Independent Oversight and Assurance Group on Tayside's Mental Health Services

Appendix 3: Tayside Executive Partners' Final Submission To The Oversight Group

Independent Oversight and Assurance Group for Tayside's Mental Health Services

Purpose of this document

This paper forms the Tayside Partners written submission to Independent Oversight and Assurance Group on Listen Learn Change progress at 07Oct22.

Setting the Context

The story of Mental Health service change in Tayside is one of evolving transition over the long term. This particular chapter of change begins with and moves through:

• the commissioning of the Independent Inquiry in 2019;
• the publication of Trust and Respect in 2020;
• the drafting and publication of Listen Learn Change (LLC) which is the action plan response to Trust and Respect) in 2020;
• the publication of Living Life Well (LLW) in 2021;
• the conversations with the Independent Oversight and Assurance Group (IOAG) through 2021/22;
• the implementation and progression of actions within LLC and LLW up to 30Sep22. And finally;
• the intentions and provisions for the continuing commitments and efforts to improve our Mental Health services in Tayside beyond 30Sep22

The following briefing represents collaboration across the Tayside Partners (Angus Council, Dundee Council, NHS Tayside, Perth and Kinross Council and Police Scotland) and their broader networks to tell the story of two years worth of change across 49 recommendations, during a time within which an unprecedented global pandemic occurred. The briefing aims to set out the story of change in a way which is transparent, based on evidence, and which sets a shared recognisable staging post for future plans and continuous improvement.

Engagement is a key theme throughout Trust and Respect. Effective and impactful change follows the principles of the Staff Governance Standard and partnership working. In order to fully realise the Tayside Partnership's ambitions, it is vital that change appropriately involves its staff, its partnership colleagues, and its communities at all stages of planning and implementation. There is recognition that the approach to this has been variable. There are strong examples of successful engagement and partnerships, and yet there is significant work still to be done in this regard. There is an intention, therefore, as an immediate next step following submission, to share this document and co-ordinate a set of conversations with; local committees, boards, staff partnerships, staff, delivery partners, people with lived experience, and the broader communities that constitute Tayside.

The scope of Trust and Respect was wide, and so this briefing is also broad in scope. Whilst each of the 49 narratives responds to a specific recommendation, the reader will see overlap, inter-dependency and cross-reference throughout. This reflects the whole-system of care and the inter-relationship of each of the partner organisations within it. Some recommendations naturally cluster together, so the reader is encouraged to consider not just each narrative, but also how these inter-relate to tell the story of our improvement journey

A "Red Amber Green" (RAG) system has been designed by the IOAG to help make visible progress towards and distance from the outcomes being pursued. The definitions used here are different than those used earlier in the change process. RAG ratings assessed in isolation may lead the reader to wonder how they are arrived at and why, in some cases, things appear to have deteriorated compared with previously publicly reported RAG ratings. Changes in RAG ratings are not just derived by what has changed in practice. They are also derived by the understanding of the recommendation, the way outcomes are described, and the interpretation of progress towards those outcomes. For these reasons, comparisons of current RAG ratings with past RAG ratings are problematic.

In his progress report "One Year On", Dr Strang assessed an over-reporting of progress, which led to a challenge about the credibility of self-assessment against his recommendations. The opportunity provided by IOAG, therefore, is welcomed to lay out for the reader, for each recommendation;

• the intended outcomes being sought;
• an understanding of why the recommendations arose and what they mean;
• what's been done so far;
• how RAG ratings reported herein have been arrived at; and
• Intentions for planned changes, set out in clear terms.

Reporting in this way will hopefully reduce the risk of disparity in the interpretation and assessment of progress to date, and will enable consistent reporting and tracking of progress moving forward.

Finally, change is rarely linear or complete where mental health and wellbeing support is concerned. That is particularly true around relational change, and around recommendations made in relation to culture and workforce. The overarching message that the Tayside Partners wish to convey, therefore, is one of continuing progress. Whilst there is a full commitment to celebrating with teams and communities the many improvements in care that have been achieved so far, local plans extend beyond Listen Learn Change and into Living Life Well. As progress and actions taken over the last two years are considered, the operating context has changed, services have changed, the workforce has changed and through collaborative leadership, thinking has moved on. Recognising that there are things that have been done well, there are things that could have been done better, particularly in how more could have been done to involve people fully in the journey. The local approach to managing change across these services has evolved in relational terms. The partner organisations included in the programme consider it a strength to be in a more reflective and collaborative place. There is an emboldened commitment to ensure that everything done going forward is underpinned by effective and inclusive engagement.

The learning and experience gained during the Pandemic around collaboration, compassion and understanding of each others' needs provided an opportunity to further build a collective focus on the needs of people and communities, of togetherness and a lowering of perceived organisational barriers to progress.

The infrastructure designed to oversee, direct, resource, coordinate and deliver the changes set out within this document is significantly different from when Dr Strang undertook his observations, and is built for the long term. Tayside Partners' collective intention is to continue co-creating a compelling programme of improvement alongside its communities and its workforce for the challenges faced now and those yet to come.

Tayside Partners

30 Sep 2022

RAG Status:

Green – actions are complete, and the intended outcomes have been achieved or actions are on track and the intended outcomes are very likely to be achieved in the timescales required.

Amber – actions are marked as complete but have not achieved the intended outcome or actions are underway but are unlikely to achieve the outcomes in the timescales required – additional action required.

Red – actions are not underway and / or not on track and urgent remedial action is required to achieve the intended outcomes

Recommendation 1:

Develop a new culture of working in Tayside built on collaboration, trust and respect.

Intended outcome(s):

• As a workforce, we feel supported, enabled and valued in our role and task.
• We collaborate in the interests of our communities, underpinned by an ethos of trust and respect.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

This recommendation arose from contributions staff made to the Independent Inquiry about how it felt to work in our mental health services across Tayside. Many staff felt they were not treated with respect, and did not feel valued. We know that this experience pervaded many parts of the system.

These views came at a time when there was considerable media attention and a public view, which focused on failures of our services and poor outcomes for our patients and communities. There was a notable negative impact on staff and the need for stronger leadership and support was clearly indicated.

We know that some parts of our workforce felt that the negative portrayal in public, of the services they worked in, was not effectively challenged where appropriate, nor balanced out in a proactive way to reflect positive aspects of the service.

Stronger collaborative leadership at all levels was required to strengthen a shared approach to:

1. Vision and mission

2. Staff involvement

3. Values and behaviours

4. Embed a learning culture

This Recommendation sets the context within which all other recommendations are made, and benefits specifically from being collectively considered alongside Recommendations 2, 3 and 4.

Summary of Actions:

Organisational and Leadership Development

An Organisational Development (OD) diagnostic report was developed in November 2020 along with an accompanying OD plan. The plan included:

• In order to create the conditions for healthy conversations to take place and support the changes set out in the ambitions in the Listen Learn Change Action Plan, OD worked with Human Resources (HR) colleagues to deliver Policy Engagement Sessions to understand current cultural dynamics across the system of care. The feedback from these sessions indicated that there was still work to be done to progress the cultural shift required and has been a helpful benchmark of progress in some areas.
• Relationships and relational practice are core to ways of working across Health and Social Care. The Integrated Leadership Group (ILG) recognised the need to develop a deeper understanding and appreciation of individual and organisational perspectives. 1:1 confidential coaching conversations were offered to members of the ILG throughout 2021 to strengthen each individual's appreciation of their role, contribution and further build authentic and trusting relationships. The ILG have a key role in attending to and maintaining the cultural direction and tone within services and role model respectful and trusting relationships. Traits like kindness, optimism, creativity and forgiveness can't be created through formal policies and interventions. Sustainable cultural shift will rely as much on modelling and social movement as corporate ideals.
• To increase skills and capabilities and create the conditions for change, staff working in mental health services were prioritised for leadership and management development opportunities. The wider leadership programme and opportunities for staff include:

Development Offer	Staff attended
ILM Level 3 Certificate in Leadership & Management	26 to date
CMI Level 5	Selection process ongoing 5 nominations received to date
Supervisors Development Programme	10 to date
Leading for the Future	1
Tailored Leadership Programme	1
Supervisors Development Programme	10
7 Habits of Highly Effective People	11

Each OD intervention / offer will continue on an as needed basis.

Our efforts to improve culture have extended far beyond those noted above.

Broader Workforce Development

Our plans around workforce development have included recruitment to many new roles at all levels of the system. We have been successful in recruiting to existing gaps as well as testing out new roles, against a backdrop of a national shortage of psychiatrists, mental health and learning disability nurses and AHP's and psychologists.

Equally important is the work we have done to train, develop and upskill our workforce, as we know this leads to improvements across the staff, patient and carer experience and there has been a sustained focus on staff development. Examples include the Registered Nurse and Health Care Support Worker development days which bring together staff from across Tayside. The development days have been designed around the identified needs of the workforce and include presentations from third sector organisations, people with lived experience and cover topics such as suicide prevention and trauma informed practice. At the August Health Care Support Worker (HCSW's) development day, 16 HCSW's attended from across all the Health and Social Care Partnerships and some Board retained services.

Recognising good practice is an important aspect of how valued and recognised people feel. We are proud to acknowledge and celebrate with our teams the individual and team awards that have been achieved across our organisations, many of which have been achieved in our Mental Health and Learning Disability Services. For example, in 2021, at the Mental Health Nurse Forum Scotland Awards;

• Angus HSCP won the Community Mental Health Nursing award in recognition of its Enhanced Community Support model, and was joint winner of the overall winners' award.
• Dundee HSCP was highly commended for Digital Innovations in Care.
• Moredun Ward won the Inpatient Care award.
• Perth and Kinross Community Learning Disability Nursing Service nominated for an NHS Tayside STAR Award in recognition of the ongoing work around Physical Health Screening for those with Learning Disabilities.
• In 2022, a range of Mental Health teams and individuals, representing community and inpatient teams have been selected as finalists for NHS Tayside STAR awards. The categories include;
  • Clinical Staff Award
  • Support Staff Award
  • Unsung Hero Award
  • Innovation and Improvement Award, and;
  • Inspiring Educator/ Trainer Award

These awards build on previous successes at the 2018 and 2019 Awards.

We also feel it is important to celebrate not just the bigger achievements but also the many small kind thoughts and acts our teams make. For example, CAMHS have begun to use "Learning from Excellence". Esk ward in Rohallion have begun an initiative called "Eskellent Esk". These approaches encourage teams to draw attention to the small things that go well.

We have changed our approach to workforce planning. Each partner organisation has published its 3-year workforce plans. The plans include information on developing career pathways, developing flexible working, equity for all staff and so on.

Planning and conversations take place at both operational and at a whole-system level. For example, the recent opening of an NHS24 site in Dundee risked an acceleration of staff attrition rates. Peer to peer discussions have taken place between executives of these organisations to look at how to explore blending opportunities for staff who wish to experience a different setting, in order to protect staffing levels at a whole system level.

New Forums for Collaboration

Tayside Executive Partners (TEP) convenes periodically and provides a forum for Chief Executives of NHS Tayside, Perth and Kinross Council, Dundee City Council, and Angus Council and the Divisional Commander of Police Scotland's D Division to connect, share intelligence, collaborate and advise on the strategic direction of travel for Mental Health and Learning Disability Services across the Tayside region.

OD has supported the Integrated Leadership Group to establish purpose, roles and responsibilities through baseline surveys and 1:1 conversations with the membership.

A peer group has been initiated with participation from all five Tayside partner organisations, mirroring the TEP representation, to provide a safe and supportive environment in which to collaborate in their leadership roles. This group is informal, and is a forum to provide mutual support for operational managers. The peer group has supported the opportunity to strengthen and redefine our ways of working as leaders with a focus on how we collaborate through a sense of mutual connection and common purpose. Our ongoing focus is to build momentum, belonging and trust so that we continue with purposeful discussion, healthy agreement and disagreement and attend to our ways of working. The peer group has already navigated and arrived at whole system agreement on areas of common purpose such as the ANP Framework and ANP Leadership roles.

MH & LD Inpatient Operational Leadership Group meets weekly. A baseline survey to establish levels of psychological safety has been completed. A development session is being scheduled to develop a values framework and ways of working together to build on the already growing levels of trust amongst this group of professionals.

LLC weekly leadership team mirrors TEP membership at a service level. This group shares skills, experience and knowledge and works in collaboration to develop further plans for service improvement. This gives one consolidated leadership plan for all partner organisations and creates a shared approach to improvement.

Work groups have formed around specific initiatives and actions for Listen Learn Change. The starting position around convening project work has been to ask for representation from all partner organisations and staff side. The intention has been to develop solutions as a shared endeavour focused on achieving shared standards of care (even if the delivery mechanism may differ from locality to locality in line with local need and resourcing).

Our collaborative strength is evidenced for us not just "within" our teams, but we have reached out to colleagues elsewhere in our organisations and beyond, to foster more open collaboration in the interests of our communities. Lots of examples of this form of collaboration can be evidenced which show a system of care with teams learning from each other, and with an outward looking approach to learn about what works elsewhere that we can consider for adoption locally. Examples include Police Scotland and Community Planning Partnerships.

Greater sharing of information

We have taken action to improve the provision of information needed for decision makers at all levels, including information on workforce, on clinical and patient activity, and on budget information. Information is also routinely shared across agencies. Rather than information residing in the hands of the few, we are actively promoting sharing of information to increase the sense of agency for our teams.

Strategic Leadership Development

A review of progress by Dr Strang highlighted the need for greater cross-agency collaboration and a stronger approach to collective leadership across the main organisations linked to Trust and Respect. To this end, a commitment was made by Chief Officers across the five organisations to give their personal time to participate in a leadership gathering sponsored by Scottish Government and hosted by Columba1400 and the Hunter Foundation, at Ardoch by Loch Lomond, on the weekend of 26-28 November 2021. The outcomes included a greater sense of the collective leadership responsibilities around Listen Learn Change and the values, behaviours and actions needed by all to realise that. Outcomes were summarised by participants as follows:

• A much clearer understanding of each other's pressures, a greater respect has been developed, greater clarity and sense of purpose achieved and an absolute and resolute focus and drive to improve and deliver
• Commitment and desire to grow as a partnership and make important sustainable changes across Tayside in order to deliver better outcomes for our communities
• Relationship building which is fundamental to our collaborative approach
• Shared values and commitment to supporting a whole system approach to change in Tayside.

Greater Flexible working

The pandemic placed a requirement on all agencies to find flexible ways to deliver consistent and high quality care within the context of significant clinical, personal and societal challenge and uncertainty. Like many other organisations, we worked hard to ensure that our staff were supported and empowered to be as flexible as possible during those times. In addition to a strong focus on wellbeing support for staff, flexibility around equipment, working patterns, base, flexibility in new policies introduced by Scottish Government and so on were part of our response to Covid and staff in many cases reported feeling well supported and enabled to work flexibly. Many of the solutions to support flexible working have remained beyond the pandemic, providing more choice for staff and supporting a positive culture. We know however that there is more to do to ensure that our staff feel supported to work flexibly.

Staff Support

Wellbeing of staff has been and remains a central focus of our efforts to create a healthy culture. In addition to promoting the work of our Wellbeing service and our wellbeing work at organisation level, we have introduced Trickle. Trickle is an App that makes it easy for staff to give each other shout-outs, fist bumps and mentions when things go well, and to draw attention quickly to issues that can be easily dealt with.

Are the actions sufficient to achieve the intended outcome(s)?

No

Please briefly explain your response here:

Our assessment is that we have taken a broad range of actions in response to this recommendation to date, and we are pleased that in parts of our service, there are greater levels of trust and respect being reported and in evidence. It is our belief that the work we have done since the publication of Trust and Respect has given us a firm foundation to build on.

We also recognise that further modelling of trusting and respectful behaviour is needed throughout our whole system of care before we can be confident that we are continuously growing a thriving culture across the full breadth of our system of care.

Some of our cultural indicators suggest improvements in how well we collaborate. A number of Tayside-wide service developments have been collaboratively agreed and implemented to date since the publication of Trust and Respect. These include; contingency planning for Psychiatry cover, ANP framework, Distress Brief Intervention, etc.

Collaborative work to foster and sustain a thriving culture must be a continuous focus at all levels.

Evidence and Milestones:

We feel caution is needed in "measuring culture" in a complex network of dynamic services. We recognise that perceptions shift around context, the ways people and services relate to each other, values and ways of working. The actions we have taken above therefore are multifaceted and continuous and so is our approach to looking for evidence of success. And so a relational approach underpins our sense-making on this recommendation. Nonetheless, we feel there are useful markers around the extent to which there is agreement about our:

1. Vision and mission

2. Staff involvement

3. Values and behaviours

4. Evidence of a learning culture.

Helpful markers of the above include;

• iMatter survey results
• Formal and informal feedback from staff across our localities
• The extent to which there is a collective understanding of the priority to LLC and transformation of Mental Health services
• Participation in leadership development
• The progress made against all other recommendations within Listen Learn Change
• Whole system change being made in collaboration across the service in line with our plans.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The system we work within, and our readiness and ability to collaborate in the interests of the people who use our services, has evolved and strengthened since the publication of Trust and Respect.

That said, there is still much work to do to ensure that our collaborative efforts permeate throughout the full extent of our decision making, planning and service delivery. We believe there has been much done to strengthen a culture of collaboration, trust and respect for our workforce. And so an assessment of "red" would undermine the efforts taken to date. Likewise however, an assessment of "green" may inadvertently signal that our work is done in this domain, and that signal is equally problematic. Therefore, we arrive at an assessment of Amber to signal a work in progress for an aspect of Listen Learn Change that will be ever-present for us to attend to as part of our ongoing efforts to improve what we do and how we do it.

RAG Status: Amber

Any further action proposed:

• Collectively develop a values and behaviours framework and promote a culture of reflection and learning against this framework
• Further modelling of trusting and respectful behaviour, including how we positively challenge and manage and work with difference
• Systematic surveys to understand experience and views and act on them
• Continuing offers of targeted and generic leadership development opportunities
• Learn from culture work in other areas and from colleagues in organisations further afield
• Explore further opportunities to strengthen flexible working
• Creating opportunities for future leaders to learn about and participate in extended leadership collaboration
• Continuation of OD support including further diagnostic of where OD can add value aligned to iMatter outcomes, and continuing the rollout of Trickle
• Provide values based leadership experiences for leaders and managers working in Mental Health and LD
• Support relationship-building experiences with stakeholders and people with lived experience to promote a culture of mutual respect and to support an inclusive approach to improvement and service change.
• Extend our peer support model to elevate the voice of lived experience as core component of service design, development and delivery.

All of these actions to strengthen a collaborative culture based on trust and respect will be taken forward in full partnership.

Recommendation 2:

Conduct an urgent whole-system review of mental health and well-being provision across Tayside to enable a fundamental redesign of mental health and wellbeing services for Tayside.

Intended outcome(s):

• People in Tayside receive the mental health and wellbeing support they need.
• People have access to the right kind of mental health and wellbeing support at the right time and place.
• A collaborative approach underpins whole system mental health and wellbeing activity in Tayside.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that there were a number of concerns arising from the Independent Inquiry. These included a lack of collaboration between Tayside partners in terms of a whole system approach, significant risk attached to people not having quick or easy access to the right kind of support, and a lack of engagement / co-production with key stakeholders.

Summary of Actions:

The Leadership Team has established effective working relationships which are evidenced within a range of regular forums:

• The Integrated Leadership Group established and progresses collaborative work via monthly meetings and associated work outside the forum
• A Listen Learn Change Leadership Team meet weekly to co-ordinate activity, plan ahead and review progress
• A Chief Officer Scrutiny Group for Listen Learn Change is in place to support the Leadership Team and provide oversight
• Tayside Executive Partners have come together to provide strategic leadership and support
• A Peer Group of leaders was established in late 2021 and meets fortnightly. This offers an opportunity for leaders to come together to test out thoughts / receive peer support in a less formal meeting
• Mental Health and Wellbeing Strategic Board and Operational Steering Group established to support and oversee work related to Living Life Well

New pathways / models of support have been developed. Some have been implemented and some are in the process of being implemented:

• Recommendations from Tayside Urgent Crisis and Urgent Care review are being progressed, including the introduction of Community Wellbeing Centres
• The new Community Perinatal Mental Health Team has been operational since November 2021 and the new Maternity and Neonatal Psychology Service has been operational since May 2022. These services will be complemented by a new Infant Mental Health Service to be operational this year in 2022.
• A new Early Intervention in Psychosis Service is being developed and the phased implementation of the service in Dundee started in August 2022. Service implementation is linked to recruitment and a number of key posts to the team require recruitment prior to full implementation of the evidenced based model. The service development is part of a national pilot with Healthcare Improvement Scotland working with Tayside and NHS Dumfries and Galloway. The Tayside pilot is planned to extend into Perth and Kinross and Angus in 2023.
• The unscheduled care pathway has been strengthened with the introduction of the mental health paramedic ambulance in Dundee which brings together a Mental Health Nurse and Paramedic response to mental health emergencies. A range of service developments across Primary Care such as the Mental Health Enhanced Community Support model in Angus are working to ensure that people receive the right support at the earliest opportunity.

Integration Schemes have been drafted, consulted upon with our communities, and reviewed. The schemes include strategic responsibilities for the commissioning of mental health and wellbeing services.

A Programme Team has been appointed to on a permanent basis, funded by all partner organisations. The Programme Team will ensure that change expertise is embedded into this programme on a substantive basis for the foreseeable future.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We consider that there is some way to go before the outcomes can be fully achieved. However, we do also consider that the actions we are taking, in addition to planned actions, will take us to where we need to be.

Evidence and Milestones:

Governance diagrams are available

Terms of Reference

Agendas, minutes and actions from meetings are documented

The schemes of integration (and associated consultations) are available

Revised Models of care are available

Key metrics that tell us how well we are meeting needs are monitored and shared regularly with Leads and Operational teams

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Overall, we consider our collaborative effort to have improved since the publication of Dr Strang's report.

A Tayside Leadership Group has established and maintained an effective and productive working relationship and respective forums established (with terms of reference) for progressing matters related to Listen Learn Change, Living Life Well and 'business as usual'.

Our thinking has moved on since the publication of Living Life Well in terms of what we view as our collective task. We recognised some time ago that greater clarity was needed about areas of improvement / co-production that require to be progressed locally within the approved priorities set out within each of the HSCPs Mental Health and Wellbeing Strategic and Commissioning Plans, and which require a Tayside-wide approach. We also deemed some of the prospective workstreams outlined within Living Life Well to be underpinning themes or areas of principle that required to be woven through all our effort rather than workstreams in their own right e.g., human rights approach, data and digital needs.

RAG Status: Amber

Any further action proposed:

The Chief Officer for Perth and Kinross HSCP since her appointment in May 2022, has commenced a programme of activity to advance the Lead Partner role for mental health services across Tayside. As reported to NHS Tayside Board and Perth and Kinross IJB, this includes:

• The establishment of a 'strategic leadership group' for Tayside Mental Health Services comprising the three Chief Officers for Angus, Dundee and Perth and Kinross IJBs; the Medical Director, Director of Finance and Executive Nurse Director for NHS Tayside. The group will provide collective leadership to ensure the right support, resource, data, information, and expertise to take forward the strategic planning coordination and financial framework to support the delivery of the strategy.
• We recognise that there has been an interruption to progressing plans for consolidating inpatient provision into sites where expertise can be pooled and excellent practice promoted. The clarity provided by the revised integration schemes and the renewed impetus as described above will allow us to work together collaboratively to re-examine and bring forward proposals as a matter of priority. These proposals will set out how we will meet our ambition for excellent inpatient mental health and learning disability services covering the short, medium and long term.
• Following a review of the requirements for programme management support, decision to establish a permanent team to support the delivery of the Living Life Well Strategy and transformation programme with recruitment underway.
• An assessment of the current capacity and resources devoted to the engagement and involvement of people with lived experience of mental health services is in progress with a view to increasing the level of support and expertise in this crucial area.
• A plan to review the governance structures for Listen Learn Change and Living Life Well, taking account of the revised Integration Schemes is underway. This will commence with a review of the terms of reference of the Mental Health and Wellbeing Programme Board. The Chief Officer as Lead Partner has held one to one discussion with workstream leads and will lead a re-evaluation and re-prioritisation of the current workstreams reporting to the Board. This will include the development of a financial framework to support the delivery of the strategic plans for mental health services.
• A workshop is planned for members of the Mental Health and Wellbeing Programme Board to consider the mechanism for transitioning the outstanding or ongoing actions from Listen Learn Change into the strategic programme of work to deliver on Living Life Well.
• The first of a series of risk workshops to ensure that the arrangements for the management of strategic risks for mental health services are in line with the responsibilities set out in the Integration Schemes was held on 18 August 2022 and will conclude in October 2022.
• The establishment of a Short-Life Working Group with representation of the 3 IJBs and NHS Tayside to prepare a governance, reporting and decision-making structure for services coordinated by a Lead Partner. This will enable the Perth and Kinross IJB to lead the strategy for the transformation of mental health services with confidence including the use of Directions.

It is also anticipated that we shall move to a more formally agreed position in relation to priority areas for collaborative work over the coming 1-3 years, taking cognisance of the work progressing within each of the HSCP areas related to their respective Mental Health and Wellbeing Plans.

Recommendation 3:

Engage with all relevant stakeholders in planning services, including strong clinical leadership, patients, staff, community and third sector organisations and the voice of those with lived experience of Mental Health.

Intended outcome(s):

• The voice of those with lived experience is central to service development.
• Our approach to planning services is inclusive and key groups of stakeholders understand the mechanisms by which they can drive, shape and influence service development.
• Key groups of stakeholders are equal partners at all phases of service development; needs assessment, translation of need into planning, implementation and review.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Several important messages were drawn from people's experiences and translated into this Recommendation.

We know that our citizens and communities across Tayside care about service design, delivery and future plans and want it to be involved in co-creating solutions and innovation.

We also recognise that in some cases, people's experience of mental health and learning disability services has fallen short of expectations and that lived experiences must be at the heart of understanding what needs to change and how our services can improve.

We understand that people's experience was characterised by feeling ignored, disrespected, marginalised and undervalued. Some people's experience appeared to be less positive in circumstances where a whole system approach across Tayside was not in evidence or where short notice contingency planning was required.

Whilst we can provide evidence of co-production with our stakeholders in specific change efforts, we recognise that has not been the experience all of the time for all of our stakeholders.

Summary of Actions:

Living Life Well strategy coproduced and published.

Specific examples of co-produced service developments include infant mental health, perinatal mental health, and the community wellbeing centre stakeholder engagement events.

Engagement with people we support and third sector partners has been central to our actions associated with Recommendations 24, 34 to 41.

Dundee HSCP used the Listen report to ensure that all concerns raised either had been or were being addressed either locally or on a Tayside-wide basis. Author of Listen also attended local Mental Health and Wellbeing Stakeholder Participation Group (SPG) to discuss local perspective / actions.

Perth and Kinross Integration Joint Board has approved the HSCPs co-produced Mental Health and Wellbeing Strategic and Commissioning Plan.

Angus HSCP prioritises the mental health and wellbeing needs of citizens through their HSCP Strategic Plan. In addition to this, an implementation plan in relation to Living Life Well is in place.

Dundee Integration Joint Board approved the HSCPs co-produced Mental Health and Wellbeing Strategic and Commissioning Plan in Autumn 2019. The Plan outlines both local and Tayside priorities for improvement.

