Section 2: Needs assessment process: history, progress, papers and outcomes Section 3: Interpretation and application of inequalities in mental health at
strategic level within the CHP.
Section 1: Local strategic context for inequalities in mental health
Introduction
The local strategic context in South Ayrshire CHP for inequalities in mental in health and for the needs assessment was explored through relevant local documents that were concurrent with the data collection period. The documents were searched to identify sources of information regarding inequalities in health and inequalities in mental health that might influence the CHP’s perspective. Most of the papers examined were produced by Ayrshire and Arran NHS Board and South Ayrshire Council, and some were
produced by local partnership groups or national organisations. The documents included population profiles, public health and health improvement documents, mental health services strategies and the Community Health Partnerships scheme of establishment, as follows:
South Ayrshire Community Health Profile, Health Scotland, 2004 Ayrshire and Arran Director of Public Health Report, 2004
Health Inequalities and Health priorities in South Ayrshire: a Discussion Paper. Adrian Shaw and Chris Doyle, South Ayrshire Council, Draft, December 2004 Ayrshire and Arran NHS Board Mental Health Strategy 1999
National Mental Health Services Assessment Locality Report for Ayrshire and Arran, Scottish Executive 2003
Improving Mental Health and Services in Ayrshire and Arran: Report and Implementation Plan, 2004
Mental Health (Care and Treatment) (Scotland) Act 2003 Draft Joint Local Implementation Plan, Ayrshire and Arran, version 2, July 2004
South Ayrshire Council Mental Health Strategy 2004-2007, Draft 3, July 2004 Ayrshire and Arran Local Health Plan 2005-2008, July 2005
South Ayrshire Joint Health Improvement Plan 2004-2007
Health Inequalities Action Plan, Ayrshire and Arran Health Board, Draft January 2005
Ayrshire and Arran Community Health Partnerships Scheme of Establishment December 2004.
Some of the documents above were provided by South Ayrshire CHP staff, and three were accessed on the internet. The remainder were accessed on request from the Communications Team at Ayrshire and Arran NHS Board.
Profiles of the South Ayrshire population
In addition to the NHS Health Scotland profile of South Ayrshire summarised previously in Chapter 3, Section 2, another profile was prepared by South Ayrshire Council to attempt to identify health inequalities and health priorities for South Ayrshire. Inequalities between communities were examined using the indicators of mortality, mental health, sexual health, drug and alcohol abuse, smoking and healthy lifestyles at datazone levels as distinct from the Health Scotland analyses which used postcode sectors. Their analysis concluded that there was very little variation between communities for mental health indicators and no correlation between economic or social deprivation and high levels of alcohol or drug misuse. The Ayrshire and Arran’s Director of Public Health’s
Annual Report of 2004 was similarly inconclusive about links between mental health and
inequalities and placed mental health under the heading of “Healthcare and Governance”. The mental health section outlined national strategic direction and local services that had been developed in response to the National Programme for Mental
Health and Well-Being.
Mental health strategies for South Ayrshire
An array of mental health strategies for broad direction and for specific services had been produced by both Ayrshire and Arran NHS Board and South Ayrshire Council, and while strategies were published by one or the other agency, most stated that they were developed by multi-agency groups. To an outside observer, the combination of strategies appeared to be occasionally repetitive, involving time-consuming processes for the authors, and resulted in similar conclusions about gaps in services and funding.
The Ayrshire and Arran Mental Health Strategy was produced in 1999 by the NHS Board in response to the Framework for Mental Health Services in Scotland (Scottish Office, 1997) but was said to have been developed by a multidisciplinary, multi-agency project Board which also included service users. The strategy aimed to create an integrated service addressing health, social and housing needs for the following groups:
People with severe and enduring mental health problems
People with a learning disability, substance misuse or alcohol problem who also have a mental health problem
People with mental health problems who commit offences
People who experience mental health difficulties which may or may not be enduring but vary in severity, frequency and duration.
The Mental Health Strategy 2004-2007 developed by South Ayrshire Council (draft
2004) noted that Year 1 of the NHS 1999 Strategy had been funded resulting in the introduction of new services but funding had not been made available beyond year 1 resulting in gaps in some services.
