Speakers: Mr. Joe Rafferty, Stephen Scott

Stephen Scott: Good morning, everyone, and welcome to this webinar for the Zero Suicides and Care initiative that's being implemented currently by New South Wales Health. My name's Stephen Scott. I work at the mental health branch of the New South Wales Ministry of Health, and I'd like to start by acknowledging the Traditional Owners of the land on which this webinar is taking place, which is the Gadigal lands of the Eora people, and acknowledge the Elders past and present. I also acknowledge the importance of suicide prevention in Aboriginal communities, in particular, in the relevance of today's webinar for Aboriginal communities. And discuss bias given their overrepresentation in the mental health system and the need for a culturally appropriate forms of care for our Aboriginal communities. I also acknowledge people with lived experience of suicide and people with lived experience of mental illness who are watching this webinar today. And thank you for your participation and interest in this initiative. The webinar today is related to the Zero Suicides and Care initiative that is a key part of the...Towards Zero Suicides initiatives that are being implemented in New South Wales from this financial year, over the next three financial years.
Zero Suicides and Care is an exciting new initiative that prioritises suicide prevention in both our in-patient and community mental health care settings. And this is particularly important to address the high rate of suicide amongst people with severe mental illness, and the really under-utilized potential of our care system to promote suicide prevention and reduce deaths by suicide. Like all of the Towards, there are suicides initiatives that which you can read details on the New South Wales health website. Zero Suicides and Care contributes to the New South Wales Premier's priority to reduce the suicide rate by 20% by 2023. New South Wales Health has benefited over the last week and also earlier this year from the expertise of Mr. Joe Rafferty who is the Chief Executive of the Mersey Care NHS Trust Foundation in Liverpool in the United Kingdom. Joe is also a leading advocate in the Zero Suicides health care movement, and has particular expertise and experience following the implementation of a Zero Suicides health care approach in Mersey Care in Liverpool. So, Joe will be presenting to you today for around 40 minutes, and you can view the presentation as Joe is speaking. There will also then be 20 minutes for questions following Joe's presentation, and you can submit questions by clicking on the blue hand icon on the screen. So, please send through questions because we will have time for discussion afterwards. This webinar is also being recorded and will be posted on the New South Wales health website afterwards for you and then for your colleagues to view it in the future. So, I'll now hand over to Joe to speak to you about the implementation of the Zero Suicides health care approach in Liverpool. Thank you, Joe.

Joe Rafferty: Thanks very much, Stephen. Good morning, everyone. Our journey Towards Zero Suicide and Care actually started as one of a package of safety measures that we tucked underneath an umbrella title called Pursuing Perfect Care. We did that because we recognise the organisation Mersey Care as it started to grow and develop. We developed a broad and complicated set of mental health services, and it became clear to us that we needed to have a very clear approach to safety and quality in our services, as well as actually an approach that also balanced off a financial stability as well. That's been doubly important for us by, as described on this slide, the very complex operating environment that we work in. Although we work in a first world environment, the population in a run in the Liverpool is one of the most socially-deprived populations in Western Europe. It is characterised by a very high degree of health inequality. So, our board took the decision that really we should address this issue by thinking about a quality and safety improvement in a very definite way. So, that response was really to think about safer, more high quality, more highly reliable mental health services with a view that safer services actually cost less money normally, and you'll see on the...this infographic presented at the moment the temptations to fall into one or other of these categories where quality without efficiency simply becomes unsustainable, and that becomes a political problem for our system. Whereas efficiency without quality is purely unthinkable. So, our approach has been really to not occupy either pole or extreme here, but to sort of fly down the middle of this. And we have operated within this level of strategic framework for quite some period of time. However, what we have had to do really as an organisation thinking about making mental health as safe as it can possibly be, is to think about the large-scale chains that necessarily accompanies that type of mission. So, you see in this diagram that it's not... there's nothing here that's remarkable. This is all pretty well-known stuff, but what we've done is think very carefully about how we operate within this five key areas for us. Many organisations start such a journey by having a very strong focus on accountability, and if I can sort of characterise that as, you know, we get job descriptions very clear. We talk about the intent of what we want to deliver and change, and then we make them an accountability issue. In our...we try some of that.
In our view, that's not sophisticated enough for the type of approach we want to take. Also, some people are, like we did in the first instance, decide to enter through improving our practices. There's no question about people who die by suicide in our care. It's arguable that they fall through the cracks in the current system. So, there is absolutely every logic in saying we should tighten our practices and processes to make sure that we close those gaps and reduce the risk of people falling through. Our experience rather is being that one tends to improve the things rather rapidly that can be improved, and then you get performance plateau. So, we've moved away actually from not thinking about accountability of practices. We do that, but we redefining them in the context of the outcomes that we want to see. So, we deliberately started our changed process, thinking about outcomes, and that's by... we have really taught the staff, people with lived experience about what matters. And quite frequently that talks to us about the importance of, you know, absolute change, rather than hitting targets and the risk of missing the point, really, in that sense. So, I'll explain a little bit about what our outcomes mean, but we've also spent a lot of time in the other two categories as you look on the left-hand side of this mindsets and culture. Everybody talks a lot about culture, but often it could be difficult to work out exactly what we mean. So, we focus a lot on mindsets. So, really what is it that people carry in their heads as a sort of informal, invisible barrier to the creation of change in any system, and then a critical event is actually capability. Often, we seem to create change without necessarily putting the capability skills in the hands of people who have to do that very change. So, those five areas for us are profoundly important, and certainly in our journey Towards Zero Suicide, we've thought very hard about the meaning of each of those five areas. We've got into the sort of notion of how to do this change using this sort of little formula. We focused on foresight, which is, what's the type of organisation we want to have.

