STARS IN THEIR EYES

When Worcestershire Mental Health Partnership trust got a zero in the 2004 star-ratings, things were looking pretty bleak. But belief and leadership have helped turn things around, with spectacular results. Emma Forrest reports Mental health trusts are used to challenges.

Their recent history includes mergers, demergers, primary care reorganisation and precarious finances. So when a trust is faced with a zero-star rating and a demanding Commission for Health Improvement report, what is it to do? Redevelop the whole strategy behind the organisation, of course.

'Challenging' is a much-used word to describe the trust's 2004 CHI report, which criticised its governance structures and said risk management and clinical audit systems should be put in place.

The report also said strategic and operational teams needed to work together and staff must be kept up to date with new systems.

Spend a day with the trust and it is clear from talking to staff that the report gave them a lot to think about, even though by the time it was published they had an idea of what it would contain. Some describe falling from two to zero stars as a 'shock', but it made the trust chair and non-executive directors realise there was a gap between staff and the trust board.

With the departure of its former chief executive in August 2003 and the return of former acting chief executive Dr Ros Keeton around a year later, Worcesterhire Mental Health Partnership trust was in a position to identify what chair Jim Calvert calls 'principal concerns'.

The aim was to 'put in place the right organisational structure, the right people in key jobs and basic human resources good practices, ' says Mr Calvert, whose professional background is in personnel management. 'Unless we got the right calibre of people to provide leadership at all levels, with the best will in the world we would not achieve the right structure.' The trust reaped the reward this year as its Healthcare Commission rating jumped from zero to three stars, one of only three trusts to achieve the leap in 2005.

Dr Keeton makes it clear that while the 2004 CHI review was 'disappointing', it provided the impetus for future improvement. 'It gave the board a good overview, and gave us a lot of objectives to work towards. By the time I got here we had a lot of information. We may not have wanted to see a lot of it, but it was useful to have a clear picture, ' she says.

It also followed several years of upheaval as local services were reorganised. 'Until primary care trusts arrived [in 2002] we were a community and mental health trust. We went from employing 4,000 to 1,400 people, from 80 to 45 sites, and a major reduction in turnover, ' says Mr Calvert. 'It was a major distraction.' Changes clearly needed to be made. 'We were fortunate, ' adds Mr Calvert, 'in having a strong non-executive team who, bar one, have been here as long as I have. As a board we needed to get basic building blocks in place in three key areas;

corporate governance structure, partnership and leadership.' Partnership had been a thorny issue. The trust provides mental health and learning disabilities services and has some shared appointments with social services. But it admits personality clashes and poor relationships resulted in a strained partnership in the past. Relations are now described as 'hugely better', with agreements on joint initiatives. Staff share premises wherever possible.

'In terms of true integration with social services, there was not a great deal to see considering that you cannot pull them apart in these services, ' says Dr Keeton. 'That has now changed.' 'This building we are sat in [Studdert Kennedy House, which was jointly funded, opened last August and houses community mental health services, mental health and social services staff] is a feature of that, ' adds Mr Calvert.

Leadership is a contender for the most repeated word of the day. Mr Calvert and Dr Keeton say that in the past the performance of the organisation was seen by too many staff as something that only the board had to worry about. Mr Calvert recalls when, shortly after the trust was given zero stars, a board member told him how on a visit to a site a senior nurse had come up to them and said how sorry she was about the star-rating.

'It was seen as an issue for the board, not an organisational issue. This time, people are sharing in with the celebrating.' Both Dr Keeton and Mr Calvert, who last year travelled 8,000 miles on visits to each of the trust's sites, emphasise the importance of them remaining 'earthed' in the grass roots of their organisation.

'Success should be owned by the whole organisation. You cannot provide clear leadership if you are not physically recognised. Getting out and about can be time-consuming; we cover 650 square miles and have 48 sites. Some of them may only have four beds but they are all equally important, ' says Mr Calvert.

Implementing the ethos that improving the organisation is a team effort has been a gradual process. 'At every stage we ensure we choose people with leadership abilities or potential.

Nothing matters more than the quality of the people in charge.' Central to this has been the organisation's board which has experienced a number of new appointments. Sitting with medical director Dr Steve Choong, head of learning difficulties for health and social services Stephen Chandler and director of integrated mental health services Colin Vines, is director of modernisation and nursing Jan Ditheridge. She points out that most of them could still be counted as new, having been in post for 18 months or less.

Many middle management positions have also seen a change in personnel, with some new posts created (see box, right).

Mr Vines acknowledges that any service will have 'middle of the road people in it, but you have to think about where to put your stars'.

'We had a lot of challenging work to do in the beginning.' The development of generic leadership skills for the trust's medics and supporting new ways of working is the responsibility of Dr Choong.

'We want our medical students to be better prepared for the real world, for consultants to realise that they do not need to see every single patient.

'As ever, consultants are the most resistant. But they will see that the nurses are working differently, that posts such as nurse practitioners are being created, and that they cannot live in a vacuum. Change can be self-stimulating, ' he says.

Dr Choong says public perceptions of mental health can make practitioners overtly risk averse.

'Change in mental health can make people nervous because if something goes wrong you are going to end up on the front page of a newspaper.

We have provided a forum where new ways of working can be agreed and discussed, ' he says.

Risk management is also now included in the organisation's service development plan (see box, left).

'There is a myth of fear around taking risks. We need to create an organisation where people can take risks and let our clients lead more fulfilling lives, ' says Ms Ditheridge.

The trust's glory at obtaining three stars will necessarily have to be short lived, as star-ratings are next year by the new Standards for Better Health.

And when asked what still needs to be done, it is clear that relaxation is not on the list. Dr Keeton and Mr Calvert provide a long list.

'Mental health commissioners still do not have a high-enough profile. It has improved but there remain significant questions about the clout they have, ' says Dr Keeton. Both she and Mr Calvert agree that raising the local and national profile of mental health is crucial to reducing the stigma still attached to mental illness.

'Ministers are not going to do it for us, and if we do not address how mental health is viewed, why should anyone else?' says Mr Calvert.

The future holds more questions. The trust is the only specialist mental health provider in its local strategic health authority patch.

And the future of its commissioning PCTs, which also provide mental health services, is uncertain.

'The biggest challenge for us now is jointly deciding what organisation we should have.

Should we merge with a specialist mental health trust? Should we be taking on provider services from PCTs? What about foundation status? All these developments form our largest challenge and will all happen sooner rather than later, ' says Mr Calvert.

Key points

In 2004, Worcestershire Mental Health Partnership trust got zero stars and a damning report from the then Commission for Health Improvement.

The resultant improvement strategy focused on promoting group ownership of organisational performance and ensuring that high-calibre leaders were in place to drive changes.

In the final round of star-ratings, Worcestershire became the only mental health trust in the country to go from zero to three stars.