Are the Avon and Wiltshire Partnership honestly ‘Putting Patients Firts’?
A recent consultation paper, follows on from a compulsory competitive tendering (CCT) process initiated by the local Clinical Commissioning Group overseeing mental health services in Bristol against a background of budget reductions . The Avon and Wiltshire Mental Health Partnership (AWP) has produced its paper – Modernising Mental Health in Bristol Consultation Paper (1), and has initiated a series of team-by-team HR briefings which have outlined a plan whereby in each of the three Recovery teams (to be renamed ‘Assessment and Recovery Service’) and the Early Intervention team there will be significant reductions in qualified staff. In particular a cut of around 50% in the amount of band 6 staff in each team, and some reduction in band 5 staff is proposed. There is still much vagueness here in that management are claiming that the exact details and amounts are not yet fully confirmed, and calculations incorporating factors such as agency staff who haven’t been replaced, and numbers of people on long-term sick, still need careful attention. The concerns raised thus include Assessment and Recovery; Early Intervention and Crisis Recovery, and are listed below.
First, it is proposed that introducing 25 unqualified band 4 Recovery Navigators (RNs) (envisaged as eventually being employed wholly by Voluntary/Third Sector partners) into each Assessment and Recovery team will make up for this loss. It is supposed that each RN will have caseloads of up to 30 service users (thus taking on effective care co-ordination responsibilities) made up, it is claimed, of the less complex/non-CPA service users. Each qualified staff member will have supervisory responsibilities for three Recovery Navigators in addition to their own caseload which we are told will consist of up to 18 people.
Trade unions in AWP have produced a response[ TUresponse] and are rightly concerned on the effects of these cuts on the quality of care for patients. In particular, they are arguing the case that:
- It goes against professional standards of safety and duty of care to expect each qualified staff member to carry significant responsibility for the well-being and risk management of around 90 service users in addition to their own caseload.
- The time and effort alone required for this additional supervisory work, which is likely to require regular guidance and advice, will add much to already high workload pressures. Furthermore, it is being proposed that qualified staff will have to shoulder the major burden of completing risk assessments for service users under the care of RNs, including for service users whom they may lack a full picture for and thus will risk their professional registration. In any case, there are still many unanswered questions about the nature of the training to be given to the RNs.
- Currently Band 5’s do not have supervisory responsibilities and thus this is a marked change of role. It is not evident that this change of role been properly evaluated. This also applies to the potential for band 5s to be given a new role to help fill gaps in the assessment teams.
- There is a strong case for not trusting the promises that caseloads for qualified staff will be limited to 18 service users. Previously promised limits have been ignored. Thus Recovery caseloads were supposed to be pegged at 25 at the last re-design in 2012, before rising to around 30+ (in addition to assessment and duty roles), and management itself has recognised that a number of band 4s have struggled following a change of their role to include managing a caseload of clients in the 20s, partly manifesting in a high turnover of staff. Yet it is band 4s who are billed as having a central role in the new model.
- With regard to the claim that RNs will have less complex/non-CPA clients, it is should be noted that already much work was supposed to have been done in the last year, 2013, involving two band 8 staff specifically employed to scrutinise team caseloads identifying less complex cases to be stepped to band(s) 5/4 or for discharge back to the care of their GP’s. At the end of the process it was found that only about 10% of Recovery caseloads in Bristol were ‘less complex cases’. Many of these were not appropriate for discharge and band 4 and 5 caseloads were already at full capacity. This exercise ended with caseloads for Bristol Recovery teams remaining at levels in excess of 30.
- This puts into question claims that avoiding risky clients being allocated to RNs will be a straightforward exercise. Currently in Central Recovery around 67% of caseload are considered complex enough to be requiring CPA. With reference specifically to the EI caseload, non-CPA clients presently form only a small part of it hence begging the question of where the less complex clients will come from.
- Further cause for concern regarding capacity under the new model is the complex clients – requiring intensive multi-agency working – under Ministry of Justice sections, CTOs, Safeguarding, MARAC, Child Protection and MAPPA. Again, we are faced with the prospect of more of such clients being pushed down to band 5s and even band 4s. On top of this there will be additional clients with RNs who may still require depots from qualified staff.