Talking to consumers and to staff, what would make them proud of their organisation, what would a perfect care organisation be doing or products they would be producing. Inside, we have benefited hugely by working with those with lived experience and with those who deliver care everyday. And that combination for us has been a really powerful engine host for change. And finally, oversight. The notion that we work in complex services and things don't always turn out as we intend them to. But there's a duty on us when that happens, to learn and to learn quickly. But our philosophy in Mersey Care is if we don't have a candorous, open, and transparent approach, indeed, an approach based on fairness and justice around learning, then actually we're likely to suppress learning. If we suppress learning, we increase the likelihood of the same thing happening. So, in terms of foresight, we have a group of Zero Best Approaches, Zero Suicide, Zero Restrictive Practices, and Zero Medication Errors. All of which directly relate with an...to creating a safety platform in mental health services. And for us, the fact that no one will die in our services is a sort of maximum expression of patient safety. And we know people die from suicide. They die from restrictive practice and restraint. They die from medication. They also, of course, die from missed physical... from physical health care problems. So, we have a Zero-based approach to missed physical health care checks. And we've also started to describe this approach to physical health care that we also run. We call these our Big Hairy Audacious Goals, the BHAGs for short. And, you know, I mean, if you want an explanation for why Zero is important. Well, the first time you talk about this to staff or you talk about it, some of your staff will be delighted. They get it instantly. They think this is a good thing, and others find it, I mean, intensely challenging. And if there wasn't that sort of curious mixture, then the goal wouldn't be big enough. It requires this sort of approach, lots of help, teamwork, guidance, research, and so on. It's not really...it's a team sport. It's not really a thing that's about individual acts of genius, and if it wasn't about a lot of team work, then the goal wouldn't be hairy enough. And actually, you wouldn't always know what the solution is. You've got to be creative, discuss, have conversations, experiment a little bit 'cause if you knew all the answers, the goal isn't audacious enough. So, that's the sort of explanation for the logic of this sort of approach. Why Zero, but for Suicide? Well, I think it's Ed Coffee often quotes, he says, If the number isn't zero, what's the right number?' And that's actually a really provocative and profoundly important statement. And I think it's when... I'd encourage it, to keep asking of all of your teams. But I sort of think really Zero has helped us in Mersey Care to be innovatively disruptive. I mean, disruptions can be a dangerous thing, but as long as you see it as an innovative disruption, then it can be really empowering for staff. I firmly believe that the majority of our frontline staff know where all the problems are, and actually they usually know what all the answers are. But something inhibitory happens about people having the freedom and empowerment to get ahead and create that innovation. And sometimes, that's the culture of the organisation. And that culture actually inhibits learning, so that we can create a virtuous cycle, rather than a vicious cycle. And that's why I think sort of radically upgrading our learning as it is critically associated with the user's error. We've been very clear, however, in the organisation that Zero isn't a target. There are no trajectories for Zero Suicide in our trust, and there won't be in it. And I know colleagues at the Ministry feel strongly about this approach as well.

We are...we also have been very clear from the onset that this is about zero suicides in our care. We believe wholeheartedly that suicide is an avoidable death. It's both preventable by wider public health interventions, where people are not known to our health care system. But for those known to our health care system, it's sort of beyond preventable in a sense. It's absolutely amenable to change. We know the people. They're often in our hospital beds or in our community services. We have the records. We know the medication and diagnoses. We know the risk factors, and we know their protection factors, and all of those sorts of things. And it's...it's within our scope to do a lot of the change of the system and process to hold those people safe. But it's in our view just about better processes, I call it here organisational performance. It's very tempting to think it's just about organisational performance, but all of what we've done shows that you have to think about better culture. We call it organisational health, but you've gotta think about the organisational health. The processes are what, you might do it. And the better culture is how you go about that. And for us, organisational health is well characterised in these nine issues. This is from McKinsey, so again, this is, you can find this stuff on how to measure these things really easily on a variety of websites, but we're very active in direction leadership, culture and climate, motivation, capabilities, and accountability. Some of the other bits we have more work to do on, but it's our firm belief that by thinking about these things you create the environment for the grid processes to be developed safely. We're also not short on evidence for the English NHS. The National Confidential Inquiry into suicide and homicide, has for a number of years said there are ten clear ways to improve safety and reduce suicide for people in mental health services. You can see that there's a range of issues there, we are active in nearly all of those areas as relevant to us, and there will be similar information sets I'm certain for the Australian system, but having this week chatted to quite a lot of people in New South Wales, everybody pretty much recognises those issues as relevant to your population as well. However, we have, in a sense met, the meaning of the actions we take place in those spheres meaningful to us, so, a lot of this is about creating some local ownership, so, we talked about our own four cornerstones and ten practices for zero suicide. I'm not gonna read out through all of these, but actually, if you quickly scan, there's nothing on there that represents rocket science. Most of this is actually about the application of common sense.

