Adult Secondary Mental Health Services: Quality Standards Consultation

SOCIAL WORK SCOTLAND RESPONSE

INTRODUCTION

Social Work Scotland is the professional body for social work leaders, working closely with
our partners to shape policy and practice, and improve the quality and experience of social
services. We welcome this opportunity to comment on the consultation to inform the Adult
Secondary Mental Health Services – quality standards.

The social work workforce landscape is vast, with workers in adult’s services, children and
families’ services, and Justice services assessing for and delivering services to people with
learning disabilities, those with mental health challenges, and those who have experienced
trauma or the impact of substance use, to name but a few areas. Individuals may live in their
own homes, in care home settings, in the case of children, in kinship or foster care settings,
and in Justice, custodial settings. In all of these settings and with all of the service user
groups, social workers, and their colleagues employed in social work settings are heavily
involved in delivering support and services in relation to promoting good mental health. In a
mental health service context, social workers work in, and manage, Community Mental
Health Teams (CMHT), hospital based services, and having undertaken the MHO
Postgraduate Award, can practice as Mental Health Officers – the only profession able to
hold this role.

It is with this lens that Social Work Scotland provides a response to the consultation.

CONSULTATION QUESTIONS

Part 1: Questions On All Of The Standards

1. How far do you agree that the standards will improve the experiences of people
using secondary mental health services?

Disagree

2. How far do you agree that the standards will improve the outcomes of people using
secondary mental health services?

Disagree

3. How far do you agree that the standards clearly set out to individuals, their families
and carers what they can expect from a secondary mental health service?

Disagree

4. We know that currently not everyone has the same experiences or outcomes when
they engage with mental health services. We want these standards to help make sure
that services meet everyone’s needs whoever you are and whatever your background.
How far do you agree that the standards will help do this?

Disagree

5. Do you have any suggestions for how the standards could go further to help ensure
that services meet everyone’s needs regardless of who they are or their background?

The drive for national standards must be tempered with the requirement to meet local need
within the context of demographics, geography and resources. The standard achievable in
large cities might be different to the standard achievable in Rural or Island populations. It is
important to note that how services are delivered might legitimately be different. This should
not be construed as a “postcode lottery” but legitimate difference due to differing
demographics, culture and delivery landscape (both literally and figuratively).

Taking account of the mental health needs of individuals in custody is important, being
preventative where possible. Prison should simply be regarded as a different community with
the same services available. Anticipatory mental health care would be advantageous as
often individuals neglect their mental health in custody.

6. Are there any other areas of mental health services in which you think these
standards could apply outside of adult secondary services? If so, which services?

See Q7 response

7. Please share with us any of your thinking on your answers above and give us your
views on the standards overall.

As noted in the Social Work Scotland submission to the Scottish Government consultation
on the Service Specification for the delivery of Psychological Therapies, without a baseline
assessment to provide evidence for understanding people’s experience of access,
assessment, transition etc., it is difficult to say whether the service standards will provide
improvement. However, we would note our support for clear and concise information that
supports an understanding of standard expectations of service delivery by individuals
accessing services, and those working within them.

We take the opportunity to emphasise the importance of a “read across” to other policy
areas and the multiple Standards and specifications that are in development by Scottish
Government across adult health, social work and social care service design and delivery
(Care of older people in hospital, psychological therapies, substance use, etc.).

We highlight the existence of the Health and Social Care Standards, and query the need for
an additional set of Standards. This approach of developing multiple versions of service
standards undermines the Scottish Government’s stated commitment of utilising a “whole
system approach” for service design and delivery, and introduces siloed approaches and
stigmatisation of people with certain characteristics. In addition, it does not support
transition across services (both children to adult’s services, and between adult’s services
e.g. mental health and older people’s services) and creates extra confusion and additional
bureaucracy for individuals working within the system.

