The NHS in Scotland
Responsibility for health and social care in Scotland has been devolved to the Scottish Government. As such, health and social care policy and funding are the responsibility of the Health and Social Care Directorates of the Scottish Government, whose ‘over-arching outcome is to ensure that where care is needed it is of high quality and is provided in a timely, efficient and effective way as close to home or a homely setting as possible’ (www.scotland.gov.uk/About/People/Directorates/HealthSocialCareIntegrat).
(a) Health Boards
Current provision of healthcare in Scotland is the responsibility of 14 geographically-based local NHS Boards.
- NHS Ayrshire and Arran
- NHS Borders
- NHS Dumfries and Galloway
- NHS Western Isles
- NHS Fife
- NHS Forth Valley
- NHS Grampian
- NHS Greater Glasgow and Clyde
- NHS Highland
- NHS Lanarkshire
- NHS Lothian
- NHS Orkney
- NHS Shetland
- NHS Tayside
The State Hospitals Board for Scotland is responsible for the State Hospital for Scotland and Northern Ireland at Carstairs, which provides high security services for mentally disordered offenders and others who pose a high risk to themselves or others.
(b) The Mental Welfare Commission for Scotland
The Mental Welfare Commission for Scotland (www.mwcscot.org.uk) is an independent statutory body which protects people with a psychological disorder who are not able to look after their own interests. It is funded through the Scottish Executive Health Department.
In Scotland, one in four people will experience a diagnosable mental health problem each year. Anxiety and depression are the most common, but others include schizophrenia, personality disorders, eating disorders and dementia. Despite recent declines, the rate of suicide in Scotland remains higher than that seen in much of Western Europe, and has been above the Western European average since 1993. According to The Samaritans’ Suicide Statistics Report (2014), in 2012 Scotland had a higher suicide rate than England, Wales, and Northern Ireland.
Rate of suicide per 100,000 population
Northern Ireland 15.2
2. Mental Health Services
Generally, mental health services are delivered via NHS and local authorities, occasionally in partnership with the voluntary and independent sectors. There have been significant developments in the last 10 years in the way that mental health services are delivered, with a focus on shifting resources from hospitals to the community, and primary care and community mental health teams (CMHT).
The services provided by CMHTs tend to vary across Health Boards. For example, within NHS Greater Glasgow and Clyde there are several specialist mental health teams. As well as separate CMHTs for children and adolescents, adults and older people in Greater Glasgow and Clyde, there are specialist teams for early intervention and eating disorders. Teams providing services for homeless people and asylum seekers also provide support for mental health problems. Composition of CMHTs also varies, and tend to be multidisciplinary, including nurses, occupational therapists, psychologists, psychiatrists, pharmacists, social workers, and so on.
Each NHS Board in Scotland has responsibility for treating people who have mental health problems within the acute hospital setting or in the community. The local authorities have responsibility for providing ongoing community-based social care and support services. From 2015, health and social care services will be integrated across Scotland, with joint boards being setup between health boards and local authorities. The aim is ‘to ensure that health and social care provision across Scotland is joined-up and seamless, especially for people with long term conditions and disabilities, many of whom are older people’ (www.scotland.gov.uk/Topics/Health/Policy/Adult-Health-SocialCare-Integration).
(a) Quality Indicators and HEAT
The Scottish Government’s Mental Health Strategy specifies a range of priorities and commitments to improve mental health services and to promote mental wellbeing and prevent mental illness. Seven key themes, and four key change areas are identified. These include, for example, developing the outcomes approach to include personal, social and clinical outcomes; rethinking how we respond to common mental health problems; and activity to support delivery of the mental health strategy (www.scotland.gov.uk/Topics/Health/Services/Mental-Health/Strategy).
An outcomes target has been set for psychological therapies, so that there is a requirement for patients to begin treatment within 18 weeks of referral – with a threshold of a minimum of 90 per cent of referrals expected to meet this target. This is known as ‘Commitment 13’ (www.scotland.gov.uk/Topics/Health/Services/Mental-Health/Strategy/Psychological-Therapies).
(b) Routine Collection and Recording of Clinical Outcomes
As well as improving waiting times for psychological therapies, the Scottish Government are moving towards ensuring that patients benefit from the treatment they receive. There will be an expectation for all mental health services to routinely collect and record session-by-session clinical outcome data. This data will be used for both clinical (i.e., patient) level purposes, and practitioners, managers, and services to measure both the quality and effectiveness of the psychological interventions being delivered.
