Wednesday, 29 July 2015

Watching the consultants



Despite (or because of?) difficult times within NHS services, NHS spending on consultancy continues to increase. Overall, in 2014 the NHS spent £640 million on consultancy, compared to £313 million in 2010 (see http://www.nationalhealthexecutive.com/Health-Care-News/nhs-bill-for-consultants-more-than-doubles-despite-government-promises-to-cut-spending for a summary - the BMJ article is paywalled). In a typically pithy short article in the BMJ, David Oliver asks serious questions about why the NHS are spending so much on consultancy, and the types of consultancy they’re buying:

“In times of war, arms dealers, rebuilders and racketeers profit from the chaos. ‘Disruptive innovation’ has led to similar spoils for management consultants, with taxpayers’ money diverted from already struggling health and care services.”

“The door between the Department of Health, NHS England, Monitor, 10 Downing Street, and the consultancy firms is constantly revolving, creating commercial advantage. People will pay as much for access and influence as for expertise.”

“Those with relevant experience of the sector rarely have a better track record of delivery than those they are advising. Consultants often sell back the solutions offered to them by the staff they speak to. Or, in glossy reports, they tell service leaders what they want to hear when they haven’t the courage to take ownership of their own decisions.”

“Consultancy firms are unaccountable and can walk away from bad or damaging advice with no consequences.”

“Spending on consultants, head hunters, and information technology advice should be prominent in every annual report and at meetings and a recurring item for parliamentary and regulatory scrutiny…Let’s ensure that all consultancy is subject to a rigorous audit of value and impact and whether it needed to be contracted out at all.”

Although I should obviously be charging thousands, because I’m a generous person in this blog I’m going to help Southern Health NHS Foundation Trust start on this road to transparency. I can’t rigorously audit value and impact, but via the genuinely quick and efficient services of the Southern Health Freedom of Information office (ably assisted by WhatDoTheyKnow https://www.whatdotheyknow.com/) I have information on Southern Health’s spending on consultancy and legal/professional services for 2013/14 and 2014/15 (available here https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in#outgoing-384702 and here https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in#outgoing-384702).

In this blogpost, I won’t be going through everything they’ve spent on legal & professional services and consultancy – partly because I don’t have the knowledge to do this and partly because it would make for an extremely long post. Instead, I’m going to pick up some of the main issues that occurred to me as I was going through them.

How much are they spending?

In 2013/14, Southern Health spent £1.555 million on consultancy, and a further £1.305 million on legal and professional services. Added together, this was 0.8% of their entire income of £354 million in 2013/14.

In 2014/15, Southern Health spent £2.166 million on consultancy, and a further £1.116 million on legal and professional services. Added together this was a 23% increase on 2013/14 even though income was down to £346 million in 2014/15. So, in 2014/15 this spending was almost 1% of the Trust’s total income, and represented more than half of the Trust’s total deficit of £6.1 million in 2014/15 (income figures are from the Trust’s Annual Report 2014/15 http://www.southernhealth.nhs.uk/about/performance/annual-report/).

Of course, some external expertise is a good thing, to keep any health organisation open to the outside world, to provide independent, honest scrutiny and to help the organisation to improve. Is this how Southern Health are spending their money? Well, to my admittedly jaundiced eye, I think the answer is largely no. There are some more obviously understandable (as in, I can more easily understand what Southern Health are paying for) types of spending that come under the categories. For example, Southern Health paid in the region of £270,000 in 2013/14 and £100,000 in 2014/15 to local pharmacies for smoking cessation services. They paid VAT Consultancy Ltd for, er, ‘VAT’ services (£20,019 in 2013/14; up to £47,273 in 2014/15). Southern Health also spent £92,392 on patient advocacy services in 2013/14 (from Solent Mind and the National Youth Advocacy Service) and exactly the same amount in 2014/15 from the same organisations – no  paid advice from learning disability advocacy organisations, however.

