Face-to-face contact with patients: How do Community Mental Health professionals spend their time and what is the impact on staff well- being?A service evaluation August 2015

A patient safety quality improvement project funded by King’s Health Partners

Project Lead: Harriet Smith harriet.m.smith@kcl.ac.ukSupervisor: Consultant Psychiatrist Dr Emily Daley

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CONTENTS 2

BACKGROUND 3

Why is paperwork a necessary aspect of the job? 3

METHOD 5

Confidentiality 5

Consent 5

Engaging with the team 5

Diary exercise 5

Staff Survey 6

Sample & data source 6

The Role of a Care Co-ordinator (CC’s) 6

RESULTS 7

Diary Exercise Results 7

Graphical results: 7

Staff Survey Results 8

Qualitative Analysis of informal staff chats and reflective practice team meetings: 10

The technology system 11

DISCUSSION AND RECOMMENDATIONS12

Presenting the results 12

Discussion 12

CONCLUSION 15

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BackgroundThis service evaluation is a patient safety quality improvement project funded by King’s Health Partners. It aims to understand how community mental health professionals in the South Lambeth Psychosis Recovery Team spend their time at work and the barriers in practice that are preventing clinicians having more face-to-face contact with patients. It is hoped that the findings will be used to improve clinician’s time-management, performance, and contact time with patients.

Why is paperwork a necessary aspect of the job?It is common knowledge that the NHS is under pressure to improve patient care and maintain public and political confidence that the service provided continues to be accountable. It is necessary for clinical governance, and for the analysis of quality and safety of patient care when measuring standards and conducting clinical audits.

Electronic recording of data is a crucial form of communication within teams, and between other services. Since the South Lambeth Promoting Recovery Team (SlaM) is not a 24 hour service, documenting paperwork following patient contact is especially important if for example, a patient has been admitted to, or has accessed other services outside of the SlaM working hours, and therefore a verbal handover is not possible.

Additionally, the NHS “payment by results” (1) system sees commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient’s healthcare needs. It is essential that the necessary paperwork has been completed in order to justify the commissioner’s payment.

An NHS Confederation review (2) of the Francis report (following the Mid Staffordshire scandal), found that bureaucracy is an essential part of any effective healthcare system, although becomes burdensome when excessive or unnecessary. The report carried out in response to the Francis report collected responses from over 500 NHS clinicians, managers, and board members. It found that four in ten workers were spending a significant amount of their working day collecting and recording what they considered irrelevant information for regulators or national requirements.

Similarly, a report by The Royal College of Nursing (3) concluded that nurses were being prevented from caring for their patients due to the burden of admin work. The government has acknowledged this widespread issue, however, most attempts to rectify the issue have been short-term, and a system that is efficient and does not impede upon staff remains to be established.

This fixation with paperwork generates frustration among staff. It is a common cause of staff burnout and disengagement, since they often consider patient contact more rewarding than the bureaucratic aspects of their role. A challenge to front-line staff is finding a balance between face-to-face patient contact and the inevitable paperwork such as documenting encounters with patients, and recording clinical outcomes. Maximising face-to-face contact with patients is important to ensure a patient-centred and compassionate service is provided.

A healthcare student from King’s College London led this project, under the supervision of Consultant Psychiatrist Dr Emily Daley. The South Lambeth Promoting Recovery Team is a community mental health service for people with psychosis (mainly Schizophrenia, Schizoaffective

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disorders, and severe Bipolar Affective Disorders). The South Lambeth Promoting Recovery Team usually comprises 20 members of staff, of which includes Psychiatrists, Psychologists, Nurses, Social workers, Occupational Therapists, Peer Support Workers, Cognitive Behavioural Therapists, Admin Staff and a Team Leader.

The aim of the team is to provide efficient services for people with psychosis and their caregivers through specialist care, and a tailored treatment plan. The Multi-Professional team works collaboratively to provide a clinically robust, therapeutic service. In mid-2014, there was a service reorganisation (Adult Mental Health Model), and a new operational policy for the Promoting Recovery pathway. The operational Policy for the Promoting Recovery Pathway (Pages 5-6) requires all Care Co-ordinators to:

Spend a proportion of the week delivering specialist interventions in line with their professional background

Have a role in crisis work across the team’s caseload Support discussions around health and social care in team meetings Fulfil specific tasks for their caseload such as preparing reports or attending tribunals

Most clinicians undertake the role of a Care-Coordinator, with the operational Policy suggesting a target caseload of 20 patients. Research by the project lead showed that the average caseload per Care Co-ordinator was 22 patients. The highest caseload per team member was 25 patients, and the team (at the time of writing this report), works with a total of 209 patients.

