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Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011

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2. ACTION PLAN

PRIORITY 1: MENTALLY HEALTHY INFANTS, CHILDREN AND YOUNG PEOPLE

Our early years play a large role in determining our mental health for life. A mentally healthy child is one with a clear sense of identity and self-worth, the ability to recognise and manage emotions, to learn, play, enjoy friendships and relationships, and deal with difficulties. A wide range of interrelated factors play a role, such as individual, family, wider society and environmental issues.

Scotland's Chief Medical Officer explained the connection between early years and a range of physical and mental health outcomes in his 2006 Annual Report. Particular emphasis was given to the importance of pregnancy and parenting in defining health outcomes. Exposure to high levels of parental stress, neglect and abuse can have a severe effect on brain development. There are clear differences between the development of children in these situations and those in less stressful households.

This informed the priorities and actions outlined in the Early Years Framework under which the Scottish Government and COSLA have already committed to:

  • promote positive mental health through a social marketing campaign which promotes the value of parenting and parenting skills;
  • move to a parenting model of ante-natal and post-natal support that will promote parenting skills and attachment;
  • build the capacity of universal services to meet additional needs through mental health training for front line professionals;
  • include skills that promote positive mental health within the planned review of training and continuing professional development needs for early years workers;
  • support relationships between parents and children as part of the work we are proposing on workforce values.

To support this planned work the Scottish Government and NHS Health Scotland will take forward work to support delivery focused on mental health improvement, as follows:

Commitment 1: The Scottish Government will work with partners and existing networks to develop by 2010 a web portal on mental health improvement for those working with infants, children and young people.

Commitment 2: Promoting Well-being and Meeting the Mental Health Needs of Children and Young People: A Development Framework for Communities, Agencies and Specialists involved in Supporting Children, Young People and their Families outlines the competencies needed for mental health improvement work with children and young people. We will build on this work and focus on infant mental health improvement. NHS Health Scotland will work with partners to improve the skills and knowledge of front-line staff with a particular focus on inequalities.

Commitment 3: There are many effective interventions for mental health improvement among infants, children and young people; however, many of these are not in general use. NHS Health Scotland will initiate a programme in 2009 to disseminate the evidence base for mental health improvement and support its use through practitioner briefings and narratives to present the case to decision makers and planners.

We are continuing to implement The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care. These actions are consistent with and will support that work.

We are also developing a national health improvement social marketing campaign aimed at young people. Mental health improvement will constitute both an underpinning element and a discrete strand in this work.

In order to assess and monitor future trends, we need to develop a national picture of mental wellbeing and mental health problems among infants, children and young people in Scotland.

Commitment 4: NHS Health Scotland will work with key stakeholders to develop a set of national indicators for children and young people's mental wellbeing, mental health problems and related contextual factors by 2011.


In addition to these particular commitments we will continue to offer the following support:

  • Learning and Teaching Scotland will host a Mental Health and Emotional Wellbeing post to facilitate mental health improvement in schools by supporting the implementation of Curriculum for Excellence and the Schools (Health Promotion and Nutrition) (Scotland) Act 2007 within the context of Integrated Children's Services planning.
  • Young Scotland in Mind will continue to support the voluntary sector in promoting mental wellbeing, preventing mental health problems and supporting those experiencing mental health problems, with a particular focus on inequalities.

Good early years and school education is a basis for lifelong learning. Not all students are young people, but we know that mental health problems can significantly disrupt the educational and emotional development and physical health of students.

In our work on reducing the prevalence of suicide, self-harm and common mental health problems and improving the quality of life of those experiencing mental health problems and mental illness we will ensure that the particular needs of infants, children and young people are recognised and that appropriate approaches and services are in place.

The Scottish Further Education Unit provides national support to Scotland's colleges and their stakeholders and supports mental health improvement through the professional development of staff and by providing guidance and other resources. Partnership Matters offers guidance to those involved in the decision-making process in relation to students with additional needs, whether they are young people or adults, and how they are supported in Scotland's colleges. Revised guidance, extended to the university sector, will be launched shortly.

