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

Culture and Engagement Work Plan

183. It is no coincidence that Dr Strang made culture his first recommendation. In fact he went further: he saw the need to develop a new culture of working within Tayside built on collaboration, trust and respect, as being fundamental to the successful delivery of all subsequent recommendations.

184. Engagement doesn't happen in a vacuum. The quality of any engagement is influenced by the relationships between those who are engaging. That may appear to be self-evident, however in Tayside there needs to be a greater focus on building relationships and in some instances, how certain relationships may need to be rebuilt.

185. An organisation's culture expresses its goals through values and beliefs. It shapes attitudes and behaviours, and its cultural norms define what is encouraged, discouraged, accepted or rejected. It is a notoriously challenging concept to manage and subsequently to measure, but all of this is possible, if you have a plan.

186. Early in our work, we shared with Tayside Executive Partners our view that we did not consider the actions they proposed as being sufficient to meet the outcome they wished to achieve. We suggested they take the opportunity to reset this agenda. However, in their February 2022 assessment, Tayside Executive Partners advised that they had a plan which they had assessed, adding that culture change is only possible over a longer term.

187. We accept that culture change is a long-term endeavour, a point made by Dr Strang in his Progress Report. But it is also important to have mechanisms in place to know you are on the right road and that your actions are having the intended effect. As things stand, we have not seen evidence of a clear strategic plan to develop the culture of mental health services across Tayside, and further, there is no baseline against which Tayside Executive Partners can measure progress.

188. This work plan brings together 15 recommendations from Trust and Respect and there is some overlap with the work plan on Workforce. We have valued the discussions we have had with Tayside's Integrated Leadership Group on this and other recommendations relating to culture and engagement. We appreciated their openness and their preparedness to look beyond the work they had done to date, to address culture and to take forward the actions now required to support a culture built on collaboration, trust and respect.

Recommendation 1

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

Context of Oversight Group assessment: Trust and Respect called for a radical new approach to restoring and building trust. There has been no clear strategic plan to develop the culture of mental health services across Tayside, nor a baseline against which Tayside Executive Partners could measure progress.

189. Tayside Executive Partners, in their final submission, have pointed to a broad range of activity they have led in support of cultural change. This has included organisational and workforce development, new forums for collaboration, greater flexibility in practice and award winning services with teams achieving national recognition for their work. Tayside Executive Partners, however, also recognise these actions are not sufficient to achieve the intended outcome and acknowledge that further modelling of respectful and trusting behaviour is needed and that there is still much work to be done.

190. Tayside Executive Partners have set out a number of further actions they will take, including developing a values and behaviours framework, creating more opportunities for learning, capacity building and leadership development, and undertaking systematic surveys to understand experiences and views, and acting upon them. These are all positive developments and are to be welcomed.

191. The new actions proposed in response to this recommendation are focused on workforce and the individual organisations. There is one proposed action, designed to: "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". Beyond that, the response to recommendation 1 is light on how culture change will build the trust and respect experienced by patients, families and communities.

192. Trusting and respectful relationships underpin how we serve the public. Dr Strang's comments on the need for culture change were not confined to responding to concerns expressed by employees, crucial though that is. He pointed to citizens feeling they were not listened to, or worse, that they were not respected or taken seriously, adding that they saw a gap between the stated values of the organisation and the behaviours they observed.

193. We have heard that too. That is why it is important that the values, qualities and behaviours Tayside partners promote for mental health services are relevant and relatable to the communities of Tayside, and recognisable from the experiences citizens have of mental health services.

194. Tayside Executive Partners have been reflective in respect of the progress they have made on this recommendation. We welcome their candour and recognise the increased scope of their actions in support of culture change. They do need to go further, however, to ensure the mental health service they seek to become, reflects the values and aspirations of the communities they serve.

195. The Oversight Group RAG rate this recommendation as Amber.

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.

