Independent review following Edenfield scandal

I mentioned the scandal at the Edenfield Centre in a previous post. The independent review of the parent organisation, Greater Manchester Mental Health (GMMH) NHS Foundation Trust, by Professor Oliver Shanley is excellent, in my view. What was striking was the level of distress the inquiry found amongst patients, families and staff. The report made clear that patient care at GMMH has, at times, been poor, and the work of BBC Panorama has made this very clear.

At the same time, the inquiry found there are a great many members of staff who are passionate, evidently talented and highly committed to their patients. But there were repeated stories of senior managers treating staff poorly and fostering a culture of fear and intimidation in order to maintain performance standards. The Trust's management of significant concerns showed slow pace of change, lack of transparency and/or clarity in reporting, lack of scrutiny of key information and lack of rigour in the monitoring of change.

At Edenfield there were a number of factors that enabled the poor care and abuse to take place. These included: 

• patients, their families and/or carers not being listened to or taken seriously

• a weak and fragmented clinical voice

• unsafe levels of staffing and high use of temporary staff

• a poor physical environment

• poor culture, including a lack of psychological safety and low morale, including unsupportive leadership behaviours, unsound HR practices including perceived unfair recruitment and promotion, and a lack of transparency about formal investigations

• conditions leading staff not to adhere to clinical policies such as record keeping and observations

• some staff described being treated unfairly because of a protected characteristic

All these findings led to these recommendations:-

1: The Trust must ensure that patient, family & carer voices are heard at every level of organisation. The Trust must respond quickly when people experience difficulties with services and make lived experience voices central to the design, delivery and governance of its services. The developed strategy in the area of hearing patient, family and carer voices needs to be implemented and evaluated to understand its impact.

2: A strong clinical voice must be developed and then heard and championed from Board to floor, and in wider system meetings.

3: The Board must develop and lead a culture that places quality of care as its utmost priority, which is underpinned by compassionate leadership from Board to floor. This culture must ensure that no staff experience discrimination.

4: The Trust must work with its current and future workforce levels to recognise, adapt to and manage the safety challenges that a staffing shortfall may pose, including ensuring the stability of nursing staff. The Trust must develop a representative, competent and culturally sensitive workforce which is supported to provide services that meet the needs of its communities.

5: The Trust needs to have a better understanding of the quality of its estate and the impact of this on the delivery of high-quality care, including providing a safe environment. It must ensure that essential maintenance is identified and carried out in a timely manner and that the cleanliness of units is maintained.

6: The Trust must ensure that its governance structure (and the culture that this is applied within) supports timely escalation and that the right information can be used at the right level, by the right staff. There must be much greater focus on the validation and triangulation of information to ensure that quality issues can be resolved quickly and learning can take place.

7: The Trust must ensure that Edenfield provides compassionate, high-quality care and that all staff, permanent or temporary, have the skills, knowledge, and support to achieve this.

8: The Trust should review the improvement plan again following receipt of this report’s findings to develop further clarity about the problems that they are trying to solve and the actions that need to be taken to achieve better outcomes. It needs to be clear on how all actions will be evaluated so that it can be assured about whether changes being made are having the desired impact. The plan should be prioritised to ensure that actions are sequenced, build on each other, and prioritise quality of care people. This includes ensuring a balanced approach between the scale of the improvements required and setting out a realistic timescale for implementing identified actions with the support of their system partners.

9: Some common concerns identified across services visited at the Trust were also prevalent within Edenfield. The Trust and wider system must consider how they understand issues identified in these services (and others) in more detail, including through the actions described below. 

10: Organisations with responsibility for regulation, oversight and support to GMMH must review their current systems of quality assurance. They must also review how they work together collectively to identify concerns in a provider at an early stage to prevent tragedies like those seen at Edenfield from reoccurring. Where learning is identified that applies nationally, this must be cascaded by the relevant organisation.

11: NHSE must review and clarify the role of the Greater Manchester Adult Secure (Northwest) provider collaborative and the governance structures needed to oversee this role. Responsibilities of collaborative need to be discharged by staff with the right experience and expertise. In light of concerns identified in relation to Adult Forensic Services (and wider issues in Specialist Services), the role of GMMH as lead provider needs to be reviewed by NHSE. If this arrangement is to continue, support should be provided to GMMH to stabilise the current situation and to develop it to deliver the role effectively in the future.

In conclusion, the report said the priority must be on people, on quality, and listening to those who use and work in services. GMMH has many positive attributes, not least its many talented staff. It must focus on enabling those staff to thrive. This will require a significant cultural shift if the required changes are to happen successfully.

The truth is that GMMH is not totally unique. I think this report has the potential to turn round the dysfunctional state of modern community mental health services in the same way as the Ely and Whittlingham Hospitals reports mentioned in the previous post above did for asylum care. 

Overstatement in the critical narrative of antidepressants

I agree with a lot of what Jon Jureidini says in The Conversation (see article) about why so many Australians in particular, and people globally, are taking antidepressants. However, as I've always said about Jo Moncrieff (eg. see my review of her book The bitterest pills), who is one of the principle proponents of the critique of antidepressants expressed by Jon, I do find niggling overstatement in the narrative.

Certainly too much antidepressant prescribing reflects the overmedicalisation of society (see previous post). I think that antidepressants may just be another example of doctors' shameless exploitation of the placebo effect (see another previous post). I also have concern about the misinformation the public are being given about side effects of antidepressants (see yet another previous post).

For example, Jon says that antidepressants are emotionally numbing agents. I’m not sure what he means by this. Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants are generally not very sedative compared to the older tricyclic antidepressants. I agree that antidepressants may prevent people dealing with their problems properly over the longer term. But Jon seems to mean more than this and I’m not clear what he is saying. Certainly people over the longer term report that taking antidepressants often leaves them with a sense of not being themselves (see previous post). They may well say that they experience a flattening of emotional responses. But I don’t think people generally notice that antidepressants on first starting have the physiological effect of emotional numbing, whatever that is.

Of course I’m not denying antidepressants can have a placebo effect. Taking a pill which people are being told improves mood will commonly counteract the demoralisation people generally feel in depression, particularly in those that believe this could be true. As I said, for example, in my OpenMInd article, “Expectation that medication will produce improvement may itself produce apparent benefit”. But, over time, the placebo effect may not last, or may diminish, or may even create other problems, perhaps especially over the very long term. These nocebo, meaning negative placebo, effects also need to be taken into account in assessing the psychological impact of taking medication. Adopting the view that one suffers from a biochemically based emotional illness can be an identity-altering experience (see previous post). 

As Jon says, it’s important to emphasise that maybe as many as half of patients stop antidepressants within weeks. Again as Jon says, and here I think he means those that do continue them beyond several weeks, antidepressants should generally be tapered rather than stopped abruptly. Unlike Jon, though, I would say this is only generally the case. How easy people find discontinuing antidepressants can vary considerably. This is not to deny the importance of withdrawal symptoms with antidepressants (see eg. previous post). 

I also agree with Jon about the importance of social factors in depression, although how depressing people find being poor, for example, does vary considerably. My final quibble is about Jon suggesting overprescribing is symptomatic of the medicalisation of distress. Actually, as I’ve already said, I agree overprescribing is a symptom of the overmedicalisation of distress. But the problem is too much medicine, not medicine itself. Psychiatry needs to be far more psychosocial, rather than biomedical, in its approach to depression and other mental health problems. It needs to stop reducing functional mental illness to brain disease.