Published: 14/10/2004, Volume II4, No. 5927 Page 30 31 32
The last round of star-ratings hit mental health trusts hard. Emma Forrest paid one a visit to find out how it intends to recover from the blow
'Welcome to a zero-star trust that is not a zerostar trust, ' announces Suffolk Mental Health Partnership trust strategy director Martin Royal, meeting HSJ off the train for a day with the organisation.
Mr Royal is not being deliberately obtuse, but rather expressing the disappointment that met the trust's recent star-rating - it failed largely on technical issues (see box, opposite). Chief executive Mark Halladay - at the time of HSJ's visit only two months into the job, having joined from the now-defunct New Possibilities trust in Essex - knows that it is not the most auspicious of starts. But he does not want the trust to be tagged with its star-rating alone. 'I was pretty angry at first. But I do not want to dwell on it. I want to make a difference.
I am not ashamed to smile in the face of adversity and I am good at keeping people's heads up, ' he says.
The trust has already had to overcome a somewhat tainted reputation.Mr Halladay is frank about its historically poor relations with other trusts and agencies. 'Primary care trusts, the health authority, patient and carers' groups - you name them, we'd alienated them. I think we are well on the way to changing this; a lot of people have left and a lot of relationships have improved.'
A series of surgeries with the chief executive for staff, carers and service users is taking place across the trust in a bid to improve communication.Mr Halladay also intends to meet every team in the trust over the next 18 months.
At one of the meetings a community mental health team (which did not want to be identified) spells out the difficulties of its daily practice. 'As clinicians we are very good at muddling through because We have had plenty of practice, ' says one community psychiatric nurse. 'But We are tired of it.Often There is only one doctor to contact so with clients it becomes a medical situation. There is not enough provision for therapies.'
Mr Halladay agrees with this last point, but is at a loss to answer; therapies of all types are in short supply across the trust. Other problems are discussed: there is no triage mental health team present at night at Ipswich Hospital's accident and emergency department.
'A new crisis team might at last be based in A&E at night and should alleviate some of that pressure. But we are at least eight to 10 months away from that, ' he tells the team.
There are also no inpatient or out-of-hours services for child and adolescent mental health service (CAMHS) provision. 'Children are not allowed to be sick after 4.45, ' says one nurse. The only nearby provision for inpatient CAMHS is in Cambridge and even further out. It has been known for an adolescent to be found a bed in an adult inpatient unit for the night in the case of an emergency.
The quality of inpatient settings at the trust varies widely. There are some specialist units (see box, overleaf ) providing high-quality accommodation. St Clement's, the area's original asylum and an impressive 19thcentury building, now contains the offices of a local PCT, most of the wards having been closed.Of the two that are left, both provide continuing care for long-stay patients.
'This is really social care; there is a constant argument with social services over who should fund such services, ' says Mr Royal. 'Effectively it is a case of delayed transfers of care. There are punitive funds to sort some of those out, but they only apply to acute services.We need to get the right care package in place for these clients before these wards are closed.'
Most inpatient care is provided in single-storey blocks built eight years ago to house patients who used to be in unsuitable St Clement's wards. Nearby is an intensive care unit, which is the subject of a debate with the trust's commissioning PCTs, which say it should be treated as a psychiatric intensive care unit (PICU).Mr Royal insists that it does not have the staff levels or security in place to be treated as such.
'Calling it a PICU now is a misnomer. If we have a high-dependency patient they have to go out of the county. The unit has dorms whereas it should have single bedrooms.We have to put in place the right processes and right people to be able to have an effective PICU, ' argues Mr Royal.
Modern matron Tim Smith, who oversees two acute inpatient units, the PICU and the trust's assertive outreach team, agrees that the PICU looks much the same as the trust's other acute wards. 'There is no sign of any additional security on our intensive care unit.'
Even an untrained eye can see that it lacks the high fencing common to most PICUs.
Work has been done to try and improve patient care.At the acute units, Mistley and Playford, rooms are singlebedded and each has a female-only sitting room.After user surveys found that people were bored in the evenings and at weekends because occupational therapy activities stopped at five, the activities programme was extended. There is a new garden, planted by clients, and the smoking rooms have been made as uncomfortable as possible; at Mistley it is a conservatory with no furniture.
