Monday, 15 February 2016

Time for actions to speak louder than words

I was briefly interviewed today by @BrekkyAliButts for BBC Radio Manchester’s breakfast show. I answered questions on the report ‘The Mental Health Five Year Forward View’ and the current state of mental health in England and specifically Greater Manchester.

I really welcome the report and will say a little more on that later. While I’m proud of all that we achieve in Pennine Care, it was uncomfortable listening to a long list of sobering facts on where mental health care fails people in our communities.

In 2011 the term ‘Parity of Esteem’ was coined with good intentions to ensure mental health care was on a par with physical care. Since then we have gone backwards in my view.

In 1999 as part of a series of ‘National Service Frameworks (NSF)’, the Government of the day launched a report specifically for mental health, from which new investment followed. Click here to read it. I know from my own personal experience at the time not all allocated funding reached the frontline, but it did lead to an overall improvement in some key areas.

However, the mental health NSF barely reached year five of its 10 year plan.  Since then there has been a series of reports and recommendations, including the arrival of Parity of Esteem in 2011 and a six point mental health strategy.

Yet today’s report talks of years of low prioritisation and chronic underinvestment in recent years. How can mental health maintain such a high profile but not receive the investment this report says is needed?

The public support it, the politicians support it, service users, carers and mental health staff all support it. The evidence is also there (in the report) to demonstrate it makes good economic sense and will improve health inequalities too. So why isn’t it happening?

Overcoming challenges

Back to the questions I faced this morning on BBC Radio Manchester (click here to listen again – forward to around 1.13).  If you listen to this you can hear Alison list example after example of where care isn’t working.

Long waits for certain types of care, people having to leave their local area for acute in-patient care, young people not getting access to the care they need. It just isn’t acceptable in my view. Before discussing the report and what I hope it will mean, I’ll share with you the position regarding Pennine Care.

Across the towns we serve we face challenges not dissimilar to the ones set out in the report. There are relatively low levels of investment in mental health, but I am hoping we are entering better times following this report and a Government commitment to invest in mental health.

I would agree with Paul Farmer (Chair of the Taskforce that has produced the report) that we now need transparency on mental health investment and clarity on where funding will go and how it will be used.

Despite some low levels of funding we do not have some of the challenges reported today; I am proud to say that we don’t send any acute patients out of area to distant hospitals - we didn’t have one episode in the last year and only a few brief instances the year before.

I know this isn’t the case elsewhere in the country. It means Pennine Care staff are working tirelessly to keep people close to their home.  However, the pressures are significant and I can’t thank our staff enough for the work they do day and night.

Maintaining quality in the face of adversity

Despite having to deliver nearly £17m of savings since 2010 I am pleased to be able to note that our overall quality has been maintained and access has improved, for example we do provide 24/7 crisis and liaison psychiatry services to hospitals.

Our 24/7 crisis services operate along an open access model and, unusually, we provide a service to children too. Overall we have increased the total number of patients seen from 32,000 in 2010 to nearly 51,000 in 2015.

We still receive good quality ratings and high scores on our Friends and Family Test, relatively low numbers of complaints and, overall, we provide safe services to the people we care for.

I am pleased that our Healthy Minds Service (psychological therapies) now takes referrals from people with long-term physical health conditions.  I think we are one of the first to actively encourage this and it is an area highlighted in today’s report.

However, this is against a backdrop of staff feeling pressures greater than I have had reported to me before. The reductions in local authority services has really been felt in community mental health teams; the work programme has, in my view, put some vulnerable people with mental illness under unnecessary and inappropriate pressure and the level of therapeutic provision (such as psychological care) can never be high enough within such limited resources.

Having listened to staff and patients over the last year, I am personally working with commissioners to call for more investment in our mental health wards.

Despite these pressures I am very optimistic that this report will make a difference. I am already seeing some very positive commissioning intentions emerging and we are revisiting our mental health strategy in Pennine Care.

The devolution work across health and social care in Greater Manchester (GM) has already made mental health a priority for the city region. Paul Farmer, as chair of the taskforce, has led an honest review, reported a plain view of the reality of the current picture and set out a very pragmatic, meaningful way forward.

Please do read the report - with a national drive and a local GM strategy I am hopeful we will see some real progress.

Overcoming the stumbling blocks

I see only two stumbling blocks to making progress.  The public and politicians recognise and call for more investment, as do those who study the evidence for good mental health care (clearly set out in the report launched today).

The first stumbling block is the overuse of hospital care. Over the last several years the wish of commissioners to invest more in mental health has been blighted by increased hospital costs every year.

Once again the Devolution Strategic Case aims to address this and, without wanting to sound blindly optimistic, in fact I am optimistic! There is a key objective to provide more care out of hospital and mental health has to be a key aspect of this movement.

