Back to the Floor: Katie Blackburn, Powys Community Health Council at Newtown Community Mental Health Team

Katie Blackburn (top left) with Newtown Community Mental Health team

In August last year I observed Superintendent Jon Cummins go Back to the Floor at the mental health inpatient unit in Powys, Felindre Ward, and wrote about the idea behind the activity and Jon’s experience on this blog. Put simply the concept is that Chief Officers, Service Directors and other high-level staff have the opportunity to experience a day in the life of a member of staff at the operational end of a service. This gives them the opportunity to find out what is really happening on the ground, and what consequences strategic decision-making can have on people who are in receipt of a service.

In late 2017 I was pleased to observe Katie Blackburn, the Chief Officer of Powys Community Health Council, go Back to the Floor at Newtown’s Community Mental Health Team. The county CHC is the “Healthcare Watchdog for Powys - an independent statutory organisation that represents the interests of patients and the public in the National Health Service in Powys”. Katie has been in post since January 2017.

Lauraine Hamer, Senior Practitioner AMHP (Approved Mental Health Professional) at the CMHT, met us at the start of the morning with details of what she had planned for Katie’s visit. This included chance to find out more about her work and that of her colleagues, plus an opportunity to join a Multi-Disciplinary Team meeting and also to accompany a Community Psychiatric Nurse on a visit to a client. In the event we had to stay flexible as circumstances changed throughout the morning… but such is life at a busy mental health service.

Before the visit: Katie’s view

I had no idea about the work of this particular CMHT in Newtown before my visit. From my previous life, I have an understanding of the roles of CPNs and social workers. I was CEO of a drug and alcohol charity and mental health is an issue there. To a lesser extent with The Prince’s Trust, I was working with vulnerable young people in the care system.

I was very keen to shadow and meet the team and listen. I felt that perhaps I could ask questions that other people were perhaps uncomfortable asking.

The key barrier I am aware of – which I know of from my domestic abuse background – is that whilst aspiring to put individual people at the heart in reality individuals are often bounced from pillar to post. For example, they might have to continually provide their national insurance number, or relate details of stressful events to different people. The journey should be (and could be) much smoother and easier. Sometimes we need to make a decision there and then, which might not fit in with governance and procedure. For example, the question of who pays to get people from A to B often comes up. If there is an individual who needs to be transferred from Brecon to Nottingham……who pays? Agencies can become tied up in which budget is paying for this journey and can lose sight of the individual’s needs.

When it comes to strategic issues, I am not aware of any recent changes within the CMHT, but, I am aware of, and have been involved with the development of the Health & Care Strategy and the intention to align health and social care in Powys. It will be nice to see the operational impact of that.

I am conscious that services are very stretched because of pressures on staff and budgets, and that things can sometimes become more complex and complicated than they need to be.

I hope that Powys’ Health & Social Care Strategy will bring change – whilst recognising that not everyone likes change; there is a risk of unsettling an already stretched workforce.

There will undoubtedly be a growing use of digitisation going forward – however, it’s about putting the individual first. With regard to a future workforce we need to identify what skills Powys needs.

Lauraine Hamer and Katie Blackburn

Back to the Floor exercise

Lauraine is an extremely experienced and knowledgeable Senior Practitioner, and was able to give Katie a very thorough grounding in the work of the team at Newtown CMHT. At the MDT meeting we met CPNs, members of the North Powys Crisis Resolution Home Treatment Team, Admin staff, a trainee AMHP, Social Workers, and a Support, Time and Recovery (STR) worker. Later we learnt more about the Accredited Accommodation Scheme* from the Co-ordinator Wendy Laws, and Katie spoke to Dr Fran Foster, a Consultant Psychiatrist.

Unfortunately, we were unable to shadow CPN Kelle Hall on a home visit to a client. This was due to a last minute change in the person’s circumstances.

After the visit: Katie’s view

When deciding whether my understanding of what the services does is correct, I think “no” is the simple answer. There were elements of it that I knew, however, other elements were new to me. Staff in the MDT meeting worked co-operatively very well together. Particularly when sharing information - the team focussed on the needs of the individual rather than their specific jobs.

The “seeing is believing” approach is very important. It would have been nice to sit in on a visit with an individual using services, but I understand the issues around confidentiality and the vulnerable lives people lead.

