Independent Oversight and Assurance Group on Tayside's Mental Health Services: quarterly report - May 2022 to August 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 third such report, updating the Minister on our work to the end of August 2022. The report provides an update of the work carried out in the last four months or so; a description of the engagement we have had so far; and an outline of the work we intend to undertake with Tayside Executive Partner colleagues in the coming weeks and months, as we move towards our final report in Autumn 2022.

Overview

We have now significantly progressed our four published themed work plans which focus on the key areas arising from our assessment of progress, as follows:

• integration
• patient safety
• culture and engagement
• workforce

The Tayside Executive Partners (TEP) have designated one of the Chief Officers and the Executive Director of Nursing to each lead on the work plans and this has been appreciated.

We have also progressed work to examine a number of other recommendations in respect of children and young people, performance and governance.

This report provides an update on all of the work plans, our lived experience engagement and we set out what we consider to be the next steps.

Themed work plans

Work plan 1 - integration

Since our last report, the successor Integration Schemes have now all been consulted upon and approved by the respective Councils and Health Board and submitted to the Scottish Government.

It is our opinion that the revised Schemes substantially improve the level of clarity regarding roles and responsibilities of the Integration Joint Boards (IJBs), Councils and Health Board in general terms, and specifically in respect of Mental Health and Learning Disability provision.

The headlines from the Integration Work Plan - which brings together six recommendations from Trust and Respect - have focussed primarily, but not exclusively, on recommendations 2, 5 and 13, and are as follows:

• the revised Integration Schemes are now much clearer and there is no room for doubt as to where responsibility sits for Mental Health and Learning Disability provision in Tayside
• there are one or two areas (for example Lead Partner responsibilities regarding Primary Care across Tayside, and certain children and young people health services) that will require further discussion between all the parties as to how exactly the responsibilities set out in the revised Schemes are to be carried out in practice
• field visits by the Oversight Group have identified very good integrated health and social care provision in some areas, including some of national significance. Specifically, we want to commend the Discharge Hub in Dundee; the work in Dundee that has been undertaken to understand and make appropriate provision for autism in the universities; maximising the opportunities available through Action 15 funding in Angus; the streamlining of approaches to assessment of Autism Spectrum Disorder (ASD) in Arbroath; peer support provision; the provision of 24/7 crisis support by The Neuk in Perth is an exemplar service; the work of ‘The Saints’ at St Johnstone points to the reach and positive impact football continues to have within communities; and the quality of support and services provided by voluntary organisations across Tayside
• however, the commissioning of services to be delivered by Health Board and Councils, and of new developments, are not emerging by decision of IJBs. The overwhelming majority of decisions taken by all of the IJBs is 'to note'
• the story is of IJBs being presented with periodic updates of activity that are being planned for and commissioned, but it would appear it is the Health and Social Care Partnership (HSCP) / Chief Officers (CO) making most decisions on this, along with resourcing and allocations, rather than the IJB. By way of an indication of this, much of the good work that is referenced above has never been visible, in formal reporting terms, to any of the respective IJBs
• the IJBs do not generally issue Directions to the Health Board or Council directly. Where Directions are issued, they appear to be from the Chief Officer following a decision by the IJB ‘to instruct the CO to issue Directions’ and there is little or no specificity about them

The Oversight Group met with the Chairs, Vice Chairs and Chief Officers in their respective localities in the week beginning 20 June and also with TEP on the 5th July. In these meetings, a PowerPoint presentation was made on the Oversight Group's observations not only of the revised Schemes but also on the functioning and performance of the IJBs in regard to Mental Health and Learning Disability historically. All parties have been made aware of where the Oversight Group believes the remaining areas of uncertainty may lie, in order that they can reflect on how to avoid confusion and ensure clear lines of responsibility. The presentation also highlighted the issues that the Oversight Group believe there are in the functioning and performance of the IJBs hitherto. The PowerPoint presentation to TEP is to be published along with the minutes of all our meetings with TEP.