A workstream focussing on community mental health teams within the context of a whole system is established and a range of stakeholders are already involved.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We anticipate that the actions already achieved along with those in process / planned will lead to the intended outcomes being realised.

Evidence and Milestones:

Agendas / minutes from local Strategic Planning and Commissioning Groups

Outputs from refreshed whole system workstreams

Feedback from a range of stakeholders eg communities' health and wellbeing networks, providers forums, Fairness Commission, locality partnership forums

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Across Tayside each HSCP has a range of voluntary sector partners. The volume of providers and services in place differs across each area. Where there is a large volume of providers in place, collaborative approaches to commissioning have been established for some years. This was developed within the spirit of integration legislation, which sought to shift the balance of power between commissioners and providers. Providers coming together to make decisions about who best to take on certain work could be fraught with complexity; the learning over the last 6 years however has been that there was already a basis of positive relationships between commissioners/ providers and that this made the shift to shared decision making possible.

We consider stakeholder engagement to be well embedded within each of the HSCP areas and in many cases at a specific service level. However, we recognise a need to engage with the SPG to consider how engagement and co-production will look both locally and Tayside-wide into the future. Our vision is that future arrangements make best use of people's time and effort and reduces any duplication / parallel process. To achieve this, we need to work with our local networks and the SPG within an easily understood overall agenda.

RAG Status: Amber

Any further action proposed:

• Work with our communities and local networks, to develop a process for engagement and co-production around Tayside-wide planning and ensure that the process is shared and followed. This will include an analysis of our current engagement network and take action to close gaps or identified imbalances. This work will enable a transition from a focus on Listen Learn Change actions into a broader dynamic and continuously evolving approach to service planning and delivery.
• Prepare and share a prioritised plan of engagement around specific areas of service planning.
• Explore how to increase capacity at all levels within the workforce and with stakeholder participants to take plans forward in a co-produced way.
• We shall seek to apply some of the learning from areas where collaborative commissioning processes are established in order to adopt a more consistent approach across Tayside and a move away from more traditional decision making relationships between commissioners and providers.
• Building on the Columba 1400 values-based leadership development, a further series of events will take place between November 2022 and March 2023. These will bring together senior leaders/managers with stakeholders with lived experience to encourage relationships and underpin a commitment to meaningful co-design and co-production in service development.
• The Chief Officer for Perth and Kinross IJB will review the current capacity for supporting and enabling stakeholder engagement with a view to ensuring that this is a core component of the delivery of Living life Well.

Recommendation 4:

Establish local stakeholder groups as a mechanism for scrutiny and improvement design to engage third sector, patient's representatives and staff representation.

Intended outcome(s):

• The voice of those with lived experience is central to service development, review and evaluation.
• Our approach to reviewing and assuring service development is inclusive and key groups of stakeholders understand the mechanisms by which this will be achieved.
• Key groups of stakeholders are equal partners at all phases of planning – including review of how well or not plans are made and need is met.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that many people, including staff, shared their experience of feeling that they were not well informed, listened to or engaged with generally. We also know that the Independent Inquiry gathered evidence that at an organisational level communication / engagement / co-production needed to be improved through a more collaborative, whole system approach.

Summary of Actions:

Key stakeholder groups have been embedded within the strategic and commissioning processes within the 3 HSCP areas.

Key stakeholders include those directly involved in strategic planning and service development of mental health and wellbeing supports eg provider groups, health and wellbeing networks that operate as part of community planning partnerships, Dundee Fairness Commission, housing and communities / neighbourhood services, Police colleagues and Scottish Ambulance Service colleagues.

Central to strategic planning and service development is the voice and views of people with lived experience, this applies both to planning for people requiring support with mental health and wellbeing and to support for people with a range of learning disabilities.

Representatives of the Stakeholder Participation Group who were involved in the Independent Inquiry have been involved in the development of Living Life Well, the Mental Health and Wellbeing Strategic Board, the Operational Steering group for Living Life Well and specific Tayside-wide workstreams.

The establishment of service / function specific staff partnership forums in some service areas has led to improved involvement of the workforce. This important aspect of staff engagement still needs further work and prioritisation to ensure that reliable staff partnership processes are present as the default approach to service change and planning.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We consider that we have continued to build and strengthen the 'pool' of stakeholders who work in partnership with us but that we still have work to do. We are confident that the combination of actions already taken and our planned actions will lead to further improvement and take us where we need to be.

Evidence and Milestones:

Agendas / minutes of strategic planning groups

Reports / feedback from stakeholders, for example within minutes, engagement processes, workstream sessions, Mental Health and Wellbeing Strategic Board, surveys, from providers forums

Minutes of team meetings

Feedback from leadership walkabouts within teams / services

Annual iMatter staff experience surveys

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We know that a range of stakeholder groups and processes have continued to evolve across Tayside within respective HSCP areas. We also recognise that some processes had already been established and consolidated prior to the Independent Inquiry.

We consider that we are becoming much clearer about the priority we must afford to encouraging and welcoming further stakeholders to be involved in the direction setting for mental health and wellbeing services into the future, both at a local and Tayside-wide level.

RAG Status: Amber

Any further action proposed:

As a priority, we shall engage with our broader stakeholder constituency to co-produce our vision and plan for effective and meaningful participation into the future. This will be aided / informed by any agreed reprioritising of collaborative effort under Living Life Well. We envisage that an output from this will be confirmation of an overall framework for engagement / involvement, both on a local and Tayside-wide basis.

We will provide and support relationship-building experiences with stakeholders and people with lived experience to promote a culture of mutual respect and to support an inclusive approach to improvement and service change.

We will elevate the voice of lived experience as a core component of staff induction, training and development.

We shall continue to consider ways of encouraging more people with lived experience in our communities to join us as we strive to improve outcomes for people in Tayside.

We need to work together with staff side colleagues to improve consistency in our partnership working together, using the resources we have available as creatively as we can.

The Perth & Kinross Chief Officer, in consultation with the Employee Director and fellow Chief Officers will revise and refresh the governance and decision-making routes associated with system wide-transformation. The Mental Health Partnership Forum Staff Partner Co-Chair will also be part of this work with the aim of improved partnership working.

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 Inpatients services in Perth & Kinross Integration Joint Board.

Intended outcome(s):

• Clarity of roles and responsibilities of all partners around lead partner role in relation to strategic planning and operational management.
• Revised Integration Schemes for all three HSCPs.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand this Recommendation has arisen from two sets of perspectives:

• First, a number of contributions highlighted that stakeholders did not know which agencies were accountable for specific aspects of service provision.
• Second, there were concerns expressed that delegated functions and the inter-relationships between NHS Tayside and the three Integration Joint Boards was not clearly understood.

This recommendation can be linked to reported uncertainties regarding:

• Who has responsibility for setting the strategic direction and operational management of inpatient services
• The governance for decision-making
• The use of legal mechanism; the use of directions to achieve whole-system change.

Summary of Actions:

• Lead reviewer identified to support review of all Integration Schemes across Tayside
• Integration Scheme Project Team established with representatives from all partners
• Each section of the Integration Scheme reviewed and revised as required
• Integration Schemes for all 3 areas presented and approved by NHS Tayside Board on 30 June 2022
• Angus Integration Scheme presented and approved by Angus Council on 21 June 2022
• Dundee Integration Scheme presented and approved by Dundee City Council on 27 June 2022
• Perth and Kinross Integration Scheme presented and approved by Perth and Kinross Council on 27 June 2022
• Approval of directions policy by Perth and Kinross IJB on 31 August 2022 and development session for IJB members on 14 September 2022. Agreement to give greater prominence to the delegated responsibilities within the Integration Scheme and detail of required directions within a revised reporting template.
• Revision of the Directions Policy by Angus IJB on 24 August 2022 and development session for IJB members.
• A report providing an update on inpatient mental health services, progress in relation to the lead partner role and Living Life Well and Listen Learn Change was provided by the Lead Partner Chief Officer and Executive Lead for Inpatient Mental Health Services to NHS Tayside Board on 26 August 2022 and Perth and Kinross IJB on 31 August 2022 helping to set a framework for reporting on the whole system.
• A short life working group established on 2 September 2022 with NHS Tayside, HSCP and IJB legal advisers to prepare a directions policy and procedure in relation to the Lead Partner role ensuring collaboration and transparency.
• A planned workshop for IJB Chairs and Vice Chairs, members of NHS Tayside Board and senior officers on implementing the above before the end of the 2022 calendar year.

Are the actions sufficient to achieve the intended outcome(s)?

Yes, in time

Please briefly explain your response here:

Revised Integration Schemes written and approved. These schemes clearly articulate the roles and responsibilities of all partners including Perth and Kinross IJB as Lead Partner for the co-ordination of strategic planning for inpatient Mental Health, Learning Disability and Alcohol and Drug services and the responsibilities for the operational management of these services resting with NHS Tayside. Terms such as Lead Partner, Operational Management, Operational Risk, and Oversight are all defined clearly and conclusively.

Evidence and Milestones:

Angus, Dundee and Perth and Kinross Integration Schemes have been approved.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Our shared vision for integration between NHS Tayside and Angus, Dundee City and Perth & Kinross Councils is for confident and ambitious Integration Joint Boards which support people to achieve better outcomes and experience fewer inequalities, where voices are heard and people are supported to enjoy full and positive lives in the community. The revised Integration Schemes are already being used as a powerful tool to aid decision-making.

The Executive Lead for Inpatient Mental Health and Learning Disability Services has operational management responsibility for delegated functions that relate to adult mental health inpatient, learning disability inpatient and drug and alcohol inpatient services.

The Integration Joint Boards will have oversight of integrated acute, mental health inpatient, learning disability inpatient and drug and alcohol inpatient services to ensure compliance with the strategic plan of the Integration Joint Board.

In respect of clinical, care and professional governance for delegated health functions where the integrated services are managed by the Chief Officer for Acute Services and the Executive Lead for Mental Health, NHS Tayside Board will establish a Care Governance Committee. The Care Governance Committee will provide oversight, advice, guidance, and assurance to the Integration Joint Board in relation to those delegated functions.

The Chief Officer for Perth and Kinross IJB, as Lead Partner will co-ordinate the strategic planning of inpatient mental health services, learning disability services and drug and alcohol services and in doing so will seek approval from all Integration Joint Boards on proposed strategy for those services and provide reports on those services to other Integration Joint Boards at least in every planning period, ensuring consultation where significant service change is planned at any point.

RAG Status: Green

Any further action proposed:

We need mechanisms and guidance about how directions and decisions will be made in relation to mental health services – how the lead partner role will be fulfilled.

We need to build understanding across IJB members and Tayside NHS Board members on this role.

Recommendation 6:

Ensure that Board members (NHS Tayside and Integration Joint Boards) are clear about their responsibilities, confident and empowered to challenge and make sound decisions. Review their selection, induction and training processes in preparation for their important role.

Intended outcome(s):

• Empowered, competent, confident Board members of the Tayside NHS Board and the Integration Joint Boards who scrutinise mental health plans and proposals at the appropriate level, demonstrate informed decision-making and connect decisions across the whole system to ensure the delivery of joined-up pathways for the population of Tayside.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Well organised and functioning NHS Board and IJBs which are able to evidence clear decision-making is fundamental to the leadership, direction and oversight of our mental health services across Tayside.

It is acknowledged that the Independent Inquiry heard concerns about Tayside NHS Board member turnover and a lack of clarity of the roles and responsibilities in particular from IJB members. It was evident from the Independent Inquiry report that there were also varying levels of confidence from the members of the four Boards in Tayside about how they made decisions in relation to Mental Health Services.

Summary of Actions:

Selection, Induction and Training:

Non-executive Board members of the Tayside NHS Board are appointed by Public Appointments Scotland and participate in a comprehensive on-boarding programme. IJBs are made up of NHS Tayside Non-executive board members and locally elected councillors.

Tayside NHS Board has specified to Public Appointments Scotland the intention to recruit non-executive members with specialist skills and experience of working in mental health services and with the third sector as it was recognised that these would strengthen the Board scrutiny and assurance across mental health services.

Members of the four Boards have had the opportunity to learn more about the progress of mental health services across Tayside at their meetings. IJBs have approved their strategic plans. Tayside NHS Board members are presented with an update report on inpatient services at each of their board meetings and board members have had a detailed session on the Listen Learn Change (LLC) Evidence Repository. This is a digital, dynamic online resource, which sets out both the progress against each LLC recommendation as a narrative and has accompanying evidence and documentation to support the reported position.

Induction sessions are offered to all IJB members (voting and non-voting) in each HSCP offering a participative and safe space to learn and explore their roles and responsibilities.

Clear responsibilities and members confident and empowered to challenge and make sound decisions:

The development and joint agreement of all three revised Integration Schemes has Ministerial approval and has been critical in setting out the responsibilities relating to adult inpatient mental health and learning disability services. There is a developing understanding of this across all four Boards (as set out in Annex 1, Part 3 in all three revised Integration Schemes) with further developments planned.

The revised Integration Schemes have presented an opportunity to clarify and reset the understanding of all Board members in regard to operational management and strategic planning coordination of adult inpatient mental health and learning disability services, as well as responsibilities for delivering community mental health services. The review and subsequent approval of the revised Integration Schemes by all members of the Boards ensures that members are clear about the importance of whole-system working to deliver pan-region services for the population.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Members of Boards have had the opportunity to attend dedicated development sessions on mental health and learning disability services, including the chance to see the online evidence repository for LLC. This has supported understanding of the extent of the LLC recommendations and how a whole-system response is required.

Some board members were also invited to a session with the Minister for Mental Health and Wellbeing and Social Care to discuss the whole-system response and roles and responsibilities in delivering mental health and learning disability services to the population of Tayside.

The revision of the three local Integration Schemes has also afforded in-depth discussion and clarity over roles and responsibilities and Tayside NHS Board and each of the three Local Authorities have approved the schemes with all organisations demonstrating a shared commitment at a strategic level to ensure the right services are commissioned for the people of Tayside.

Boards' membership has been strengthened with newly-appointed members recruited who have experience of planning and delivering mental health services and working with the Third Sector.

Evidence and Milestones:

• Composition and background of Boards' members
• Comprehensive induction process
• Protected development time for IJB members with a programme of activity
• Dedicated development time on LLC and supporting evidence
• Joint agreement of revised Integration Schemes
• Scottish Government Annual Review letter to NHS Tayside from Cabinet Secretary: De-escalation of NHS Tayside from Stage 4 to Stage 3 on the Performance Framework recognising progress has been made since publication of Trust and Respect review of progress report.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Members of the Boards have a clearer understanding of whole-system working for mental health and learning disability services and the co-dependencies of acute inpatient pathways and community pathways, and are confident to challenge.

Boards have good representation from those who have professional experience in planning and delivering many aspects of mental health services and stakeholder engagement.

RAG Status: Green

Any further action proposed:

Further development sessions on roles and responsibilities of whole-system delivery of mental health and learning disability services pan-Tayside to ensure new Board members on Tayside NHS Board and IJBs have a solid understanding of the revised Integration Schemes and what they mean for service delivery and decision-making.

In response to the approval of the revised Integration Schemes, Perth and Kinross and Angus IJBs have reviewed and updated their respective policies and procedures in relation to Directions (approved at Angus IJB 24 August 2022 and Perth and Kinross IJB 31 August 2022). As a further measure, a short life working group has been established by the Chief Officer of Perth and Kinross IJB to devise a shared policy, procedure and process in relation to services delegated to IJBs for which a lead partner arrangement applies. This will commence on 2 September 2022 and will have representation from all 3 IJBs / legal advisers and NHS Tayside Board Secretary. The plan is for this section of the policy to be prepared by mid-October and for approval at Perth and Kinross IJB on 26 October 2022 in order that it may have approved formal mechanisms for issuing Directions in relation to the strategic planning of mental health services, learning disability services and drug and alcohol services. Thereafter it is the intention of the Chair of Perth and Kinross IJB and NHS Tayside Board Secretary to arrange a joint event with IJB Chairs and Vice Chairs and NHS Tayside Board members to ensure a shared understanding and approach in recognition of the need for robust collaboration in the development of Directions and that NHS Tayside and the three Councils are involved fully in order to ensure that the Directions are supported and realised.

Perth and Kinross IJB members have been invited to two induction sessions on 22 July and 26 August 2022 and will have a further development session on 14 September 2022 specifically focused on Directions.

Once the revised Integration Schemes have been approved by the Scottish Government, a briefing session will be held for IJB members. This will include discussion on a Directions Policy which will in turn be presented to the IJB for approval at a later date.

Recommendation 7:

Provide sufficient information to enable board members to monitor the implementation of board decisions.

Intended outcome(s):

• Informed board members and evidenced decision-making pertaining to mental health services.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

In order for appropriate decision-making and associated assurance to be taken by members of the Boards (NHS and IJBs), it is vital that the right level of information flows to and from the Board in a timely and organised way.

It is recognised that during the Independent Inquiry, it was identified that there was a lack of clarity and connection between the information being presented, decision-making responsibilities and assurance processes around ongoing monitoring of the implementation of those decisions with regard to mental health services.

Summary of Actions:

The NHS Tayside Board Secretary and Local Authority colleagues ensure that there are robust governance frameworks in place for mental health services. The governance framework makes clear the responsibility for provision of information on service planning and delivery.

The review of the three Tayside Integration Schemes has also provided clarity around the governance and operational arrangements.

The nominated lead officer(s) for Mental Health provide regular reporting on identified and new standards to inform those within Tayside NHS Board Standing Committees (such as Staff Governance Committee, Performance and Resources Committee and Care Governance Committee) and the relevant associated committees in the IJB. Appropriate information is then presented from these governance routes to the Tayside NHS Board, the three IJB Boards and to the Mental Health Executive Partners Strategic Leadership Group.

Data is presented to the relevant standing committees relating to key metrics on mental health service performance to inform members of any areas where issues are emerging or trends which require further investigation and mitigating actions.

Members of the four Boards have had the opportunity to learn more about the progress of mental health services across Tayside at their meetings. IJBs have approved their strategic plans, Tayside NHS Board members are presented with an update report on inpatient services at each of their Board meetings and Board members have had a detailed session on the Listen Learn Change (LLC) Evidence Repository. This is a digital, dynamic online resource which sets out both the progress against each LLC recommendation as a narrative, but also the accompanying evidence and documentation to support the reported position.

Decisions taken or actions commissioned by members of the Boards are recorded in the official minutes and action points summary and taken forward by the relevant lead officers to report on through the appropriate committee. For example, Tayside NHS Board members wished to see further evidence of inpatient feedback in their update and performance report to the Board. Therefore this was presented to the Board for discussion and assurance and is now presented at every Board for monitoring to demonstrate improving or deteriorating trends in order that any identified action can be implemented timeously.

Recognising that there are new Tayside NHS Board members, a series of briefings on key areas of performance has been scheduled for those members who sit on Integration Joint Boards.

A report providing an update on inpatient mental health services, progress in relation to the lead partner role and Living Life Well and Listen Learn Change was provided by the Lead Partner Chief Officer and Executive Lead for Inpatient Mental Health Services to NHS Tayside Board on 26 August 2022 and Perth and Kinross IJB on 31 August 2022 helping to set a framework for reporting on the whole system.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Reports and information on service provision are brought to Board meetings and associated standing committees at regular intervals. The standing committees and the Board are able to track and interrogate the implementation of their decisions regarding mental health service change through these reports.

This includes, for example, detailed mental health data reports with key performance indicators and actions plans to mitigate risks being presented to NHS Tayside's Care Governance Committee (CGC). Detailed discussion and scrutiny of the data takes place at the CGC and the highlights in terms of improvements, deteriorations or any learning to be shared is included in the CGC's Chair's Assurance Report which is presented to the full Tayside NHS Board meeting for assurance for all Board members.

Evidence and Milestones:

Board papers in evidence, regular metrics in evidence, data presentations with commissioned further actions to lead officers to mitigate any concerns raised or trends emerging.

Development sessions and presentations on key information updates such as the LLC Evidence Repository.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The quality and frequency of information and key data reported to NHS Tayside Board and to the IJBs and those members who sit on other key standing committees has been improved.

The Tayside NHS Board CGC has designed a new report with key performance data to ensure monitoring of trends with the aim of identifying any issues and responding quickly.

Key strategic decisions in the short to medium term will further underline the progress made.

Tayside NHS Board Strategic Risk Register Development Session in May 2022 discussion and agreement regarding the ownership and reframing of the Mental Health Strategic Risk.

No matters of internal control highlighted by Internal Audit in the Internal Control Evaluation Report for 2021 / 22.

RAG Status: Green

Any further action proposed:

Further development sessions on whole system delivery of mental health and learning disability services pan-Tayside to ensure new Board members have a solid understanding of the services provided and teams involved and their roles and responsibilities in terms of decision-making and assurance.

Continued evaluation of the implementation of Board level decisions in connection to mental health service provision.

From 25 August 2022, NHS Tayside Board and from 31 August 2022, Perth and Kinross IJB (as lead partner) will receive regular reports on mental health services (standing agenda items) which will give a whole-system overview covering:

• A position in relation to inpatient mental health services (for which operational responsibility rests with NHS Tayside). This will assist the IJB to have oversight of acute, mental health inpatient services and ensure compliance with the strategic plan;
• An update on the co-ordination of strategic planning for mental health services across Tayside (which is delegated to the Perth and Kinross IJB as lead partner within the revised Integration Scheme approved in June 2022); and
• An outline of the current position in relation to Listen Learn Change, an action plan prepared in response to the recommendations outlined in Trust and Respect (the report of an Independent Inquiry into mental health services in Tayside).

As part of the development of the Directions Policy for Lead Partner Services, arrangements for the parallel reporting to the Angus and Dundee IJBs will be developed.

Recommendation 8:

Deliver timely, accurate and transparent public reporting of performance, to rebuild public trust in the delivery of mental health and wellbeing services.

Intended outcome(s):

• Accurate and transparent public reporting.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

It is understood that this recommendation was made as a result of stakeholders' reporting uncertainty about accountability for performance or about how well the services were performing in relation to standards and expectations.

Summary of Actions:

A number of actions have been undertaken to strengthen and clarify public reporting. These include:

• Tayside NHS Board now receives regular updates on progress against Listen Learn Change
• Tayside NHS Board also receives updates on key Mental Health Indicators within its Performance Report, which is discussed in more detail at Performance and Resources Committee (a public facing committee)
• The plans around mental health service delivery are published alongside all other key organisational delivery plans within the Remobilisation Plan (formerly titled Annual Operating Plan)
• Through 2022, schemes of integration were drafted and agreed, to make clear which organisations are responsible for which services
• The Chief Officers and executive members of NHS Tayside Board have commenced a series of meetings to ensure a collaborative leadership approach is taken to oversee service delivery
• Papers to Integration Joint Boards on the planning and delivery of commissioned services are published 7-10 days in advance of each meeting. IJB meetings are open to the public
• Within each Health and Social Care Partnership, there is a Strategic Planning Partnership which invites key stakeholders to participate in discussions about service planning on a quarterly basis
• In Perth and Kinross, there is a Mental Health and Wellbeing Strategy Group, open to key stakeholders including those with lived experience, which meets every six weeks
• Dundee hosts a Mental Health and Wellbeing Strategic Commissioning Group which shares information on local plans and enables reciprocal communication between strategic groups and local communities via local Health and Wellbeing Networks. The Strategic Commissioning Group meets every two months
• Angus hosts a Mental Health and Wellbeing Strategic Oversight Group and a Mental Health and Wellbeing Network, both of which meet every eight weeks. Service User representation feeds into both forums
• In April and May 2022 an infographic was developed and circulated to services, containing accessible information about key aspects of service performance. Information included performance against access standards, delayed discharges, readmission rates and volume of activity delivered within the community setting. Feedback on the infographic was positive and indicated a desire to see this sort of information on a six-monthly or annual basis
• A report providing an update on inpatient mental health services, progress in relation to the lead partner role and Living Life Well and Listen Learn Change was provided by the Lead Partner Chief Officer and Executive Lead for Inpatient Mental Health and Learning Disability Services to NHS Tayside Board on 26 August 2022 and Perth and Kinross IJB on 31 August 2022 helping to set a framework for reporting on the whole system

A separate pack showing examples of regular information products about our services, alongside narrative about how each is used, accompanies this briefing. The pack contains both public facing and internal information packs which are used to inform service planning and delivery.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

A marked strengthening of public reporting of Mental Health and Learning Disabilities service planning and performance has taken place since 2019.

Evidence and Milestones:

Formal agendas and minutes of key committee papers are available to the public

The Performance Framework is available

The agreed integration schemes and associated public consultations are available

The infographic and its evaluation are available

The extensive information and performance dashboards available to NHS Tayside staff have been shared.

NHS Tayside has been commended by Scottish Government as an exemplar in its information products, including the Command Centre suite (which has received national and international recognition) and the DCAQ packs for CMHTs (which have been assessed by Scottish Government as nationally leading in their analysis and presentation).

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

There is now a range of public-facing meetings and engagement opportunities around performance reporting for Mental Health and Learning Disabilities service provision, as set out in the actions section of the briefing for this Recommendation.

RAG Status: Green

Any further action proposed:

It will be important to continue to engage with the public around performance and planning, particularly given the need to continue the work around whole system reconfiguration and the full implementation of the ambitions set out in Living Life Well.

The infographic will be produced and circulated on an annual basis along with an invitation to discuss service performance.

A report on inpatient services, progress in relation to the lead partner role and Living Life Well will be provided by the Lead Partner Chief Officer and Executive Lead for Inpatient Mental Health and Learning Disability Services as a standing item on the agenda of both NHS Tayside Board and Perth and Kinross IJB. These reports will be provided to Angus and Dundee IJBs for information.

Recommendation 9:

Clarify responsibility for the management of risks within NHS Tayside and the Integration Joint Boards, at both a strategic and operational level.

Intended outcome(s):

• The responsibility for the management of risks within NHS Tayside and the Integration Joint Boards at both a strategic and operational level will be clarified across Organisational Partners.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We know that risk management across organisational partners at both strategic and operational levels was highlighted in Trust and Respect. A confused landscape of governance and risk management was described, and the report highlighted the issues this created for accountability, ownership and management of risk.

Summary of Actions:

We recognised the confused landscape described in the report and sought to clarify risk management arrangements across Mental Health and Learning Disability Services.

A series of risk workshops were progressed with representatives from NHS Tayside and the Health and Social Care Partnerships. The workshops were supported by the Chief Internal Auditor and set out:

• A Revised Strategic Risk for Mental Health and Learning Disabilities
• Eight System-Wide Service Risks that informed the overall Strategic Risk
• A system-wide risk management process underpinned by a standard operating procedure
• The Risk Owner and the Risk Managers.

The Strategic Risk was reviewed through the Integrated Leadership Group who managed the 8 System-Wide Service Risks. The risk review enabled each HSCP and NHST retained services to update their organisational risk rating for each system wide risk and then arrive at an agreed system-wide risk rating. The Strategic Risk was then updated on Datix.

In June / July 2022 a request was made from the Tayside Strategic Risk Management Group (SRMG) to archive the Strategic Risk based on the ongoing review of the Tayside Integration Schemes. Perth and Kinross IJB was asked to host a Strategic Risk Workshop to ensure that the strategic risks for mental health services continued to be managed. Workshop 1 took place on 18^th August resulting in a series of actions to ensure that there is a collaborative approach to risk management.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Perth and Kinross HSCP are providing leadership and support to develop the revised strategic risk which will recognise the role all organisational partners play within strategic and operational risk management.

