Commentary: the Scottish scene

Loudon and Coia (pp. 84-86, this issue) have provided an informative snapshot of the Scottish scene that is clear, succinct and objective. They set out the main organisational structures and framework within which we operate north of the border, and touch upon some of the factors working against positive change.

What they have not conveyed is the huge amount of time and energy that is being devoted to redesigning and developing mental health services, despite the impact of structural changes within the care systems, and the daunting size of the change management task.

For example, the launch of the Framework for Mental Health Services in Scotland in 1997 (Scottish Office) needs to be set in the context of the NHS and local authority changes happening around that time. I work in the Scottish Borders, a rural area with a scattered population of 106 000. The local directly managed mental health unit became part of a community NHS trust in 1995, and was translated into a primary care trust, with the inclusion of primary care and other services, 4 years later. In 1996 the local regional council and four district councils were replaced by a single unitary council. These upheavals resulted in a significant movement of key personnel and required time to be devoted to setting up new structures within the new organisations merely to maintain existing services. Perhaps what is surprising is the extent to which progress has been made under these circumstances.

The pace of change appears to be accelerating, perhaps partially a function of the new Scottish Parliament. With health representing 40% of the parliament's budget, Scottish health is being debated more than ever before. In the period immediately before devolution there was only one debate at Westminster on Scottish health issues, and that was a short adjournment debate. In the first 18 months of the Scottish Parliament there have been around 50 debates on health and community care matters.

Within the past few months the Scottish Health Plan (Scottish Executive, 2000), the Millan Committee report (Scottish Executive, 2001) and Clinical Standards Board for Scotland (2000) standards for schizophrenia have been published, all of which will have an impact on the delivery of mental health services.

The Health Plan (Our National Health; Scottish Executive, 2000) reconfirms the three clinical priorities; coronary heart disease, cancer and mental health. But adds another priority, the health of children and older people. This raises questions about what being a clinical priority means. New national targets for maximum waiting times for cancer treatment have been published, and by next year there will be maximum waits for angiography and angioplasty. There is a risk that these somatic priorities, already able to be measured on hard data, will preoccupy NHS Scotland. With only soft information being available in mental health, or crude unrepresentative measures like whole population suicide, perceptions of priorities could be distorted, with funds being diverted away from mental health. Our National Health does emphasise the Framework and it is to be hoped that the new accountability review process set out in the National Plan will ensure that health boards deliver the Framework agenda.

National differences are of interest, and not always simple to explain. Safety First, the 5-year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness is the first to include Scottish data (Department of Health, 2001). It is expected to confirm the very much higher general population suicide rate in Scotland compared with England. The Scottish Executive held a seminar on suicide prevention in November 2000, an outcome of which was the intention to develop a multi-agency framework for suicide prevention. England already has a suicide prevention strategy, but none is planned for Northern Ireland.

Such diversity should be a source of interest and strength for the College and I echo the authors' call for College business to be less exclusively related to the Department of Health of England if interest from psychiatrists working in other parts of the British Isles is to be retained.