In depth: Extracts from the report into mental staff and their views on changes
- Credit: Newscast Online
EXTRACTS FROM THE REPORT Understanding the Impact of Trust Service Strategy on staff working in the Central Adult Service Line, prepared by Marie Alexander, acting clinical education lead.
'The nature, speed and lack of direction associated with the change process and a perception that the board didn't listen to the evidence has contributed to a lack of staff engagement. Morale and motivation are low and staff stress is high.'
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'The overall result is that respondents believe they are less skilled for their current role than they were and significantly less skilled than they need to be. A negative appraisal of skill set against role requirements can result in reduced motivation and increased stress, significant features of 'burn-out' in health-care staff.
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'Concerns raised that agency staff lack the skills and experience to engage service users.'
'Insufficient staffing resource and pressures from Access and Assessment and Crisis Teams, coupled with a push towards interventions being delivered by less skilled practitioners, results in reduced service quality and compromises staff and patient safety.'
ON SYSTEMS AND PROCESSES...
'These results indicate a clear belief that systems and processes have deteriorated since service strategy adjustments have been implemented.
'Excessive caseloads result in staff fire-fighting and trying to manage service user crises resulting in staff being unable to operate in a fully focused way. Staff are not always able to complete a joint visit where indicated, compromising staff and service-user safety. Unallocated cases result in un-assessed service-user risk.'
ON TRUST CULTURE...
'The transition to the new model has been hampered by unanticipated challenges, including increased staff sickness, vacant posts, erroneous caseload predictions and the interface with other parts of the service.
'Reports that the culture is bullying and oppressive and staff don't feel valued leading to a lack of staff engagement and a lack of trust in the organisation. A perception that the trust fails to place service-users at the centre of what it does leading to a failure of the Friends and Family Test.'
ON MOTIVATION AND JOB SATISFACTION...
'It was suggested the trust had 'done a good job of demotivating people over the last year - some avoidable, some unavoidable'.
'The impact of Service Strategy on the emotional and physical well-being of respondents included reports of people coming into work crying, increased sickness in the teams and thoughts of leaving their current role or the profession entirely. Another reported 'being burnt out from change' and would now take voluntary redundancy if offered and that was 'heartbreaking'.
'A number of respondents opined that the trust was not concerned with their level of job satisfaction, whilst others identified a reduction in job satisfaction when they felt their professional judgement was not being respected, this was particularly associated with caseloads and the expectation to keep taking on more cases.'
'The perception of some respondents was that teams are fragile and near to breaking point with the view expressed that the teams 'can't function'. Clinical Team Leaders were positively praised for their support, although concerns were raised for their welfare and the breadth of their role was described as 'impossible'.
'Communication with managers above Service Manager level was 'not particularly meaningful', with a further observation that there was 'no recognition by the hierarchy of what staff are being asked to do'. This disconnect from the most senior levels of management ultimately impacts on team cohesion.
'Disempowerment was prominent in responses. 'They've created a perfect storm... I'm constantly running from one thing to another to try and avert a crisis' another observed 'we're not empowered to say - no more referrals, we need to close the books to protect ourselves'.'
'The dominant issues throughout the project interviews were the effects of voluntary redundancy and the subsequent recruitment of agency staff in addition to other recruitment campaigns...the redundancies were described by one as 'unforgiveable'...generally respondents were lamenting the loss of 'some very sound and experienced staff'.
'There was some frustration regarding the use of agency staff 'agency staff don't work in the community, it's making it worse..they hinder me - they don't know the local set up, Personal Budgets etc' and others were perplexed by their use.
'A lack of staff was the bottom-line for many 'we knew this was coming and needed and influx of staff initially'. 'We need more staff and more recognition that things are dire'.'
'There were consistent reports of excessive or unmanageable caseloads, one stated 'this is the first trust I've worked for that expects such high numbers in the community'. There was a lack of understanding at how the figure of 35 cases had been reached. Several respondents reported that they would be unable to cope with 35 complex cases.
'Caseloads of 40+ were reported...with anecdotal suggestions that caseloads had reached 60+ for some staff. Where entirely new caseloads had ben acquired this created additional strain. In some instances up to a third of allocated cases had not been seen and respondents reported 'always being in a state of catch up'.
'The continued rate of referrals coupled with high caseloads had affected the utility of team meetings, 'in the past we used to discuss cases...not it's how many referrals...who is going to take this...and everyone's head is looking at the floor.'
