NHS Reset podcast: Ken Taylor in conversation with Dr Julie Hankin

KEN:

Welcome to this special edition interview which is being recorded as part of the NHS Reset campaign. I’m Ken Taylor, Service User Representative of the Mental Health Network Board. Today, I’m going to be talking to Dr Julie Hankin, Chair of the Mental Health Medical Directors’ Forum about her vision for the future of mental health provision as a senior clinical leader.
Julie is the Executive Medical Director at Nottinghamshire Healthcare NHS Foundation Trust, that’s right Julie, isn’t it?

JULIE:

That’s right.

KEN: And a fellow member of the Mental Health Network Board. Just to give a quick introduction to today’s conversation, the impact of Covid-19 on mental health services will be felt long after the physical health emergency subsides.

From a service user perspective whilst we are in the midst of the Covid19 crisis with its many changes, concerns and uncertainties it does feel that we are at a crossroads of how services are going to meet both current and future needs. It is clear that the health and care system cannot go back to ‘business as usual’ following this pandemic; a thought that leaves you apprehensive on the one hand but also optimistic for change on the other. So, I’m looking forward to finding out more today about what that future might look like for mental health services.

Julie, we're seeing the mental health sector adapt to the current crisis in many ways, notably by increasing digital access to services. How do you rate the effectiveness of the increased use of digital, and what lessons do you think we can use going forward?

JULIE:
I think this is probably the biggest change that people have actually experienced; both staff and patients. And I think some of the increased digital isn't completely new. It was very much indicated in the Long-Term Plan. It's things we've been talking about for a long time, but we didn't anticipate quite such a change in speed of roll out and move to it.

I think it's been quite variable, there's some elements of it that have worked brilliantly and we've definitely been able to keep closely in contact with people that we might not have been able to through the current situation.

I think we've also seen, unsurprisingly, there are some real challenges sometimes with the technology. In areas where signal's not good, where bandwidth doesn't work out, it can be really challenging and it's really challenging for some individuals. So I think what we have to do is accept this isn't going to be a blanket, one thing fits everybody. For some people, digital works really well and actually will fit much better with them maintaining employment moving forward and I can think of a lot of outpatients, people I've worked with over the years who would love it.

I think there are also people who really struggle with it and don't like that distanced approach. And I think the key is going to be having a choice. How do we have that option of digital or telephone or face to face? And it's not something that's imposed on people, but we're able to work towards. Again, it might be something that changes over time.

One of the things we're finding is digital works much better if you already know someone and have a relationship with them. So it may be more about follow ups, and ongoing work with somebody that you already know rather than that initial meeting, which can be quite hard digitally. And I think one of the key things throughout all of it is going to be making sure that we don't increase inequalities because there's a real danger that the people who get left out, if we move to a new digital world, are those who are already most disadvantaged.

So that's been a real focus of work and over trust as well, making sure that we're not actually creating a two-tier system where some people have better access than they had, but some have worse. I think we're seeing some interesting changes as well with what it's doing internally, which actually will help access. So we're now able to have meetings of professionals across organizations during supervision, things like that that we really struggled with before because everyone had to get to the same place, that's now happening really easily.

And I don't see us going back from that. But that frees up clinicians’ time to be able to spend on that day- to-day contact with service users. And I think that will help access overall as well. But I think the biggest thing is that continual evaluation now we're trying out new things, not assuming that we've got it right, but working with the service users, the families, the people are on the receiving end of that and being clear what's working, what isn't and adjusting it and keeping working with that.

KEN:
Yeah, I mean, as somebody who's really struggled with the digital side to see my psychiatrist, I’d be concerned that it becomes the default position to go down the digital line because it's perhaps quicker to use that approach than to face to face.

JULIE:
This is what I'm hearing as much from clinicians saying pretty much exactly the same thing. There are things that go on in a face-to-face consultation that you just can't replicate in the same way. So, and I think both clinicians and patients [agree], it won't be. But if you think about in a longer term relationship, there's elements of what we do that could work well over the digital that make things work better, smoother, keep contacts, particularly those sort of more monitoring and maintenance rather than very acute work.

But I think no matter what, we wouldn't have been able to have anything like as much contact with patients at the moment in the current situation. It’s getting it right for where we end up.