The second obstacle is more difficult to articulate.  To sum it up I would say the continued presence of stigma prevents mental health achieving the parity that society deserves and needs.

I’ve heard examples of stigma shared with me through conversations high up in health departments and have witnessed it locally myself.  Mental health has been too easy to dismiss or ignore by those who influence policy or determine where investment should fall. 

Unless you’ve experienced mental health stigma yourself, or in your family or friendship circle, unless you’ve worked as a nurse, therapist or a doctor with people and their families, I think there are still large numbers of people who don’t fully understand or appreciate the devastating impact it can have.

The Mental Health Five Year Forward View sets out how you are more likely to experience mental health problems if you are from a vulnerable or marginalised group, or don’t have stable housing or employment.

If you don’t experience these issues on a daily basis, policies can be just words on a page and investment plans numbers on a page. I’m not sure I am capturing this well, but I feel certain that, as a society, or maybe even just in the NHS now, we have an inherent bias towards hospital care and physical disease.

The report today says that next steps require ‘a fresh mindset’ and I would urge everyone to reflect on their own contribution and role in ensuring mental health is a priority.
Stigma is nowhere near what it was when I started nurse training in 1984.  It was appalling 32 years ago. Now we live in much more enlightened and educated times, with members of the public leading the way in calling for better mental health care.

I think it’s time for the NHS to catch up with the public mood and deliver against the excellent report published today. 

It is now time for implementation - where actions will speak louder than words.


Tuesday, 2 February 2016

Time to grasp the nettle

I recently attended a retirement lunch for one of our mental health Clinical Directors and naturally we talked about the challenges ahead at a time where we have the Devolution Manchester Strategic Plan, a GM mental health strategy and a national mental health strategy all emerging. We shared a sense of great optimism, whilst recognising the challenges ahead will be, well, challenging.

It struck me that whilst moving forward, we still need to look back and not forget what we have done well and should celebrate and learn from our achievements but if ever there was a time to grasp the nettle, it’s in 2016.

Working together  

If 2015 was all about strategic development then 2016 should be about implementation.  This year will also be about partnerships and new ways of working together across health and social care.

But if I was to look back, what partnerships have we developed that have taken care forward and what have we implemented to do things differently?  In mental health specifically, what developments can we learn from to inform our plans for the future?

If we are to change the way we deliver health and social care to address the challenges set out in the GM Devolution Strategic Plan, what are the key two or three things we need to do differently in 2016 and beyond?  To achieve difference we have to do different.

Pennine Care launched its whole person care strategy in 2014 and I’m pleased to say that it remains relevant today and reassures me that our ambitions were the right ones.

The NHS England Five Year Forward View talked about a broad consensus on what the future should like for healthcare. Pennine Care’s strategy drew on that, as well as the voice of our staff and those who use our services. The Devolution Strategic Plan endorses much of our strategy but also sets a bigger picture vision and stretch challenge for providers to develop evermore far reaching plans, in partnership with others.

When thinking about partnerships, I look back and can see we knew then it was important that we changed the organisation and started to deliver through 'place and people', not through Pennine Care the ‘Trust’. We have still some way to go but it does mean that over the last two/three years we have been on this journey, we are comfortable working in places, with partners and developing local care organisations together. We bring to the table a strong track record on managing quality, safety, money and large groups of staff, blended locally according to the needs of each town.

Partnerships in practice

For instance in Oldham, we have worked with primary care, social care and voluntary partners to establish an independently chaired Care Consortium.  It was important to bring agencies together to promote innovation and I believe we have delivered some real change.  We are currently undertaking an evaluation of the work and will publish this over the coming weeks.

Around 25% of the Greater Manchester population have a mental health and wellbeing issue and as a GM economy, we spend more than £1bn on long term conditions linked to mental health.  So I feel very enthused about the opportunities to improve mental health care across Greater Manchester.  There are more leaders coming together than ever before and more commitment too.

The three NHS providers responsible for the majority of mental health care in GM are starting to collaborate more, such as across specialist services and supporting the acute mental health pressures facing the city. This has ranged from rapidly opening additional beds, to putting capacity in the system, through to setting up psychiatry liaison services to help with hospital pressures.

In Stockport, we have worked with commissioners and Stockport NHS Foundation Trust to set up a new ground breaking facility, called Saffron Ward.  Saffron provides intermediate care for older people with delirium, who often don’t get the care they need when in hospital. This ward, linked to our RAID services, brings people from the acute hospital setting and provides an integrated care pathway, to provide treatment and care. We have found patients and their families really value this bespoke care, the outcomes are better, older people retain more independence and it has significant financial benefits over the costs to run the service.

Through these examples I hope to show that partnership working has many faces, local partnerships, partnerships with different types of providers and between trusts with common care pathways.  In our recent experience, we have learned to listen, engage and find ways to work with partners that helps everyone feel on board and with a voice to influence how we develop services. This principle of co-production will be key to our future success.