Given the nature of psychosis, working as a Care-Coordinator can at times be challenging. Whilst recent research into this area is limited, a systematic review of 17 papers conducted by The Journal of Psychiatric and Mental Health Nursing (4), found specific stressors to include “increases in workload and administration, time management, inappropriate referrals, safety issues, role conflict, role ambiguity, lack of supervision, not having enough time for personal study and NHS reforms, poor general working conditions and lack of funding and resources.”

There is a growing body of evidence suggesting that working in Community Mental Health is associated with high levels of stress, burnout, and poor job satisfaction, making these services difficult to sustain. Therefore, this project also sought to examine how staff well - being was affected by the inevitable bureaucratic demands undertaken by Care Co-ordinators.

Previous research was conducted in 1999 (5) across three inner city psychiatry services in London and concluded that working in community-based services may be more stressful than working in in-patient services. Burnout, deteriorating mental health and poor job satisfaction were reported amongst staff.

This service evaluation focused on face-to-face time with patients and carers, time spend on other activities (e.g. paperwork, phone calls, and emails), routine versus duty work, and specialist versus general interventions. There was also a focus on how the inevitable bureaucratic aspects of the job impacted on staff wellbeing and their perception of the service that they offer.

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Method

ConfidentialityThe project lead did not have direct contact with patients and did not review the clinical records directly for this project. However, the project lead was present for clinical team meetings when patient and carer information was discussed. The Project lead therefore completed The South Lambeth and Maudsley (SlaM) Information Governance online training. No patient identifiable information was included in the data collection. Staff information was made anonymous before the final report was written.

ConsentThe team were briefed in both the team business meeting and other Multi-disciplinary team meetings (MDT’s) about the project. They were advised that participating in the project was optional.

Engaging with the teamThe project lead spent a total of three weeks with the MDT, which included joining team meetings and participating in team reflective practice. The project lead attended daily morning team meetings during which Care Co-ordinators discussed their caseloads. The project lead spent time in the clinical team office observing health professionals at work to develop an understanding of the activities done on a day to day basis such as report writing, crisis plans, social care plans and referrals to other services. During this time, the project lead spoke informally with staff to understand their thoughts and feelings about how the service runs.

The project lead attended the team Reflective Practice meeting, facilitated by a psychotherapist. During the meeting, the group discussed issues they experiences as Care Co-ordinators that related to this project. The project lead also participated in a team discussion about staff wellbeing.

The data collected from the reflective team meeting and the informal discussions with staff have been documented in the results section.

Diary exercise:The team lead designed a simple diary sheet (Appendix) that was distributed to Care Co-ordinators over a period of seven days. They were asked to document how they spent their day at work in as much detail as possible. A list of abbreviations was included alongside an example of a completed diary entry (Appendix) to assist them. Diary forms were handed out each day at the morning team meetings, and collected at the end of the day. The project lead ensured that where possible, Care Co-ordinators from a variety of different specialist backgrounds were included in this exercise.

This data was then entered into a Microsoft Excel database at the end of each day, to record the number of hours spent on a variety of tasks (Appendix). The database was used to record the number of hours spent on different tasks. These tasks were then sorted into four categories and total of the number of hours spent per day on the categories was calculated.

1) Specialist Work

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2) Generic Work3) Face-to-Face patient contact4) Crisis work

An average was taken across the seven days, to produce percentages of time spent per day on these four categories for comparison against the Operational Policy for the Promoting Recovery Pathway.

The supervisor of this project will keep all completed diary entries for future research.

Staff Survey:In order to assess staff wellbeing and mental health, the SLaM Mental Health and Stress in the Workplace policy was used. It contained a SLAM stress indication and mental health tool survey for staff, originally designed for use by team managers. The project lead edited this survey to ensure all questions included were applicable to this study. Copies were distributed to staff to complete as a simple tick box activity. Participation was voluntary and anonymous.

Sample & data sourceCertain team members were part-time, and therefore could not complete diaries on all days of this project. Admin staff and psychiatrists were not included, since they do not work as Care Co-ordinators, were supervising this project, or were too busy to participate. The following professions participated in this project:

Occupational Therapists Psychologists CBT therapists Nurses Advanced Nurse Practitioner Social Workers Support workers (not a Care Co-coordinator role)

Diary data was collected over a period of seven days due to time constraints.

