Norfolk and Suffolk NHS Foundation Trust’s full answers to our 20 questions

1) Why has Norfolk and Suffolk NHS Foundation Trust not conducted a public consultation over its radical redesign plans?

In February 2013 a joint Norfolk and Suffolk Health Overview and Scrutiny Committee (HOSC) was formed with the purpose of publicly scrutinising the plans contained within the Trust Service Strategy.

The HOSC made 9 recommendations for the Trust and commissioners; one of which was to keep them up to date with the progress of plans and report back to them every 6-9 months. This will happen in September 2013 where our plans again will be scrutinised in public.

In addition, the Trust has been clear since the beginning that where any plan involved changes in the Trust estate, bed numbers or usage we would work with our commissioners on a public consultation. This is now happening as the Trust has reached a point where we need to consider how we use the buildings and beds at Carlton Court in Lowestoft and Northgate Hospital in Great Yarmouth. Together with Health East CCG we are in the early stages of planning a public consultation to start in autumn 2013.

2) When will the recruitment process start for a new permanent chief executive?

The Trust plans to commence recruitment for a new chief executive in September. Andrew Hopkins took up the role of Acting Chief Executive from 1 July 2013 and will continue in this role until a new Chief Executive is permanently in post. The Trust announced last week that Aidan will be leaving to take up a new role as Chief Executive of Cambridgeshire and Peterborough NHS Foundation Trust in September 2013.

3) How much has the trust set aside for redundancy pay as part of the restructure of services and job losses in Norfolk and Suffolk?

The Trust set aside £4.788m in its 2012/13 Annual Accounts for the costs of change (redundancies) arising from the Service Strategy.

4) How has the radical redesign of services taken into account the increase demand for health services in Norfolk and Suffolk in the future?

The Trust Service Strategy 2012-2016 has been developed specifically to ensure that the Trust can continue to deliver high quality, evidence based and innovative services into 2016 and beyond.

The Strategy itself sets out how the Trusts services and support functions will operate in an environment where the key challenges include an ageing and growing population as well as responding to the national economic situation. It has been well documented that the NHS going forward will need to be doing more and looking after more people without an increase in budget.

The core principles of the Trust Service Strategy include an emphasis on prevention, early intervention, wellbeing and recovery – enabling us to 'future-proof' mental health care in Norfolk and Suffolk into 2016 and beyond.

5) Will the trust reopen wards and dementia beds if it is found that the new community Dementia Intensive Support Teams are not working as envisaged?

This is perhaps more a question for our commissioners.

We have been clear since the outset that we will not re-configure any building or reduce the number of beds in any service, including dementia, until we are sure the new community based teams are working.

The evidence from the Dementia Intensive Support Team (DIST) in central Norfolk which has been up and running since 2011 shows that intensive support at home does work and works well. In the 6 months from January to June 2013 the central Norfolk DIST received 257 referrals. Only 9 of these resulted in an admission to hospital. The type of support offered by our DIST will mean that dementia bed usage in Norfolk and Suffolk will be greatly reduced and provide dementia treatment at home to significantly more people than currently receive any help along with increased services which include weekend and out of hour's provision, none of which are available now.

The commissioners in Norfolk have been extremely supportive of the implementation of DIST. They are excited by how the idea behind intensive support for people with dementia at home can develop and better support people living with dementia to lead independent, fulfilled lives at home for as long as possible.

The Trust has said since the outset that anyone needing a hospital bed will continue to be admitted as they are now and if it does become evident we need more dementia beds in Norfolk and Suffolk it will be the responsibility of our commissioners to fund these.

6) What is the trust's response to the letter of the Royal College Registrar (Dr L Mynor-Wallis), who wrote directly to Hadrian Ball, medical director, expressing serious concern and offering to help in 'improving meaningful engagement between college members and the management of the trust?

The Trusts Medical Director, Dr Hadrian Ball has met individually with all consultants in Suffolk and has responded to the Royal College of Psychiatrists concerns directly.

He stated that patient safety is the main priority and focus for the Trust throughout the implementation of the Trust Service Strategy.