Why we said that zero isn't a target, the ten practices, we do embed annually in our operational plan. So, we do make sure that the things that are most likely to drive reduction and suicides and towards zero, are things that we do measure and we do understand progress against those on a really regular basis. And that's something I would recommend you or sort of make a habit of. So, some of the things we've done. Training to support competency and suicide prevention, and this, we've introduced the minimum standard for all staff. So, level one training, doesn't matter whether you're a clinician or a non clinician in the organisation. We want people to do this training. If you look at the little sort of coloured and compliance brackets, that's up there, you'll say that most of our services are over 90% compliant on this training. Interestingly, we haven't made it mandatory, it's optional, but it's optional to the extent that people know over nine out of ten people in the organisation and this is an organisation of 8,500, 9,000 people, that tells has told us and indicated to us that there's a real poll for training, this is a level two which is for technical staff. But you can see the brackets inside there are not about the usual, low, medium and high risk stuff, it's actually about understanding suicide in a different way, person centeredness, and proper formulation, the use of formulation, the embedding of thought into safety plans, which are co-produced with consumers, ideally with their protective people in the room, their families, their friends, their relations, and honouring and understanding and supporting lived experience as a component of this and in a fallen frank way. And we've done some very simple 20 minute online training that is actually publicly accessible and it will be accessible to use right after this if you wish. The key point here is, we assume that our staff professional and non professional staff would be more comfortable in suicide prevention, because of course, they work in a big mental health trust, but actually, what was clear to us was they do feel that they've got a capability gap. And addressing that capability gap is really, really important. So, awareness and competency training is actually an easy early, engaging and effective when in your journey towards zero suicide and certainly conversations I've had this week, people are saying, yeah, they would like training because actually, you know, you can be a specialist in what you do, but still not feel like you've enough experience or exposure to people with suicidal ideation, and that's particularly true for people who are non clinical in the organisation. The great benefit of course of doing training basic training for your staff, for us is, that we send 9,000 people home every night, trained in suicide prevention, basics was like prevention and awareness back into their communities. And they're more able to talk to their families or they're more able to talk at their sports club or wherever it is. So, you can see not only do you benefit the organisation, but it sweeps through into a community benefit as well. One of the big areas out of the National Confidential Inquiry was the reduction of patients out of area, so, away from their protective friends and family roots, and from services like ours where we're continually trying to drive improvements, and you can see on the right hand side of this, we have another patient out of Medicare's area for 650 I think, odd days. The point is, that for us has been a fantastic achievement. But the point of this slide is to say, we introduced Zero Suicide on that red line, but started to talk about no out of area treatments. Just about a year later or so, the point about this is, there are some things you can do quickly some things are very challenging, and you don't have to do everything at once, it's a marathon, it's not a sprint in that sense.

The critical thing is to think about the timing. So, don't get overawed, in a sense, by the complexity of what needs to be done, start to break it down into bite sized chunks. And a lot of socialisation will take place as you start to put some early wins in place. This is a bit of a safety plan, and it doesn't give the detail of the safety plan, there are lots of places you can go for safety plans. But two things on ours, it's embedded on our clinical system, so you have to do the safety plan, that seems really logical to me, in the yellow box, for those people who fully implement our safety plan or where our safety plans fully implemented, better to say, not present readmissions to inpatient boards, and a reduction in reattendance to the ED department from 65% down to 15. That seems to be a pretty stable finding. Critical thing is, of course, it says, fully implement our safety plan. Like many organisations, we rushed to get a dumb thing, we've got over 100 safety plans in the organisation. We don't have yet 100 really good ones. But, where we do really good ones, you can see the sort of effect we get. So, again, safety planning is something where people are really picking up, now in the Zero Suicide sphere that this is one of the key things that can really make a difference quickly. We've integrated a lot of our surfaces, here you see police ambulance, and British transport police, and this is about starting to close the gaps. So, the relationship with key partners is critical. While it is zero suicide in care, you got to start looking outside your walls to make sure which of your key partnerships you need to stitch into this as quickly as possible. And this is something that we feel will really flourish over the next couple of years.

This is about intentional self harm, now, when you try to plot your suicide numbers, that's a complex game, these are rare events, they drift up and down, they dependent on a coronal decision, so, often it's several years before you know where your actual suicide rate in practice, so, we've looked at intentional self harm as a leading edge indicator, the risk of suicide in the first year following intentional self harm, is 49 times greater than in the general population. Likely in the first six months. So, we've taken the measurement and intervention around that as a critical thing to deal with as a leading edge indicator. In our system, we used to just assess people, and then refer them on into our system, but it might take a long time, sometimes weeks and months to get into service, so, what we've done is introduced a brief therapy, psychodynamic interpersonal therapy, and elements of CBT, CAT sorry, and of 92 patients who we've looked at in this study, 92% of them never reattend with self harm. Only about 7.5% reattended with self harm. A few people came back 4.3%, but not with self harm. And critically, I think the thing we did here was, move to intervene rapidly, so, the median number of days to get referred to the hope surface, as we call it, is a day, and the median went from referral to treatment, first treatment and a five stage treatment is four days. If you think about it in the English NHS, a council referral is 14 days. So, this has really stepped up our sense of urgency around treating people who are at huge risk potentially of certainly suicidal ideation if not completion, in this group, and it has moved us, I think, to a new place around urgency in relation to suicide prevention. Which I think is a is a critical gain that comes from the approach to zero. And we're seeing a statistically significant clinical change in depression anxiety and suicidal ideation for these guys. And this is two slides, the principal point of which is to make it easy for clinicians to look at their caseload, this is a caseload monitor, this is an individual practitioners caseload, it's based on an artificial intelligence algorithm that looks at the risk of crisis, traditionally, we've tried to keep caseloads in our community safe by looking at the size of the caseload and then trying to make sure we've got the right staff, associated with that caseload this because it's based on risk of crisis, actually moves from the size of the caseload to the complexity of the caseload. And we know that competent staff, in relation to complexity is a critical safety driver for prevention of suicide, and this allows our guys to look at the caseload, see where the complexity is, and to move our staff with particular skills and competencies to support that caseload in real time. So, one of the impacts of that we think is, if you look at the top graph, we used to have a significant issue with deaths post discharge either from inpatient community or the emergency department, and in the past four years, we've seen one death in the not seven days post discharge. That's a good indication of progress, in terms of insight, there's 20 minute training that I talked about has given us some really big insights and I'd suggest that one of the things you want to do through implementation is work out how you get some of these insights. This is training that was produced by people with lived experience of suicide, and with staff as well. Who at later turned out had a lot of knowledge of how their own lived experience of suicide.

