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.

Engaging with Powys teaching Health Board to help shape future services

Last Thursday I attended an event in Llandrindod Wells where representatives from the Third Sector discussed the future planning of services and activities as part of Powys teaching Health Board’s three year Integrated Medium Term Plan. This plan will be used as the basis for future commissioning of the Third Sector by PtHB. The meeting was attended by several mental health charities, including Brecon & District Mind, Mid Powys Mind, Ponthafren Association and Hafal.

Carl Cooper, Chief Executive Officer, Powys Association of Voluntary Organisations

Carl Cooper, Chief Executive Officer at Powys Association of Voluntary Organisations, introduced the day, explaining that the Third Sector is a significant partner in the process working with people in communities and organisations to help the health board plan and deliver “better health and care services” in Powys.

Carl said that “we are here today to be part of the process to shape and influence and be involved in the planning and delivery process.” He observed that there were several challenges to bring to the discussion, particularly in terms of resource allocation and budget planning in a climate where prevention and community resilience are key priorities.

Carol Shillabeer, Chief Executive Officer, PtHB

Carol Shillabeer, Chief Executive Officer of PtHB followed, to describe how the IMTP emerged following a decision by the Welsh Health Minister in 2009 to set out a collaborative approach. This was during a period of major legislative reforms at the time. The IMTP aims to bring together a number of other strategies already being worked on, including the Hearts & Minds Mental Health strategy, and those focussing on Older People and Carers. Carol assured those present that the IMTP does not just sit on a shelf, but act as a guide for the population as a whole, and for Welsh Government, to test PtHB against the commitments it made to deliver services.

The overall vision of the IMTP is: “truly integrated care, centred on the needs of the individual.” This year during a staff engagement exercise (“Chat to Change”) PtHB emphasised the need to work together with other organisations alongside other specific values and behaviours.

Carol also introduced us to the 4 Aims (out of a total of 6) which were to form the basis for further discussion at our tables:

• Improving health & wellbeing
• Ensuring the right access
• Involving the people of Powys
• Making every £ count

In speaking about mental health Carol said that it is “a huge area where we can make a difference to people’s lives. We have kept the priorities of mental health services but there is a long way to go and much more do to.” She explained that the management of mental health services had been brought back into Powys in the North of the county and also in Ystradgynlais. Services in the Mid and South are currently still managed by Aneurin Bevan Health Board, but will return to Powys later in the year. On another positive note Powys has received 500,000 Euros to introduce computerised Cognitive Behaviour Therapy a service which people can access in their own homes.

PtHB want to make sure that there is effective partnership working and to engage with people to achieve a good plan. Staff are already looking at working more closely with Powys County Council, and want to use continued integration as a way of achieving objectives in the future around all areas of health service provision. Carol explained that this is already happening in terms of mental health services.

Freda Lacey, Senior Officer Health & Social Care, PAVO

Freda Lacey and her team had planned the day down to the finest detail. Once the table discussions were complete (report to be circulated later) Carl opened up the floor and asked for key issues to be highlighted. These included (just a brief sample):

• The need for more services to be delivered locally.
• Sharing of resources – including people, skills, premises, training.
• Emphasis on the Third Sector not just being “polyfilla” to fill the gaps.
• The Third Sector are asked to do more and more for less and less.
• The vital importance of introducing and using more innovative technologies.
• The need to remember those that are digitally excluded for whatever reason.

Hayley Thomas, Interim Director of Planning & Performance, PtHB

Hayley Thomas, Interim Director of Planning & Performance at PtHB, commented that this was to be an ongoing process and that PtHB is absolutely committed to working with the Third Sector. An “everyday” version of the IMTP will be developed taking into account the feedback given at the event and shared via PAVO.

Trish Buchan, Third Sector Organisation rep, Powys teaching Health Board

Trish Buchan, previously of PAVO and now Third Sector Organisation rep on PtHB, added that one of her objectives is to raise the profile of the Third Sector at Board level, and reiterated the commitment of the health board to work closed with the Third Sector going forward.

