The below article originally appeared in Managers in Partnership's Healthcare Manager publication.
Taking a walk through the grounds of St Ann’s Hospital with chief executive Maria Kane reveals as much about her leadership style as interviewing her. In just a few minutes, she stops to help patients who are lost or struggling with kerbs, greets many staff members by name, jokes with several of them, and inquires after the health of another whose foot is in a cast.
Kane would probably deny knowing everyone on the rambling St Ann’s site – or at the trust’s other facilities across north London. But the chief executive of Barnet, Enfield and Haringey Mental Health Trust (BEH) is obviously a visible presence for many staff, including those based at remote sites or who work irregular hours. To hear their views and concerns, she holds regular sandwich lunches for a cross section of staff, as well as visiting out-of-hours services.
The St Ann’s site may be green and pleasant, but it’s one of Kane’s major challenges. The buildings are no longer fit for purpose and, as the Care Quality Commission (CQC) said earlier this year, hamper the trust’s ability to deliver safe services. A planned redevelopment will have to be funded by the controversial sale of part of the site for housing. In the current financial climate, Kane sees this as the only way to secure better healthcare facilities.
The poor state of its buildings was a factor in the ‘requires improvement’ rating the CQC recently gave the trust. Although there were positive findings too, the CQC highlighted problems common to many trusts in both the mental health and other sectors, including a shortage of permanent staff and excessive use of temporary workers. As an outer London trust, BEH faces the challenge that many people will prefer to travel a few tube stops further to get the increased pay (and perhaps prestige) that comes from working for an inner London trust.
The trust’s deficit – forecast to be £12.6m this year, £3.5m above the control total set by NHS Improvement – is another challenge shared with many NHS organisations. But with mental health trusts, cost cutting can have a quick and brutal impact on patient safety.
This is “not a comfortable place to be,” Kane admits, and managers have to consider the minimum requirements for a safe service. “It’s about managing risk – probably an increasing risk as the thresholds [for access to treatment] have got higher.
“That’s a line we’ve consulted on,” she continues. “We’ve had a lot of clinical input on it. We try to have sensible conversations about trying to make sure that the resources go to where they make the most difference.”
This trust’s deficit persists despite a strong savings record, and some of the lowest costs per referral in London. “Need goes up and finance in real terms is, at best, flat,” Kane says. “You get to the crux where it is no longer doable. That’s where we are. It’s a balance between keeping as lean as we can but also keeping the goodwill of staff.”
None of these myriad challenges diminish Kane’s obvious enthusiasm for the job or her appreciation of the sometimes very hard and testing work the trust’s staff do. But she knows that many people’s care will need to be delivered in a different way in the future, and that prevention and early intervention need to come to the fore. With the population of its catchment area increasing by 2% a year, and an ever changing cultural mix, the trust’s services can’t remain static.
As well as mental health, the trust runs general community services in Enfield, so the opportunities offered by more integrated services should be significant. For older people, the three Ds – dementia, depression and diabetes – should make a co-ordinated approach to both physical and mental health particularly valuable, potentially offering better care and a more holistic approach to patients with multiple conditions.
Mental health leads the way
Other services can learn a lot from how mental health services have developed over recent decades. “A lot of the skills needed to help people self-care come from mental health care,” Kane points out. “We have very skilled staff, who are really able to help that motivation, that ability to look for ways for people to help support themselves.”
Young people, used to looking at screens, may not want traditional approaches to healthcare, she adds. Although the UK is certainly lagging behind the pace of technological development in healthcare, she warns it is just as important to develop a workforce which is competent to cope with the technology.
But even with technological innovations, mental health care is going to remain a very workforce-focused service, where ongoing relationships and trust are key to realising therapeutic benefits. Kane claims the ethos of care at BEH has very much moved from “what’s the matter with you?” to “what matters to you?”. Patients want to “live, love, do”: they want to have somewhere safe and secure to live, to be connected through relationships, and have something meaningful to do.
