Rights in mind - mental health reform is centred on human rights
You do not need to go back very far in time to find mental health services completely unrecognisable from what they are today.
A 40-year transformation from huge scandal-hit institutions and harmful treatments to community support and nurturing has been a moral imperative, a recognition of fundamental human rights.
This is based on the basic realisation that we all have mental health and, like physical health, there will be times when everyone feels less well than at others.
The UN’s right to health gives us the right to health protection, prevention and treatment. But there is also the right to be free from non-consensual treatment, and in this lies the conflict between policy ambition and the fact acute care can still occasionally mean being admitted to hospital against your will.
The UN Committee on the Rights of Persons with Disabilities has said people should always be treated as having equal decision-making competency. This means vulnerable people must always have a say over their treatment, using supported decision making if they lack capacity.
This made many countries re-examine their laws in relation to mental health.
Scotland’s mental health legislation, passed by its new parliament at the start of the century, was ground-breaking in taking a human rights-based approach. Restraint, isolation or segregation is a last resort and the vulnerability of patients is recognised in law.
The Adults with Incapacity Act 2000 provided a framework to safeguard the welfare of those who are deemed to lack capacity due to a mental illness. This was followed by 2003’s Mental Health Act.
Recent pledges to review these laws is underpinned by a commitment to go even further to protect human rights.
Minister for Mental Health Clare Haughey said government would put the voices of those with lived experience “front and centre” of a review of the Mental Health Act.
“The time is right to examine these issues so that our laws fully reflect our ambitions and the needs of those our laws are intended to support,” she said.
The review, she said, could “bring change to people’s lives” by making recommendations that reflect people’s social, economic and cultural rights.
While the policy ambition has been lauded by those working in the sector, how much is it reflected in practice by services?
Some patients who have suffered acute mental health conditions and have been forcibly treated told Holyrood that they felt their rights “had been taken away”.
Adrian Ward MBE, convener of the Law Society’s Mental Health and Disability Law Sub-Committee, said the way rights are protected can be improved through the legislative review.
“While Scottish adult incapacity legislation was originally world-leading, it has now fallen behind modern human rights standards,” he said.
“It is particularly welcome that the current review of that legislation is now to be combined with the new review of mental health legislation.
“We believe that the time is right for fundamental change, and we hope that the Scottish Government will use the period of review to enhance the adoption of modern best practice by all relevant professions and service providers in advance of law reform.
“The review provides a space in which to tackle the current deficits in practice under the existing legislation.”
Forced treatment is rarely used. Most people being treated for mental ill-health are speaking to GPs, community mental health teams or in an outpatient setting.
The Scottish Association for Mental Health (SAMH) welcomed the reviews but told Holyrood that the rights of all those patients must also be protected. For while in more recent years a breakdown of the stigma around mental health has meant more people are willing to talk about their mental health and come forward with problems, the experience they have when they do get treated can be inconsistent.
Sometimes it is difficult to access appropriate treatment at all, while many people are unaware of their existing rights.
SAMH chief executive Billy Watson tells Holyrood: “We are looking forward to participating in the review of mental health legislation. There can be few more important laws than those which set out when people can be treated against their will, and we need to make sure the legal framework gives people as much autonomy as possible.
“However, we also need to protect the rights of the thousands of people who seek treatment and support on a voluntary basis, and that includes the right to get help quickly, at the first time of asking.
“With one in five referrals to child and adolescent mental health services (CAMHS) being rejected, and just one NHS board meeting the 18-week target on psychological therapies, there’s still some way to go.”
Scotland was the first country in the world to set waiting-times targets for access to a therapist rather than medication, but recent figures show only one health board in the country has met them.
Research shows that the longer someone waits for therapy, the more likely it is that their mental health will deteriorate.
For children and young people, SAMH undertook an audit of CAMHS for the Scottish Government which found many people listed as having been ‘signposted’ to support were merely given a list of websites.
The audit resulted in a new taskforce being established, chaired by Dr Dame Denise Coia. There has also been investment into policy solutions such as an increase in school counsellors.
However, there is still an apparent lack of real progress on the ground.
Writing for The National newspaper in December, Coia said: “We have some of the best government policy in the world on children and young people, such as Getting it Right for Every Child (GIRFEC), which is designed to ensure services work together to support children and their families.
“We have committed ministers. We have a caring community in Scotland. But the fine words and pledges on mental health aren’t enough, and on the ground, people are saying it’s simply not working.”
Latest figures show that although more children and young people are being seen by services, more than a quarter of CAMHS patients are waiting over 18 weeks for treatment. NHS Borders, NHS Grampian and NHS Tayside met the target for fewer than half of patients.