My main observation is that the people in this team are doing the best they can in the circumstances. There is clearly an issue around staff capacity. Other obvious issues include – cross-border, cross-boundary provision and the lack of in-county beds for people. In the MDT meeting, the real focus was on the discussion of high-end/vulnerable situations and not on the preventative side of the service. I wonder if there is an opportunity for reflection and discussion on what might have prevented a specific situation and what changes could be made in the future (if any)?

Staff are very much dealing in the here and now. They are not looking at people’s pasts or where they might be in five years’ time. I wonder - is there an opportunity to look at where resources should be channelled?

This experience will definitely mean I’m able to contribute more effectively at times when strategic decisions about services are made. I am a big believer in real-life examples. There are also pressures on recruitment for the CMHT. There appears to be an element of disjoint between strategic and operational. The staff clearly work well as a team, and there are a number of opportunities to build on (and share) existing good practise across Powys. In addition, their working environment is extremely poor, despite this, it strikes me that they are a dedicated, professional team doing their best in the circumstances.

Going forward, I am keen to do something in my role at the CHC around listening to vulnerable voices. There is definitely an opportunity to start with this service - certain groups do not access our service or receive support including young people and young carers. Listening to Vulnerable Voices will be a priority for Powys CHC in 2018-2019.

* Wendy Laws co-ordinates the Accredited Accommodation scheme in Powys, which is the only one of its kind in Wales. People supported by secondary mental health services are entitled to access day visits or overnight stays with registered accommodation providers who have their own lived experience of mental health distress. People accompany their hosts on shopping trips or days out to the seaside, for example, and enjoy a caring and nurturing environment. This service prevents hospital admission and people have described the incredible benefits of feeling part of an extended family.

Back to the Floor: Superintendent Jon Cummins at Felindre Ward

Superintendent Jon Cummins, Staff Nurse Melanie Fletcher, Dr Frank Medford

Years ago there was a BBC TV documentary series called Back to the Floor, where bosses returned to the shop floor to find out what life was really like as a worker in their company. This turned out to be both intriguing and extremely useful for the managers who took part.

Here in Powys the approach has been adapted by the Powys Mental Health Planning & Development Partnership* to give Chief Officers, Service Directors and other high level staff the opportunity to experience a day in the life of a member of staff at the operational end of a service. They have chance to find out what is really happening on the ground, and what consequences strategic decision making can have on people who are in receipt of a service. For someone experiencing mental distress in Powys, that service could be provided by a voluntary organisation such as a Mind centre or Kaleidoscope, or the statutory sector such as the NHS or the police, for example.

Every couple of months I attend the PMHPDP’s Engage to Change sub-group which focusses on enhancing the Partnership’s communication, participation and engagement activity to support delivery of the Powys strategy Hearts and Minds: Together for Mental Health. The great thing about this role is that it gives me the opportunity to participate in some of the Back to the Floor activity as an observer (I make notes, take photographs and feed back to the Partnership). The Partnership has identified three clear learning opportunities for the exercise: 1. Are we meeting our purpose? 2. What gets in the way? 3. What can we do better?

So it was that in mid-August I observed Powys Divisional Commander, Superintendent Jon Cummins, who is a member of the PMHPDP, go Back to the Floor at the mental health inpatient unit in Powys, Felindre Ward at Bronllys Hospital. Towards the end of our visit Jon also had chance to meet staff from the South Powys Crisis Resolution and Home Treatment Team. It was a brilliant opportunity for both of us to find out more about the workings of the ward and the CRHTT, and for the agencies to build stronger and better working relationships.

Felindre Ward, Bronllys Hospital

Before the visit: Jon’s view

I had been to Felindre Ward before during a Section 136 three years ago when I had a different role in Dyfed Powys Police. At that time I didn’t see beyond the S136 suite. The person was compliant and of no trouble to police or health partners, but in spite of this I could see that the joint working at the time was not quite there. I am keen to see how things have changed.

Throughout my career I’ve only been fleetingly in mental health secure and non-secure units across both England and Wales purely from a policing perspective and they all appear broadly the same. I have an image of rows of beds and people receiving care and attention in a stuffy unwelcoming environment.

I did not make such a visit to a mental health ward during my induction as a newly appointed student police officer a number of years ago when I entered the service. However, I would expect Dyfed Powys police staff to have some understanding of what goes on in Felindre Ward – it is important to have this understanding as part of their training and is something that we are currently working on with partners to implement. As only 11% of demand of what Policing is currently dealing with is crime related, it is even more important today for officers to have that rounded knowledge and perspective on mental health and vulnerability than when I first joined the police service as the nature of our work has changed.

