Independent Oversight and Assurance Group on Tayside's Mental Health Services

Final Report from the Independent Oversight and Assurance Group on Tayside's Mental Health Services.

Workforce Work Plan

249. The Trust and Respect report recognises the central importance of effective workforce planning and engagement in ensuring high quality mental health and learning disability services in Tayside. This work plan brings together 10 recommendations from Trust and Respect and there is some overlap with Work Plan 3 on Culture and Engagement.

250. Members of the Oversight Group spent two days in Tayside in June 2022, focusing on issues around workforce. We have, of course, spoken to many members of staff throughout our work on other work plans, so these two days built on our experience overall, rather than starting from scratch.

251. Once again, we have been struck by the commitment, professionalism and resilience of colleagues across Tayside, in both inpatient and community mental health teams. We have also heard positive feedback about the way in which Police Scotland engages in the mental health delivery across Tayside. We are grateful to all concerned for their time and candour during our meetings.

252. We spoke to a range of colleagues in Carseview and Strathmartine, as well as colleagues from the Human Resources and Organisation Development teams and staff side representatives from NHS Tayside. We also met with colleagues from community mental health services across Angus, Dundee and Perth and Kinross. Finally, we spent half a day with the Tayside Integrated Leadership Group, doing a deeper dive into each of the recommendations.

253. We recognise that the context for workforce planning and engagement is highly challenging and many of the issues we highlight here will be found across the country, particularly in relation to recruitment and retention. We recognise the steps taken by NHS Tayside to manage these challenges, for example recruiting to newly graduated health practitioner posts.

254. The pandemic brought unprecedented pressures across the system and ongoing financial and recruitment constraints mean that developing a strategic approach to workforce planning is difficult. But, those same pressures and challenges mean that effective workforce planning and engagement is more important than ever.

255. These challenges are recognised in the NHS Tayside's own strategic risk reporting, as set out to the Staff Governance Committee in October 2022. In an assurance report on the 'workforce optimisation' strategic risk, the risk is rated as 'high'. This provides a detailed description of the significant challenges in relation to recruitment, retention and absence, concluding that the controls in place to mitigate the risk are 'incomplete' (defined as 'Controls are appropriately designed but these are not consistently applied').

256. Before considering each recommendation in turn, we would make the following observations in relation to progress against the workforce recommendations overall:

  • It is clear that teams across Tayside continue to be under severe pressure due to unprecedented demand and staff shortages, primarily caused by vacancies and absence. Teams are doing all they can to mitigate these pressures on a day-to-day basis, but it is taking its toll and we have detected at times a fragility in some staff and managers' emotional resilience as they discuss the carrying out of their duties.
  • The workforce strategy presented to the Oversight Group is very high level and requires further development if it is really to shape decisions around the future of the mental health workforce in Tayside. It remains challenging for the partners to plan on a pan-Tayside basis, and much of the human resources and organisation development support continues to be NHS Tayside focused.
  • There is a feeling, particularly in inpatient teams, of 'ground-hog day'. We found little expectation that things were going to be different this time around. Staff with longer service spoke of the many different reviews and oversight groups that have come and gone in Tayside over the years, and felt that fundamental, sustainable change remained elusive.
  • There continues to be a need for more visible leadership in some parts of the system. Some colleagues, particularly in inpatient teams, feel very strongly that decisions around the future shape of inpatient services need to be progressed urgently. Staff continue to do their best to take action to improve care for their patients within their immediate sphere of influence, but there is a strong sense of powerlessness when it comes to more strategic decisions.
  • It is therefore, important that the Tayside Executive Partners' approach to collective leadership creates the right environment for managers and staff to work together to redesign mental health services and deliver continuous improvement across the system. The Integrated Leadership Group needs to know they have the permission, and the capacity, to drive change on a pan-Tayside, cross organisational basis.

Recommendation 10

Ensure that there is clarity of line management for all staff and that all appraisals are conducted effectively.

Context of Oversight Group assessment: Ensuring that all staff receive a meaningful appraisal is an important contributor to staff and team performance and organisational culture more widely.