“These are the sorts of things that give people the resilience to cope with their conditions,” she explains. It may not look like much to ask for – but her teams have had patients who are living in sheds and cars, and the lack of social housing in London is always a challenge, especially with increasing numbers of people living alone. “We need to look at a very extended workforce,” says Kane. “Do we have mental health workers who can support both mum and children, for example? Who are the people in Surestart or early years’ services?”
Seizing opportunities for interventions also means looking beyond the boundaries of traditional services. Could, for example, north London’s Turkish community be offered support through the many barber shops in the area? Their staff are used to dealing with men in very intimate situations – perhaps they might be prepared to open up about how they’re feeling and can be directed to services which could help. Kane feels very strongly about the inequalities faced by people with mental health issues. “We know that someone with a serious mental health illness is [on average] going to die 15 or 20 years earlier than someone without,” she says. “There are certainly [parity] issues in terms of outcomes.” And while there are standards prescribed for much of physical healthcare – such as referral-to-treatment times – she points out that these are only just beginning to creep into mental health services.
Social care ‘decimated’
Kane warns that many determinants of mental health lie outside the scope of healthcare services and funding, and changes in the rest of the public sector are making things harder. “Some social care has been absolutely decimated. We’re seeing people break down more,” she says. The shortage of housing stock and care homes prepared to take older people who have had a mental health admission also makes it harder to place people back in their communities.
“One of the key planks of caring going forward is, what can we do to prevent things developing in the first place? That includes trying to deal with children,” Kane says. “The first 1,000 days of someone’s life are the most important. Are we offering enough care in pregnancy and those early years? We’re very short sighted on this. There is fantastic evidence about investing early, especially around children’s behavioural disorders where the savings are multiples of the cost.”
Early intervention can reduce costs later on, when children run into problems at school, such as exclusions, or get involve in crime. “We’re just creating lifelong problems which consume huge amounts of public sector resources as well as the cost to the person themselves,’ Kane says. “Commissioners are often very willing to look at children’s mental health, but the way the system works – when you budget one year at a time – [means] the facility to invest to save, to invest in years one to five to get the returns in years five to 20, does not appear to be there.” she continues. And while there has been money coming through for children’s’ mental health services, it is often earmarked for specified additional activities.
With a very diverse population, there are also different cultural attitudes to unpick. “There may be cultural backgrounds where parents would rather their son is in prison than diagnosed with mental health problems,” Kane says. “It means that our first encounter with someone may be in the back of a police van.”
Signs of hope
But there are signs of hope. Sustainability and Transformation Plans (STPs) have “enormous potential”, she claims, because of their focus on care, regardless of where it is delivered, and the ability to look at healthcare provision at a population level. “The STP in our area is looking at mental health with a view to investing because we do need to transform. The enablement ethos is probably how we’re going to do this.”
With good community services, Kane argues that inpatient services can almost be seen as a tertiary service. “Often inpatients is not the right environment – it’s increasingly for patients who’ve been sectioned, which makes it harder for voluntary patients.”
However, Kane’s trust, and many like it, are struggling with a falling bed base while the population is increasing. “We’re putting people in the private sector because every single bed is full. This is happening everywhere. It feels as if it started two years ago, when we suddenly had a spike in people coming in,” she says. There are many reasons, but the disintegration of community support and the effects of austerity could be the most significant, she says.
At the same time, Kane’s trust has familiar problems with delays in discharging people back into the community. Some of these may originate with the NHS, but most are external – housing, for example. “These are the sort of things that mean that the pathway is not as free flowing as we would like,’ she says.
Working in mental health can be a tough choice for both managers and staff, but it brings rewards, Kane insists. “Our staff give people their life back – a real meaningful life. It’s not the kind of job that gets you boxes of chocolates and thank you cards. You see people through a time in their lives when they don’t want to be here… they don’t want to be breathing.
“I have friends and some extended family members who have had lifelong mental health problems, and for 30 years I have been either a volunteer or a trustee in mental health organisations – I’m currently a trustee of Young Minds. I feel naturally drawn to people who don’t have much of a voice.”