Doctors in Tayside have warned psychiatric services in the region may be unsustainable due to staff shortages.
Inspectors from Healthcare Improvement Scotland were told the service relies on locum doctors but there are concerns about the number of these available.
They were told the shake-up of psychiatric services in Tayside, currently under way, may take years to bear fruit.
Healthcare Improvement Scotland carried out a review of general adult psychiatry services in Carseview and community mental health services in December last year.
The watchdog returned for a follow-up inspection in June, the results of which were published this month and lay bare the full extent of the crisis in psychiatric services.
NHS Tayside has ordered an independent inquiry into mental health services following a campaign by the relatives of patients who took their own lives but the new HIS report reveals staffing issues remain a major problem at Carseview.
It states: “The management team spoke about the continued challenges in maintaining a consistent medical psychiatrist workforce. They told us that the use of locum psychiatrists remains high and has increased since the review visit in December.
“They also told us that there were real anxieties about the sustainability of the medical service and a real concern that the availability of locum psychiatrists is reducing.”
It continues: “There continues to be ongoing challenges in recruiting psychiatrists, whether it be in a permanent post or a locum post.
“We have significant concerns about those ongoing challenges and the use of locum staff.
“The inconsistency of psychiatrists will continue to impact on patients being able to build and sustain therapeutic relationships with their psychiatrist and will lead to inconsistency in medical leadership in clinical teams.”
Inspectors were also told staff believe patients will not see the benefit of the redesign of psychiatric services for several years.
The report states: “The general consensus was that the plans being put in place today will not see immediate rewards but will take years to come into effect.”
A spokesperson for NHS Tayside said: “Like many other Health Boards, NHS Tayside is affected by a national shortage in some specialist services and professions, including consultant psychiatrists.
“To help address this, the Tayside Mental Health and Learning Disability Services Redesign Transformation Programme, approved by Perth and Kinross Health and Social Care Partnership in January this year, is redesigning how services are delivered in line with the current and future availability of medical staff.
“While our transformation plans are implemented, locum staff continue to be employed to ensure we can provide clinically safe and effective care for our patients.”
She said the health board has appointed a permanent medical director to oversee psychiatric services.
She said: “Locum psychiatrists in Dundee have been managed by an interim associate medical director however Professor Keith Matthews, an experienced consultant psychiatrist and senior academic has now been appointed permanently into this role.
“As an experienced and effective clinical leader, Professor Matthews will be instrumental in leading the redesign and improvement of mental health services across Tayside.”
Gillian Murray, whose uncle, David Ramsay, died after being turned away from Carseview in 2016, said NHS Tayside must address shortfalls in its psychiatric services.
Ms Murray, who played a prominent role in the campaign that led to a review into mental health services in Tayside, said: “How long has this mental health crisis gone on for?
“How many cases have been swept under the carpet?”
David Strang has been appointed chairman of the inquiry, which NHS Tayside has stressed will be fully independent.
Youngsters in Tayside are facing an “alarming” mental health crisis after care bosses admitted standards have plummeted in six months.
The number of kids getting help for mental health problems within a reasonable time frame dropped from 96.6% in June 2017 to 43.9% in December.
The rate covers the proportion of youngsters who are referred to and seen by NHS Tayside’s child and adolescent mental health services (CAHMS) team within a target of 18 weeks.
Across Scotland, the target health boards are expected to meet is 90%.
Keiran Watson, of youth support charity Eighteen and Under, said he found it “alarming” that less than half of kids were being seen on time.
He said: “As it is, the 18-week timescale is too long.
“If you’re a young person who is feeling depressed or has delusions, or is self-harming or even feeling suicidal — or if you are a parent of a young person like that — can you imagine being faced with an 18-week wait?
“The fact that less than half of young people are being seen within that 18-week target is shocking. It’s really quite alarming.”
Lorna Wiggin, NHS Tayside’s chief operating officer, told the health board at a meeting this week the slide was due to staff shortages equivalent to 3.3 full time workers.
She said: “Previous attempts to recruit have been unsuccessful. However, the posts have been re-advertised and interviews are due to take place in March.”
Ms Wiggin said significant improvements would not happen until those positions are filled, but added that high-priority children can be seen within five days of referral if their case is judged to be an emergency. We’re expecting a slight improvement in the next three months, but not a major one.
“We were able to rely on adult (mental health) services for some support but they’re not able to do that now.”
NHS Tayside may well reach out to other health boards for support with CAMHS in the near future.
Chief executive Lesley McLay said she had requested a review of the system with managers to avoid any further repeats of the situation.
She added: “We recognise that action is already happening (to improve performance). We may involve another health board as well.”
Health chiefs in Tayside have stated having two centres of excellence is the only safe way forward for inpatient mental health services.
The decision was taken at a meeting of Perth and Kinross Integration Joint Board following months of consultation, campaigning and protest.
