nice but not essential’.

Mental Health in Scotland – a 10 year vision

Consultation response


What is Recovery?

Recovery concepts are increasingly part of mental health policy around the world. Our

understanding of recovery has been driven by first person accounts of recovery from people

using mental health services including those documented by SRN’s narrative research which

resulted in our definition of recovery:

Recovery is being able to live a meaningful and satisfying life, as defined by each person, in

the presence or absence of symptoms. It is about having control over and input into your

own life. Each individual’s recovery, like his or her experience of the mental health problems

or illness, is a unique and deeply personal process.”

We know that recovery is experienced as a unique and individual process or a journey.

Central to this is the belief that people are experts in their own experience and have skills,

strengths and capabilities which need to be supported and nurtured. This is in contrast with

the more clinical understanding of recovery as an outcome defined by the reduction or

cessation of symptoms.

While recovery is a unique and individual process it is possible to identify key elements that

support recovery. A systematic review of research on personal recovery confirmed evidence

from Scotland found that there were five essential components of recovery: connectedness,

hope and optimism, identity, meaning and empowerment.1

1 Leamy, M. et al., 2011. Conceptual framework for personal recovery in mental health: systematic

review and narrative synthesis. The British journal of psychiatry : the journal of mental science, 199(6), pp.445–52. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22130746.

http://www.scottishrecovery.net/Submit-Your-Story/stories.html


Question 1 Our framework sets out 8 priorities for a new Mental Health Strategy that we think will transform mental health in Scotland over 10 years. Are these the most important priorities? Yes No Don’t know If no, what priorities do you think will deliver this transformation?

We support the commitment to a 10 year vision for transforming mental health in Scotland.

The current high level of interest in mental health is welcome but achieving the desired

transformation in mental health will require us to think very differently about our approach

and how people are supported in their recovery from mental health problems.

The framework and priorities proposed do go some way to articulating this but we feel that

a 10 year vision for mental health should clearly describe the aspirations for mental health

in Scotland in 2026. It should also recognise that transformation will require different ways

of thinking and doing by engaging with a wide range of voices and opinions to ensure the

‘Vision’ is widely understood and accepted.

Crucially, mental health cannot be seen as an entity that stands on its own. Creating a

mentally healthy Scotland requires us to work beyond the confines of the sector and

promote conversations about mental wellbeing in all parts of Scottish society including

physical health,social care as well as other policy areas that impact on some of the key

determinants of good mental health e.g. housing, employment, social security etc.

We would urge the Scottish Government to accept to the proposal by the Mental Health

Partnership that a Commission of Enquiry be established to lead and inform the

transformation needed to significantly improve the mental health and wellbeing of

Scotland’s population and to reduce inequalities in mental health and wellbeing . This

commission would bring together a range of people including those with lived experience of

mental health problems to develop a longer term vision and make recommendations for

change including legislative reforms.

This Commission could form a part of the next mental health strategy and would not

prevent current and proposed actions from going ahead. SRN would welcome the

opportunity to participate in and/or support such a Commission and would be well placed to

help ensure that the views and perspectives of people with lived experience inform the

vision for the future and recommendations.


We would suggest that any mental health strategy needs to start from a strong and clearly

articulated vision of a mentally healthy Scotland where all people have the resources and

support they need to live a fulfilling and contributing life.

This vision accepts that;

We all have mental health and that anyone can experience mental health problems

at some time in their life;

Recovery from mental health problems is possible and that, with the right support,

people can and do recover from even the most serious mental health problems;

Mental health problems have a variety of causes and this means that we need to

invest in range of services and different types of support for people rather than

relying solely on medical approaches;

We need to look beyond mental health services and recognise that action to address

health inequalities, poverty and discrimination are needed. Health inequalities,

poverty and discrimination impact not only on the prevalence of mental health

problems but also on how people experience them and the resources that they have

to support their recovery;

People need access to appropriate services and support not only when they are ill

but also to manage their own recovery and maintain their wellbeing;

People living with mental health problems are part of the solution and their

experience and expertise needs to inform all that we do to achieve a mentally

healthy Scotland.

The priorities proposed have the potential to begin this transformation but much depends

on how they are interpreted and implemented.

Prevention and early intervention

We welcome the focus on prevention and early intervention and the recognition that

supporting people to manage their mental health and wellbeing is important. Improving

access to services and support is required if this is to be achieved. It is important that

prevention and early intervention is seen as a priority for all age groups so that more people

of all ages get the help they need when they need it and do not always have to get support

from secondary mental health services.


