We published Driving Improvement in seven mental health trusts in March 2018. It told the story of how Lincolnshire Partnership NHS Foundation Trust had improved its CQC rating from ‘requires improvement’ to ‘good’.
Since then, the trust has continued to improve, achieving a rating of ‘outstanding’ for well-led.
Anita Lewin is Director of Nursing, AHPs and Quality. Anita says “I believe what led us to improvement was the work we’d done with staff: developing people and investing in talent management – and getting people to talk about what they are proud of. The biggest change, and one that we have sustained, is the desire of staff to share their stories and share good practice”.
She adds that the way senior managers listen and act has “unlocked lots of doors.” And it’s given staff confidence to speak up. For the executive team, that means “no surprises - we now know about issues”.
Jane Marshall is Director of Strategy, Planning and Partnerships. As Jane puts it: “Now as an executive we are giving ‘air cover’, not permission, to act. People now feel more in the driving seat to make the changes they need to improve the care they deliver. If things go wrong, we aim to support staff instead of jumping in and starting with blaming people.”
Vision and values
The approach is underpinned by the trust’s vision and values. These were co-produced with staff following a ‘cultural and leadership’ diagnostic - a complete analysis of how staff felt about the trust. “I think that process helped our teams feel they were being heard and could act. This helped to improve the culture of the organisation”, says Jane.
The result was a slimmed down vision: ‘To support people to live well in their communities’. The core values are compassion, pride, integrity, valuing everybody, innovation, collaboration. And there's now a set of co-produced behaviours.
The vision, values and behaviours helped to ensure stability of purpose. This was at a time when the trust had a number of senior changes in the executive team. These included a new chief executive, medical director, and director of nursing, AHPs and quality.
Teams across the trust then considered what the vision and values meant for them and their service. In this way, teams were empowered and supported to make changes to drive improvement. “I think that’s one of the things that demonstrated the board’s support to devolving leadership. The board worked as a team to do the exercise as well,” says Jane.
Communications and engagement
Yolanda Martin is Associate Director of Communications and Engagement. She says communications and engagement with staff have been central to the trust’s improvement journey. “The Board sees the importance of communications and engagement. We are a listening organisation, with lots of engagement with staff about what’s important and a good feedback loop so that we go back to staff to say what’s been done.”
The trust has 57 sites across a rural county, making face-to-face engagement with staff difficult. To overcome this there's a range of regular communication channels:
- a weekly e-bulletin
- a monthly video team briefing led by the chief executive scheduled so that teams can set up briefings to follow
- a divisional update within five days of the team brief
The trust surveyed staff about where they got information they trusted about the trust. It found the top five sources were trust communication channels. NHS staff survey results for the trust have also improved in each of the last three years.
But there are also events that bring people together. “There are staff engagement events constantly – every division does them”, says Anita Lewin. “And they are not tokenistic. That’s one of the main shifts from six or seven years ago. On service changes now, from day one there’s full staff involvement in the process.”
“Lots of communication and engagement activity is about quality and the difference it makes to patients”, says Yolanda, who is a member of the trust’s weekly executive team meeting, underlining the importance of the quality improvement work that runs throughout the trust.
Quality improvement
“Continuous QI started with four trust-wide priorities in early 2017”, says Jane Marshall. “In May 2019 we reviewed these.”
The first priority (CQI 1) had been to introduce a new clinical system. This replaced a system that staff had found difficult to use. It could not, for example, link data about a patient from different sources. And it stored different bits of information about a patient in different parts of the system.
CQI 1 was improving the data collection, quality and use. Part of that was putting in a new clinical information system called Rio. “It works and our staff say they prefer it”.
Jane says the introduction of Rio demonstrated the executive and senior leadership team was listening to and acting on staff concerns. “The goodwill that buys in terms of ‘you said, we did’ at trust level can’t be underestimated.” That in turn encouraged people to develop their own quality improvement projects at local level.
There is a ‘celebrating CQI’ meeting every other month. This showcases each of the four clinical divisions’ work on continuous quality improvement. “These meetings are full of energy and life” says Jane. “In the past,” she adds, “executive directors would have led the meetings, but they now sit at the back of the room and let people showcase their work and share their ideas and celebrate success.”
Assurance
But the board and executive team need assurance that things are on track. And Jane says the trust has arrived at a position. It's somewhere between a directive, assurance led approach and a more empowering approach. Teams feel able to do things in their services that benefit patients, carers and staff. “You can’t let things go so much that you do not seek assurance. We are open to feedback on how it is working, however I think we have found a way of doing that which isn’t about jumping on people when things do not go exactly right”. Fortnightly meetings look at the practicalities of service performance and improvement. These are led by two executive directors.
The trust is now using statistical process control (SPC) charts. These provide a year’s trend data in the trust’s integrated performance reports. “It allows us to be more sophisticated in our analysis of variation in performance and how we hold each other to account,” says Jane. “We would recommend the “Making Data Count” national NHS programme to assist in this particular transformational approach to using data.”