It will see general adult psychiatry acute admissions centralised at the Carseview Centre at Dundee’s Ninewells Hospital.
Learning disability inpatient services will be provided at Murray Royal Hospital in Perth alongside other specialist services, including rehabilitation and substance misuse.
The decision will see services relocated from the outdated Strathmartine Hospital and the Mulberry unit at Stracathro Hospital in Angus.
The board voted five to one (an abstention) in favour of the preferred option.
Clinicians believe the steps will secure the future of inpatient services, improve the quality of service and environment available to patients and make services more attractive to potential staff.
Individual health and social care partnerships in Angus, Dundee and Perth and Kinross will be working to enhance mental and health and learning disability services in local communities, where 94% of mental health care is delivered.
More than 100,000 people took part in an often-criticised consultation process and more than 57% of those who responded said they were against the proposals.
NHS Tayside’s medical director Andy Russell, however, said the present model of care could not continue, with the redesign proposed “the only safe option”.
“Deep concern” has been expressed over a 10% drop in acute mental health beds across Tayside over the past five years.
The number of beds for men and women dropped from 99 in 2013 to 90 last year.
Health chiefs said the reduction was due to a reconfiguration in Perth and the interim relocation of the Mulberry Unit in Angus to the Carseview Centre and insisted most patients were now treated in the community.
However, Angus MP Kirstene Hair is seeking a reassurance from NHS Tayside that the numbers will not fall any further.
She said a total of 44 beds were likely to be relocated from Murray Royal Hospital and the Mulberry Unit at Stracathro in Angus as part of a shake-up of mental health care, while a similar number will be set up in Dundee at Ninewells Hospital.
But she added: “This research finds that the number of beds for a growing problem is reducing anyway – which is of deep concern.
“There needs to be a reassurance from NHS Tayside this number will not shrink any more.”
Conservative MP Ms Hair said she was also concerned that there are no eating disorder beds locally, meaning people are still having to go to Aberdeen for specialist treatment.
“It’s my concern and that of many of my Angus constituents that local health services are disappearing in the background,” she added.
“It is only huge change, such as ward closures, which makes people sit up and take notice.”
Closure of the Mulberry ward at Stracathro Hospital has been identified as the preferred option in a programme to address what officials have described as an unsustainable model for mental health care across the region.
Perth and Kinross integration joint board will have the final say on the package next week.
The move is likely to mean the axe for the Angus unit while general adult psychiatry acute care will be provided from four wards at Dundee’s Carseview Centre, along with learning disability inpatient services from three wards at Murray Royal Hospital in Perth.
Chief officer for Perth and Kinross health and social care partnership Robert Packham said only around 6% of people who access mental health services each year need hospital care.”
He acknowledged there had been a small reduction in the number of acute general adult psychiatry beds in the last five years, adding: “This is due to the reconfiguration of Moredun Ward at Murray Royal into separate male and female environments, and the interim relocation of the Mulberry Unit to the Carseview Centre.
“We have also been redesigning services to adapt to the changing needs of our populations and new services have been introduced to manage people in crisis and support people to remain at home,” said Mr Packham.
“Our communities would expect treatment to be available to them and their families when it is required and we remain committed to ensuring our patients can access the best treatment in the most appropriate place.”
A controversial restraint technique has been used on patients in NHS Tayside psychiatric hospitals almost once a week.
In the first 10 months of 2017, 53 patients were subjected to “floor — face-down” restraints in psychiatric institutes across the region.
The practice can be dangerous as a person is restrained, face down, with the weight of one or more people on top of them, which can lead to the person’s breathing being restricted.
The technique is generally carried out when a person is acting as a danger to themselves or others.
In the 2016, it was used 39 times across Tayside’s mental health facilities.
Research by the mental health charity Mind found that some mental health trusts across the UK no longer use face-down restraint because it is considered “too dangerous and traumatic” and the charity previously called for a ban.
Calum Irving, director of See Me — which tackles mental health stigma and discrimination — said: “When people are struggling with their mental health they deserve to be treated with dignity and respect, free from discrimination of any kind.
“This is especially true in health and social care settings, therefore restraint should always be a last resort and every effort made to avoid it.”
Colin McKay, chief executive of The Mental Welfare Commission (MWC) for Scotland, which protects and promotes the human rights of people with mental illness, said: “Any form of restraint must be legally justified, and be the minimum which is reasonably necessary, for the minimum possible time.”
A spokeswoman for Perth and Kinross Health and Social Care Partnership said: “In some instances, it is necessary for staff to use a reasonable level of force to restrict a person’s movement to avoid a greater harm occurring.
“The ‘floor – face down’ restraint is a response to a high level of physical risk from a patient and is used only when all other options have failed. It is generally considered to be the last resort and is used for the shortest-possible time to ensure the safety of patients and staff.
“All physical interventions are taught from the perspective of being the last resort for the shortest period of time using the lowest level of force/restriction and the smallest number of staff.”