New models of supporting mental health in primary care

Ensuring people get the help they need, when they need it will require new models and

approaches to supporting people experiencing mental health problems. This will require

changes in the way we support people in primary care. There are many good examples of

social prescribing and community links type approaches which are providing people with

person-centred and outcomes focused support to help them lead their recovery and

manage their wellbeing. Despite growing evidence of the benefits of these approaches to

people and services they have not been adopted in many areas. Having this as a priority may

provide the direction and impetus needed for this to become the norm.

However, we need to develop and implement new models of supporting mental health

beyond primary care. We would suggest that there is a need to develop new models of

community based support for people experiencing mental health problems that do not rely

on statutory primary care services. The third sector is not only a major provider of social

care services and other forms of community based support but has also been at the

forefront of many recent innovations in mental health e.g. peer support workers, link

workers and social prescribing. There is strong evidence that these and many other

innovative approaches to support prevention, early intervention and self-management work

well but are often under-valued and under resourced because they are not seen as being

“mainstream” health services.

Given that the strategy is for a 10 year period we would suggest that this priority is widened

to be focused on all forms of community based support for mental health and wellbeing and

not just the statutory primary care sector. Within this there is also a need to ensure that

judgements about the effectiveness of new models are informed by all available evidence,

including the lived experience and perspectives of people living with mental health

problems.

Support people to manage their own mental health

This priority is of great importance but can sometimes be seen as a way to move people on

from services or reduce access to services and support. This is an area where the voluntary

organisations and community based approaches work best, providing people with a

framework and the tools to develop their own self-management strategies, promote hope

and optimism; and connect them with other people with shared experiences.

We know from our work in promoting WRAP (Wellness Recovery Action Planning) and other

wellbeing tools that this works best in a group setting in the community where people are

encouraged to share experiences and learn from each other.


Improve access to mental health services and make them more efficient, effective and

safe

We need to clarify what we mean by mental health services and to ensure that this is wider

than just clinically led services based in the NHS. It will not be possible to meet the demand

for support from people experiencing mental health problems and increase accessibility to

support from within the NHS. To be able to provide the support that people need, when

they need it, the role of the third sector and community based initiatives needs to be

recognised, valued and properly resourced.

An increased focus on community based, non-medical services will increase access to

support and will meet the increasing demand for more choice of support and better support

in the community. This will require a rebalancing of investment with more resources going

into community based and non-medical services and supports. It will also require changes

in thinking which tend to portray such services as ‘non-specialist’ or see them as having

lower value than medical services. These changes in thinking are required by many people

including the public and people living with mental health problems but can be encouraged

and supported by government. Sharing experiences of people who have used such services

and support e.g. through peer support and peer leadership will have an important

contribution to make in achieving these changes in attitudes.

In recent years recovery has become part of the landscape and language of mental health

services across all sectors. Awareness, understanding and acceptance of recovery have

increased greatly and practices are changing. However it is clear that the unique and holistic

nature of personal recovery can often present challenges to those seeking to operationalise

it in terms of organisational systems and practices.

SRN has a track record of working with services to look at how they can become more

recovery focused; develop and implement peer working roles and improve training and

development of practitioners. We developed SRI 2 (Scottish Recovery Indicator); a self-

assessment, service development tool to help translate recovery principles into practice.

Since its launch in 2011, over 400 services, mostly within the NHS, have completed an SRI 2

and produced an action plan. This demonstrates the high level of enthusiasm for, and

commitment to, recovery. However, it is also clear that mental health services still tend to

be deficit rather than strengths based and that this sets the tone for the relationship

between practitioners and people using services.

Our analysis of action plans produced by services that have completed an SRI 2 suggests that

many services are still struggling to operationalise ways of working that are person-centred,

strengths based and support people to become more connected and more involved in

managing their own mental health and wellbeing.

http://www.sri2.net/


The recent report from the Mental Welfare Commission for Scotland on the experience of

people living in the community with severe and enduring mental illness reached similar

conclusions and in particular highlighted the need for services to do more to support social

inclusion, self -management and advance planning for people living with mental health

problems.

This highlights the need for continued work to develop recovery approaches in existing

mental health services and for statutory services to be more open to learning from the

voluntary sector.

Improving the physical health of people

We welcome the focus on improving the physical health of people living with significant and

long-term mental health problems. This is a complex area and requires us to consider not

only lifestyle issues but the impacts of long term prescribing of mental health medications.

Realise the human rights of people with mental health problems

We support the adoption of a rights based approach to mental health and mental health

services in Scotland. SRN has worked with a range of partners including, Mental Health

Network (Greater Glasgow), Scottish Human Rights Commission, Scottish Independent

Advocacy Alliance, See Me and Voices Of eXperience to develop a Rights for Life

Declaration. This declaration was published in early 2016 following extensive consultation

with people with experience of mental health issues and family and friends who care for

them.

