Reputation on the line

    Case notes   

    Practitioner: Clive Sexton, support and resources manager.

    Field: Mental health.

    Location: Norwich, Norfolk.

    Service: Rehabilitation unit, run by Norwich and District Mind.

    Case history: Norwich and district Mind has been providing services since 1966. As with many voluntary organisations its funding came in part from local authority grants and public donations. The organisation’s main source of funds in the late 1990s was its rehabilitation hostel which charged a weekly bed occupancy rate to the local authority: the more beds filled the more Mind was paid. “At one point that was financially satisfactory as we had plenty of clients in beds and made a surplus and this helped fund some of our other services,” says Sexton. However, in recent years a noticeable change in the profile of clients – with a trend toward younger males with volatile behaviours, often with a dual diagnosis of mental health problems and substance misuse – resulted in the service accepting people with needs that were difficult to meet by staff who did not feel they had all the skills.

    Dilemma: While the unit needed to provide a more intense service for fewer clients, it was still the main plank of the organisation’s funding.

    Risk factor: Mind’s reputation as an effective service provider could be lost if the situation continued.

    Outcome: With 16 fewer places the unit now offers a more focused rehabilitation service, which is so well regarded that negotiations are taking place about opening a second unit.

    While services throughout the social care world seek to manage risks to individuals and groups of service users, sometimes an organisation overlooks the risks to itself in providing a service.

    This realisation dawned on the Norwich and district Mind management team when it looked at the effectiveness of its 28-bed rehabilitation hostel on the outskirts of the city. For some time it had provided the organisation with its main funding with the local authority being billed when a bed was filled. When occupancy levels were high it provided a handy surplus to help fund Mind’s other activities.

    However, should occupancy levels drop there is a danger that the service would lose money with could lead to job losses or even closure. Consequently, in order to keep beds filled the unit had a wide eligibility criteria. Social workers realised that difficult-to-place clients would not be turned away.

    Younger clients with more complex needs (often with a dual diagnosis of substance misuse and mental health problems) and challenging behaviours began being placed. By default the unit found itself with a “reputation” as a dual-diagnosis specialist. “However, staff knowledge and experience of such wide-ranging needs was at times limited,” says support and resources manager Clive Sexton. “For example, people who self-harmed proved problematic for staff who had joined us without the expectation of dealing with such clients.”

    Because of its reputation the unit’s more traditional clients simply stopped being placed there. “It got to a point where referrals were dropping off. We used to be pretty much full but were only beginning to fill 18 or 19 beds. Financially, that wasn’t viable. The income was not sufficient to meet staff costs,” says Sexton.

    The organisation needed a prompt re-evaluation of the service it was providing. “We consulted service users, staff, trustees and funders about what we should be providing and for whom. We’ve got a piece of land with a building on it. We could have sold it off and put the money in the bank. I think it’s important to remember that we could have done that. Local authorities have a statutory obligation to provide or commission services – we don’t,” says Sexton.

    However, rather than re-shape the service as a specialist dual-diagnosis unit, for which there was – and is – an undeniable need, it was decided to run a rehabilitation service with much tighter eligibility criteria and a clearer focus on identifying outcomes. And it would be smaller. It became a 12-bed unit – thus improving the client-staff ratio. According to Sexton, the trick was to convince the local authority that the same funding for fewer clients was good business. “On a cost per unit basis it didn’t compare well with the previous agreement. However, based on outcomes, it was a much better service. And it would have a better impact on moving people out from hospital,” he says.

    Referrals were now to be agreed between a panel of funders and Mind whereas in the past a phone call from a social worker – “they had a body, we had a bed” – sufficed. “From the moment they come in the plan is ready for the moment they leave. We look at what skills are needed and where they want to live,” says Sexton, who does not underestimate the importance of assessment: “We only place people with potential and motivation to move on and if we can actually help them. And although we don’t put time limits on stays – this is not their permanent home – if someone is still here beyond six months that suggests to me they are in the wrong place.”

    Sexton was, nonetheless, aware of the risks to organisational credibility. He says: “The decision to close the old service was risky because it was the biggest of our services – and at that point there was no guarantee that we would get funding for any other service that we provided. But equally there was a risk in not making that decision because if we carried on as we were, there was a danger that we would become unstuck financially because of slowing referral rates.”

    The reality is that the unit, which has a “lengthy” waiting list, has a reputation for excellence. Says Sexton: “The service is respected locally – so much so that there are possibilities of opening up another unit.” 

    Arguments for risk 

    • The policy of being open to referrals in order to improve bed occupancy was in danger of backfiring – as it had led to the assumption that the unit specialised in dual-diagnosis – and it was financially imperative to review the service provided. Importantly, Mind consulted the local authority, which “was receptive to the idea of our re-configuring the service”, says Sexton. 
    • Overall, staff qualifications, skills, experience and knowledge were not matched with the needs of people with a dual diagnosis. This was potentially damaging to everyone. 
    • The day-to-day nature of funding is riddled with uncertainty. Everything is fine only if occupancy is high. The move to block funding – a fixed agreed sum over the year – meant that Norwich Mind could plan and staff the unit properly. 
    • With a scaled-down service, a more person-centred approach focused on outcomes could be tailor-made. Clients are now on individual programmes.   

    Arguments against risk

    • It could be viewed as an odd decision to concentrate on a rehabilitation unit when national trends suggest that such services are being less used. As Sexton admits: “Being placed into a hostel seems alien when you could be in your own home with plenty of support. Reconfiguring seemed a bit strange as we were also looking at expanding our outreach and community work. But this is a much more dynamic model.” 
    • Even if good rehabilitative work is carried out there is always the potential restraint of finding accommodation for people when they are set to leave.  
    • The impact on staff of this decision must be concerning, not least on morale, which could affect the care provided. Sexton says: “It was clear to them that we were going to stop running the service as it was. There was no guarantee that any of the jobs from the old service would make up the new one. There were redundancies – it was a stressful time.”

    Independent comment

    Being heavily dependent on one purchaser is a common position for voluntary organisation providers, writes Martin Willis. Being funded by individual spot purchases creates pressure to fill places and can result in losing sight of the original aims of the service and accepting referrals of people whom the staff are unable to work with effectively. 

    With less than two-thirds occupancy, Mind risked going bust. It could have cut fixed staffing costs, relying on agency or temporary staff to manage fluctuations in demand for places. However, this would have consequent risks of staff availability and service quality.  

    Or Mind could diversify, developing its outreach work to substitute for falling demand for rehabilitation places – if the charity could have attracted funding from another source, such as health. With most mental health services now operating pooled budgets, the potential for achieving two major separate funding sources has been reduced. 

    In the event, Mind proactively negotiated with the local authority to change the nature of the service. It demanded courage and foresight to persuade the local authority to adopt a more strategic approach to its commissioning of rehabilitation places. Losing key staff would have seriously risked success and crucial decisions must have been made about how and when to involve them in discussions and the handling of redundancies. 

    Martin Willis is senior lecturer in social services management, Birmingham University.

     

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