Several key factors involved in the following mental health case will be familiar to social workers from all settings. It involves a redesign of services that was introduced to improve care but had the unintended consequence of leaving frontline teams overwhelmed and, in the view of an independent panel, unable to deliver the standard of care they should have been providing.
The same panel also found that the tragic incident that triggered the report could not have been predicted. The case is highlighted here because – at a time of huge organisational change in health and social care – it might offer reflective learning on caseload monitoring and planning for the impact of service overhauls on frontline staff.
In October 2009 at Teesside Crown Court a 49-year-old man was sentenced to life in prison after pleading guilty to murdering his girlfriend. The killing had happened six months earlier. At the time of the incident the man received support from a community psychosis team at Tees, Esk and Wear Valley mental health trust. He had been known to mental health services since the age of seven.
More than four years on from the offence, NHS England has published the findings of an independent review into the mental health care provided to the man – referred to as ‘patient 2009/3245’. In cases where a mental health patient has committed a homicide, a rarer situation than some press reports might have us believe, the NHS has a statutory duty to commission an independent review of care.
The independent panel’s 126-page report on the care provided to ‘patient 2009/3245’ is comprehensive. The panel concluded that the actions of ‘patient 2009/3245’ on that day in April 2009 could not have been predicted. However, they also found that his care team had been unable to provide him with the level of care they should have in the period leading up to the killing. Why? I’ve pulled out two key factors below:
- A service redesign that led to ‘overwhelmed’ community teams
The report shows that in 2008 the mental health trust implemented a service restructure. Prior to the change, large numbers of patients were managed in outpatient clinics. They were on consultant psychiatrist caseloads or seen by junior doctors. The junior doctors routinely only spent six months with specific teams so “were not well placed to make long term treatment decisions” and possibly maintained patients in secondary care longer than was needed, the panel heard.
The new model
The restructure aimed to address this issue and also boost care by deploying consultant psychiatrists to the most complex cases. The new model would see the psychiatrists head up multi-disciplinary community teams where they would promote “delegated responsibility and leadership” on cases to care coordindators. This approach was in line with national guidance, the panel’s report said.
What went wrong?
Leading up to the 2008 changes, the consultant psychiatrists (who were to prepare to focus on complex cases) were “appropriately encouraged” to reduce their caseloads by discharging people back to GPs or transferring them to other members of the community mental health team.
However, the panel heard, this process was completed without any formal handover process or guidance to staff. The result was that community teams suddenly inherited hundreds of new patients that they had no prior knowledge of.
At the same time these teams had a responsibility to risk assess these patients, review their clinical paper notes and input notes in electronic form to an IT system they were unfamiliar with. This all had to be done within strict timescales.
“The panel heard evidence that the numbers and the complex nature of the cases transferred from outpatients made the task overwhelming,” the report found.
“The fact that hundreds of patients were being transferred across one team to another to staff that lacked any knowledge of them without any summary document was, in the panel’s view, of significant governance concern,” the report added.
- A care coordinator with a caseload of 80 instead of 20
The impact of the restructure on ‘Patient 2009/3245’s care coordinator was stark. She told the panel she had no knowledge of the background, diagnosis or treatment of around half of the patients transferred onto her caseload from psychiatrists. She had to rely on self-reporting by patients in the short-term as she didn’t have adequate time to review all the paper notes.
Around the time of ‘Patient 2009/3245’ committing homicide, the care coordinator had a personal caseload of 80 patients, a number she told the panel “was far too high and should have been closer to 20”.
The service redesign had also significantly changed her role. She had been made team manager of the psychosis service but told the panel she was concerned she had not been given “specific training to take on the new role”. Specialist psychosis training was not provided to the care coordinator until 2 years after the psychosis team launched, the report stated.
The report states:
“The panel considered that her excessive case load, assessing patients she was unfamiliar with, dealing with the impact of the reconfiguration, coupled with managerial responsibilities and having to adapt to changes in a high pressured environment with specific deadlines set, meant that she was unable to comply fully with both the Trust’s Clinical Risk Assessment & Management Policy and the CPA policy and to deliver the standard of care that should have been given to 2009/3245.”
- How the trust has responded
The discussion above focuses on just two factors of an extremely complex case. A series of other issues, notably the lack of continuity of care for patient 2009/3245, are also raised in the independent review. Yet the two factors above were key to the panel’s priority recommendation that Tees, Esk and Wear Valley NHS Trust needs:
“…to look at monitoring work load pressures taking into account individual practitioner’s caseloads in order to prevent staff becoming overstretched, overloaded and ineffectual in their role which in turn impacts on the level of care and treatment provided.”
In response to the review’s findings, Tees, Esk and Wear Valley NHS Foundation Trust has produced an action plan. Among the actions is a commitment to put a process in place to identify the impact of organisational change on practitioners’ workload by the first quarter of 2014/15.
In a statement, Chris Stanbury, the trust’s director of nursing and governance, said:
“We carried out our own internal investigation in 2009 and as a result made a number of changes to the way we work. We recognise that there are always things we can do better and we welcome this report and its recommendations, which we will use to continue to improve our services.”
Andy McNicoll is Community Care’s community editor