And we asked a question before and after is suicide inevitable? 55% of clinicians said yes, it is inevitable beforehand, 65% of non clinical staff, I was surprised actually, by the size of that, particularly the clinical staff, ten, 20 minutes later, after the training, that reduces to 10%, that's a major impact. That's a rapid way to change some mindsets, but I suppose I've dwelled on this question for a while, how do you prevent something if you think it's inevitable? That's a really critical issue and I think everybody's journey towards zero suicide, that's why the mindset question in terms of culture is so critical, and as you implement, I think it's really important to think about asking the questions around these sorts of issues. And then lastly, for us oversight. So, how do we become learning organisations, and our viewers that if an organisation lacks candour and transparency and openness and fairness, they're not drives learning on the ground. It is a huge inhibitor to the learning space. Yeah, we know, there are massive opportunities to learn from all of these adverse incidents. Our Trust Board set the Pursuit of Perfect Care as a core of our strategy and our staff actually, really quite like the BHAG approach. But they did say to us clearly, we like it, but we want it to happen in the context of a just and learning culture. They were right. I think there is that this is a barrier to transparency question we asked in the trust, what does it feel like when something goes wrong? These are the results from 400 senior clinicians top line fear of consequences blame, shame and been dismissed. A lack of support, trust, it's adversarial, it's retributional. That's a massive issue to be faced with, and those sorts of failings, those sort of experiences will not allow us to be a learning organisation. So, we thought hard about the need to actually tackle this head on. We talked about our people BHAG, and the notion of adjust culture. Which accepts nobody's account as true or right, and others as wrong, instead it accepts the value of a round table multiple perspective, and that somewhere in the centre of that, is the opportunity to discuss sensibly accountability, and then they'd critically to drive learning. There's a book called 'Just Culture', which is a great on addressing it. The retribution aspect is characterised by I think four key features, which bridge is broken. Who did it, who did it? How bad is that bridge and what should the consequences for the person who made that bridge be? And I think a lot of people experience this sort of look back into a serious incident with those sorts of questions or at least that sort of philosophy on the background. What's hardwired into our approach. People are the problem. Find out who did what wrong. If the rules are broken, write more rules, seems to be the thing we often do. Tell everyone to try harder, get rid of the bad apples and so on. And that of course, if you're running an accountability system like that, it's going to scare people. It is going to not certainly make your culture open and transparent and candorous. And then the things we say, hearings, witnesses, allegations feels like you're in court. It doesn't really feel like it's an open approach. And it drives on the grind. All of these things here, which are the things that precisely we need to run great organisations to have a true organisational health and to precipitate every opportunity for an organisation to learn. So restoration is about who's hurt, what are their needs, whose obligation is it to meet those needs? And how do we involve the community, which might be a community of bereaved people. It might be a community of practitioners that might be a ward, you know, you can interpret that as you need. And we've produced a restorative just culture checklist, which really prompts our thinking in relation to these areas that will go out with a slide pack, so you can look at it in a more allegedly way, but you can see the value just of prompt questions in each of those areas. Which will be, who is hurt? Well, actually there are lots of people hurt in a major incident. Of course, primarily the first victim, but then there are secondary and tertiary victims who pass through this as well. And it's the extent to which, A we appreciate and then B, we acknowledge this issue and what we explore, what we identify, what we do and what we achieve. So that's the sort of approach we've begun to adopt. It's based fundamentally on a compassionate response to things rather than a sort of a full heavyweight full Judi process.

It's not blame free, but instead, accountability is about not what happened and we're going to make you accountable for that. We're going to give you the ticket for it. It instead says, if something has happened, what can we do to prevent that ever happening again? And what steps do we need to take? This sort of things that we've asked in the checklist, what sort of things do we need to do to make sure that we close down the opportunities for that to happen again. That is about learning that's best fully in a concept of learning. Really, in our system, we asked those people to talk to the rest of our staff about their reflective experience. Now that's a really tough thing to do. Don't tell me that you don't feel your accountability when you do that. You do. But actually, it's based on driving learning and that's a truly mature place to be. Our little giveaway line. Ask what and how, but don't ask who. Because a bad system beats a good person every single day. And if you ask who, you forget that that part system is there and you just look at the person involved rather than thinking about your system. Lastly, we talk about it as delivering a safety dividend. If we can get things done early, resolved early things, sorted out properly, everything work into people's satisfaction in a learning environment, we spend less time looking at legal defence and liability protection. We actually, we pay the lawyers less money and the money we save the safety dividend. Why don't we reinvest it back in our services? Making our patients and staff feel safe and everything we do with them? It's just a describing the lamentable state of our employee relationship before we introduce restorative practice. And you can see the drop off. And that, interestingly, our union said to us, one of the biggest things I wanted to say was a reduction in this sort of activity. That for them was a litmus test as to whether or not adjusted learning culture was an interesting thing to talk about or something that the chief executive and the board was sincerely going to pursue. What'd you say as a 54% reduction in disciplinary investigations over a two year period. It's of course, much greater than that. But interestingly, we doubled our number of staff during that time period and still reduced it by 54%. And here comes the, for me, a critical bit, 1.7 million pounds saved in clinical suspensions over two years. So, hey Presto, that's the safety dividend we talked about. So by reducing the number of people out of work because of disciplinary activity, we're not having to pay a locum costs to backfill them. That's high, that safety dividend is calculated. But lots of other things that have happened reduced by 50%, well over 50% actually, the cost of running an investigation because we don't spend weeks doing that, we often spend hours rather than weeks doing investigations. It's based on less paperwork and much more on conversation and dialogue and didactic interaction. Our surveys have increased in terms of this sort of fairness, effectiveness, openness and transparency questions, which is really great. Retention has improved, turnover has reduced.