The Role of a Care Co-ordinator (CC’s)According to the SLaM operational Policy (reference), a CC should have a caseload of 20 patients of different levels of need. The CC’s are expected to allocate their time as follows:

1 day per week- Duty/Crisis dealing with unplanned patients/emergencies

1 day per week- Specialist Interventions relating to their professional background for all patients

3 days per week- provide Care Co-ordination for individual clients on caseload- About 21 hours

Approximately 30 % of time during the week should be spent on attending meetings, undertaking admin tasks

14 hours per week should be set aside for face-to-face patient contact per month

The results collected from the diary exercise will be compared against these SLaM operational standards.

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Results

Diary Exercise ResultsOver the seven days of the data collection, an average of 7.14 diary entries were recorded and completed per day. The most received on any particular day was nine. Given that there are nine Care Co-ordinators, (one of which was part-time), the staff participation was encouraging. The project supervisor at the end of the project will keep the Microsoft Excel database that recorded the precise details of each day. Diaries were filled in with precise detail, and many staff referred to the abbreviations sheet and example sheet that had been provided for their use.Please note that team members who are not Care Co-Ordinators are not included in these results, despite two non CC’s participating in this study for their own interest.

Graphical results:

32%

68%

Time Care Co-ordinators spend Face-to-Face with patients Vs generic ad-

min work

Face-to Face contact with patientsGeneric Admin work

11%

89%

Specialist Vs Routine work over an average of 7 days (%)

Specialist WorkRoutine Work

7

Specialist work10%

Face-to-Face appointments

15%

Crisis Work7%

Generic Admin Work68%

Average over 7 days (%)

- The 10 % of time spent on specialist work includes and is not limited to Cognitive Behavioural Therapy, Family Interventions, Mindfulness, Group Sleep workshops, Art Therapy, and Healthy Living sessions. Note that majority of specialist work was face- to -face. However, some specialist work included other tasks such as planning a group, delivering team training, liaising with outside agencies (e.g. the physical health nurse liaising with local diabetes intermediate care team to explore opportunities for service development and identify local resources for patients). Since it was not possible to distinguish from the diaries alone whether specialist time was spent planning, or conducting sessions with patients, the overall figure for time spent with patients may be a slight over-estimate.

- Therefore, 25% of total time was spent on planned face-to-face contact with service users.

- Including crisis work, a total of 32% of time was spent on face-to-face contact with patients (planned and unplanned).

- 7% of time per day on average was spent on crisis/emergency work (this is duty cover by a Care Co-ordinator for the team as a whole, excluding the CC’s own patient case load).

- 68% of time per day was spent on generic Care Co-ordination roles not involving patient contact, including telephone, email, administration, ePJS entries, social care arrangements, and other mandatory forms and referrals. A complete list of generic roles can be found in the appendix.

- On average, one hour of breaks were taken per day between an average of 7.29 staff members. That equates to less than 10 minutes per staff member.

Staff Survey Results A sample of the SLaM Stress Indication and Mental health tool survey for staff is included in the Appendix. Eight staff members participated in this survey. Significant results are discussed below and refer directly to the questions asked.

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Of these results, the following observations were made:

- 100% of team members felt they had clear view of what was expected of them at work (Q1)

- 50% felt different groups at work often demanded things that were hard to combine (Q3)

- 50% felt that they sometimes had unachievable deadlines (Q6)

- 50% felt that they were not always given supportive feedback on the work they do (Q8)

- 75 % felt they often/ always had to work very intensively (Q9)

- 62.5% regularly have to neglect tasks because they have too much to do (Q12)

- 75% are sometimes or often unable to take sufficient breaks (Q16)

- 100% agreed they were often pressured to work long hours (Q18)

- 87.5% were neutral or in disagreement that they could question managers about change at work (Q26)

- 75% were neutral or disagreed that staff were always consulted about change at work (Q28)

- 75% were neutral or disagreed that when changes were made at work, they were clear how they would work out in practise (Q32).

- 75% agreed that their line manager encourages them at work (Q35).

- Many staff did not take a break throughout the day. Some were unable to get away from their desks until mi-afternoon for lunch.

- Several staff members have been coming in outside of their working hours to complete admin tasks. Several staff members reported coming into work at weekends to complete admin tasks.