Evidence and Milestones:

Organisational partners worked collectively to develop and agree a revised strategic risk and the process followed will inform the next steps for the strategic risk development.

ILG Risk Reviews took place on the following dates:

• 23^rd August 2021
• 21^st December 2021
• 21^st March 2022

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Whilst there is further work to do, we consider that significant progress has been made since 2020 to collectively identify, assess and review the key risks across our services.

RAG Status: Amber

Any further action proposed:

Perth and Kinross Integration Joint Board as Lead Partner will lead the development of a revised strategic risk acknowledging the roles, responsibilities and accountabilities of organisational partners across Tayside.

Recommendation 10:

Ensure that there is clarity of line management for all staff and that all appraisals are conducted effectively (Medical, Nursing, Management Leads).

Intended outcome(s):

• The line management structure is clear and understandable to all staff in scope.
• Appraisals are conducted annually for 95% of staff in scope and are reported to be effective

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that during the Independent Inquiry, some staff described a lack of clarity about their line management arrangements. Further, some staff also reported not having had a timely appraisal. We recognise that these factors can lead to a sense of not feeling valued or listened to. We recognise the importance of both to a well organised and supported workforce, and our aim is to ensure that everyone knows their line manager and everyone in work receives timely and effective appraisals. These two factors form part of a broader approach to workforce development and support.

All staff have an identified annual appraisal process. However, the nature of the appraisal and the systems on which that appraisal is captured varies by professional grouping. For example, non-medical health staff appraisals are captured on the TURAS system; Social Work within Annual Development Reviews. The primary focus of attention within the Independent Inquiry was the group who engage in annual appraisals captured within the TURAS system.

Summary of Actions:

Clarity of Line Management

Management structures were clarified and shared with the workforce. Staff were also encouraged to speak with their line manager should any uncertainty remain, particularly in the event of staff turnover.

Appraisals

Agenda for Change Appraisals were stepped down nationally by Scottish Government during the pandemic. However, during the pandemic, we provided awareness and refresher sessions for managers and staff on the appraisal process and its importance across our mental health and learning disability services.

We developed reports to monitor the uptake of appraisals. TURAS monitors NHS staff uptake other than for Medics. These reports go to Mental Health Integrated Leadership Group and through Local Partnership arrangements.

Appraisals for Medical Staff within mental health and learning disabilities services are monitored separately by the Operational Medical Director for Mental Health and Learning Disabilities.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We believe that the actions we are taking are the right ones, as part of a broader approach to workforce development and support. We also believe, through the review of indicators (iMatter, Trickle, Pulse surveys) that the experience of working within our services is improving.

However, given that the current rate of appraisals across all services varies, and currently is below 30% we recognise that an effective sustained response to this recommendation requires an ongoing commitment.

Evidence and Milestones:

Key evidence against this recommendation includes:

• A monthly report on uptake of appraisals (completed and in progress) in each service
• Gathering a report on effectiveness of appraisals
• Organisation charts and associated staff communications are available within the LLC Evidence Repository
• We anticipate that some services will achieve the 95% target early, where the appraisal process is less impacted by service delivery pressures. We are aiming for 50% uptake of appraisals for all staff in scope by 31 March 2023, rising to 95% by 31 December 2023

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Improvement Plans are either developing or are in place for all services in scope.

Progress against this ambition is monitored on a monthly basis through the local monitoring arrangements. Assurance at executive level will be taken through Staff Governance Committee.

RAG Status: Amber

Any further action proposed:

As part of our recovery from the pandemic and the temporary pause in the appraisal process, services are in the process of further developing improvement plans (including trajectories). Performance against the plans and associated trajectories will be monitored through the above arrangements and via NHS Tayside Staff Governance Committee and Area Partnership Forum.

Actions included in the plans will include:

• Review of which services are achieving progress, and which are not, with detailed recovery plans
• Reports will go regularly to partnership forums
• For those not achieving progress, identify barriers to progress (etc. knowledge, skills, adequate time, recording of progress, ratio of line manager to direct reports etc)
• Support to overcome barriers (e.g. training, agility around process, protecting time, sharing of burden, sharing of knowledge about what works, peer support etc)
• Review and revision, as required, of actions to achieve progress

With regard to clarity of line management structures, we will update and circulate annually to all staff our organisation structures and we will encourage conversations about any areas of uncertainty for staff. Particular reference will be made to situations where a manager is moving on.

Finally, we intend to assess the effectiveness of appraisals through line management conversations with staff and build into our leadership work discussion about what we know regarding the effectiveness of appraisals, as we implement the ambitions of Living Life Well.

Recommendation 11:

Ensure the policy for conducting reviews of adverse events is understood and adhered to. Provide training for those involved if necessary. Ensure that learning is incorporated back into the organisation and leads to improved practice.

Intended outcome(s):

1. Adverse event management is performed consistently in line with the NHS Tayside Policy for Adverse Event Management. This will ensure that reviews are conducted in accordance with the HIS National Framework.

2. Staff performing adverse event reviews are skilled with the necessary tools to ensure there are robust and transparent reviews that seek to capture learning and improvement for patient care.

3. Learning from reviews is cascaded through the organisation via a clear clinical governance structure providing regular assurance that action has been taken to improve practice.

4. Patient and families are included as equal partners in reviews ensuring that they have confidence in the level of review undertaken. Their testimony is listened to with empathy, dignity and respect. Recommendations and actions taken for improvement are shared openly.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

In any complex system, adverse events are likely to have significant effects on the people involved. For a number of years NHS Tayside has had a policy for conducting reviews and regards these events as an opportunity to learn and improve care. The Independent inquiry highlighted a number of issues with adverse event management:

• There was a need for the policy to be updated in line with Healthcare Improvement Scotland (HIS) national framework (published Jan 2020) to improve consistency of how reviews are conducted. In particular, to ensure that those events requiring a Significant Adverse Event Review (SAER) are chaired by a trained independent reviewer.
• There were a significant number of events not being reviewed within the timescales outlined within the Policy. This led to a loss of trust between the service, staff, patient and families that events would be reviewed in a systematic and timely manner to capture learning.
• The depth of review, terminology and methodology seemed to differ across teams.
• There was not a consistent approach to family involvement in the process leading to a loss of faith in the transparency of reviews by service users. Families reported a need to have to fight for information and feeling let down by the lack of detail and personalisation of reports having waited long periods of time to receive these.
• Reports from some reviews were considered to lack clarity and not address questions raised by staff and families.

Whilst the recommendation has a focus on ensuring the Adverse Event Management policy is understood and adhered to, it was considered that other underlying issues needed to be addressed to restore confidence in the approach to learning from these events in a just and transparent system. Particularly:

• Improving organisational capacity to conduct Reviews in a timely manner
• Ensuring Reviewers are skilled in investigative enquiry to ask the right questions and design recommendations that foster a culture of continuous improvement in practice
• Transparent systems of quality assurance.

Incorporating learning is a major challenge for any organisation where there are a number of component parts. The recommendation highlights the need for clinical governance structures that ensure accountability for learning across Partner organisations whilst recognising the strength that comes with cooperation at senior leadership level to achieve spread of learning and 'checks and balances' to decision making around depth of review required.

Sumary of Actions:

It is important to remember that not all Adverse Events – even where patient death is involved – require a SAER. This process is reserved for those events where there is evidence that action(s) or failure to act at a level that breaches duty of care may have contributed to the patient's death, where there is multi-agency, cross-speciality or cross-Board involvement where the review would benefit from having an independent chair, there is evidence that the review will require a level of analysis that will benefit from the expertise of a carefully chosen SAER team, at the time of death the patient was an inpatient or an open case to the Intensive Home Treatment Team (or within 7 days of discharge from these services) or there is evidence that systemic failings may be common to other mental health areas within Tayside and the review process may need to investigate processes beyond the immediate area where the incident took place.

Adverse events not meeting these criteria are still subject to review. The depth of Review is proportionate to the event and potential learning but is still thorough and often using the same methodology as SAERs; only without an independent Chair. For example, Mortality Reviews and Local Adverse Event Reviews. Many more adverse events will fall into this category than require SAERs. Each HSCP and NHS Tayside have in place formal structures and groups – fully integrated within Governance structures – to oversee these Reviews.

The following actions pertain mainly to the SAER process.

1. NHS Tayside Adverse Event Management Policy was updated to reflect HIS adverse events national framework in March 2022. Prior to the formal update to the policy, actions had been taken to help staff prepare for the new Significant Adverse Events Review (SAER) process and to standardise the approach to reviews across the whole service. There is a now clear level of accountability within the senior leadership team and agreed processes regarding commissioning of SAERs. When Reviews are completed, there is signed ownership of Reports, a process of quality checking by the clinical governance team and Medical and Executive nurse level sign off. Quality checking and standardisation of the process for reviews has resulted in less variation across the services and will, hopefully, result in recommendations that services can action and more easily evidence change.

2. A Mental Health & Learning Disability SAER group was established in January 2022. This is a weekly meeting with representation from the 3 HSCP's, Inpatient and GAP, CAMHS and Forensic services which has improved standardisation on proportionate level of review for events. It also allows for discussion of recommendations and actions that cross services and provide a forum to ensure learning is shared with senior leaders. This group was key to designing and implementing the Suicide death protocol that clearly advises teams on when SAER is required.

3. Patient Safety Clinical Governance and Risk team (PSCGRM) employed Consequence UK to train in total 28 members of staff in nationally recognised methodology for conducting reviews. The most recent 28 form a bank of independent reviewers who have ongoing professional development sessions and quality assurance sessions for peer support for conducting reviews in the independent reviewer role. Independent reviewers have been trained to improve quality of the investigation, reports and recommendations. They are able to support family and carers to be actively involved if they wish in the review. This adds to the number of Reviewers across Partner organisations already trained by Consequence UK and local training initiatives to support and improve the skills of all those expected to lead on Reviews.

4. The Clinical Governance structure was mapped for across MH services and all key groups identified for where assurance is given and learning disseminated through. This exercise in March 2022 was endorsed by the three HSCP's and inpatient services. Assurance is also provided by teams reporting back on actions and learning to the Executive Nurse Director and Medical Director for SAER to fulfil all aspects of Statutory Duty of Candour.

5. The PSCGRM team has collaborated with the University of Dundee running a project to improve family engagement with reviews. This has lead to families being supported to meet with the independent reviewers, share information and questions for the review and then be party to the drafting of the report. A toolkit was co-designed by engaging with families involved in reviews and the independent reviewers with support from the university team.

6. Police Scotland and NHS Tayside have begun redesigning a Quality Improvement forum to enable shared learning from adverse events across the organisations. The aims of the forum are to promote shared learning and to reduce the likelihood of matters escalating to the level of LAER and SAER.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The actions have ensured that there is significant improvement in SAER with appropriate forums in place to manage the process, maintain quality through training and assurance on actions taken through governance structures.

There now needs to be similar levels of investment in supporting non-SAER Reviews, to ensure that the processes are seen as equivalent in thoroughness and achieve the same level of family engagement.

Evidence and Milestones:

• Consequence UK were commissioned and delivered training to two cohorts of staff to enable the independent SAER reviewer process to be established (July 2021, April 2022).
• AEM policy approved by Clinical Policy governance Group March 2022 ensuring the policy is transparent, just to staff, and will meet the needs of patients and families seeking answers.
• MH SAER Leadership Group established Jan 2022 to agree on levels of review, commissioning and sign off processes and provide professional support to senior clinical leaders deciding on levels of review for consistency across the service.
• PSCGRM Triumvirate weekly review all category 1 events, mortality learning events in MH, any upgraded or downgraded events and all triggers for Statutory Duty of Candour to provide assurance.
• Medical and Executive Nurse Director established closing the loop session for clinical teams to report back on actions taken from SAER and share learning (Oct 2021 – monthly held meeting)
• Project ECHO (Feb 2022) PSCGRM presented at national event to share learning on family engagement in reviews. Toolkit presented has now been shared across the Adverse Event Network to promote family engagement.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The Adverse Event Management team within the Patient Safety Clinical Governance department has been strengthened with a senior post and dedicated staff to continue to drive both advances in the quality of reviews, training for reviewers, and family carer engagement. This enables strategic leadership and accountability for supporting the service to perform well.

Quality of reviews and performance of the SAER process is now incorporated into the PSCGRM annual report this autumn for the Care Governance Committee for assurance.

Audit from Jan 2022 has shown significant improvement in the number of open significant adverse events – all category 1 events are now accounted for as ongoing SAER or are complete. There are less than 30 mortality learning events currently running with the majority of reviews completed across the HSCP's and inpatient services.

RAG Status: Green

Any further action proposed:

Future work will focus on greater support for strengthening the quality of reviews in areas with increased need such as healthcare reviews following death in the prison population, many of which have a mental health component.

Working with families will be extended to creating specialist interest groups to play an active role in the design of the AEM process to be inclusive of their opinion on how reviews are conducted in future. We will engage with National initiatives seeking to support relative bereaved by suicide.

Mediation (linked to recommendation 50) – there are currently two trained mediators within the team that have valuable skills to support the rebuilding of relationships when adverse events have occurred, particularly for families and carers taking part in SAER. This opportunity for conflict resolution should be incorporated into the process of review.

Recommendation 13:

Ensure that there is urgent priority given to strategic and operational planning of community mental health services in Tayside. All service development must be in conjunction with partner organisations and set in the context of the community they are serving.

Intended outcome(s):

• Co-produced mental health and wellbeing strategic and commissioning plans are in place within HSCP and have been approved by Integration Joint Boards.
• Community service developments that require a Tayside approach are progressed through collaboration

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry report that concerns were raised about poor strategic leadership of mental health services in Tayside. The operational and strategic arrangements in place were deemed to be difficult to understand and had previously failed to adequately incorporate lived experience to the heart of planning. These factors, in addition to a lack of evidence of a whole system response being taken to key areas of risk, for example within the workforce, led to this recommendation being made.

Summary of Actions:

Tayside Executive Partners established as the Oversight and Leadership Group, producing a Statement of Intent.

An Internal Scrutiny and Assurance Group is in place to support the Mental Health Leadership team and provide oversight.

A Tayside-wide Mental Health Leadership Group has been formed and continues to strengthen its collaborative effort and activity.

Local strategies have been produced and approved across the 3 HSCPs.

New and emerging pathways / models of support have been agreed and are at varying stages of implementation, and all of which will have a positive effect on available mental health and wellbeing support in communities.

A collaborative workstream taking an improvement approach to community mental health teams across Tayside is currently underway. This is within the context of a whole system approach extending from inpatient care through to a range of community care and supports.

The Chief Finance Officer for Dundee HSCP (on behalf of their colleagues across Tayside) has supported early discussions / plans to develop a financial framework. They also are a member of the Integrated Leadership Group and this has ensured more timely financial advice and guidance and has supported the Mental Health Leadership team to progress some key areas of improvement.

Integration Schemes across Tayside have been reviewed.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We consider that the actions already taken, in addition to those in course, will take us to where we need to be.

Evidence and Milestones:

Local plans that are in place:

• Perth and Kinross Integration Joint Board recently approved the HSCPs co-produced Mental Health and Wellbeing Strategic and Commissioning Plan
• Angus HSCP prioritises the mental health and wellbeing needs of citizens through their HSCP Strategic Plan. In addition to this, an implementation plan in relation to Living Life Well is in place
• Dundee Integration Joint Board approved the HSCPs co-produced Mental Health and Wellbeing Strategic and Commissioning Plan in autumn 2019. This outlines both local and pan Tayside priorities for improvement
• Strategic Planning Meeting agendas / minutes in each HSCP area
• Evidence of engagement across 3 HSCP areas, both generally and for specific purposes e.g. Community Wellbeing Centre developments
• Output from Tayside workstreams e.g.Crisis and Urgent Care, Learning Disability
• Output from discussions between Chief Finance Officers/Leadership team to support MH / LD developments

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We recognise the scale of work that remains to be achieved in order to ensure good mental health and wellbeing outcomes for the people of Tayside. Within this specific Recommendation however, we consider that good progress has been made to ensure communities have been involved in agreeing priorities and co-producing local plans. The absence of a financial framework to date has not inhibited our ability to move forward with new models supported by Chief Finance Officers.

RAG Status: Amber

Any further action proposed:

Revised Integration Schemes across Tayside have been approved.

Through the strategic leadership of the Chief Officer for Perth and Kinross HSCP we anticipate a refresh of our collaborative priorities, considering local plans and Living Life Well. This will in turn enable the completion of an implementation plan and financial framework to support new pathways and models of support and balance of care intentions.

As part of the above, consideration will also be given as to how we ensure the needs of people with learning disabilities are prioritised and that strategic and operational matters continue to be approached both locally and collaboratively across the whole system.

The Chief Officer for Perth and Kinross HSCP since her appointment in May 2022, has commenced a programme of activity to advance the Lead Partner role for mental health services across Tayside. As reported to NHS Tayside Board and Perth and Kinross IJB, this includes:

• The establishment of a 'strategic leadership group' for Tayside Mental Health Services comprising the three Chief Officers for Angus, Dundee and Perth and Kinross IJBs; the Medical Director, Director of Finance and Executive Nurse Director for NHS Tayside. The group will provide collective leadership to ensure the right support, resource, data, information, and expertise to take forward the strategic planning coordination and financial framework to support the delivery of the strategy.
• Following a review of the requirements for programme management support, decision to establish a permanent team to support the delivery of the Living Life Well Strategy and transformation programme with recruitment underway.
• An assessment of the current capacity and resources devoted to the engagement and involvement of people with lived experience of mental health services is in progress with a view to increasing the level of support and expertise in the crucial area.
• A plan to review the governance structures for Listen Learn Change and Living Life Well, taking account of the revised Integration Schemes. This will commence with a review of the terms of reference of the Mental Health and Wellbeing Programme Board. The Chief Officer as Lead Partner has held one-to-one discussions with workstream leads and will lead a re-evaluation and re-prioritisation of the current workstreams reporting to the Board. This will include the development of a financial framework to support the delivery of the strategic plans for mental health services.
• A workshop is planned for members of the Mental Health and Wellbeing Programme Board to consider the mechanism for transitioning the outstanding or ongoing actions from Listen Learn Change into the strategic programme of work to deliver on Living Life Well.
• The first of a series of risk workshops to ensure that the arrangements for the management of strategic risks for mental health services are in line with the responsibilities set out in the Integration Schemes was held on 18 August 2022 and will conclude in October 2022.
• The establishment of a Short-Life Working Group with representation of the 3 IJBs and NHS Tayside to prepare a governance, reporting and decision-making structure for services coordinated by a Lead Partner. This will enable the Perth and Kinross IJB to lead the strategy for the transformation of mental health services with confidence including the use of Directions.

Recommendation 14:

Consider developing a model of integrated substance use and mental health services.

Intended outcome(s):

• People who use substances and have mental health problems have timely access to care which is well-coordinated.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

People with co-existing mental health and substance use problems (often referred to as dual-diagnosis patients) within Tayside receive assessment and treatment from separate services, with an expectation that care is co-ordinated on an individual basis. There has never been a specialist dual-diagnosis service. Surveys suggest that around 30% of people accessing specialist mental health or substance use services meet definitions for dual-diagnosis.

We understand from the experiences shared by people during the Independent Inquiry that there were concerns expressed about a lack of seamless support for people experiencing substance use and mental health challenges.

Summary of Actions:

National support to aid the development of an improved, more integrated approach for people experiencing substance use and mental health challenges is being provided through HIS Pathfinder Project. This work will develop prototypes for integrated working through system understanding, system redesign, co-design and co-production and learning system.

Within Angus and Perth and Kinross a high degree of integration is already in place. Perth and Kinross have integrated health and social care aspects of drug and alcohol recovery into a single operating unit, I-DART. In Angus there is an agreed Angus-wide integrated care pathway between mental health and substance services. A new Enhanced Community Hub has been tested and evaluated, and brings together primary care, mental health, substance services, psychology and 3^rd sector, including peer support. The Hub has one referral pathway and an ethos of no wrong door, and no rejected referral. This model is being rolled out across Angus, and has won an award, been recognised nationally and is being adopted by other health boards.

The importance of developing integrated pathways as a priority was highlighted within The Dundee Drug Commission Report "Responding to Drug Use with Kindness, Compassion and Hope," which was followed up by a subsequent report in March 2022. Whilst the original action plan from this did not overtly address the specific needs of dual-diagnosis patients, there has been two subsequent developments that do:

1) A successful bid to the CORRA Foundation to develop tests of change for a co-produced model of care in Dundee City by August 2023

2) Engagement with HIS in the pathfinder work on the same topic

The tests of change in Dundee are specifically aimed at ways of working that allow "robust joint working systems and processes between substance use and mental health service provision in the community to enable person-centred support for people and their families."

The overall aim of the Tayside Pathfinder Project is to redesign care pathways to improve quality of care and health outcomes for people with mental health and alcohol / drug us support needs.

The aim was underpinned by the following objectives:

• System understanding – to understand the current state, and the user and service needs that can be met by service redesign and improvement
• System redesign – to work with NHS Tayside and three HSCPs/ADPs (Angus, Dundee and Perth and Kinross) to develop and test an integrated approach to delivering mental health and substance use services (building on lessons from the Covid response)
• Co-design and Co-production – to increase opportunities for people with lived experience, communities and partners from across mental health and substance use services
• Learning system – to identify, share and spread good practice, innovation and learning about 'what works' Scotland-wide to drive improvement and change in developing and delivering integrated mental health and substance use services (including informing policy development)

The programme of work, supported by HIS has included a wide range of engagement and exploration of available views:

Discovery phase – (January 2021 – September 2021)

Towards a Test of Change Workshops

• Exploring Integration Workshops – stakeholder events to look at what good looks like across short/medium and long term.
• Interconnected Systems Mapping Sessions – to discuss and describe what services make up the 'system'
• Data summary – provide overview of key data around prevalence and dynamics of substance use and mental health, along with service demand and risk profiles.
• Equality Impact assessment of inequalities
• Literature review

The work identified the following ambitions:

• No wrong door – not having to tell story more than once, not being passed between services
• Taking a person-centred approach
• Ongoing collaboration

and the following four areas for focus:

• Meeting Complex Needs
• Adapting and Responding
• A Collaborative System
• Workforce and Capacity

A number of the areas identified are embedded within current workstreams.

An initial Dundee test of change was developed by focusing on women with complex needs. A multi-disciplinary team was developed to assess and respond to women presenting to the Dundee Women's Rape and Sexual Abuse Centre. The team of third and statutory services review each women presenting for support. The team considers both substance use and mental health services and are accessing supports at an early stage taking both a person centred and trauma informed approach.

Development of a Tayside Leadership Programme – looking at supporting leaders to implement the changes. The next session is for the 21^st September 2022.

Trauma Informed Practice Development – working with Dundee Council Protecting People Team to support with Trauma Informed Practice; with the intention of bringing together a range of services to co-design a training and development series that is based on self-reflection, directed inputs and peer learning.

Funded peer support worker network in Dundee and engagement with people with lived experience to influence and inform developments.

For Dundee, further stakeholder sessions have developed the into the following four change ideas which (June – July 2022):

1 How might we avoid people falling through the support net and that the first contact with providers is a positive experience:

• Development of a peer support model role based in GP practices to support people to access
• Creating an advocacy role or support/link worker to introduce into communities to develop a person-centred care/support package

2 How might we improve follow-up support from acute mental health, drug or alcohol rehabilitation inpatient settings?

• Provide holistic exit (care) plans for discharge whilst in hospital, bridging gap from acute mental health care to social and community substance use and mental health support

3 How might we help statutory and third sector support services connect better around the person despite the person's mental health or addiction?

• Connecting support services around the person by establishing day to day multi-agency working and information sharing around individual support needs
• Establishing a multi-agency approach to providing intensive support that includes attention on transitions into and out of this level of support

4 How might we improve support in crisis?

• Development of a 24- hour multi-agency response, to support people affected by substances, prior direct referral to mental health and substance use services, or at times of crisis. This will be aligned with the development of the Community Wellbeing Hub.

These proposals are in the very early stages of development and will be tested over the remainder of this project term.

To some extent the Corra and Tayside wide programme of work has been hindered by both capacity across services, with all service areas affected by staff shortages and personnel changes. The Substance Use Medical Lead, for the Tayside programme has taken up a post in another area of Scotland and as a result of the current overall psychiatric workforce, it has been difficult to identify a replacement clinical lead.

It took time to recruit the Dundee programme co-ordinator, who moved after 9 months to take up a promoted permanent post. Recruitment to a new co-ordinator has not been successful.

The national priority to implement the Medication Assisted Standards, with a focus on standards 1– 5, has taken priority for development and implementation across substance use services. However, Standard 9 which relates to the access to mental health services for those who use substances has a much later lead in time, but sets out a criteria for this work which will be embedded into this programme.

The ask of this programme of work was to consider an integrated model of working between Mental Health and Substance Use services. While the workshops have identified that there is no appetite for a single fully integrated service model of mental health and substance use, those with complex needs require a more co-ordinated approach which is integrated in its delivery to the person. Testing models at key points of support: referral and response; points of transition and those with complex comorbidities will be further tested going forward.

Are the actions sufficient to achieve the intended outcome(s)?

Yes. However, there is a requirement to see a greater pace of change through the current programmes of work.

Please briefly explain your response here:

There are models within Tayside which deliver the approach required.

We consider that the combination of actions already taken and those planned will take us to where we need to be.

Despite the difficulties in progressing, there remains a willingness to continue with the programme of work, which will be strengthened through the introduction of MAT Standard 9.

By identifying key pathway points for support, the next stages of work will take a more focused approach on Tayside systems, with learning across the services of what is currently working.

Evidence and Milestones:

There are a range of reports produced by Health Improvement Scotland on the progress of the programme

Tests of change are underway

There is slippage in the original timelines as originally defined through the Dundee CORRA bid, particularly around implementation and the further development of hubs

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The workstream continues, with Dundee Corra funding in place over the next 6 – 9 months.

Angus Hub model in place and sustainable.

During the next phase we would be looking to bring forward more evidence of change at a Tayside level.

RAG Status: Amber – actions are marked as complete, but have not achieved the intended outcome or actions are underway but are unlikely to achieve the outcomes in the timescales required – additional action required.

Any further action proposed:

Implementation plans for the further identified changes will be considered over the next two months.

Completion of programme co-ordinator recruitment.

Recommendation 15:

Develop comprehensive and pertinent data-capture and analysis programmes, to enable better understanding of community need and service requirement in the community mental health teams.

Intended outcome(s):

• Our Community Mental Health Teams have regular data to help them understand the level of need from the communities they serve, and the data is used to drive improvements in service planning and delivery

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Our understanding is that recommendation arose from the need to really understand what our communities need at this tier of our model of care. Without understanding need at this level, it would be difficult not only to ensure that need is met at this level, but it would also be risky to reconfigure care at other tiers of need without this information.

In 2019 at the time of the Independent Inquiry, team level analysis of demand and how well this demand was being met was not routinely provided to teams. There was also no systematic or standardised way of identifying number of people waiting for routine assessment, nor for how long.

Summary of Actions:

Work was done in 2020 to compare prevalence of Mental Illness at disease level across Tayside communities with national prevalence rates.

Our Health and Business Intelligence Team took an analytical model around Demand, Activity and Queue that had been developed for acute physical health departments and applied the model to Community Mental Health Teams.