Commitment 5: The National Union of Students represents students in most of Scotland's universities and works in partnership with the Scottish Further Education Unit. NUS Scotland will deliver a three-year project aimed at long-term gains in mental health improvement practices.


We will also work with Universities Scotland to advance work on mental health improvement.

PRIORITY 2: MENTALLY HEALTHY LATER LIFE

35% of Scotland's population are 50 years old or more and this proportion will increase in the coming years. Older people play a crucial role in life in modern Scotland and the Scottish Government is committed to empowering older people to live healthy, active and independent lives. All Our Futures: Planning for a Scotland with an Ageing Population outlines the opportunities and choices available to people as they get older. Promoting mental health and well-being in later life, the 2006 UK Inquiry by Age Concern and Mental Health Foundation into Mental Health and Well-being in Later Life, identified five key thematic areas for mental health improvement - tackling discrimination, supporting participation in meaningful activity, supporting positive relationships, improving physical health and tackling poverty.

Commitment 6: The Scottish Government will address mental health improvement in later life through the creation of a national group (hosted by NHS Health Scotland) which will produce an action plan in response to All Our Futures and the UK Inquiry by 2010.




Improving the treatment and care for those who suffer from dementia as well as improving support to carers is an established national priority of the Scottish Government. Mental health improvement has a contribution to make to this work, both generally and specifically through improving the awareness and education of both health and social care staff and the general public.

Commitment 7: Working with see me..., the Scottish Government will pilot and evaluate awareness-raising approaches on dementia with a focus on encouraging people to seek early diagnosis. The pilot will take place in the first part of 2009 in Dundee and the outcomes will be reported to the National Dementia Forum.


Commitment 8: NHS Health Scotland will publish and disseminate new dementia resources Worried about your Memory? and Facing Dementia: how to live well with your diagnosis. Facing Dementia provides practical information for people who have recently been diagnosed with dementia. Worried about your Memory? is aimed at helping people who are concerned about their memory to decide whether they should see a doctor.


In our work on reducing the prevalence of suicide, self-harm and common mental health problems and improving the quality of life of those experiencing mental health problems we will ensure that the particular needs of older people are recognised and that appropriate approaches and services are in place.

PRIORITY 3: MENTALLY HEALTHY COMMUNITIES

Good mental wellbeing and reduced incidence of mental health problems is important for the healthy functioning of communities. They affect behaviour, social cohesion, social inclusion, crime and prosperity. Similarly, the quality of the physical environment, proper access to nature and green space and access to cultural experiences have an important role to play in shaping the mental state of individuals. Good community relations, civic engagement and local participation support both individuals' mental states and that of the community as a whole.

Most actions intended to promote and regenerate communities will also support the development of social capital and mental wellbeing. There are particular strands of work in place that will support this priority.

The quality of the physical environment (noise and light levels; the layout of buildings; access to escape facilities such as green space and community facilities; the design of buildings including good, secure housing; and transport systems) has an important role to play in mental health improvement.

Commitment 9: The Scottish Government is implementing Good Places, Better Health which will look at the relationship between the physical environment and children's health. It will concentrate on four child health priorities including mental health improvement, with the evidence being used to support policies and decision-making at national and local level. The work will be ongoing to March 2011.


Culture and the arts have significant value for mental health improvement. The Scottish Government will continue to work with the Scottish Arts Council and, when established, Creative Scotland, and others, to develop increased arts and mental health improvement opportunities and to promote increased access and participation. This will include support for the development of high quality artistic practice in the field of the arts in mental health improvement and development of the evidence base for this work.

Commitment 10: Culture and the arts can also support a range of local outcomes and the Scottish Government is collaborating with local government and other Community Planning and stakeholder interests in developing a toolkit to help Community Planning Partnerships to work with culture and creativity in delivering priority outcomes; this will include action in support of mental health improvement.