Context of Oversight Group assessment: There is a plethora of activity in relation to this recommendation, through working groups and project boards. However, much of it is fragmented with no real sense of people working together on shared priorities. There is little strategic oversight of progress or of the need to maintain momentum on Trust and Respect and Living Life Well.

196. Recommendations 3 and 4 are similar in their purpose and focus. They concern the engagement of all stakeholders in the planning, scrutiny and improvement of mental health services. This is reinforced by Tayside Executive Partners having the same intended outcomes for both of these recommendations. It is also noteworthy that in their final submission, Tayside Executive Partners have now assessed their own progress as being Amber, rather than Green.

197. Tayside Executive Partners consider stakeholder engagement to be well embedded within the strategic and commissioning processes within the 3 Health and Social Care Partnership areas. We agree with this, but we also think there are areas where this can be strengthened. In this respect, the forthcoming assessment of current capacity and resources devoted to the engagement and involvement of people with lived experience of mental health services, is a very welcome action.

198. The development of Living Life Well involved engagement with significant numbers of communities and partner organisations: there was a high level of expectation from stakeholders that change was going to be possible. However, we have expressed concern over the 'industry' which appears to have grown around the implementation of this policy. As we have said, it involves numerous work streams and change projects. We have witnessed staff 'running to stand still' and heard from community members who feel that although they have a seat at the table, their voice is too often not heard.

199. For citizens to be meaningfully engaged, they must feel that their involvement and the contribution they make means something. Many have told us that's not how they feel.

200. We believe this is in part due to the sheer scale and breadth of activity that staff are being asked to take forward to advance Living Life Well. This is addressed elsewhere in the report. We therefore welcome the forthcoming actions set out in a joint report from the Perth and Kinross Chief Officer and the NHS Tayside Executive Director of Nursing, approved by Perth and Kinross Integration Joint Board and Health Board respectively, to review the governance structures and evaluate current work streams for Living Life Well with a view to their re-prioritisation. This is an encouraging and much needed step.

201. The way people work together is key to the delivery of this recommendation. The Stakeholder Participation Group, and other Third Sector Organisations, have told us about being invited to meetings, often with little notice or advance details of the business to be considered. The Stakeholder Participation Group tell us they presently sit on 14 project boards and working groups which is clearly unsustainable. The proposed reprioritisation needs to involve all stakeholders and focus on what matters most to them.

202. Tayside's joint new Communications and Engagement Strategy is a very good communication plan. However, it is quite transactional in the way it sets out processes: it needs to focus more on the development of relational practice. We have seen many excellent examples of this including day services in Perth and Kinross, peer support in Angus and the engagement of people with a learning disability and people with a learning disability and autism, in Living Life My Way In Dundee. Different places and different people, but the common thread is the development of trusting and respectful relationships. We valued the discussions we were able to have with the Integration Leadership Group on this matter and welcome the attention this has now been given by Tayside Executive Partners, in their final submission.

203. Trust and Respect highlights the need for staff to be heard and to have the opportunity to contribute to service development and decision making. In all of the settings we have visited, both inpatient and community, we have met with staff who are deeply committed to the people they care for and to the delivery of safe and effective mental health services. Staff, however, have shared with us their feelings over what they see as "reviews upon reviews" over the years, with little sustained action or evident improvement. These views were expressed strongly in relation to the lack of progress on single site proposals for inpatient mental health services.

204. Tayside Executive Partners recognise the need to work with Staff Side colleagues to improve consistency in partnership working. Proposals for the Perth and Kinross Chief Officer and the Employee Director, together with fellow Chief Officers, to revise and refresh governance and decision-making routes in support of system-wide transformation, are to be welcome. Whilst Area Partnership Forums are well established, it will be important for colleagues, looking to improve consistency and partnership working, to create the right environment where there can be broad engagement and staff feel able to bring forward and develop ideas for change.