We have indicated to TEP that they, along with the leadership of the IJBs, will need to demonstrate to us by the end of September how they are going to individually and collectively respond to the revised Integration Schemes and the clarity that these now provide, to ensure that Mental Health and Learning Disability provision delivers the services that people need. We will also be scheduling one final meeting with the three Chief Officers in September to consider progress being made in each area on this. There is much work to be done by the IJBs, the Health Board and the Councils to ensure the effective discharging of responsibilities now more clearly set out in the revised Schemes. 

The Oversight Group was surprised that at the Health Board meeting on 30 June, when all three revised Schemes were presented for approval prior to submission to the Scottish Government, there was not a single comment or question from non-Executive Directors. Given the importance of the schemes to the operation of the Health Board generally, and in mental health and learning disability provision in particular, we would have expected to see a greater degree of engagement and scrutiny from Board members.

Finally, we plan to take a detailed look at work being done to develop a model of integrated service for people with a dual diagnosis in respect of mental health and substance use. This is addressed in Recommendation 14, but we believe has now been superseded by Medication Assisted Treatment (MAT) Standard 9. In any event, we are seeking more assurance on the pace of progress and what seems to be a fragmented approach. We have asked to meet with those directly responsible for this work.

Work plan 2 - patient safety

The patient safety 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. The plan also includes the national Recommendation 32 for the Scottish Government, on the need for guidelines on substance misuse on inpatient wards. We have substantially completed our work in respect of this plan following our final meeting with the Executive Director of Nursing at the end of July.

We have looked in some detail at Recommendations 11 and 31 relating to Significant Adverse Event Reviews (SAERs). We held a comprehensive and scrutinous discussion with the Executive Director of Nursing and her colleagues at the end of July. In particular, we explored in depth the robustness of whole system learning from events; the involvement of families and carers; openness about failures, closing the loop and sharing learning; and the protocol for reviews for unexpected deaths where mental health and substance abuse issues were present.

The final piece of work to be undertaken on the Patient Safety work plan is the external Subject Expert Review of the completed SAERs since October 2021, of which we are advised there are five. A remit has been agreed between the Oversight Group and the two external experts and they are aiming to complete their work by the end of September. 

There has been significant work undertaken by the HSCPs to apply the new definition of 'complex case' that has been developed in response to Recommendation 17. There is now clarity across the three areas as to the numbers of patients that are on the caseload for each Community Mental Health Team (CMHT) and within that, how many patients are deemed to be complex. This work has identified a number of further issues which are of note:

• the achievement of arriving at a definition of 'complex case' is worthy of commendation. We have been advised that there is no nationally set and shared definition and we have been advised by Tayside that they are the only Board area that has produced such a definition
• however, NHS Tayside and its HSCPs, operate seven different variations of a care plan, each of which broadly incorporates many of the areas for patient consideration that the HIS Anticipatory Care Plan (ACP) document contains. This could create confusion for staff and clinicians, but more importantly lead to a disparity of service provision to patients across Tayside. We have indicated that for all new patients deemed to be 'complex' - or for existing patients who are at a later stage reassessed as complex and who therefore should have in place an ACP-type document - NHS Tayside need to consider adopting just one of the seven care plans they currently use and apply it consistently across Tayside
• the work undertaken on complex care definitions has provided the Tayside Partnerships with a strategic opportunity to contribute to a shifting of the balance of care in mental health services as it has identified that just 40% of the CMHT caseloads in Angus and Dundee and only 25% in Perth and Kinross are considered to be complex. This, in our opinion, creates an opportunity to be more creative for those non-complex patients who remain on CMHT caseloads in the support arrangements made for them which needs to be considered by the Tayside Partnership

We have seen and heard much that is good and positively developing across Tayside in relation to the Patient Safety work plan recommendations. We have also noted that this tends to be in pockets of services and places. There is, therefore, still significant work to be done to ensure consistency of application of new and revised policies, practice and innovative models of provision (some of which are of national importance) across Tayside.

We have also heard examples from family members and carers with lived and living experience of where provision continues to be less than satisfactory. Whilst most of this is of a historical nature and was reflected to Dr David Strang in his evidence gathering for Trust and Respect, the fact that the issues of concern continue for these family members and has not been addressed by the Tayside Partnership is an issue for us. We will reflect further on this as we address our final work plan, Culture and Engagement.