PRIORITY 4: MENTALLY HEALTHY EMPLOYMENT AND WORKING LIFE

Paid or unpaid employment or voluntary work is generally better for mental health than unemployment, but its value depends on both the work itself and culture and relations in the workplace. Good mental wellbeing and reduced levels of mental health problems and mental illness can make a substantial contribution to the economy, in terms of increased productivity and creativity and reduced sickness absence. The linkages between mental health and employment have been set out in the three documents Healthy Working Lives, Equally Well and Workforce Plus.

Employers have a legal duty of care to ensure that their employees' mental health is taken into account. A comprehensive and integrated approach to mentally healthy employment and working life should include promoting the mental wellbeing of all employees and preventing work-related causes of mental health problems. Good practice also requires retaining and supporting people in work when they develop or experience mental health problems and facilitating the return to work of people who currently have, or have experienced, mental health problems.

The Scottish Mental Health and Employment Network is committed to improving the mental health of Scotland's population and supporting the recovery of individuals who have experienced mental health problems in relation to employment. The Scottish Government provides support to the Network which aims to raise awareness and disseminate messages about the benefits of employment to mental health, including the role of health and local authorities in promoting best practice.

The Scottish Centre for Healthy Working Lives works to provide advice, information and training on good workplace practices and policies for mental health improvement. It works with partners to promote mentally healthy workplaces, with a specific focus on public sector workplaces and small- to medium-sized enterprises. It is working with the Mental Health Foundation to lead on the European Union public health programme 'Promoting good practice for mental health in the workplace'. It is also working with the Scottish Trades Union Congress and Scottish Development Centre for Mental Health to explore areas where trade unions can offer more practical and sensitive support and make sustainable changes to develop mentally healthy workplaces.

The Scottish Government will work with NHS Health Scotland and the Scottish Centre for Healthy Working Lives to develop an outcomes framework for health and work which will include mental health improvement.

Commitment 11: The Scottish Centre for Healthy Working Lives will work with partners to develop a comprehensive programme of work to promote mentally healthy workplaces, with a specific focus on public sector workplaces and small- to medium-sized enterprises.


Commitment 12: The Ministerial Task Force on Health Inequalities said in Equally Well that we need to do more to address the factors that lead to people losing work or remaining out of work as a result of poor health. The Scottish Government will undertake a review of the current Healthy Working Lives policy early in 2009 with increased emphasis on mental health improvement.


The Scottish Government, NHSScotland and local authorities are major employers and have a key role in promoting good employment practice that supports health and wellbeing. It is important that the public sector shows leadership and demonstrates the behaviours and cultures that we recommend to others. Increasingly we hear the idea of being an 'exemplar employer', but without a clear and common understanding about what that means in practice.

Commitment 13: The Scottish Government will take forward work to develop consensus on what it would mean to be an exemplar employer and agree standards and consider an implementation plan for public health bodies to achieve the standards.


PRIORITY 5: REDUCING THE PREVALENCE OF SUICIDE, SELF-HARM AND COMMON MENTAL HEALTH PROBLEMS

Reducing the Prevalence of Suicide

The suicide rate in Scotland has been reducing since 2001 but it is still higher than in other parts of the UK. In 2002, in its Action Plan to prevent suicide, Choose Life, the then Scottish Executive, established the target of reducing suicide by 20% by 2013. Suicide prevention continues to be a significant priority for Scotland and this target continues to be a long-term ambition for the Scottish Government. Delivery on this target will require action by all sectors.

There is a particular focus in the NHS on developing workforce knowledge and skills. The NHS is working with partners to:

reduce the suicide rate between 2002 and 2013 by 20%, supported by 50% of key front line staff in mental health and substance misuse services, primary care and accident and emergency being educated and trained in using suicide assessment tools/suicide prevention training programmes by 2010.