So we're now currently running our nursing vacancies around 3%, which is the lowest in our history. So understandably what happens is, when it feels like the culture is restorative and just, and balanced in favour of staff having a reasonable say and everything that goes on and a good hearing when things don't work out well, that leaks out, people talk, and folks want to come and work in an organisation like that. And that accounts for something like a 1.8 million safety dividend. So we've moved I think, a long way from who's responsible and legal sanctions to sift psychological space and forward looking accountability. Of course, this is work you never stop doing. You've got to keep consistently improving and shining this and making sure that it evolves as people wanted it to. But fundamentally by asking what is responsible rather than who is responsible, you get a different insight. In the middlebox, in the orange and blue, there are a set of issues that have been live in the organisation over I guess the past year or so. Now in a retributional approach. Generally speaking, all of those things would have been farmed off into professional or personal accountability issues for our staff. That's generally speaking what happens, but actually now when you ask what is responsible rather than who, the bit in the yellow box or the orange box actually becomes really clear that these are system issues. They're not individual practitioner or team issues, they're system issues. So we're not able to separate off the professional or personal accountability issues from the organisational accountability issues. And that's profoundly important because, you know, for somebody like me and board and the very senior leaders, we are responsible for the organisational system. That's our day job. So you can see on the right hand, we moved to a system that is much fairer, much more open and transparent.
So we just established in the presentation this sort of importance of getting great processes in place. And also making sure that those processes are operated on an improved by frontline staff, who feel capable and competent and well trained and safe in terms of an environment of change. Sort of reflect down on some of the sort of outcome data that we have, as to whether or not that's, what I've just said is a fine form of words or is actually something that can be verified. You see data in front of you on reducing physical restraint. This is all of our services across the trust. And if you remember the second slide that I showed, we run services from sort of standard inpatient services for mental health, but we run the biggest forensic practice for learning disability in the NHS and we run of the NHS is three high secure hospitals. So we've got a very complex range of patients in the organisation. And what you can see is on our inpatient wards is we've reduced by circa 50% the number of restraints in the organisation since 15, 16. And below that, you see assaults on staff causing harm. And that's also reduced by around 50%. Now, the relevance of that to suicide prevention is our wards are more stable, calm, confident places. As a result of this, our staff are much more engaged. People are associated with that reduction in results. We see people coming back from longterm sickness or taking a brief period of but not going into longterm segments. So we end up with a stable staff grouping and all of that stuff we know is very protective for people on wards for suicide prevention. And of course with this about a 1.4 million safety dividend. So I think you can see where I'm going, in that every time you do this to try and make surfaces safer, you can also actually safely reduce the cost of those services. This is our suicide RIT reduction evidence. Each stop you see there is a three year rolling average. We think it has to be something like that because these are very rare events. So you plot in the numbers is, it's sort of not really instructive. These are the suicide rates per hundred thousand. Starting the 1st of April, the 1st of January, 2015 and you can see here that we have accumulated an approximate 30% reduction in three years. So I think, Stephen, if the ministries approach was 20% in what, four years? 2023, is it?

Stephen Scott: That's right.

Joe Rafferty: Yeah. So we've met a 30% reduction in three years. So I think that's very encouraging to show that with a sort of focus. You can certainly get into that sort of range. I would argue, probably no problem. The last piece of data is from a prison service in Liverpool, which we took over last April. About four and a half people per year on average die in a lot surface by suicide. We take over the orange bar. The first six months we saw three deaths. But as we then introduced the 20 minutes digital training, safety planning, co-produced safety plans with prisoners, good awareness training for staff and good critical case review. You can see from like October of last year to today, we've had no people die by suicide in that prison. So, you know, that's a one year snapshot of zero, but actually, that zero's really significant. That shows that, in locations where you apply the evidence, you actually can start to see zero as the most common thing to happen. It doesn't mean the say, this happen, but zero was the most common state is perfectly possible. So last key messages for you. It's a marathon. I say it's a marathon but with some sprints, I think it's useful thinking about the things that staff are asking you for that are practical and attainable. I'm trying to put those in place relatively quickly cause some people's confidence, it shows that you're listening because these big hairy audacious goals are big hairy audacious. So in a sense, we do need to have, a field for supporting people through them. And the more that we can give people off the simple stuff they want, the more they'll buy in to the whole thing. Don't let project Titus, think that's the newest a word I can go with. But get in the way of real deep change. Cause this is about real deep change. This is about the health of organisations. Zero basin as a mechanism has allowed us to get into things historically and mental health of people have said you can't do. So we talked about zero suicide on where we're on our way describing zero in many different types of ways. And it's been hugely reputation on Hudson for the organisation to do that. Restorative just culture is the most potent way to engage with staff, I've ever experienced and in a reasonably long career and it definitely done well and sensitively drives up staff satisfaction, drives up staff competence and puts staff in a place where absolutely the thirst for learning starts to get satisfied and combine the two as you've seen from a number of examples that I've given. What do you see are real benefits, real benefits for your system, real benefits for patients, consumers of course, and real benefits for staff. But what you see is we increase patient safety, while at the same time we're able to safely reduce costs. So I'm going to leave it there, Steve.

Stephen Scott: OK, thank you very much for that, Joe. And congratulations on your success with this implementation. It's very impressive. Especially some of that very compelling data you were presenting at the end of the presentation there. Now for everyone online, we have another 15 to 20 minutes now, for some questions and discussion, so, I would encourage you to continue submitting comments or questions using the blue hand icon on your screen. But just to go to some discussion points now, Joe. One of the most critical elements of this that we have picked up from you in our discussion with you over time is the importance of leadership and executive support in promoting and maintaining the just and restorative culture, so, how would you suggest New South Wales health services work on engaging and sustaining that executive support? And for staff, how would you think that support is best demonstrated?

Joe Rafferty: Yeah, that's a great question, Stephen. Am completely convinced that sort of executive level sponsorship of this is critical to get a sort of implementation that has got any legs on it really, I think there's an important role from the ministry, in a sense in terms of set an expectation, if I can put it that way, that a framework that is, is live and real and under discussion by boards, is something that they can demonstrate, I think principally, we've got to look for some evidence that the senior leadership of an organisation are in themselves. For example, if we take the restorative practice piece, are in themselves practicing restorative justice in the organisation. One of the things I'm clear on in MercyCare is I know when I take decisions, I know that staff wants me to see whether or not I display a restorative approach, so, it's a sort of goldfish bowl piece in that sense, and I think, however, an organisation chooses to do it or a Local Health District, chooses to do it, there has to be a way to test the authenticity of that. So, I think if we said we gonna do, we put it in the plan, and then we continue to do our behaviours, as we've always done our behaviours, there's a real risk that this doesn't flourish. If you look at the history of large scale change, about 70% of large scale change fails. And outbreaks are roughly as about 40% of that is done to staff who don't engage, and the other 30% is probably done to leadership who don't change their methods of management. So, you got to do that, And the thing that we did, of course, with our unions in particular, was to say, what measure would matter. And I think that's the open question that your leadership should pose to the front line. And that way, if the leadership delivers that change, that builds goodwill and aware that, I think you've got a massive springboard to then push ahead with all of that process stuff that we talked about.

