Independent Oversight and Assurance Group on Tayside's Mental Health Services: quarterly report - February 2022 to April 2022

To:

Grant Archibald
Chief Executive, NHS Tayside

Greg Colgan
Chief Executive, Dundee City Council

Phil Davison
Divisional Commander, Tayside
Police Scotland

Thomas Glen
Chief Executive, Perth and Kinross Council

Margo Williamson
Chief Executive, Angus Council

8 June 2022

Dear Colleagues

Quarterly report - February to April 2022

Please find attached to this letter, a copy of the Oversight Group’s second quarterly report, covering the period February to April 2022. The report has been signed off by the Minister for Mental Wellbeing and Social Care, and it is our intention to publish the report at 12 noon on Friday 10 June. Can I ask that you please share this with your Chairs and Leaders, as appropriate, prior to publication and with a reminder about the need for confidentiality at this stage.

You will also be aware that the Terms of Reference commit us to publishing copies of all formal letters from the Oversight Group to the Tayside Executive Partnership. This letter will therefore also be published on the website accordingly. The Secretariat will provide you with a link to the website once the report has gone live.

Best wishes.

Fiona Lees

Chair of the Independent Oversight and Assurance Group on Tayside’s Mental Health Services

Second quarterly report to the Minister for Mental Wellbeing and Social Care - February to April 2022

Introduction

The Oversight and Assurance Group’s terms of reference requires us to report on progress on a quarterly basis to the Minister for Mental Wellbeing and Social Care. This is the second such report, updating the Minister on our work to the end of April 2022. The report provides an update of the work carried out in the last three months or so; a description of the engagement we have had so far; and an outline of the work we intend to undertake with TEP colleagues in the coming weeks and months as we move towards our final report in Autumn 2022.

Overview

In our first Quarterly Report, we reported on the outcome of the assessment of progress we had undertaken of all 51 of the recommendations from Trust and Respect. You will recall there was a significant gap between our assessment and that of Tayside Executive Partners. We continue to believe that this is a gap which is capable of being closed. 

This report does not provide an update of our assessment on the 51 recommendations. We do not believe it would be particularly helpful, or practical, to provide a running commentary on the status of those recommendations. Rather, we have been focusing our work on the four workstreams to gain assurance on the work that is underway in Tayside to transform mental health services. We will, of course, provide a final assessment of progress against the 51 recommendations in our final report, which we expect to publish this Autumn.

Due to the pandemic and the impact of successive variants, we have not been able to spend as much time in Tayside as we would have wished or to meet in-person with colleagues. Happily, that is changing, and we are all now in Tayside on a regular basis, meeting with Tayside Executive Partners, local teams from across the health service and the partnerships, third sector and stakeholders including people with lived experience: the difference has been palpable. Such engagement across Tayside will continue at pace over the next three months.

Programme of engagement

We continue to engage widely with stakeholders across Tayside. Since our last report, we have undertaken a significant number of meetings and engagement sessions, many of which are now taking place in person. This section of the report provides some more detail on our programme of engagement.

We continue to meet regularly with the Tayside Executive Partners and have set out a clear meeting schedule which takes us up to October 2022.

We are meeting bi-monthly with the Stakeholder Participation Group (SPG). The experiences of the group’s members continue to be at the forefront of our collective scrutiny and assurance considerations. We are also making plans to meet with the much wider group of individuals who engaged with Dr Strang on his original report.

Our meetings with third sector organisations have been particularly helpful in increasing our understanding of the breadth of work that is taking place on the ground. For example, we have visited The Neuk in Perth to learn about the excellent work they do in supporting those experiencing mental health crises. What we are not yet seeing, however, is this excellent local work being drawn together at scale and finding its way into strategic plans to shift the balance of care across Tayside.

We have convened sessions for both constituency and regional list MSPs, as well as Members of Parliament. The recurring themes from these meetings have been concerns over the safe and effective delivery of mental health services, culture and the need to increase the pace of change.

There is a great deal of crossover in respect of the Oversight Group’s work with substance use and reducing drug related deaths in Scotland. On that basis, we met with colleagues from the Dundee Drugs Commission in advance of the publication of their report “Time for Kindness, Compassion and Hope: The Need for Action Two Years On”. Many of the recommendations align with those in Trust and Respect, as does the need for culture change and pace on delivery.

We have also met with Dr David Strang, the purpose of which was two-fold: firstly, to connect with Dr Strang in his new role as Head of the Drug Deaths Taskforce; and secondly, to recap on particular aspects of the Trust and Respect recommendations where further discussion was very helpful.

We are also engaging with Healthcare Improvement Scotland to understand the work they are leading around care pathways for those with addiction and mental health issues. We also plan to meet Public Health Scotland colleagues to hear more about the work they have been leading on the implementation of the Medication Assisted Treatment (MAT) Standards. 

We have met with each of the Council Leaders and with the Chairs and Vice-Chairs of each Integration Joint Board (IJB) in Tayside as we look to deliver on our integration themed work plan. We continue to seek assurance that the review of integration schemes in Tayside provides the required clarity and understanding on roles and responsibilities in relation to the commissioning and delivery of mental health services. We will meet with the IJBs again in June.