ON SYSTEMS AND STRUCTURES...
'An exponential increase in paperwork caused particular frustrations with a number of respondents reporting that the ratio of time spent on paperwork by comparison to direct service:user contact was 60:40.
'This clinical service paradox caused some respondents to observe that the service did not feel safe and that morale and job satisfaction were also affected as a result.
'Others were concerned that if they prioritised service-user contact over paperwork they would not be supported in the event of a serious incident, even if they had reported that multiple pressures had rendered them unable to complete it in a timely way.
ON SERVICE QUALITY...
Some respondents reported feeling that they needed to apologise to service users and carers for the poor quality of the service and letting them down, 'sorry I have to cancel another visit', 'sorry no-one's seen you.' One reflected 'I almost want to add an apology when I say I work for the trust'.
'It was identified by a significant number of respondents that, although they enjoyed their job, they could no longer provide a comprehensive service. At its most extreme they worried about service-users killing themselves, 'We have had to do police welfare checks on people and you sit there for an hour and we sit here waiting, thinking are we going to have another body on our hands, or is it going to be alright, you get through that and you get another one''.
'There was identification of the conflict between practicing safely to uphold a professional registration whilst having to take more people on to their caseload, compromising the quality of the service they could provide.
'Staff were trying hard but outcomes were not reaching 'even satisfactory levels'... though 'some very good care' is being provided.
'It was reported that the emphasis on face-to-face contact had decreased and some respondents reported that they had to delegate work to others, which they sometimes found difficult.
'A reduction in staffing and other resource was complicating the delivery of a quality service; the loss of a base to see service users in the city was particularly challenging.
'The lack of a base resulted in more time spent in the car...Time spent looking for a parking space in the city had an impact on the time available for service-users and therefore affected the quality of the service.
'There was acknowledgement that a review of the service was required. It was asserted that managers had less capacity to do this because service changes had resulted in a reduction in staffing levels of around a third. This was particularly evident at Clinical Team Leader level where staff in post had reduced from 12 to 2, temporarily 4. These changes had resulted in increased serious incidents and increased staff sickness. Managers were therefore in a cycle of spending more time reviewing serious incidents and less time able to review the service to improve its effectiveness.'
'The multiple challenges facing the service concerned respondents and the outcomes on service delivery were marked, 'we know there are hundreds of people in crisis not allocated'... respondents identified that only 'very risk or complaining people' were being allocated.
'People were 'left to fend for themselves' because of the lack of capacity in teams. This was culminating in a reduced quality of life and 'the most unwell service users were being let down'.
'The cumulative effect was clearly visible 'we are seeing practitioners...that I would always see as strong, confident, competent, capable, excellent practitioners and... they are absolutely crumbling at the moment'.
'Increased complaints were noted and some service users were getting angry with staff. Although it was recognised that people should exercise their right to complain it was demoralising 'the more you hear from service-users, their carers and families...how angry, upset, let-down and disappointed people are feeling and it's hard to hear when you know that the majority of the time you and your colleagues are striving to achieve something'. One respondent stated that, prior to service strategy, they hadn't been used to complaints 'but now I'm almost numb'.'
ON WORKING DIFFERENTLY...
'It was noted that some of the message 'had got lost in Voluntary Redundancy, re-banding, people having to move, jobs under threat and other things not coming on line'.
'Respondents often felt unsupported by senior managers commenting that people were 'flogging their guts out to give a service then the finger points when things go wrong'. This was summarised as, 'fatalities are going up...it's the person on the shop floor who has to go to the coroner's inquest, deal with the writing of the report and potentially with relatives screaming across the inquest room floor'.
'Concerns were raised about service-users who had received support for a number of years...with changing criteria they were at risk of being side-lined.
'The main effect was apparent with service users previously in contact with the Assertive Outreach teams and admissions had increased. A change request had been submitted for a 'high intensity service' for people in greatest need. This was necessary following the deaths of a number of former Assertive Outreach patients. 'The new 'mini-team' would in some way re-establish pre-service strategy structures but on a smaller scale within one overarching team.'
ON THE BOARD...
'Respondents suggested the decision-makers didn't relate to ground floor staff who, in turn, were unaware of who had made what decision, resulting in the absence of a feedback system.