But these are a small fraction of the total amount spent. Generally, it looks to me like Southern Health are spending their money on external people for four broad purposes (most of which overlap)…

Purpose 1: Surfing the wave of failure

Several types of legal and professional spending reveal Southern Health’s struggles and panic-stricken priorities around staffing issues. For example, in 2013/14 Southern Health paid NHS Professionals Ltd £85,500 for organising agency staff; in 2014/15 this jumped to £188,810. This figure doesn’t include the astonishing £290,000 paid to an external company to secure the services of Della Warren (Director of Nursing & Allied Health Professions) – quite why a senior manager and Executive Board member is paid in this way perplexes me greatly – see page 67 in the 2014/15 annual report accessible from here http://www.southernhealth.nhs.uk/about/performance/annual-report/  ). It certainly puts a question mark against the value for money of the £37,180 paid in 2013/14 to Odgers Interim and Hays Recruitment for ‘specialist recruitment’.

I also wonder about the £106,376 paid to Charlotte Housden Consulting for “HR advisory services”. As Charlotte describes it on her LinkedIn page (https://uk.linkedin.com/in/charlottehousden I just love google…):

Charlotte has 22 years experience and has been working as an independent Director level consultant since 2007 helping clients with internal communication, employee engagement, change management, leadership/ management development and employer branding. Most recently she worked as interim Associate Director for Workforce Development at Southern Health NHS Foundation Trust. “

Given the catastrophic levels of sickness absence, staff turnover and staff vacancies repeatedly reported in Board papers, again this doesn’t seem like money well spent, unless her role as Principal Advisor for KPMG has anything to do with it.

In 2013/14, Southern Trust paid out over £18,000 for “employment tribunal support” – there is no expenditure in this category for 2014/15.

And there’s more: in 2013/14, Southern Health paid out over £220,000 for “employment, procurement and contract law” services (mainly to Capsticks; Bevan Brittan; DAC Beachcroft; and Legal Fees). In 2014/15 this figure was £169,036 (to Capsticks; Paris Smith; and Bevan Brittan – although Bevan Brittan’s services included “healthcare” advice). There is a whopping £85,000 for “aggregated claims settlements under the NHSLA scheme” – the NHSLA is the NHS Litigation Authority. Regular readers of @sarasiobhan’s blog will know that Bevan Brittan are the lawyers that Southern Health are using for Connor’s strictly non-adversarial inquest, and among other things they like to advertise their “Inquest management” service:

We are able to provide all aspects of assistance in connection with inquest management - liaising with the coroner, managing witnesses, statement taking, co-ordination of evidence, management and representation at the inquest as well as post inquest follow up advice.  We can also deal with all other issues which may be linked to inquests such as the police or multi agency investigation, and helping the client to manage its internal inquiry and investigation.” (http://www.bevanbrittan.com/services/medical-law/Pages/inquests.aspx).

As part of its asset stripping estate management programme, Southern Health also paid out a total of £64,584 in 2013/14 and £40,656 in 2014/15 to four companies (Savills, Paris Smith, Lester Aldridge and Robert Prowting) for ‘property management and disposal’.

Purpose 2: Reputation management

For Southern Health, shoring up its reputation (with the nobs, rather than with people who actually use their services) is crucial, particularly as reality keeps intruding on the story it wants to tell about itself. So, in its ‘strategic plan’ (see https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/390638/HANTSPART_Publishable_Summary_Strategic_Plan_1415.pdf), Southern Health lists two of its ‘weaknesses’ as:
·        Regulatory compliance ratings as a result of quality issues in LD services
·        Current reputation largely based on quality issues in LD services

[Note that neither of these ‘weaknesses’ are about the learning disability services actually being crap]

What strategies do Southern Health use to manage its reputation? Well, from some of this spending one tactic is to commission ‘specialist independent service reviews’ (a grand total of £79,012 in 2014/15, across M P Kerr, Winchcombe and Associates, HASCAS and Pat Shirley).