(c) The Matrix
In collaboration with the Scottish Government’s Mental Health Division, along with a number of other key stakeholders, NHS Education for Scotland has specified various standards for training in psychological interventions. Detailed guidance has been developed, focusing on the delivery of safe, effective and efficient care. Termed The Matrix – A Guide to Delivering Evidence-Based Psychological Therapies in Scotland, the document was first published in 2011 (www.nes.scot.nhs.uk/education-and-training/by-discipline/psychology/matrix.aspx). The guide reviews the evidence base for a range of psychological therapies used for various mental health problems across adults, children/young people and families. It also makes reference to the management of long term conditions, and physical health care.
It should be noted that The Matrix was not developed to be a rigid, prescriptive, document. Rather, the intent was to provide appropriate guidance around the delivery of psychological therapies. In addition, a further aim was to support the planning and development of psychological services towards meeting outcome standards. The document will be regularly reviewed and updated, taking account of a developing evidence base.
4. Psychology in Scotland
(a) Training Programmes
Within Scotland there exist doctoral training programmes in Clinical Psychology at the universities of Glasgow and Edinburgh, and Counselling Psychology at Caledonian University in Glasgow. In addition, there are a number of Masters level programmes in Health Psychology, Psychological Therapy in Primary Care (adult and child), health psychology, educational psychology, and forensic psychology. The British Psychological Society also offers the Qualification in Counselling Psychology (QCoP), a route to Chartered Counselling Psychologist status provided as an alternative to university and Practitioner Doctorates in Counselling Psychology (see http://exams.bps.org.uk/exams/counselling-psychology/counselling-psychology_home.cfm).
(b) Psychological Services
Each Health Board has a specialist psychological service, managed or professionally-led by an Area Head of Psychology Service (HoP). The largest services are those provided within NHS Greater Glasgow and Clyde; NHS Lothian; NHS Lanarkshire; NHS Tayside; and NHS Grampian. Generally services are provided by clinical psychologists, counselling psychologists, clinical associates in applied psychology (CAAPS – adult and child), CBT therapists, and counsellors. Most, though not all, psychological services employ counselling psychologists.
(c) NHS Education for Scotland
NHS Education for Scotland (NES) has two major areas of responsibility with regards to psychology:
- Training of psychologists for NHS Scotland
- Upskilling the existing multi-professional workforce in psychological care
In practice, NES funds the doctoral programmes in clinical psychology, Masters programmes in psychological therapy in primary care (adult and child) and, recently, a small number of health psychologists in training. No funding has been provided for counselling psychology training.
NES regularly offers a range of training, workshops and courses, and these are open to a wide section of clinicians working in mental health. Each Health Board has a Psychological Therapies Training Coordinator, who is the local point of contact for all NES training. In addition, NES help coordinate supervision training for psychologists, this being an essential component of effective service delivery. This supervision is open to both clinical and counselling psychologists, recognising that both clinical psychology doctoral training programmes permit, where appropriate, clinical psychology trainees to be supervised by qualified counselling psychologists. This also applies to the Masters programme in psychological therapy in primary care.
The NHS in Scotland is geographically, and politically distinct from that of the rest of the United Kingdom. The drivers are different, as are the socioeconomics. In the largest conurbations, multiple deprivation goes hand-in-hand with mental health difficulties. This requires a holistic, systemic perspective to the improvement of health and well-being. It is in this context, then, that the Scottish Government is emphasising the importance of effective integration of health (NHS) and social care (local authorities). Boundaries must become less obvious and, in some cases, removed entirely.
At the end of 2014, the Scottish Government demonstrated its determination to provide better mental healthcare by appointing the first ever Scottish Government minister to have mental health in his/her job title. Recognising that mental health has, for many years, been perceived as the ‘Cinderella’ service within the NHS, additional funding has been released to recruit more clinicians for CAMHS services, and to establish an innovation fund to come up with better ways of delivering mental health services. There is also an increasing focus on suicide/self-harm, older people, and in developing low-intensity interventions, including the use of evidence-based computer-based CBT programmes. Given increased funding, and a consistent focus upon mental health improvement, there will be a need for continued growth in the number of applied psychologists able to work within the NHS in Scotland.
Dr Gary Tanner, AFBPsS
Head of Psychological Services
Wishaw General Hospital