Clear and robust transition plans have been developed by senior clinicians, operational managers and service managers leading on the changes. These have been shared with commissioners to ensure patient safety is maintained throughout. The Trust has been clear that no changes will be implemented until they have been tested and is sure they will work and are clinically safe.

In total, 230 clinicians have been involved in developing the TSS plans and the majority of staff are supportive of the proposals and understand the need for change.

7) The Royal College has recently published adjusted figures of how much medical time per 100,000 population is needed to operate a safe and efficient service. Is NSFT meeting those recommendations under the service redesign?

The latest Royal College figures were published in November 2012. It can be difficult to translate the guidelines in terms of local services for a number of reasons, including levels of morbidity, model of service delivery and supporting services. Nevertheless, we believe that current consultant numbers within NSFT at the very least are consistent with the published guidelines. We have shared our medical staffing figures with the Royal College.

There is one possible exception to what is stated above which is in relation to child and adolescent services. The Royal College guidelines in this regard are ambiguous as they refer to the whole population rather than the relevant age-group population. We have asked the Royal College for clarification on this point and are awaiting feedback.

8) Is it true that the recently opened adolescent inpatient unit near Lowestoft had to be closed to admissions shortly after opening because of the risky environment and staff difficulties? And at what cost?

The Trust runs an 8-bed Child and Adolescent Mental Health inpatient unit in Oulton Broad which opened in October 2012 to manage the most complex adolescent mental health patients. As an inpatient unit for young people there are strict, national guidelines for the Trust to follow relating to patient mix.

The Trust needs to closely manage the balance of young people and the clinical conditions treated on the unit in order to maintain patient safety.

This unit was closed briefly to admissions earlier this year while the Trust reviewed the staffing skill mix on the unit to ensure that the best possible care was being delivered.

There was no significant financial implication.

9) How many patients are currently placed in mental health beds outside Norfolk/Suffolk and at what cost?

This is not a simple question to answer.

The use of inpatient beds is complicated and is different for patients in Norfolk and Waveney and in Suffolk. There are also two different types of out of area mental health placements.

Patients in Norfolk and Waveney can be placed in a bed outside Norfolk and Waveney if there are no available beds at the time of admission. This happens very rarely and the Trust has an excellent specialist bed management team who use bespoke IT technology to manage bed occupancy.

At the moment there is only one patient placed in an adult acute bed outside of Norfolk and Suffolk at a cost of £589 per day.

However, patients in Norfolk and Waveney can also be admitted to a specialist mental health unit not run by the Trust. This also happens rarely and is necessary when the patient needs specialist care for a condition not provided by the Trust.

At the moment there are 12 patients placed with providers within Norfolk and Suffolk. Costs are dependent on care pathway and range from £390 to £610 per day. There are also three patients placed outside of Norfolk and Suffolk. Again costs are dependent on care pathway and range from £390 to £510 per day.

The system is different for Suffolk where the Trust does not commission out of area beds for patients – this is done by Suffolk County Council. If a patient in Suffolk needs admitting and there are no Trust beds available Suffolk County Council will source and fund the out of area or specialist bed.

10) Can the trust reassure staff that there will not be another reduction in staff following the service redesign?

Again, this is a question more for our commissioners.

Norfolk and Suffolk NHS Foundation Trust is a provider of mental health services in Norfolk and Suffolk.

The mental health services the Trust provides are commissioned and funded by seven CCGs – two in Suffolk and five in Norfolk who in turn receive the money for the services they commission from central government. The economic challenges facing the current coalition government are well documented. All parts of the NHS are expected to provide more services for more people in the context of limited resources. The same is true for the Trust, which is tackling falling levels of income and increasing costs over the next few years.

The Trust Service Strategy 2012-2016 was developed by the Trust to ensure we are well equipped to continue to provide high quality mental health services despite the economic situation that we face.

Providing there are no further constraints placed on NHS budgets locally, nationally and from the government then no further service changes will be necessary.

However all indications from the Department of Health are that further savings will need to be found and this will present increasing problems for both commissioners and providers of healthcare across the country.