Choose Life set out a 10-year strategic framework and action plan which identified objectives and priority groups to improve the understanding of suicide and what can be done to prevent it. National implementation support for suicide prevention is now hosted by NHS Health Scotland who:

  • support local activity on suicide prevention;
  • mainstream suicide prevention training and support increased delivery of training;
  • co-ordinate short life working groups and guidance on key issues such as postvention;
  • support the media to improve the standard of reporting on suicide;
  • develop and improve data collection mechanisms for suicide information;
  • continue to collaborate with partners in the United Kingdom and elsewhere in developing knowledge and understanding.

The Choose Life strategy is now over six years old and an independent review published in 2006 identified areas where it should be developed further or reconsidered.

Commitment 14: The Scottish Government will take forward a further review of Choose Life in conjunction with key delivery partners, including NHS Health Scotland who have a lead responsibility for national implementation, and local government, who have a lead responsibility for local action. The review will be overseen by a National Suicide Prevention Reference Group with the work being completed by 2010. The work will be informed by an independent review of the second phase of implementation (2006-2008).


Data on people who have completed suicide or committed homicide and who had been in touch with mental health services in the previous year helps to develop recommendations for improved patient care. The Scottish Government will continue to fund the Scottish element of the UK Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The next five-year report is due in 2012.

We lack extensive information on suicides in Scotland. Consequently, we do not have a clear picture of all the key factors underlying suicides - information that may help prevent future suicides.

Commitment 15: Working with partners, NHS Health Scotland will develop a secure, confidential suicide register for Scotland by December 2009.


The Breathing Space telephone listening, advice and signposting service for people experiencing low mood or depression, complements and supports work on suicide prevention. The Scottish Government will continue to support this service, which is run by NHS 24.

Reducing the Prevalence of Self-harm

Self-harm is a response to underlying emotional and psychological distress, which can include feeling isolated, having a poor body image, academic pressures, powerlessness and abuse or trauma. Self-harm can include cutting, burning, scalding, banging heads and other body parts against walls, and hair-pulling, biting, and swallowing or inserting objects as well as self-poisoning. The full extent of self-harm is unknown, but more than 7,000 people are treated in hospital each year in Scotland following episodes of 'non-fatal deliberate self-harm'. Truth Hurts, the report of the UK National Inquiry into Self-harm among Young People, identified that a comprehensive approach to self-harm requires both a broad, generic focus on mental health improvement and behaviour specific information, training and intervention. The independent evaluation of Choose Life also recommended further development of responses to non-fatal aspects of self-harm.

Commitment 16: The Scottish Government will work with partners to improve the knowledge and understanding of self-harm and an appropriate response. In taking forward this work we will:


  • agree a definition of self-harm and develop a non-stigmatising language and description of self-harm;
  • increase awareness of self-harm and its determinants;
  • map and assess existing training provision and projects across Scotland;
  • increase our understanding of effective methods of prevention and offer guidance to those delivering both general and specific services;
  • develop local and national information.

Reducing the Prevalence of Common Mental Health Problems

Common mental health problems refer to those symptoms which can be regarded as extreme forms of 'normal' emotional experiences such as depression and anxiety. These problems are common in the population. For example, an estimated 1 in 5 of the population of Scotland will experience depression at some point in their lives and the World Health Organization ( WHO) predicts that depression will soon be the second biggest cause of illness worldwide. Those experiencing depression or anxiety often experience physical symptoms.

Similarly, common mental health problems are more frequent in patients with physical illness ( e.g. diabetes or cardiac problems) than in those without. The evidence base for reducing risk factors associated with depression and anxiety, and increasing protective factors, is developing. Effective interventions include the development of psychological or behavioural skills, prevention of discrimination and abuse and the promotion of better physical health.

The Scottish Government is continuing to take forward work to offer appropriate and timely access to treatment for depression and anxiety and is committed to a range of approaches that meet the different needs of patients, including increased access to psychological therapies, guided self-help, non-pharmacological interventions and prescription of medication. The voluntary sector also offers a range of counselling services to those requiring help with bereavement, trauma, abuse and relationships.