In June 2022, Social Work Scotland published our report “Setting the Bar” which sought to
establish an evidence-based indicative caseload limit for social work staff in Scotland. In
actuality, the research provided evidence far beyond its original remit and gave a clear
illustration of the commitment and perseverance of social workers, working within an
increasingly complex system, with ever increasing administrative demands that, at best,
evidence small parts of their overall duties and responsibilities as Social Workers, and at
worst, reduces relationship based engagement, arguably the core element of good
outcomes in Mental Health, to a task based function.

The response to the call for evidence was much bigger than anticipated, with over 1500
people employed as Social Workers or within a social work context providing a response to
our initial survey. The messages that came from the report were clear and consistent; social
workers and those working in social work teams are overburdened with administrative tasks,
casework has become more complex, and yet the size of the workforce has remained static.
Social work departments are facing significant challenges due to a combination of
unprecedented financial pressures and the cost of implementing several new pieces of
legislation simultaneously.

Social work and social care are currently experiencing a crisis in terms of recruitment and
retention, this is borne out in discussions around the lack of available community supports
for people leaving hospital and in the fact that, 53% of councils reported shortages of social
workers and 28% of councils reported shortages of mental health officers in 2021 resulting in
higher caseloads for colleagues and less opportunity to deliver relationship-based, personcentred support. Whilst it is understandable that Scottish Government would wish to be
aspirational in its approach to delivering services for people with challenges associated with
poor metal health and wellbeing, it is necessary to be realistic regarding the deliverability of
services and resources. Consideration must be given to where additional resource is
required in order for the standards to be achieved.

Part 2: Access Questions

8. How far do you agree that the standards within this theme will improve the
experiences of people using secondary mental health services?

Disagree

9. How far do you agree that the standards within this theme will improve the
outcomes of people using secondary mental health services?

Disagree

10. How far do you agree that the standards within this theme clearly set out to
individuals, their families and carers what they can expect from a secondary mental
health service?

Disagree

11. Do you think there is anything missing from the Access standards?

See Q14 response

12. We know that currently not everyone has the same experiences or outcomes when
they engage with mental health services. We want these standards to help make sure
that services meet everyone’s needs whoever you are and whatever your background.
How far do you agree that the Access standards will help do this?

Disagree

13. Do you have any suggestions for how the Access standards could go further to
help ensure that services meet everyone’s needs?

See Q14 response

14. Please share with us any of your thinking on your answers above and your views
on Access standards overall.

As noted in the Social Work Scotland submission to the Scottish Government consultation
on the service specification for the delivery of psychological therapies, we would highlight
our support for clear and concise information to support an understanding of standard
expectations of service delivery by individuals accessing services, and those working within
them. This is in line with other developments such as the Health and Social Care Standards, and The Quality Principles: Standard Expectations of Care and Support in Drug and Alcohol Services (recently updated by the Medication Assisted Treatment (MAT)
Standards.

However, the existence of Standards alone is unlikely to be responsible for an improvement
in the outcomes of people accessing and using secondary mental health services.
Improvement in outcomes is deeply subjective but can be reasonably associated with social
connections; housing circumstances and the cost of living impact for most individuals.
Coupled with this, from a service perspective, appropriate levels of resource, including
workforce, and community assets, is required to support individuals to achieve their
outcomes.

Part 3: Assessment, Care Planning, Treatment and Support Questions

15. How far do you agree that the standards within this theme will improve the
experiences of people using secondary mental health services?

Disagree

16. How far do you agree that the standards within this theme will improve the
outcomes of people using secondary mental health services?

Disagree

17. How far do you agree that the standards within this theme clearly set out to
individuals, their families and carers what they can expect from a secondary mental
health service?

Neither Agree or Disagree

18. Do you think there is anything missing from Assessment, Care Planning,
Treatment and Support standards?

The Standards would benefit from an explicit link to the Equality Act 2010.

19. We know that currently not everyone has the same experiences or outcomes when
they engage with mental health services. We want these standards to help make sure
that services meet everyone’s needs whoever you are and whatever your background.
How far do you agree that the Assessment, Care Planning, Treatment and Support
standards will help do this?

