The offices of social workers in Edinburgh’s North Mental Health Service are shoehorned into a corner of the council’s city chambers. It is a grand 18th century building at the heart of the ‘Royal Mile’ – the strip that runs from Edinburgh Castle down to the Scottish parliament building and Holyrood Palace, the Queen’s official residence in Scotland.
This is the heart of Edinburgh’s tourist town but the social workers’ caseloads also cover parts of the city that are given a wide berth by tour guides.
These include housing estates at places like Muirhouse and Craigmillar – the latter was Scotland’s “most poverty hit area outside of Glasgow” according to a 2006 study. The team also covers Leith, an area undergoing significant regeneration but best known as the setting for Trainspotting, Irvine Welsh’s depiction of heroin culture.
“The thing about our town centre is that it looks beautiful and is steeped in history, but there’s a lot going on,” says Elizabeth Stirling, a senior social worker with the team.
“You walk down the street and see all these tour guides with posh English accents. But I also see people nipping into the chemist to pick up their methadone, or groups of homeless people. The thing is, if you’re not looking for it, you might not see it.”
One challenge that faces Stirling and her colleagues annually is harder to miss: the Edinburgh Fringe. Edinburgh’s population doubles every August as the world’s largest arts festival takes over the city. Inevitably, a proportion of the 1.5 million festivalgoers become mentally unwell during their stay.
“It puts pressure on services. We find that the rate of mental health assessments does go up,” says Ian Waitt, a team leader at the service.
Stirling and Waitt recall supporting Fringe visitors from Australia, the USA, Hong Kong and Khartoum, the capital of Sudan, in recent years. Often people, understandably, don’t have documentation at a point of mental crisis; there can also be language barriers; and coordinating care across borders can prove particularly hard.
“There’s a lot of negotiation about how we repatriate them and try to get the follow-up treatment that they need,” says Waitt. “Plus, if someone has been detained under the Mental Health Act then we need to seek the approval of the Scottish government too.”
In forensic cases, added pressure from border officials to have people deported “can trump everything,” says Stirling. “But all along you’re trying to do the best you can for someone to ensure they get the support they need,” she says. “Sometimes what they are going back to isn’t much support either.”
The Fringe aside, the mix of the team’s caseload will be familiar to social workers in adult services across the UK. Adult safeguarding and mental capacity cases are a constant presence and the combination of mental illness and any number of factors including homelessness, unemployment and substance misuse, feature regularly on caseloads.
When I visit the team is “extremely concerned” about the impact of the Westminster government’s incoming welfare reforms on their clients. “If your ability to cope is already fragile, this is an additional pressure you really didn’t need,” says Waitt.
An emerging issue is the use of ‘legal highs’ – synthetic drugs that mimic the effects of illegal drugs like ecstasy, ketamine or cocaine. The substances, which can be bought online, are often manufactured in the Far East, where drug labs attach a few additional molecules to an illegal drug’s chemical formula in order to make sure the new variant evades UK drug laws.
“Many of them seem to have a really detrimental impact on people’s mental health,” says Waitt. “Trying to keep up with what’s on the streets, and what people can access online, is a real challenge.”
With names like ‘Benzo fury’ and endless variants of chemical formulae, little is known about how legal highs interact with the various antipsychotic and antidepressant medications prescribed to many mental health patients.
Stirling feels that one client who has schizophrenia “would have really good outcomes if it weren’t for legal highs”.
“He responds really well to medication and doesn’t have too many side effects so he’s able to get back on with his life. But he takes these legal highs and becomes incredibly unwell again,” she says.
“He takes clozapine – which is used to treat treatment-resistant schizophrenia. But we’ve had to stop the medication because he stops taking it when he takes legal highs and the effects of that are very dangerous. I think there is a mindset that ‘this is legal, it makes me feel good, what’s the problem?’”
The legal highs issue “isn’t something social workers can address on our own”, says Waitt. But he’s confident that social services’ joint working with health and other agencies is “one of the strengths” in Edinburgh and an increasingly important one at a time of budget cuts across the board.
The integration conundrum
At strategic level, health and social services work from a joint mental health strategy. Finding the right structure to boost integrated working on the frontline has proved harder.
The service used to be set up with a dedicated team of mental health officers (roughly speaking the Scottish equivalent of the approved mental health professional role), a hospital-based social work team and four individual social workers based in different NHS community mental health teams around the city.
Then, in December 2011, a decision was made to pool the staff and bring them together as one Mental Health North Team.
The restructure was made for various reasons, says Waitt. Firstly, the service wanted to establish a presence that was more “community-based and reaching in to the hospitals” than the other way round.
Plus, social workers based in the NHS teams had problems accessing local authority IT systems, some felt marginalised in health-dominated services and – in a familiar gripe voiced by local authorities across the country – it was difficult for the council to manage its NHS-based social workers remotely.
The ambition is to, eventually, co-locate social services staff with NHS colleagues “so that the weaknesses of only having one or two practitioners based in health would be removed,” says Waitt.
Two issues are preventing that from happening, he says. The first is problems in the way NHS and local authority IT systems work, or more to the point don’t work, with one other. The second is a lack of suitable office space to accommodate health and social care staff.
The team’s current office space in the city chambers isn’t ideal. Social workers can’t see service users in the building so a lot of time is spent booking meeting rooms elsewhere. Plus, being based in the congested city centre can make getting out to home visits difficult.
“Edinburgh is just a nightmare to get around,” says Paul Flaherty, a senior practitioner with the team.
“For a start, there’s nowhere to park, so the only car access is through the city car club (a car hire scheme that the council pays for staff to access). I tend to cycle or walk most places.You’re constantly having to factor in travel time because it can take you an hour to get to the west part of the city.”
A botched project to install tram systems in Scotland’s capital has created added transport chaos. Huge stretches of key city centre roads have been dug up for the scheme, which is already over budget and years behind schedule (the service was originally due to be up and running in 2011).
Flaherty says that Edinburgh council “hasn’t exactly covered itself in glory” with its role in the tram scheme. But he stresses that there’s plenty of positives in working as a social worker in Scotland’s capital.
“Every council and every city has its pluses and minuses,” says Flaherty. “There are issues here – the cost of living is high for example. But I feel Edinburgh’s got a reasonable culture of genuinely trying to provide a social work service that meets the needs of its people as best it can amid all the pressures. That’s important.”Andy McNicoll is Community Care’s community editor