The Government is committed to increasing the availability of evidence-based psychological therapies for all age groups in a range of settings and through a range of providers. This work is being taken forward by NHS Boards with support from NHS Education for Scotland. In addition NHS 24 is piloting access to telephone-based cognitive behavioural therapy and self-help coaching in five board areas. The Scottish Government is also supporting a pilot programme which provides training for staff in supporting the use of the Living Life to the Full resources and this work is hosted by NHS Greater Glasgow and Clyde.

Commitment 17: During 2009 the Scottish Government will take forward work to develop referral criteria and information systems that would support the creation of access targets for psychological therapies.


In addition to patient-focused interventions there is a need to identify and engage those in the population who are at the greatest risk of mental health problems and illness.

Commitment 18: The Scottish Government will work with NHS Boards to implement the Equally Well recommendation that work to address depression, stress and anxiety is targeted in deprived communities, building on the action already being taken forward under the Keep Well programme (which is focused on anticipatory care) and the Living Better programme (which is focused on the mental health of those suffering from long-term conditions such as diabetes and chronic heart disease).


To address the co-morbidity of substance misuse and mental health problems and illness, Delivering for Mental Health made the commitment to translate the principles of Mind the Gap and A Fuller Life into practical actions. As a result, substance misuse staff identified as providing frontline services have been included in the NHS suicide prevention HEAT target.

The Scottish Government will continue to fund Depression Alliance Scotland, the national charity working with people affected by depression in Scotland to:

  • improve public understanding of depression and challenge stigma associated with it;
  • provide a national information and signposting service in Scotland working collaboratively with statutory and voluntary sector agencies;
  • promote positive mental health in Scotland by encouraging self-help, self-management and recovery;
  • initiate a discussion on a strategic approach to population approaches to preventing depression.

PRIORITY 6: IMPROVING THE QUALITY OF LIFE OF THOSE EXPERIENCING MENTAL HEALTH PROBLEMS AND MENTAL ILLNESS

Discrimination and Stigma

Those who suffer from mental health problems and mental illness are likely to experience discrimination and social exclusion because of stigma. The law prohibits discrimination and requires public bodies to act in a way that promotes the inclusion and fair treatment of those with mental illness. The Scottish Government tackles discrimination, stigma and social exclusion both through its general equalities and diversity work and through continuing support for the see me.... campaign. In the next two years see me.... will continue to:

  • deliver a social marketing campaign to improve public attitudes and behaviours towards those experiencing mental illness and their carers;
  • deliver specific social marketing campaigns that address inequality and multiple discrimination and stigma;
  • engage people with experience of mental illness and their carers in their work;
  • support the media to improve the standard of reporting on mental illness;
  • encourage the take-up of local anti-stigma initiatives and build local capacity.

Working for a Healthier Tomorrow shows that tackling stigma around ill-health and disability is central to enabling more people to find work and to stay in work.

Commitment 19: see me.... will develop a strategy for tackling stigma within public services and will work with public services, trade unions, employers' bodies and the media to raise the profile of mental health in respect of the Disability Discrimination Act.


The Mental Health Foundation is leading Scotland's contribution to the EU public health programme to address stigma in respect of depression and to develop a toolkit for tackling stigma in workplaces. They will explore, with the Scottish Centre for Healthy Working Lives and NHS Health Scotland, the development of an online mental health improvement awareness course for employers and employees that addresses stigma.

To ensure that equality and diversity considerations are considered and mainstreamed within work to advance mental health improvement in Scotland, we will ensure that any major initiatives funded under this policy, framework and implementation plan undertake and publish an Equality Impact Screen or Assessment. This assessment will include consideration of gender, religion, ethnicity, age, sexuality, disability and socio-economic status. Equality impact screens or assessments will be carried out and published by see me...., NHS Health Scotland, and the Scottish Recovery Network. An assessment was completed for Breathing Space in 2008.