The analysis this generates quantifies graphically at team level the volume of requests for CMHT input, the activity the team is achieving over time, the number and type of appointments offered, the volume of new and return appointments provided, and shows the shape, size and length of waits. The information is sent to Team Leaders across all seven Tayside CMHTs on a monthly basis.

Team Leaders were trained in how to interpret and use the analysis, with the training reported as favourably received.

Services are now using the data to plan and make changes to service provision to improve the care that is provided to our patients within the community setting. Some examples include;

• Work to reduce rate of rejected referrals in Angus
• A revised model of referral triage within Dundee
• Work to validate and cleanse waiting lists in Perth and Kinross

A separate pack showing examples of regular information products about our services, alongside narrative about how each is used, accompanies this briefing.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The process of supplying ongoing good quality analysis is built into Business-as-Usual reporting. There is evidence and there are examples of how Team Leaders are routinely using their data to plan and improve service delivery within the community setting and to ensure that ongoing need is understood and met as effectively as possible.

Evidence and Milestones:

The initial work to understand and benchmark prevalence is held in the LLC Evidence Repository.

Examples of the CMHT Demand, Activity and Queue packs are also stored within the Evidence repository and copied to key individuals at leadership level.

Examples of service reconfiguration are on file within the Evidence Repository.

This work has generated interest nationally, with Scottish Government reporting that Tayside's CMHT data is now amongst the best in Scotland.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The analysis and reporting of CMHT activity is fully embedded into Business-as-Usual processes.

The LLC Leadership team will continue to be curious about how the data are being used to improve care in the community setting. The data will be of particular interest as the whole system model is reviewed and adjusted.

The processes around this recommendation are now Business as Usual and represent a marked change in transparency of CMHT performance from 2019.

RAG Status: Green

Any further action proposed:

Ongoing monitoring and learning about changes that are made to service planning and delivery as a result of the data.

A review of Mental Health disease prevalence within Tayside communities once benchmarking data is available in the near future.

Recommendation 16:

Prioritise the re-instatement of a 7-day home treatment team service across Angus.

Intended outcome(s):

• Home treatment services across Angus are available 7 days per week.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The provision of home treatment services across Angus is available 7 days per week.

Summary of Actions:

The extended 7-day community mental health service was established in May 2021 in the North of Angus and following a successful pilot extended to include South Angus in September 2021. The service supports existing service users of the Community Mental Health Team (CMHT) who require an increased level of support for a limited period of time in addition to their existing care plan, or new service users who have been assessed and have a risk assessment and care plan in place which details the need for weekend support.

The aim of the service is to offer person centred support in the local area to prevent crisis, manage risk, prevent a further deterioration, prevention of admission, early supported discharge from hospital and support service users who are on pass home from hospital when weekend support is identified within their discharge plan.

During the week all staff in the team provide a home treatment service.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Service is now implemented across Angus and initial evaluation complete.

Evidence and Milestones:

Service implemented fully across Angus in September 2021.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The extended 7-day community mental health service was established in May 2021 in the North of Angus, and in South Angus in September 2021. There have been 254 contacts with services provided to 101 individuals in this time period. On average 3.4 people are referred each weekend, and the highest number of people referred in one weekend was 9 people. There has been a 94% attendance rate overall.

RAG Status: Green

Any further action proposed:

Review recommendations from evaluation but now consider as business as usual with ongoing monitoring of performance and impact.

Recommendation 17:

Review all complex cases on the community mental health teams' caseloads.

Ensure that all care plans are updated regularly and there are anticipatory care plans in place for individuals with complex/ challenging presentations.

Intended outcome(s):

• All people on our Community Mental Health Team caseloads have care plans that reflect their needs and wishes
• People with complex needs have an anticipatory care plan in place that is helpful to them, reflects a format that they are comfortable with and is reviewed regularly

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that during the Independent Inquiry it was observed that care was not following a multi-disciplinary and multi-agency approach and that different professions / care giving services were often not able to provide consistent care due to a lack of documented anticipatory care planning to meet the needs of people needing complex support.

The Independent Inquiry indicated that people were sometimes admitted to hospital in crisis as a result of a lack of anticipatory care planning, and as a result of missed opportunities to set out proactive, preventative interventions to support community care.

Summary of Actions:

A project group was established bringing together senior leaders from across the Angus, Dundee and Perth & Kinross. This group had multi-professional representation and was chaired by the Associate Director of Nursing for Mental Health and Learning Disabilities in Tayside.

The group identified the lack of a nationally agreed definition of complexity to support the review of CMHT caseloads. Work progressed to develop a definition which provided specificity and sensitivity to accurately identify people considered to require complex care support. This definition included the option for staff, in discussion with colleagues to determine complexity on professional/clinical acumen. All caseloads across the community-based services have been reviewed against the definition agreed.

Individual CMHTs are now working towards all people requiring complex care to have anticipatory care documented and reviewed on an annual basis.

Sitting alongside the definition of complexity work, the group also worked with service users, carers, staff and 3rd Sector organisations (Angus Voice, Penumbra, Carers Trust) to understand which anticipatory care document was already in place for people receiving care. As a result of this work, it has been identified that there are several different used including Wellness Recovery Action Plans (WRAPs), Advanced Statement with personal statements, Recovery Plans.

We have reflected on the benefits of using the Healthcare Improvement Scotland (HIS) ACP document which is consistently used across Tayside.

Carers and service users indicated that where they have alternative documentation to the HIS ACP, they prefer to keep this and not have a further document to complete and update.

Community Mental Health Service in Perth and Kinross will implement the HIS ACP for all new complex cases from June 2022.

The project group have developed standard operating processes and a flow chart to support staff to implement the processes.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The recommendation sets out the gaps identified in practice across the service to support the needs of people with complex needs. As a result of the work associated with Recommendation 17 the service can now articulate the proportion of the people requiring complex support. The services are now working to ensure that where documentation was already available this includes all components of an ACP and that this will be reviewed at least annually.

Evidence and Milestones:

Definition of complexity developed through collaboration

Report of the work undertaken by CMHTs to review caseloads

Report from stakeholders including service users and their carer on the applicability of HIS ACP

Evidence of care planning review processes in Angus, Dundee and Perth & Kinross

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We have made significant progress in agreeing the definition of complexity and the processes and documentation that we use to capture and review those needs. Much has been done to implement those processes, taking into account the views of people we support whose needs are complex.

However, we do recognise we have some way to go before we can be confident that every person on a Community Mental Health caseload who has complex needs has been reviewed in line with the new definition and processes.

It is recognised that the routine use of ACPs to help patients articulate their care needs and wishes will take time to fully embed into practice.

RAG Status: Amber

Any further action proposed:

We need to complete the review of people with complex care needs using the new criteria.

We need to ensure that there is a reliable process for identifying and reviewing complex needs for people who newly join our Community Mental Health caseloads.

We need to fully embed the use of ACPs where appropriate.

Learning from the work to be shared as part of the Community Mental Health redesign process and support the transition from a recommendation to a key element of community practice.

Recommendation 18:

Plan the workforce in community mental health teams in the context of consultant psychiatry vacancies with the aim to achieve consistent, continuous care provision across all community services.

Intended outcome(s):

• CMHT waiting times in keeping with National standards (and before this to current Emergency, Urgent and Routine definitions)
• Improved patient experience
• Improved carer experience
• Improved ability to review patients quickly at times of increased clinical need
• Radical shift in the workforce to reduce dependence on traditional medical roles by investing in other disciplines to provide a wider range of core functions.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Community Mental Health Teams (CMHT) were established in Tayside in 1997. These have always been multi-disciplinary in nature and there are currently three within Perth & Kinross, two within Angus and two within Dundee (as well as an Assertive Rehabilitation Team). There has not been a systematic review of CMHT functioning within the last decade despite the significant challenges that have occurred: for example, increasing (general) referral rates, significant emergent demand around ADHD and other neuro-developmental conditions, the emergence of legal highs and the increasing societal rates of alcohol and drug use.

Initial models of CMHT care had Consultant Psychiatrist time split between CMHT and aligned inpatient beds. This allowed continuity of care for service users and carers and fostered good working relationships between inpatient and CMH teams with Social Workers and Clinical Psychologists also 'following' people between care settings. This was changed to try and reduce the number of relational interfaces/MDT meetings for inpatient teams. However, it is also likely that an unintended consequence was that Consultant planning became fragmented with a primary focus on what was required to provide safe inpatient care. HIS recommendations that this model should be re-considered was reinforced by the Independent Inquiry, with an emphasis on the importance of continuity. However, in the period since then, Consultant staffing has been both an acute and chronic issue. CMHTs are currently staffed almost exclusively by Locum Consultant Psychiatrists. Energetic recruitment processes have not improved the situation.

This position is mirrored Nationally. In the Royal College of Psychiatry Workforce Survey in 2021, within Scotland, there were 830 full or part-time Consultants in post but with 161 Locums in post and a further 63 posts vacant with no cover at all. Of 49 retirements during 2021 only 19 returned to the workforce in any capacity.

The above requires three shifts:

1. Consideration of the functions required to be provided within CMHTs (as opposed to the people that have historically been employed or provided these roles)

2. A change of role to ensure that Consultant Psychiatrists are providing those functions that can only be undertaken by them

3. A re-modelling of the workforce to expand the numbers and roles of those disciplines who can provide functions previously provided by Consultants

Summary of Actions:

Workforce plans have been produced for each HSCP and for Inpatient Services.

Needs assessment analysis for Advanced Nurse Practitioners completed

ANPs are now in place within each CMHT with further ANPs in training.

Specialist Mental Health Pharmacy resource in place.

Additional nursing resources made available.

Locum Consultants no longer offer 'routine review' appointments to stable patients open to other Team members to increase time available to see patients with increased need.

Early engagement of Tayside Psychiatric Trainees to match person to preferred job.

Regular advertising of vacant posts.

Workstream for Community Mental Health Service provision is established.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The above can only achieve change over time. Continued investment in training ANPs is required.

This recommendation is impacted by increasing rates of referral to CMHTs (particularly for neuro-developmental disorders) and the longer-term management of significant numbers of people experiencing personality disorder. Condition-specific workstreams are in place for both and this should allow a natural refocus on more severe and enduring mental health conditions.

Evidence and Milestones:

Needs assessment (complete)

Increased headcount for ANP resource:

• Angus have 2 wte in post and a further 2 wte in training
• Dundee have 2 wte in post and a further 2 wte in training
• P&K have 2 wte in post and a further 1 in training (in Integrated Substance Use)

Increased headcount for pharmacy resource:

• 3 wte Specialist Clinical Pharmacist post established (one in each HSCP) with Dundee post filled, 0.4 wte filled in Angus and P&K expected to be in post by September 2022. The Angus additional sessions have been subject to a round of unsuccessful recruitment but will go back to advert in Autumn 2022
• 3 wte Senior Pharmacy Technicians (one for each HSCP) with all posts filled as of August 2022 (some for a period prior to that)

Community Mental Health Workstream now meeting

Outputs from the Community Mental Health Service workstream.

Neuro-developmental Workstream in progress.

Senior Clinical Psychologist post agreed to lead on implementation of services to people with personality disorder (with A4C matching panel) which will be supplemented with time from other disciplines (building on models used for Perinatal, Maternal, Neonatal Mental Health and Early Intervention in Psychosis) – expected to reach recruitment stage by October 2022.

Recruitment to permanent Consultant Psychiatry posts continues to challenge – last round of advertising in June 2022 yielded no applicants. Permanent Operational Medical Director for MH & LD in post. Re-employment of retired staff to new roles.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Actions are either complete or remain as ongoing actions.

Work-streams will continue through 2022 and into 2023.

RAG Status: Amber

Any further action proposed:

The outputs from the Community Mental Health Service work stream will inform the next set of actions we take around this recommendation and we will ensure staff side involvement in the plans at every stage going forward.

Recommendation 19:

Prioritise the development of safe and effective workflow management systems to reduce referral-to-assessment and treatment waiting times. This should also include maximum waiting times for referrals.

Intended outcome(s):

• CMHTs will receive regular provision of data that captures rates of referral, waiting times and measures of throughput.
• CMHTs will use the data to inform operational work and more strategic workforce planning.
• People will not be subject to unnecessary assessments (or time delays) to access the assessment that matches their need at any given point in time.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

There is no HEAT target for access to treatment in CMHTs. Informal local agreement meant that for a considerable period CMHTs worked to the 12-week access target applicable to acute care, but this was not reported through any formal mechanism. Importantly, the data and associated analytics were not provided in the same way that they are for Psychological Therapies (PT) and CAMHS HEAT reporting.

The primary systems through which data is captured are Electronic Referral Management and Trakcare and the primary system for analysis Qlikview. Whilst permission to access Qlikview has always been available, few staff were aware of this or how to use the system.

For PT and CAMHS, the data is made available to service leads from the Business Unit. This includes detail down to individual patient level. This allows for accuracy checking and encourages ownership of waiting times in a way that anchors there as being a person at the heart of every wait.

The period over which demand for CMHT assessment has increased, has coincided with significant reductions and gaps in Consultant staffing; the net effect being increases in numbers of people waiting and length of wait. The worsening trajectories associated with this were not fully appreciated because of the lack of routine data provision.

The data bundle and examples of how this has been used has been presented previously (in meeting with DHSCP).

It is important to note that the wait for CMHT assessment is not a chronological queue. Referrals are triaged and appointed based on perceived need and priority given to groups of people based on known (population level) risks; for example, on discharge from inpatient care. This means that those waiting for more 'routine' care are pushed to longer waits.

Cognisance must also be given to people accessing mental health systems through alternative routes. For example, presentations at Emergency Department (ED) and through university mental health systems.

Summary of Actions:

Monthly CMHT Data bundles are now supplied by the Business Unit. The data is used within operational planning and Clinical Governance groups.

Team Leaders being supported to understand and make use of data.

Pathway for Scottish Ambulance Service (SAS) to directly access mental health assessment without having to admit people to ED.

As detailed in Recommendation 22, improved pathways from University to CMHT and CRHTT.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

There are two parts to this work: ensuring that the analytic information is available and being used; and improvement/transformation work to ensure that demand and capacity are equally matched. The first part of this is significantly improved but achieving waiting times that are congruent with need and good risk management is contingent on a number of the other recommendations being advanced.

Evidence and Milestones:

1. Data bundles

2. QI presentation

3. Services changes (for example, changed new to return ratio appointments for Consultant appointments; structured support for people waiting; staffing increase)

4. SAS to mental health pathway

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We consider that good progress has been made. However, further work is required to ensure that all outcomes are fully met.

RAG Status: Amber

Any further action proposed:

Firstly, further work with the Business Unit to achieve data at the level of the individual as available to PT and CAMHS.

Secondly, the improvement work to decrease waiting times and numbers waiting.

Recommendation 20:

Consider the development of a comprehensive Distress Brief Intervention (DBI) training programme for all mental health staff and other key partners to improve pathways of care for individuals in acute distress.

Intended outcome(s):

• A wide range of staff and partners are trained in DBI Level 1
• A dedicated DBI service is in place within Tayside, offering support at Level 2
• Sufficient DBI resources are in place to meet demand

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

During the Inquiry the need to improve the response to people presenting in distress was strongly advocated by people who have experience of distress and by front line service providers.

It was considered that the development of DBI in Tayside would form an important element within an overall range of available scheduled and unscheduled mental health and wellbeing support in Tayside.

Summary of Actions:

An aspiration to develop a DBI service within Tayside was agreed during early 2019 as part of our Tayside review of urgent and crisis care. This coincided with the development of local strategic mental health plans across Tayside, where DBI again was agreed as a priority area for development.

Following an approach to Tayside by the Lead for the national development of DBI programme, an offer of 200K from Scottish Government was made and the national development Lead was instrumental in supporting our process.

A Service Specification for a Tayside Distress Brief Intervention Service was produced, drawing on similar specification already in place in pilot areas across Scotland.

A Memorandum of Understanding (Scottish Government Distress Brief Intervention) has been in place since 31 January 2022. This demonstrates respective partners' commitment to collaborate on the delivery of DBI.

A tendering process was undertaken, with representation from all 3 HSCPs and led by Dundee HSCP as Lead Partner. Penumbra were successful at tender and a contract has been in place since 1 October 2022.

The Service became operational on 1 April 2022, with an initial focus on the referral's pathway from the Police and an extension of level 1 training to Police colleagues.

Level 1 and Level 2 training continues to be scheduled and delivered across Tayside.

Penumbra have produced a flyer about DBI which has been circulated in local areas.

Penumbra are represented within DBI National Programme Board meetings.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The actions to date have led to a DBI service being established in Tayside and operational since April 2022. Robust support and monitoring arrangements are in place between Penumbra and a monitoring group established.

We recognise that the monitoring group will need to assess level of need for any increase to DBI resources into the future in order to build this into ongoing service and financial planning.

Evidence and Milestones:

Contract with Penumbra and associated service specification.

Monthly service update from Penumbra as a key element of discussion within the monitoring group (Penumbra, Lead Officer for the contract, Contracts Officer). The service monitoring report covers activity and demand, human resource matters and up to date performance around the expansion of level 1 / level 2 training across Tayside partners.

Dundee HSCP Finance Manager and Locality Manager lead Tayside-wide DBI financial planning processes. All 3 HSCPs identified monies from Action 15 funding to commit to the development of DBI in Tayside.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Between April 2022 and the end of July 2022 23 people have been referred for Level 2 Support. Each person's journey and outcomes are discussed as part of ongoing monitoring arrangements and individuals' stories will form an important part of driving continuous improvement within mental health and wellbeing services within Tayside.

A schedule of Level 1 and Level 2 training has been in place since December 2021.

RAG Status: Green

Any further action proposed:

Based on demand, ongoing consideration will be given to the further expansion of the Service. An example of this is the commitment in Dundee to use recently allocated Mental Health in Primary Care Services monies to further increase DBI training and delivery capacity between 2022 and 2026.

As Lead Partner, representatives of Dundee HSCP will provide the Mental Health Integrated Leadership Group with 6 monthly performance updates.

Recommendation 21:

Foster closer and more collegiate working relationships between the crisis resolution home treatment team and community mental health teams and other partner services, based on an ethos of trust and respect.

Intended outcome(s):

• Embedded multi-disciplinary and team-based approach to joint working across CRHTT and CMHTs, to provide seamless care.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Inter-Team collaboration is crucial in moments when a person's care needs are changing to the extent that input from other services is needed. That can apply as care needs are escalating, as well as when someone is moving past a moment of crisis. Without good inter-team collaboration, patients could receive poorer care or experience poorer care than is needed. This recommendation arose from staff reported perceptions of how well these teams work in the interests of patients at points of care escalation and de-escalation.

Summary of Actions:

Members of staff from CMHT, Crisis and from inpatient settings were brought together to work collectively on arrangements for patients whose care needs are changing. This group revised processes for the management of people whose care needs are rapidly changing. This includes standardisation of processes and documentation surrounding admission and discharge to and from inpatient settings. This includes development of discharge processes including the Intensive Home Treatment Services in Perth and Kinross, Angus, and the Mental Health Discharge Hub in Dundee City.

Developed a shadowing system so that colleagues can build greater understanding of each other's service.

Created a tool to measure the levels of collaboration across services in those moments where Inter-Service collaboration was needed between CMHT and CRHTT, and developed a whole system virtual capacity and safety huddle, centred round a Mental Health Command Centre dashboard. The dashboard provides visibility of real-time patient movement and inpatient service capacity.

Are the actions sufficient to achieve the intended outcome(s)?

No

Please briefly explain your response here:

The work has been collaboratively designed by key members of staff across services and is underpinned by a solid theory of change; that clear agreed processes for transitioning of care will result in better working relations across teams. In addition, a means of measuring the tenor and interaction between professionals at those times where inter-service care is required, provides information about the interaction.

However, further work needs to be done on the relational component of this recommendation to ensure that when individuals within services collaborate, the conversation is positive, professional, transparent and respectful. Where issues arise, the system's response needs to ensure swift de-escalation and resolution.

Evidence and Milestones:

Key documentation is available on the processes for transitioning care between CMHTs, CRHTT and Inpatients.

A system is in place to monitor uptake of shadowing.

The tool to assess the quality of interactions between CRHTT and CMHT has delivered positive analysis of the working relationship between services.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Capacity and flow processes are now more resilient and transparent than they were previously. Teams now understand what to do and who to call in situations that require inter-team working in the interests of patients.

The level of support for patients following a crisis has been strengthened.

There is however further work to do to improve the relational aspect of the interactions across the teams and to further strengthen escalation and de-escalation processes.

RAG Status: Amber

Any further action proposed:

A number of actions remain. We will;

• Continue to monitor the reliability and effectiveness of the revised processes for transferring care from one service to another.
• Facilitate a piece of work to bring services together to explore and develop shared relational practise, particularly around transitions.
• Promote and monitor the uptake and feedback from the shadowing model that has been put in place.
• Collaborate to ensure that good practice around discharge planning is fully embedded into how the teams work, so that as patient care is de-escalated, it is planned and clearly communicated to ensure seamless transition.

Recommendation 22:

Develop clear pathways of referral to and from university mental health services and Crisis Resolution Home Treatment Team.

Intended outcome(s):

• Understanding user experience of pathways
• Understanding service delivery of pathways
• Prioritising areas for improvement

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Tayside has a large student population, largely but not exclusively, centred around Dundee. Over 20,000 students are enrolled between the Universities of Dundee and Abertay with GP registration concentrated on a number of practices.

The Independent Inquiry highlighted the particular vulnerabilities of the student population with many living away from home for first time and with reduced family support. It also highlighted that many students will arrive with mental health conditions and expectation of being able to access support from University and HSCP when required.

Whilst the Universities have their own student counselling and mental health nursing supports, the Independent Inquiry highlighted that pathways for students requiring higher intensity treatments and/or emergency assessment was highly variable. The particular concern was that University mental health services – in order to respond quickly to a crisis - should have access to direct referral pathways into CRHTT.

Summary of Actions:

Understanding existing systems

What was current pathway of referral between 2 Dundee Universities and CRHTT?

Identifying student need

Engagement with respective student associations to develop survey questions, delivery method and evaluation process.

Develop person centred and trauma informed pathway

Referral pathway developed in collaboration with 2 Dundee Universities and CRHTT taking into account student feedback.

Identify measurement criteria for referral pathway.

Identify mechanism for collection of student feedback.

Developing survey to be issued to students 72 hours after assessment by CRHTT to gain insight into student experience of using the pathway.

Information Governance

Secure approval from information governance to share information between sites.

Testing of Pathway

Test referral pathway with 2 Dundee Universities and CRHTT using pseudo patient.

Practical steps info graphic developed email 9 May 2022.

Link with IT services to secure generic email address and share with universities.

Develop feedback questionnaire for staff at both ends to comment on effectiveness of referral pathway and process.

Adapt pathway following initial testing.

Agree formal date for going live with referral pathway - 23 May 2022.

Development of information leaflet for all 3 services involved.

Creative teams involved in developing different formats – electronic and paper.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We have achieved development of a pathway and tabletop testing has been completed with amendments made to pathway following feedback. From the date of the pathway going live there have been no referrals required from either university.

Evidence and Milestones:

Record of regular monthly meetings as project team to progress work

Testing & implementation phase of pathway

Email detailing confirmation of testing completed 4^th May 2022 (UOD) 11th May 2022 (UOA).

Email detailing staff experience of testing pathway.

Amendment to pathway based on testing recommendations.

Identifying student need

Engagement with student respective student associations to develop survey questions and evaluation process.

Delivery of student survey exploring key themes of student experience and need.

Data Protection Approval

Secured DPA and information sharing agreement to share patient information between universities and NHS Tayside crisis resolution home treatment team.

Communication of service pathway

Collaborative development of information leaflet for students identified as in need of emergency referral.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Abertay University presented the pathway on behalf of partners at a recent national Student Referral Pathway meeting.

Achieved outcome as requested and referral pathway ready for students returning in September 2022.

Significantly strengthened relationships between both universities and CRHTT.

RAG Status: Green

Any further action proposed:

Engagement with Perth campus for the University of the Highlands and Islands to share learning and develop similar referral pathway for students.

Explore options to spread referral pathway across more educational establishments in Tayside.

Develop a working interface between the universities and the CMHT (referrals already accepted directly from Mental Health teams, without needing to direct this via General Practice).

Recommendation 23:

Develop a cultural shift within inpatient services to refocus on de-escalation. Ensuring all staff are trained for their roles and responsibilities.

Intended outcome(s):

• Staff within inpatients services will have the knowledge and skills to work with patient in a least restrictive, rights based and person-centred way.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that some patients shared experiences and concerns about overly restrictive practice, overuse of restraint, in appropriate use of restraint and ward cultures that did not feel therapeutic, or person centred. Some staff echoed these concerns and highlighted further concerns about training, development, supervision and ward cultures.

This feedback was particularly focussed on the Carseview Centre, and concerns raised about the standard of care, staff attitudes and overly restrictive practice within the centre.

Summary of Actions:

Improving Observation Practice is a national improvement project which focuses practice towards a culture of inquiry, personalised assessment and proactive, skilful mental health care and treatment interventions for all patients. NHS Tayside was involved in this national improvement work and has used the guidance and its "9 Strands" as a framework to support the development of this work

IOP Steering group supported the development and implementation of a new Observation Protocol across all Inpatient Mental Health and Learning Disabilities services.

Development and Implementation of Person-Centred Care Planning Standards in 2018 by care planning collaborative supported embedding the standards into practice. The standards are applicable to all mental health and learning disabilities nurses across Tayside and clinical areas are audited monthly. The standards have been reviewed annually and the principles of trauma informed practice has been embedded in them as was a standard to support patient and carer involvement and improve communication. (linked to Recommendation 24).

Delivery of a CPD programme which is co designed by staff focusing on the 9 strands of the guidance. The programmes aligned to local and national drivers and focuses on the learning needs and skills required for staff to carry out their role.

Development of a training pathway for staff who work in Inpatient MH & LD

Delivery of Trauma training commensurate to staff's roles and in line with the NHS Education Trauma Training Programme. Mental Health & Learning Disabilities service are committed to ensuring that the principles of trauma informed practice are embedded in the work we do. We have included trauma training into our leadership programme as well as Prevention & Management of Violence and Aggression training. All staff within the service now receive level 1 training on induction.

Harm data is produced at a ward and service level to enable teams to have a detailed understanding of rates of harm and factors that contributes to harm. The teams use this data to help understand their system and measure improvement activity.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

There is not a single intervention that leads to a cultural shift within services – the development of IOP has been a key factor in delivering new ways of working, underpinned with training and education, harm data and patient feedback which helps triangulate our activity and its impact.

Evidence and Milestones:

Observation protocol implemented May 2020

Person Centred Care Planning Standards & monthly audit results

Training data and staff evaluations

Patient Stories

Patient feedback

Harm data

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Observation protocol has been in place since May 2021.

Programme of education for staff is in place and is aligned to local and national priorities and data is reported through local governance structures.

Person Centred Care Planning Standards are audited monthly and reported via governance structure.

Patient feedback is actively sought and is an area for further development.

IOP and Person-Centred Care Planning has been recognised nationally with the service winning awards at the Scottish Mental Health Nurse Forum in 2019 and 2021.

RAG Status: Green

Any further action proposed:

Whilst we have rated this recommendation as green, we know that we will need to constantly attend to ward based cultures through robust governance, leadership, local audit, harm data, external visits and the experiences of staff and patients. This will include linking in with local partnership forums.