11) The MAC (Medical Advisory Committee) has surveyed all consultants in the trust as to their opinions on the trust strategy and management performance. What is the outcome of this survey?

The survey was developed by, and sent out to, members of the MAC asking their opinion on the service strategy development and roll out. The results have gone back to the Chair of the MAC who will discuss them with Committee members at a future meeting.

12) Why has the trust systematically reduced medical posts over the last 3 years? How many posts have been lost through early retirement, leaving the trust, voluntary redundancies, doctors resigning, long term sick leave and recent redundancy plans?

Any reduction in medical posts has been planned and due to service change to reflect new ways of working. As part of the strategy we have reviewed the numbers of clinicians in post, they are in line with national guidance from the royal colleges.

We do not collect the data as set out in your question; however we can advise that as part of the current strategy, 3 doctors will take voluntary redundancy.

As in all areas of the Trust, there are some vacant medical posts. In order to reduce the number of redundancies resulting from the implementation of the Trust Service Strategy the Trust has been carefully managing vacancy levels.

13) Who is doing the work, previously done by doctors? How many nurse prescribers does the trust employ and how many has the trust trained up recently?

The Trust still employs doctors including consultants, staff grade doctors and junior grade doctors. There is a consultant available at all times across all services in both Norfolk and Suffolk.

Work that requires to be undertaken by a doctor will still be done by a doctor. However, with advances in training and nationally agreed changes and developments in clinical care, other professionals can undertake some tasks previously undertaken by doctors , freeing them up to focus on the more specialised area of care.

Throughout the implementation of the Trust Service Strategy each new service staffing structure has had the number of nurse prescribers increased and these nurse prescribers are helping the Trust manage patient safety in areas where we have vacant doctors posts.

In total, the Trust currently employs 211 qualified nurse prescribers across Norfolk and Suffolk.

It is worth mentioning though that the planned restructure of the Trust medics has been phased. Until now, the Trust has made very few small changes to the medics staffing structure in both Norfolk and Suffolk to help us oversee and maintain patient safety throughout the Trust Service Strategy implementation.

14) Staff have raised safety concerns directly with Aidan Thomas, Hadrian Ball and Kathy Chapman on numerous occasions. What has been done about this and why has the trust not shared their risk assessment for the service changes with staff?

Every group that has raised a concern has received a response and has had the opportunity to talk to members of the executive team. We have robust programme governance arrangements in place which includes risk registers for each work stream, developed by the clinicians leading the work. These are discussed at every steering committee and with the staff involved in delivering the strategy.

Patient safety is also reviewed at ever steering committee and a dash board has been developed by the director of nursing, quality and governance and medical director to provide assurance that services remain safe while we make the service strategy changes.

15) How many locums has the trust employed over the last 3 years and at what cost?

This question is easier to answer broken down into Norfolk and Suffolk. Since June 2010 in Norfolk and Waveney the Trust has used 56 locums in total. The cost of this to date is £3,935,266.11.

In Suffolk, we have only recently starting capturing the number of locums used and the following is the number of locums in Suffolk on the last day of each month:

2012/13 (March) – 13 locums

2013/14 (April) – 12 locums

2013/14 (May) – 14 locums

2013/14 (June) – 10 locums

The the cost of locums to date in Suffolk, since June 2010 is £3,985,000.00.

It is important to remember when looking at these figures that, in order to reduce the number of redundancies resulting from the implementation of the Trust Service Strategy the Trust has been carefully managing vacancy levels. By using locums we have protected roles so to reduce the potential of redundancies.

16) What is the trust doing about the poor outcome of the NHS Staff Survey 2012?

I don't agree that the outcome of the 2012 NHS Staff Survey was poor.

I, along with the rest of the Board were pleased with the results of the 2012 Staff Survey which show despite all the challenges currently facing the Trust, staff understand the direction that we need to take.

This was the first NHS Staff Survey since our merger in 2012 and is a great opportunity for staff to have their say. Whilst a small sample of staff was surveyed there are a number of points, such as the high number of appraisals, which show we are on the right track.

The annual Staff Survey reports are an opportunity for us to see areas we can improve on. Where issues have been raised we have already started work to address these.