Stephen Scott: OK. And I guess the flip side of that in some way is that the clinicians that work in our system and the other stuff as well, for that matter, need to be on board with this approach. It also can't be a just a top down, executive driven approach either. So, looking at the issue from that perspective, how did MercyCare work on that ground up staff engagement bringing clinicians on board, this whole approach from the very beginning? And how have you worked on sustaining their support for the approach?

Joe Rafferty: So I guess at a top level, you know, for me as chief executive on my chair, we did a lot of board level, so, of course, there's a medical director and the director of nursing, and the director of operations, and the director of workforce in our structures. And if you think about those four people, they interact directly with the majority of the operational system, you know, some of them clinical, some of them non clinical, so, you know, the use of medical director and a nurse director, to be a key cheerleader for this sort of stuff is critical, we used a lot of engagement methodology, we used an approach called mega compensation, where we would draw or probably over a period of ten days, we would invite like, 100, 150 people into the room, and we would talk about the issue of let's say, you know, Zero Suicide and adjust culture, and the approach would be based on what is it like right now? And what needs to change, and what's stopping us doing that change? Three simple questions asked in the same way, in a very open format, and over ten days, you draw a huge amount of internal intelligence in relation to that. And then that comes back to the executive team and the operating officers to sort of say, well, OK, how do we create a, you said we did sort of approach. So, I think, and there are people in organisations will have ways of doing that. But it's very important, I think, to stimulate the dialogue. Let people talk it a little bit. And I think the other thing is, this bit about making training available, sometimes it's the suicide awareness thing, I majored on that, but we asked the question, how many of you feel competent and capable to do basic change management in your service?

Stephen Scott: Right.

Joe Rafferty: And I said there were very few people trained in something like PDSA, you know, a very simple tool. So, we've upped the number of people who have PDSA train and things like that. They're not complicated things to address, but often, we make an assumption that it's happened. So, I would encourage particularly senior leaders in the system, senior operational leaders in the system, to ask those sorts of questions and find out what it's really like.

Stephen Scott: The training component is really important. Isn't it? And I appreciate the point you made there about, this is not just about suicide prevention skills, but it is about another set of skills around change management and those kinds of more cultural processes that need to be looked at.

Joe Rafferty: And also we've led in, so, we've built four different layers of sort of management and leadership training inside the organisation, so, I think if you think about that, organisational health, the nine things on that, it's sort of useful to reflect on those, and almost have a little bit of an audit, I think around, you know, how much are we really doing in these areas and how much can we really show that we've made it right for the frontline to sort of to get itself going? So, I'd suggest that people start to think a little bit about that. And, you know, I think like everybody has discovered the reloads, the gaps. There just are.

Stephen Scott: True.

Joe Rafferty: You know, but the critical thing is what you do about that information, not the fact that there are loads of gaps.

Stephen Scott: Yeah. And the communication loop is really critical

Joe Rafferty: Fundamental.

Stephen Scott: Now, we have some questions that have come through from our viewers. So, firstly, this is an interesting conceptual point which I...to recall you discussing a little earlier this week as well. And that's around the first and second victim language as well. And there is some controversy about the application of that to the Suicide Prevention context. And so, we have a question here, or participant who makes that point that, this kind of language can cause conflict and concern from the family and that is more contemporary language which is more focused on caring for the caregiver and clinician and I've heard you this was referring to, and I think you did earlier as well to the tertiary victims as well. So, do you wanna just clarify, how you were

Joe Rafferty: Yeah. It's certainly...

Stephen Scott: Organising.

Joe Rafferty: It's certainly like language that we have picked up more broadly from the safety community.

Stephen Scott: Right.

Joe Rafferty: Because we've got patient safety but I mean, we've looked at the airline industry, nuclear industry, all sorts of safety crucial industries. And there is a bit of language in there, I mean, I think it's a very reasonable point, and the issue of staff been second victim is also very interesting. So, we have moved to tertiary victims with clearly a first and second set of victims been brief people and family and so on. So, getting that hierarchy of approaches absolutely right. And, you know, language evolves. It's one of the things I would say about the restorative practice, is you've got to be prepared to examine your language and it evolves over time. I'll give you a great example. We don't like talking about the notion of an investigation, you know.

Stephen Scott: Right.

Joe Rafferty: We actually on our policy have, let's have an exploratory conversation or words to that effect, yet I still say incident all the time, or investigation all the time. So, sometimes it's hard to break away from, and this is why I say, this takes a lot long time to get dumb, because you've got to get over your own and led instincts and your own training and all of those sorts of things.

Stephen Scott: It's a cultural change.
Joe Rafferty: Of course it is. You know, so, one of the things is around the prospective accountability, but is to think about getting the core of it right, and then sort of crafting the language that feels right for you locally in that sense?

Stephen Scott: OK, thank you for that. Now, just moving along, another of our participants has said that she works in custodial mental health, and she asks if you can please outline some of the practical steps you took with your prison staff to reduce the suicide rate, and whether you're aware of any online resources that could be used for that context. Certainly some of that data you presented at the end of the presentation about the work you've done in the correctional setting is especially compelling.

Joe Rafferty: Yeah. So, we find in having taken over that facility, we find absolute lack of training and in the sort of basics around suicide prevention, so, given that we had developed that simple 20 minute module, we sort of said everybody needs to do that. And that module, which is actually available free on the Zero Suicide Alliance website, is all it does is say, look, it's OK to have a conversation with someone. You won't trigger their suicide by having a conversation.

Stephen Scott: Right.