Observation Protocol will be reviewed Annually and is audited monthly.

Programme of education will continue aligned with local and national priorities.

Recommendation 24:

Involve families and carers in end-to-end care planning when possible.

Intended outcome(s):

• To ensure families and carers are involved throughout the patient's care journey and are actively involved – where the patient wishes, in care planning activities.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that during the Independent Inquiry, patients and carers shared experiences of not feeling involved in care planning or decision-making.

Care planning should involve and include all relevant people and services involved in the person's care. Involving carers and families in care planning supports effective therapeutic relationships and good outcomes for patients in most circumstances where patients agree.

Securing feedback from people using our services and their families and carers is essential to let us know if we are providing the care and support people need from our mental health and learning disabilities services.

Summary of Actions:

NHS Tayside's Person-Centred Care Planning Standards were reviewed in July 2020. These have been updated to include a new standard that will evidence relative/carer involvement where applicable, and a clear communication plan will be recorded. The person centred care plan standards apply to all settings.

Audit results reported monthly to the inpatient clinical and care governance group. Findings are used to inform improvement activity.

Care Plan Collaborative now working on the development of documentation pathways. Now completed.

Following a planning meeting in August 2020, a Triangle of Care steering group is developing a term of reference and has representation from carers groups from each Health and Social Care Partnership and National Lead from Carers Trust, to progress further implementation.

Regular patient experience data provides information on patient engagement in the care planning process.

There is a prompt on EMIS to ensure patients are offered their care plans once completed.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

There are robust quality control processes in place to monitor the levels of compliance with the Person-Centred Care Planning Standards. This information is reviewed on a monthly basis. Engagement with 3rd Sector colleagues who provide advice and support to develop mechanisms for effective and transparent engagement and feedback on carer/family experience.

Standards have been recognised by the Mental Welfare Commission and Highly Commended at the Mental Health Nurse Forum Awards 2019.

This Recommendation is closely linked to Recommendations 23 and 25 where the involvement and experiences of carers and families are integral to on-going service development.

Evidence and Milestones:

Monthly auditing activity is business as usual.

Reviewing of Care Planning Audit data is standing item on monthly Care and Professional Governance Meeting Agenda.

Triangle of Care meeting group has Terms of Reference and Co-chairs.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Robust person-centred care planning well established and part of business-as-usual activity.

Monitoring of activity against standards is business as usual.

Good example of effective processes to be shared across the service from POA.

RAG Status: Amber

Any further action proposed:

Revisiting the existing Patient Centred Care Standards.

Person Centred Care Planning Collaborative is on-going.

Documentation Pathway for review as part of Inpatient Pathway development – Living Life Well Strategy.

Robust mechanisms to gather experience data from carers and families guided by the Triangle of Care/Strand 1 Group.

Existing work in Psychiatry of Old Age (POA) to encourage family and carer involvement in care planning to be tested in General Adult Psychiatry (GAP).

Extension of the Patient Experience work described in Recommendation 25 to incorporate Family and Carer Experience data providing qualitative feedback of how Families and Carers experience working with Tayside Mental Health Services to care for their relative.

Recommendation 25:

Provide clear information to patients, families and carers on admission to the ward, in ways which can be understood and remembered.

Intended outcome(s):

• Patients, families and carers have clear and accessible information setting out how the person being admitted will experience admission to the service

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that during the Independent Inquiry it was observed that information for families and carers about how the service is delivered and developed was difficult and challenging and needed an innovative approach.

Patients had shared with the Independent Inquiry team that they were uncertain about rules and procedures, this causes anxiety and concerns about doing things wrong.

Information is required which is clear and accessible for everyone using mental health services – this information should set outward routine, timetables, arrangements for meals as well as how to get help while in the ward.

Securing feedback from people using our services and their families and carers is essential to let us know if we are providing the care and support people need from our mental health and learning disabilities services.

Summary of Actions:

Draft information leaflets were created in collaboration with patients in the service.

Leaflets have been created in different formats i.e., easy read, large text and different language.

Leaflets were shared with Speech and Language practitioners to ensure a accessible read age format.

We have developed a mechanism to hear from people cared for in our inpatient wards which lets us know how people are experiencing our services and what areas we should work on to improve that experience. Quantitative and qualitative data is collected from patients on a monthly basis to help us understand this and to develop improvements to address gaps.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Patient and carer leaflets have been developed and are provided on all wards. There is ongoing feedback received relating to the efficacy of the leaflet gathered via the Ward Community meetings, this informs adaptations and amendments.

We have mechanisms which we have tested in Carseview and Murray Royal wards and are now spreading to other inpatient wards. The information provided by this data is informing service developments and improvement activity.

Evidence and Milestones:

Availability of accessible leaflets.

Feedback from patients on how clearly they understand the admission process

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Completed in March 2021 with patients reporting clear on admission process.

RAG Status: Green

Any further action proposed:

• Ongoing development guided by service development and patient, family and carer feedback. Closely linked to the Strand 1 Group established as part of the Improving Observation Practice, Families and Carers group established to introduce Triangle of Care.
• Ongoing development of the existing Patient Experience work in wards to support learning and improvement activity guided by patient, family and carer experiences.

Recommendation 26:

Make appropriate independent carer and advocacy services available to all patients and carers.

Intended outcome(s):

• Independent Advocacy support is available for people across Tayside
• Independent Advocacy support is available to support people where they are
• Support is available for carers in Tayside

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the evidence gathered as part of the Independent Inquiry that there were concerns as to the availability of independent advocacy support and support for carers, predominantly where people were in hospital. We also took from the report a need to promote cross agency working with advocacy organisations to best use available resources, while maintaining locally based advocacy support which is central to local planning.

Summary of Actions:

Five independent advocacy organisations are commissioned by the 3 HSCPs to provide support to people and carers across Tayside;

• Independent Advocacy Perth and Kinross
• Angus Independent Advocacy
• Advocating Together (Dundee)
• Dundee Independent Advocacy Support
• Partners in Advocacy (Dundee)

These organisations were in place before the Independent Inquiry, however since 2020 each organisation has seen an increase in demand for independent advocacy. Increased investment has been made to increase capacity since 2020.

Service specifications, contracts and monitoring arrangements were already in place pre-2020, however discussions about capacity, demand and available resources have become more prominent since the start of the pandemic.

Increased investment in advocacy organisations has enabled more proactive input for people who are in hospital.

Information about independent advocacy, and carer, organisations has been made more readily available within inpatient settings.

A focus is regularly given to ensuring that social work teams continue to enable/promote independent advocacy and carer support as an option for people facing a range of challenging situations.

Carers Strategies have been produced within the 3 HSCP areas, having been approved by respective Integration Joint Boards, and are being implemented.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We consider that there are appropriate contractual arrangements in place for advocacy and carer supports across Tayside, which allow for support to be provided wherever a person happens to be e.g., at home, in hospital. Since 2020 additional advocacy support has been made available within Mental Health and Learning Disabilities inpatient settings.

Evidence and Milestones:

Service specifications and contracts in place across the 3 HSCPs.

Annual reports by advocacy providers across Tayside.

Monitoring information across 3 HSCP areas, including people's stories and capacity and demand information.

Output from collaborative work across advocacy organisations

Carers Strategies across all 3 HSCPs.

Feedback through Care Opinion

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We consider that there has been further development in this area since 2020. Additional capacity within local advocacy contracts has been introduced to increase the availability of advocacy support wherever a person may be e.g., at home or in hospital. The provision of annual reports and robust monitoring arrangements are in place. Advocacy providers across Tayside work in a collaborative way in order to maximise the use of overall resources. An example of this has been where specific organisations have joined Tayside workstreams on behalf of all advocacy providers.

We recognise that the availability of advocacy support and support for carers will continue to be central to the health and wellbeing of people across Tayside, and our ability to use resources creatively will be crucial. This is a priority area across the whole system, and as such will be a focus for discussion at regular intervals through the Integrated Leadership Group.

RAG Status: Green

Any further action proposed:

We recognise that the availability of advocacy support and support for carers will continue to be central to the health and wellbeing of people across Tayside, and our ability to use resources creatively will be crucial. This is a priority area across the whole system, and as such will be a focus for discussion at regular intervals through the Integrated Leadership Group.

Recommendation 27:

Provide adequate staffing levels (inpatient gap) to allow time for one-to-one engagement with patients.

Intended outcome(s):

• Staffing levels will enable one to one engagement with patients to take place.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand the importance of one-to-one engagement in meaningful therapeutic relationships and how this contributes to a sense of safety and therapeutic purpose for patients. We know that some patients have described nurses as being distant, disinterested and that some staff have described not having enough time to meaningfully engage with patients on a one-to-one basis.

We are also aware of the constant change within Nursing Teams as staff leave to take up new opportunities and new staff join as part of our ongoing recruitment.

Summary of Actions:

The provision of adequate staffing is attended to in a number of ways:

Roster Management

Roster management is undertaken using an electronic health roster system. The roster can only be signed off once a Senior Nurse has approved the roster to include staffing numbers and skill mix.

Each ward has an identified shift requirement and skill mix.

Identified gaps are escalated to the Nurse bank and made available to staff through extra hours or overtime.

Escalation to Contracted Agency Nurse providers.

Twice daily hospital huddles to ensure safe staffing levels.

Workforce tools

The workforce tools in GAP were run in October 2021 and March 2022

Patient Feedback

Patient feedback is sought across the GAP Admission Wards.

Two of the areas for feedback is time with the patients named nurse – I knew who my named nurse was, I had the opportunity to meet regularly with my named nurse.

The feedback shows that whilst many patients responded positively these are areas that require a continual focus.

Role development

A new additional activity co-ordinator role has been introduced to each of the GAP wards in recognition of the value and importance of meaningful and purposeful activity. The activity coordinators provide a range of individual, and group based therapeutic activities alongside the occupational therapy programme.

The GAP admission wards have increased the number of Charge Nurses on each ward from 2 to 3 within existing establishments. This is to increase the presence of more senior clinical leadership and increase the supervision capacity within the nursing teams.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Safe Staffing is a key requirement for inpatient services influenced by the supply and availability of staffing. Staff often experience a sense of staff shortage based on availability rather than the overall team establishment and there are ongoing efforts to recruit staff to GAP Admission Wards.

The NHS Scotland Safer Staffing Legislation mandates the use of the national workforce tools to ensure a systematic assessment of workforce requirements is undertaken.

The range of measures in place ensures a focus on roster planning, daily assessment of workforce requirements and a planned approach to evaluation and analysis through use of the workforce tools.

Evidence and Milestones:

Workforce Tool analysis reports. Example provided from GAP wards;

Clinical Area	Budgeted Establishment	Professional Judgement Tool Outcome October 2021	Professional Judgement Tool Outcome March 2022	Nursing Staffing Levels per Shift
Ward 1	29.55 WTE	28.58 WTE Ward noted operating with additional bed in use	24.93 WTE	Day Shift 6 Night Shift 4 Budgeted Establishment allows for the above staffing numbers allowing for 1 patient to require direct 1:1 interventions
Ward 2	29.55 WTE	31.88 WTE Ward noted operating with additional bed in use	31.76 WTE	Day Shift 6 Night Shift 4 Budgeted Establishment allows for the above staffing numbers allowing for 1 patient to require direct 1:1 interventions
Mulberry	29.35 WTE	32.12 WTE Ward noted high acuity on ward	Incomplete data	Early 5 Late 5 Night 4 Budgeted Establishment allows for the above staffing numbers allowing for 1 patient to require direct 1:1 interventions
Moredun	39.33 WTE	38.06 WTE Ward noted operating with additional bed in use	Incomplete data	Day Shift 8 Night Shift 5 Budgeted Establishment allows for the above staffing numbers allowing for 1 patient to require direct 1:1 interventions
IPCU	29.55 WTE	22.73 WTE Operating with Reduced Bed Numbers due to Ligature reduction works	24.7 WTE (tool run Aug22)	Early 5 Late 5 Night 4 Budgeted Establishment allows for the above staffing numbers allowing for 1 patient to require direct 1:1 interventions

Patient Feedback and Ward based Reports from the Mental Welfare Commission visits also forma crucial part of evidence around staffing levels.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Safe staffing levels is a key focus for GAP admission wards on both a planned and reactive basis. However staffing numbers alone are not the only factor that influences therapeutic relationships that enable 1:1 interventions to take place.

Continuity is a critical factor in ensuring safe and effective mental health care in that it supports the development of meaningful therapeutic relationships with people. In addition, continuity builds knowledge and understanding of people's needs, trust between patients and staff and the ability to support recovery beyond the immediate care requirements, Continuity also builds a sense of belonging and purpose for staff who then work in a stable psychologically safe team environment which in turn enables positive risk taking and decision making.

RAG Status: Green

Any further action proposed:

Lead and Senior Nurses working with colleagues in NHS Lothian regarding use of the safe care module in Health Roster. Safe Care provides a real time assessment of staffing against acuity of patient group.

Workforce Tool – minimum of annual analysis.

Ongoing feedback from patients.

Recruitment of 27 NQPs to GAP Admission Wards from September/October onwards.

Progression of the Band 4 Associate Practitioner role within GAP Services.

Partnership forums will receive regular reports on staffing challenges so that a workforce plan can be collated in partnership.

Recommendation 28:

Ensure appropriate psychological and other therapies are available for inpatients.

Intended outcome(s):

• Improved therapeutic milieu
• Safe & appropriate risk-informed decision making
• Assessment & formulation of complex cases at point of greatest need

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The availability of psychological expertise within inpatient settings has varied considerably, both over time and across settings. This has been influenced by a number of key factors including availability of staff, variation in funding across localities, the movement of inpatient wards around Tayside (which impacts on what one can easily deliver & from where) and the use of different models of care. The two main models utilised are:

a) Dedicated inpatient posts (still have in Rehabilitation at Murray Royal; previously had in Carseview and Mulberry when at Stracathro)

b) In-reach models where CMHT Clinical Psychologists have protected time for inpatient work

There are advantages to each with the first better supporting indirect patient work, including staff training, ward-based formulation work and support for staff providing low intensity psychological approaches. The second allows continuity of treatment and, within a whole system approach, allows one to target fluctuating demand for therapeutic work and 'smooth' staff absence as any change to a small staff group cause disproportionate effects.

The added value of psychology to inpatient settings is well recognised. The Accreditation for Inpatient Mental Health Services (AIMS) state that all service users should have access to evidence-based psychological therapy from an appropriately trained practitioner (Royal College of Psychiatrists, [2011]; Perry et al., [2015]; Penfold et al., [2019]). The National Institute for Health and Care Excellence (NICE) ([2009], 2014a, 2014b) Guidelines recommend several structured psychological therapies during the acute phase of schizophrenia, borderline personality disorder and other serious mental health problems. However, the data indicate that standards set by NICE and other professional bodies are rarely met.

It should be noted that the evidence base for inpatient psychological therapies is relatively weak at present. Whilst service users consistently report a desire for psychological treatment during inpatient stays, four systematic reviews conducted examining the efficacy of psychological interventions delivered in this setting (Jacobsen et al., [2018]; Paterson et al., [2018]; Wood et al., [2020]; Evlat et al. 2021) demonstrate that the research evidence is small and of moderate to poor quality. Effects were only found on a small number of outcomes including psychotic symptoms (at the end of therapy but not at longer-term follow-up), readmission, depression and anxiety.

Notwithstanding the above, there is complete agreement that consistent provision of psychological expertise to inpatient settings is required.

What does good look like?

There is no area in Scotland with a pre-existing model to replicate. However, there is learning from our local Forensic Psychology Service which, despite the challenging nature of the environment, is fully staffed with no issues in retention or recruitment. Likely ingredients of success are:

• Strong leadership from Consultant
• Sense of identity with clinical team
• Sense of small 'speciality' working

With this is mind, the preferred model is to establish a critical mass with dedicated senior Leadership and rebuild the CMHT capacity to provide in-reach for individual patients.

Summary of Actions:

The initial workforce plan around this work detailed the need for:

0.5 8b; 1.0 8a Clinical Psychologist in Learning Disability inpatient care

1.0 8b; 2.0 8a; 1.0 Assistant Psychologist; admin time in General Adult inpatient care

There were two unsuccessful rounds of recruitment for the Clinical Psychology posts detailed above during 2021.

Following a change in Director of Psychology and taking the learning from Forensic Psychology into account, the proposed posts have been re-configured to include a 1.0 wte Consultant Psychologist post; 0.5 wte for this post and 0.5 wte for Early Intervention in Psychosis (EIP) post. The job description for both these posts are currently awaiting Agenda for Change matching panels (this being the only barrier to forward movement).

In the interim, CMHT psychologists are providing input on a case-by-case basis where this is crucial to inform care planning. Inpatient Rehabilitation (Murray Royal) have 1.0 wte Clinical Psychologist in post.

Additionally, inpatient staff are able to attend training provided by wider psychological therapies staff (for example, A Formulation Based Approach to Suicide Risk Assessment).

Additionally, there has been significant investment of time in advancing the NES Transforming Psychological Trauma Workforce plans. The focus has been on inpatient staff where over 95% have engaged in Level 1 training / Level 2 training commensurate with their role and 36% have received Level 3 training following a hiatus through Covid.

60 staff are engaged in Decider Skills Training; a model which teaches people to recognise their own thoughts, feelings and behaviours, enabling them to monitor and manage their own emotions and health.

A decision was taken by the Integrated Leadership Group in early 2022 to constitute a Tayside-wide commissioning group for Psychological Therapies, led by Dundee HSCP as lead partner.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

There is a recognised national shortage of qualified Clinical Psychologists (around 170 wte across Scotland) and the challenge to achieving the above will always be securing the detailed workforce. As the shortage is apparent across all specialities, simply moving staff to cover these vacancies is not an option. By enhancing the Leadership component of the service (it is notable we have no vacant Consultant posts with all recent recruitment at this level successful) and tying this together with a small specialist area (which also have higher levels of success in recruitment), we hope to maximise the chance of filling this post. Once a Consultant is in post, it becomes easier to 'market' other vacancies. However, where there are staff expressing an interest in inpatient work during our cohort interviews (where we advertise across specialities and look to match people to vacancies balancing their interests with our areas of greatest risk) we will facilitate this regardless of the progress of the Consultant post.

Evidence and Milestones:

Needs assessment document for initial staffing proposal

Advertisement x 2

Submission of post to A4C panel

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Currently awaiting recommencement of Tayside A4C Job Matching Panels. The Consultant post(s) have been accepted in the priority list when this begins. All other aspects of recruitment are ready to move, and we will routinely re-advertise the 8a / 8b posts within Tayside cohort adverts.

Further 6 months to have Consultant in-post; 2 years for fully staffed model.

It is anticipated that the Tayside-wide commissioning group for Psychological Therapies will ensure timely strategic needs assessment across the whole system and reduce any unnecessary delay in delivery/ financial decision-making.

RAG Status: Amber

Any further action proposed:

Wider Leadership & cultural changes within Psychological Therapies will continue to allow flexible use of budgets to ensure we employ all appropriately trained staff wishing to work within Tayside. Also, to improve retention of current staff.

The development of specialist Personality Disorder Services (Consultant Psychology post at 8d agreed and funding secured) will contribute to the outcomes articulated above.

Recommendation 29:

Reduce the levels of ward locking in line with Mental Welfare Commission for Scotland guidelines.

Intended outcome(s):

• Tayside Inpatient mental health and learning disabilities wards provide care to patient is the least restrictive way possible while maintaining the safety of vulnerable people.
• Wards should only be locked in line with the Mental Welfare Commission Good Practice Guide "Rights, Risks and Limits to Freedom" March 2021 and should not be locked for long periods of time.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

It was observed during the Independent Inquiry that it was not uncommon for wards to be locked for long periods of time.

The Mental Welfare Commission Good Practice Guide "Rights, Risks and Limits to Freedom" March 2021 sets out that where wards need to be locked this should only be for short periods of time.

As a consequence, this recommendation raised questions regarding how well rights of safety and those of a person's ability to move around freely were being balanced in our wards.

There was a protocol available in Tayside which set out practices related to the locking of ward doors; at the time of the Independent Inquiry this was scheduled for review.

Summary of Actions:

Audit of practice undertaken across the inpatient wards to understand levels of ward locking as well as reasons for ward locking. At the time of the audit, ward locking related to practices to minimise the impact of Covid.

The pre-existing Door Locking Protocol was reviewed and updated against The Mental Welfare Commission Good Practice Guide "Rights, Risks and Limits to Freedom" March 2021.

Updated Protocol was submitted through the Inpatient Governance structure for comment and sign off by the multi-disciplinary team in March 2021. Following Governance sign off the Protocol was shared with all inpatient areas. The Door Locking Protocol sits as an adjunct to the Seclusion Protocol which is being developed to support Recommendation 23.

In line with the update provided for Recommendation 30 work is underway with Senior Charge Nurses and NHS Estates to agree the specification and locking mechanisms for new ward entrance doors. This will include consideration of how patients can safely access and leave the ward.

Conversations with ward staff were held to explore the different ways decisions about ward locking could come about, and what that meant for how well the balance between safety, security and freedom was held.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Local NHS Tayside Door Locking protocol has been revised, with the revision informed by and replicating the Good Practice Guidance set out by the Mental Welfare Commission (Scotland).

This has been reviewed by the multi-disciplinary team and reviewed through the governance structure supporting Mental Health and Learning Disabilities services.

Staff have been advised of the Protocol amendment and following established processes for Policy and Protocol development and revision these have been disseminated across the InPatient wards.

Evidence and Milestones:

Baseline data of door locking practices November 2020

Audit of Door looking practices August 2022

Revised NHS Tayside Mental Health and Learning Disabilities Door Locking Protocol

Minutes of Governance meeting where the revised Protocol was signed off

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Completed

RAG Status: Green

Any further action proposed:

On-going auditing of Door Locking practices across Inpatient Services in NHS Tayside Mental Health and Learning Disabilities Services.

Specification for new ward entrances including access and egress agreed. New entrance doors installed and operational.

Recommendation 30:

Ensure all inpatient facilities meet best practice guidelines for patient safety.

Intended outcome(s):

• Inpatient facilities provide safe and therapeutic environments for patients and staff

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The quality of the care environment has a key role in supporting an individual's recovery and we recognise that the quality of the environment is variable across the main hospital sites. We have had a focus on safety influenced by adverse events within the inpatient services and the lessons learned from these tragic events has informed and shaped our approach to improving safety within our wards. However, we need to ensure that there is an equal focus on the comfort and aesthetic of the environments to promote wellbeing and recovery.

In the absence of national best practice guidance/standards the Mental Health Safety and Quality Board has commissioned a working group to develop best practice guidance / standards for the Mental Health Estate. The group had its first meeting on the 26^th July 2022 with NHS Tayside represented in the group.

Summary of Actions:

There has been a number of actions undertaken and these are set out below:

Investment in MH Estate Ligature Anchor Point Risk Reduction

2020/21 - £1,000,000

2021/22 - £600,000

Endowments

A bid for £30,000 from the NHS Tayside Endowment fund was successful and used to purchase new day room and quiet room furniture for the Wards at the Carseview Centre.

Royal College of Psychiatry Accreditation

In the absence of nationally agreed best practice guidance the GAP Service committed to working towards accreditation with the Royal College of Psychiatry Standards for Psychiatric Intensive Care and Working Age Adult Wards. Whilst this is a longer-term piece of work the standards do contain a section on environmental standards. Teams will be supported to complete a self-assessment against the environmental standards within the document to provide a benchmark the environment against the standards,

The Royal College of Psychiatry self-assessment and Peer-review culminated in a report following a visit on 14^th January 2021 to IPCU. The report provided by the Royal college identified "Areas of good practice," and identified standards "met," "partially met" and "unmet" standards across the 152 standards. The unmet standards sat within the "Environment & Facilities," "Workforce" and "Governance" sections.

Standard rating	Percentage met January 2021
Met	72
Partially Met	24
Unmet	4

Of the 33 partially and unmet standards identified in the January 2021 review the IPCU team have completed 12 of the locally agreed actions and are continuing to work on the remaining 21. Status of the standards will be reassessed during the next Peer Review cycle.

Ligature Anchor Point Risk Reduction Programme

A key element of ensuring safer ward environments is the removal of ligature anchor points. A ligature anchor point risk reduction programme is well established and phase 1 of the works programme focussed on General Adult Psychiatry Wards and the Young Persons Unit. This phase of works is complete and the next phase to include Older Peoples Mental Health Admission Wards, Secure Care Admission Wards and Amulree is in development.

The next phase of works will also consider the replacement of the main GAP ward entry/exit doors. This work will link with Recommendation 29 and consider design solutions available to enable safe access and egress.

Progress updates have been provided to the Care Governance Committee as part of the Mental Health and Learning Disability Strategic Risk Assurance report.

Standard Room Specification

A standard room specification for Mental Health Estate refurbishment was developed and sets out the proposed architectural products that should be used during refurbishment. This includes a range of products from bathroom sanitary wear to bedroom doors and windows. Over time the knowledge developed by the service and the increase in products available is such that a number of different products have now been identified. The specification will be updated and will continue to set out the standard of products required for refurbishment within Mental Health Services. The mock up room is available to be viewed.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We recognise the importance of ensuring inpatient environments for all patients are safe, comfortable, therapeutic places that support recovery and provide purposeful, safe places for people to work. There is work still to do to ensure the balance is struck between safety and comfort and the service has developed significant experience and knowledge from both past adverse events and the contemporary requirements of inpatient services.

The service has embarked on a process of accreditation through the Royal College of Psychiatry and whilst some Ward Teams – IPCU and Amulree are progressing there is a need for the Integrated Leadership Group to revisit the benefits of this work in light of the development of national standards for secondary mental health services in Scotland.

There is variation in the quality of the inpatient estate across the four main hospital sites – Strathmartine has a number of significant issues linked to the design and age of the accommodation which does not reflect the changing complex needs of people with a learning disability. Whilst there has been investment in the Strathmartine estate there is acknowledgement of the need to provide alternative accommodation of a greater standard than currently available within Strathmartine.

Evidence and Milestones:

A summary of key safety work includes:

• Replacement of all bedroom windows at Carseview and bedroom windows on Moredun
• The installation of new bedroom doors with door top alarm across Carseview, Moredun and the Young Persons Unit
• Replacement of ensuite bathroom doors with shower curtains / antiligature saloon style doors
• Replacement of ensuite bathroom sanitary ware
• Replacement of smoke detector heads
• Replacement of ventilation grills
• Replacement of soap and towel dispensers
• Upgrade of staff attack / nurse call at Carseview
• New furniture for day areas

Phase 2 of the ligature anchor point reduction programme is in development and updates on progress are provided to the NHS Tayside Care Governance and the Health and Safety Committee.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The work to improve the safety of inpatient services is being progressed through:

• Environmental improvements to include furniture
• Ligature Anchor Point Risk Reduction
• Participation in the development of national best practice guidance
• IPCU membership of the Royal College of Psychiatry Quality Network for IPCU's currently undergoing a review process
• Amulree Ward membership of the Royal College of Psychiatry Quality Network for GAP Wards.

This work will remain ongoing as we continue to improve the safety and quality of our inpatient wards.

RAG Status: Amber

Any further action proposed:

Planned investment:

Further investment in the Carseview Centre is planned through an allocation of £384,000 from the 2021-22 Mental Health Recovery and Renewal allocation to IJBs for mental health facilities improvement. This money will be used to upgrade the Mulberry ensuite bathrooms and deliver new bedroom furniture for all patient bedrooms.

