What’s the best thing to come out of service strategy?
A majority of respondents replied ‘nothing’ when asked their views on the best thing to come out of Service Strategy. One reflected sadly, ‘finding positives is difficult. I rely on finding positives for my clients’.
This ‘corporate video’ was made in preparation for the visit of the Care Quality Commission (CQC) to Norfolk & Suffolk NHS Foundation Trust (NSFT).
Watch the video and then compare below what NSFT staff said in the Alexander Report with the managers’ claims. No wonder NSFT’s Board fought tooth and nail to keep the Alexander Report secret.
The CQC didn’t visit the community teams at Gateway House or the Peddars Centre which were the subjects of the Alexander Report. If the CQC had, the NSFT Board would have been sacked.
The lead doctor responsible for Central Norfolk has applied to be Deputy Medical Director of NSFT. There have been no consequences for the other managers and clinical leads except promotions. Astonishing.
Did the CQC see the Alexander Report or just these corporate videos?
In the post Francis Report world, is it acceptable for an NHS Trust Board to attempt to ‘game’ the regulator like this?
The nature, speed and lack of direction associated with the change process and a perception that the Board didn’t listen to the evidence has contributed to a lack of staff engagement. Morale and motivation are low and staff stress is high.
Culture in the Trust
Reports that the culture is bullying and oppressive and staff don’t feel valued leading to a lack of staff engagement and a lack of trust in the Organisation. A perception that the Trust fails to place service-users at the centre of what it does leading to a failure of the Friends and Family Test.
Fluctuating levels of motivation and Job satisfaction were reported. It was suggested that the Trust had ‘done a good job of demotivating people over the last year – some avoidable, some unavoidable’.
The impact of Service Strategy on the emotional and physical well-being of respondents included reports of coming in to work crying, increased sickness in the teams and thoughts of leaving their current role or the profession entirely. Another reported being ‘burnt out from change’ and would now take voluntary redundancy if offered and that was ‘heart-breaking’
One respondent observed ‘I don’t need my employer to do an awful lot for me to be motivated but there are things I need them not to do to keep me motivated ‘
Not feeling valued by the Trust was a significant factor in reduced job satisfaction, ‘You’re either valued or you’re not and I just don’t feel valued’. This has associations with a verbalised loss of goodwill following the Service Strategy process. Observing the experiences of others led to a report of being ‘disillusioned and angry, seeing people I value treated so badly’
However, the (Name Redacted) had moved out of the Peddars Centre and senior managers were identified as ‘less visible’ and ‘more distant’. Communication with managers above Service Manager level was ‘not particularly meaningful’ with a further observation that there was ‘no recognition by the hierarchy of what staff are being asked to do’. This disconnect from the most senior levels of management ultimately impacts on Team cohesion.
Disempowerment was prominent in responses, ‘They’ve created a perfect storm….. I’m constantly running from one thing to another to try and avert a crisis’ another observed ‘we’re not empowered to say – no more referrals, we need to close the books, protect ourselves’. It was suggested that ‘when you are coming to work and the message you get is that…… it is ultimately negative, the quality is poor’ it was difficult to build on anything positive. However, there was a sense of optimism that empowerment and autonomy could be returned to teams and practitioners.
One questioned ‘What is it the Trust wants from us? Whether you’re a B3 or an 8c we should know… what’s expected of us by this Organisation’. Another agreed that ‘the lack of definition and sense of direction impacts’. For Approved Mental Health Professionals (AMHPS) on Social Care Terms and Conditions who were interviewed and appointed to NHS posts from October 2013 this was particularly relevant; at the point of the project interview none had received their contracts or any back-pay due to them.
The dominant issues throughout the project interviews were the effects of voluntary redundancy and the subsequent recruitment of Agency staff in addition to other recruitment campaigns, ‘The lack of staff – them saying it’s not their fault – well all the VRs were sanctioned by somebody….’ The redundancies were described by one as ‘…unforgivable’
A lack of staff was the bottom-lime for many ‘we knew this was coming and needed an influx of staff initially’.
Respondents noted that depletion of staff in their teams limited the service they could provide and expressed the view that workloads were not understood by managers. There was a request for the basic resources to do their job including office space and the following comment refers to the loss of access to 80 St. Stephens as a base for meeting service -users, ‘How much does the Trust value your safety. Having an office base is a basic. If the Trust didn’t keep taking away things that make it ok….’
For some staff who had departed through voluntary redundancy it was anecdotally reported that having gone through the Cost improvement process and Service strategy they didn’t want to be part of it anymore ‘it’s about how the job has changed…. it’s about what they see and what the Trust has done and is doing..’ For others revised service models were deemed ‘unworkable’ with ‘no acknowledgement of the failings’.