The review by Prof Mike Kerr gives a revealing glimpse of how this tactic works. Because of the ordure being revealed by #JusticeforLB, #JusticeforNico and other campaigns about the toxic state of Southern Health services for people with learning disabilities in Oxfordshire, Prof Kerr was commissioned to do an independent review of Southern Health’s learning disability services - in Hampshire. The full report (available here ) states in its conclusions that the model “is excellent and http://www.southernhealth.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=80753 at times world class”, but that “elements of the model remain in development” (it’s important to note that part of the ‘vision’ is to be ‘world class’, so this phrase didn’t appear from nowhere). In Southern Health’s Annual Report for 2014/15 (available from this webpage http://www.southernhealth.nhs.uk/about/performance/annual-report/ ) this becomes “A review of Learning Disability services by Professor Mike Kerr found evidence of world class services now being provided”.

There is also a strain of using big, influential companies for various, murkily described ‘advice’ and ‘reviews’ – I don’t know what the following activities mean, but my guess is that at least part of their function is to reassure Monitor, NHS England and other cheeses that Southern Health is fundamentally OK really and those pesky “non-Hampshire” learning disability services are just a little local difficulty:

2013/14:              Procurement advice – KPMG (£115,397)
                              Board & Quality Governance Review – Deloitte & Touche (£65,455)
2014/15:              Financial & governance assurance services – PWC (£28,800)
                              Financial recovery & strategy support – Deloitte (£258,128)

And of course there is the notorious award winning set of programmes that I guess I have to call the Viral Suite – in the words of Talent Works (paid £904,411 in 2013/14 and £642,272 in 2014/15 for this work, not forgetting the £135,000 spent on hotels in 2013/14 for senior managers to enjoy a viral environment – see http://www.talentworksltd.com/case-studies/going-viral-wins-national-award ):

“Going Viral is shaped around the reality facing patients and staff across the health and social care system, both of whom were (and still are) involved in its development.  Whilst focusing on preparing leaders for challenges that lie ahead, Going Viral is also about developing the values and behaviours required to make change sustainable.”

No, me neither. But one of the most important purposes of Going Viral for Southern Health was achieved in 2013, when it won a Leadership Innovation Award at the 2013 Guardian Healthcare Awards. And the satisfied customer with the quote, “Working with Talent Works has been a game changer!”, is also identified as an award winner (HSJ CEO of the year 2013, no less). The obsessional awards chasing of Southern Health, to me at least, is a vital part of their reputation management strategy – a constant flow of them (no matter how meaningless or bought) results in a constant surface impression of continuing ‘success’ to the casual observer, they provide reassurance for a narcissistic culture that the nobs doing the judging are still your buddies, and awards open all sorts of doors to present yourself (to yourself as much as to others?) as an innovative, go-getting, future-forward organisation.

I believe this is also the prime reason for Southern Health hopping on any innovobandwagon that comes along (vanguards ahoy) – to look good, get in the right rooms with the right people, and network until it becomes too embarrassing for other people if you’re found to be failing.


Purpose 3: Hobbing with the nobs

As David Oliver says in his article, part of the purpose of paying for consultancy may be more about the doors they can open for an organisation rather than any useful advice they can offer. As we have seen, Southern Health are using all the big mainstream consultancy companies, as well as spreading the money round to other potentially influential organisations (£62,775 to the Kings Fund and £10,000 to the NHS Confederation in 2014/15, for example, both for ‘staff development and leadership’).

Beyond this, we’re really into the world of murky mcmurk, as @sarasiobhan describes it, with large amounts of money going to organisations whose functions are unclear to the untutored punter such as myself.

For example, MBI Health Consulting were paid £25,000 in 2013/14 and £103,235 in 2014/15 for ‘health governance and assurance’. According to the 2014/15 Southern Health annual report “MBI Health was contracted to work with the Learning Disability Management team to review the model of care and implement a comprehensive plan of actions that was monitored by a Project Board led by one of the executive directors.” I don’t know what this means about what they’re actually doing (after all, the model is world-class already, isn’t it?), but their website (http://mbihealthgroup.com/operations-improvement-waiting-times/) says: “ MBI delivers significant impact to organizations undergoing or anticipating profound change or facing issues on clinical and operational performance. We provide guidance drawn from deep expertise on leading NHS organisations in structuring operations and improving performance and building organizational capabilities.  We work with our clients to identify their challenges and then master the changes required for both short term and long term success.”

