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NSFT – A Warning from History: March 2013 – Unison’s submission to the Joint Norfolk & Suffolk Health Overview & Scrutiny Committee

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Fourteen months ago, when Unison sent the letter below, the Board of Norfolk & Suffolk NHS Foundation Trust (NSFT) wasn’t campaigning for fairer funding for mental health. As recently as December 2013, the current NSFT Chair, Mr. Page, was claiming that it wasn’t appropriate for the NSFT Board to question mental health funding as this was ‘political’. Mr. Page made no effort to contact us for the first four months of this campaign but could find the time to challenge our claims and legitimacy in radio studios and the press. Mr. Page claimed there was no crisis in mental health services, merely a ‘so-called crisis.’ As someone who formerly worked for Royal Bank of Scotland, recipient of the biggest state bail-out in British history and in large part the cause of post banking crisis ‘austerity’, you’d imagine Mr. Page would be able to recognise a crisis.

Back in March 2013, the NSFT Operations Director, Kathy Chapman, was promising nothing but ‘improvements’ in mental health services in an astonishing display of hubris. The Operations Director remains obliviously unrepentant in the face of public disgust, as she demonstrated four times at the HealthEast consultation meetings this spring.

Since this submission, the then NSFT Chair, Maggie Wheeler, and Director of Nursing and Governance, Roz Brooks, have retired, the Chief Executive, Aidan Thomas, has resigned and the Medical Director, Hadrian Ball, has announced his retirement. Perhaps the architect of the ‘radical redesign’, Operations Director Kathy Chapman, should join them?

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Norfolk and Suffolk NHS Foundation Branch 21111

Julian Hospital

Bowthorpe Road

Norwich

NR2 3TD

TO: Chairperson, Norfolk and Suffolk Joint Scrutiny Committee

5th March 2013

Dear Chairperson

UNISON asks Norfolk and Suffolk Health Overview Scrutiny Committee (HOSC) to consider the following information in their examination of the service changes proposed by Norfolk and Suffolk NHS Foundation Trust (NSFT).

We understand that NSFT will be presenting HOSC with updated staffing numbers.  At the time of writing we have not had access to that information, so our comments are based on the best available evidence that we have.  We will respond to updated figures when we give evidence on 12 March 2013.

We would firstly like to challenge the narrative of these service changes.  Whether you euphemistically call it “Radical Pathway Redesign” or “Service Strategy” the reality is that this is a significant cut to local mental health services, and should be described as such.  To not do so causes confusion and ambiguity in the minds of the public.

  1. The proposed reduction of 502 whole time equivalent staff represents a reduction in 24% of front line clinical staff.  The actual number of effected staff will be greater, as there are many part time workers within the workforce.
  2. NSFT anticipate that the same number of patients will be seen by this 24% reduced clinical workforce.
  3. We find it incredible that providing care to this number of people, with 24% fewer staff can be done in such a way that does not effect the quality or safety of patient care.
  4. There is no evidence that teams or clinicians currently have 24% spare capacity, or that clinicians’ time and skills are underutilised.
  5. We believe that the actual reduction of staff could be even greater, given feedback from staff that maternity cover is either not provided, or not provided in a timely manner.  This amounts to an additional ‘hidden’ cut.
  6. We believe that the number of “frozen” or “vacant” posts have proven to be a false economy.  Both in terms of the temporary staffing costs (at last report £17 million) and by increasing the workload of staff in services where there are vacant posts.  This has led to a significant increase in workplace stress and staff mental illness within some clinical areas – a result of there simply being too many patients to see, and not enough time to see them.  Staff are frequently distressed and overwhelmed by lack of resources, and some feel that they are not able to provide care to a standard that they are happy with.
  7. There are currently 245 vacancies.  There are an additional 102 fixed term posts.  There will be a reduction of 103 posts following the Dementia and Complexity in Later Life reorganisation currently underway.  This is a total of 450 posts.  We therefore ask the question – is this 24% cut in staffing “front loaded”.  If so, is there a risk that further reductions will be needed in the following 3 years?
  8. We consider that the risk register for the cuts is inadequate, and not sufficiently up to date.  We suggest that the HOSC request to see the risk register, and any plans in place to mitigate against gaps in service provision and risks.
  9. We share the concerns presented by both the RCN and BMA that the proposed measures for monitoring the risk of these changes focuses too heavily on “safety” rather than “quality”.
  10. We suggest that measures are introduced that take account quality of care are developed.  This should include the average length of face-to-
  11. face contact, and measures that take account of continuity of care, such as frequency of change of care co-ordinator/lead professional, or number of different practitioners seen by one person.  We also suggest that the number of missed / did not attend appointments is monitored, as an increase could indicate a lack of satisfaction with care being offered.  The number of appointments cancelled by clinician should also be monitored, as this could indicate clinicians needing to cancel routine visits to deal with an emergency or crisis, as there may be reduced capacity to do this due to increased caseloads.
  12. Staff in some clinical areas are reporting pressure to provide telephone support rather than a face to face visit.  We believe that this approach is a false economy.  So much of the care that we provide is based on face to face communication.  A telephone call significantly restricts the ability to use clinical judgement and assessment skills.  For example, assessing the risk of suicide and mental health is about more than words someone says to us.  By visiting people at home clinicians are able to see how a person is managing their day to day life – is post unopened? is there food in the house? are they taking care of their hygiene? Are they vulnerable? is anyone coming to the house who may be exploiting them?.  Early warning signs of relapse are much harder to detect on the telephone, and if people relapse or reach a crisis, the support needed to help them recover is more costly.
  13. We will not comment further on dementia care services, as we believe this service line was adequately examined at the last HOSC.
  14. We accept that some proposed changes are positive.  The changes to the under 25 service in Norfolk do appear to have taken in to account both the evidence base, and views of young people. A move to earlier intervention is a positive step forward.  However, the evidence does not support a move to this model at the cost of resources for people with enduring and chronic difficulties.  Ideally the funding to such services would be reduced gradually, year on year, as the benefits of earlier intensive intervention take many years to be realised.  In reality the U25 service is largely being funded by taking resources from recovery and CMHT services.  We believe that there is not sufficient evidence available as to how the proposed service reorganisation will safely meet the needs of those who are over 25 with chronic and enduring difficulties, simply due to the speed of change and significant reduction in resources.
  • We question how, if an evidence base has been at the centre of changes, Norfolk and Suffolk have developed such different models of care?  We see no evidence that needs of the population of Suffolk and Norfolk are significantly different.  We believe that NSFT is at risk of developing an internal post code lottery of services.