257. The Tayside Partnership has taken steps to ensure that line management arrangements are more clearly understood. However, appraisal completion rates are significantly lower than the target and it is clear that many staff are not benefitting from a regular, formal appraisal discussion.

258. We recognise that expectations around the completion of appraisals were relaxed during the pandemic. Appraisal completion rates are monitored by the Integrated Leadership Group and reported to Staff Governance Committee. As at March 2022 the completion rate for appraisals was below 25%. In October, the rates for appraisals competed and in progress was 43.9%, significantly short of the target of 95%.

259. It is clear that the Staff Governance Committee is concerned about completion rates and the scrutiny of the issue is welcome. In the end, though, it is the responsibility of leaders, managers and staff to ensure that appraisals are completed timeously. The Tayside Executive Partners' submission sets out a number of actions to increase completion rates and progress will continue to be monitored on a monthly basis.

260. Given the significant improvement still required in appraisal completion rates, the Oversight Group has rated this recommendation Amber.

Recommendation 18

Plan the workforce in community mental health teams in the context of consultant psychiatry vacancies with the aim to achieve consistent, continuous care provision across all community services.

Context of Oversight Group assessment: Long standing and continuing challenges in recruiting consultant psychiatrists requires a fundamental rethink of workforce planning and the development of new roles across community teams.

261. Planning the workforce for mental and learning disability services in Tayside clearly operates in the wider context of workforce planning for health and social care services across Tayside. NHS Tayside's Corporate Workforce Plan for 2022-25 was submitted to the Scottish Government in September and the Staff Governance Committee considered the Scottish Government's feedback at its October meeting. We would concur with much of the feedback from the Scottish Government team and more work is required to fully develop an effective plan that will begin to meet the workforce challenge in Tayside.

262. More specifically, the Tayside Executive Partners' submission quite reasonably highlights that challenges in recruiting consultant psychiatrists is a national problem. It is unlikely that consultant vacancies will be filled any time soon.

263. It is therefore, more important than ever that partners in Tayside look to redesign services and the roles that different professionals play in delivery. A needs assessment for Advanced Nurse Practitioners has been carried out and some progress is being made in recruitment and training for these roles. This will go some way to easing the pressures.

264. But, there is a long way to go, and community mental health teams continue to be almost wholly reliant on locum consultants. It is also the case that Tayside has one of the highest proportions of inpatient mental health nurses in Scotland. It is therefore vital that effective workforce planning is in place for mental health services across Tayside.

265. With this in mind, we have reviewed the document, 'A Plan for Whole System Workforce, Recruitment and Retention 2022-25', which supports the Tayside mental health and wellbeing strategy. While this contains some good data and analysis about the existing workforce challenges, it is perhaps best described as 'a plan for a plan'. It remains unclear, therefore, exactly how the partners in Tayside are going to reshape the workforce to build a more sustainable and resilient model of community mental health provision.

266. Given the scale of the challenge ahead in terms of workforce planning, the Oversight Group has assessed this recommendation as Amber.

Recommendation 42

Ensure all staff working across mental health services are given opportunity to contribute to service development and decision-making about future service direction. Managers of services should facilitate this engagement.

Context of Oversight Group assessment: Staff engagement is key to ensuring that people delivering services feel connected and empowered to provide the best possible services for patients and families. It also ensures that service development and decision making is informed by those closest to services and patients.

267. The Tayside Executive Partners' submission outlines a range of activity undertaken to develop thinking and plans in relation to how staff are engaged in service development and decision making. Staff were engaged in various ways during the development of Living Life Well and a series of engagement events have been held over the last 12 months, including the NHS Tayside partnership conference in July 2022.

268. In addition to these 'set piece' engagement events, we have been interested to understand the extent to which staff feel engaged in service development and decision making on a more day-to-day basis. During our work we heard from many staff that they were involved in how their immediate work is delivered, often in response to difficult circumstances and staff shortages. But, they were much less clear how to influence service change and decisions at a more strategic level. There was a sense that, despite engagement events and communication plans being in place, they had little expectation that their voice would be heard in more significant changes.