205. Towards the end of our engagement with Tayside Executive Partners, we benefitted from meeting with the new Chair of the Area Clinical Forum who is also a Non-Executive NHS Tayside Board Member. The Chair brings a wealth of experience to his new role and is clear about the contribution clinicians need to make to the planning, improvement and scrutiny of services across Tayside.

206. The final point to be made here, is on the importance of Tayside Executive Partners now building upon the revised Integration Schemes. There is an opportunity to reset the agenda and to revise working and reporting arrangements. This should include Integration Joint Boards and the Health Board, determining how they will hear the voices of people with lived experience and secure the skills and talents of all stakeholders in the planning and improvement of mental health services.

207. The Oversight Group has assessed this recommendation as Amber.

Recommendation 4

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

Context of Oversight Group assessment: Have local stakeholder groups been established and supported, and to what extent have they been able to undertake scrutiny and contribute to service improvement.

208. There is a wealth of organisations across Tayside who seek to promote mental health and wellbeing. These organisations provide a breadth of activities and supports within their local communities including information and advice, counselling, advocacy, community care and crisis support, social activities and opportunities for companionship. In the course of our engagement, we have sought to meet with as many of those organisations as possible. We have also met with the Stakeholder Participation Group on a bi-monthly basis and they have continued to be a valued and trusted point of reference and an important source of challenge and support.

209. The Stakeholder Participation Group came together as a result of Dr Strang's call for evidence during the Independent Inquiry. The Stakeholder Participation Group was supported by The ALLIANCE and members made a significant contribution to the Independent Inquiry.

210. At that time, over 50 people participated in those early meetings. The Stakeholder Participation Group has a wider network and around 20 people have remained members of the group. All have experience of mental health services: some people presently receive support from mental health services; others have been patients; some are parents and relatives who care for a family member who presently receives mental health services; others are parents and family members who have been bereaved through suicide; and finally there are people who tell us they have had poor outcomes which continue to impact upon them. What members of the Stakeholder Participation all have in common, is a desire to see better mental health services in Tayside.

211. Following the Independent Inquiry, the Stakeholder Participation Group has been an active participant in the formulation to Tayside's new mental health strategy, Living Life Well. Despite a high level of involvement in working groups and project boards, the Stakeholder Participation Group has told us they don't have a sense of belonging and don't feel that their voice is heard.

212. In 2021, four independent organisations that work to promote mental health and wellbeing, conducted a survey to find out how service users felt about the quality of care they had received from NHS Tayside Mental Health Services. The organisations were Plus Perth, Angus Voice, Dundee Healthy Minds Network and the Stakeholder Participation Group.

213. In response to the survey, 403 people who use mental health services expressed their views. The results were published in "Listen - Experiences of NHS Tayside Mental Health Services". The findings helped to inform Dr Strang's Progress Report. He commended the survey team on the quality of their analytical work and report writing, as do we.

214. 'Listen' is a hard but instructive read. Many of the service users who responded praised highly skilled and compassionate individuals and teams working within mental health services. But negative comments outweighed positive comments by more than 5 to 1. Emergent themes included poor response to suicide risk, excessive waiting times, absence of follow up and people being unsupported in times of heightened risk. Overall, the percentage of respondents describing Tayside's mental health services as excellent, very good or good, fell from 58% to 36% over a four-year period.

215. The 'Listen' report made a number of recommendations for NHS Tayside and whilst the Board acknowledged receipt of the Report and invited the survey team to present and discuss their findings at a Board Development Day, we are to understand that there has been no formal consideration of the Report by the Board or response to the recommendations. Tayside Executive Partners have advised the Oversight Group that the 'Listen' report was submitted to all 3 Integrated Joint Boards.