All in all it was an extremely interesting morning. I was facilitating some of the discussions focussing on how to involve the people of Powys. Around the various tables it really felt that there was a passion and enthusiasm for more collaborative and innovative working – if time can be set aside by all to really consider the most effective way of achieving this. And whilst there was much healthy debate on one thing we all agreed – the Third Sector is absolutely not just “polyfilla.”

Co-producing the Annual Report for Mental Health

L-R: Aled Davies (Powys County Councillor), Sophia Bird (Powys Public Health), Meriel Richards (individual rep National Forum for Service Users & Carers), Seamus O'Doherty (Welsh Ambulance Service), Louisa Kerr (Powys teaching Health Board), Clare Lines (Strategic Lead Mental Health - PtHB), Michelle Forkings (Aneurin Bevan Health Board), Jackie Davies (Children & Young People's Partnership), Steve Pearce (Powys Youth Justice).

Following development of the new Powys mental health strategy – Hearts and Minds: Together for Mental Health – the first annual report was produced by the Powys Mental Health Planning and Development Partnership Board for 2012-13 (you can read it here). This reports on which key elements of the delivery plan had been achieved during that year. As far as I am aware, it was written primarily by staff working for Powys teaching Health Board.

At a recent meeting of the National Partnership Board (minutes available here) the individual representative who is based in Powys, Rhydian Parry, gave feedback from the National Forum for Service Users and Carers. One of the points he made was:

“Service user and carer views need to be clearly and accurately embedded in annual reports.”

“The Chair (of the NPB) responded saying all Local Health Boards and Trusts have been informed of this requirement. A small amount of financial support has been made available to each Partnership Board to support this process. Sian Richards (Welsh Government Mental Health Strategy Lead) will be meeting the Service User and Carer members immediately after this to discuss how they can play an active role in the development of the Welsh Government report.”

I knew that an event had taken place in late September this year, pulling together the members of the Powys Mental Health Planning and Development Partnership (PMHP&DP), including those using mental health services and those close to them, to look at production of this year’s annual report. The work was being described as “co-production” – a word which can mean so many different things to different people. It is defined by the New Economics Foundation “as delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours”.

So, I asked my colleague Freda Lacey for an update about last week’s event.

Freda told me that four of the individual reps – Rhydian Parry, Meriel Richards, Kate Van Ende and Michelle Willingham – had contributed along with people working to provide statutory mental health services, Powys Public Health, a Powys county councillor, Powys Youth Justice Service and the Welsh Ambulance Service. Prior to the event the four individual reps had given feedback first on the structure of the event, and then about the way their contribution would be included in the Annual Report.

The idea of a “timeline” was developed – the journey of an individual’s life from cradle to grave – along which mental health services could be accessed. Feedback was then given about these services.

The completed Annual Report will be signed off by Powys teaching Health Board (PtHB) in October before being passed to the Welsh Minister for Health & Social Services – Mark Drakeford. It comprises two parts – a written section, where the reps have made detailed feedback on the delivery plan and overall report, and an audio version containing real life voices. The voices will include contributions from an all age perspective, including children from the Sparks Project run by Tros Gynnal, an interview with an older couple relating to dementia, and excerpts from the DIY Futures book of stories – it’s the inside that matters, covering adults’ and older adults’ perspectives. Additionally, partners have been asked to give their feedback on how the voices of people in contact with services have helped shape their services. There will be contributions from Dyfed-Powys Police and the Children and Adolescent Mental Health Services team (CAMHS).

Clare Lines, Strategic Lead for Mental Health at PtHB, and chair of the Powys Mental Health Planning and Delivery Partnership, will also speak about the positive impact that the individual reps have made on her work and that of the Partnership.

We will let you know as soon as the Annual Report for 2013 - 14 is published. Watch this space!