 

  • In particular, members working in the CAMHS service have expressed concern that the proposed Suffolk model for children and families (U13s) will not provide safe, evidence based care for children. In particular they assert that children should been seen separately in a service staffed and suitable for their needs, and that such a team needs to be of a size that is viable professionally to provide the benefits of specialisation.  They have raised concern about the ability of the LIDT to safely manage clinical risk and safeguarding issues in particular, due to the fragmentation of CAMHS practitioners across the locality.  They are also concerned that this will impact negatively on the provision of Eating Disorder services.  They consider the risks of proposed changes to be staff burn out, rising waiting lists, increase in tier 4 admissions, increase in serious untoward incidents. This is contrary to what is happening in Norfolk, where practitioners are being brought together to increase sharing of skills and expertise.

 

  1.  We are not confident that the Suffolk model will be compliant with the DOH policy implementation guidance for Early Intervention Services, and seek reassurance that young people in Suffolk with a first episode of psychosis will have access to the full range of evidence based interventions (ie. Intensive case management, CBT for psychosis, family intervention).
  2. We consider that the risk register for the cuts is inadequate, and not sufficiently up to date.  We suggest that the HOSC request to see the risk register, and any plans in place to mitigate against gaps in service provision and risks.
  3. We believe that the plans have not adequately taken account of the wider context and impact of welfare reforms.  We accept that many people who use our service prefer care at home rather than in hospital.  In principle trying to support people at home is the right thing to do.  However, a large number of people who access our service are at risk of being in an unstable living environment.  The increase in shared or hostel accommodation for those under 35 as a result of the changes to housing benefit will mean that some people who access our service may not be in a safe or stable enough environment to provide treatment at home in a safe and dignified fashion.  The “bedroom tax” will impact on a high number of people within our service, (Norfolk and Suffolk data available here:http://www.housing.org.uk/media/news/bedroom_tax_local_impact.aspx) putting them at increased risk of homeless, or increased debt – both of which are likely to have a significant detrimental impact on their mental health thus increasing need for support from our service.
  4. We are unclear on the impact of the cuts to social care budgets in both counties.  If there is a reduction in provision of other services that people access, this may have a knock on effect and further increase demand on mental health services.
  5. Some partner agencies that we have successfully worked alongside are equally facing funding difficulties.  If there is a reduction in the number of services that we can signpost people to, this again will have a knock on effect on mental health services.  In particular we are noticing a significant reduction in availability of welfare rights advice, advocacy and representation.  This has a significant detrimental impact on mental health, and adds to the workload as care co-ordinators attempt to support increasing numbers of service users facing such issues.
  6. We accept that the Trust has attempted to consult with service users.  We do not accept however that there has been wide enough consultation.  We would like further information on what % of people who access our service have actually been consulted.  Feedback from our members is that many people that they see are completely in the dark about the changes.   Feedback from our members is that they find it incredibly difficult to provide service users with accurate information, as they themselves are unclear.  Their job is also at risk, so it is difficult to speak objectively about a process that is directly impacting on you personally.
  7. We support the views submitted by the BMA (considered at the HOSC in February) that the consultation has been flawed.  In addition to the BMA submission, people are having to apply for jobs where essential information is not available, for example the hours of operation of the service.  Such information is vital, especially for those staff with caring responsibilities.
  8. We dispute the assertion made at the last HOSC that previous redundancies as part of the “cost improvement process” were solely managerial or corporate services.  Senior, experienced clinicians especially from a psychology/therapy background were lost.  This has had an impact on the supervision and support available to remaining staff.  These forthcoming proposed cuts risk further reducing the number of skilled, experienced staff who contribute to the development of more recently qualified staff, and help deliver safe and high quality care.