This links back to the work to get fit-for-purpose clinical information systems. The current level of data collection and analysis would not have been possible with the former clinical information system.
Robust quality assurance is vital to sustaining improvement. Anne Harris, Interim Quality Assurance Lead for Adult Community Services, says:
One of the ways the trust is driving improvement and assuring quality is by using ACOMHS. That's the Royal College of Psychiatrists Accreditation for Community Mental Health Services. So far, eight teams have signed up for this. Four have already achieved accreditation, one is imminent at the time of writing. And the remaining teams are all expected to achieve accreditation during 2020/21. Individual teams also pursue their own service improvement initiatives. For example, one community team set up a benefits group to help service users navigate the benefits system. The team is looking to set up a joint physical health clinic with older adult service colleagues.
Importance of system working
It is, says Jane, massively important for the trust to be an important partner in the local system - taking a leading role. “Over the last three years we have made sure that our clinical strategy aligns fully with what the STP is saying. Through that we have been able to demonstrate improvements in mental health, learning disability and autism services.”
Anita Lewin notes that some of the new services being developed are system based. For example, the community rehabilitation team works with the local authority and the CCG. The national funding for transforming community mental health care is for the system, not just the trust.
The trust led the development of the system commissioning intentions for 2019/20. It identified priorities for the next commissioning round. Sarah Connery, the trust’s director of finance and information:
- led the system finances for the Lincolnshire system
- developed thinking around shared services
- streamlined commissioning and contract meetings
At a regional level the trust is involved in developing new care models. For example, on eating disorders, mother and baby services, veterans and learning disability services.
Recruitment and retention
One of the main challenges continues to be workforce, particularly in an area such as Lincolnshire. “We need to retain the good people we have and get people to come and work with us”, says Jane Marshall. About a third of nurses and a quarter of the trust’s doctors are due to retire in the next few years. Vacancy rates are good compared to the rest of the country but are still a concern. Anita Lewin says she's working system-wide with directors of nursing to tackle the issue. The trust is also looking at the career structure of AHPs and thinking about new ways of deploying staff. For example, a paramedic could be based on each of its mental health acute admission wards.
The trust has a suite of leadership development programmes, including the ‘Band 7 Ready programme’. This programme aims to help address recruitment problems. It equips Band 6 nurses with the skills they need to step up to take Band 7 roles.
Improving adult inpatient services
The acute wards in the trust’s adult services is one of the services that has improved since the last inspection. The wards moved to ‘good’ overall. And the responsive element from inadequate to good. Eve Baird is Interim Divisional Manager, Adult Services. Eve says the trust focused on “stripping back and asking, ‘why is it the CQC looks for things?’”. This shows an understanding that these are indicators of good care. “We started to reframe the conversations, rather than looking at targets. Looking at why something is important to patients, why it matters to staff, how it improves quality of care”. She cites the example of clinical supervision. The division went from 13 per cent of staff having had clinical supervision, to over 75 per cent.
In 2018, the trust opened a male psychiatric intensive care unit and a psychiatric clinical decisions unit. Both contributed to a reduction in the number of patients cared for in acute and PICU out of area placements. In 2019, there has been an increased focus on work that can be done across the mental health and social care system. That work supports the agenda of caring for people closer to home. Examples of this include:
- community mental health services and crisis teams working jointly to prevent people needing admission to hospital
- working with commissioners around appropriate housing solutions that enable people to be discharged from inpatient services
CQC’s 2017 inspection identified some areas of estate as not fit-for-purpose. These included an older adults’ inpatient unit in Boston - a 17-bed, mixed-sex dormitory.
Alan Pattison is Business Manager, Older People and Frailty Services. Alan said an analysis of what could be done with the area showed it would not be viable to make changes to the building. At the same time, the trust had an opportunity to develop another ward to single bedrooms to create 18 single rooms. That would address dignity and privacy issues inherent in the dormitory accommodation.
As redevelopment was taking place, staff from that ward were redeployed. They staffed a community home treatment team for older adults - 8am to 8pm weekdays and 10am to 6pm weekends. They supported patients who would otherwise be admitted to inpatient units. This proved very successful. Very few patients went out of county when the ward closed. And repatriations were quick, within days or weeks.
The older adult home treatment team will continue following the future temporary closure of Rochford Ward at Boston and the reopening of the newly refurbished Brant Ward in Lincoln. This supports the preferences of patients and carers to be treated at home as an alternative to hospital admission.
Eve Baird thinks one of the drivers for improvement, was that staff owned the improvement. Another is embracing the idea that change should be led by the people doing it - and patients. That ownership helps meet the challenge that Anne Harris noted: Teams can focus on quality and improvements while meeting the demands of achieving performance targets.