The report by the Mental Welfare Commission and Scottish Human Rights Commission on

progress towards meeting the commitment in the last strategy recommended that Scottish

Government use a human rights framework to shape its priorities. It also suggested that this

should be informed by the lived experience of people using mental health services. It is

important that this is not defined narrowly in relation to mental health legislation but that

we look at all aspects of a human rights approach in legislation, policy and in how services

are designed and delivered.


Question 2

The table in Annex A sets out a number of early actions that we think will support improvements for mental health. Are there any other actions that you think we need to take to improve mental health in Scotland? The framework and priorities set out in the document seem to indicate that a whole

population or health improvement approach is being taken but this is not reflected in the

action plan. We are concerned that the early actions proposed concentrate on mental

health services- particularly NHS services- when what is needed is a much wider approach.

The significant role of the third sector in mental health services and support is not reflected

in the proposed actions. We do not believe that the actions proposed will, in themselves, be

sufficient to achieve the transformation of mental health in Scotland as envisaged in the 10

year vision.

We have some suggestions for other actions which we believe would contribute to the

transformation desired.

Priority 1 Focus on prevention and early intervention for pregnant women and new

mothers

The actions proposed are overly focused on acute clinical services. We believe that there is a

need to develop approaches which build on the important role of front line staff e.g. health

visitors, working with pregnant women and new mothers and to develop approaches which

include a focus on peer support.

Priority 2 Focus on prevention and early intervention for infants, children and young

people

Prevention and investment in young people will bring longer term financial benefits both to

society and to individuals. On the other hand simply doing more of the same will not

provide better outcomes and will not be sustainable in the longer term.

It is not clear if these actions refer to CAMHS or more widely. We believe that there is a

need to clarify the particular role of CAMHS and to build on the work of voluntary

organisations working in mental health and/or with children, young people and families to

develop programmes which provide the support people need when they need it without

having to use CAMHS services. This will include investing in good quality services and

supports in the community and working with primary care services, schools and other


educational organisations to ensure that there is more than one referral route for children,

young people and families seeking help.

As a means to develop prevention and early intervention approaches we would suggest

investing in and developing early intervention in psychosis services extended beyond

Glasgow and Edinburgh. We would also suggest learning from international experience and

evidence of emerging models e.g. Open Dialogue (Parachute Project, New York and England)

as well as Respite/Recovery Houses that are community based and peer led.

Priority 3 Introduce new models of supporting mental health in primary care

This is an area where there is potential for transformation which will have a positive impact

on the experiences and outcomes of people of all ages.

We would suggest that the new models developed should seek to transform the culture of

mental health services and the way that people interact with them. There is also a need to

change how people are supported by adopting more strengths based and person-centred

ways of working within primary health care services.

One way to achieve this is to diversify the expertise among the staff team by significantly

increasing the number of peer worker roles in services. There is a growing and positive body

of evidence of the benefits of peer working roles in services (Iriss Insight 31 Peer Support

Roles in Services). There is potential for an increase in peer roles in community based

mental health services and also in new models of supporting mental health in primary care.

There is also a need to look beyond primary care and look at ways to rebalance the use of

resources in mental health towards community based support. The success of new models

in primary care will be dependent on the availability of a wide range of services and

supports in the community. However current financial pressures are putting this in danger.

Priority 4 Support people to manage their own mental health

We welcome the recognition of the role of peer support workers and community links

workers in supporting self-management. However, our experience suggests that people

need more than information and tools. Our experience of promoting and supporting self-

management in mental health has highlighted the importance of approaches which bring

people with shared experience together. Information and signposting are not, in

themselves, an effective way of promoting self-management that produces long term,

sustainable outcomes.

http://www.iriss.org.uk/sites/default/files/insights-31-interactive.pdf

http://www.iriss.org.uk/sites/default/files/insights-31-interactive.pdf


We would suggest that there is a need for an increased focus on and investment in peer led,

group based approaches to supporting self-management in local communities. This means

supporting the development of peer support groups and activities. Peer support workers

would be ideally placed to undertake this role. There is much activity in this area but it is

fragile and lacks co-ordination due to a lack of investment and a preference in NHS mental

health services for professional led, one to one, approaches to providing self- management

support.

Priority 5 Improve access to mental health services and make them more efficient,

effective and safe

It is not clear how the proposed actions will contribute to meeting this priority. The actions

are overly focused on NHS services and it is unlikely that they will be able to meet the level

and nature of demand for support. While the level of demand for services is reducing access

and resulting in increased barriers to support the services are not necessarily designed to

address the type of demand being experienced. We need to develop new approaches which

can support people whose mental health problems are rooted in trauma and who find it

difficult to access services driven by medical diagnosis.