Putting people first

So far I haven’t included the most important partnerships of all… the most significant shift in how we plan, deliver and operate care will be through the partnerships we develop with patients, carers and wider communities. Changing the way we deliver health and social care, will only work if we can change the way people use services and how they look after their own health.

I am very optimistic we can and the work Pennine Care has done through My Health My Community has seen a substantial change in our approach to care. At its heart, MHMC is a living well academy, a self-care resource and a movement towards self-management at scale.  Importantly, the self-care resources and support programmes are entirely co-produced with service users and carers, from ideas, through to development and delivery. 

The NHS has a long standing history of great care, I am proud to be a part of it and my 31 years as a nurse, a leader and now a Chief Executive. However, we have to move away from 'doing to' patients and start working with people and their communities.

As a Trust we know we haven’t got it all right, there is much to do, but for 2016 onwards our staff have partnership working, place-based delivery and whole person care as three key driving principles. Importantly, we can adapt how we work this way wherever and however the local conditions are set. Even more importantly we are changing how we relate to an individual’s care. Across all providers and with all staff, we will need to be both open minded, flexible and progressive as we move forward together.

New models of care and mental health 

The examples I have outlined show how we are developing an alternative narrative to hospital care. Hospitals do great work, but they are busy and under pressure. Local care provider arrangements have to build better and alternative care models to the offer we currently provide. But we can’t just say it needs to happen, we have to make the case for it and demonstrate propositions that we can confidently invest in, knowing it will help reduce hospital pressures and keep people out of hospital-based care.

We must be able to measure, demonstrate and show the benefit over cost of the new care systems we are building and so health economic modelling, such as that undertaken by Pennine Care, is increasingly an integral part of how we plan and implement care.

With new models of care, I still think we underestimate the importance of mental health and how good mental health care can have far reaching benefits. In 2016 we are in a much better place than when I started my psychiatric nurse training in 1984. Back then ‘psychiatric patients’ were viewed negatively, a significant amount of care was provided through large asylums, the media often portrayed people with mental illness as dangerous and talking about your mental health problem was largely still a taboo.

Today, the vast majority of care is provided in community-based settings, most often in people's own homes.  Many patients prefer to be described as service users and have far greater involvement in planning services and their own care than ever before. I would never try to say we have arrived, we still have a long way to go, but we have travelled an incredibly long distance in the right direction. 

We now have national campaigns such as Time to Change, issues on mental health are much more accepted in the media with substantially more positive reporting. Whether it’s through soap operas such as Coronation Street or EastEnders dealing sensitively with mental illness or well-known celebrities talking about their own mental health, the stigma associated with mental illness has dramatically reduced. However, it is still there, it is still a problem and we must do more.

I believe education on mental health is at the core of further reducing stigma, I think it’s at the core of delivering better health services overall. So education is key and specifically we must ensure we are acting on the evidence that demonstrates good mental health care leads to better health overall.

For example, back in 2011 the London School of Economics published a review of the evidence for good mental health care and wider health and economic benefits. The Kings Fund have also reported on the benefits of better mental health for people with long term conditions and its health economic benefits. 

The new Greater Manchester strategy also draws together the known benefits of good mental health care improving physical health and the need for good physical care for those with a severe and enduring mental illness. The body of evidence is substantial yet the investment in and integration of good mental health care in all care, remains patchy at best.

A five year forward view across Greater Manchester

This could be a blog in its own right, a book even!  I thought I would close with some key features I would like to see in place by the time we get to 2021. These are just a few examples based on where I think we need to make substantial progress: 
  • All people with health care needs having their own self-care/self-management plan and feeling in control of their care
  • Less hospital beds and more virtual beds, in people’s homes, supported by technology, care coordination and support for carers
  • Mature partnership working and collaboration, between healthcare providers, primary care, social care, third sector, housing, employment and wider
  • A collaborative system for Greater Manchester which unifies mental health care standards but delivers through local integrated models of care
  • Psychological care and mental health care at scale where it can help reduce hospital usage, improve physical healthcare outcomes and help prevent future health problems
  • A vibrant third sector and leisure sector leading on prevention and wellbeing and helping communities become more active and healthy
  • Increased prosperity across the city region and better employment prospects for those who we don’t adequately support now, specifically those with mental health needs
  • A recognised standard care offer for people in their own homes or communities, a hospital system with the time to care and reduced pressures, with far reaching programmes of health prevention and education
  • Better care and prospects for young people and support to families to give young people the best chance in life

I could go on, but I don’t need to as this is a good time for Greater Manchester. There is a shared view on what the right things are that need to be done. The trick now is selecting the two or three most important things (that will deliver the most impact) to start with in 2016 and build from there as we work towards 2021. 

I’m looking forward to being a part of it and hope you are too...