Health system's culture problem goes from 'board to floor'

The review, undertaken by outstanding-rated Northumberland, Tyne and Wear Foundation Trust and published today, looked primarily at services provided by Lancashire Care FT, but also examined the role partner organisations played.

The reviewers said: “Significant cultural challenges exist at a senior level in the system, between providers, and between them and commissioners, which creates a direct impact on front line service delivery.

“Some senior leaders have challenged the mental health knowledge of some commissioning colleagues, with a direct impact on their relationships and approach to one another.

“The authors note that some senior leaders appear to take pleasure in each other’s challenges, and that moving these relationships forward in a positive way will take significant time, leadership and commitment on all sides… Staff on the front line are acutely aware of all of this, and share these challenges with service users and carers.”

The report suggested LCFT has had poor relationships with multiple organisations, including clinical commissioning groups, police officials, and acute trusts. It said “significant issues” were also found with its relationships with Lancashire, Blackburn with Darwen, and Blackpool councils.

At the time of the review, the trust was led by Heather Tierney-Moore, who retired in March after 10 years in charge and has since set up a consultancy business. HSJ contacted her but she did not wish to comment.

Caroline Donovan became chief executive of LCFT last month, having previously led North Staffordshire Combined Healthcare Trust to an “outstanding” Care Quality Commission rating. 

Some of the review’s most alarming findings – such as patients being illegally detained in seclusion rooms for more than seven days – were revealed by HSJ last week.

Other problems noted in the NTW FT review included:

• An assessment process routinely used to continue holding patients detained under section 136 of the Mental Health Act (which allows someone to be held in a “place of safety” until they see a clinician) was “not supported by any legal framework”. Staff claimed this was “acknowledged and supported” by senior trust leaders. The CQC had previously raised similar concerns after an inspection in January/February 2018;
• A third of patients detained under section 136 did not receive follow-up care, with some subsequently attempting suicide;
• The lack of interventions by the health and care services led to service users being “criminalised” when the police were forced to section them; 
• Every conversation with community-based staff involved them raising problems with culture, attitudes and relationships across the system, from board to floor, with strong references to a blame culture;
• Community staff said service users were the targets of racism, and that providers did little to tackle this;
• Service users requiring crisis treatment were “told to have tea and a bath”;
• LCFT had closed beds while reducing community services, according to some staff; and
• Seventy per cent of patients awaiting a bed at the time of the visit had a diagnosed personality disorder, but there was no clear clinical pathway for them.

However, the NWFT reviewers added there were “many pockets of good practice described across all providers and commissioners which can be built upon, spread and shared beyond organisational boundaries”… and said there was a “strong desire of staff across the front line to deliver better services”.

Many of the deep-rooted issues described by NTW FT were similar to those identified by a separate review from consultancy firm Channel 3, which HSJ also reported last week. Both reports raised broad concerns about LCFT’s under resourced community services, a lack of bed capacity, inadequate support for patients in crisis, and overstretched accident and emergency liaison psychiatry teams.

The review was commissioned by the Healthier Lancashire and South Cumbria Integrated Care System, which was selected as one of the country’s leading health economies by NHS England.

In response, LCFT said it had established a “strategic partnership” with NTW FT, and set up an improvement programme to address the shortcomings.

Ms Donovan, who joined LCFT last month, said in a statement: “We welcome this report and its recommendations even though it makes for very difficult reading for all of us involved in the delivery of mental health care. We are so sorry that our services have, in many instances, fallen way short of what we aspire to, and that our patients and families deserve.

“The vast majority of our staff are dedicated, professional and compassionate. They are the life blood of [the trust] and we will work with them, listen to them and support them so that they can deliver our vision…”

Commissioners said they would support improvements, including being transparent about spending on mental health, and commissioning crucial bed capacity which has been lacking.

Dr Amanda Doyle, the ICS’ chief officer, said: “We are grateful to the service users, members of staff and stakeholders who contributed to the review. Their open and honest input has helped to create a clear picture of where we have gone wrong, and what we need to do to improve.”