269. That said, we also heard evidence that new leadership in inpatient services and Integration Joint Boards is improving this. Staff felt more involved and more engaged than they had done before. But, the big test will come with the decisions to be made about the future of inpatient services in Tayside, which presents an opportunity for genuine engagement and, in the words of the Tayside Executive Partners' submission, 'co-creation of development of the service'.

270. The Tayside Executive Partners' submission references the Mental Health Partnership Forum as a vehicle for partnership working and staff engagement. The minutes of the Area Partnership Forum meeting in July 2022 notes some concerns about partnership working in mental health and learning disability services and it is suggested that 'an overarching mental health and learning disability partnership forum is established and attended by suitably senior representatives.' A meeting of the relevant stakeholders took place on 31 August 2022.

271. Finally, the October 2022 meeting of the Staff Governance Committee considered a paper setting out Tayside's response to the Scottish Government National Framework for Staff Governance. The Scottish Government proforma asks for, 'an example of how partnership engagement through the area partnership forum has influenced policy and practice in your health board over the last year'.

272. Tayside's response was that, 'Due to Covid-19 recovery, work in this area has not been able to be progressed quickly. However, meetings will take place in 2022/23 with the Chief Executive, Employee Director and Director of Workforce with the Chief Officers of the Health and Social Care Partnerships to discuss progressing Partnership working...' This response suggests that, despite the work to develop approaches to communications and engagement over the last 12 months, examples of how partnership working has contributed to service development remain elusive.

273. For these reasons, and while recognising the commitment in the Tayside Executive Partners' submission to engaging staff more effectively in future, the Oversight Group's assessment of this recommendation remains Amber.

Recommendation 43

Prioritise concerns raised by staff by arranging face-to-face meetings where staff feel listened to and valued.

Context of Oversight Group assessment: Trust and Respect found that too many staff did not feel heard and found it difficult to raise concerns safely. This recommendation is about the extent to which staff feel able to raise concerns in an effective and safe way.

274. It is clear that new leadership in mental health and learning disability services has brought a renewed focus to staff engagement. As well as the more formal staff engagement sessions that ran over the summer of 2022, managers are now trying to be more visible and ensure there are more opportunities for face-to-face communication.

275. The Tayside Executive Partners' submission highlights the results of iMatter surveys as a key source of evidence for this recommendation. We recognise the value of iMatter as a tool for gathering feedback on how staff feel about working in Tayside. There are undoubtedly some encouraging messages about the extent to which staff feel heard and listened to.

276. The October 2022 meeting of the Staff Governance Committee received an update on iMatter for 2022. The response rate across NHS Tayside and the three Integration Joint Boards sits at 58%, and has been relatively consistent in recent years. It is also the case that the completion of action plans in response to the survey results has dropped off somewhat, with 42% of action plans completed within 8 weeks.

277. Inpatient mental health services had one of the lowest response rates across Tayside, at 46%. Inpatient services also had one of the lowest rates of action plan completion, with just 22% of plans being completed within 8 weeks. This is worthy of further exploration by the Integrated Leadership Group.

278. So, while there has clearly been real effort to respond to this recommendation, we are still not assured that the actions contained in the submission will be sufficient to achieve the desired outcomes for staff. So, the Oversight Group's assessment remains at Amber.

Recommendation 44

Arrange that all staff are offered the opportunity to have a meaningful exit interview as they leave the service. This applies to staff moving elsewhere as well as those retiring.

Context of Oversight Group assessment: Exit interviews mark an important juncture in the employee/employer relationship. They provide a forum to hear and learn from colleagues who are leaving or moving within the organisation. For the employee, it is an important opportunity to receive recognition for their service and the contribution they have made to the organisation. Importantly, information from exit interviews informs recruitment and retention and workforce planning.

279. Revised arrangements for exit interviews were introduced following review of NHS Tayside's Talent Management Strategy, 'Planning Potential', which was approved by its Staff Governance Committee in June 2021. The first report arising from exit interviews following the introduction of these arrangements, was considered by the Staff Governance Committee in April 2022. We welcome the fact that exit interview data will be presented to the staff Governance Committee every six months.