Some of the stories we have heard from family members and carers are not historical and as described, point to an experience that is not at a level that is either in keeping with the improvements introduced by Tayside in response to Trust and Respect or consistent with safe and protective standards of provision. In such circumstances, we have engaged separately with key clinical and professional leads in Tayside, to draw attention to the respective family or individual’s story and their experiences which, in turn, may also point to wider lessons which would inform our work.

Work plan 3 - culture and engagement

We have deliberately kept our focused activity on culture and engagement towards the end of our considerations as, to some extent, our work across all the work streams informs our judgements around culture and engagement.

The work plan for culture and engagement covers fifteen recommendations from Trust and Respect and there is some overlap with the workforce theme (see below), given the importance that Dr David Strang rightly attached to staff engagement in his report. 

It is no coincidence that the first recommendation in the Trust and Respect concerns culture. It is worth repeating here in its original form:

Recommendation 1 - Develop a new culture of working in Tayside built on collaboration, trust and respect

Culture is a notoriously challenging concept to manage and, subsequently, to measure. This is particularly true in the context of complex systems, such as mental health services in Tayside. But it is absolutely central to the Trust and Respect report and to the Living Life Well strategy. It is therefore important that we are able to give assurance on the extent to which TEP is building the kind of culture envisaged by Dr David Strang, built on ‘collaboration, trust and respect.’

Members of the Oversight Group spent a day with the Integrated Leadership Group (ILG) on the 2nd August, discussing in some detail the recommendations relating to culture and engagement. As ever, we are grateful to colleagues for their time and candour in that meeting. Our observations so far on culture and engagement are as follows:

• we are encouraged by the fact that members of the ILG recognise that there remains a long way to go in relation to building a new culture for mental health services across Tayside. As things stand, we have not seen evidence of a clear strategic plan to develop the culture of mental health services across Tayside, and there is no baseline against which TEP can measure progress
• that said, we recognise that there are many new faces around the ILG table, presenting an opportunity to develop and embed new ways of working. We heard from this group of senior leaders how their own relationships and ways of working have improved over the last 12 months or so, providing a good foundation from which to build
• in the end, positive organisational cultures need to exist across services and need to be felt and nurtured by all members of staff. Culture makes a difference day in, day out, to how services are experienced by patients and their families. Cultures within teams are therefore critically important and we have seen evidence, across all of our work streams, of practitioners doing their best in local teams to develop positive ways of working. It is also fair to say we have heard, particularly from the families of patients, of instances where culture and practice fall well short of what the Trust and Respect report envisaged
• finally, we are struck by the clear public pronouncements made by TEP since the Trust and Respect report was published. TEP published its collective statement of intent on publication of the original report, and the Living Life Well strategy contains a Collective Leadership Promise from TEP, setting out 13 commitments. We are engaging with TEP to better understand how this work is being progressed, and how it will demonstrate to the people of Tayside that it is keeping its promise

The final part of our work to address culture and engagement is a series of 1-1 meetings with TEP colleagues during August and September, and we are looking forward to exploring these questions with them in more detail.

Work plan 4 - workforce

This work plan brings together ten recommendations from Trust and Respect and there is some overlap with Work Plan 3 on culture and engagement. Members of the Oversight Group spent two days in Tayside on the 28th and 29th June focusing on issues around workforce. We have, of course, spoken to many members of staff throughout our work on other work plans, particularly patient safety, so these two days built on our experience so far, rather than starting from scratch.

Once again, we are struck by the commitment, professionalism and resilience of colleagues across Tayside, in both inpatient and community mental health teams. We are grateful to all concerned for their time and candour during our meetings.

We spoke to a range of colleagues in Carseview and Strathmartine, as well as colleagues from the Human Resources (HR) and Organisational Development (OD) teams and staff side representatives from NHS Tayside. We also met with colleagues from community mental health services across Angus, Dundee and Perth and Kinross. We then spent half a day with the ILG doing a deeper dive into each of the recommendations.