Question Number Never (%)Seldom (%)

Sometimes (%)

Often (%) Always (%)

1 50 502 12.5 25 12.5 503 12.5 25 50 12.54 12.5 37.5 505 75 256 12.5 12.5 50 257 12.5 12.5 758 12.5 37.5 37.5 12.59 25 25 50

10 37.5 12.5 25 2511 62.5 37.512 25 37.5 2515 37.5 37.5 2516 25 25 25 25

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17 12.5 12.5 62.5 12.518 12.5 12.5 37.5 37.519 12.5 50 37.520 50 50

Question NumberStrongly Disagree (%)

Disagree (%) Neutral (%)

Agree (%)

Strongly Agree (%)

24 12.5 50 37.525 37.5 50 12.526 12.5 25 50 12.527 25 67.5 12.528 12.5 25 37.5 12.5 12.529 12.5 75 12.530 25 25 5031 25 67.5 12.532 12.5 37.5 25 2533 12.5 25 50 12.534 50 37.5 12.535 25 50 25

Qualitative Analysis of informal staff discussions and reflective practice team meetings:- Some staff felt that they have not been consulted, and are unable to challenge changes to

policies and practices.- Staff feeling greater psychological flowi during specialist activity. They would therefore like to

spend more time on their specialist interventions.- Some feel unable to take a sufficient break. Many rush to eat lunch at their desk, and some have

reported being unable to get away from their desks until mid-afternoon.- Staff reported coming into work early and leaving as late as 8pm in order to finish

administration tasks for their patient caseloads.- Many staff reported feeling stressed, and felt unable to maintain a healthy work-home life

balance.- Staff felt they do not receive enough acknowledgment and positive feedback from patients and

their fellow team members.- The computer system is inefficient. Files often crash due to their size, and therefore have to be

uploaded onto the patient record system in several instalments, which takes a lot of time.- The daily team meetings run over the recommended 45 minutes. During the time the project

lead spent with the MDT< she noted that on several occasions, the team meetings lasted almost 2 hours.

- In addition, many team members felt it was only necessary to have a team meeting at the beginning and end of the week.

- Frustration about duplication of information in different parts of the case notes resulting in wasting time chasing up, and clarifying matters with colleagues.

- The team reported that they enjoyed working in an MDT environment- The numbers of patients per Care Co-ordinator exceeds what is manageable

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- Some Care Co-ordinators feel the nature of the CC role is more suited to a social worker

Reflective Team discussion:

Do you think patients are satisfied with the service?

Generally yes, although given the extent of most service user’s psychotic state, patients do not always appear grateful of treatment. The team commented they noticed a difference when working in other areas of mental health that are considered less severe with patients verbally communicating their satisfaction with their treatment more openly.

Do you feel staff think the way the service runs is a success?

CC’s enjoy the multi-disciplinary team approach. However, CC’s constantly reported that a significant amount of their working week is spent on generic (such as housing and financial arrangements) rather than their specialist clinical work.

Do you believe this is a patient-centered service?

Yes-a multi-disciplinary team

Is the system made to prioritize paperwork over face-2-face time with patients?

It would appear a lot of the team agree with thisCaseload

How many patients?

Over the recommended 20 patients per CC

Is this a manageable amount?

No since the caseworker is responsible for every aspect of their patient’s health and treatment plan-unrealistic demands.

HEALTH AND WELLBEINGIndividual staff surveys completed based on the SLAM Stress indication and Mental Health Tool and Policy

The technology system

Do you believe the computer system impacts your time spent with patients?

Yes- staff constantly reporting computing issues. Many computers in the patient consulting rooms were not working during the project lead’s time with the team. This was experienced during a Best Interests Meeting. As results, this impacted on time spent with patients. A staff member was therefore required to conduct shorthand throughout the meeting. Staff reported that often-patient reports exceed the file size when loading onto ePJS (the electronic patient record system). They therefore have to save the report in sections, and upload them separately. This wastes a lot of time, and reduces contact time with patients.

Do you think the role of care-worker is suitable for how this service runs?

Mixed reviews-many agree that an MDT approach is necessary, but resent the amount of generic and bureaucratic work. Some felt this was a role specifically for a social worker. Some social workers reported feeling under-valued as a result of this view.

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Discussion and recommendations

Presenting the resultsResults will be presented to The South Lambeth Promoting Recovery Team in writing, and at a later date during a team development meeting. In addition, the project lead wishes to present the results to Service Managers, Team Leaders, and Senior Managers of SlaM to assist with service planning. It is hoped that this will contribute to recognising and validating work done by team. It will also enable the team to reflect on current structure, and how the operational policy is working in practice.

DiscussionIt was apparent from the time spent with The South Lambeth Promoting Recovery, that they deliver a reputable service of excellent quality. The team at SLaM are proud of the service they deliver; however feel they are not always appreciated by their patients, perhaps due to the extent of their illness’. All of the team agreed through the staff survey that they knew what was expected of them at work, and the majority felt that their Line Manager encouraged them. Staff appreciated the reflective group sessions, team lunches, and positive endorsements and feedback during team meetings.