Joe Rafferty: Actually, it's protective to have a conversation.

Stephen Scott: Yes.

Joe Rafferty: And then we lead in our level one training as well. So, what we did for prison officers, as well as our own staff in the environment was to give them some basic uplift in how to have a conversation. For our clinical staff, we did the level tutoring. So, that was about making sure that we moved away from that largely discredited approach I would say of well, he's low, she's medium, and no one is high. Into this is a formulation of risk based approach. And then, as you could see from that graph, there were lots of incidents that have taken place previously, so, we use that debriefing approach to understand what had happened, and that's a much more informal discursive we used independent people to come in and do the debrief, people skilled in understanding the issues, but it wasn't me, it wasn't the top thing person, it wasn't a sort of threat of somebody coming in, and one of the fundamental things we then did in the prison was to recognise, that a high proportion of prisoners have a learning disability or a learning...impairment. So, we find that the biggest risk was in first night reception, and we were given people complicated documents to read, and in fact, there were photocopies of photocopies of photocopies. So, even if they could have read them if you know what I mean.

Stephen Scott: Yeah.

Joe Rafferty: So, there was something about producing engaging booklets about self care. And speaking out and those sorts of things. So, none of it ironically is actually complicated, the good thing, however, I would say that has helped us make this work we've worked very hard to forge a link with the prison governor, so, the prison system itself saw the importance of suicide prevention. So ,it's a combination of those things, my email address is on the front of the presentation. So, if whoever that is wants to email me, I'd be very happy to send the package of stuff that we did or put them in contact with the people who have done this work very happy to share because I'm giving you a summary but the people who have done it can really tell you what happened.

Stephen Scott: Sure. Well, thank you for offering that. And, you know, it's excellent for us to say this example of both mental health service as well what's been done in the corrective space as well, which is such complex and challenging environment as well. So, thank you for that. We have a couple more questions here as well, next, is there any data to view statistics on suicide across the area that MercyCare covers for the general population of believe it might be 90,000 people, and maybe you can correct that if that's incorrect, but I guess to look at the broader community effect of the implementation of the just and restorative culture?

Joe Rafferty: Yeah, that's a big question. We have in a sense focused very hard on in care with the view that it will sort of progressively move out and about, but if you look at the population of Cheshire and Merseyside, which is around 1.6 or 7 million or 900,000 for the better Merseyside that we work with, the suicide rates are either reasonably stable by local government RIT although in a couple of places they're in the top decile for the country, so it's not evenly distributed. It's quite as often with community based analysis. It's quite complicated. So we don't know why there are a couple of places that spike up. We are currently working to think about a community of best approach, which is more about recognising that sort of partnership pace between particularly local government, schools, social care and the health service space. Our sense is that there is a cohort of people in families where either the adults are living complex and risky lives with lots of rescue behaviours and actually children are accumulating lots of adverse childhood events. And probably the route into this is to think about those families as cohorts. Pushing to our sort of prevention work that way. Whereas at the minute I think our system would be characterised as lots of people in and trying to do things.

Stephen Scott: Right.

Joe Rafferty: And some coordination but not anything like enough coordination.

Stephen Scott: It's a fascinating insight that you presented that requires some, I think quite advanced thinking around data analytics

Joe Rafferty: Yes.

Stephen Scott: And drawing out this cohort.

Joe Rafferty: Yeah, that cohort, we get to that using a population health segmentation approach, which tells you is a data driven insight driven process. But of course, what we can do is do what we can with the data we have right now.

Stephen Scott: Sure.

Joe Rafferty: But I guess your point Stephen is, as we build the data sets, we get a lot more precision, I think in terms of what we can do. But I'm wholly convinced that that's probably the route into the community protection piece, which is to think about it a bit differently.

Stephen Scott: It's fascinating and it really helps to guide the nature of the coordination.

Joe Rafferty: Yeah, absolutely. And I mean, I heard a couple of local health districts talk about their sort of intention to get some sort of integration pieces going with their sort of community space and to think about spending the money once rather than multiple times and all of those sorts of things. And I think that's great, but actually, we've tried that loads in the NHS and it can get very bureaucratic. Whereas if you've got that sort of insights piece around the segmentation done. Frankly, when you look at it, you think we're crazy not to spend once.

Stephen Scott: Sure.

Joe Rafferty: You know, be more laser focused in what we do than do the things we present later.

Stephen Scott: That is duly noted. Thank you for that advice. Now there's another question here, which relates to the use of peer workers and I think, you know, of course, this taps more broadly into the participation of people with little experience in the approach as well. But the question specifically is about how mercy care is utilised peer workers, especially in the mental health service of course to aid in the process of implementation. And specifically how the peer workforce has deployed as part of the just and restorative culture initiative.

Joe Rafferty: Yeah, so. And that's quite a big and complicated question, but first of all peer impact, peer input has been central largely to everything we've done, our biggest earliest insights actually came from the reduction of restraint.

Stephen Scott: Right.

Joe Rafferty: With the use of people with peer support. In fact, if you look on the figure where we show those restraints going down, the one in the top left hand corner is our expense and who has been in our service for a very long time. But it's actually about two years ago employed as our senior peer lead in our centre for preferred care. But Iris told the story of how in effect restraint was a retraumatisation for it. And of course that moves the dial, doesn't it, from restraint to something that we have to do logically to keep people safe into something that actually is a form of, alter genic harm in a health system, you know, the health system has recalls alarm to that person. We have used people like Iris. Trained, supported, you know, thoughtfully managed through this. Not just push that there to do lots of significant events with our clinicians and to really move people from that medicalized model to recognise the psychological harm. And the fact that we need to, to think very differently about the impact of what we do. Cause as clinicians, people are of course very conscious of what they do in terms of clinical practice, but they're much less conscious sometimes by the actual outcome and then the sort of non stated outcomes.

Stephen Scott: Right.