Sessions have been arranged in May between the Oversight Group with Healthcare Improvement Scotland and with the Mental Welfare Commission who both have vital roles in respect of oversight and assurance and in sharing intelligence, which was reflected through Trust and Respect recommendation 12.

Themed work plans

We are now heavily engaged in the next phase of our work which as you are aware, focuses on the key areas arising from our assessment of progress namely:

• integration
• patient safety
• culture and engagement
• workforce

We have put in place work programmes in support of each of these areas, which we are now taking forward and are published on the Scottish Government’s website. We have set out for Tayside Executive Partners what we need to see, what we need to know and understand, along with our next steps. This includes meeting with teams from across the partnerships, spending time in hospital and community settings, meeting with employee groups and trade unions, visiting local community projects, engaging with stakeholders and listening to people with lived experience.

Work plan 1 - integration

Prior to our appointment as an Oversight and Assurance Group, Tayside Executive Partners had already commenced the Review of their respective Integration Schemes (IS).

Trust and Respect recommendation 5 (‘Review the delegated responsibilities for the delivery of mental health and wellbeing services across Tayside, to ensure clarity of understanding and commitment between NHS Tayside and the three Integration Joint Boards. This should include the decision to host General Adult Psychiatry inpatient services in Perth & Kinross Integration Joint Board’) is a key foundation for the improvement of mental health service in Tayside. Tayside Executive Partners indicated that they would ‘Develop successor schemes for all services in Tayside’ as part of their response to this.

From our earliest engagement in Tayside, it was apparent that the operation of the IS required attention with the need for “clarification” frequently being cited by many of those we spoke to, as being “missing” and a barrier to progress. This included some of the Chairs and Vice Chairs of IJBs, senior colleagues and local stakeholders. This has therefore been a priority action for the Oversight and Assurance Group.

Revised draft Integration Schemes for Angus and Dundee have been out for consultation since the end of March and these consultations are concluded. The Perth and Kinross consultation has also just concluded, having been delayed due to further continuing dialogue between that Council, the Health Board and the other two Councils. We understand that this dialogue has centred on roles and responsibilities on Mental Health inpatient services..

Despite the fact that the review of the schemes has been described to us as ‘light touch’, it has clearly been an extensive and lengthy process. It was therefore surprising that some important issues surfaced with the Perth and Kinross scheme so late in the day.

In relation to the central issue identified by David Strang - strategic planning and commissioning of services, and operational management of GAP inpatient services – it is evident that there has been a greater level of clarity set out in the Schemes that have been consulted upon in Angus and Dundee, and further clarity again is contained in the Perth and Kinross scheme. Partners expect that this further clarity can be incorporated within the Dundee and Angus Schemes before being considered by the respective IJBs.

We have expressed concern to the Tayside Executive Partners regarding the extent and scope of the consultations being undertaken on the revised integration schemes. These concerns are broadly as follows: the length of time for consultation is around 3 weeks in length; the consultation does not appear to include any face-to-face engagement; and there is little detail that accompanies the consultation materials, to explain the need for any changes that are being proposed.

There is clearly continuing work that will be required following the conclusion of the revision of the Integration Schemes, not least on how the revised Schemes land and are operationalised by all the parties. We have indicated to Tayside Executive Partners that they should begin to consider their action plans in this regard.

As part of our work programme on Integration, we expect to have meetings with the Chairs, Vice-Chairs and Chief Officers of the IJBs in June as a follow-up to the conclusion of the Schemes’ reviews with a view to exploring with them how they will ensure that they will fully take forward their respective responsibilities.

Work plan 2 - patient safety

This work plan brings together 14 recommendations from Trust and Respect, including Significant Adverse Event Reviews; anticipatory care planning; de-escalation; inpatient psychological services and support for junior doctors. This plan also includes the national recommendation 32 for the Scottish Government, on the need for guidelines on substance misuse on inpatient wards.

We have received a detailed presentation from the clinical and professional senior leads within Tayside on their revised approach to adverse events learning, incorporating national guidance, which is currently being implemented. Tayside are reporting that they have significantly reduced the outstanding Significant Adverse Event Reviews (SAERs), although nearly all of the remaining reviews are beyond the expected completion timeline of 140 days and they are as yet unable to say when they expect to be concluded. They have been asked to consider this and provide clarity to us.

We have indicated to NHS Tayside that we will want to undertake a sample review of the SAERs that have been completed since October 2021, when the new process was systematically implemented across NHS Tayside and within the HSCPs. The Oversight and Assurance Group will be seeking a subject matter expert to conduct this review. 

We welcome the progress that has undoubtedly been made. There remains some way to go before Tayside are able to demonstrate that they have a robust and consistent independent process in which stakeholders, principally patients and their families, can have confidence. There is a need to demonstrate that learning from each review is systemic and sustained. We will want to spend more time with colleagues in Tayside to understand how lessons learned from adverse event reviews are being applied across services.