Following the publication of the 2012 Staff Survey results in October 2012, our priorities have been:

• Staff engagement

• Staff Wellbeing

• Mandatory and statutory training • Incident reporting.

17) How many staff has been off with work related stress over the last year?

Norfolk and Suffolk NHS Foundation Trust employs 4,400 members of staff and between 1 July 2012 and 30 June 2013 197 members of staff were off work stating stress as the reason.

18) Is it true that in Suffolk an Old Age Community Service has been moved out of a purpose built building into completely unsuitable temporary accommodation to make space for management to move in, whilst the clinical service is expected to move twice in a short period with huge upheaval to staff and patients?

The Trust Service Strategy plans and implementation are different in Norfolk and Suffolk.

In Suffolk, the changes focus on community based services being provided in a more integrated way.

On 1 July 2013 five Integrated Delivery Teams (IDTs) were launched across Suffolk. Each IDT is a large team of 75 clinicians, social workers, psychologists, psychiatrists and support workers all with skills of looking after different service users – older people, adults, young people and children.

Each of the IDTs are designed to work together, sharing ideas, community knowledge and expertise to improve patient experience.

This IDT model of care is new and innovative and works best when each of the five IDTs are co-located.

In order to find five locations across Suffolk large enough to accommodate teams of 75 people with space to see patients and meet the IDTs clinical needs it has been necessary to move some teams around.

The Suffolk Old Age Community Service has been incorporated into each of the five IDTs, so the service as it was before no longer exists and the purpose built site they occupied in Ipswich is now being used by the Ipswich IDT. This is to provide a working base for the clinical teams and see patients where appropriate.

While we have tried to ensure that teams do not move twice, due to service needs, some may need to however this will be a limited number of people and it will be some months away.

19) How have the service redesign plans been changed following the consultation with staff?

Following conclusion of the collective consultation in January we made over 50 changes to Trust Service Strategy proposals. These changes were the result of 900 individual pieces of feedback received from staff throughout the collective consultation period and were shared with the HOSC earlier this year. The following are a sample of the type of changes made:

• changes to the Section 75 social care arrangements with Norfolk County Council. Staff said we needed to make accessing social care simpler and easier and jointly with Norfolk County Council we have done this.

• Changes to the implementation timetable. For example, it was suggested that no changes were made to the administration structure until the end of the clinical services redesign. This allows the Trust to identify where admin support is needed once the new services are up and running.

• Medical staffing numbers should be reviewed taking into account the implications for teaching and SIFT, as well as service provision.

• People between the ages of 25 and 35 with a first incidence of psychosis will be treated using Early Intervention principles, In Norfolk as part of the EI Service in the young people's pathway, and in Suffolk as part of the Integrated Delivery Teams

• There should be designated identified Assistant Mental Health Practitioner posts in every service.

• Nurse consultant posts will be reviewed and adopted where appropriate.

• To develop and consult on the Peer Support Worker job description

• The Trust will clarify alternatives to admission based on models elsewhere (including brief admission services, crisis services and fostering) with commissioners.

• The Trust will develop a clear definition of complexity in later life to assist clinical decision making.

20) How involved have your patients been during the plans to change services in Norfolk and Suffolk and what has been their response?

Engagement with our service users throughout the original Radical Pathway Redesign (RPR) programme and into the current Trust Service Strategy implementation has been extensive.

The first engagement event with service users was held in Norfolk in October 2011 and since then we have held monthly meetings with service users to discuss our plans.

These meetings are open to any person that has used or is currently using any service provided by the Trust. These meetings will continue throughout the Trust Service Strategy implementation into 2014.

In total, over 300 service users have been involved in Trust Service Strategy engagement events and suggestions from these groups have been picked up by the pathway clinical leas.

A great example of this is in the training of our staff who work in our new Access and Assessment Service. At a service user engagement event in October 2012 it was suggested that service users could be involved in advising Access and Assessment service staff on how best to answer the phone. This was an excellent suggestion and there has been and will continue to be service user involvement in the training of our Access and Assessment service staff.