Face-to-face contact with patients

After three weeks with the team, the project lead was anticipating low amounts of face-to-face contact time spent with patients due to the heavy burden of paperwork witnessed whilst shadowing the CC’s. This was the biggest concern of all staff members, and therefore the final result of 32% of time being spent face-to-face with patients was expected.

The SlaM Operational policy states that as a guideline, after administrative roles, there should be 14 hours available for face-to-face contact with patients per week. However, this was not achieved on any of the seven days that the diary exercise was conducted on. For example, on day four, on average each CC spent just 1.6 hours with patients. To reach the targets, 2.8 hours would need to be spent with patients per day. To achieve this, is clear that management must reduce the number of patients on each CC’s caseload, or take on extra staff.

Care Coordination workIt is apparent that CCs are currently spending more than the recommended three days providing care coordination for their patient caseload. According to the Operational Policy, staff should be spending three days (or 60% of their time) on Care Coordination. In reality, staff reported spending 68 % of their time on Care- Coordination. In addition, CC’s were working during out of office hours. Therefore the 68% of time spend on CC included the out of office hours worked, and would equate to significantly more than the three days set out in the guidelines.

Specialist Work

It was concerning to see that specialists are only spending an average of 11% of their time on their specialist interventions. On some diary entries, specialists did not appear to spend any time on their

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specialist interventions. On further discussion with one specialist, it transpired that they had 25 patients on their caseload, and could rarely dedicate time to their speciality on top of these demands. It is possible however, that some CC’s did not differentiate between generic and specialist work in their diaries.

Four CCs reported that they were unhappy with how their time is spent at work through informal discussions with the project lead. They felt that the majority of their work was in areas completely unrelated to their trained speciality or profession. This is supported by the results, which showed that CC’s are unable to meet the guideline of spending one day per week on Specialist interventions (as outlined in the SlaM Operational Policy).

The effect this had on staff was that 62.5% regularly had to neglect tasks because they have too much to do, and half of CCs felt that they sometimes had unachievable deadlines. As a result, many staff were experiencing low psychological flow, and there were mentions of high stress levels, and one CC reported experiencing early symptoms of burnout, and was considering leaving SLaM.

Spending time delivering specialist interventions is found by staff to be purposeful and enjoyable. Structuring the service to allow greater time for staff to spend on specialist interventions would improve wellbeing, help with staff retention and potentially reduce burnout.

Staff breaks

Staff breaks were rarely taken. On two days of the diary exercise, a total of 0.5 hours were spent on breaks, which when split between the seven CCs involved in this project, equates to less than five minutes each. On further discussion with staff, most reported that they ate at their desk, and worked through their lunch breaks. On several occasions, the diaries showed that CCs were unable to take a break until 4pm in the afternoon.

Research by BUPA (6) has showed that in a study of 2,000 workers from UK organizations, two-thirds claimed they were not always able to take their legally required 20-minute break when working six hours or more. Similarly, the SLaM Stress and Mental Health survey has showed that 75% of CCs are sometimes unable to take sufficient breaks.

Taking a lunch break allows staff to take time out of the working day to relax and recharge. This leads to higher productivity, and business outcomes. In addition, it allows staff to remain focused and alert, which means they will be performing at their peak. BUPA go on to say that whilst everyone is busy, staff must recognize the importance of taking breaks, leading by example and not letting breaks fall by the wayside.

The main reason for staff at SLaM not taking a lunch break was due to their workload. This project showed that 50% felt that they sometimes had unachievable deadlines. In addition, 75 % felt they often or always had to work very intensively because they had too much to do. Managers are also setting a bad example, since if they see their boss’ not taking a break; they are likely to feel pressured to do the same.

The British Dietetic Association performed a literature review into workplace health (7), and found that eating at the desk whilst working can lead to ‘mindless eating’, which can result in eating the wrong types or amounts of food and contribute towards weight gain. Other benefits of getting away from the desk include getting fresh air, and exposure to sunlight for Vitamin D production. It is also unhygienic to consume food at a desk or keyboard due to harboring of bacteria. Getting away from our desks and moving around also helps prevent the onset of musculoskeletal disorders, and other conditions that result from remaining sedentary. Therefore, in light of this, the project lead and staff

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involved in this project felt that more emphasis must be placed on the importance of implementing sufficient lunch breaks.

Therefore, Team leaders and service leads should encourage and facilitate all staff being able to take their legal breaks. In addition, Team leaders should also set a good example by taking a break away from their desks.

Team meetings

The team morning meeting provides the MDT with crucial patient information about urgent referrals, patient updates, zoning and crisis work. Some staff approached the project lead independently about their concerns regarding these meetings. They said that most days, the meeting ran over the recommended 45-minute guideline. During the time the project lead spent in these meetings, on several occasions, it lasted for more than double this recommended time.