The Scottish Government has funded NHS Health Scotland to host a national mental health and race equality programme since 2006. This programme works with stakeholders to explore experiences of recovery and develop work with black and minority ethnic communities to tackle stigma and improve services. Three local projects in NHS Lothian, NHS Greater Glasgow & Clyde and NHS Highland will explore how primary care mental health services can be better designed to meet the needs of these communities.

Social Inclusion

In 2007 the Scottish Government published With Inclusion in Mind which offers guidance to local authorities in respect of their duties to promote the social inclusion of people who have experienced mental illness in the way in which they deliver services. We will continue to offer financial support to this activity and will take forward further collaborative work with COSLA and other partners to develop this agenda.

Commitment 20: The Scottish Government will put in place a programme of support for local areas to implement With Inclusion in Mind.


We will also continue to support VOX (Voices of Experience) to ensure user involvement in service development and action focused on discrimination, stigma, social inclusion and recovery.

Employment is a key element of social inclusion for those with mental illness. The Scottish Government has taken forward the recommendations of the Scottish Parliament's Equal Opportunities Committee by creating a Supported Employment Task Group. This group is responsible for the creation of a disability-focused Supported Employment Framework for Scotland, including the establishment of a strategic plan and national standards. We will consider how this work can apply to mental illness.

The Employability Framework for Scotland, Workforce Plus, aims to help disadvantaged people back into work by harnessing the support of devolved policies and services and adding value to the UK Government's employment programmes. Workforce Plus aims to bring together partners to plan and deliver services in an efficient manner.

A UK Government Mental Health and Employment High-Level Steering Group has been established and the Scottish Government has established a reference group to develop a Scottish perspective to feed into this group. The Scottish Development Centre for Mental Health represents Scotland's interests on this group and aims to bring a Scottish perspective to the development of the UK Government Mental Health and Employment Strategy.

Physical Health

We know that those experiencing mental health problems and illness are at increased risk of poorer physical health including heart disease and diabetes and that this group has higher levels of smoking, alcohol consumption, drug misuse and reduced life expectancy.

In Delivering for Mental Health the Scottish Government made the commitment that:

"... by 2009 we will improve the physical health of those with severe and enduring mental illness by ensuring that every such patient, where possible and appropriate, has a physical health assessment at least once every 15 months."

The information that we receive from monitoring of the General Practice contract suggests that this is largely being achieved with health checks being offered and taken up. However, we know that further improvements can be made in terms of both uptake and the quality of the assessment. We have recently published further guidance with recommendations for implementation. In addition, Equally Well said that health improvement should be more proactive, better focused and better structured for those at greatest risk and in greatest need.

Commitment 21: NHS Health Scotland will review evidence-based approaches and develop health improvement information on smoking cessation, weight management and physical activity designed for people with mental health problems; and will work with NHS Education for Scotland to build knowledge and skills in the workforce.


Recovery

Recovery and the principles which underpin it have become increasingly important to the way we support mental health in Scotland. The Scottish Recovery Network describe recovery as follows:

"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."

Both the Mental Health Nursing Review and Delivering for Mental Health set out the Scottish Government's commitment to a recovery-based approach to mental illness. The Scottish Recovery Indicator is a tool designed to allow for an assessment of the degree to which local services have developed a recovery orientation.

Commitment 22: The Scottish Recovery Indicator will be available from end April 2009 and should be in use by the majority of mental health services by 2012. The Scottish Government will monitor its use.


The Scottish Government will continue to fund the Scottish Recovery Network ( SRN) to promote recovery-based service delivery and self-directed approaches to recovery, such as Wellness Recovery Action Planning. The SRN has published the Realising Recovery learning materials in partnership with NHS Education Scotland and will support the continued development of the Scottish Recovery Indicator, as well as offering support to those using the Indicator. In addition SRN will work with the Scottish Qualifications Authority to develop new learning materials on recovery and peer support, designed for people with experience of mental health problems. The SRN will also support the continued development of peer support by creating a network and programme to support employers.