- Halving the number of band 6 posts in Recovery teams to just eight staff on this grade creates a high likelihood that a number of qualified staff – especially, but not exclusively, band 5 – will lose their jobs.
In sum, these plans are unworkable and a threat to the well-being of already over-burdened staff, but most fundamentally they are extremely reckless in relation to patient safety. Furthermore, it is hard to see how the attendant workload pressures will allow the spaces required to deliver decent therapeutic interventions, or even just to properly listen to clients.
The concerns do not stop here.
For example so far as the Early Intervention Service (EI) is concerned The publicly stated plan is for a service which ‘replicates the existing high-performing early intervention in psychosis service presently provided’, one which adheres to the national pattern of reducing suicide rates, improving longer term outcomes and helping reduce the number of service users having extended careers as patients within secondary services. However, even acknowledging that the proposed EI model remains especially poorly defined and fluid, there is good reason to question the viability of this planned continuation of EI given proposals which significantly undermine central EI principles of lower caseloads and structured psycho-social interventions.
- In the proposed new model there are reductions in the number of staff including medical staff, registered staff including band 7s, band 6s and band 4 staff as well as the re-banding of staff to lower grades.
- As in the recovery teams it is proposed that band 4 staff care coordinate a caseload of less complex, non-CPA service users. Currently these service users make up a small percentage of the EI caseload and band 4 staff in EI do not care-coordinate. This shift reduces the capacity of the band 4s to facilitate recovery via interventions such as the Recovery Star, practical support, assertive engagement, active life, specialist Individual Placement and Support (IPS) model vocational support, and numerous core group activities.
- As in the Recovery teams this and the de-banding of half the band 6 staff will add increased supervisory pressures for registered staff reducing capacity to deliver core recovery focused interventions including psychosocial interventions. A reduction in the number of band 7s is a concern. The introduction of band 5s to make up numbers are a further concern given that staff at this grade have less post graduate specialist training to deliver the specialist interventions that this client group require to best aid recovery. Band 5’s will also have less clinical experience at managing clients with complex needs and high levels of risk.
- It’s proposed that qualified caseloads will expand up to 20 (and likely beyond given current pressures). Current EI caseloads are supposed to be capped at 15, but regularly run above 20.
Serious concerns similar to those above have been expressed surrounding issues of expanding caseloads and resulting issues of patient safety and clinical responsibility.
Thirdly, there are further concerns over plans for the Crisis Service whereby the consultation paper suggests that ‘the new Crisis Service model will provide an enhanced high quality service to people contacting us in distress’, there remains much confusion about what the staffing levels will be, the effect of the changes in geographical team bases, and the knock-on effects of the wider changes to the Recovery teams.
- The impact of the band 6 changes proposed for the Assessment and Recovery and Early Intervention teams is likely to increase risks and the team workload. There is concern that many complex service users, who are likely to feel the effects of these changes, will present regularly in crisis.
- There are concerns by staff about how the team ‘must…(undertake) mental health emergency assessments seen within 60 minutes (p.14). Although staff do acknowledge the importance of responding immediately to service users in distress, there are questions as to how feasible this will be due to the caseload pressures of the team and overall assessment numbers. 60 minutes is potentially setting the team up to fail and placing staff under increased pressure to deliver. This could put other service users at risk.
Frontline assessors have highlighted the importance of taking time to think, talk and reflect on assessments that come in as this promotes good clinical practice.
Finally, staff have concerns that the fragmentation of the teams is likely to have a detrimental effect on staff decision making. Risk sharing and ‘corridor conversations’ are crucial to the work of the intensive team. To think carefully and have support from colleagues when making complex decisions regarding services users’ care is paramount. Recovery staff have raised similar concerns, acknowledging the significantly reduced office space available in the new sites. There is also a general consensus that mobile working with laptops and using ‘where appropriate public spaces’ (p. 12) is inappropriate and has potential for issues around confidentiality. Non-cycling staff based in at least one of the proposed sites (Well Spring) will be faced with severely limited parking capacity and efforts to circumvent this problem (such as by using public transport or parking greater distances from the base) will eat further into already pressured work hours.
In sum we are extremely worried that the management proposals of AWP will have a serious detrimental effect on the welfare and quality of care of the mentally ill in Bristol.