  9. Morale of staff is low in many places.  Members are reporting to us that they are distressed at not being able to give a good service.  They chose to work in mental health to care, to build relationships with the people that they work with, and support them to make sense of their experiences and learn how to stay well.  This takes, time, skill and experience – all of which are being reduced by the proposed cuts. Or, as one member put it “I feel like I’ve been trying to do my job with my hands tied behind my back for the last couple of years.  Now they’re trying to blindfold me as well”.
  10. Some members report feeling as though they are being reduced to administrators of care packages, dressed up as personal choice.  This risks fragmenting care, increasing administration and bureaucracy, and increasing the number of different people and services for people to navigate.
  11. We welcome the news that NSFT is working with commissioners to request transitional funding.  We however remain fearful that this will not be sufficient to mitigate the risks.
  12. We ask the committee to consider whether they accept the assurance that no beds will be closed until it is demonstrated there is no need for them.  This will rely on a temporary increase of staffing within some areas.  Is this realistically achievable within the significant reduction in front line staffing?
  13. We support the BMA submission that Suffolk and West Norfolk commissioning groups have under-spent on mental health care compared to even the national average.  We are unclear on what attempts have been made to bring their funding in line with, at the very least, the national average, and what impact this would have on the need to make 20% cuts.
  14. We are not convinced that the business model for the Tier 4 camhs unit is sound.  A significant amount of money has been spent on capital costs, and we have seen no evidence that it has had the desired impact on reducing the spend on out of area beds.  With the reconfiguration of U25s services, could these resources be better spent on providing intensive community based services? What are the risks to the service strategy, in light of the overspend and difficulties with the Tier 4 unit?  Is there a risk of further reductions in other services to mitigate the costs associated with the Tier 4 unit?
  15. Concerns about the delays and difficulties with mental health act assessments have already been raised by UNISON with the CQC.  The HOSC may want to satisfy itself that these issues are being addressed
  16. We are concerned that there is no “plan B”.  We do not have clear information about what action will be taken if, as changes are made, significant harm emerges.
  17. We call on the Trust to make a more honest and transparent description of the reality of the cuts that we are facing, and work with Trade Unions to lobby the Department of Health and local Members of Parliament, to be clear that this cut in funding cannot be implemented without a negative impact on the quality and safety of care.

On a more general note, we would like to remind the committee that Doctors and Nurses did not cause the financial crisis. The people who rely on our services most definitely did not, yet they are the ones who will find themselves at the sharp end of the consequences.

We find ourselves at odds with our employer over these cuts, when clearly we are at odds because of a failure of government to provide funding adequate to meet the basic needs of provision.

We will be attending HOSC on 12th March to answer any questions that the committee may have.

Yours truly

Branch Officers

UNISON Branch 21111

 

 

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One thought on “NSFT – A Warning from History: March 2013 – Unison’s submission to the Joint Norfolk & Suffolk Health Overview & Scrutiny Committee

  1. m says:

    I am so angry that the management of this trust cannot see there is a very serious and dangerous situation that is getting worse by the day.  Causing untold stress and distress on staff, SU’s and Carers.  The board questions, about whether beds are being used appropriately, yet who will be in the firing line when the tragedy(s) occur.  The poor old clinician, trying to do her/his best.  The trust board don’t even seem to  acknowledge that there is a problem, and staff are under increasing pressures.  Can’t they be bothered.? Do they care.?  What does that say…They hold us in contempt.?………………….and instead  hire a PR firm and a negligence lawyer.  The board are  NOT FIT FOR PURPOSE. Time for all who heralded Radical Redesign as a good idea to resign, and resign now.

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