Operational Leadership Team to review the current approach to engagement with the Royal College of Psychiatry Quality Network for GAP Wards.

The work to review and revise the Inpatient service across Tayside will include provision to ensure that the environmental considerations highlighted in Dr Strang's report are attended to within the redesign.

Recommendation 31:

Ensure swift (timeous) and comprehensive learning from reviews following adverse events on wards.

Intended outcome(s):

• Events should be reported and verified as accurate in a timely fashion following any adverse event.
• Any immediate patient safety concerns should be identified and addressed with immediate learning implemented by frontline staff.
• Decisions on the level of review required made by the senior leadership team promptly.
• Robust mechanisms are in place to share learning from reviews across the service so that frontline staff understand and take ownership of improvements in their own clinical environments.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The Independent Inquiry raised concerns from staff and patients that there were delays in responding to adverse events, particularly in the inpatient ward environments.

We understand this situation needs addressed by reviewing key stages in the management of adverse events in this acute setting, where there may be patient safety issues and ongoing risks of harm to other inpatients if action is not taken swiftly.

Learning in a timely fashion is hugely important in building and maintaining trust and confidence of staff, patients, families and carers. Transparent processes that are quality assured and uphold NHS Tayside commitment to deliver safe, effective patient centred care is necessary for rebuilding trust across these groups and the wider community. Previous adverse publicity, particularly to tragic events in places that are regarded as 'places of safety', means that we have to evidence that all concerns have been addressed and demonstrate ongoing quality assurance processes are in place.

Summary of Actions:

1. Following an adverse event, staff with professional responsibility and knowledge of the event report onto the Datix Adverse Event Reporting system (a nationally recognised adverse event management reporting system used by the majority of healthcare organisations in the UK).

The software aids staff to categorise the severity of the event and risk of recurrence. Datix will automatically send an alert through email for all events graded as category one (the most serious) advert events to designated senior leaders across mental health and key members of the Executive Team and the Board Secretary. This ensures that all senior leaders are immediately aware of the event and can support staff with necessary action in the immediate aftermath of an event.

The Datix reported event is verified in terms of accuracy by senior members of staff who have expert knowledge of the clinical area where it was reported from. The Patient Safety, Clinical Governance and Risk (PSCGRM) team have responsibility for training all staff before they can be registered onto the system as verifiers, thus ensuring that training has occurred for this role and maintain the quality. Events require to be verified within 72 hours which is recognised across the organisation, time to verify is a performance measure reported on by all parts of the service through performance review meetings.

Staff who are reporters are provided with immediate feedback from verifiers which is considered essential in the verifier role for encouraging staff to report and ensuring timely feedback.

Mental Health Services are able to monitor numbers of events, severity of events, status of the events, trends in near misses, through the use of Dashboard systems that the PSCGRM team enable across the organisation for senior leaders to have immediate access to data.

2. Immediate safety concerns and action is taken after adverse events through the use of rapid reviews and situational reports provided to senior leaders included in the Datix alert system described above. Any immediate concerns or learning from the rapid review is disseminated to frontline staff through the use of Safety Huddles. These are used on a daily basis at the start of each shift to highlight immediate feedback and necessary changes to staff as a timely response. The Senior Triumvirate in the PSCGRM team are included in the alert response across the organisation and provide quality assurance by scrutinising all category one events on a weekly basis across the organisation, including checking for events that have been downgraded and where all incidents of Statutory Duty of Candour will be evoked. When themes are identified as being a risk of recurrence, automatic safety alerts can be generated through the Datix system. An example of this would be the use of ligature points in inpatient services. There are now mandatory fields designed within Datix to alert all relevant staff when an adverse event or near miss report is generated by staff reporting a ligature related incident. This ensures that risks are highlighted immediately, and action can be taken by staff in a timely fashion to learn from the event.

3. Beyond the immediate review period where there is a necessary focus on safety issues, the wider learning regarding deeper scrutiny of systems and processes needs to take place for adverse events.

The weekly Mental Health SAER leadership group meeting (as described in recommendation 11) provides scrutiny and standardisation to this process. For category one death adverse events there is an agreed protocol across the services regarding the commissioning of SAER or use of Mortality Learning Event Reviews. The SAER process and quality assurance process is discussed in detail in recommendation 11.

The Mortality Learning event reviews use methodology that is recognised by the Royal College of Psychiatrists and follow the college standardised template to maintain quality. The timescale for reviews of this nature and sharing of reports with families is the same as the SAER process to ensure the correct level of scrutiny and openness regarding the findings.

For reviews of events that have less serious outcomes, Team Based Quality Reviews are being held across a number of service areas in Mental Health. These reviews use recognised methodology to review systems and process, including human factors, and attendance is encouraged for all members of the team across specialty areas. The use of Team Based Quality Reviews for adverse events encourages a flat hierarchy to ensure all staff can participate in a fair and transparent review.

4. These processes do not take place in isolation from the other components of the mental health system. Each HSCP has an equivalent process in place and where adverse events happen within inpatient care, consideration is given in every case as to which partner should lead on the review process. Where care has been delivered across different components of the system, there is full participation in the review process.

5. Where SAER may be required, the Mental Health SAER leadership meeting has helped to streamline decision making whilst also taking advantage of peer scrutiny. Whilst it remains appropriate and likely that some events initially reviewed by Mortality Review may be advanced for SAER, discussing level of review at an early stage will hopefully avoid reviews going through multiple stages and result in reviews being completed in good time.

6. Learning. There are a number of mechanisms for spreading learning from adverse events. There include:

• Team Based Quality Reviews, where engagement in the process is the learning methodology
• Review outcomes being shared at team level
• Remobilisation from Covid has allowed us to recommence our System Wide Learning From Adverse Events Sessions which allows a significant numbers of staff from a range of disciplines to come together in workshop-style meetings designed to facilitate change in practice
• Learning from reviews is openly shared both within the clinical governance structures as described in recommendation 11
• Learning summaries are shared with HIS and published on the Adverse Event Network to aid cross Board learning
• Tayside Multi-Agency Suicide Review Group publish an annual report that highlights learning from across health and other public services such as police and social services
• The PSCGRM annual report this Autumn will report to the Care Governance Committee on the quality assurance of level of reviews and evidence the mechanisms in place for staff to take ownership of learning and implement change.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The actions have ensured that there is significant improvement in both immediate response to adverse events but also most importantly that there are appropriate forums in place to manage the process, maintain quality through training, and assurance on actions taken through governance structures.

Evidence and Milestones:

• AEM policy approved by Clinical Policy governance Group March 2022 ensuring the policy is transparent, just to staff, and will meet the needs of patients and families seeking answers.
• MH SAER leadership group established Jan 2022 to agree on levels of review, commissioning and sign off processes and provide professional support to senior clinical leaders deciding on levels of review for consistency across the service.
• PSCGRM Triumvirate weekly review all category 1 events, mortality learning events in MH, any upgraded or downgraded events and all triggers for Statutory Duty of Candour to provide assurance.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Monitoring of performance regarding staff reporting is re-assuring that adverse events are openly reported. NHS Tayside PSCGRM provide data to HIS which publishes levels of reporting across health boards. NHS Tayside is reporting for 2021-22 at a level expected for its size of population, this compares to the previous year when there was a lower rate of reporting than would be expected. The involvement of senior leaders following the revised AEM Policy has led to better engagement as evidenced by this data.

NHS Tayside is an active member of the HIS Adverse Event Network and openly publishes learning event summaries to ensure there is transparency and quality assurance.

RAG Status: Green

Any further action proposed:

Mental Health services are now leading the way in terms of the high-quality team-based reviews taking place and standardisation of their mortality learning events. The AMD for PSCGRM will be chairing a group for senior clinicians to spread this practice to other clinical services in the organisation to improve morbidity and mortality reviews. Sharing good practice in this forum will enable a culture of continuous improvement for leaders running reviews. This group is currently being formed with the first meeting arranged for Oct 2022.

The PSCGRM team will facilitate an Adverse Event Learning Forum to run bi-annually for all teams across the organisation to share best practice and action taken from reviews. Mental Health services have excellent examples of how staff have been empowered to make change and this should be widely publicised to encourage further progress and help with positive communications around significant improvements that have taken place. The first organisation wide event is planned for February 2023.

Recommendation 33:

Focus on developing strategies for prevention, social support and early intervention for young people experiencing mental ill-health in the community, coproduced with third sector agencies.

Intended outcome(s):

• Project within the MHW Change Programme will include mental health and wellbeing of Children and Young People, universal services through to specialist interventions required and include transition model

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry that focus was needed for co-development with third sector agencies the development of CAMHS Outpatients strategies for prevention, social support and early interventions for young people experiencing mental health in the community.

CAMHS Outpatients now participates in many forums to facilitate this and is part of the Tayside Regional Improvement Collaborative, which drives projects and strategies, and ensures co-developed joint working to this end.

Summary of Actions:

Implementation Plan

1. Tayside Mental Health Strategy for Children and Young People called an Emotional Health and Wellbeing Strategy for Children and Young People developed in conjunction with a Tayside-wide multi-agency children's services stakeholder group.

2. Children and Young Persons specific Draft Wellbeing Strategy (called 'Connected Tayside') was put out for consultation across Tayside.

3. 'Connected Tayside' approved by Tayside Regional Improvement Collaborative (TRIC).

4. Linkages created between 'Connected Tayside'; An Emotional Health and Wellbeing Strategy for Children and Young People' and the relevant chapter in the Tayside Mental Health and Wellbeing Strategy.

The 'Connected Tayside' - An Emotional Health and Wellbeing Strategy for Children and Young People Strategy was reviewed by the Tayside Regional Improvement Collaborative (TRIC) Leadership Group for final approval on June 2021. The draft Implementation Plan was also presented to the group as part of the June meeting.

The implementation of Connected Tayside is one of the main objectives within the statutory Tayside (multi-agency) Children Services Plan 2021 – 2023.

The 'Connected Tayside' (TRIC) Task and Finish Group, set up to develop the strategy, has concluded its work and the TRIC Health & Wellbeing Priority Group now has responsibility to demonstrate the added value and improvements from delivering on the aims within the new strategy. This work includes looking at the data and measurement outcomes required to evidence the progression of the strategy.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

There is a sustainable governance structure around Tayside Regional Improvement Collaborative (TRIC) which links into the CAMHS continuous improvement framework. This has been further enhanced very recently through a sharing of 'project resource' across CAMHS and the TRIC.

Completed within an established governance process to manage regional improvements (TRIC), involving universal services that has demonstrated sustainability.

Evidence and Milestones:

30th Nov 2021 - Launch Event for 'Connected Tayside': An Emotional Health and Wellbeing Strategy for Children and Young People 2021-23.

Connected Tayside: An Emotional Health & Wellbeing Strategy for Children and Young People 2021-23. This document can be found on the TRIC Website - Resources - TRIC - Tayside Regional Improvement Collaborative (taycollab.org.uk)

Connected Tayside outlines a charter designed by children and young people from across Tayside. This charter shares their vision of what support should look and feel like from any organisation they connect with.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

A monthly Clinical Governance Summary within CAMHS Newsletter – available within the LLC Evidence Repository.

Improvement meeting minutes, standard agenda item – available within the LLC Evidence Repository.

RAG Status: Green

Any further action proposed:

There is no further action planned as the process is now sustainable. The Tayside Regional Improvement Collaborative coordinates and drives "Connected Tayside", and this includes measures around milestones and outcomes.

Recommendation 34:

Ensure that rejected referrals to Child and Adolescent Mental Health Services (CAMHS) are communicated to the referrer with a clear indication as to why the referral has been rejected, and what options the referrer now has in supporting the patient.

Intended outcome(s):

• To ensure strong referral plan to CAMHS is within the strategy, including communication process.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry that clear parameters for CAMHS Outpatient referrals were not in place and as a consequence not accepted referrals were occurring. As a consequence the GP CAMHS RefGuide was developed that included Mental Health and Neurodevelopmental guidance, which was communicated to GP partners via networks and CAMHS Website. Information for other professionals detailed on CAMHS website, including information on signposting for patients, families and carers. In addition, printed CAMHS information brochures have been designed and these are now routinely inserted in CAMHS letters / communications, along with website and signposting links within letters.

Summary of Actions:

Implementation Plan:

1. Guidance has been developed for people referring into the system.

2. Development of a process and communication for referrals that require redirection has been established and is now routinely used.

3. New CAMHS website has been developed which contains information regarding the referral and redirection of referrals process.

An improvement plan was developed and recorded on the CAMHS Outpatient Plan for Continuous Improvement system pertaining to the Young Person Triage Service (YPTS), with the aim 'to create a new CAMHS nursing work stream in 2022 to reduce the number of referrals that were not accepted by CAMHS, that focuses dedicated clinical staff to support GPs across all Tayside regions (GP Clusters – 13 in Tayside {4 Dundee, 4 Angus and 5 in Perth}) to refer or signpost children and young people to the most suitable staged approach intervention, including the third sector and self-help resources, by reviewing GP referrals and providing appropriate feedback on the content and information needed, by March 2023'.

An implementation plan is underway and only one third of staff are recruited to this work stream, resulting in 6 GP clusters utilising this service across Angus and Dundee. Once full recruitment is completed (1.2WTE) a Tayside-wide service will be operational, to include Perth / Kinross.

The YPTS is for GP practices and not for schools which would explain why Penumbra may not have oversight into these initiatives. The YPTS has a communication plan within the implementation plan, and this is targeted at all GP practices across Tayside.

Schools are not involved in this initiative.

Website live: Welcome to CAMHS Tayside

Monthly social media topics are determined based on clinical themes and scheduled promotional mental health and wellbeing items. This generates targeted Facebook topics that promote linkage to information / signposting in the CAMHS Outpatient website. On a quarterly basis, the content within the website is reviewed and updated based on consumer feedback and emerging clinical themes. Examples include:

• CAMHS Outpatient Website Improvement Page developed and launched in February 2022 and focused on improvements being worked on for the Neurodevelopmental Parent Portal.
• For our social media promotion, webpage analytics sought in April 2022 was used to identify possible series for social media based on those pages most visited. Most visited areas in the website included: Sleep, support in education (Enquire), Teenage Brain (SpeakEasy), behaviour that challenges, and anxiety. Proactive anxiety management and coping with exam pressures was released via Facebook in June 2022.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Feedback from GP's has indicated this is no longer an issue for the service.

Evidence and Milestones:

Key evidence against this recommendation includes:

• A monthly report on Website Traffic
• RefGuide and Website within the LLC Evidence Repository
• Standard letters to referrers
• Meeting minutes

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Closed out Improvement Plans (PCI 029) shows scope of work and evaluation.

Monthly CAMHS MH & ND Performance Reports details rejected referrals.

RAG Status: Green

Any further action proposed:

There is no further action planned as the process is now sustainable.

Recommendation 35:

Ensure the creation of the Neurodevelopmental Hub includes a clear care pathway for treatment, with the co-working of staff from across the various disciplines not obfuscating the patient journey. The interdisciplinary of the Hub may give rise to confused reporting lines or governance issues. A whole system approach must be clarified from the outset.

Intended outcome(s):

• Clear care pathway for treatment within Neurodevelopmental Hub,

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry there was no documented Neurodevelopmental Care Pathway in CAMHS and co-working and multidisciplinary working was unclear.

Summary of Actions:

A clear Neurodevelopmental Care pathway was produced in 2021 and awareness of how it works communicated to staff via induction/orientation/in-house education and shared with partners via networks and multidisciplinary/multi-agency collaboratives. Information on how the Neurodevelopmental care pathway operates from referral onwards is detailed within CAMHS Website.

The existing Neurodevelopmental care pathway was analysed by the Neurodevelopmental Improvement Group (Specialist Clinicians) and the current model was identified as not meeting demand. An improvement project was undertaken to develop and new Neurodevelopmental Care Pathway, based on newly released CAMHS Neurodevelopmental Service Specifications and National Autism Implementation Team Guidelines in October 2021. This new pathway also involved determining capacity required to service the new pathway, and this has been built into CAMHS Workforce Plans.

Implementation plan:

1. Recruitment of the Clinical Lead for the Service remains outstanding, and whilst attempts to recruit have occurred, a new focus by the Interim Medical Director to again pursuing advertising is again occurring.

2. The Neurodevelopmental Care Pathway was developed and signed off in March 2021.

3. Creation of the Neurodevelopmental joint working across agencies formed part of the Neurodevelopmental Care Pathway and permanent joint working occurs with CAMHS and Armisted.

4. Partnership working with commissioned specialist external providers commenced in 2020 to assist in the management of patients in Neurodevelopmental Care Pathway.

5. Development of a New Neurodevelopmental Care Pathway occurred in 2021 and service redesign presented to Scottish Government and Senior Management and supported. Neurodevelopmental Improvement Group undertaking improvement work to deliver the new pathway.

Current improvement initiatives, relating to the New Neurodevelopmental Care Pathway, include pre-referral screening within schools. This will support a new Neurodevelopmental referral pathway into CAMHS ensuring self-directed help mechanisms are utilised prior to accessing services. Additional Mental Health Education Officers engaged mid 2022 to expand working with schools and task sharing initiatives, including the development of a Neurodevelopmental Parent Portal, 'Decider Skills' and 'My Resilience' training and promoting 'Essential CAMHS' education for school and other universal service providers. A new work stream called the Young Person Triage Service has been rolled out to GP practices. This is a service that is working with GP Practices to support appropriate Neurodevelopmental referral and signposting.

Significant improvements have already been implemented including:

• Development of a new ND pathway to support an efficient and sustainable model.
• Establishment of a multidisciplinary ND improvement group.
• Recruitment of programme manager to drive ND improvements.
• Improved referral management into CAMHS Outpatients to ensure patients are appropriate for the service.
• Education for GPs and partners to ensure preparatory work is undertaken to best utilise CAMHS outpatients' resources.
• Focus on signposting to self-directed or other services prior to referral to CAMHS where appropriate.
• Commissioning of external agencies to address backlogs.
• CAMHS Outpatient website in 2021 added sections on homepage called CAMHS Improvement Updates, to facilitate better communication around Neurodevelopmental initiatives.
• CAMHS Outpatient in July 2021 introduced social media communication channels, which demonstrates successful expanding engagement and reach.
• Routine engagement with stakeholders who use CAMHS Outpatients is utilised for improvement initiatives, current example includes Neurodevelopmental Parent Portal development.

Are the actions sufficient to achieve the intended outcome(s)?

No

Please briefly explain your response here:

The successful implementation of the New Neurodevelopmental Care Pathway is reliant upon substantial investment. Losses within the CAMHS Neurodevelopmental Specialist workforce capacity has created further pressure on existing capacity delivery.

Neurodevelopmental risks have been created to assist the service to manage these challenges. Investment from Scottish Government for Neurodevelopmental Covid Recovery only £410k. The current backlog of patients is over 1600 (external waits).

Existing capacity within the Neurodevelopmental work stream identified as being under resourced by 7 WTE which has been further impacted by maternity leave and resignations of senior clinicians in 2021 and 2022. There is no capacity to manage the existing waiting times and specialised commissioning services are being sort for short term work, to remedy this while in house recruitment targets expanding the workforce to support the new Neurodevelopmental pathway occur.

Evidence and Milestones:

Key evidence against this recommendation includes:

A new Neurodevelopmental (ND) Performance Report generated monthly by the Business Unit on demand and capacity within the ND pathway.

Monthly Management Updates and creation of ND Waiting Times risk. Clinical Governance and Executive Meetings show reporting around same.

Existing ND Pathway, New ND Pathway, Locality Staff Model and ND Waiting Times SBAR are available within the LLC Evidence Repository.

SBAR on ND Waiting Times includes Trajectories of reduction of waiting times with Commissioning Services.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

ND Pathway redesign and commissioning included on Plan for Continuous Improvement

Progress against this ambition is monitored on a monthly basis through the local monitoring arrangements. Assurance at executive level will be taken through Staff Governance Committee.

RAG Status: Amber

Any further action proposed:

A Neurodevelopmental Service Redesign and Waiting Time Management Improvement Initiative has been developed by CAMHS Outpatients, and is reflected on their Plan for Continuous Improvement. CAMHS Workforce Plans are being developed to improve capacity and capability in the workforce, and Neurodevelopmental performance monitoring measures have been established. A Neurodevelopmental Coordinator has been appointed to the service as well as a Programme Manager, to drive these improvements.

Further discussions will need to take place to identify the resourcing required to fully implement the designed model.

Recommendation 36:

Clarify clinical governance accountability for Child and Adolescent Mental Health Services.

Intended outcome(s):

• Ensure clear clinical governance structure for CAMHS is within the strategy.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry that there was a lack of clarity and reporting structures for Clinical Governance. In addition the availability of medical staff for prescribing was challenged due to reduction in medical capacity and non-medical prescribing initiatives were needed. This was exacerbated by a perception of lack of pharmacy participation into assurance and therefore clinical governance.

Summary of Actions:

Implementation Plan:

1. Clear clinical governance structure for CAMHS is within the strategy.

2. Clinical governance accountability for CAMHS now includes pharmacy and others with knowledge of prescribing as this is a major clinical concern within this service and Partnership expertise.

3. Work was undertaken with Mental Health Director to align reporting of CAMHS and routine governance reporting is now in place.

A robust clinical governance system was introduced into CAMHS, and the committee was developed to evolve sustainable assurance frameworks. The committee now routinely meets every month to maintain oversight and assurance on CAMHS services, as per the Terms of Reference and is now led by the new Nurse Lead (new post). Part of the standard agenda items monitored monthly is clinical incidences and risks.

The monthly CAMHS Clinical Governance forum routinely monitors incidences within the service, which includes medication related issues. Assurance is provided around medication incidences via DATIX reporting and routine notes auditing. Pharmacy is invited to all Clinical Governance forums and provides prescribing auditing oversight for the service. These are sustainable reporting processes which feed into the Quality Performance Reporting forum (NHS Governance) ensuring themes are used for learning and improvements. Workforce development initiates in the last 18 months have included the introduction of non medical prescribers (pharmacy and nursing) to better support the prescribing demands within the service. Formal training, mentoring and supervision processes have been introduced including the piloting of nurse led clinics, to manage mental health anxiety and low mood prescribing.

Since 2020 a pharmacist has been employed to undertake non medical prescribing. 2021 three nurses successfully completed non medical prescribing training, facilitating three localities non medical prescribing work streams to be established, resulting in increased capacity within prescribing care pathways. Workforce planning is scheduling additional non medical prescribing roles annually, to meet projected demand.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Sustainable clinical governance forums have been in place within CAMHS since October 2020. Meetings are scheduled on a monthly basis and meeting minutes evidence this. Clinical Governance Meeting Summaries are published for all staff in the monthly CAMHS newsletter. This is then reported through the Quality Performance Review committee (division governance forum).

Evidence and Milestones:

Key evidence against this recommendation includes:

• A monthly Clinical Governance Summary within CAMHS Newsletter – available within the LLC Evidence Repository.
• QPR presentation slides and meeting minutes – available within the LLC Evidence Repository.

This improvement was captured on the Plan for Continuous Improvement (PCI 028) and is closed. This is available within the LLC Evidence Repository.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Meeting schedule audited annually for adherence and TOR achievement evident.

RAG Status: Green

Any further action proposed:

There is no further action planned as the process is now sustainable.

Recommendation 37:

Support junior doctors who are working on-call and dealing with young people's mental health issues.

Intended outcome(s):

• Junior doctors working on-call and dealing with young people's mental health issues feel and are supported in their decision making and treatment choices

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Providing out-of-hours care for Child and Adolescent Psychiatry presentations has the potential to feel risky for junior doctors. It is understandable that some may have reported to the Independent Inquiry their uncertainty, discomfort and ambiguity about the decision-making framework they are asked to work to, particularly at the beginning of a placement within Psychiatry. This feeling may have been exacerbated by the pressure on beds for young people out of hours in crisis, as decision making may have felt like a Hobson's Choice of least-worst option.

Summary of Actions:

Out of normal working hours, medical support to the CAMHS service is provided by a tiered psychiatry on-call rota, led by the duty consultant psychiatrist. The tiered rotas (junior medical, higher trainee, and consultant) have clear inbuilt supervisory and escalatory procedures. All junior doctors are expected to seek supervision from a more experienced psychiatrist for any issue related to CAMHS.

Specifically at induction, all junior doctors are instructed and expected to discuss all of their out of hours assessments of young people with a senior on-call psychiatrist at the time of assessment. Senior doctors take on the responsibility for management decisions.

In addition to the specialist psychiatry rotas, trainees are also able to discuss individual cases with the on-call consultant paediatrician. Admission beds within the paediatric service are available out of hours.

On commencing their posts, all junior doctors attend induction with a dedicated session on CAMHS presentations and advice on management and procedure. In addition specific CAMHS cases are presented and discussed during the weekly teaching programs attended by trainees within a supportive developmental and learning environment.

A survey of views from junior doctors was undertaken to understand perceptions around quality of learning, use of the Mental Health Act and appropriateness of levels of supervision provided in and out-of-hours.

Deanery reports on the learning environment were reviewed and discussed with Deanery staff as part of the regular training review meetings.

A short life working group was formed to look into the model of care for young people in crisis out of hours. The group shared insights, examined good practice guidance, sourced, encouraged and supported staff to attend training on the care of young people in crisis, and clarified the service model to make clearer the options for decision makers out of hours. This work helped to inform the creation of the Community Wellbeing Pathways.

The link between this part of our care system and that of the Community Wellbeing model is important. Better provision of preventative and supported self-management for wellbeing before crisis happens, has a vital role to play around the pressure junior doctors face when working out of hours. It is also the responsibility of all services operating out of hours to collaborate in the best interests of those in need, not just the junior doctor.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Our junior doctors have reported positively on the level of support available to them in dealing with young people with mental health issues out-of-hours.

Evidence and Milestones:

On-call rota

Escalation Framework

Peer Group meeting provision and Survey results in 2021

Deanery reports

Model of care out-of-hours developed in 2021

Training uptake and reported levels of confidence 2021

Community Wellbeing model plans

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The intended outcomes have been achieved and evidenced through a collaborative approach across multiple services involved in the provision of care for young people in crisis out-of-hours. The responses put in place have been multifaceted.

RAG Status: Green

Any further action proposed:

Each junior doctor rotation resets the clock, so to speak, in terms of levels of confidence within a junior doctor cohort in dealing with challenging cases at challenging times of the week. The CAMHS induction program will continue for all new entrants and needs to be completed before starting any out-of-hours duties. Our intention is to ensure that regular feedback from junior doctors is gathered, discussed and acted upon within the appropriate supervision forums and within the operational review of our crisis models of care.

There is a collaborative forum of North Of Scotland Health Boards reviewing CAMHS provision. One of the areas under early discussion concerns the development of a North of Scotland out of hours rota of CAMHS consultants providing specialist advice on a remote basis. Whilst this necessarily (due to being remote) cannot replace the current on-site senior medical staff provision out of hours, this may provide helpful supplementary support for the senior medical decision makers.

Training is discussed at our Higher Training Specialist Training Committee meetings. As a result of recent discussions, we also intend to deliver more training via post graduate teaching for junior doctors through the Autumn.

