We published Driving Improvement in seven mental health trusts in March 2018. It told the story of how North Staffordshire Combined Healthcare NHS Trust had improved its CQC rating from ‘requires improvement’ to ‘good’.
Since then, the trust has sustained that improvement and achieved ‘outstanding’ status. The trust sees the achievement of this rating as the start of a new phase in its continuing improvement journey. The trust is emphatic in stressing this is a continuation rather than a culmination.
Vision and culture
Chief Executive, Peter Axon joined the trust shortly after it received its outstanding rating. Peter says an early board conversation was about keeping up the momentum. Previously, the trust's central vision was of being on a “journey to be outstanding - in all we do and how we do it”. This needed to be reinforced and reemphasised. “When a milestone is achieved, you have to define the next milestone”, he says.
An annual cycle of self-evaluation and review supports the ambition. This highlights areas where improvement is needed, he says. The trust triangulates the self-assessment in different ways. This includes the Freedom To Speak up data and emails Peter receives from staff.
Chris Bird is Executive Director, Partnerships and Strategy. According to Chris the previous chief executive, Caroline Donovan, and the executive team had created a culture “where everyone is equally responsible for improvement - it had to be a whole organisation thing. The drive for improvement is now part of the trust’s ecosystem - it’s part of the day job”. The action plan developed after the last CQC inspection helped focus and drive improvement.
Jonathan O’Brien is Executive Director of Operations. He says there was a ‘buzz from staff’ after the outstanding rating was announced. There was a culture of every department wanting to show how good they were. “The key thing is not taking your eye off when you are already good”, he added. Stories showcasing high performance are a feature of every trust board meeting.
Executive Medical Director Buki Adeyemo agrees. “The challenge was maintaining and not losing momentum. We needed to keep a focus on QI and continue to motivate staff and show them their views are valued.”
Quality improvement
Having a positive culture of improvement is one thing. But it needs to be backed up with robust improvement processes. Jonathan O’Brien says the trust revised the way it measures improvement. “We moved from RAG ratings to ‘plot the dots’ [statistical process control charts - SPC]”. In other words, measurement is now more about plotting trends that show if processes are under control. “It’s a more sophisticated way of looking at performance”.
But there's still a place for RAG ratings going beyond performance to track assurance. Buki Adeyemo explains how the trust has added a ‘blue’ rating as the highest rating. Blue indicates that a performance target has been achieved and there is evidence to prove it. The trust has also developed its own inpatient and community safety matrices. These include quality of care plans and waiting times. These are audited monthly by means of a peer review of five sets of records every month for every team.
Following staff feedback, adult and community services restructured into four directorates. This brought services closer to the community and primary care. And it strengthened the way professional leaders work with the directorates. All directorates have continuous improvement as part of their culture. They look externally and internally to help them achieve this.
Buki Adeyemo says there was a renewed focus on formal quality improvement. The trust now has a partnership with the Advancing Quality Improvement Alliance (AQuA). And it has adopted the AQuA approach. This involved developing improvement projects with staff. For example, observations on acute wards and reducing falls on older people’s wards.
The trust also looked externally for improvement support - working with NHSE/I and CQC on the mental health safety improvement programme. This bespoke programme works to move 'good' areas to ‘outstanding’. According to Peter Axon, “The organisation has taken on as many quality improvement initiatives as it can reasonably do at one time. We bring in things we’ve seen elsewhere”. But he adds, there's then a need to take a step back to see which are working well. If they're not, tweak them. If they're not right for the organisation, drop them. The key point is having the ambition to want to improve.
Leadership
The trust continues to recognise the importance of good leadership. The training budget and established leadership programme are being maintained. Programmes with Keele University have been developed for medics and psychologists. The trust is piloting the High Potential Scheme (HPS). This is a National Leadership Academy programme for clinical or non-clinical leaders. It helps high potential, aspiring middle level leaders accelerate their career to senior executive roles.
Improvement in action
There have been particularly impressive improvements in some services. For example, the trust has been one of 12 to pilot a 4-week wait target for its child and adolescent mental health services. Some extra resources were available. But Jonathan O’Brien said the message to staff was that this wasn’t about having more money to do more of the same. It was about taking a fresh look and reviewing the pathway to be more efficient and to make sure those at risk were seen first. He says the trust now achieves 70 per cent of referrals in four weeks and aspires to get to 95 per cent.
The trust’s crisis service is now rated outstanding - it was rated inadequate in 2015. CQC’s latest report highlighted the access and crisis team’s call centre as highly responsive and exceptionally well organised. Patients did not have to wait long to speak directly to a clinician. And the interventions provided by staff were of an excellent quality and range. Buki Adeyemo says the crisis team generated the improvements. Response time is now one hour for urgent needs and four hours for routine. And people can call the team directly.
In line with the determination to continue its improvement journey, the trust announced a major development. A new £1.1 million Mental Health Crisis Centre will be based at the Harplands Hospital. The new service is unique in the NHS, says the trust. It will bring together under one roof a range of teams offering a service to people of all ages - all day, every day.
Importance of system working
Chris Bird emphasises the importance of working with partners. “To be successful we need a vibrant and pluralistic voluntary sector economy, so we need to be a more active presence in the voluntary sector market.” He sees the trust as being an ‘anchor institution’. “Not just looking at people who use our services, but staff, local businesses, the university - asking ourselves, what’s our contribution to the community?”
“As an organisation we had to put a lot of thought about what ICSs [Integrated Care Systems] and ICPs [Integrated Care Partnerships] are to us. We had board development sessions on what the ICS means to us and what PCNs [Primary Care Networks] mean to us. We are now a provider of front-line primary care as we have two GP practices. Alignment with primary care is very relevant as we want to be sure that the new model of delivery is done in a way we can complement. What opportunities are there to expand interest in primary care to other services? One in three GP appointments have some kind of mental health link - so in our interests to make sure model for primary care is responsive to people’s needs and linked to us.
“We have used formation of PCNs as a catalyst for conversations about locality services: what should be at a local level and what at a PCN level?”
According to Peter Axon, sustained improvement will only be possible through the trust being an active participant in an effective local system. “Integrated [care] partnerships are where it’s at.” His vision is for three ICPs in the integrated care system. And the North Staffordshire ICP would cover an area which is co-terminus with the trust. The ICP would operate all delivery and outcome focused services. Key within that will be population health management. That would need to be more predictive and joined up with social care and the primary care networks.
“The ICP has to be the hub that drives outcomes for local people… The challenge is the practicalities – having the right data and the right analytics to proactively manage the resource... We have to be innovative and transformational and do things differently.” The trust is already an active player in the system. It leads the mental health workstream for the STP. And it coordinates the system response to the NHS long term plan for mental health.