Critical report says poor leadership damaging mental health care

Friday 19 November 2021

An independent review of adult mental health services has identified a lack of senior leadership, inadequate systems to learn from serious incidents, and poor management structures.

The study – commissioned by the Health itself after recognising that its own care was not up to scratch – is the first of many external reviews that the department says it intends to carry out.

Senior management say that honest appraisals of what is going well and what isn’t has not been part of the culture of healthcare in Jersey, which it hopes to change.

Health say it had accepted all the recommendations made in the £12,000 review, which was carried out over six days across September and October by clinical psychiatrist Professor Peter Lepping and Simon Pyke, a mental health nurse.

It has also published the report’s executive summary and recommendations in an effort to be “open and transparent”.

Earlier this year, the department came under fire for not publishing a performance report for fear that it would be “sensationalised” in the media. 

It later released the document, saying it was always the intention to do so.

The review into adult mental health services only covers Health’s input; it does not include the activities of charities, the Listening Lounge – which is commissioned by the Government to provide a ‘front door’ to services – and CAMHS, which comes under Education.

Pictured: Health Director General Caroline Landon has started chairing a weekly meeting providing 'executive oversight' of adult mental health services.

It was commissioned after Health saw an increase in concerns raised to the executive.

These included metrics showing increasing admissions of mental health patients, and those patients staying for longer in care.

Also, not all parts of Health are subject to independent inspection and regulation; therefore external review does not always happen as a matter of course.

The review found:

• There is a lack of senior management leadership and direction

• There is a lack of a system that formalises multidisciplinary team-working, which brings lots of skills together, from doctors and nurses to physiotherapists and pharmacists, to discuss a patient’s needs

• There are inadequate systems to learn from serious incidents with adult mental health. This was also highlighted last week at the inquest of a patient who was wrongly given end-of-life care after the pain she felt was attributed to cancer instead of a rib fracture.

• There is ‘silo working’ professionally and within teams.

• There is a lack of a system to “ratify, manage and implement policies and procedures

• There are poor management supervision structures 

• There are many professional staff in Adult Mental Health who are highly motivated to develop and improve the service. 

• Inpatient services have made some recent improvements, but further is required.

The reviewers have made recommendations in ten areas, which Health say they have, are or will implement. These are:

1. Senior management structure in Adult Mental Health. Recommendations include defining clear objectives that should be reviewed; and pausing the integration of Adult Mental Health and Adult Social Care “until such time that Adult Mental Health is considered safer”.

2. The service needs to introduce a ‘care programme approach’ to improve communication and create a practical multidisciplinary way of working that involves clinicians, teams, patients and relatives.

3. The review supports the direction of the Jersey Care Model but, within that, Adult Mental Health needs to develop its own clear model that is understood across all of Health.

4. Management roles within Adult Mental Health should be reviewed to ensure that they receive regular management supervision, have clear objectives, and understand their role within the whole service.

5. Policies and procedures. Recommendations include creating a ‘clinical risk management policy’ as a priority and providing ‘electroconvulsive therapy’ in Jersey “as a matter of urgency”.

6. The Community Mental Health Team should work across clear catchments area in the island rather than around services, as they do now.

7. Job plans for consultant psychiatrists need to be reviewed to ensure they help multidisciplinary working. They need to include management time for senior leaders and be in line with Royal College of Psychiatrists’ recommendations.

8. The model of care in Adult Mental Health inpatient wards should be reviewed to ensure effective multidisciplinary working and continuity of care between inpatient and community-based provision.

9. Adult Mental Health should join the networks established by the Royal College of Psychiatrists and work towards accreditation in each mental health specialism. 

10. There needs to be a “clear communication process” in Adult Mental Health that informs and allows staff to feel involved in the development of services.

Health senior management say have already starting to act on the review. This includes:

• Recruiting a Director of Mental Health, who is expected to start in January and will sit on the executive team – the ‘top table’ at Health. This will be the first time that mental health is represented at this level. It follows Dr Miguel Garcia-Alcaraz stepping down from the role of Associate Medical Director for Mental Health after two years, though he remains a clinical psychiatrist in the service.

• Pausing the joining of Adult Mental Health and Social Care services

• Reviewing the existing Adult Mental Health management team and putting the Deputy Medical Director in charge of a team supporting the service.

• Starting a weekly ‘executive oversight’ meeting chaired by Director General Caroline Landon

• Updating and ratifying polices

Commenting on the report, Health Minister Richard Renouf said: “Adult Mental Health is a much-used and much-valued service which we are committed to improving and the colleagues who work in them in a huge variety of roles do all they can for the islanders in their care. But we want to improve the way they are run even further.

“This report was commissioned by us; I think it is important to stress that we have chosen to publish it, we have not been asked to.

“The report was commissioned to provide an important external set of “fresh eyes” as an overview of Adult Mental Health services.

“Importantly, the findings of the report, which identified both positive findings and some areas for improvement are not about culpability or blame; it is about learning and transparency and part of a journey of change

“It is good practice which we support and I commend our staff for engaging with the review so openly and honestly, that engagement is how we ensure we deliver safe care and make improvements in the way our services are run.”