216. Tayside Executive Partners have advised that the concerns raised within the 'Listen' report were checked against commitments in all areas to ensure that any raised within 'Listen' were being progressed within existing plans. There was however, no formal response to that effect to the organisations who had sponsored 'Listen' or to the report's authors. Importantly, there was no public visibility of this in terms of oversight and governance. We consider this a missed opportunity by the Health Board and also the Integration Joint Boards to demonstrate that they are indeed listening, learning and changing, in the way they serve their communities.

217. Tayside Executive Partners have never met collectively with the Stakeholder Participation Group, something we have encouraged them to do. Tayside Executive Partners point to the importance of listening to feedback from present day patients and we agree with them. We have heard views expressed that the Stakeholder Participation Group's experiences are in the past. This is incorrect. For the majority of members, either they or their families have current experiences of mental health services. However, for all members of the group, even where there are historic cases, the impact of what happened to them or to their relatives, in the absence of change and improvement, continues to be their reality.

218. We welcome the commitment within the final submission from Tayside Executive Partners to bring together senior officers, members of the Stakeholder Participation Group, along with others who bring a valuable contribution of lived experience, to consider how engagement and co-production will work in the future, both locally and Tayside wide. Tayside Executive Partners also point to the need to work with their local networks and the Stakeholder Participation Group within an easily understood overall agenda. The intention by Tayside Executive Partners, as an immediate next step, to share their submission and coordinate a set of conversations with local stakeholders is an important one, which will undoubtedly assist in resetting and rebuilding relationships.

219. There are of course many other organisations in this space and colleagues in Tayside have set out within their final submission how they intend to build on present arrangements, with a particular focus on Integration Joint Boards and the effective implementation of their revised Integration Schemes. This provides an opportunity to ensure that there is the widest possible engagement with stakeholders and that they, in turn, feel their contribution is valued and their time is well spent.

220. Given the distance still to be travelled on this recommendation, we assess progress as Amber.

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.

Context of Oversight Group assessment: The need for citizens across Tayside to receive seamless person-centred care when their needs are changing rapidly and for that support to continue back in the community, when the moment of crisis has passed.

221. In Tayside, the Crisis Resolution Home Treatment Team delivers a 24-hour service 365 days of the year, to people experiencing an acute mental health crisis so severe that, without intervention from the service, the person would require hospitalisation. The service covers all of Tayside.

222. The operational protocol in place for the Crisis Resolution Home Treatment Team states that "the multidisciplinary team will provide an alternative to acute hospital admission by providing emergency assessment and intensive intervention within the community. The team will act as the single point of access to all inpatient mental health admissions. Where hospital admission does occur, the Crisis Resolution Home Treatment Team will assist in providing intensive home treatment to support early discharge back to community living".

223. Healthcare Improvement Scotland made a number of recommendations in respect of these services in their Review of Adult Community Mental Health Services 2020. In their update to Healthcare Improvement Scotland in March 2021, NHS Tayside reported "The Crisis and Urgent Care Pathway Redesign Group have recommended a preferred option for a radical redesign of the current home treatment, urgent and crisis care provision carried out by the Crisis Resolution Home Treatment Team. This option includes commissioning a third sector provider to operate community mental health hubs linked to clinical professionals". Progress on the community hubs has been extremely slow in all 3 Health and Social Care Partnerships, with not one yet operational.

224. The recommendation made by Dr Strang focuses on relationships, and Tayside Executive Partners acknowledge that 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. There is evidence that revised protocols have been developed to support admission to hospital and discharge back home. Job shadowing arrangements to promote a better understanding of respective roles and responsibilities have also been put in place, as has a tool to measure collaboration levels between Community Mental Health Teams and the Crisis Resolution Home Treatment Team.

225. In their final submission, Tayside Executive Partners recognise that more work needs to be done on the relational component of this recommendation and point to a number of further actions they propose to take. We agree with this assessment and welcome the steps proposed.

