Saturday, 30 July 2016

Failing and flailing: the Southern Health Annual Report 2015/16

Every year, Southern Health (as an NHS Foundation Trust) has to present to parliament its Annual Report and Accounts. About two years ago I looked at the 2012/13 Annual Report to get a sense of what the Trust was reporting about itself, particularly with reference to their services for people with learning disabilities. The 2013/14 Annual Report successfully repelled me, but I’ve managed to have a look through the 2015/16 Annual Report and Accounts.

There is an awful lot of it (the document bundle for 2015/16 runs to 197 pages), so in this extremely long blogpost I’ve tried to focus on those aspects that jumped out at me as being relevant to #JusticeforLB and the many other people trying to gain some measure of accountability from Southern Health. I’ve also generally stuck closer to the numbers so I can report some trends over time (sometimes looking back at older Annual Reports), although some choice examples of Southern Health reporting speak are included.

[GIF from ]

Under pressure

Overall, the 2015/16 Annual Report presents a picture of a failing and flailing NHS Trust. It reports that Southern Health are shrinking, by ‘withdrawing’ (their word) from providing TQ21 services in Oxfordshire (April 2016) and Hampshire and Dorset (2016/17), and learning disability services in Buckinghamshire (Sept 2016) and Oxfordshire (December 2017 possibly?) [page 7].

Without explicitly saying so, many of the Trust’s 13 ‘Key Actions’ for 2016/17 [pages 7-8] reflect serial failures, including:
·        “Delivering the SIRI and Mortality Action Plan in response to the Mazars report”
·        “Continuing to deliver our quality programme in response to the findings of the CQC comprehensive inspection in Oct 2014 and subsequent inspections in July 2015 and Jan 2016”
·        “Restoring public confidence in the services provided by the Trust by demonstrating delivery of high quality services, and engaging with our service users, their families and our staff” [NHS Improvement enforcement actions, a CQC warning notice and the reasons for the lack of public confidence in Southern Health services are not mentioned]
·        “Transforming the provision of secure mental health and learning disability services within a limited capital budget” [note the lightly veiled pleading for extra capital funding there, even though the acquisition of the former Ridgeway Learning Disability Trust in 2012 came with over £8 million in reserves]
·        “Ensuring the safe transfer of Learning Disability services to new providers in Oxfordshire and Bucks” [this is apparently a “Key Action to introduce new models of care to meet the needs of tomorrow”]
·        “Recruiting and retaining sufficient staff with the skills and competence required to deliver high quality care, and minimise the level and cost of usage of agency staff in line with nationally set targets” [the closure of a major inpatient mental health service, Antelope House, for at least 8 months due to their inability to recruit staff, is just one illustration of their problems with recruitment]

Money’s too tight to mention

Overall, Southern Health’s income has deteriorated over the last few years, from £353.9 million in 2013/14 to 332.8 million in 2015/16 (a drop of 6% in two years without even taking inflation into account). An operating surplus of £5.4 million in 2013/14 has turned into deficits; £6.2 million in 2014/15 and £5.8 million in 2015/16.

Southern Health report this as an improving position in 2015/16, as a wave of redundancies will not recur once Southern Health has shrunk. In 2015/16, Southern Health spent £2.2 million on ‘staff exit packages’ for 122 staff, compared to £1.4 million in 2014/15 on exit packages for 43 staff.

They also say that a major reason for their improved finances in 2015/16 “has been a better position with respect to the use of out of area beds within Adult Mental Health services (2014/15 £4.8 million vs 2015/16 £1.4 million). Not only does this improve our financial position, but it also provides a much better service to our service users, their families and carers.” Indeed, but the closure of Antelope House and shipping people off to a private sector Huntercombe Group hospital in London instead will blow a rather large hole in these arguments for 2016/17.

How does Southern Health spend its income? Overall, from 2013/14 (£348.5 million) through 2014/15 (£344.2 million) to 2015/16 (£331.6 million) there has been a steady drop in expenditure reflecting the drop in income (a drop of 5% in two years).