Other actions which should be considered is the development of new approaches to crisis

and respite services where people can access a safe space in a non-medical environment to

prevent a mental health crisis and possible hospital admission.

We have concerns about the narrow focus on cognitive behavioural therapy (CBT) and

would suggest that we seek to provide a wider choice for people seeking psychological

therapies. While there is a role for using technology to reach people and increase access to

services we must be mindful of the importance of connections and relationships to people

living with mental health problems and the role that these play in supporting recovery.

Priority 6 Improve the physical health of people with significant and long term mental

health problems to address premature mortality

We know that outdoor, environmental and conservation activities are very popular and can

be transformative for people living with long term mental health problems. We would

suggest that work to assess the physical and mental health impacts of this type of activity be

undertaken.

There is also considerable evidence that participation in cultural and community based

social activities can help improve people’s mental health and wellbeing. The benefits of

participating in these types of activities should be given wider recognition and be actively

promoted and supported by the Scottish Government.


Priority 7 Focus on ‘All of Me’: Ensure parity between mental and physical health

We welcome the commitment to parity between mental and physical health. However, this

needs to be about more than just financial resources. Simply spending more money on NHS

based mental health services will not produce the transformative change that is necessary

to address Scotland’s mental health problems. There also needs to be a parity of esteem

between physical and mental health, continued efforts to challenge stigma and

discrimination and a recognition of the contribution that can be made to improving mental

health and wellbeing by all parts of government and across all sectors, including the third

sector and community led organisations.

We also welcome that reference is made to the role of employment and social security

programmes in improving mental health and wellbeing and supporting recovery.

Whilst employment can be a positive for many the implementation of welfare reform has

undoubtedly adversely affected many people’s mental health and wellbeing and also

increased concerns and anxieties around the promotion of recovery. It is essential that the

Scottish Government works with the mental health sector to ensure that the experiences of

people living with mental health problems inform the design and delivery of employment

and welfare programmes.

We also welcome the recognition of the role of SRN in promoting and supporting recovery.

However, we believe that this is not only our role but is one for all parties including Scottish

Government. While recovery is now more accepted and has moved from the edges to the

mainstream of our mental health discussion there is still much to be done to translate this

into changed attitudes, behaviours and practices in services and communities.

A commitment to recovery needs to be clear in all policy areas and not just in mental health

services in their narrowest sense. This commitment also needs to be translated into

practice that result in more recovery focused ways of working. We look forward to working

with Scottish Government to develop this further.

Priority 8 Realise the human rights of people with mental health problems

We would suggest that the work of See Me and SRN may fit better within this priority than

the previous one.

The actions set out will not contribute to the embedding of a human rights based approach

in mental health as they are focused only one specific aspect – the legislative framework.

Within this focus we would suggest that there is a need to review all mental health


legislation not just that concerned with incapacity to see how we can ensure that it is fit for

purpose and promotes and supports people’s rights.

Human rights is about more than legislation. It is about awareness and acceptance of rights

and being able to exercise them. There is also a need for actions to improve the way people

with lived experience of mental health problems are effectively involved in a long term

dialogue about mental health strategy and the design and delivery of the mental health

system of the future.

To achieve transformational change in services we would suggest that we need to build on

the investment in peer support worker roles. One way to achieve this would be to promote

opportunities for peer leadership within mental health services to ensure the experience

and expertise of people with lived experience is brought centre-stage and moves beyond

involvement and participation to true co-production by including paid employment

throughout the sector within governance, planning, research, education.

Question 3

The table in Annex A sets out some of the results we expect to see. What do you want mental health services in Scotland to look like in 10 years’ time? The results set out in Annex A give some indication of the vision for mental health services in 10 years’ time. However given the narrow focus of the actions they do not necessarily articulate a vision for a mentally health Scotland and the services and supports needed to achieve this. Our vision for mental health services and support in 10 years’ time would be:

People have access to an appropriate choice of services and supports in the community which support them to lead their recovery and manage their wellbeing;

People do not feel discriminated against by services and in the community as a result of their mental health problems;

There is an increased emphasis on the social and economic determinants of poor mental health and a need to address inequalities in both mental and physical health.

Access to services and supports is not based on medical diagnosis but on need and people can get the help they need when they need and for as long as they need it;

Lived experience is at the centre of the design and delivery of our services and people living with mental health problems are part of the solution;


The rights of people living with mental health problems are not only enshrined in legislation but are the basis upon which services are designed and delivered;

The concepts of solution focused approaches, strengths based practice, building on

existing resilience and appreciative inquiry are accepted practice and inform the way

we all work with people experiencing mental health problems;

We have the courage to stop doing things that do not promote and support recovery and use the resources available to develop and implement new approaches;

mental health in scotland a 10 year vision consultation ......srn: mental health in scotland – a...

Documents