The barriers to this that I am aware of are often around knowledge, training and the sharing of information between partners. Although we are consciously improving, we can be quite parochial and not always create opportunities for joint training and provision of services. And we can sometimes have misunderstood expectations about what the other agencies can do for us and us for them. 

There are also challenges around available resources in the right place at the right time. Powys is such a huge geographical area and the public rightly need the right resource dealing with them. For instance we were once asked by health colleagues to attend the home address and check on an admitted patient’s cat! It’s the little practical things which can make a significant difference, ensuring that both the community and our partners have an understanding of what the police can and should be doing to protect our communities.

When it comes to strategic issues, I am aware that all mental health services in the county have recently returned to be managed by Powys Teaching Health Board, having previously been outsourced to neighbouring health boards. A move to a single place of safety for S136 into Powys is one strategic issue that we will be working on over the coming months.

And I know there are current service gaps around the mental health provision for children – unbelievably they can still currently end up in police custody and then there will be headlines in the media and scrutiny on the police from a number of external partners such as HMIC (Her Majesty's Inspectorate of Constabulary) and the IPCC (Independent Police Complaints Commission). Policing feels that this can be a significant burden to carry when there are service gaps from other partners.

The perception is that people often using services at Felindre Ward are from certain aspects of the community. As we know children are ruled out due to age. I think the profile of service users differs across Wales. Here in Powys we don’t see the high volumes of abuse of drugs/alcohol as in other parts of Wales. Well, people may have a dependency, but they are often more willing to engage with their community as they are smaller and generally known to each other, this also provides services with opportunities to identify people earlier.

And people are less transient in Powys. They are often either from Powys or have moved here. It feels that the majority of service users are unemployed and from the 25 – 40 age group. There seem to be more men than women who are suffering from mental health and who will be engaged with the police and health partners.

Many men who are subject to a S136 have self-harmed, either at the point of contact or previously in their history. There are also some women who are repeat service users who are also very well known to the police, they are smaller in number as a group, but often have a higher individual demand on police and partners' services.

90% of those calling the police around mental distress do so themselves when in crisis. If they are making the call to the service themselves it is often a cry for help and we strive to put the appropriate intervention in place. It is not unusual for people to call police 20 – 30 times and say they are going to kill or seriously harm themselves. What is more concerning is those whom are not known to police or other partners and are suffering in silence, not being comfortable to tell someone they are not ok.

Back to the Floor exercise

Jon and I were shown round Felindre Ward by Staff Nurse Melanie Fletcher. We saw nearly every nook and cranny from laundry rooms to bedrooms, common room to garden space, clinical room to nurses' station. 

En route Melanie introduced us to colleagues and some of the people currently staying on the ward and happily answered our many questions. She explained that staff can voice their opinions at regular team meetings and she felt that there is a “good listening ear”.

We then met and spent a considerable time talking to three members of the South Powys Crisis Resolution Home Treatment Team.

After the visit: Jon’s view

Well, I had hoped to learn more about mental health services and I have absolutely done that! I have made some great contacts within the Mental Health services at an operational and tactical level which mean that I can put processes in place around information sharing, across all of Powys, but particularly in the South Powys area. There is a real opportunity for information sharing and problem solving meetings to be set up between the different services – ambulance/police/mental health.

I learnt that people aren’t necessarily admitted on any form of section, but do need support and that there is problem-solving going on around these individuals which is something police officers will be unaware of.

There appears to be a gap around providing support and/or services for those people who are distressed but have not committed a criminal offence and are not on the ward, but are regularly coming to the attention of police. There needs to be a problem-solving forum around these people who are regularly in contact with police officers but have not passed the threshold for admittance to the ward on a form of section, which is something that I will take forward with the police management team in Powys.

Jon with Sharon Stinson and Laura Charles-Nelson
from the South Powys Crisis Resolution Home Treatment Team

I also now have a much greater understanding of the work of the CRHTT. They seem to act in much the same way as a mental health triage team that operate in other areas of Dyfed Powys. So there is the opportunity and willingness for officers to put in a call to the staff about people we come into contact with and see if the person is known to them and what solutions can be provided or advice given.

Seeing the inner workings of the ward was also very useful. There are a quite a few activities going on in the ward. Everyone currently on the ward seemed happy. They are getting the care and attention that they need and no issues were raised. They seem to have made the ward home, so it was a positive experience in that regard.