Some respondents reported feeling that they needed to apologise to service users and carers for the poor quality of the service and for letting them down, ‘sorry I have to cancel another visit’, ‘sorry no-one’s seen you.’ One reflected ‘I almost want to add an apology when I say I work for the Trust’
It was identified by a significant number of respondents that, although they enjoyed their job, they could no longer provide a comprehensive service. At its most extreme they worried about service-users killing themselves, ‘We have had to do police welfare checks on people and you sit here for an hour and we sit here waiting, thinking are we going to have another body on our hands, or is it going to be alright, and you get through that and you get another one’.
It was suggested that staff go round with blinkers on ‘trying not to look at how bad it is’ and several respondents reported feeling ‘deskilled and incompetent’. There was identification of the conflict between practicing safely to uphold a professional registration whilst having to take more people on to their caseload, compromising the quality of the service they could provide.
Clinical staff were working with mixed caseloads (some cases should have been transferred to a different team, for example ‘The West Plus are sitting with us…….because the West Plus haven’t got any staff, so ……we are still carrying the 135 West Plus cases’), it was sometimes problematic to achieve medical or psychological intervention. Even where transfer was not required there were reports of long gaps between referral and seeing a doctor or getting a psychology assessment for service users. The potential for these delays was reported to have been ‘told to senior managers before the changes’. Delayed transfers increased the sense of having no control over caseloads and contributed to a lack of capacity to discharge people, ‘can’t discharge people, can’t do that work’.
A reduction in staffing and other resource was complicating the delivery of a quality service; the previously referenced loss of a base to see service users in the city was particularly challenging. It was averred ‘you do nothing for recovery by taking the only presence out of the city and renting a room at the Vauxhall Centre 2 days a week for depots. We have no presence where people can come seeking help’.
The lack of a base resulted in more time spent in the car ‘I’ve had my lunch in the car, written notes waiting in the queue for the car-park,’ ‘spent hours looking for parking’.
The focus on parking became more significant when senior managers questioned whether it was cost-effective to issue staff with parking permits. Suggestions included purchasing a certain number of permits for the teams; this would result in a complicated system that required additional driving to and from the base at the start and end of the day. Time spent looking for a parking space in the city had an impact on the time available for service-users and therefore affected the quality of the service. The very raising of parking permits as an issue had caused to some staff to feel less valued by the Trust.
Concerns were raised that respondents had ‘no tools and support to deliver effective care’ and it wasn’t possible to ‘get on top of basic treatments’, the ‘depot nurse’ had taken voluntary redundancy and there was no contingency plan in place. One respondent suggested that ‘the whole thing has become dysfunctional and quite tragic’. It was made apparent that depots were regularly missed because of workload capacity, compromising patient safety.
The multiple challenges facing the service concerned respondents and the outcomes on service delivery were marked, ‘we know there are hundreds of people in crisis not allocated’ there was a clear sense that responsibility for these failings lay with unspecified individuals, ‘You’ve done away with AO and loads of staff. You must have seen this coming’. Respondents identified that only ‘very risk or complaining people’ were being allocated.
A number of service users requiring depot medication were not yet allocated a new care co-ordinator. Nurses administering depots to unallocated service users were potentially taking on extra work following those appointments, adding to their workload but not reflected by their caseload. Service users were unhappy with different people visiting each time to give depot medication. Some service-users had had 3 or 4 care co-ordinators in the space of a few months due to staffing changes which created difficulties for all.
One respondent stated that, prior to service strategy, they hadn’t been used to complaints ‘but now I’m almost numb’.
Respondents believed they were carrying increased risks associated with their caseloads and also ‘the verbal abuse from people and their families who expect Mental Health services to do something’. They felt ‘stuck in the middle’ and found themselves apologising and trying to manage disappointment. It had been observed that only ‘very risky or complaining people’ were being allocated.
The underlying message of ‘working differently’ generated mixed reactions, ‘in theory these changes could work, in practice it’s a whole different ball game’. It was noted that some of the message ‘had got lost in Voluntary Redundancy, re-banding, people having to move, jobs under threat and other things not coming on line’. The need for a more efficient service and working differently was dismissed as ‘nonsense – it’s all about saving money’. It was suggested that there hadn’t been openness about that or consultation with staff, it had ‘been insulting’. The question was asked ‘how did they see this being implemented’. The message about working efficiently was demoralising. It was observed that ‘there just aren’t enough staff and it’s just not acknowledged openly’. Respondents often felt unsupported by senior managers commenting that people were ‘flogging their guts out to give a service and then the finger points when things go wrong’. This was summarised as, ‘Fatalities are going up….. It’s the person on the shop floor who has to go the coroner’s inquest, deal with the writing of the report and potentially with relatives screaming across the inquest room floor. It’s horrendous, but when you’re doing your best, not being given the wherewithal to do it ….. and what’s even worse is when the Trust doesn’t support you….that’s a recipe for disaster’.