Oh, and according their website their clients include Monitor, NHS England, and a multitude of NHS Trusts and commissioners.

Bigger money still goes to Consilium Strategy Consulting (£158,250 in 2013/14 and £79,886 in 2014/15 for ‘planning and strategy support’). A google search on this reveals at least four different consulting agencies calling themselves Consilium (my theory, which may say something about how management consultancies operate, is that consilium is what you get if you put ‘advice’ into the Google English-Latin translator). Our prime candidate is actually Consilium Partners (http://consiliumpartners.co.uk/about-us ), who are working with Southern Health in “Supporting this large and innovative community and mental health provider to develop pioneering strategies to deliver integrated care for the local population.” Confusingly, Southern Health also paid £34,375 in 2014/15 to Consilium Strategy Consulting for ‘planning and strategy support’.

This list goes on and on. Who are Rowlands Associates, and what did they do for their £91,552 in 2013/14 for “strategic planning and corporate services redesign” – surely it can’t be the Canadian interior design company? (http://rowlands-associates-inc.squarespace.com/ ). And Margaret Geary (paid £55,000 in 2013/14 and £9,579 in 2014/15 for “service integration and joint working”) surely can’t be the nun who was trapped in an elevator for 3 days and 4 nights? (http://catholicreview.org/article/work/spirituality-aids-nun-trapped-in-elevator-for-three-days-four-nights ).

My suspicious mind suspects that this slippery murkiness has an important function, to make my eyes glaze over, to conceal who is really involved, what they’re actually doing, and what the connections are between them. As millions of pounds of public money (and this is just one NHS Trust) is pocketed by them, with in this case no discernible benefit to those people actually using their services.

Purpose 4: Maintaining the Matrix

So far, if you’re a person only interested in money, status and power, then all the above strategies are logical, if morally reprehensible. But there seems more to it than that in the vile ways that Southern Health have behaved towards @sarasiobhan. It’s almost that anyone who talks about the truth of what is happening to real people in Southern Health services is taking the red pill (in the terms of the film ‘The Matrix’) and tearing a hole in the carefully constructed unreality that Southern Health wants to present to the world (and to itself). And in a wildly over the top narcissistic reaction, rather than allow any glimmer of reality in, the bearer of that reality must be absolutely crushed.

Why was Joe McCrea paid £47,248 in 2014/15 for ‘communications development services’, when Southern Health’s public communications are stuck in anodyne broadcast mode, with #JusticeforLB campaigners blocked from the twitter account and even the most trivial facts relentlessly spun to present Southern Health as never responsible for anything going wrong, ever? Why do independent investigations (£99,595 in 2013/14 and £14,592 in 2014/15 to Verita for ‘independent investigations’) have to be dragged kicking and screaming out of Southern Health, and why are there so many redactions? Why has Southern Health’s complaints system been redesigned so it mainly captures compliments? Why is Southern Health so neurotic about this shiny, unreal Matrix-world that it’s trying to insist on it throughout its own organisation with Going Viral (how apt that name is) in a way that is positively cultic? And so on and so much worse, so much worse.

It feels to me like pretty much all this consultancy spending is part of a frantic, overwrought attempt to maintain this fa├žade of unreality in the face of increasing intrusion from the real world. As more of the veil is ripped away, the attempts to maintain it become more desperate and more violent, and more and more debts are being called in from fellow Matrix-dweller buddies. My hope is that it’s too late – too many people have taken the red pill when it comes to Southern Health and won’t go back to the blue pill. And to mix metaphors horribly, certain senior elements in Southern Health feel to me like Wile E Coyote – they’ve run off the cliff and are still going in mid-air, and are only now noticing the length of the drop.