Not all staff were engaged or required in the discussions, and thus were multi-tasking and performing other administrative roles such as checking emails during the meeting. This could be distracting for other team members, and mistakes could be made if staff members do not give full attention.

Two CCS’s suggested that the team meeting should instead be held twice a week: once at the beginning of the week, and once at the end of the week. Even if these two meetings were significantly longer than the 45-minute recommendation, the CCs felt that this would result in a more productive working week. In the meantime, any urgent issues could be dealt with specifically as they arise, and brought up with the team leader, or with another relevant colleague.

The team could further explore ways to reduce the length and frequency of its meetings. For example, use of an electronic board during zoning meetings could improve the efficiency of these meetings so that information can be documented into the electronic record system contemporaneously.

Case loads and staffing

The caseload size could be reduced to 20 patients. This would reduce workload including work spent on completing mandatory documentation.Use of a dedicated team duty worker to cover crisis work could reduce the frequency of interruptions from unplanned work and allow staff to plan their day better, including incorporating breaks.The support workers in the team help perform many of the generic care coordination tasks. Use of additional support workers could help free up time for other staff to focus on their specialist interventions.

Computer SystemsAlthough this project did not focus on the computer system that SlaM operates, the project lead felt it was important to acknowledge staff concerns regarding this matter, and it’s direct effect on staff well being. As mentioned previously, files that exceed a certain size must be uploaded as multiple smaller files to prevent the system crashing. This is time consuming, and laborious. A system is required that allows patient reports to be uploaded as one file, without the risk of a computer crashing. In addition, all consulting rooms must have functioning computers for use during

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consultations. There should be a designated person responsible for implementing this, and responding to any issues should they arise. This would significantly reduce the amount of time spent on generic paperwork, short hand and admin and therefore increase the amount of time available for face-to-face contact with patients. This is an avoidable issue that causes significant stress and extra work for CC’s.

The team should highlight the practical problems with the electronic patient journey system and with computer hardware to clinical service leads and ICT leads. Regular input from a named lead for ICT to ensure that all computers are functioning and there are no new problems would help, rather than having to rely on urgent requests for support when things break down.

Summary of recommendations

Team leaders/managers should encourage and facilitate all staff being able to take their legal breaks, and should also set a good example by taking a break away from their desks

There should be further research conducted into establishing an efficient ePJS system, and a designated person should be available to ensure all consulting rooms have working computers and equipment.

The Promoting Recovery Team’s Operational Policy should be reviewed and amended in light of this project’s findings.

Reduce the number of patients to the recommended 20 on each CC’s caseload to reduce work load and stress on staff

Further clarification into the difference between the role of a CC and the role of a Social Worker are needed

More time dedicated to specialist interventions-this could be through taking on more staff, or re-defining how time should be spent on the role of a CC.

Limitations

The project lead spent a total of four weeks working on this service evaluation, and three weeks at the team headquarters shadowing and working with staff. The diary exercise was conducted over seven days due to time restraints. In the future, a similar project could be conduced over a longer duration of time, for a more precise measure of face-to-face contact time.

Additionally, the number of participants was limited to an average of 7.14. More participants are required for development of these findings. In addition, this project was conducted in The South Lambeth area, and therefore represents a small community area. It would be useful to carry out a similar project in different geographical locations throughout the United Kingdom for comparison against these findings. This would allow us to see if the problems highlighted in this report are characteristic of community mental health generally, or are solely linked to working in inner city London.

Some diaries were left incomplete, and some were completed in greater detail than others. In future, the project lead would include examples of diaries that were completed to a satisfactory standard, for staff to use to assist them.

It would also be useful to interview patients and see if they also perceive the SlaM service to be user centered, and how they feel about the amount of face-to-face contact time they spend their health professionals.

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Additional comments since writing this report:

Since writing this report, the project lead wishes to positively acknowledge the recent (September 2015) NHS “Five Year Forward View” announcement. It has a focus on improving health in the NHS workplace (8) in order to benefit staff and taxpayers. The NHS England Chief Executive Simon Stevens talks of achieving this through promotion of physical activity, providing health checks, and improving access to healthy food and mental health talking therapies amongst other things. It is hoped that this will in turn help to reduce stress levels amongst staff, produce a positive working environment, and promote positive general and mental health.