Hearts and Minds

Yesterday I drove down through sun and snow flurries to the Royal Welsh Showground near Builth Wells. I was attending an event organised by Powys teaching Health Board (PtHB) to look at the future of mental health services in Powys. The “vision” for future services was developed during late Autumn 2012, and very much informed by feedback from people who use services and their carers at the time. I posted about that here. Then it was christened Hearts and Minds, and included information not just about the vision but how services would be delivered – you can link to more information here.

So, yesterday it was the turn of staff providing services (for the health board, social services, the voluntary sector and other agencies) to say what they thought. There were about a hundred people in total, including (in a bit of a mini A-Z of professions) advocates, nurses, occupational therapists, psychiatrists, social workers, support workers and police officers. And many of them spoke very passionately about their views, and some key themes emerged throughout the day.

Facilitator Dr Les Rudd, of the Centre for Mental Health Services Development, introduced the morning session which started with a series of presentations to inspire and set the mood. 

Jo Mussen

Vice Chair of PtHB, Jo Mussen, spoke first, about the need to give the people of Powys the best possible mental health services that we can, taking into account the many challenges and opportunities that face us. She also referred to the “incredibly vibrant Third Sector” which went down well with some of my colleagues.

Ian Hancock and Les Rudd

Then Ian Hancock gave us a Scottish viewpoint. He has turned round mental health services in the Dumfries & Galloway region in just three years. It is very similar to Powys in many ways, with its rural geography and a population of 147,000 (Powys approx. 133,000). His approach as the General Manager appears to have been both innovative and brave, and the Powys staff were clearly very impressed by the achievements he described.

Richard Bundy from Gofal

After Ian came Richard Bundy of the mental health and wellbeing charity Gofal. He described a service which has “bucked a few trends in Wales” – the Crisis House in Cardiff. The house is an alternative to hospital, with the average length of stay at 7 days. Some of Richard’s stats said it all really, with 95% of people using the house rating it as good or excellent, and 80 – 90% consistently returning home rather than going to hospital. There is more about the project here.

Stephen Hunter, Assistant Medical Director of Aneurin Bevin Health Board (providing mental health services in Mid and parts of South Powys), had sent recommendations which Carol Shillabeer (Director of Nursing) delivered in his absence.  There were some interesting points here, including the need to:

• Consider more cross-sector working (again identifying the Third Sector as a real asset), but involving other organisations too such as Job Centres, social and care services, and other people who are regularly out in the community even (postmen came in for a mention several times).
• Focus on supporting GPs and practice staff to care more for people experiencing mental distress.

The rest of the day was taken up with workshop sessions looking at what a good service would look like for adults, older people, and younger people, in the following three areas:

1.    Community services, primary and secondary care.

2.    In-patient services (crisis and accommodation services).

3.    New services/innovation.

Some of the key themes which I picked up on:

• Services are very different in different parts of Powys. There is certainly something of a postcode lottery going on here. (Services are currently provided by three different out-of-county health boards).
• Everyone wants it made simpler. The police often have to pick up the pieces when the mental health service providers have closed for the day. They would like to see “one procedure, one place, one pathway” for hospital admission, for example.
• More training in psychological therapies is urgently needed – it was suggested this could be “joint” training involving many agencies.
• What can the Third Sector provide? Exploring this topic could form a whole day in itself! (Supported housing and counselling being just two suggestions I picked up on – and the need to “think outside the box”).
• It is crucial to build confidence around mental health issues with other areas of health, eg: health visitors, district nurses and community hospitals. And Third Sector of course! “Mental health is everyone’s business”, as one person said.

Carol Shillabeer and Harold Proctor

So, it was a really interesting and useful day all in all. Harold Proctor, (Planning and Performance General Manager Mental Health and Learning Disability – phew, some job title!), who is leading much of the work for PtHB around transforming mental health services, tells us that this event is the beginning. So, watch out for more updates and events to follow once a proposed new model of services has been put to PtHB in April.

As someone said, summing up towards the end – “we have only just lit the torch paper today… this is very much the start.”

PS: And… did I mention the Third Sector…?!