'It was believed that a number of problems could have been foreseen, and therefore avoided, if staff concerns had been heard in the beginning, and one respondent summarised this point, 'neither did they ask nor listen when told'.
'On-going leadership at board level was experienced as 'inconsistent' or lacking but there was some hope for the incoming Chief Executive. At the point, however, there was mistrust, 'they're not honest with us' and the relationship with the Board, service strategy had been 'the watershed'.'
'The question regarding an individual's ability to influence change drew a range of responses from the disenfranchised 'our feedback isn't taken seriously, if we're listen to at all' through to the apprehensive 'there's a culture of blame and finger-pointing, people aren't willing to be made scapegoats' and frustrated and saddened 'I feel helpless, disempowered'.
'Respondents reported that they had repeatedly flagged paperwork and issues with depot clinics but nothing had happened, some were resigned 'just trying to get anything done is pointless'. It was further suggested that change would only really take place 'when people start dying'.
'It was opined that higher managers would listen 'if it is a fit for them' but there was 'too much pride to halt the service strategy'.
'Although a previous chief executive had stated that the strategy would not continue if it wasn't working that was described as 'a farce, they had their plan and they bulldozed through it'.
'The views were expressed that service strategy was 'top down and financially driven, disempowering local services' and the board were unable to appreciate the impact of the changes.
'It was observed that existing teams were 'overloaded and felt out of control and solutions couldn't be affected that way'.
'The Access and Assessment Team was described as 'crazily bureaucratic' and a high proportion of referrals through to the service line were being re-assessed because the quality of treatment was in doubt.
'Meaningful consultation with service-users and carers regarding service development was required. Some service users had to switch care co-ordinator when the service changes were implemented based on their GP practice, with no apparent appreciation of the impact this might have for service users and carers.
'A revision of the geographical spread of caseloads was necessary, currently being too large and community resources too few meaning most people were seen at home, 'I work out of my car. It constantly feels like chaos'.
'More Clinical Team Leaders were required because their workload was so great.
'Some respondents urged caution in proceeding with further change, 'it's important they don't press ahead with acute service changes until the community services are robust enough to cope with it'. Others called for a halt to the change process 'more changes would send people into chaos' and 'we need to build on what we have, not change again'.
'A number of respondents wanted more clarity in their role and to feel less overloaded, one reported 'the constant pressure makes me ill'. Respondents variously identified 'regularly driving up to 70 miles a day between visits', 'working long hours with no acknowledgement,' experienced 'difficulty being flexible' and wanted to be 'given a job that is do-able by one person'.
'There was some optimism and that 'things seem to be turning a corner', there were more staff and the atmosphere was more pleasant as a result.
'There was no sense that staff well-being was a trust priority, 'it seems the Trust don't allow us to look after our own well-being. It's a bit of a contradiction really'.
'Lines of responsibility were unclear, 'nobody knows who's responsible for what'. There was 'chaos' and 'confusion and disillusion with the whole thing' with the outcome being 'the service can't be delivered'.
'There was less ability to respond to people becoming unwell in the community; a number of respondents linked an increase in admissions and patient deaths to service changes, particularly the disbanding of the Assertive Outreach service.'
PROJECT MANAGER'S REFLECTIONS AND SUMMARY...
'I had underestimated the strength of feeling that still surrounded the service strategy five months post-implementation. It was clear that a number of staff did not feel able to function effectively either as individual practitioners or as a group. They were largely disengaged, disempowered and believed that clinical and service-user safety was being compromised and that no-one with the ability to affect change was listening to them.
'I interviewed staff from across the clinical spectrum and was saddened by the on-going distress that some were visibly experiencing as they continue to try and provide a service in very challenging circumstances.
'It became apparent at an early stage that respondents were taking a psychological risk by becoming involved in this project and, on reflection, I believe they were prepared to do that because they retained some hope for the service and so were willing to revisit what had been a traumatic experience for many of them.
'The report may illustrate a service not recognisable to decision-makers, respondents have repeatedly raised concerns over the quality of service delivery and the maintenance of staff and patient safety. However it is essential that having raised these concerns remedial action is taken to prevent further deterioration and to develop a cohesive, resilient workforce that can negotiate future changes.
'Failure to attend to the experiences of clinical staff through service changes may result in increased levels of burn-out amongst staff, decreased resilience and poor levels of engagement.'