'Urgent action needed to restore trust in Tayside mental health services'

There needs to be urgent action to restore people's trust in mental health services in Tayside.

That is according to the final report from the independent inquiry into mental health services in the region.

The inquiry was commissioned by NHS Tayside in 2018 to examine the accessibility, safety, quality and standards of care provided by all mental health services in Tayside.

Five themes have emerged, which need to be addressed to improve services in the region.

They are: strategic service design, clarity of governance and leadership responsibility, engaging with people, leaning culture, and communication.

Inquiry chair David Strang said: "Over 1,500 people contributed to the inquiry's work. 

"I am grateful to everyone who gave evidence to the inquiry - listening to their voices has shaped the inquiry's approach.  Their evidence has been central to the findings and recommendations which we have published today. 

"The report's title, Trust and Respect, reflects the main conclusions of the inquiry - that there has been a loss of trust in mental health services in Tayside.  

"Trust needs to be rebuilt by treating everyone with respect. The active involvement of staff, patients, communities and partner organisations will be essential to building a new culture and approach to delivering services and treating patients in Tayside.

"The publication of this report provides an opportunity for Tayside to develop world-class mental health services, where the population are served with commitment and passion."

All 51 of Mr Strang's recommendations are laid out below.

1. Develop a new culture of working inTayside built on collaboration, trust and respect.

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

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.

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

5. Review the delegated responsibilities for the delivery of mental health and wellbeing services across Tayside, to ensure clarity of understanding and commitment between NHS Tayside and the three integration joint boards. This should include the decision to host general adult psychiatry inpatient services in Perth & Kinross Integration Joint Board.

6. Ensure that Board members (NHS 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.

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

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

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

10. Ensure that there is clarity of line management for all staff and that all appraisals are conducted effectively.

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

12. Conduct a national review of the assurance and scrutiny of mental health services across Scotland, including the powers of Healthcare Improvement Scotland and the Mental Welfare Commission for Scotland.

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.

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

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.

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

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.

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

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.

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

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.

22. Develop clear pathways of referral to and from university mental health services and the crisis resolution home treatment team.

23. Develop a cultural shift within inpatient services to focus on de-escalation, ensuring all staff are trained for their roles and responsibilities.

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

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

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

27. Provide adequate staffing levels to allow time for one-to-one engagement with patients.

28. Ensure appropriate psychological and other therapies are available for inpatients.

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

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

31. Ensure swift and comprehensive learning from reviews following adverse events on wards.

32. A national review of the guidelines for responding to substance misuse on inpatient wards is required.

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

34. Ensure that rejected referrals to Child and Adolescent Mental Health Services 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.

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 interdisciplinarity of the hub may give rise to confused reporting lines or line management structures/ governance issues. A whole system approach must be clarified from the outset.

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

37. Support junior doctors who are working on-call and dealing with young people’s mental health issues.

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.

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 in-patient services.

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/monitoring of services. This should be aligned to national reporting requirements.

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.

42. Ensure all 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.

43. Prioritise concerns raised by staff by arranging face-to-face meetings where staff feel listened to and valued.

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.

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.

46. Encourage, nurture and support junior doctors and other newly qualified practitioners, who are vulnerable groups of staff on whom the service currently depends.

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.

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.

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.

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.

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.

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