280. Between July-December 2021, 101 unique leavers submitted an exit questionnaire which represented 11.3% of total leavers during that period across Tayside. All of the respondents had completed an exit 'interview' by way of an online questionnaire. The report provided an assessment of those leaving, or moving within, NHS Tayside, including Health and Social Care Partnerships. The report helpfully outlines some of the main reasons cited for leaving. We note that the exit interview papers considered at Committee in April and October were presented, 'for awareness' and the committee was asked, 'to consider the report, making any suggestions for improvement'. However, no assurance was sought or received and there were no clear actions arising from the report.

281. The final submission from Tayside Executive Partners confirms that staff who are leaving/exiting/retiring from mental health services are given the opportunity to provide feedback on their experiences within work either via online questionnaire, or face to face, as preferred. It is stated that due to the low uptake of interviews, data collected has been insufficient to provide reports which do not identify individuals (although no indication is given as to face-to-face interviews vs online questionnaires). Managers have been asked to share themes to be discussed at operational meetings, although it is not clear what those themes are, or how regularly they are discussed. The data is also shared with Local Partnership Forums.

282. The figures from July 2021 to March 2022 show 9 exit interviews were completed in mental health and learning disability, from a total of 36 leavers. In terms of supporting evidence, Tayside Executive Partners point to staff being aware of the opportunity of having an exit interview, as 25% availed themselves of this.

283. The update to the October Staff Governance Committee contained similar key messages, with relatively low numbers of leavers completing an exit questionnaire. The numbers in mental health and learning disability services were too low to provide any meaningful analysis of trends.

284. Given the low levels of uptake, and the subsequent limitations on the analysis that can be undertaken, the Oversight Group assesses this recommendation as Amber.

Recommendation 45

Prioritise recruitment to ensure the Associate Medical Director post is a permanent whole-time equivalent, for at least the next 2 years whilst significant strategic changes are made to services.

Context of Oversight Group assessment: The Trust and Respect report recognised the importance of dedicated senior leadership to lead the changes required.

285. It is clear from our work that Tayside partnership has invested in senior leadership roles for mental health and learning disability services. Having unsuccessfully tried to recruit to an Associate Medical Director post in 2020, the more senior role of Operational Director Medical Director, Mental Health and Learning Disabilities was advertised and filled on a permanent basis in September 2021.

286. More broadly, we also recognise that there have been significant changes in the leadership across mental health and learning disabilities, in both inpatient teams and in Integration Joint Boards. We welcome these changes and it is clear that the Integration Leadership Group are committed to change and improvement.

287. The Oversight Group assesses this recommendation as Green.

Recommendation 47

Develop robust communication systems both informally and formally for staff working in mental health services. Uses of technology are critical to the immediacy and currency of communications.

Context of Oversight Group assessment: The extent to which staff working across Tayside benefit from robust communication systems which not only keep them informed and updated on what they need to know to do their job, but are also two-way and allow staff to engage and have their voice heard.

288. In their final submission, Tayside Executive Partners acknowledge that a history of poor communication about service development and planning around mental health services in Tayside contributed to a lack of trust amongst staff. They recognise that communication systems need to be inclusive and reach colleagues working across Tayside in both inpatient and community settings.

289. The new Communications and Engagement Strategy put in place by Tayside partners, is multi-channel in its approach and includes e-bulletins and corporate e-briefings and a wide range of fora for in-person briefings. Whilst we have made comment about the potential for this to be more relational in its delivery and impact, there is a clear framework for communication and engagement.

290. Staff we spoke to were positive about these developments and valued the opportunity in-person briefings afforded them to engage in reflective practice and service improvement. There was also positive feedback on the increased use of new technologies thereby allowing communication and engagement across a bigger geographical area. It was acknowledged this had been accelerated in response to the pandemic.

291. However, staff also told us about some of this engagement being circular with decisions not being taken, when that was clearly needed. This was frequently cited in respect of proposals for a single site for General Adult Psychiatry inpatient services.

292. A number of improvements have been put in place in response to this recommendation, however, Tayside Executive Partners will want to satisfy themselves that feedback mechanisms including iMatter, Pulse Surveys and Trickle, to assess delivery against outcome and the need for further improvements are being fully utilised.

