On October 27th I attended a meeting of the Mental Health Reference Group in Hereford. This group has been in existence since 2008, lobbying to improve mental healthcare in Herefordshire by involving service users and carers.
There were about ten service users and carers at the meeting. A representative of Healthwatch Herefordshire also attended.
The guest speaker at the meeting was one of the 2gether Trust’s managers in Herefordshire. He started by drawing an organization chart on the whiteboard, which is usually a very bad sign indeed at the start of a presentation. But this presentation proved to be an exception — informal, candid and realistic.
The speaker has two levels of management above him just in Herefordshire, which I found a little odd considering that the people being managed are skilled professionals. He had previously managed the psychiatric inpatient unit in Hereford, and is now in charge of adult mental health services in the community.
He reported ongoing consolidation across the county of the services he manages, although staff may remain area-based. Indeed, paradoxically, some staff may become more area-based as unnecessary travel is eliminated.
This led to a discussion about psychiatrists, because a patient might see one psychiatrist depending on where they live in the county, and a different psychiatrist while they are an inpatient. They can’t generally choose which psychiatrist they see.
Amongst the changes he hopes to bring in, there will be a more standard approach to care plans to ensure that patients always have the opportunity to agree their care plan and get a copy of it. It was widely agreed that this doesn’t often happen at present.
Someone pointed out that work on care plans has been going on for years and years, but many patients still don’t get care plans. Someone else reported seeing a care plan briefly before it was whipped away, unsigned, and never seen again. And someone asked how he could get a care plan as he didn’t think he had one at all after recently being discharged from hospital. He was told to ask his care coordinator or CPN. (Whose contact details, presumably, are in the care plan.)
A vision of the future in which patients would all own their care plans was put forward, and the general feeling was that this is how things should be.
Other planned changes will affect supervision of staff — that is to say, professional support for clinicians. Arrangements are to be standardized throughout the county and record-keeping improved.
Someone mentioned that supervision for volunteers is equally important, but the speaker ignored her remark (rather pointedly, I thought).
Quite a lot of other changes were mentioned, and the group generally welcomed them. The feeling was that things are moving in the right direction but there are still significant problems.
The speaker, being a manager, naturally had a process view of mental healthcare. Outcomes were never mentioned, although he did make some remarks in passing that suggested he understood something about patients’ individual needs — the clinical importance of formulation, and the value of continuity of care.
Members of the group fitted in with his process view. For example, the discussion about care plans was all about making the care plan process work, as if a care plan is the desired end result. No one said it in terms of, “If I had a care plan I could…” There seemed to be no desired real-world end result in terms of mental health or anything else.
An exception to this was a comment by one group member near the end of the meeting. She expressed her dissatisfaction with the constant changes taking place in the NHS locally, and in particular that patients like her were constantly having to get to know new clinicians. This is where the process view and the real world clash. In the process, clinicians are interchangeable and it doesn’t matter if a patient sees a different nurse at each appointment. In the real world, it’s important for people to develop relationships that they can trust.
The Healthwatch representative, in response to a question, spoke briefly about his organization’s role, which he said was to monitor and inspect services and report its findings to those in charge. He said that lack of resources meant they had to prioritize, and that they had therefore decided to inspect care homes.
This was an interesting choice, because it turned out that Hereford County Hospital has been having significant problems that Healthwatch presumably missed. A Care Quality Commission inspection there found that A&E and medical care were inadequate, with improvements also needed in other areas. Wye Valley NHS Trust, which runs the hospital, has been placed in special measures by the NHS Trust Development Authority.
Healthwatch is now inspecting the hospital wards. The Healthwatch representative was unapologetic.
The group’s next meeting will be on November 24th, but I don’t know the agenda yet. I might well go along again because it’s always interesting to hear people’s experiences of mental healthcare at first hand.