Of the ten participating local NHS organisations and NHS England itself, they have agreed to commit to six key actions. These include (not are no exclusive to) implementing Public Health England’s “Workplace Wellbeing Charter assessment and accreditation process” and the National Institute of Clinical Excellence’s Public Health Guidelines on workplace health. Additionally, they will identify a Board level director lead and senior clinician to champion this work, while providing training to all line managers to help them support their staff’s health and wellbeing.

In light of the findings in this report, the above announcement is encouraging,

Conclusion

The project lead is grateful for The South Lambeth Psychosis Recovery team for allowing them to carry out this service evaluation. Staff participation was excellent, and it was encouraging to see how passionate staff is with regards to the service that they offer to their users.

The project lead was keen to investigate how much time Community Mental Health Professionals spend as face-to-face contact with patients, and how staff wellbeing was affected by the inevitable bureaucratic demands undertaken by Care Co-ordinators.

This service evaluation had similar findings to the literature review mentioned at the beginning of the report. Staff at SlaM also reported high levels of stress, heavy workloads, and at times, poor job satisfaction. However, it was encouraging to see these issues result from a small number of issues in how the service currently runs, and could be significantly reduced if service managers consider the recommendations listed in this report.

Therefore, the team should discuss with senior managers and suggest that the guidelines outlined in the Promoting Recovery Operational policy are reviewed in the light of these findings listed within this report.

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i “Psychological flow is the mental state of operation in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity. In essence, flow is characterized by complete absorption in what one does.” Source: https://en.wikipedia.org/wiki/Flow_(psychology)- Accessed August 2015

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Bibliography

- Adult Mental Health Operational Policy (Promoting Recovery teams) 2014, South London and Maudsley NHS Foundation Trust.

Appendix

Daily Activity – Example Name: Job Title:

Week 1/2 Please delete as appropriatePlease refer to the abbreviations sheet enclosed and the example diary entry

Time / period Day: Notes

8-9am

9-10am

10-11am

11-12pm

12-1pm

1-2pm

2-3pm

3-4pm

4-5pm

5-6pm

Daily Activity – Example Name: Job Title:

Week 2 Monday Please refer to the abbreviations sheet enclosed and the example diary entry(NB information in brackets does not need to be recorded. Included here for explanation only)

Time / period Monday Notes

8-9am 8:50am Y (checked emails), O read ePJS

9-10am C (Zoning) Y (Checked and responded to emails)

10-11am

G, F1, F2, I4 (Documented event about patient in crisis and zoning, Home Treatment referral form, updated full and child risk assessments)

11-12pm 11-130 – T=25, A, T=25(Home Visit Face to face meeting with client)

130-2pm - X (Lunch)

Talked to patient and administered

depotHome Visit

12-1pm

1-2pm

.R5 (Tc to CSC to chase referral).T/c from patient’s family member - 20 minutesR8 (T/c to a patient’s GP and left message as GP not available).G (Documented events from home visit and above phone calls)

2-3pmT = 30 mins (Travelled to Lambeth hospital)

A Met with patient on ward before ward round then attended ward round

T = 30 mins (Travelled back from Lambeth hospital)

Picked up a message left by patient and returned call and left a message

R8 Received call back from GP and arranged a joint review.

Ward round running 30 mins late.

3-4pm Email system not working 2-4pm

4-5pm

Briefly reviewed and gave medication to patients (x 3) - total approx. 30 minsReceived urgent phone call from a support worker and arranged duty review with patient tomorrow. Documented in events and made Alert.Faxed a prescription chart to pharmacy and phoned pharmacy to confirm receipt and arrange for patient to collect medication from pharmacySpoke with Dr to write FP10 as medication not available in cupboard.Phoned a patient whose CC is on leave to check in

Duty cover

5-6pm 5-5.15pm G (documented ePJS events)

Was unable to document some of duty events so will

document tomorrow.

Letter to participantsProject title: How do Community Mental Health professionals spend their time?

Thank you for taking the time to consider participating in this service evaluation.This project has been funded as part of a King’s Health Partnership Quality Improvement Scholarship

The project lead is Harriet Smith - King’s College London.IntroductioA challenge for frontline clinical services is balancing time spent delivering specialist interventions with patients and carers, with time spent on other tasks such as paperwork. The aim of this 4-week project is to understand how community mental health clinicians spend their time at work currently.In particular the project will evaluate face to face with patients and patients, time spent on other activities (e.g. paperwork, phone calls, emails), routine versus duty/crisis work ,and specialist versus general interventions.1 – Diary ExerciseI would be grateful if you would fill in the enclosed diary for the following two weeks, starting 3 rd August 2015. A sample of a completed diary entry is included to assist you. A contents page is included with abbreviations that can be used for completing the diary. I would recommend you complete the diary throughout the day to avoid forgetting important details. 2 – InterviewsI would be grateful if we could meet for 20 minutes so I can ask you some questions about your experiences, including your thoughts about how the service is run and changes you would like to see occur. Your feedback will be kept anonymous and confidential throughout the study. OutcomesThe findings will be presented to the Community Mental Health team, service leads and senior managers in the Psychosis Clinical Academic Group. It is hoped that these findings could be used to inform team development. All participants will be informed of the outcomes at the end of the study.Please contact the project lead if you would like more information and thank you again for participating in this project.Harriet Smith (King’s Health Partnership) harriet.smith@kcl.ac.uk