Whilst not a direct contributor to levels of perceived support on the part of junior doctors, the work to implement and embed our Community Wellbeing Hub models needs to be completed and embedded. Once that new element of our care model is up and running, we will again review how well it is impacting the issues raised in Dr Strang's report in relation to Recommendation 37.

Recommendation 38:

Ensure statutory confidentiality protocols for children and young people are clearly communicated to all staff. The protocols should also be shared with patients and families at the outset of their treatment programme, so that parents and carers know what to expect during the course of their child's treatment.

Intended outcome(s):

• To develop confidentiality protocols and share with parents and carers.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry that CAMHS confidentiality protocols were unclear and not always evident in staff practice with patients and families not always having clarity around expectations of confidentiality and information sharing during the course of their child's treatment.

As a consequence the following outcomes around confidentiality protocols were undertaken:

1. Exploration of the exact protocols referred to. Staff undertake annual education around confidentiality (LearnPro)

2. Develop if they do not exist and share as required to ensure an inclusive and best practice approach is applied when working with children, young people and their families. Improved Website and brochure – complete

3. Review process and make materials available to staff and families. CAMHS Referrer acknowledgement letters are sent out to patients and families to explain service programming and information signposting that may be useful. CAMHS Brochure sent as routine, which details what to expect when coming to service and rights regarding confidentiality.

Outcome - To develop confidentiality protocols and share with parents and carers

Summary of Actions:

Implementation Plan

1. Confidentiality Protocol identified and is in place

2. Audit process have been developed to ensure the Protocol is being followed correctly with monthly monitoring undertaken as part of routine Clinical Governance Notes Audit

3. Confidentiality processes are communicated to parents and carers through the new CAMHS website and via the CAMHS Brochure highlighting confidentiality protocols and what to expect during the course of child's treatment, including what is shared with parents and carers

Website live: Welcome to CAMHS Tayside

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Established staff education programmes are in place relating to statutory confidentiality and child safeguarding, which is tracked via LearnPro online systems, and compliance reported through clinical governance systems. Staff undertakes annual education around confidentiality (LearnPro) and this is being proactively managed through the CAMHS Training Committee. All new staff are offered orientation and induction on the CAMHS website, where information is available to professionals, patients and parents / carers.

Evidence and Milestones:

Key evidence against this recommendation includes;

• A monthly report on LearnPro training adherence (completed and in progress) in each service which is available within the LLC Evidence Repository. This is reported monthly in the Clinical Governance Committee and is in the LLC Evidence Repository.
• Tayside wide information sharing protocols and guidance to all staff on Child Protection and GIRFEC processes are available
• The CAMHS website updating improvement project included better information for patients, families and carers: including what to expect around communication and confidentiality protocols for patients and families which is available within the LLC Evidence Repository.
• The CAMHS Training Committee demonstrates sustainable processes around planned training for staff.
• New CAMHS website went live Dec 20 (NHS Tayside), confidentiality covered in new CAMHS Information Brochure (Parents/Carers and within Factsheets) frequently asked questions section of website)

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

A monthly Clinical Governance Summary is routinely reported within the CAMHS Newsletter and is available within the LLC Evidence Repository.

QPR presentation slides and meeting minutes show surveillance of staff training and is available within the LLC Evidence Repository.

This improvement was captured on the Plan for Continuous Improvement (PCI 026) and is closed. This is available within the LLC Evidence Repository.

In November 2020 a new CAMHS Information Brochure was developed and was offered to all new patients and those scheduled for appointments, from December 2020. This is now routinely inserted into patient letters and is available electronically on the CAMHS Website.

RAG Status: Green

Any further action proposed:

There is no further action planned as the process is now sustainable.

Recommendation 39:

Consider the formation of a service for young people aged 18 – 24, in recognition of the difficulties transitioning to adult services and also recognising the common mental health difficulties associated with life events experienced during this age range. This may reduce the necessity for these patients to be admitted to the adult inpatient services.

Intended outcome(s):

• A good transition process which has the needs of young people at its heart.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that transition between services for people aged 18-24 occurs at a potentially turbulent time in many young people's lives. Moving from one service to another without clear planning, communication and management of expectations resulted in some transitions not being well managed. As a consequence, some families and carers voiced concerns to the Independent Inquiry that the transition process needed to be better. At the time, Scottish Government Transition Guidelines were not implemented uniformly across CAMHS Outpatient localities, only established in Angus and CAMHS Service.

Summary of Actions:

An early review across department, in consultation with young people, was conducted to determine whether this recommendation would be best served by the introduction of a new service, or by taking action to strengthen existing service transitions. The review concluded that inter-service collaboration to strengthen the existing transition process would better ensure good transitions.

Audit process for Transitions developed and being used for first time in August 2022. Auditing linked in with SOP (RAG) Group within CAMHS Outpatients clinical audit systems now operational.

A CAMHS workforce plan has been developed to build capacity and capability across all health professions within CAMHS. This includes the expansion of other health professionals to support consultant psychiatrists and specialist psychologists, as these work streams remain challenging to recruit to. Examples of expanded service provision within the CAMHS include: Neurodevelopmental Intellectual Disability pathway; Tier 4 services such as MacX (Multi Agency Complex Cases) and CRT (Crisis Response Team), Non Medical Prescribers and Allied Health Professionals.

Transitions are clinically assessed and negotiated with young people and a new transitions standard operating procedure have been implemented, to guide staff on the planning, engagement and management of this process, to ensure CAMHS consistently follows NHS Scottish Government Transition Care Planning Guidance. The Transitions Pathway identifies young people within CAMHS, who have a requirement for ongoing treatment, before they are 17.5 years. The possibility of transition to Adult services is firstly discussed with the young person and family (if consent obtained), and information given about the process and possible options, including no transition. This can then be revisited as required during the period of input from CAMHS until a decision point is reached. A decision should be reached by the time the young person is 17 yrs 9 months. The young person's core worker identifies relevant parties to be included in the transition management process and undertakes engagement with Adult Mental Health Services and completes a referral and Transition Care Plan.

Additional key staff allocated to participate in Transitions from CAMHS Outpatients inclusive of Intellectual Disability Team Lead, MacX / Eating Disorder Team Lead and senior nurse as Medical staff leadership impacted by capacity issues within the medical work stream.

Children and Young People Mental Health Transitions 18-24 Group, established in 2021 involving CAMHS and Adult MHS. The group has collaborated to;

1. Identify specific "Transition Link Workers" in each service to ensure that this aspect of service delivery is continually being considered, reviewed and discussed across the teams.

2. Implement the CAMHS transition SOP

3. Embed a triangulation process of documentation audit, feedback from service users and knowledge from teams around how transitions are being experienced, documented and delivered in practice, and

4. Keep meeting as an inter-service group to further promote and develop the skills needed to ensure a good transition in every case, between the services.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

New Transitions SOP being trialled for 6 months across all localities. Adult service yet to establish their own SOP. Improvement outcome date moved to June 2023 to allow for Adult Service to establish Transition Links.

Evidence and Milestones:

A monthly Clinical Governance Summary within CAMHS Newsletter updates staff on Transition Improvement work – available within the LLC Evidence Repository.

QPR presentation slides and meeting minutes show surveillance of staff training – available within the LLC Evidence Repository.

This improvement was captured on the Plan for Continuous Improvement (PCI 004) and is closed and is available within the LLC Evidence Repository.

Transition Data reports – available within the LLC Evidence Repository.

Transition Audits Tool – to be added to the LLC Evidence Repository.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Transition Improvement items are reflected within the services Plan for Continuous Improvement (PCI 004), and governance structures around communication and consultation with wider staff occurs within monthly Management and Quality Improvement meetings.

Monthly Management and Quality Improvement Group forums are in place and schedule for work planned, ensuring key staff have protected time for Transition work.

CAMHS Newsletter detailed Living Life Well and Listen Learn Change work, including Transitions with summaries from key meetings communicated out to all staff.

A CAMHS Outpatients Transitions Group has been established with key contacts in each locality for Transitions, and Transitions is now a routine agenda item within each monthly Locality Team meeting.

A Transitions Standard Operating Procedure has been created and is to be trialled for six months within CAMHS, in conjunction with Adult Mental Health Services.

Data for CAMHS Transitions surveillance and reporting of Transitions measures is being progressed through the CAMHS Outpatient Transitions Group and establish standardised monitoring protocols to be generated routinely by Business Unit quarterly.

CAMHS Outpatients Transitions Group established key contacts in each locality for Transitions, and Transitions now a routine agenda item within each Locality Team meeting (monthly).

The triangulation of data from young people, from staff, and from documentation is in the process of being implemented.

RAG Status: Green

Any further action proposed:

Sustainable governance processes exist around the CAMHS Transition Group, who is monitoring Transitions. Within this process are quarterly transition monitoring processes and auditing of transitions, against the Scottish Government Transitions Guidelines. These are routinely reported through local Clinical Governance and Improvement forums for assurance.

Recommendation 40:

Ensure comprehensive data capture and analysis systems are developed to appropriately manage waiting lists and service users' expectations. Work should be undertaken to look at what data is available and what could be useful to inform decision making on service development and monitoring of services. This should be aligned to national reporting requirements.

Intended outcome(s):

• To develop metrics and outcomes around waiting times (including service user's expectations) ensuring these take account of national reporting requirements

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry that routine and established monitoring and surveillance systems for data and performance were not established and did not drive service delivery or improvement.

Summary of Actions:

Implementation Plan

1. Comprehensive data capturing and analysis systems have been developed to appropriately manage waiting lists and service users' expectations.

2. Work was undertaken to look at what data is available and what could be useful to inform decision making on service development/monitoring of services.

3. Reporting was aligned to national reporting requirements.

4. Validation was undertaken by NHS Tayside Business Unit.

Comprehensive dashboard in place to support service planning waiting list management.

A separate pack showing examples of regular information products about our services, alongside narrative about how each is used, accompanies this briefing.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Sustainable process evidenced and monthly performance reporting exists and is used within Clinical Governance and other assurance forums.

Evidence and Milestones:

Monthly Performance Reports generated by Business Unit which are available within the LLC Evidence Repository.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

No changes.

RAG Status: Green

Any further action proposed:

There is no further action planned as the process is now sustainable.

Recommendation 41:

Consider offering a robust supportive independent advocacy service for parents and carers of young people who are engaged with Child and Adolescent Mental Health Services. This may include carer support groups.

Intended outcome(s):

• Independent advocacy service for parents and carers of young people who are engaged with Child and Adolescent Mental Health Services.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand from the Independent Inquiry that there was a lack of understanding of independent advocacy service that are available for parents and careers of you people who engage with CAMHS. Information needed to be provided to demonstrate the supportive independent advocacy for parents and carers of young people that already exists and which CAMHS signposts to routinely. Better evidence of this being used and signposted was needed.

Summary of Actions:

Implementation Plan

1. There are clear links to Independent Advocacy Services on CAMHS website.

2. Independent Advocacy Services links to the Service are included on the newly designed CAMHS website.

3. Staff is aware of the Independent Advocacy Services through mandatory training and audits capture that staff are signposting to these services.

Advocacy Service information included on website (completed).

Website live: Welcome to CAMHS Tayside

A range of advocacy services for parents, carers and young people have been identified. Details for all agencies are linked in the CAMHS website. Staff are also aware of available support and signpost as appropriate.

Staff receive mandatory training on the rights of the child and advocacy services. This core training is monitored via within LearnPro and routine assurance for staff is provided to the Clinical Governance Committee and also reported into the Quality Performance Reporting forum. CAMHS as a service prominently display independent advocacy services within CAMHS and in outward facing communications. Examples of these include the CAMHS website, CAMHS Information Brochure and within routine Letters.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Sustainable clinical governance forums are in place within CAMHS with meetings scheduled on a monthly basis and meeting minutes evidence this. This forum monitors staff training and audits and provides assurance around staff mandatory training. This is then reported through the Quality Performance Review committee (division governance forum).

Evidence and Milestones:

Advocacy services are prominently displayed within CAMHS and in outward facing communications. Website, Letters, Information Brochure – available within the LLC Evidence Repository.

Customised CAMHS information brochure developed in November 2020 and loaded onto new CAMHS website Dec 20 A guide for young people and their families

Advocacy has discrete tab on Website Home Page (landing page)

New CAMHS information brochures delivered to CAMHS 10.02.21 and distribution managed by Administration Lead - all new referrals / rejected referrals get one, all appointments for existing clients.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Completed Improvement Plans (PCI 023) show scope of work and this item completed – available within the LLC Evidence Repository.

RAG Status: Green

Any further action proposed:

There is no further action planned as the process is now sustainable.

Recommendation 42:

Ensure staff working across mental health services are given opportunity to contribute to service development and decision-making about future service direction. Managers of service should facilitate this engagement.

Intended outcome(s):

• Staff are involved in co-creation and development of the service.
• Managers engage staff at all levels in the co-creation and development of the service, using various opportunities and methods to be far reaching.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that the Independent Inquiry found that staff were not given the opportunity to be involved or provide comment into future service direction which resulted in them feeling that decisions were made without engagement and contribution from the staff who the change would affect. We recognise the importance of engaging and consulting with our staff groups so that their voice can be heard and that they have valuable insights, information and understanding of how our services need to change to provide high quality safe and effective patient care.

Summary of Actions:

A Mental Health Staff Briefing was established.

Tayside formed a whole system Mental Health Partnership Forum related to Recommendation 3 to further embed partnership working with trade unions as the standard employee relations model at all levels of decision-making,

Tayside Mental Health and Wellbeing Strategy Events were circulated to staff via the Mental Health Staff Briefing and ongoing whole system change opportunities that are contained in the programme were communicated and staff were supported by their organisation and line managers to attend.

A Mental Health Communication and Engagement Strategy was put in place which encompasses staff engagement across General Adult Psychiatry inpatients and community teams. This has been recently revised.

Health and Social Care Partnerships have communication and engagement plans for local delivery.

Across Tayside leadership and engagement sessions were held with staff in the General Adult and Learning Disability services both inpatient and community services.

NHS Scotland Staff Governance Standard requires all staff to be involved in decisions that affect them and as such we need to ensure that staff side are involved and we are working together in partnership to ensure that staff are engaged and can influence.

We provided a series of planned staff focus groups throughout the year to enable us to engage and keep staff informed about LLC and the MHWB Strategy.

In addition to more structured invitations around planning, improvement and redesign, leaders are now more visible and encourage conversations with staff within their place of work about potential future service development.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We believe that the Recommendation has focused us on providing opportunities for staff to engage and be consulted on the Living Life Well Strategy and the Listen Learn Change Recommendations as well as service improvement and redesign.

All managers across the Partnerships and Inpatients held focussed staff meetings. The purpose of these meetings was to encourage staff to express their views and to offer and encourage staff to take up the opportunity to be involved. This was done with staffside support.

The formation of a Mental Health Partnership Forum enables a whole system understanding of our application of the staff governance standards and ability to share whole system understanding and involvement. It also provides an opportunity for us to work in partnership and explore the best ways of consulting and engaging.

The opportunity for staff to be consulted, engaged and involved in service changes is a continuous opportunity and leaders of all levels across the organisation are encouraged through, informal team meetings, iMatter action plans and informal and formal methods. We recognise that we have further consultation to do in regard to the issues around service redesign but feel we have good learning and tested ways to enable this to happen and for staff to feel consulted, engaged and being offered the ability to participate.

We believe the actions we have taken and will need to take in the future are the right ones. We can see this through feedback from some indicators such as iMatter, Trickle and Pulse surveys that the experience of feeing engaged and consulted is improving.

Evidence and Milestones:

Key evidence against this recommendation includes:

A Mental Health Staff Briefing was established which was a regular communication sent out to all staff across Tayside, this focuses on providing staff updates on progress with LLC but also provided information on how staff could be involved and share their views and experiences.

Staff were invited to join Tayside Mental Health and Wellbeing Strategy Events and ongoing whole system change opportunities and were encouraged to attend by their line managers and organisations.

Changes that may affect staff are shared with partnership and with staff to ensure that we consult and engage and to provide a feedback loop to staff.

We have continued to have a series of planned staff focus groups to enable us to engage and keep staff informed in regard to LLC and the MHWB Strategy.

We have a communication strategy which will support the ongoing engagement and communication with staff in relation to issues which affect them.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We have a revised communication strategy which will support the ongoing work

Partnership working is improving and the current Mental Health Partnership Forum is being reviewed. They support the ongoing review of the Pulse survey, iMatter and opportunity to raise awareness of any concerns or issues around our adherence to the staff governance standards.

We recognise that ensuring staff who work across our mental health services have the opportunity to contribute to future service development and decision making about the future service direction. This is a continuous action for managers of services and although we believe we have met the objective, further work needs to be done to ensure we continue to keep this important process in place to affect change and improved outcomes for patients.

We are noting increased attendance from front line staff at workshop opportunities and strategy programme meetings and in response to iMatter questionnaires.

The pandemic and the increased use of Teams has supported the ability of staff to be involved to inform service redesign.

RAG Status: Green

Any further action proposed:

This action will be an ongoing process as communicating, engaging and listening to our staff is of paramount importance and reflects that we work with the Staff Governance Standards.

In order to ensure that staff engagement is strengthened, we will ensure that:

• Any gaps in engagement resource are filled by agreed and explicit arrangements.
• The arrangements within each partner organisation for engagement are linked together through a programme team whose remit will be to support, coordinate and connect change efforts at an area-wide level and to connect local engagement conversations to the strategic conversations.
• We regularly self-assess our adherence to the Staff Governance Standards and commitment to working in partnership.
• All of the above is held within a plan that all partner organisations recognise and contribute to.

Changes that may affect staff will be worked up in partnership which will ensure we engage and involve staff.

Recommendation 43:

Prioritise concerns raised by staff by arranging face-to-face meetings where staff feel listened to and valued.

Intended outcome(s):

Staff are actively listened to and engaged in discussions relating to concerns and other matters in the workplace.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that during the enquiry, staff had expressed concern about lack of opportunity to engage with their managers, raise concerns and make suggestions, in relation to their workplace and the service.

Summary of Actions:

A collective leadership decision was taken to practically increase visibility of managers and to reduce the distance between teams and their leaders in response to this recommendation.

Work has been done to foster a more continuous conversation across all levels of the service about service development and delivery to ensure that informal discussions flow naturally and feed into and out of the formal decision and discussion forums.

A review of the use of meetings was done in some areas to ensure that operational discussion and decision making around caseload management was separated off from discussions about team support, development and accountability.

Engagement sessions were delivered to staff for a fixed period between April and November 2021 (54 managers and 35 staff in non-managerial positions).

An evaluation of the sessions has been gathered with actions to be developed from the feedback.

iMatter action plans have been developed and continue to be included in the iMatter cycle.

The Trickle App has been piloted within Inpatients and is being evaluated with a view to further roll out across other parts the service, if it is felt that it enhanced communications.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

A lot of work has been done formally and informally, from a leader perspective and at team level, and using specific feedback tools as well as conversation to involve and engage with staff about service development. There are a number of good opportunities in our improvement plans to test out how well we are involving our teams in service development.

Evidence and Milestones:

Key evidence includes: -

• Evaluation report from staff engagement sessions. 20% of participants responded
• iMatter response rates/action plans
• Trickle evaluation to be undertaken August 2022
• Softer intelligence around staff concerns, how much people feel listened to and valued.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Data/feedback gathered with work being undertaken to develop action plans to address issues raised.

RAG Status: Green

Any further action proposed:

The management team are continually exploring methods to create opportunities for staff engagement which can be embedded into regular communication.

iMatter continues to be a vehicle to create discussion opportunities and develop action plans to which all staff can contribute to. The Trickle App is in the process of being evaluated within Inpatients with a view to further roll out in other parts of the service if it is felt that it enhanced communications.

As a result of the evaluation of the Workforce Development programme a number of actions have been identified which will be addressed in a Workforce action plan.

Actions include: -

• Ensuring that there has been a sufficient spread of attendees from across the service
• Further sessions to be determined if felt uptake was poor in any area
• Managers to discuss the themes raised within their teams to establish if there are any outstanding issues to be addressed
• The opportunity to discuss the themes at local partnership forums

As part of an action plan to address workforce issues, managers will be reminded of the need for engagement in every part of the employment journey from induction to exit and all opportunities in between, including appraisal, which will create opportunities for discussion at every stage.

Recommendation 44:

Arrange that all staff are offered the opportunity to have a meaningful exit interview as they leave the service. This applies to staff moving elsewhere as well as those retiring.

Intended outcome(s):

• Reasons for moving on are captured and help us to learn about and improve our service.
• All staff are offered the opportunity of a meaningful exit interview as they leave.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand that during the Independent Inquiry, staff who had recently resigned from their posts felt that there was no formal system of undertaking exit interviews. It was also noted that the existence of an exit questionnaire seemed inadequate in terms of capturing reasons for leaving and informing discussions about service planning and workforce retention.

Whilst exit interview uptake can be low, and whilst Mental Health and Learning Disability Services are not an outlier in the response rate and turnover / vacancy rates are a cause for concern across Scotland, it is important that meaningful feedback is considered and acted upon.

Summary of Actions:

A Vital Signs newsletter was issued to all staff in July 2021 advising them of a refreshed exit interview process.

All staff leaving / exiting / retiring from Mental Health Services are given the opportunity to provide feedback on their experiences within the workplace, either via an online questionnaire or face-to-face as preferred.

Due to low numbers of interviews and information shared in those interviews, managers were asked to share themes arising in conversation as members of staff moved on from their posts. Those themes are discussed in operational meetings.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Data collected has been insufficient to provide reports which do not identify individuals; however, managers have been able to report feedback which has been gathered in informal conversations. The importance of the opportunity around exit interviews has been reinforced at all levels.

Evidence and Milestones:

Prior to the refresh in 2021 all mental health and learning disability inpatient staff were captured within Perth and Kinross Health and Social Care Partnership data. Further work has been undertaken to extrapolate this data to create an inpatient report.

Community mental health service, Psychiatry of Old Age and CAMHS staff are contained within each Health and Social Care Partnership / Clinical Care Group Reports and at present further drill-down to these services cannot be achieved due to system limitations.

Data from July 2021 to March 2022 is as follows:

• 9 exit interviews have been completed in Mental Health and Learning Disabilities from 36 leavers.
• Numbers are sufficiently low at present that some feedback may be identifiable.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Staff have a choice to complete an exit discussion / complete a questionnaire. Evidence suggests that staff are aware of this opportunity as 25% of leavers took this opportunity.

RAG Status: Green

Any further action proposed:

As part of an action plan to address workforce issues, managers will be reminded of the need for engagement in every part of the employment journey from induction to exit and all opportunities in between, including appraisal, which will create opportunities for discussion at every stage to allow any opportunities to make improvements to retain staff.

Invitations to staff to undertake exit interviews/questionnaires will continue to encourage uptake.

Line managers will be asked to mandatorily signpost online confidential exit interview questionnaire alongside invitation for one to one discussion

Measurement through ongoing sample audits will help to monitor the reliability of the process and ensure that opportunities for exit interviews are extended to all leavers.

Recommendation 45:

Prioritise recruitment to ensure the Associate Medical Director post is a permanent whole-time equivalent, for at least the next 2 years whilst significant strategic changes are made to services.

Intended outcome(s):

• A senior Medical Manager with the requisite skills and experience to provide leadership and management for the psychiatry workforce is in post full time in a permanent capacity.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The Independent Inquiry heard from consultants and the wider workforce the challenges presented by a lack of Associate Medical Director input and availability. This raised questions of accountability of, and support for senior medics and wider clinical workforce. It also presented a significant gap in psychiatry input at strategic level around future service development and direction.

Summary of Actions:

The interim Associate Medical Director put in place a range of remedial actions to support the medical workforce through the early part of Listen Learn Change, while external recruitment ran. The first rounds of recruitment did not deliver an appointable candidate.

Upon review of the level of seniority and experience required, the job description was adapted and re-advertised as Operational Medical Director, Mental Health and Learning Disabilities.

Recruitment ran and the revised role was successfully appointed to on a permanent basis in September 2021.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

We now have a full time, permanent, Operational Medical Director for Mental Health and Learning Disabilities Services. The incumbent has significant experience of Mental Health and leadership, and is fully involved in service clinical governance, delivery and future development.

Evidence and Milestones:

Job description

Selection process documentation

Individual in post

Evidenced participation in the discussions and work to operationally implement the ambitions of Living Life Well.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We consider the outcome of this recommendation to have been demonstrably achieved.

RAG Status: Green

Any further action proposed:

The work to strengthen and stabilise the medical workforce in psychiatry within Tayside will continue under the leadership of Dr Le Fevre and the extended Leadership Team.

A plan to review the governance structures for Listen Learn Change and Living Life Well, taking account of the revised Integration Schemes is underway. This will commence with a review of the terms of reference of the Mental Health and Wellbeing Programme Board. The Chief Officer as Lead Partner has held one to one discussion with workstream leads and will lead a re-evaluation and re-prioritisation of the current workstreams reporting to the Board. This will include the development of a financial framework to support the delivery of the strategic plans for mental health services.

Recommendation 46:

Encourage, nurture and support junior doctors and other newly qualified practitioners, who are vulnerable groups of staff on whom the service currently depends.

Intended outcome(s):

Positive staff experience and promote those who train here to be recruited and retained in Tayside Mental Health.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

We understand the value and importance of our junior doctors and newly qualified practitioners and that some staff did not feel nurtured and supported in their roles at the time of the Independent Inquiry. This support is important for all staff at all times but particularly so for staff who are at the very early stage of their career. We recognise the importance of ensuring these early experiences are purposeful, professional and enable people to maximise their potential.

Summary of Actions:

We have completed an overhaul of the support available for NQPs since the time of Trust and Respect.

Newly Qualified Nurses:

• All newly qualified nurses to Mental Health & Learning Disabilities within Tayside now attend a bespoke induction which is co designed by the previous year's NQPs. The inductions are fully evaluated and the information is used to inform future inductions.
• All NQPs are supported in their first year by attending action learning on a monthly basis. These sessions are set for the year and NQPs are supported to contract with their SCNs to ensure attendance. Each NQP is given the opportunity to evaluate action learning which has consistently evaluated positively. One NQP described how action learning made them safer, surer and stronger in their practice as a nurse.
• Action Learning is an established support for all NQPs in Mental Health & Learning Disabilities and is a safe place for NQPs to share their experiences with peers, reflect, evaluate and develop personal action plans to help take forward any issues raised.
• Action Learning is facilitated by 2 experienced Mental Health and Learning Disability Nurses.
• All NQPs are provided with training plan specific to Mental Health & Learning Disabilities which includes mandatory, essential and desirable training.
• All registered nurses have access to a full CPD programme which is co designed by staff and includes local and national learning priorities.