There remains work to be done to fully assess the evidence we have gathered in relation to workforce and TEP’s final assessment will provide an important input to our final considerations. That said, we would make the following observations in relation to progress against the workforce recommendations:

It is clear that teams across Tayside are under severe pressure due to unprecedented demand and staff shortages (caused by vacancies and absence). Teams are doing all they can to mitigate these pressures on a day-to-day basis, but it is taking its toll and we have detected, at times, a fragility in some staff and managers’ emotional resilience as they discuss the carrying out of their duties.

The workforce strategy presented to the Oversight Group is very high level and requires further development if it is really to shape decisions around the future of the mental health workforce in Tayside. It remains challenging for the partners to plan on a pan-Tayside basis, and much of the human resources and organisation development support continues to be NHS Tayside focused.

There is a feeling, particularly in inpatient teams, of ‘ground-hog day’. We found little expectation that things were going to be different this time around. Staff with longer service spoke of the many different reviews and oversight groups that have come and gone in Tayside over the years, and felt that fundamental, sustainable change remained elusive.

• we have discussed what level of local system support has been in place to address the trauma of working in mental health in Tayside over these last few years and in particular, in response to Trust and Respect, which continues to attract negative media attention
• not surprisingly, the issue of resources came up in our discussions with staff, both in overall terms and in terms of how the available resources are distributed across the mental health system in Tayside. Trust and Respect Recommendation 2 calls for a whole system strategy which will require TEP to ensure that needs and resources are addressed, in terms of an action plan and resource framework
• we explored in some depth important HR and OD processes such as sickness absence, exit interviews and performance appraisal. The ILG recognises there is more work to do here and will be providing further information as part of their final assessment
• there continues to be a need for more visible leadership in some parts of the system. Some colleagues feel very strongly that decisions around the future shape of inpatient services needs to be progressed urgently. Staff continue to do their best to take action to improve care for their patients within their immediate sphere of influence, but there is a strong sense of powerlessness when it comes to more strategic decisions
• it is therefore imperative that TEP provides collective leadership across the system and ensures that progress can be made and decisions taken in a way that provides for meaningful engagement with colleagues across mental health services in Tayside

Work plan 5 - governance

Throughout our work we have taken a strong interest in the extent to which effective governance is in place across the mental health system in Tayside. This is important for many reasons, particularly in ensuring that Board members, both in IJBs and NHS Tayside, have sufficient information and feel equipped to make the difficult decisions that lie ahead. There are several recommendations in Trust and Respect that relate to governance.

Our work has included undertaking an analysis of Board papers for the three IJBs and NHS Tayside. We have also observed Board meetings of all four organisations, including the standing committees of NHS Tayside. Our analysis of this work is ongoing and we will publish our conclusions in our final report.

We have provided feedback to the Chairs and Vice Chairs of the IJBs, and have offered a similar meeting to the Chair of NHS Tayside. The Chair has informed us they would prefer to invite the Oversight Group to a Board meeting to discuss our final report after its publication. We will therefore write to the Chair separately with our observations on governance.

Work plan 6 - performance

The performance work plan covers four recommendations, including national Recommendation 12 for the Scottish Government which relates to conducting a review of the scrutiny landscape around mental health services. On this recommendation, we have met with Scottish Government officials, and we are clear on work to date and more importantly, plans going forward. We have issued guidance on the final submissions we need to receive in respect of both Recommendation 12 and 32.

Whilst the Scottish Government has lead responsibility for Recommendation 12 around scrutiny, it is of course incumbent upon those national organisations who have a responsibility for assurance, inspection and improvement, to assure themselves that they are taking proportionate and effective action in respect of Tayside. We are keen to understand how the wider scrutiny and improvement systems have responded to the Trust and Respect report and, more importantly, the kind of scrutiny and support that will be in place for Tayside moving forward. We met with the Mental Welfare Commission on 31 May and we have now received their written submission which we will consider. We met with Healthcare Improvement Scotland on 29th August to better understand how they have responded to Tayside, within the current context.