It was opined that the Strategy could have achieved more success if services had been cut back before they were dissolved, inpatient and community changes should have been staggered rather than concurrent and further assertions that ‘the process was never clinically-lead’.
Concerns were raised about service-users who had received support for a number of years, ‘legacy patients who require a high degree of support’; with changing criteria they were at risk of being side-lined. The main effect was apparent with service users previously in contact with Assertive Outreach teams and admissions had increased.
At this point in time it was stated that services ‘are not working’; each service, community, in-patient, Access and Assessment and the crisis team has an impact on the ability of other services to function and none of it was working.
Post-implementation the information held by the Board was ‘out-of-touch’. Respondents consistently expressed the belief that ‘the message is softened and massaged’ as reports move through the layers of management to the Board whilst others observed that reports reduced ‘clinical situations to numbers, skewing the data’. One commented that ‘My biggest fear is that when we’re reporting up it’s not acceptable to say ‘it’s too difficult, we can’t do it, it’s not working, we end up putting lots of positive messages around it’. Ultimately this created a ‘complete disconnection between staff above (Name Redacted) (Service Manager) level and staff on the ground’ further compounded by a lack of visibility of Board members in teams.
Respondents suggested that decision-makers didn’t relate to ground-floor staff who, in turn, were unaware of who had made what decision, resulting in the absence of a feedback system. It was remarked that ‘The Board are saying everything is lovely, and we’re running around saying no it’s not…. we’re asked where is the evidence? Surely we are the evidence?’
Commenting respondents were unhappy with a lack of ownership of service strategy at Board level stating ‘someone needs to be responsible and accountable’ and ‘everybody needs to feel that the damage is recognised.’ It was believed that a number of the problems could have been foreseen, and therefore avoided, if staff concerns had been heard in the beginning, and one respondent summarised this point, ‘neither did they ask nor listen when told’.
On-going leadership at Board-level was experienced as ‘inconsistent’ or lacking but there was some hope for the incoming Chief Executive. At this point however, there was mistrust, ‘…they’re not honest with us’ and in the relationship with the Board, service strategy had been ‘the watershed’.
The question regarding an individual’s ability to influence change drew a range of responses from the disenfranchised ‘Our feedback isn’t taken seriously, if we’re listened to at all’ through to the apprehensive, ‘there’s a culture of blame and finger-pointing, people aren’t willing to be made scapegoats’ and frustrated and saddened, ‘I feel helpless, disempowered’ and ‘TSS has unravelled the service’. It was opined that, ‘we should be able to influence change given the current situation, to try and remedy the service but it hasn’t happened’. A number of respondents stated that questions to senior managers brought no useful change and believed there was an element of self-protection, ‘it’s all – oh they must be wrong’.
The varying degrees to which it was believed involvement and feedback had featured in service changes was marked, ‘they’ve been very good at wanting feedback’; although it was also noted that with an overwhelming message of ‘don’t do it’ it was less easy for that to be listened to, through to ‘no invitation whatsoever’ and respondents feeling that their concerns had been disregarded. One respondent referred specifically to the Project asking ‘who really will listen?’
There were concerns that teams were paralysed, ‘staff are frightened to make changes and change fatigued, exhausted’. Respondents reported that they had repeatedly flagged paperwork and issues with depot clinics but nothing had happened; some were resigned ‘just trying to get anything done is pointless’. It was further suggested that change would only really take place ‘when people start dying’.
Layers of management had reportedly made it more difficult for staff to get their message through and it was recalled that in previous structures managers had been more visible. It was opined that higher managers would listen ‘if it’s a fit for them’ but there was ‘too much pride to halt service strategy.’
Staff were angry at being misrepresented, ‘It was written in the EDP as clinician-lead, this was insulting,’ ‘There wouldn’t be a reduction in the quality of service. To suggest it had come from all of us was offensive’. There were a number of requests for the (Title redacted)to visit teams, (Name Redacted) needs to come and face us and listen to us’ and the Board were currently viewed as ‘far more removed’ this was particularly apparent when discussing unallocated cases ‘(Name Redacted) said it was a lie about the unallocated cases. Do management think we’re lying?’ The need to have contact with Board members was not universal and one respondent observed, ‘Whichever Trust you work for there will be a level of chaos, financial issues etc. My job doesn’t change. CEO changes, Service Manager leaves. It doesn’t matter’.
