By Julie Meikle, Director of Quality at St Andrew's.
As former Head of Hospital Inspection at the Care Quality Commission (CQC), I’ve seen first-hand the challenges which exist in the mental health sector. Some of the fundamental issues have been written about time and time again: funding challenges, the delayed discharge of patients from secure care, and the increasing use of restrictive practices.
But for providers to really move forward and invoke positive change, quality must be put at the heart of every service and this is something I have spent the last 15 years promoting. It was for this reason I took the opportunity to move on secondment to St Andrew’s – a provider who has known challenges and been struggling for several years - and take up a role as the new Director of Quality.
My move prompted criticism in the Twitter sphere, with some questioning how I could work for such an under-fire mental health service. But from my perspective, in order to help invoke positive, sustainable improvements I must be part of the solution, and not just refereeing from the side-lines.
Since joining St Andrew’s two months ago, I recognise there are problems to overcome, however I can see the green shoots of recovery emerging, which is partly down to a commitment and openness from the senior leadership team to make changes.
St Andrew’s, founded in 1838, is the UK’s largest charitable provider of mental health. It offers specialist care for patients with exceptionally complex mental health needs. Patients are often admitted once they’ve been through the NHS system and have nowhere else to go.
But it got too big too quickly. In 2017, a 110-bed Child and Adolescent Mental Health (CAMHS) unit, the largest in Europe, was opened under the previous management, and St Andrew’s was accepting the most seriously ill patients, while NHS beds were being decommissioned. Parts of the Charity became too heavily reliant on a temporary workforce in order to staff wards, and as a result the quality of care it was providing was not of a high enough standard.
There is a now a new clinically-led, senior leadership team who are focussed on rightsizing the Charity and taking it in a new direction. The Chief Executive, Katie Fisher and the Deputy Chief Executive, Jess Lievesley, have both had extensive NHS experience and are committed to making changes which will support the charity’s overarching purpose – to promote recovery and give hope.
An organisational restructure means the Charity is now more aligned to that of an NHS Foundation Trust, with clinical divisions instead of the previous and somewhat complicated 16 separate business units. Each division mirrors peer-NHS organisations using a power-of-three leadership model, well established in many organisations and critical to delivering sustainable change. Staffing levels and staff not having the right values are being addressed by reducing the number of patients cared for, as well as holding employees to account if their values don’t align. There has also been an active drive to reduce restrictive practices, with both restraint and seclusion levels falling since the start of the Coronavirus pandemic, whilst other providers have documented an increase.
But turning a tanker in such a complex ocean of health and social care need is no mean feat, and is certainly not something which can happen overnight. In order to help the mental health system as a whole, St Andrew’s and other mental health providers must continue to inject strong leadership in order to fix the system. As beds are reduced- supporting the policy direction across the UK- this will ultimately leave a gap in the system, which NHS commissioners will be required to fill.
Historically, decommissioning plans which have made local systems more efficient, have not always supported the wider jigsaw puzzle of need across the whole population and this has placed commissioning responsibility for some people with highly complex needs in the grey area between Local Authorities, Clinical Commissioning Groups and NHS England. But it’s these grey areas which have led to the most vulnerable in our society falling through the gaps, often with no place to go. It is often in circumstances like these where providers are criticised- even where the solution is not within their gift- to facilitate the appropriate move. In these circumstances, people would be right to say the ‘system’ is letting them down.
This can no longer be the case. Going forward, instead of working in silos, there must be a much more joined up approach from providers, regulators and commissioners to work together to fix this issue, so that those most vulnerable in society are given the best possible care.
The current pandemic has tested the UK healthcare system like never before and in particular has laid bare challenges that have existed for many years regarding pathways of care, particularly where this crosses funding streams. We must all be ready for a spike in demand for mental health, which will put the system under even more pressure. But by working together, sharing concerns, as well as areas of good practice, we can and must emerge stronger.