In 2002 another multi-disciplinary, multi-agency group met to review pressures and problems within mental health services across Ayrshire and Arran, and a stakeholders meeting was subsequently arranged to explore views of service users and carers and staff groups (Community Health Division, November 2004). A redesign project was then set up and named Improving Mental Health and Services in Ayrshire and Arran, which was said to fit within the framework of the National Programme for Mental Health and
Well-Being, implementation of the 2003 Mental Health (Care and Treatment) Act, and a
model for mental health services called the Tiered Model of Healthcare. The redesign project identified nine priority topics focused on re-shaping service delivery in line with national priorities such as providing appropriate 24-hour care, person-centred care management approaches, improving services to primary care, improving mental health profiles and developing information and systems. These priorities were also said to inform South Ayrshire Council’s Mental Health Strategy (South Ayrshire Council, July 2004) along with the Choose Life Action Plan. Actions and timescales for implementation of the Mental Health Act were specified in the Joint Local
Implementation Plan for Ayrshire and Arran (JLIP) which involved the NHS Board and all
three Ayrshire Councils, and identified JLIP Coordinators and Implementation Coordinators for each of the four partners.
An objective view of progress on mental health services at local level was provided for all areas across Scotland by the National Mental Health Services Assessment which was set up by the Scottish Executive to assess the extent to which existing mental health services could meet the objectives of the 2003 Mental Health Act. The Ayrshire
and Arran Locality Report produced from the assessment identified that users and
carers’ priorities were to provide services that were responsive to locally identified needs such as for people with drug and alcohol problems, carers, homeless people with a mental illness and to highlight mental illness as something everyone needs to play a part in. In addition, challenges were identified in implementing the Act, including getting GPs involved in the development and delivery of mental health services, improving transport, recruiting and retaining Mental Health Officers and pressure on the one forensic psychiatrist.
Inequalities or variations were not mentioned in any of the documents other than issues relating to particularly vulnerable groups, which were usually credited as being raised by service users and carers.
Reducing health inequalities
The main plan where health inequalities might have been prioritised was the NHS
Ayrshire and Arran Local Health Plan 2005- 2008, which brought together the three Joint
Health Improvement Plans from each of the Ayrshire Council areas. The Local Health Plan identified that there were considerable variations in health and deprivation across the NHS Board area and proposed the use of the Scottish Index of Multiple Deprivation to pinpoint specific areas of need, although the use of datazones in the profile mentioned above had been unable to link deprivation to health outcomes. The plan
highlighted that the NHS Board carried out an Equity Audit for Coronary Heart Disease (CHD) Services in 2002 which demonstrated that people living in areas with higher levels of deprivation, including North and Central Ayr within South Ayrshire, had higher levels of need for CHD services but were less likely to receive interventions. The audit focused on statin prescribing but also suggested that the results provided evidence that the NHS had the potential to increase inequalities through inequitable service provision. It also noted that poverty and socio-economic deprivation had a huge impact on health inequalities, but that other factors including gender, race, disability, employment and education should also be considered in strategic planning. An Equity Audit for Mental Health was said in the Plan to be underway but had not been carried out by the time of writing in 2007. The Local Health Plan also included sections on mental health and on mental health improvement, where core mental health services across Ayrshire and Arran were listed, and the local response to the National Programme for Mental Health
and Well-Being was described as already given in the Director of Public Health Report 2004.
A Draft Health Inequalities Action Plan was produced around the same time as the Local Health Plan by Ayrshire and Arran NHS Board. This short, draft report again re-iterated that there were measurable inequalities between affluent and disadvantaged areas. It also stated that depression was expected to be the second most prevalent illness worldwide by 2020 and that people in deprived areas are nearly one and a half times more likely to suffer from a mental health problem than those living in an affluent area. The draft paper did not provide specific actions but outlined a range of planning processes and broad aspirations to reduce health inequalities, including work on priority health topics, lifestyles and life circumstances such as improving access to health services for the most disadvantaged groups and ensuring effective sharing of information between agencies.
The role of Community Health Partnerships
There were three Community Health Partnerships (CHPs) linked to Ayrshire and Arran NHS Board for North, South and East Ayrshire, each of which was coterminous with a separate Council. The Scheme of Establishment for NHS Ayrshire and Arran CHPs set out their vision for delivering the healthiest life possible for the people of North, South and East Ayrshire as being based on principles that emphasised understanding and meeting local needs, integrating services and reducing inequalities within and between local communities.
Community mental health services were to be managed within the CHPs. Each of the three CHPs were to host some area-wide services but a decision had not been reached on the management arrangements for Clinical Psychology and Psychiatry. Each CHP would also have partnership arrangements at strategic level for community care planning, children’s services planning, joint health improvement planning and supporting people and implementation of the Joint Future Agenda.
Summary for local strategic context
There was no lack of strategies and polices setting out different aspects of managing and delivering mental health services or consulting staff, patients and carers on their perspectives of what the services should provide. Inequalities in health made a startling appearance in the Local Health Plan which offered an unusually frank analysis of the potential for the health service to contribute to inequalities through service provision, and that poverty and socio-economic circumstances had a strong impact on health inequalities. These issues did not appear to have been picked up by other reports with the one exception being a draft health inequalities strategy. However, this had been in the process of being written for some time and had no expected date of publication.