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Stark challenges for new chief at Wiltshire’s mental health trust as GPs start commissioning

The Avon and Wiltshire Mental Health Partnership Trust (AWP for short) which has survived some recent tragedies and some rocky years, is taking fresh directions under its new Chief Executive, Iain Tulley. He joined AWP in November three months after an independent report was severely critical of the Trust’s management and governance.

The report was responding to widespread anxieties about AWP after three killings in Swindon in 2007 by mental health patients in its care.

Iain TulleyIain TulleyMr Tulley started his NHS career as a registered mental health nurse in Scotland.  From 1999 to 2001 he was a director at the Wiltshire Health Authority, and most recently spent eight years as chief executive of the Devon Mental Health Partnership Trust.

AWP also has a new medical director. Dr Hayley Richards replaces Dr Arden Tomison who retires after thirty-two years in the NHS.  Dr Richards has been the Trust’s director of medical education, but the NHS world can be smaller even than that: Dr Tomison was once Dr Richards’ clinical tutor when she was doing her post-graduate training.

The 2012 report into AWP said there was “an urgent need to change the culture and leadership from one of central control to one in which all staff are positively engaged in determining and delivering safe, high quality care.”   

During an interview with Marlborough News Online, Mr Tulley said the 2012 report was as important to AWP’s future as the recent Francis Report on the Mid Staffs scandal was for acute hospitals. He characterised the report on AWP as finding it had “top-down management, was target driven and with staff who had experienced bullying”.

“We are now”, he said, “ahead of the game” in bringing about the necessary changes.  AWP is moving from away from its system of strategic business units each delivering across the huge area the Trust covers (Wiltshire, Swindon, Bristol, Bath and North-East Somerset, South Gloucestershire and North Somerset.) Dr Hayley RichardsDr Hayley Richards

“This Trust has got to realise the need to think about patients as being at the centre of their work, about quality of service and staff engagement.  With the complex geography of AWP, if we try to run everything the same way across the map, we’ll probably end up again catching the cold we’ve already got.”

The new look AWP will be based on a switch to a responsive local management for front line services.  Each of six areas (of which Wiltshire is one) will have a clinical director (leading the service for their area), a head of professions and practice (looking after quality of care and safety) and a managing director (the local executive leader.)  

AWP has already appointed clinical directors for five of these six areas. They are all working clinicians.  And here AWP’s next problem comes into focus – the switch in three weeks’ time from Primary Care Trusts (PCTs) to GP-led Clinical Commissioning Groups (CCGs):

“We’re putting our clinicians in touch with their clinicians – and clinicians do tend to get to common sense responses about what patients need.”

The problems come when the CCGs do not want to continue with all – or perhaps even any – of the services currently provided by AWP. Swindon CCG are committed to getting more mental health services from third sector (charitable and non-profit) organisations.

But most challenging for AWP is the situation in Bristol. The PCT, Mr Tulley explains, “wanted change to its service from AWP and didn’t get it”, so they consulted widely on altering their whole approach to mental health care and designed a new way of providing mental health services.

Now Bristol CCG have taken up that baton and said they will decided in April whether they will re-commission AWP or go ahead with the plan to break mental health care down into separate services and put them out to tender. There is a great deal at stake: Bristol’s contract currently provides thirty-seven per cent of AWP’s total income.

While Iain Tulley’s response is calm and matter of fact, he is determined to win any tendered services and wants AWP to be an integral part of the Bristol system of care: “I absolutely support the proposals around the modernisation of mental health services in Bristol – and we are already engaged with them.”

But he is aware of the risks of fragmentation that such a move away from the public sector involves:  “There is a risk that while there is a view that moving services away from the public sector will drive up quality and drive down costs, fragmentation will let some patients slip through the net. There is a risk in fragmentation.”

Mr Tulley says his aim will be to work “in partnership with new providers rather than seeing it as a competition”.  He wants to provide ‘bespoke services’ for different areas be they urban or rural.  With fragmentation looming and risk registers likely to become splashed with red for danger, Iain Tulley is keen to minimise any risks that will occur. He stresses it is essential to have one organisation that is accountable and would like AWP to have an over-arching role as “a bit of a coordinator” for third sector providers.

Wiltshire CCG have decided to continue with their AWP contract for adult mental care. (Children and adolescents are looked after by the Ox and Bucks service.)  But will undoubtedly work to secure primary care liaison staff to work in their three localities to ensure better care and faster care.

“I am committed to helping CCG’s raise the quality of mental health services in each area and to working in partnership with them to achieve their goals.”

AWP will be bidding to roll out the new dementia diagnosis scheme that Wiltshire CCG has already piloted successfully in the south of the county under Dr Celia Grummitt – as Marlborough News Online has reported.

The tasks facing Mr Tulley, the new Clinical Director and senior staff are not straightforward. The legacy from previous management lingers. He called the recently published results of the annual staff survey ‘deeply disappointing’ insofar as it showed low scores on staff engagement.  
While other responses show improvement in staff attitudes to the quality of service they can provide, the uncertainties brought about by the government’s restructuring of the NHS will not help.  Iain Tulley is redoubling efforts to transform AWP and so boost staff morale.

Mr Tulley’s next aim is to secure Foundation Trust status for AWP.  Its application was suspended until the independent report was delivered and measures taken to improve AWP. 

He now hopes to gain FT status early next year. This would secure AWP’s future, give more flexibility in how they operate and address the democratic deficit that some politicians mention.  They already have 16,500 Trust members who would get to vote for the Foundation Trust’s governors.

Iain Tulley’s views on the Trusts’ future are very down to earth and very grounded in the current realities of change and funding. But talking more widely to people in the mental health service there is some dismay that while one in four of us will need some mental health care sometime during our lives and with dementia increasing exponentially, such a small proportion of the NHS budget for England is devoted to mental health.

In NHS Wiltshire the amount spent on secondary mental health care (that’s not GP’s and community nurses) is just 7.93 per cent of the PCT’s total budget.

NOTE:  The Charter House in-patient unit in Trowbridge – to which some patients from the Marlborough area have been sent – has been closed temporarily.  Iain Tulley says AWP ‘can no longer provide a viable service of sufficient quality’ in that building: “It would not pass the ‘would you admit your relatives to this ward’ test.”  Discussions are underway with NHS Wiltshire and Wiltshire CCG to find out how Charter House’s in-patient services can best be provided.

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