The overwhelming view was that service changes had been imposed and this had been experienced negatively by respondents, ‘It’s the signing off on plans that are unrealistic. We all said you’ve got the numbers wrong’ and similarly, ‘I don’t know a single colleague who didn’t comment and say there’s not enough staff, unsafe, it made no difference’. Involvement in the changes was viewed as ‘tokenistic’ and consultation events, ‘an act of stupidity to even go along’, ‘they can justify everything by saying they’ve consulted staff’. Although a previous Chief Executive had stated that the strategy would not continue if it wasn’t working that was described as ‘a farce, they had their plan and they bulldozed through it’. Senior managers were also criticised for ‘not doing the groundwork and making informed decisions’ although there was an acknowledgement that they were working under direction.
There was an understanding that external influences had driven Service strategy, nonetheless there was a clear view that these had not been well-managed by the Board. Some described their surprise at the pace of change, ‘I thought everyone knew that with change you should do one thing at a time so that you can see how effective it is’ another recalled thinking ‘they won’t do it, they won’t put people at risk but they did it anyway’. The views were expressed that Service strategy was ‘top down and financially driven, disempowering local services’ and that the Board were unable to appreciate the impact of the changes. Another warned, ‘any more of these punitive changes and… the eagles are going to fly, you’ll lose everybody. Anyone who’s got a conscience won’t be able to work here’.
The view was expressed that, ‘New layers and management appear regularly, we need more clinical staff’
Changes in the senior structures were also suggested, ‘Consultants should be more involved in planning. Their role should be looked at’ as should the Lead Clinician’s role which had reduced to ‘that of a spectator’. A further recommendation was made to ‘review manager’s performance more stringently’ and a plea to ‘incentivise others and let them get on with it’.
There was no sense that staff well-being was a Trust priority, ‘It seems the Trust doesn’t allow us to look after our own wellbeing. It’s a bit of a contradiction really’ and the belief that ‘staff haven’t been treated very kindly’. Demoralisation was compounded because the ‘portrayed image is not the reality’ and it was noted that ‘Staff and service users feel discredited by the Board who are saying it’s not true.’ The view was held by some that the ‘Trust doesn’t care; we are pawns in a game of chess’.
Lines of responsibility were unclear, ‘nobody knows who’s responsible for what.’ There was ‘chaos’ and ‘confusion and disillusion with the whole thing’ with the outcome being ‘the service can’t be delivered.’
It was believed that the Trust, ‘undervalued the therapeutic relationship’, and failed to recognise that it was, ‘the core component sometimes of keeping someone safe and well in the community.’ Service users were ‘not getting a decent service’. The Access and Assessment Team was not functioning effectively and was affecting capacity in teams. There was less ability to respond to people becoming unwell in the community; a number of respondents linked an increase in admissions and patient deaths to service changes, particularly the disbanding of the Assertive Outreach service.
Many respondents struggled to make sense of the changes suggesting that Service strategy was, ‘all about money’ but had not been cost effective, ‘Getting rid of staff and then having agency staff it’s ludicrous and a waste of money.’ One respondent summarised, ‘Small amounts of money like a care co-ordinator being paid to go equals an unallocated caseload and a person going into hospital at £1,000 per day it makes no sense.’ It was noted that ‘decreasing beds saves money but costs patient well- being.’ Bed shortages had further resulted in service users being moved to a different ward whilst on leave, resulting in a ‘new consultant, new care plan’, potentially extending their admission. The need for financial efficiency was understood ‘everyone understands that …savings need to be made’ but there was a lack of confidence in decision-makers ‘Cutting community services and beds, a decision made by someone who didn’t know what they were talking about’. Another suggested ‘You almost feel there’s a resistance on high to acknowledge that they could have done it a lot better’.
Looking to the future it was asserted, ‘the most important thing is that we don’t do this again. It cannot happen again. There has to be a structural change that means it isn’t possible.’
It was clear that a number of staff did not feel able to function effectively either as individual practitioners or as a group. They were largely disengaged, disempowered and believed that clinician and service-user safety was being compromised and that no-one with the ability to affect change was listening to them.
I interviewed staff from across the clinical spectrum and was saddened by the on-going distress that some were visibly experiencing as they continued to try and provide a service in very challenging circumstances.
Of those that did not participate one person explained that they did not believe that the Trust was a caring organisation or would respond to the project findings. A number of others cited work pressures as reasons for non-participation.
The report may illustrate a service not recognisable to decision-makers; respondents have repeatedly raised concerns over the quality of service delivery and the maintenance of staff and patient safety. However, it is essential that having raised these concerns remedial action is taken to prevent further deterioration and to develop a cohesive, resilient workforce that can negotiate future changes such as those imposed by the ending of the Section 75 agreement and the, as yet unknown, outcome of the IAPT+ tender.