Joe Rafferty: So people like Iris in our system have become people who've fundamentally changed the way and our view of doing things. We've been careful about the use of peer workers. I mean, it's interesting around language. I'm not even sure I like peer worker. Why aren't you a worker? Yeah, why are you a peer worker, you know, interesting. And we've had that dialogue internally. Don't call me a peer, just, you know, I'm a worker who happens to have lived experience that I'm declaring. Now there's lots of other workers out there who've got lived experience. They don't declare it and we don't call it, you know.

Stephen Scott: Yes.

Joe Rafferty: So language is important on this one. We did start very early with peer support workers. Let's go with the phrase on our inpatient units. And I say that was not a great success story for us. I think it was retraumatizing, they observed things that they didn't like to see happening and all of those things. So we pulled back from that. But what we have done is use peer support workers in two places in particular. One is in our criminal justice liaison service. They've been hugely effective there. There's something about that key moment when somebody is, you know, very close to a breach of the law, that lived experience seems to sort of doubly matter for some reason. So all of the people we've placed into the criminal justice layers on surface that we have love it under hugely effective and don't appear to be actually harmed by doing the job. And then two other places. One is in our emergency department with people in crisis and psychiatric liaison. I think the instancy of having somebody beside you who gets it really worked. And there's a big feedback loop there for guys doing that. And the third element is something I haven't talked about, but an approach we have called the life rooms, which is really about social, sort of social prescribing. It's recovery college plus, sort of is what we call it and peer support workers. They are the cornerstone actually of doing that. And all of the training we've done, the three packages of train and we talked about today in the presentation were all largely led by people with lived experience. So it's very hard for me to untangle the use of however we choose to call the lived experience or peer support workers from the core of what we do. I think we would just be much less effective. So the one last thing we did was create a significant volunteering program and the trust. So we have, I think something like 500 or 600 volunteers in the trust.

Stephen Scott: Right.

Joe Rafferty: About 75% of whom have lived experience. And actually, that felt like a more comfortable way. So it's a volunteer role, it's not a paid role. But that felt like a more comfortable way for people to engage because if you come on board as a peer worker, an employee, then even though we're doing some, sort of adjustments to the workplace and so on to make it manageable, people still feel you know, I'm prepared for this. So, you know, I've got to produce something. The volunteer piece has been a really great way for us to get people to come in and contribute their experience, but do it at ease, if I can put it that way, you know, nothing's going to fall over, if actually, you don't show up today, that type of thing. So that's a very large number of volunteers for a mental health service. And so, you know, we keep looking at ways to continue to explore the value of lived experience.

Stephen Scott: Sure. Look, I think the whole topic could probably be a webinar in it's own right, there's just so many points to discussing that and you know, many different issues to explore in such an important evolving part of both our workforce.

Joe Rafferty: Indeed.

Stephen Scott: And our response to suicide prevention. Now we're just about on time, Joe. So I might just ask you one final concluding question. You've been in New South Wales twice this year. Now, you were here in February working with us and you've been here over this past week as well, which has included participating in the first zero suicides in care, a workshop that was held on Friday last week. And then you've also visited three of the local health districts. Since then, so from what you've seen over the last week and also earlier this year, what would you say are the top three pieces of advice that you could give to us, if you could distil those down in terms of our implementation of this zero suicides and care initiative?

Joe Rafferty: OK. I think there's a continued communication issue, which is the one about. This is zero suicides in care, but that doesn't mean that the community stuff doesn't matter.

Stephen Scott: Right.

Joe Rafferty: These are under narrative that says, actually these are complementary to each other, but certainly, some of the conversation sort of invisibly flirts between, you know, in care and more broadly.

Stephen Scott: Right.

Joe Rafferty: And I think for the purpose of the program, it would be useful just to continue in a sense to focus up and down. I have heard, let me call a huge demand for restorative, just culture to be putting in place. And I think that's a probably, you know, one of the significant things that needs some thinking about. It needs some thinking about, because you know, everybody gets the restoration piece pretty instantly.

Stephen Scott: Right.

Joe Rafferty: But how you go about doing it is actually something that takes a bit of time, a bit of thought, a bit of sensitivity and so on. And so my advice would be to keep looking at the places that are making some progress on that and think about some sort of approach that allows acceleration of that piece. And the last bit would be to, I think critical in this will be the relationship between the leadership of the LHDs, the frontline and of course the LSTs and the ministry itself.

Stephen Scott: Yeah.

Joe Rafferty: So I think a program of work that is, is actually about drawing out what those guys are thinking, what the tensions are and where to mitigate and manage those tensions will be really important because it's very difficult I think to stimulate this directly from the frontline. So what I say is you need the sponsorship at the senior level and the freedom to innovate at the frontline. But if you just got the innovation and no sponsorship, I think you'll end up with frustrated people. So there's actually a double risk there, which is A, you don't deliver it and B actually irritate people in the process. So I think those three things feel pretty much like, they're sort of important mission critical things to do, but they're relatively obvious and there are solutions to all of them. And the one thing I would say is, what I've met as huge enthusiasm.

Stephen Scott: Sure.

Joe Rafferty: Which has just been tremendous actually. So I wish you the best of luck with it.

Stephen Scott: Thank you very much, Joe. Thank you for all of your advice.

Joe Rafferty: Pleasure.

Stephen Scott: And for all of your ongoing supportive, the work we're doing here in New South Wales, it's greatly appreciated. And we have had Joe on a very hectic schedule over this last week, so I'm sure he's going to look forward to his flight back to the UK a little later today and to have some well deserved rest.

Joe Rafferty: Yes.

Stephen Scott: On the way I hope. So, thank you all very much for participating in this webinar. And if you are viewing the recording of this, thank you for your interest in the zero suicides and care initiative as well. As I said, there is a lot more information on the New South Wales Health website about all of the work that's being done towards zero suicides initiatives and also the Premier's priority to reduce suicide by 20% by 2023. So, thank you again very much for your participation and we look forward to seeing you again in future webinars.

Current as at: Thursday 18 June 2020
Contact page owner: Mental Health Branch