226. From our work in Tayside, however, we believe the scope of the original recommendation is limited, in respect of the present-day challenge. Community and crisis services need to be developed as part of a whole system and not as separate entities. We believe more needs to be done to ensure that ward staff are aware of the roles and responsibilities of the various home treatment and 7-day services across Tayside. The revised Integration Schemes again offer the opportunity to ensure that the services in scope here - namely inpatient, crisis, home treatment and community - are fully integrated to best serve people across Tayside.

227. Finally, there is the need to know the impact all of this is having and the difference it is making for people at times of crisis in their lives. Dr Strang pointed to the need for Community Mental Health Teams to know their local areas well and for Health and Social Care Partnerships to seek to empower communities to develop local services to support early intervention and the prevention of more complex mental health issues. We have been inspired by many of the community led responses to mental health and wellbeing we have seen, and encouraged by the work of local teams to better understand need and complexity so that people get the right help when they need it. We refer to this in our assessment of Recommendation 17.

228. The Oversight Group has assessed progress against this recommendation as Amber.

Recommendation 24

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

Context of Oversight Group assessment: The importance of involving families and carers in end to end care planning and the extent to which these arrangements meet the needs of patients and their carers.

229. NHS Tayside's Person-Centred Care Planning Standards were reviewed in July 2020 and updated in March 2022 to include a new standard that will evidence relative/carer involvement and the existence of an agreed communication plan. These standards apply to all settings.

230. This work is aligned to the Triangle of Care and the local planning group has representation from carers groups from each of the Health and Social Care Partnerships and the national lead from the Carers Trust.

231. Tayside Executive Partners have told us that they have robust quality control processes in place to monitor levels of compliance with the standards. This includes regular patient experience data which provides information on patient engagement in the care planning process which has routinely been reported to the Health Board since implementation in 2021. This endeavour is to be commended. It is noteworthy, however, that in the report to the Health Board meeting in August 2022, just over 40% of patients reported receiving their care plan and only 50% could say that they were involved in their care plan development. These figures have been broadly static throughout.

232. Tayside Executive Partners point to monthly auditing activity, along with care planning audit data being a standing item on the Local Care and Professional Governance Meeting agenda.

233. Tayside Executive Partners have identified a number of further actions including revisiting the standards and arrangements for gathering feedback from carers and families and testing of new care planning modules within general adult psychiatry. We have RAG assessed this as Amber.

Recommendation 25

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

Context of Oversight Group assessment: The extent to which clear information has been produced for patients, families and carers on admission to inpatient settings, in ways that it is understood and remembered.

234. Tayside Executive Partners have told us that patient and carer leaflets have been developed and are provided on all wards. Leaflets have been tested in Carseview and Murray Royal wards and are being disseminated to other inpatient wards. We have been provided with the suite of leaflets in use within mental health inpatient settings and it is clear that patients have been consulted on the information they would find it helpful to know upon admission. We have not seen what patient information is available in respect of admissions to learning disability settings.

235. We have also had the opportunity to learn about the arrangements in place when a young person is admitted to CAMHS inpatient facility at Dudhope. This includes a welcome meeting for the young person and their family, along with an information pack and appropriate signposting to support organisations.

236. We have already made mention of the arrangements that have been put in place to hear from people cared for in inpatient wards. It will be important to know that information available to people at the point of admission, continues to be relevant and understood. We note that a working group has oversight of these arrangements including the need to implement any best practice suggestions. In our discussions with some families, they have told us of their concerns over the lack of information they have had when a family member is admitted to inpatient care, including how they can best support their recovery. In the existing patient leaflets, the significance of family and friends is highlighted and patients are reminded that family and friends can play an important part in their recovery but that their involvement in their care and treatment, is a matter for them. It may be helpful for the working group to reflect on the information that is given to families upon admission of a family member to inpatient care, to ensure they are aware of the choices patients have and how they can best support them. Tayside Executive Partners should ensure that inpatient services have in place suitable information in respect of admissions to learning disability settings. The Oversight Group has RAG rated this as Green.

