The Trust responded to our Campaign’s Open Letter of 25/11/13 with a letter circulated to Trust Governors and partner organisations (but not us) which attempted to refute our contention that the service is in crisis, and alleging certain inaccuracies in our statement. It should be pointed out that not one member of front-line staff, service users or carers has criticised our open letter or drawn our attention to any inaccuracies. If anything, staff and service-users have told us that the situation is even worse than we thought. The following headings were used by the Trust in their reply:
1. The Trust denies it is accelerating cost reductions over 2 years instead of 4 years.
If this is not the case why is the service in such a state of chaos with staff and service-users overwhelmed by the pace of change and left in the dark about where their future care would be coming from? Service users and carers were the last to know that there would no longer be a Community Mental Health Team at 80 St Stephens Rd, Norwich. Many members of staff only knew a week before moving where they were going. Why are inpatient beds being reduced before any alternative to hospital admission is up and running? Why has the Access and Assessment Team been overwhelmed by referrals because of the precipitated abolition of the link-worker service? Why no pilot project, especially when the Trust were given extra interim funding for the period of reorganization? Why so many people made redundant or offered redundancy when in many areas the Trust is unable to fill posts, and a large number of referrals cannot be allocated? Why is there such heavy expenditure on agency nursing staff and locum doctors? What is the Trust’s excuse for such poor management of change?
2. The Trust denies it is planning to close either Carlton Court or Northgate Hospital in Gt Yarmouth; it says that the closure of Meadowlands is temporary, due to reduced bed occupancy, and has nothing to do with the radical redesign or with cost-cutting.
Since this statement was issued Kathy Chapman, Director of Operations, has submitted a report to the Trust’s Board of Directors, entitled “Acute Services Strategy“ to the Trust’s Board of Directors on 19/12/13 in which she outlined their future intentions for the service. In Paragraph 3.1.9, she states that, after public consultation, the planned changes for 2015 include the amalgamation of Carlton Court and Northgate Hospital acute psychiatric units into one site; she does not mention how many beds will be lost in this equation but it is clear that one of these units will close if the Trust continue with this disastrous policy of bed closures.
To say that the closure of Meadowlands has nothing to do with cost cutting, and is due to reduced bed occupancy is disingenuous. We all know that if you wish to close a unit you can ensure that no admissions take place. As admitted by the Trust, patients have been moved from Meadowlands to other secure beds in Norwich; this clearly reduces the availability of secure unit beds for new admissions or for transfers so that at the time of writing this response we have 19 patients placed Out of Area, 8 patients in The Priory Hospitals at an enormous cost, and two patients admitted last weekend hundreds of miles away from their homes, one to Harrogate in Yorkshire and one to Weston-super-mare in Somerset.
3. The Trust admits there are no inpatient Older Person Mental Health Units in Kings Lynn.
The Trust admits this and states that acute psychiatric wards now cater for all adults irrespective of age; whether this is a good thing or a bad thing can be argued but the fact remains that this means a loss of available beds and an increased likelihood of patients being admitted many miles away from their relatives and care team. They admit that older people with dementia and complex physical and mental health needs in the Kings Lynn area now have to go to the Julian Hospital in Norwich making care planning for discharge and involvement of relatives very problematic.
4. The Trust has accepted that they are making staff redundant and downgrading their posts.
We have already referred to the farcical way the Trust has managed this issue, and the unnecessary costs incurred. What the Trust does not acknowledge is the cost to staff morale and the hugely adverse effect on the service caused by constant change and uncertainty, and the transfer of staff from areas where they are highly competent to areas where they have to start from scratch. From a service-user and carer point of view the whole concept of continuity of care, of the therapeutic relationship, has gone out of the window. Another issue we have probably not highlighted sufficiently is the reduction in the numbers of team managers, and the pressure they are now under with the high numbers they are now expected to line-manage. At the same time the numbers employed in senior management and non-clinical administrative jobs has increased within the Trust.
5. The Trust admits that it has disbanded crucial specialist teams.
The Trust admits this then claims that somehow it is a good thing and that “There will be no reduction in the service or the numbers of people seen.” Quite frankly this is a farcical statement. The Assertive Outreach Teams were set up in the mid/late 90s in response to a series of tragedies which occurred because a number of severely mentally ill people were slipping through the net because the standard CMHT did not have the time or the resources to help them engage. The Assertive Outreach Team in Norwich had 2 psychiatrists, a psychologist, 3 social workers, community mental health nurses, OTs, and support workers, its own team leader and team secretary. The caseload of this team has now been transferred to Community Mental Health Teams which are already overwhelmed by large caseloads and cannot even allocate the referrals that have been made to them. In Norwich we had two dedicated workers for the homeless mentally ill who worked closely with the other agencies and actively tried to seek out homeless people who often do not even have a GP, and enable them to get the treatment they need. These posts have been abolished and again their function will now presumably fall to the already overwhelmed Access and Assessment Team, or who?
6. The Trust acknowledges that there is a backlog of unallocated referrals.
The Trust acknowledges this but tries to present it as a temporary situation which they are monitoring closely. Similarly they try to deny that workers have excessive caseloads and that the average caseload is 25-35. In reality the Trust has no caseload management system and Team Leaders are under pressure to allocate more and more cases to clinical staff who are unable to offer a safe service to their patients. The situation can only deteriorate as sickness levels increase and as staff who have been foolishly offered voluntary redundancy seize on the chance to escape from a stressful working environment.