Watson tells Holyrood: “The most recent Programme for Government paid more attention to mental health than ever before, and that’s a great thing. We’ve welcomed announcements of an additional £250 million for mental health over five years, and we were especially delighted at the investment of £60 million for counselling in secondary schools, something our campaigners worked hard to achieve.
“Now we need to see real change on the ground. In particular, we need to see a transformation in children and young people’s mental health, with meaningful involvement of non-statutory mental health organisations who can help to make a difference at an early stage, before a young person becomes seriously unwell. This is urgent, and progress must now happen at pace.”
Similarly, there is a gap between ambition and reality when it comes to the mental health workforce.
The Scottish Government pledged to hire 800 new mental health workers by the end of 2022, but the latest figures show the figure is going the other way.
Information Services Division figures show there were 269 fewer workers in 2018 than in 2017.
There is also inconsistency in the geographical spread of specialists, with NHS Tayside enjoying a far higher number of mental health staff per head of population than health boards in Lanarkshire and the Highlands.
Against the pledge to hire 800 extra staff, research by the Scottish Conservatives found just 106 additional staff have been recruited since it was announced two years ago.
The party’s mental health spokeswoman Annie Wells said: “The SNP’s promise to hire hundreds of much-needed mental health workers is falling woefully short.
“And unless serious improvements are made fast, this target will be missed spectacularly.
“Mental health is meant to be a priority for government – that’s something all political parties agree on.
“But instead, we have an SNP government presiding over falling numbers of mental health workers, and a recruitment campaign which – two years in – is barely off the ground.
“That will have a detrimental impact not only on vulnerable patients, but hardworking staff on over-stretched wards.”
Furthermore, bed numbers have reduced, with 3,941 psychiatric beds in 2018, compared to 4,015 the year before, and 4,376 in 2014.
Of course, a shift to community services and prevention is the context for this drop, but how much has this shift really happened?
Many who call for help do not meet the high criteria needed to access specialists.
Coia said: “While serious mental illness in young people is not significantly increasing, emotional distress, which can be equally devastating, is on the rise. This calls for a different type of response focused on greater support in communities.”
That response could come from Coia’s taskforce itself, which was deliberately not called a review or commission so that it could be focused on practical solutions.
“We expect to see real action,” she said.
When it comes to children and young people, this action could have a human rights context too. The Scottish Government has committed to incorporating the principles of the United Nations Convention on the Rights of the Child (UNCRC) into domestic law. What impact could that have on services?
Could it finally see funding channelled into preventing mental ill-health in the first place? An environment where young people can flourish and be nurtured includes having the confidence and opportunities to talk about their feelings.
A commitment in January to modernise personal and social education in Scotland’s schools to include lessons on healthy relationships, sexuality and consent could have an impact.
However, with only one in ten teachers feeling adequately trained to support the mental health of pupils, there are questions about how effective this could be as a preventative measure.
Furthermore, a commitment to have counselling services in every secondary school must be fulfilled so that pupils can easily access one-to-one support.
An early recognition of mental health as a specific issue could have a big impact on furthering the idea that everyone has it.
Last year Scotland’s suicide prevention plan made a pledge to reduce the suicide rate by 20 per cent in the next four years, after taking 15 years to achieve a similar drop so far.
A new National Suicide Prevention Leadership Group, chaired by former Police Scotland deputy chief constable Rose Fitzpatrick, was established to investigate every suicide, not just those of people already known to services.
There will also be better and more consistent support for families affected and refreshed suicide prevention training for NHS staff.
But there was little detail in the suicide prevention plan about how to prevent, rather than mitigate, when a third of Scots men never ask for help in the first place.
Survivors of suicide attempts told the ALLIANCE’s Health and Social Care Academy that help is often offered “too little and too late” to make an impact.
If that ambitious target to reduce the suicide rate is to be met, this will need to be addressed urgently.
One area where this urgency is being felt is support for the mental health of those incarcerated for criminal activity.
Following a number of suicides at Polmont Young Offenders’ Institution in recent years, a review by mental health experts and HM Inspectorate of Prisons was ordered by Justice Secretary Humza Yousaf in November and is due to report soon. It is led by consultant forensic child and adolescent psychiatrist Dr Helen Smith.
Yousaf said young people in custody would also fall under the remit of Coia’s taskforce and Fitzpatrick’s Suicide Prevention Leadership Group.
“Any death by suicide is tragic and the impact on family and friends is unimaginable for most of us. We have made both suicide prevention and reforming young people’s mental health key priorities with a significant focus on early intervention,” he said.
But these priorities haven’t yet stopped people waiting too long for help or even failing to get the service they need before things get worse for them.
Many preventative support services come from third sector organisations and projects which find themselves on the sharp end of shrinking local authority budgets and integrated joint board ‘efficiency savings’.
Understanding the importance of early support is to understand the human rights at the centre of the issue. And because all of us have mental health, those are our rights too.