KEN:
Absolutely. And in terms of getting it right. For where we end up, how do you see service-users being involved in the designing of future services?

JULIE:
So my hope is that we can use this to really build on what we've done and actually it take that next step again. I think mental health has always prided itself to a certain level on service-user involvement and engagement. But I think we both know, and I'm sure have seen situations where that can still feel tokenistic even now and not sufficient. I think we need to use this as our challenge to say, so, if we are hitting a real period of transformation and moving forward at speeds, how do we make this more involvement and engagement rather than less?

And can we use that to do that real jump from involvement that can equal “we'll tell you what we're going to do” into actually creating it together and focusing on that. I think there's going to be some real advantages in what it is driving is that focus on local intel. But we haven't had time before. And I think as soon as you move back to a very local focus, then it becomes much easier to identify who are the people who should be in that conversation and how do you work with them.

And I think that's an area as well, that digital may actually help us because we do struggle with how do you reach wide numbers of people and really join up with a population on a wider scale about what are the needs and wants and failings, so I think we could have much more of the raft of moving everything from sort of the big meetings, focus groups like we tend to have that much wider surveys as well, ways for people to be able to come in and get their opinion in ways that suit them.

KEN:
And do you see the Primary Care Networks as part of that?

JULIE:
Absolutely, yes. I mean, it's been an interesting time for them as they were just coming into being at the start of all this. But again, I think actually having to work through this and work together has strengthened them in most places. And again, they get that ability to say, so what's our local? How do we focus on that have to that link to the outcomes that we want to achieve nationally?
So I think with anything, we could make it better or worse. But I think there's real opportunities for making it much better.

KEN:
I'm extremely optimistic about it. I think there's a real chance, real opportunity here to bring about a change for the better, for service-users and for staff as well.

JULIE
And I think shared vision about where we're trying to go. I don't think there's any difference in what we want to achieve. So hopefully doing it together we’ll be much stronger.

KEN:
Can I go onto a point; the Centre for Mental Health published that in the next two years Covid-19 is likely to increase the number of people in Britain experiencing a mental health problem, which we’ve just touched on. There’s the potential and real concern for CAMHS (Child and Adolescent Mental Health Services) to see one of the largest increases in demand. How will this demand be met?

JULIE:
So I don't think we have a clear answer to that yet. And I think that's probably one of our biggest concerns, certainly as a group of medical directors looking at the work and talking to the centre. I think we are very clear we're seeing the start of that surge now, we're seeing that increased demand come in and some concerns still, but that increased demand is happening. But people are anxious about contacting services either because of risk of infection or thinking that services aren't up and running.

So there's a combination of how we encourage people to be in contact, that the services are there and should be contacted, but also how we get that modelling right about what's the demand going to be, what's our capacity and how we meet it. And I think we need to accept that surge isn't going to be a crisis surge. It's not going to be short term. This is about huge changes to how we're all living, what people are experiencing.

And I think we're going to see a much larger surge that stays as at increased demand. Particularly if we see a lot of economic fallouts with redundancies, loss of financing etc. So I think a lot of it- What we definitely do see is that commitment to understanding there is going to be a surge and an increase and that we need to meet it. And I think that's driving that modelling. But the key bit is going to be about do we actually see resources coming across to it. I think there is an element within that, though, of services have to do their part as well. This needs to drive forward faster the transformation paths we're already on. It shouldn't be just more of what we already doing because we knew we thought we could improve on that anyway. And I think thinking really differently about how we work with primary care, with schools, with all the other settings, particularly the CAMHS that we mentioned, or those other settings where we can influence and support access for young people.

How do we think differently about that?

KEN:
And as part of that, the ability to change, move, shift the NHS around to bring about these changes, not taking years and years to do that, but do it in the short term.

JUILE:
Absolutely. I mean, that's been the interest.

KEN:
Is that possible?

JULIE:
Well, we've certainly seen the last few months we can move differently and move away from organizational structures and do things at speed. And I think there's definitely a desire to not see us go back into rigid structures.