In respect of the remaining recommendations on performance, we will be issuing a question set to TEP. In particular, we are keen to see the information Tayside relies upon for their own assurance and of the arrangements they have put in place to deliver timely, accurate and transparent public reporting which is covered in Recommendation 8 which also references the need to rebuild trust. To this end, we had a useful meeting with Public Health Scotland on 24th August to understand what performance information is available on a national basis. We will be exploring with NHS Tayside the extent to which they make use of this data.

Work plan 7 - children and young people

This work plan covers seven recommendations and we have spent time with CAMHS in Tayside and have issued our final question set. Some further engagement is planned, particularly in respect of advocacy and young people’s organisations.

Engagement

We have continued to engage with a wide range of people and groups as we progress our work. We continue to meet regularly with the Stakeholder Participation Group (SPG), which came together as a result of Dr David Strang’s call for evidence during the Independent Inquiry. The SPG made a significant contribution to the Inquiry and they continue to be an important point of reference and sounding board for the Oversight Group.

The SPG presently has membership on at least 14 Working Groups or Project Boards set up by Tayside partners to advance local community mental health strategies and Living Life Well. This is not sustainable and TEP need to find better ways of engaging with this group of people. While we recognise that there are many other groups and organisations with a keen interest in mental health services in Tayside, we believe there is an opportunity to reset the relationship between TEP and the SPG. The approach to engagement is an important element of recommendations 3 and 4 and we are looking forward to hearing more about this in TEP’s final submission to us. 

For our own part, we have continued to meet with a number of organisations in respect of our Work Plans, including:

• Dundee Voluntary Action
• Reach Across, Arbroath
• Brooksbank Centre, Dundee
• Mandown, Montrose
• Penumbra, Angus
• The Saints at St Johnstone
• Perth and Kinross Mental Health and Wellbeing Festival
• Carse of Gowrie Men’s Shed, Dundee
• Feeling Strong, Dundee
• The Hot Chocolate Trust, Dundee
• The Samaritans, Perth
• PKAVS Mental Health and Wellbeing Hub Walled Garden, Murray Royal
• Advocacy organisations from across Tayside

During our time in Tayside, we have received unsolicited requests from individuals who have themselves experienced mental health services or who have worked in Tayside. In all cases, we have met with people but have been clear that the Oversight Group has no powers to investigate, or to take evidence, and that we cannot become involved in individual cases, nor advocate on behalf of individuals or their families. Our purpose therefore has been to listen to people’s story and their experiences which, in turn, may point to wider lessons which would inform our work.

Throughout our engagement, people have been very open with us and we are grateful to have heard their stories. We have been humbled by the trust people have placed in us and by the importance they attach to our work as an Oversight Group, reporting directly to Scottish Ministers.

Next steps

We are now entering the final phase of our work. We have shared with TEP our thinking on the structure of our final report which, in addition to providing a reassessment by the Oversight Group of progress against all 51 recommendations from Trust and Respect, will also include an assessment of the commitment and capacity within Tayside for change and improvement. This will include commentary on Tayside’s leadership of the transition from Listen Learn Change to Living Life Well, and the need for an accompanying action plan and resource framework.

We have issued further guidance to TEP, with the request that they use this to provide us with a realistic and current assessment of progress utilising the same RAG status definitions we used in November 2021.

We have also asked TEP to provide us with their own collective assessment of their delivery as a leadership group against their Collective Statement of Intent and their Collective Leadership Promise, set out within Living Life Well.

Finally, it should be noted that our Second Quarterly Report, published in June, contained three recommendations for TEP:

• a need to progress the decision about single site provision in Tayside for inpatient Mental Health care as a matter of priority
• addressing environmental issues arising from the accommodation provided to patients with a learning disability at Strathmartine
• addressing the 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

We do not expect these difficult issues to be resolved by the time we produce our final report. Our expectation is that we see fit-for-purpose plans and evidence of early action in respect of these areas, by the time we conclude our work.

We plan to be in a position to submit our final report to the Minister upon conclusion of our work at the end of October, for publication thereafter.

Fiona Lees

On behalf of the Oversight Group

5 September 2022