The main barrier to service delivery, as it always has been, is around communication. One thing I didn’t realise we had finalised until today was that student police officers are having work experience with mental health staff on the ward, which is hugely positive. And information sharing is starting to happen now with the joint mental health training which takes place.

Following on from the Back to the Floor session I want to put some formal structures in place and circulate information about the various mental health teams and what they can offer to colleagues – what they do and where they are. And finally I would just like to say that it would be extremely useful for all managers within policing to do a similar exercise themselves. Thank you to the staff and all at Felindre Ward for their warm welcome, allowing me to experience what they do and how they do it to benefit the partnership working approach with Dyfed Powys Police.

And finally

Many thanks to Jon for taking part in this Back to the Floor exercise at Felindre Ward. All of the learning from this and subsequent BtTF visits will be fed into the Powys Mental Health Planning & Development Partnership* to share with others and to help with future planning and delivery of the Hearts and Minds: Together for Mental Health Strategy. Over the next six months a number of other members will also be visiting partner agencies to recognise the excellent work staff do and to talk to people using services so watch this space for future blog posts.

*The Powys Mental Health Planning and Development Partnership brings together key stakeholders including Powys County Council, Dyfed-Powys Police, Powys Teaching Health Board, Powys Community Health Councils, Powys Association of Voluntary Organisations, and representatives of people using services and those close to them.

Our Chief Exec goes "Back to the Floor"

Carl Cooper, who is our Chief Executive Officer at Powys Association of Voluntary Organisations, writes a guest post about his recent experience going ‘Back to the Floor’ – an initiative where senior managers learn from their experiences of finding out how services are delivered locally on the frontline.

Counting the cost of people's involvement -
Carl settles people's expense claims

"As part of the 'Back to the Floor' initiative of Powys Local Service Board, I was privileged to spend a day with my colleague, Freda Lacey (Mental Health Participation Officer), at a national gathering of service users and carers to consider how best to organise involvement in the Welsh Government's new Mental Health Partnership Board.

The use of language was a constant source of discussion and debate. It was clear that some people identify themselves as carers and feel that this label empowers them to get services, respect and support. However, others completely reject the label insisting that they are not "carers" just because services/society want to define them in this way and challenge the label insisting that they are mothers, husbands, daughters, friends etc. Equally, some people accept the label service user for various reasons and, in fact, fight to ensure this term is kept in common use. Alternately, others completely reject the label insisting that those people that have been forced into contact with mental health services (i.e.sectioned and forcibly medicated) don't see themselves as "service users". Recipients of parking tickets don't say that they are using traffic police services!

My first impression was of the very high level of knowledge, experience and ability in the room. Participants contributed to the discussions from an informed and articulate perspective. This gave the contributions an authority and an integrity that was almost palpable.

I was a little surprised at the format of the meeting, which was formal and concentrated on papers and documents. We examined terms of reference, job descriptions, person specifications, and organisational structure diagrams. This way of working would not have been out of place in any board meeting or strategic partnership. I was expecting a meeting about engagement to be much less stuffy and much more participative. Were the organisers reverting to type? On the other hand, the commitment from Welsh Government and others to engage people came across as genuine, open and honest.

Because the day focused on processes and structures, there was consideration of reimbursement of expenses and remuneration. It was this element of the day that surprised me and caused me some concern. Everyone agreed that people that participate in engagement mechanisms should not be out of pocket. However, many viewed this role as a job and spoke of the role as 'working for the government'. As such, some felt that remuneration for participants should be akin to that of, for example, public appointments. I came away reflecting that, if not careful, we were in danger of professionalising engagement and creating an industry of 'engaged voices'. If this were to happen, we would lose the 'raw' voice so vital to decision making. Any commitment to co-production would be seriously damaged.

On a practical level, Welsh Government needs to adopt a consistent approach to how it supports people's involvement. For example, mechanisms are already in place with its Citizens Panel for social services. Should not these be applied to other arena? Developing different packages of support will introduce inequality and inconsistency to public engagement.

The afternoon session was not helped by a confusion within the group regarding how the procedures and mechanisms across Wales were meant to operate. Welsh Government officials and others dealt with this effectively, sensitively and with humility. Clearly, this will need to be addressed again when greater clarity brings about a shared understanding of how the process will work.

All in all, I came away from my 'Back to the Floor' experience having learned a lot and having been inspired and challenged by those I was honoured to meet."

We would be interested to know what you think about Welsh Government's engagement with people in contact with services. Do you agree with Carl, or do you have different ideas? Let us know!