Doctors in Training:

• Peer support groups for the junior and senior trainees have been established and these groups have an identified standing on the agenda in our mental health Teaching and Training Management Group and therefore access to both the Associate Director Medical Education and the Medical Director in Mental Health. The peer group reps report that they can now access senior support for any issues arising and a recent survey identified that trainees feel more comfortable raising concerns. Our key focus has been on engaging the trainees in their training scheme and with operational management to improve their experience.
• The current local teaching program blends in-person and online training opportunities. This reduces the need for travel, promotes attendance and allows us to record the meetings so they can be watched later. All of the clinical supervisors are aware that Thursday is a protected teaching time and only the duty / on-call doctors should be contacted during this protected time. The timetable for most trainees now should allow attendance at their specialty specific teaching, with appropriate cross cover arrangements. Formal and informal feedback suggests these opportunities are well utilised and that accessing teaching is not an ongoing concern.
• The organisational development team have continued with their monthly ongoing program to engage with trainees of all levels with a leadership / management focus
• Core Psychiatry induction is led by the Training Programme Director (psychiatry – East Region) and we have focussed on improving psychiatry specific induction as well as local orientation.
• The provision of an experienced clinical supervisor for all trainees ensures that this requirement is met and provides pastoral and educational support for trainees during their time with us.
• A post graduate medical teaching programme is well established via Teams and meets on a Thursday morning during the academic year.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The extensive work done to ensure that NQPs are well supported and oriented into their roles is reliably in place. We now routinely gather feedback from all NQPs and we use that feedback to continually strengthen the induction experience for forthcoming cohorts of NQPs.

Evidence and Milestones:

Evaluation from induction days

Action Learning Attendance & Evaluation

National Award for Action Learning Process

Deanery visit reports highlighting GAP training positively

Trainee handbooks

Buddy System process

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Induction and Action Learning in place for all NQP's to Mental Health & Learning Disabilities.

Feedback from both within and beyond our Organisations gives us confidence that the outcome we are seeking from this recommendation is being achieved and will continue to be achieved into the future.

RAG Status: Green

Any further action proposed:

NQP development is business as usual and embedded in QI / PD work plan.

Recommendation 47:

Develop robust communication systems both informally and formally for staff working in mental health services. Uses of technology are critical to the immediacy and currency of communications.

Intended outcome(s):

Well-informed staff who are aware of and involved in information-sharing and ongoing dialogue about their directorate or service, how it fits into mental health and learning disability services across Tayside, and who feel able to feedback to colleagues and the leadership team.

Information and communications are shared in the right way at the right level and at the right time, with new technologies explored and online communication used, as well as established methods both online and face-to-face.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The history of poor communication about service development and planning around Mental Health services in Tayside created a lack of trust amongst staff. At the time of the Independent Inquiry, the predominant approach to communication was a combination of meetings (of which many staff could not attend) and email briefings (which many staff did not have access to computers to read).

We recognise that staff working in mental health and learning disability services work across a number of sites covering a large geography, in both inpatient and community settings. Therefore it is recognised that coordinated and consistent communications tailored to the teams in their specific workplaces are required. This means that there must be a multi-channel approach using more formal and established methods including directorate e-bulletins, directorate and service staff emails, corporate e-briefings, leadership briefing sessions, in-person briefing sessions, on-ward and at base huddles, and manager briefs and dedicated staff sessions. These all must present opportunities for staff to feed back and also have follow-ups to learn what has happened with their feedback and build on their ideas for improvement and change.

There is a need to continue to build on the positive changes made across mental health and learning disability services, including those identified in the Independent Inquiry Review in 2021 in which Dr Strang stated he was impressed with the commitment and dedication of staff seeking to make a difference for patients and the wider community in Tayside.

We understand this recommendation to be primarily about communication. The engagement components are addressed in recommendations 3 and 4.

Summary of Actions:

A Communications and Engagement Strategy including the approach for staff communications has been developed

Dedicated staff engagement sessions have been taking place monthly, open to all staff across the whole system to give everyone the chance to learn more about the improvement and change plans in place and being developed and to also raise comments and concerns and ideas. These have been reviewed and each session is moving away from a general approach to topic-specific sessions.

Staff have participated in videos to talk about their roles and services and raise awareness and wider understanding about their parts of the service for colleagues and the wider public.

Ward managers and the leadership team brief staff regularly on emerging issues and changes and improvements to services. There is also a procedure to alert staff to high profile stories which may appear in the media to make sure they are aware and supported.

System-wide e-bulletins are issued, as well as local service level communications to respond to emerging issues and to ensure immediate communications are issued in the right way to relevant teams and staff groups.

To improve two-way communication further, the Trickle app which is an online communication tool for groups of staff has been introduced which provides real-time staff feedback of their experiences in the workplace to identify good practice, maintain local engagement and promote early discussion of concerns and emerging issues.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Through the review of indicators such as iMatter, Trickle and Pulse surveys, communication across the directorate is improving and staff are aware and have a better understanding of the work and improvements under way.

Staff are engaged through the monthly briefing sessions and their feedback is refining both the format and the content of the sessions going forwards.

Staff are engaged in raising awareness about their service to the public through participation in videos for the Tayside population, mental health campaigns and other public communications

Staff support mechanisms and special two-way communication opportunities are in place for occasions when issues appear in the media which have the potential to portray the service and teams in a negative way.

Evidence and Milestones:

Communications and Engagement Strategy 2022

Monthly staff briefing sessions – evolving from feedback received from staff and regular community staff briefings in localities

Ongoing alert communications and two-way communications channels to ensure staff are supported at times when the service is potentially impacted by negative media and public attention

Trickle app introduced

Mental health improvements and achievements highlighted in whole-organisation communications

Staff engagement in mental health campaigns and information sharing with the population of Tayside

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Communications and Engagement Strategy 2022 being implemented.

Assets and communication channels as listed above in Evidence and Milestones section all in place.

Leadership group and managers supporting line managers in briefing and information sessions.

RAG Status: Green

Any further action proposed:

The monthly briefing sessions are under ongoing review following staff feedback to ensure content is relevant and feedback loop is completed.

Trickle app being launched in more areas, with dedicated training and promotion.

Regular reporting will be undertaken through Partnership structures.

Recommendation 48:

Ensure that bullying and harassment is not tolerated anywhere in mental health services in Tayside. Ensure that staff have confidence that any issues or concerns they raise, will be taken seriously and addressed appropriately.

Intended outcome(s):

• All staff are clear about the process for reporting any concerns around Bullying and Harassment and that they are aware of acceptable behaviours. An increased awareness of acceptable behaviours.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

There is a zero-tolerance approach to Bullying and Harassment across NHS Scotland, its Health and Social Care Partner Organisations and Police Scotland, but we know and acknowledge that it exists. We understand that staff need to be assured that if they raise any concerns they will be taken seriously and addressed appropriately. It is essential that managers (and staff) are aware of acceptable behaviours and that these are highlighted on a regular basis and routinely in any conversations in the workplace where these types of issues might arise. This recommendation highlights issues in culture and we wish to give staff confidence to raise matters, whether it be in informal discussions, team meetings or through staff side colleagues via the Local Partnership Forums.

Summary of Actions:

The Workforce Development programme provided information on policy and reporting arrangements but also allowed for staff to discuss these matters.

Reporting on Bullying and Harassment is in place through the Integrated Leadership Group and organisation-wide via the Staff Governance Committee. The figures within NHS Tayside have demonstrated that the formal case numbers remain low within Mental Health Services i.e., less than 5 per year in the last 3 years and 6 cases in one year. The evidence from this data for that period has shown that there is no indication of any correlation, key themes or poor culture in any one service. Mental Health Services are not an outlier within NHS Tayside for numbers of cases.

Number of formally reported cases is not the only source of information to help us understand perceptions and experiences around bullying and harassment. Leadership meetings consider information from iMatter surveys, from partnership forums, from team interactions, from one-to-one supervision, from corridor conversations and from levels of participation in team exercises.

There is also a link to the appraisal process and objective setting to ensure that expectations around service delivery are jointly agreed and clear. Provision of regular opportunities to discuss individual performance also help to ensure that expectations are appropriately managed.

It is also important for managers to be personable, accessible and approachable. So the actions against this recommendation link closely with Recommendation 1, and all of the other recommendations around workforce and culture, and in particular Recommendation 43.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

The conditions for reporting have been created but staff need to feel confident to take the first step in raising concerns and a number of further actions have been identified to encourage this on a regular basis. It could be viewed that the low numbers suggest that there is little bullying in the workplace but also that staff are still reluctant to report any concerns. However, the risk of suppressing reporting is, to an extent, mitigated through the triangulation of intelligence across a range of other formal and informal sources. A continuous focus on acceptable behaviours and the encouragement to report concerns is something that is highlighted for managers.

Evidence and Milestones:

Training in the Bullying and Harassment Policy and Mediation has been made available to managers and supervisors across Mental Health Services, with attendance recorded as follows:

• 40 Mental Health Managers attended Once for Scotland Bullying and Harassment awareness sessions highlighting the difference between the previous policy and the new national policy;
• 128 Managers attended specific bullying and harassment sessions to discuss the policy, refresh awareness of acceptable behaviours and enhance confidence and skills;
• Sessions were delivered to line managers and supervisors to enhance knowledge and skills in the management of bullying and harassment. A recording of the session was made available;
• NHS Tayside commenced a roll-out of Bullying and Harassment sessions in June 2022 and to date 4 Mental Health and Learning Disability staff have attended;
• The OD Team have offered 1:1 confidential conversation with managers and supervisors to support this as the new Once for Scotland policy encourages early resolution and it was felt that this may provide the appropriate support for these staff to have these conversations.

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

Within the most recent iMatter report, nearly 4 out of 5 respondents stated that they felt treated with dignity and respect and described the organisation as a good place to work.

RAG Status: Green

Any further action proposed:

In addition to the other workforce and culture actions described in other recommendations, we will;

Check on the spread of those being trained across the service and highlight any areas which have low numbers to encourage participation.

Deliver organisation-wide Bullying and Harassment awareness sessions, delivered in partnership with our trade unions, which refer to the Policy and the Sturrock Report and staff will be encouraged to attend. Numbers will be monitored to ensure a spread of uptake.

Sign-post staff to supporting information (e.g. YouTube video).

Provide regular reporting to ILG and local Partnership Forums for further discussion.

Offer managers the option of on-site sessions encourage attendance.

Develop an information checklist for managers to ensure that they are aware of their responsibilities and have appropriate signposting for information to support them.

Remind managers of the need for engagement in every part of the employment journey from induction to exit and all opportunities in between, including appraisal, which will create opportunities for discussion at every stage.

Rate of incidence of Bullying and Harassment will continue to be monitored through NHS Tayside structures.

Recommendation 49:

Ensure there are systems analysis of staff absences due to work-related stress. These should trigger concerns at management level with supportive conversations, taking place with the staff member concerned.

Intended outcome(s):

• Effective promotion of health and wellbeing in the workplace.
• People who work in our services feel that their wellbeing matters to their managers.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

Staff are our greatest asset, and their wellbeing is of the utmost importance. During the Independent Inquiry, some people contributed their feelings that their organisation did not care about them.

When things become untenable and staff members end up on work-related absence due to stress connected to their work, we require to understand the reasons for absence from work, what the triggers may be in the workplace and that managers are equipped to support staff, particularly in relation to work-related stress. It is also essential that managers engage with staff who are absent from work and create the conditions for staff to feel comfortable discussing their health issues and be engaged in any actions to provide a supportive workplace.

Summary of Actions:

Understanding the reasons for work-related absence is important, but most of the work to do with ensuring staff feel supported in work takes place long before an absence occurs.

Clarity of expectations

We see a strong link between wellbeing in work and the cycle of setting of expectations of staff through the appraisal, review and personal development cycle. So there is a link between this Recommendation and Recommendation 10.

Ways to feel looked after and cared about, especially when things go wrong, is also important.

Wellbeing Conversations

We now frequently ask our staff groups what would support their wellbeing. For example, recently CRHTT team specifically asked for a room outside of the clinical area to be able to have breaks. That request has been accommodated and has included items they requested to support them having down time.

Some of our teams have chosen to use of RED, AMBER, GREEN, BLUE descriptors at start of meetings to enable conversations about how people are feeling. People can choose to discuss their own rating or listen. This can be effective in enabling sharing of issues or concerns and to get support or problem solve with the team.

Our Chaplaincy Service has been invited regularly to team meetings to do a wellbeing session and this has been received positively.

Listening to staff and supporting their ideas for positive change is an integral part of our approach.

Wellbeing Champions are staff members embedded within teams who can support wellbeing and resilience by encouraging discussion on mental wellbeing and connecting colleagues to relevant support. The Champions have received training and receive ongoing support through the Wellbeing Centre and Healthy Working Lives (HWL). Currently there are two Champions in Carseview, 18 in Murray Royal Hospital (MRH) and one in the Centre for Child Health, Dudhope.

Visible, Approachable and Active Leadership

Visible leadership is key to ensuring staff feel supported in work and are supported with potentially stressful situations. Within inpatients we try to ensure each huddle is supported by a Senior Nurse and that we are visible as a team. We have prioritised and can evidence face-to-face meetings with staff where we have been made aware of concerns / stress-related issues. A recent example would be Moredun Ward and CRHTT; both areas where staff attrition rates were a concern and possibly an indication that staff were feeling stressed due to acuity / workforce / environmental issues. We have responded to the concerns by meeting with staff face-to-face and working with them to develop plans and solutions. We have worked in collaboration with Partnership colleagues, who have joined us in these face-to-face meetings with teams and provide ongoing support.

Within our Community teams, we have examples of the service leaders attending team meetings regularly for info sharing, listening to staff feedback and discussing 'hot topics'.

In addition to regular team meetings where any staff member can approach their manager, there have been several examples of Senior Manager walkrounds accompanied by a Staff Side representative. Although the main purpose of these walkrounds was to assess, check and reassess the physical distancing measures required during Covid, staff were openly encouraged to ask any questions, give feedback, or ask to meet separately with those on the walkround.

The Healthy Working Lives program is highly active in NHS Tayside and encourages teams to be involved in promoting health and wellbeing in the workplace. They have an online resource with information and signposting to all the linked wellbeing activities. Teams are recognised through the HWL award scheme with MRH currently holding a Gold HWL award.

The Staff Wellbeing Service provides Staff Support Workshops and Values Based Reflective Practice (VBRP) training. VBRP uses tools to help the teams reflect together in order to shape future practice and focus on the values that underpin our work.

Anticipatory Preparedness and Ongoing Support

Mental Health Nurses may at some point in their career experience the death of a patient to suicide. The death of a patient to suicide can have a profound effect on Mental Health Nurses and often leave Nurses with a sense of grief, guilt and loss of confidence. The Mental Health Nurse Forum has led discussions in relation to how as a professional group we need to recognise and attend to this issue and create a culture through which staff can discuss suicide and be supported and encouraged to discuss and reflect on their concerns and fears during the aftermath of a patient suicide. The Lead Nurse for Child and Adolescent Mental Health Outpatient Services and the Carseview Hospital Chaplain are leading a group to consider this important issue. Colleagues have linked with the University of Dundee to learn from the approaches underway in the undergraduate Mental Health Nurse Training and will develop a new approach to supporting staff affected by suicide.

Conscious that new graduate Mental Health Nurses joining the CMHTs had a less practical learning experience prior to qualification due to Covid related placement restrictions; in Dundee steps have been taken to provide additional support beyond the standard induction process. A post retirement senior Community Mental Health Nurse was appointed on a part time basis to provide on the job coaching sessions for our new graduates. This has been especially helpful in terms of their role in the Duty Worker on-call System where 1:1 coaching and support to increase confidence in decision making has been valuable. Group coaching sessions covering a range of topics to further support and mentor graduates has also been embedded within the practice of the CMHTs. Although developed as a consequence of Covid, this valuable support will continue to be part of our permanent staffing establishment.

Scottish Government money has been utilised in teams to support staff to choose what activity they wanted to do as a team, to support their wellbeing. Budget used for team afternoon with cross cover, to enable team building and stress relief/time out.

In Angus the adult mental health operational management team have been supported by NHS Tayside Improvement Advisors to review and develop the vision, values and culture of the service, around the themes of quality of care, communication and teamwork. These sessions are being cascaded to team members to ensure all staff can contribute to developing the shared values and culture within the service. The next step is to engage with service users and carers prior to finalising this work.

At Organisation Level

The Staff Wellbeing Service is available to all staff and can provide individual staff support sessions to explore any aspect of wellbeing at venues across Tayside and on MS Teams. They are available to establish bespoke programs of support for teams depending on need.

NHS Tayside has established Rest, Relax and Recharge rooms (Triple R Rooms) throughout all sites. These are quiet spaces that allow staff to get away from their daily routine and take time to relax. There are Triple R rooms in MRH, Carseview and Strathmartine Centre. Staff on the Ninewells site are also encouraged to make use of the Ninewells Community Garden Space as an outdoor, calm area to relax and recharge.

Care First is the Employee Assistance Provider available 24/7 to all staff. Care First can provide short term counselling support with a free phone number. The website has a wealth of information and resource to support all aspects of staff wellbeing and they have frequent on line webinars covering key wellbeing topics such as money concerns and mental health. They can also provide advice and support to managers.

A Workforce survey has been conducted to gather feedback and inform future adult mental health services workforce plan. This is separate to AHSCP plan.

We monitor supervision and appraisal information on a monthly basis.

Team training plan in place. New advanced roles have been developed and offer career progression.

From an organisational perspective managers are provided with a monthly absence report which indicates levels of absence and reasons for absence. (The Scottish Standard Payroll System does not allow for work-related stress to be reported separately from 'anxiety / stress / depression / other psychiatric illnesses'.)

To extrapolate this information, it is essential for managers to engage with staff when absent and on return to take supportive action where possible.

As part of the Workforce Engagement sessions, managers were provided with guidance and training on how to apply the policy but specifically to have the engagement to ensure that any incidents of work-related stress were addressed. This would be conducted in accordance with the Health and Safety Executive Management Standards for managing stress at work.

Work has also been done to promote and support early resolution of conflict, noting the potential for escalating disputes to be a probable source of stress for those involved.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Reports are available to track absence rate trajectories, managers have been equipped with the tools to manage absence (including work-related stress) and absence reports are discussed at various management meetings.

Evidence and Milestones:

Conversations, both informal and formal, with staff are a key mechanism for feedback on this Recommendation

Workforce Staff Development engagement was undertaken with 54 managers / supervisors and 35 staff (non-supervisory) participated in the sessions

Additional support has been made available to managers and supervisors in applying policy and supporting staff through difficult health situations

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

We feel that we have systematically strengthened the approach we take to promote and support staff wellbeing. We have a range of evidence both in terms of staff absences due to stress, and in terms of conversations with our teams to suggest that we have attended well to this recommendation and have the mechanisms in place to ensure that wellbeing remains high on the workforce agenda.

RAG Status: Green

Any further action proposed:

Discussion to take place with management teams to establish if more in-depth reporting can be undertaken within the teams, whilst avoiding any staff identification.

Regular discussion to take place at Local Partnership Forums and to ensure that the principles within the Staff Governance Standard for employers and employees alike is promoted and enacted.

An information checklist will be developed by Workforce colleagues for managers to ensure that they are aware of their responsibilities and have appropriate signposting for information to support them.

As part of an action plan to address workforce issues and staff engagement, managers will be reminded of the need for engagement in every part of the employment journey from induction to exit and all opportunities in between, including appraisal, which will create opportunities for discussion at every stage.

Recommendation 50:

Ensure there are mediation or conflict resolution services available within mental health services in Tayside. These services should exist to support the rebuilding of relationships following adverse events and other aspects of service delivery, including with families and carers and NHS Tayside's relationship with the local press.

Intended outcome(s):

• Serious Adverse Event Reviews (SAER) are independently chaired and take a thoughtful, inclusive and sensitive approach to the involvement of service users and carers.
• There are mechanisms that staff recognise to support them around sensitive public messaging.
• Our services are represented in a more balanced way in the published press.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

The Independent Inquiry reported that Adverse Event Reviews were a particular source of dissatisfaction for patients, families and carers. Participation and engagement in the reviews, and also in follow-up meant there was a lack of confidence that any changes and learning would happen.

In the Independent Inquiry report, staff identified that the ripple effect of the publicly reported difficulties and criticisms of Tayside mental health services resulted in a challenging working environment and they felt that no-one spoke out for them in response to negative reporting in the media.

We consider this Recommendation therefore to be about how to create a sense of organisational support for staff and for patients and families. This would be particularly around incidents of serious harm, and the steps we can take to strengthen the positive aspects of the service delivered by teams across Tayside and publicly report these providing the population with a more representative view of our services in all forms of the media.

Summary of Actions:

Since the publication of Trust and Respect, the process for SAER's has changed markedly. To ensure an objective approach is taken the process now includes sourcing an independent chair.

Communication with families following a SAER has been updated around the process. Communication emphasises the importance of family involvement in the review, to increase transparency, inclusion and compassion in the process. This process is described in more detail around Recommendations 11 and 31. However it is mentioned here because we feel that process has a direct bearing on what then happens in terms of staff perceptions following a SAER and what is published.

A Mediation Service has been introduced (organisation wide) in conjunction with staff side partners to aid with internal staff disputes and with conflict resolution. The service has a bank of 10 accredited mediators. This service sits as part of our broader approach to workforce development and our work to foster a more supportive and open culture where people feel listened to, valued, supported and developed.

Corporate Communications department has taken several steps to understand the balance of positive and negative stories in the press about NHS Tayside. Following this analysis a more proactive approach has been taken to the use of social media to ensure that positive improvements, progress in services and staff achievements are made available to the public. Tracking of comments under those stories has shown a reduction in negative press and negative comments on social media about NHS Tayside overall.

Are the actions sufficient to achieve the intended outcome(s)?

Yes

Please briefly explain your response here:

Health and care will always be the subject of press scrutiny and an area of interest to the public. The tendency across all media to report and focus on issues and when things go wrong is likely to persist. However, we believe that a more inclusive and thoughtful approach to sharing learning following incidents of harm, coupled with strengthened support for our staff as conflict arises will help staff to feel more supported, alongside our other commitments around workforce development. The more balanced and more representative view of the care we provide with the public across all forms of media we hope will feel less critical for our teams.

Evidence and Milestones:

Staff reported perceptions of sense of feeling supported

SAER process and documentation

Mediation Service evaluation

Media Workplan 2021/22 and 2022/2023

Analysis of all media platforms and social media interactions shows shift in positive / negative balance

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The outcomes for this recommendation have been met and evidenced.

RAG Status: Green

Any further action proposed:

We will continue our plans around culture and workforce development and will ensure that we factor into that work the role that the media plays in influencing staff perceptions of feeling valued.

The Media Workplan 2022/2023 is being implemented.

We will also monitor the uptake and impact of the Mediation Service as part of our operational leadership approach.

Recommendation 51:

Ensure that all external review processes are embraced wholeheartedly and viewed as an opportunity to learn and develop. Managers should ensure that all staff receive details of the Recommendations from reviews and are included in the analysis and implementation.

Intended outcome(s):

• There is confidence across all stakeholders and communities that external reviews are embraced wholeheartedly and that stakeholders have the opportunity to both participate in service developments and evaluate progress.

Understanding of Recommendation (including any assessment of underlying issues which gave rise to the recommendation):

A theme running through both the Trust and Respect Final and One Year On reports is that external reviews are not seen as an opportunity for collaborative learning and service development.

External scrutiny is a vital aspect of our ongoing quality assurance and improvement journey. Organisations that deliver excellent services and the very best outcomes use every mechanism available to learn and to improve.

This Recommendation highlights the importance of welcoming independent scrutiny and inspection as a hallmark of a partnership that is striving for excellence, public accountability and as a helpful means to secure continuous improvement. It is also about ensuring that leaders take appropriate action to share the findings of external scrutiny and internal review in order that staff at all levels understand what needs to improve and can own the actions required to make those improvements.

Summary of Actions:

Extensive work has taken place to involve and collaborate with our stakeholders during LLC.

Beyond Trust and Respect, we currently welcome visits and reviews from a number of external organisations.

External Visits Reviews

The Mental Welfare Commission (MWC) routinely carry out announced and unannounced visits to Mental Health and Learning Disability hospital wards and teams across Tayside. The reports set out recommendations where indicated, and all reports are published on MWC website and are fully accessible to the public.

Services respond on all occasions to Recommendations through the development of local action plans which are monitored through operational management and governance routes for each partner organisation.

The MWC hosts an annual review with all partner organisations coming together to discuss themes, feedback and action taken.

Healthcare Improvement Scotland (HIS)

HIS have provided important support in key areas of the Mental Health Patient Safety Programme which is being remobilised following the pandemic. Examples include our work in Improving Observation Practice and recent membership of the new patient safety collaborative focussing on restraint reduction and seclusion.

We have worked with HIS over the last 18 months as one of two national pilot sites for Early Intervention in Psychosis. The work has focussed on the design and delivery of a hub model based in Dundee in the first instance.

Engagement with the HIS Personality Disorder Pathway work is at an early stage as we seek to build our engagement and involvement in this work

Listen Learn Change

The publication of the Trusts and Respect follow up report provided an opportunity for reflection and review given the lack of confidence people described in the assessment of actions undertaken. It is fundamentally important that people have trust and confidence in work underway and / or completed. This is best achieved through a range of people leading, participating and co-producing the work which should be done with as well as on behalf of the people of Tayside. There is still work to be done. Initial actions in expanding the members of the LLC Leadership Group have been helpful and have ensured a greater cross organisational partnership and sense of collective accountability. However, we are mindful of the need to expand this further into different groups and communities and are thoughtful about how this is meaningfully progressed.

A revised governance structure has been developed to ensure that the Tayside Executive Partners through the Chief Officers Group have the balance of information needed to provide them with assurance that their collective commitment to improve mental health services in Tayside is delivered.

The presentation of evidence to support the progress of change has not been an easy process. Listen Learn Change and Living Life Well are complex change programmes. At times the balance of detail and the volume of evidence gathered has provided a density of information which is understandable to people involved in the work but has proved difficult for others to navigate and understand.

This work will be ongoing as there is recognition that how we collectively evidence what we do, what we've done and what we intend to do needs to be accessible, understandable but also have depth to evidence the work and its impact.

Are the actions sufficient to achieve the intended outcome(s):

Yes

Please briefly explain your response here:

We recognise that rebuilding confidence takes time but there is an absolute commitment through the LLC Leadership Group, Chief Officers and the Tayside Executive Partners as set out in Living Life Well to be accountable for the work required and the key role stakeholders have in the development of services in Tayside.

Evidence and Milestones:

Service action plans associated with MWC visits

Deanery/GMC Action Plan

Shared Intelligence Report – HIS, MWC and Deanery

Independent Oversight and Assurance Group Themed Visits:

• Initial Meeting
• Patient Safety
• Integration
• Workforce
• Culture

Revised membership of the weekly Listen Learn Change Leadership Group

Assessment of Progress / Achievement of Outcome(s) as at end-Sept 2022:

The Tayside Executive Partners assessment of the status of the 49 Tayside Recommendations will be complete.

The assessment will be underpinned by a range of evidence to include the documents, processes and feedback gathered that have underwritten the reported assessment of progress.

There have been high levels of engagement with the Mental Health Independent Assurance Oversight Group across the range of services and organisations that deliver mental health and wellbeing services across Tayside. This we believe reflects our commitment to improve mental health services, the quality and commitment of staff and the commitment, passion and energy of local communities to be central to this work.

RAG Status: Green

Any further action proposed:

Central to this work will be how we move forward with people across Tayside and shift our focus from delivering from recommendations to delivering a future focussed strategy underpinned by the needs of our local communities.

This will require support and infrastructure and an immediate action is to build the programme resource needed to take the work forward.

Finally, we wish to embed a learning culture which includes rigorous and systematic self-evaluation within and across services. This will be reported openly and include external / independent support and challenge into this. This will promote self-awareness, collective responsibility for performance across the whole system and ensure that leaders and decision-makers are well-informed about the strengths and challenges. We will build on the good practice that exists within our public protection arrangements as a model for this.