STAFF FOCUS Group EvaluationProject Lead: Harriet Smith Evaluation for the

period:August 2015

Job title:Supervisor: Dr Emily Daley Department: The South Lambeth

Psychosis Recovery TeamTitle Service Evaluation studentship

for King’s Health Partners

Do you believe the way this service runs is a success? Do you think patients are satisfied with the service?

Generally yes, although given the extent of most service user’s psychotic state, patients do not always appear grateful of treatment. The team commented they noticed a difference when working in other areas of mental health that are considered less severe with patients making their satisfaction more apparent.

Do you feel staff think the way the service runs is a success?

Comments are that workers enjoy the multi-disciplinary team approach. However, caseworkers constantly reported that a significant amount of their working week is spent on generic (such as housing and financial arrangements) rather than their specialist clinical work.

Do you believe this is a patient-centered service?

Yes-a multi-disciplinary team

Is the system made to prioritize paperwork over face-2-face time with patients?

It would appear a lot of the team agree with thisCaseload

How many patients?

Approx. 20 per caseworker

Is this a manageable amount?

No since the caseworker is responsible for every aspect of their patient’s health and treatment plan-unrealistic demands.

HEALTH AND WELLBEINGIndividual staff surveys completed based on the SLAM Stress indication and Mental Health Tool and Policy

Your current work-TO what extent do you agree with the following statements? My current job is focused on where my specialist training lies (i.e. psychiatrist/social worker etc…)

Diary exercise will reveal where more times is spent in terms of specialist Vs generic work

All caseworkers spend approximately the same proportion of their time on admin tasks and face-2-face time

What do you feel overrides-crisis work or routine care?

Do you believe the computer system impacts your time spent with patients?

Yes- staff constantly reporting computing issues. Many computers in the patient consulting rooms were not working during my time with the team. This impacted on time spent with patients. Staff reported that often-patient reports exceed the file size when loading onto ePJS (the electronic patient record system). They therefore have to save the report in sections, and upload them separately this wastes a lot of time, and reduces time with patients.

Do you think the role of care-worker is suitable for how this service runs?

Mixed reviews-many agree that a multi-disciplinary approach is necessary, but resent the amount of generic and bureaucratic work. Some felt this was a role specifically for a social worker. Some social workers reported feeling under-valued.

List of abbreviations for diary use

Face-2-Face meetings with clients A

Face-2-Face meetings with parentsPhone contact with client/parent/carer

A1

A2

Attending meetings such as zoning (including morning meeting) BTravel time B1Mandatory or other training CSpecialist Interventions (FI/CBT for psychosis) DClinical Activity (dispensing medicine/organising clinical cupboard/checking BMI…) ELunch/breaks XResponding to general emails YMandatory for each patient FFull riskChild RiskHoNOSCPA rev tabSummary of NeedsRecovery and Support Plan (including crisis plan)

F1F2F3F4F5F6

Updating patient records as needed GIncidents HDatrixFact Finder

H1H2

Referrals to access other services (or email) IReferral to R & S WorkerTREAT ServiceForensicsHTTInpatientAMHPSHARPMAPPAMARACChild Social CareStatus Employment form and risk assessment

I1I2I3I4I5I6I7I8I9

I10I11

Other forms JESA/PIPMedical CertificatePhysical health e.g. ECG requestBlood formNeuroimaging requestFreedom Pass proformaDVLA fitness to driveGASS side effect scale

J1J2J3J4J5J6J7J8

Social Care KFACE AssessmentSafeguarding alert/activitySocial care related to referral (to housing provider)Covering Support Later for housing applicationCarer’s assessment

K1K2K3K4K5

Mental Capacity LMental capacity assessmentsCourt of Protection Applications

L1

L2Prescribing MCreate electronic TPLANAmend TPLAN (electronic)Write community prescription cardPolarspeed prescriptionPolarspeed registration

M1M2M3M4M5

Mental Health Act N

NB: Any duty that does not fit into these categories please refer to as “Other” and specify in writing