We have heard from Tayside partners that significant work is underway in relation to de-escalation approaches within inpatient units. This is positive, and we have explored this further with frontline staff during site visits to Carseview, Strathmartine and Murray Royal. We have seen the ownership being demonstrated by the leadership of Senior Charge Nurses at ward level, and the extent to which they can speak to the positive impact they are having. During these visits we have considered all patient safety issues raised by Dr Strang including the matter of the ward locking practice in the inpatient wards.

We have been struck by the genuine commitment, passion and compassion of staff that we have met during our visits. We are encouraged by the way that de-escalation policy and practice has been embraced within the inpatient units. We have seen evidence that the inpatient wards are able to begin to demonstrate the positive impact of new ways of working that are person-centred and less medically orientated. Of course, there is always more to do, and we will continue to seek assurance that the new approaches are truly embedded and being rolled out in a sustainable way.

We have also become aware of some issues that require urgent attention by the Tayside Executive Partners:

There is a need to progress the decision about single site provision in Tayside for inpatient Mental Health care as a matter of priority. The lack of action to address this over the past several years has created a barrier to progress for the Health Board, in terms achieving sustainable clinical inpatient care and also the delivery of whole system care in which the population of Tayside can have trust and confidence.

Environmental issues arising from the accommodation provided to patients with a learning disability at Strathmartine, in our view, raise concerns for patients and staff who care for them. We have raised this matter with NHS Tayside and we will also wish to discuss this with HIS and MWC.

Finally, during our site visits and engagement with key stakeholders, we have become increasingly aware of significant issues of delay in discharge for some patients who do not require to be in either the Mental Health or Learning Disability inpatient beds.​​​​​​

Work plan 3 – culture and engagement

This work plan brings together 15 recommendations from Trust and Respect, including arrangements for engagement, the development of relational practice, cultural change and specific work around exit interviews, bullying and harassment, stress management and support for employees. We will be taking forward this work plan towards the end of June / early July and will, to some extent, draw on all our other work.

Work plan 4 - workforce

This work plan brings together 10 recommendations from Trust and Respect and focuses on the steps Tayside Executive Partners have taken to support employees and to facilitate their engagement in the change process. Other recommendations address the need to have in place an effective workforce strategy with plans to deliver the workforce of the future. We will progress this work plan from June to August.

Other themes

There are a number of other recommendations which we will seek to progress in parallel with these four primary workstreams. These are in respect of children and young people, performance and governance. We have spent time in Tayside hearing from colleagues on those recommendations made by Dr Strang on CAMHS provision. We continue to be impressed with the practice we have seen around CAMHS service delivery, some of which we think is of national significance.

On performance, we have drawn together 3 recommendations including the need for timely and accurate performance reporting, data capture and analysis programmes to better respond to community need.​​​​​​​

The governance work plan draws together 4 recommendations including members of NHS Tayside Board being clear about their responsibilities, and confident and empowered to challenge and make sound decisions, and national recommendation 12 for the Scottish Government regarding assurance and scrutiny of mental health services across Scotland.​​​​​​​

We have met with the Chair of NHS Tayside and attended meetings of the NHS Tayside Board and its Standing Committees. We have identified a number of issues regarding governance and we have offered to spend further time with the Chair and Committee Chairs to provide feedback.​​​​​​​

Next steps​​​​​​​

Our terms of reference are due to be reviewed and only one minor addition is proposed to respond to a request from Tayside Executive Partners that engagement with IJBs be included.​​​​​​​

We have been giving thought to the structure of our Final Report. The Report will include our final assessment of progress against all 51 recommendations, but it needs to be much more than that. We believe there needs to be a level of confidence with regard to Tayside’s commitment and ability to continuously improve, with arrangements embedded in support of that. Accordingly, we consider that we need to comment on Tayside’s capacity for improvement along with an assessment of the support we think they need. This will include the extent to which Tayside Partners have a clear, resourced, delivery plan in place to deliver Living Life Well, their Mental Health Strategy published in February 2021.​​​​​​​

Further, even where we are recording a “Green” assessment on recommendations, it may be necessary to recommend further action to ensure progress is sustained. Many of the issues contained in Trust and Respect will always be a work in progress, in the spirit of continuous improvement.​​​​​​​

During our meeting with Tayside Executive Partners in February, we recommended that they produce their own report towards the end of the process, which would also be for a wider audience. We discussed this further with the TEP at our meeting in May and we expect them to be producing this report by mid-September.​​​​​​​

Finally, NHS Tayside continues to be an escalated Health Board in respect of its delivery of mental health services. At Escalation Level 3, Tayside can expect to receive an “Scottish Government commissioned tailored support package". We are keen to understand exactly what this means and what arrangements will be in place to support continuous improvement and take a level of assurance about ongoing support to the Board, following the Group’s conclusion in the Autumn.​​​​​​​

Fiona Lees

Chair of the Oversight and Assurance Group

31 May 2022​​​​​​​​​​​​​​​​​​​​​