Disagree

20. Do you have any suggestions for how the Assessment, Care Planning, Treatment
and Support standards could go further to help ensure that services meet everyone’s
needs

See Q21 response

21. Please share with us any of your thinking on your answers above and your views
on Assessment, Care Planning, Treatment and Support standards overall.

As noted in the Social work Scotland submission to the Scottish Government consultation on
the service specification for the delivery of psychological therapies, we would indicate our
support for clear and concise information to support an understanding of standard
expectations of service delivery by individuals accessing services, and those working within
them. This is in line with other developments such as the Health and Social Care Standards, and The Quality Principles: Standard Expectations of Care and Support in Drug and Alcohol Services (recently updated by the Medication Assisted Treatment (MAT) Standards.

However, the existence of Standards alone is unlikely to be responsible for an improvement
in the outcomes of people accessing and using secondary mental health services.
Improvement in outcomes is deeply subjective but can be reasonably associated with social
connections; housing circumstances and the cost of living impact for most individuals.
Coupled with this, from a service perspective, appropriate levels of resource, including
workforce, and community assets, is required to support individuals to achieve their
outcomes.

Part 4: Moving between and out of services Questions

22. How far do you agree that the standards within this theme will improve the
experiences of people using secondary mental health services?

Disagree

23. How far do you agree that the standards within this theme will improve the
outcomes of people using secondary mental health services?

Disagree

24. How far do you agree that the standards within this theme clearly set out to
individuals, their families and carers what they can expect from a secondary mental
health service?

Neither Agree or Disagree

25. Do you think there is anything missing from the Moving between and Out of
Services standards?

See Q29 response

26. We know that currently not everyone has the same experiences or outcomes when
they engage with mental health services. We want these standards to help make sure
that services meet everyone’s needs whoever you are and whatever your background.
How far do you agree that the Moving between and out of services standards will help
do this?

Neither Agree or Disagree

27. Do you have any suggestions for how the Moving between and out of services
standards could go further to help ensure that services meet everyone’s needs?

See Q29 response

28. We know that substance use and mental health difficulties can be co-occurring.
We want to ensure that people with both a mental wellbeing concern and substance
use receive access to treatment that is tailored to their needs. How far do you agree
that we should include a specific standard on support for those with substance use
issues within these standards?

Agree

29. What should a standard around substance use contain?

As noted elsewhere, the implementation of the ten Medication Assisted Treatment (MAT) Standards is underway with MAT standard 9 specifically referring to “All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery”. Integration Authorities are responsible for developing MAT implementation
plan and this will be monitored and reported on by Alcohol and Drug Partnerships. Across
Scotland, most Health & Social Care Partnerships have Integrated Drug and Alcohol
Recovery Teams which are most often multidisciplinary; comprising of doctors (both
speciality and psychiatrists), psychologists, nurses, social workers, support workers and
peer support workers who will often refer to community mental health teams and other
community resources. A read across the MAT Standards by substance use and mental
health services respectively would support multidisciplinary approaches and a holistic
understanding of how best to support an individual.

In addition to the MAT Standards, which are related to drug use, and specifically, opiate use,
it is imperative that an equal lens is used in the consideration of support for people with
affected by problem alcohol use and other drugs. To this end, a read across the Quality
Principles: Standard Expectations of Care and Support in Drug and Alcohol Services
is essential.

Social Work Scotland concurs with CoSLA that any substance use standard included within
the secondary Mental Health quality standards, should reflect a person-centred, trauma
informed approach while also considering the impact of stigma on accessing treatment. The
Cross Government Action Plan on drug deaths recognises, and aims to address, stigma as a
barrier preventing access to treatment. As there is long-standing research on the impact
stigma has on those with mental health conditions, it would be beneficial to include a
standard aiming to tackle this.

30. Please share with us any of your thinking on your answers above and your views
on the Moving between and Out of Services standards overall.