7. The Trust denies that the Access and Assessment Teams have been a failure.
The Trust suggests that the Link-worker service was a failure and that the AA teams were set up as a request from GPs. There were some problems with the Link-workers service but probably the main problems was that the Trust were unaware of how much work they absorbed and how much work they diverted from secondary mental health services. The problem of an easy access to a prompt service is a difficult one especially in an area like Norfolk and Suffolk with such huge geographical spread and poor transport systems. A single-point of access was one of the key goals of the National Service Framework (remember that!). Having such a point of access did not mean having to abolish the link-workers. We understand that GPs are asking for the return of link-workers; Norwich CCG are in the process of consulting on a redesign of Primary Care Services; if this service is redesigned it will have to go out to tender. Who knows which organization will be the provider? Are we facing further fragmentation and privatization of mental health services in Norfolk and Suffolk? The Trust needs to rethink its strategy urgently.
8. The Trust denies that the Crisis Resolution and Home Treatment Teams are no longer providing a safe service.
The Central Cluster CRHT used to consist of two dedicated teams each with their own psychiatrist, their own assessors, social workers, CMHNs, support workers etc. Before the radical redesign the teams were amalgamated and were left with only one psychiatrist. Since then the team has taken on responsibility for older persons with functional illness, it is constantly asked to cover gaps in the service elsewhere so that frequently it is not able to cover care planned visits. Our psychiatrist has been off sick recently and we have been left, especially over the festive period without medical cover for acutely ill patients. Our social work establishment is running at 50% because of lack of cover for maternity leave and secondments, and the social fund we use to help people in dire straits has just been abolished. Members of the team are often tied up transporting patients hundreds of miles away to units in places like Dorking in Surrey, Harrogate and Weston, not to mention nearby places like Bury and Chelmsford. The Trust says it is its intention to “enhance” the CRHTs and make them a real alternative to hospital admission. If this is the case why have we just received notice that CRHTs will be going through the same disastrous process that the Community Teams have just been through. Staff have already started their one to one interviews and are being offered coaching in how to interview well so that they will be able to compete with one another for less jobs. The Trust will downgrade experienced staff and de-motivate them, will transfer some to other areas and will replace them with cheaper support workers; four Band 7 staff are going to join the team transferred from community teams but they will also be covering as Approved Mental Health Professionals. If you really want to develop the CRHTs as a real alternative to hospital admission, don’t disrupt it but add more medical cover and add support workers without reducing the numbers of qualified experienced staff.
9. The Trust denies that patients are being discharged too early.
In making this claim the Trust uses a benchmarking system of comparing themselves to other Trusts in the country. This ignores the fact that the service is in crisis nationally with 1700 psychiatric beds having been lost in the last 2 years (see report in national social work publication Community Care). We cannot believe that when there is such a pressure on beds and the Trust is spending a fortune on out of area placements that clinicians are not also being pressurized to discharge patients before they are ready. This is certainly our experience in the Crisis Resolution and Home Treatment Team where patients are being discharged under our care before a care coordinator has been allocated, or even before acceptance by a CMHT, and often to chaotic home circumstances.
10. The Trust admits that the wards are operating at over 100% capacity.
It does not admit however that this inevitably leads to a poor standard of care for many patients. Also the whole concept of rehabilitation is put in jeopardy as red leave beds are often filled by newly admitted patients. Informal admissions are often delayed even for serious cases of Clozapine titration.
11. The Trust plays down the bed crisis.
AMHPs warned the Trust over 18 months ago that the bed situation was at crisis point; since then the situation has got 10 times worse. It has now become impossible to document all the untoward incidents that are taking place in particular within the context of MHA assessments. For example, there have been two incidents in the last month where patients have been held illegally (ie breaching PACE regulations ) in police stations because of a lack of a suitable bed and a suitable means of conveyance to hospitals many miles from Norfolk. The Trust does not acknowledge this crisis at all, and is now going ahead with the closure of 13 predischarge beds at Hellesdon Hospital, which will only increase the pressure on beds.
12. There are often delays in voluntary and compulsory admissions.
The Trust does not comment on this point, so presumably it has no answer to it.
13. The Trust assert that caseloads are monitored closely and are at an average of 25-35.
Care Coordinators tell us that there caseloads are around 40+ mark even for part-time staff and that they are under constant pressure to take on more work; There appears to be no system in the Trust of caseload weighting, since the number of cases is not a measure of its workload, and allocation does not take into account other duties that the Care Coordinator has such as AMHP duty, supervision, special lead responsibilities, etc.
14. The Trust denies it is complacent in its response to the increase in unexplained deaths.
The suicide rate in certain categories has risen nationally in the last 3 years whereas before it was decreasing. One of these categories is “patients in contact with mental health services”. Our Campaign was launched by front-line staff following a fortnight of tragic events in which a number of service-users died. To us it made us question even more what was going on and we were starting to feel ashamed of the service we were being asked to provide; on top of this, quotes from the Trust’s senior management in the press came over as callous and complacent. You would think that these tragedies plus negative feedback from staff, service-users and carers about the radical redesign/service strategy would have led the Trust to call a halt to the plan and review it urgently. Instead it continues to deny any kind of crisis and plough on regardless; in this sense it is complacent and clearly divorced from the front-line experience.
RESPONSE FROM THE CAMPAIGN TO SAVE MENTAL HEALTH SERVICES IN NORFOLK AND SUFFOLK
DATED: 8th January 2014