Recommendation 50

Ensure there are mediation or conflict resolution services available within mental health services in Tayside. These services should exist to support and empower staff in the rebuilding of relationships between colleagues, between managers and their staff, and between the services and the patients, during or after a period of disharmony or adverse event. This includes NHS Tayside's mental health services' relationship with the local press.

Context of Oversight Group assessment: We recognise that this recommendation covers several aspects, but at its heart it is about Tayside being able to rebuild relationships between staff, families and the wider community when things go wrong.

237. The Tayside Executive Partners' submission quite reasonably points to the revised process for undertaking Significant Adverse Event Reviews as part of the evidence of this recommendation. We report our assessment on Significant Adverse Event Reviews under Recommendations 11 and 31.

238. We recognise the work that Tayside has undertaken to better understand, and rebalance, the way in which Tayside services are reported in the local media. Local scrutiny via the media is a critical and valuable part of accountability in delivering public services and Tayside has worked hard at shifting the perception locally.

239. There is an established mediation service in NHS Tayside to help resolve internal staff disputes and conflict resolution. The Tayside Executive Partners' submission does not give any indication of how well this service is used.

240. However, there is no evidence of Tayside having responded to the final element of the original recommendation, namely a mediation service that helps rebuild relationships with families and carers. The revised Significant Adverse Event Review process may go some way to mitigating this risk, assuming it is always implemented effectively. But, it still falls short of what was envisaged in the original Trust and Respect report.

241. Relationship breakdown, however, is not limited to issues surrounding Adverse Events difficult though they may be. Relationships fail when there is a poor communication, a lack of understanding and the failure to follow through on commitments made. This leads to a breakdown in trust and respect, something we have heard much about from people who have talked to us, including families and those who have a stake in mental health services.

242. Tayside Executive Partners should satisfy themselves that the responsible authorities consider the need for independent mediation to be utilised in circumstances where relationships with families and stakeholders need rebuilding.

243. For this reason, the Oversight Group's assessment remains Amber.

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.

Context of Oversight Group assessment: The extent to which external review is embraced and staff are aware of all reviews thereafter, including findings and recommendations and are included in analysis and the development and implementation of any action required.

244. The action required in response to this recommendation is twofold. The first is relatively straightforward - a system needs to be put in place to ensure there is awareness of any external reviews being undertaken and the results require to be publicly reported including decision taking, on any improvement action required. The second requirement is about creating and promoting a culture that is open to learning and change, where staff are encouraged to be reflective and feel safe to talk openly or to think about doing things differently.

245. The final submission from Tayside Executive Partners is very thoughtful in respect of their assessment of the underlying issues which gave rise to this recommendation. Colleagues recognise that a theme running through the Inquiry Report and the Progress Report, was that external reviews were not seen as an opportunity for collaborative learning and service development. Tayside Executive Partners acknowledge external scrutiny as being a vital aspect of their ongoing quality assurance and improvement journey and further, that welcoming independent scrutiny and inspection, is a hallmark of a partnership that is striving for excellence, public accountability and service improvement.

246. In their summary of action taken, Tayside Executive Partners point to the arrangements put in place for receiving externals reviews and inspections and the reporting of findings and any recommendations. We recognise this from our work in Tayside, but it does need to be more visible and systematic. We also think that standard reports would bring a level of consistency and also reduce workload.

247. Turning now to the 'authorising environment' and the extent to which staff feel able to talk freely and openly question existing practice. Tayside are on a journey and they recognise that. We have witnessed high levels of staff engagement around elements of change and improvement with local ownership clearly evident and staff confirming that they consider their voice to be heard, and their contribution to service redesign is welcome. However, we have also observed a level of defensiveness on occasion and a tendency to point to good practice when hearing about any negative experiences of a service, when both can equally be true. Care and constancy in communications by leaders is vital to the development of a learning environment where staff feel that change is possible.

248. The Oversight Group has assessed this recommendation as Amber.