There is significant read across between this section and the Health and Social Care
Standards – For example;

1.14 My future care and support needs are anticipated as part of my assessment.

1.15 My personal plan (sometimes referred to as a care plan) is right for me because it sets
out how my needs will be met, as well as my wishes and choices.

2.17 I am fully involved in developing and reviewing my personal plan, which is always
available to me

2.20 If I need or want to move on and start using another service, I will be fully involved in
this decision and properly supported throughout this change

3.4 I am confident that the right people are fully informed about my past, including my health
and care experience, and any impact this has on me

4.12 I receive proper notice and I am involved in finding an alternative if the service I use
plans to close or can no longer meet my needs and wishes.

4.13 I have enough time and support to plan any move to a new service

4.17 If I am supported and cared for by a team or more than one organisation, this is well co-ordinated so that I experience consistency and continuity.

4.18 I benefit from different organisations working together and sharing information about me
promptly where appropriate, and I understand how my privacy and confidentiality are
respected

It would be reasonable and useful, therefore, if further Standards are to be developed, to
use the Health & Social Care Standards as the Framework for understanding any other area
specific Standard or Specification. We note that this model is referenced within the
consultation document and offer our endorsement for this approach – should further
Standards be felt necessary.

Part 5: Workforce Questions

31. How far do you agree that the standards within this theme will improve the
experiences of people using secondary mental health services?

Neither Agree or Disagree

32. How far do you agree that the standards within this theme will improve the
outcomes of people using secondary mental health services?

Neither Agree or Disagree

33. How far do you agree that the standards within this theme clearly set out to
individuals, their families and carers what they can expect from a secondary mental
health service?

Neither Agree or Disagree

34. Do you think there is anything missing from the Workforce standards?

See Q37 response

35. We know that currently not everyone has the same experiences or outcomes when
they engage with mental health services. We want these standards to help make sure
that services meet everyone’s needs whoever you are and whatever your background.
How far do you agree that the Workforce standards will help do this?

Neither Agree or Disagree

36. Do you have any suggestions for how the Workforce standards could go further to
help ensure that services meet everyone’s needs?

See Q37 response

37. Please share with us any of your thinking on your answers above and your views
on Workforce standards overall.

Once again, there is significant overlap between these proposed Standards and the existing
Health and Social Care Standards. In addition to this, there is significant overlap with the
Safe Staffing Act 2016, which places a statutory duty on care service providers to ensure
that, at all times, suitably qualified and competent individuals are working in such numbers
as are appropriate for the health, wellbeing and safety of people using the service, and the
provision of safe and high-quality care and in so far as it affects those matters the wellbeing
of staff.

Part 6: Governance and Accountability Questions

38. How far do you agree that the standards within this theme will improve the
experiences of people using secondary mental health services?

Neither Agree or Disagree

39. How far do you agree that the standards within this theme will improve the
outcomes of people using secondary mental health services?

Neither Agree or Disagree

40. How far do you agree that the standards within this theme clearly set out to
individuals, their families and carers what they can expect from a secondary mental
health service?

Neither Agree or Disagree

41. Do you think there is anything missing from the Governance and Accountability
standards?

See Q44 response

42. We know that currently not everyone has the same experiences or outcomes when
they engage with mental health services. We want these standards to help make sure
that services meet everyone’s needs whoever you are and whatever your background.
How far do you agree that the Governance And Accountability standards will help do
this?

Neither Agree or Disagree

43. Do you have any suggestions for how the Governance And Accountability
standards could go further to help ensure that services meet everyone’s needs?

See Q44 response

44. Please share with us any of your thinking on your answers above and your views
on Governance and Accountability standards overall.

There is significant read across between this section and the Health and Social Care
Standards – For example;

2.3 I am supported to understand and uphold my rights.

2.4 I am supported to use independent advocacy if I want or need this

2.11 My views will always be sought and my choices respected, including when I have
reduced capacity to fully make my own decisions.