I think it is a danger that we will because things are still set up in contracting mode and other structures that drag us back into that. But certainly I'm hearing an awful lot of dialogue about how do we not lose this? How do we use this to move to true system working at speed and stop being so focused on what organization it is compared to what's the need and how we provide it?

KEN:
A key issue that's come out of this, is that inequalities have had disproportionate effect on certain groups such as BAME. How do we mitigate against that in future?

JULIE:
So, again, I think we're very clear about the problem. I think we're less clear about the solution. And it's a problem that we've been working on now for 10, 15 years without necessarily reaching that solution. But what I think this has given us is a clear refocus again and commitment that it needs to be addressed.

I think what we were working on very much before all of this was what the shift to population health would give us in terms of addressing inequalities and really starting to understand it in a different way through more of a public health lens as well as an individual lens. And I think that in some ways now needs to be speeded up and moved forward as we move into - and again, that pulls you back to that very local system working. I think what the current situation has particularly flagged up is also, of course, the issues for those BME staff in terms of within clinical workforce, as we've seen that disproportionate effect.

But I wonder whether actually there's a conversation we're going to have to have about do we need to rethink where our inequalities are, whether the care home discussion, particularly over the last few weeks, would suggest we have another area where people potentially are experiencing inequality, but we wouldn't necessarily have put into that conversation initially.

KEN:
Clearly there has been a huge impact on staff wellbeing during the Covid-19 crisis. How will you support staff in the future as well as currently in terms of their own mental wellbeing?

JULIE:
So again, I think this is one we'd already started, pretty much all Trusts doing a huge amount of work about, before all of this. This has just intensified it and I think what we need to do is make sure we don't just focus on clinical staff as well. I think it's easy to underestimate the impact for all of those, all of the other people who help us keep our hospitals running and actually where is dependent on our housekeepers and porters and all those other staff who've been in here making sure we're up and running. And that's really stressful on them. I think we've got well-being offers in place across the Trusts.

I think what they're going to have to do is focus more in terms of some of that supporting people following trauma. Whether that's the experience of Covid or where we go to in the future, I think what we have seen is much wider use of different communication channels for staff, so the use of Facebook pages, the use of - again so back to some of that digital, as at least giving ways for staff both to support each other, but also to have far more of a voice and an impact back in. And I think that, well, will help. But I think a lot of my concern will be, again, it's back to that danger of if we have an increased demand, but we do want to either change how we're working or have more resource, that's just going to be more and more demand and workload coming into a workforce that we're already struggling.

And I think that's when we really will see a huge problem if we can't address that. And I think, again, going back to how do we take that as a wider conversation as well? How do we start thinking about care, home staff and other stuff as well, which I don't think we've been good enough at.

KEN:
Finally, what's your greatest concern for the future of mental health provision in the UK Post Covid-19?

JULIE:
So I think my greatest concern is that we don't take the advantages and the opportunities now that we have and we watch that increase in demand come, but without changing anything to address it, that would be my greatest fear. I think if we don't see this as a fundamental change in provision, in demand and the need rather than a short term crisis, that we'll just come out of and go back to the status quo, then we will not achieve what we need to.

But I think there are also huge opportunities in it that are really exciting to move far more speed into all of that work we've already been trying to move to, around system, around population health, around co-creating solutions at a local level that people are fully engaged with and moving away from some of those silos we work in so that it's not just about health. It's about health and care, but as a single unified thing. And it's not about mental health services over here in one corner, but your GP is in another corner. How we actually move to a completely different paradigm of how we deliver those services that mean we focus on what it is we should be delivering, not the needs of the organizations that deliver them.

KEN:
I fully agree in the whole process of co-production needs to be a part of that moving forward, with service users at the centre of that decision-making process.

JULIE:
And that's the core of how we get to something different. If we do it the way we've always done it, we'll get what we've always had. This is our opportunity to say we could do something really different and really exciting and get to a better place.

KEN:
So that’s the end of the questions. That brings us to the end of our conversation today – although there is definitely more to focus on in the future and discuss. I just want to thank you very much indeed Julie for taking part and for sharing your views with us.

I’m Ken Taylor and this the NHS Voices interview recorded for part of the NHS Reset Campaign. To find out more about the campaign, please go to nhsconfed.org/nhsreset.
Thank you very much.

ENDS