293. Tayside Executive Partners point to this recommendation being primarily about communication but communication is two-way. In addition to processes needing to be effective, the environment has to be conducive particularly when it comes to listening to alternative views or things that are difficult to hear. We address this further at Recommendation 51.

294. Nonetheless, we are assured that Tayside have developed a comprehensive approach to communicating with staff and so we assess progress against this recommendation as Green.

Recommendation 48

Ensure that bullying and harassment is not tolerated anywhere in mental health services in Tayside. Ensure that staff have confidence that any issues or concerns they raise, will be taken seriously and addressed appropriately.

Context of Oversight Group assessment: As well as unambiguous messaging around bullying and harassment, and clear processes for reporting, it is important that Tayside partners are able to understand the extent to which staff have confidence that any concerns will be taken seriously and addressed appropriately.

295. Tayside partners have a range of policies and procedures which make it clear that bullying and harassment will not be tolerated. We welcome the recognition in the Tayside Executive Partners' assessment that, even with clear policies in place, bullying and harassment can exist.

296. Mechanisms for reporting formal cases of bullying and harassment are well established, via the Integrated Leadership Group and Staff Governance Committee. We also recognise the point in the Tayside Executive Partners' submission that the experiences of staff in the workplace more broadly are monitored through mechanisms such as iMatter and pulse surveys.

297. Numbers of formal cases are very low, with less than five in mental health services in each of the last three years. The Tayside Executive Partners' submission recognises the possibility that this could be an indication that staff still do not feel confident to come forward and formally report any experiences of bullying and harassment.

298. The submission sets out a range of actions that have been taken to ensure that staff and managers are aware of their responsibilities in relation to bullying and harassment. This includes training for managers, NHS Tayside wide briefing sessions and an offer of 1:1 confidential conversations with the Organisation Development team (although there is no indication of take up of the latter in the submission).

299. The October 2022 meeting of the Staff Governance Committee considered NHS Tayside's annual response to the National Framework for Staff Governance. Amongst other things, the Framework requires a response on the number of bullying and harassment cases raised and resolved across NHS Tayside, with information broken down into 'early resolution' and 'formal' stages. The Tayside response states that they are unable to provide data on the early resolution stage, despite this being a requirement in the national policy for bullying and harassment.

300. We recognise and welcome the increased acknowledgement in the Tayside Executive Partners' submission that bullying and harassment can exist, even where clear policies are in place. We believe there is still some way to go to gain full assurance that staff feel confident that issues and concerns raised would be dealt with seriously. For this reason, the Oversight Group's assessment for this recommendation remains Amber.

Recommendation 49

Ensure there are systems analysis of staff absences due to work-related stress. These should trigger concerns at management level with supportive conversations, taking place with the staff member concerned.

Context of Oversight Group assessment: Working in mental health and learning disabilities services can be incredibly rewarding and can be difficult. It is crucial that stress related absence is understood and monitored, in order for the partnership to take a proactive and holistic approach to the wellbeing of staff.

301. The Tayside Executive Partners' submission sets out a wide range of activity designed to help the wellbeing of staff. It is clear that senior management is very aware of the pressures on staff and the risks that can pose to people's mental health and wellbeing. We accept the points made in the submission that dealing with stress related absence is best achieved as part of a wider approach to employee wellbeing, and is closely related to issues such as clarity of roles, effective appraisals and a positive working environment.

302. We also recognise the resources that managers and staff have at their disposal to help manage wellbeing, such as Wellbeing Champions, anticipatory preparedness and Care First, an employee assistance service. These are all welcome developments on support of staff wellbeing.

303. However, the original Trust and Respect recommendation is specifically about the analytical systems and processes used to identify and manage stress related absence. We understand that the limitations of the national NHS Scotland reporting systems mean it is not possible for mental health services in Tayside to specifically identify and report on absences due to work related stress. This is a significant gap in arrangements to monitor and manage stress related absence.

304. Therefore, while recognising the good work taking place in Tayside on wellbeing, this appears to require action from the Scottish Government. The Oversight Group's assessment remains Amber.



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