But there are still problems.Mr Smith shows HSJ around Playford, a 24-bed rabbit warren. It is a hot day, but neither of the two wards are air conditioned and the requested fans have not turned up. In winter it is cold.
More worryingly, maintaining levels of care is an ongoing concern.
'The units are divided between sexes but that can be difficult to maintain because of high turnover of service users.We have a bed occupancy rate of 110 per cent and the length of stay is two weeks because there is not the capacity for people to stay longer, ' says Mr Smith.
Poor accommodation can also be found at the top.
Directors' offices are housed in prefabs that in winter will have water streaming down the walls. 'You can't even open the window because if you lean on the panes, they will fall out, ' says Mr Royal.
Mr Halladay says executive offices are at the bottom of his list of priorities - accommodation for patients is much more important.Mr Royal agrees: 'You felt how hot it was on the wards.How can we complain about our offices when they are like that?'
By 2007-08 it is hoped that a business plan now being worked on will have provided a£29m boost for trust accommodation. Sites being considered include St Clement's or the old Ipswich Hospital site. The sale of land surrounding St Clement's would help fund the move but selling the building itself would mean having to find new homes for the trust and PCT.
'A new build will have fewer beds because by then the community services that we will have in place will mean we will not need as many inpatient places as we have now.
It should meet the needs of the population until 2020, ' says Mr Royal.
Although Mr Halladay claims that financial arrangements with Suffolk Partnership's PCTs have improved ('because they trust us now'), pressures remain. The region is facing a deficit of£4-5m, and mental health has been told it has to play its part in reducing the burden. One of its PCTs has asked the trust to make savings of£700,000. Negotiations are ongoing about what cuts have to be made.
'Next year is going to be even more difficult; we might be looking at having to make savings of£1.2m along with a very difficult cost-efficiency target, ' says Mr Royal.
Deciding where to invest what funds there are seems terribly difficult. There are numerous recruitment issues to tackle. In addition to a lack of therapists, there is a severe shortage of psychologists. The trust should have six learning disability psychologists. It actually has one-and-a-half in post.
Meanwhile, Mr Royal says that locum costs for psychiatrists are crippling the trust, which currently has eight psychiatrist vacancies. To top it all, a third of the trust's staff are due to retire in the next five years. 'This is a lovely part of the world but is considered a bit of a backwater, ' he says.
A data forget: how the trust lost a star
Suffolk Mental Health Partnership trust lost at least one star as a result of not having collated all the data required for the star-rating system.
It failed to submit data on three clinical focus areas and two areas relating to capacity.This is thought to have been caused largely by poor data collection.There are two electronic data collection systems in use by the trust, and different parts of the organisation (health and social care) struggle to access each other's data.
Work has now begun to get the whole organisation on one system.There are also discrepancies in the recording of data for reference costs and remuneration from PCTs, a situation that will have to change if the trust is to meet the efficiency savings demanded of it by its commissioners.
Take it to the Bridge: a club in the community
Bridge House's role hovers between health and social care.Located in the centre of Ipswich, it provides a service for people who live in the community but have a long-term mental illness. It is run by staff and clients, who on the day of HSJ 's visit were manning the internet cafe and reception desk and helping prepare lunch.The clubhouse is cleaned and maintained by members.Others work in the office and on the club finances.
The clubhouse's newspaper is written by members.There is also a transitional employment programme which places clients with local employers, including major firms.
It is the type of service that, if the figures alone were taken into account, could not be justified.'In the face of the kind of financial pressures the trust is facing, we had to ask if we need things like the club house, 'says Mr Royal.
'But we came to the conclusion that services like that add value.We are actually now looking at increasing their use in the community.'
The 16-bed Chiltern House rehabilitation unit, which opened four years ago, is another service that could be thought of as a luxury at first glance.Decorated and furnished to look as homely as possible, with domestic-style kitchens, comfortable bedrooms and no nurses' station or NHS-style colours on the walls, the unit is home to people who have previously lived on acute wards for several years.
'We expected our discharge rate to be 50 per cent but it is over 70 per cent now, 'says manager John Andrews.'What makes us very proud is when we have a resident who comes here under a section and we get them off it.'
A zero-starred mental health trust is battling to turn around its reputation.
The trust believes it is reversing its history of vexed relations with other trusts and agencies.
The trust is expecting a£29m boost for accommodation.