4.1 My human rights are central to the organisations that support and care for me.

4.2 The organisations that support and care for me help tackle health and social inequalities

4.3 I experience care and support where all people are respected and valued.

4.4 I receive an apology if things go wrong with my care and support or my human rights are
not respected, and the organisation takes responsibility for its actions

4.8 I am supported to give regular feedback on how I experience my care and support and
the organisation uses learning from this to improve.

4.20 I know how, and can be helped, to make a complaint or raise a concern about my care
and support.

4.21 If I have a concern or complaint, this will be discussed with me and acted on without
negative consequences for me.

Arguably, the health and social care standards go a step further by promoting the co-design
of services with people who use them. It would be reasonable and useful, therefore, if
further Standards are to be developed, to use the Health & Social Care Standards as the
Framework for understanding any other area specific Standard or Specification.

Part 7: Implementation and Measurement

Implementation Question

45. Overall, what support do you think services will need to implement the standards?

Social Work Scotland welcomes the reflection within the consultation document to other
Scottish Government led policy and strategic initiatives such as the Health and Social Care
Standards, though we are of the opinion that this could have been much more robust and
reflective of the scale of work being undertaken to develop Standards in Older Peoples
Hospital Care, the Care Home Framework, the ongoing work of the MAT Standards, and the
in place Quality Principles: Standard Expectation of drug & alcohol services. In seeking to
implement the Standards across multiple workforces, it is important to first understand the
landscape in which they are practicing.

To effectively change and improve services, the drafting of legislation, policy and guidance
alone is not enough. To truly create change and embed it within practice, implementation
requires to be carefully planned and managed, and given similar level of attention.

Implementation Science facilitates the identification of the key components necessary to
develop and improve the ability to implement innovations in practice, as well as how to
create an enabling context for the new ways of working to be sustainable. It posits that
skills-based training is essential, and that this must be supported by a coaching approach.
From a social work perspective, this is best supported by good quality professional
supervision.

If the aim is consistent national delivery as outlined – then training, and refresher training
which is timely and trauma informed is essential, as is the monitoring of standards to ensure
that there is consistency of delivery across the country. In addition, consideration should be
given to the fact that the physical venues should be psychologically informed environments
(PIE) which is conducive to the complexity of the work. This is particularly relevant to those
living and working in custodial settings. For children, consideration of child friendly and
trauma informed environments based on sound evidence – such as that underpinning the
Barnahus model – is critical.

The drive for national service specifications and standards must be tempered with a
requirement to meet local need within the context of demographics, geography and
resources. The standard achievable in large cities might be different to the standard
achievable in Rural or Island populations. It is important to note that how services are
delivered might legitimately be different. This should not be construed as a “postcode lottery”
but legitimate difference due to differing demographics, culture and delivery landscape (both
literally and figuratively).

Measurement Questions

46. How far do you agree that some of the standards should be measured using a
validated self-assessment tool?

Neither Agree or Disagree

Please explain the thinking behind your choice.

Self-assessment tools can inform a useful part of an inspection process, alongside context
gathered from engagement with service users and key partners. We would not see an
annual self-assessment as a useful tool out with this wider context of inspection activity.
Further to this, the social work profession are a regulated profession through the SSSC, who
register the workforce and are responsible for their training, and services delivered by the
social service workforce are regulated by the Care Inspectorate. Any self-assessment tool
used to determine the effectiveness of practice would need to be developed and agreed with
the Care Inspectorate and embedded as part of its inspection activity to ensure its relayed
meaningful activity that aligned with current inspection activity. Setting a self-assessment
tool with an annual return expectation would require to feed into ongoing improvement
activity to ensure it was meaningful and able to be used effectively to embed a high standard
of practice. The detail provided in this consultation thus far does not suggest that a wider
read across other improvement activity and practices has occurred, so in that respect this
may not have the designed effect anticipated if not connected into wider improvement
activity.