As with pretty much any NHS Trust, by far the biggest expenditure is on staff. For staff (excluding Directors), spending has also dropped, from £258.9 million in 2013/14 through £258.1 million in 2014/15 to £236.6 million in 2015/16 (a drop of 9%, mostly in one year).

Spending on Non-Executive Directors has stayed fairly static (£143,000 in 2013/14; £139,000 in 2014/15; £146,000 in 2015/16).

Bucking the trend is expenditure on Executive Directors: this has increased from £1.0 million in 2013/14 through £1.3 million in 2014/15 to £1.5 million in 2015/16. This is an increase of 48% in two years, at a time when the Trust (and its income) is shrinking.

While the Chief Executive, Katrina Percy, has the largest salary (£185-£190k per year), if pension contributions are added (hers was £52.5-£55k) then she falls some way down the league table of Executive Director pay. Chief Operating Officer Chris Gordon (who seems to have become the de facto Chief Executive of Southern Health) had a salary of £180-£185k in 2015/16 (with possibly an additional £60-£65k of salary from a time when he wasn’t on the Board, although I’m not sure if this is additional or folded into the £180-£185k). His pension contribution of £175-£177.5k in 2015/16 bumps him up to a total of £360-£365k. Even this doesn’t outstrip relatively newly promoted Medical Director, Lesley Stevens, who had a salary of £140-£145k in 2015/16 (with a possible additional £45-£50k in non-Board salary), and a £222.5-£225k pension contribution, taking her to £365-£370k in total.

Also astonishing are payments made to two directors, not as salaries but as fees to private companies owned by the person in question. For 9 months work (she has stopped her Director of Nursing role for Southern Health), Della Warren’s company was paid £165-£170k in 2015/16. New kid on the block is Mark Morgan, a non-voting Director in charge of mental health, learning disability and social care services. His company, Arundel Interim Services Ltd, was paid £285-£290k for 8 months of Mr Morgan’s work in 2015/16. It may be relevant that Mr Morgan has held a series of interim roles, including a post-Winterbourne stint at Castlebeck while it was being readied for sell-off.

Putting these figures together, it’s no surprise that the ratio of the highest paid person in Southern Health to the median staff pay level (the level at which half the workforce are paid less than this amount) has also increased, from 7.22 in 2013/14 to 7.64 in 2015/16.

Another sign of a failing health organisation is the amount the Trust has to spend on clinical negligence cases – this has also been increasing, from £649,000 in 2013/14 through £715,000 in 2014/15 to £1.1 million in 2015/16 (an increase of 69% in two years).

When is a consultant not a consultant?

In another superb piece of investigative reporting, Michael Buchanan of the BBC reported recently the huge amounts being paid out to two consultancy companies, Talent Works and Consilium (Consilium is what you get when you put ‘Advice’ into Google English-Latin translate), in the seeming absence of due process or evidence of results. Southern Health put out a statement saying that all their consultancy contracts were fully justified and procured correctly.

Southern Health reporting of consultancy spending in their Annual Report and Accounts is not easy to make sense of. In the main text of the Annual Report, they state that consultancy spending fell from £1.5 million in 2014/15 to £704,000 in 2015/16, which “followed the introduction of tighter controls”. First, if all their consultancy was necessary and procured properly, why were tighter controls needed? Second, the figure of £704,000 for 2015/16 doesn’t match the figure of £1.06 million in consultancy which they provided in FoI requests. Third, the figure of £1.5 million for 2014/15 doesn’t match the £2.2 million figure they cite in the Annual Accounts at the end of the report.

But, taking the Annual Accounts figures at face value, these show a big decrease in consultancy spending from 2014/15 (£2.2 million) to 2015/16 (£704k). Spending on legal fees increased to a much smaller extent over this time period, from £1.1 million in 2014/15 to £1.4 million in 2015/16. What did surprise me was a massive increase in spending on training, courses and conferences, from £975,000 in 2014/15 to £2.7 million in 2015/16). Is there some shuffling of expenditure categories going on here, or has the training budget almost trebled in a year at time of huge financial pressure?

Will the last member of staff left please turn out the lights (Environmental Strategy 12.92)?

As I’ve mentioned above, Southern Health has cut its (non-Directorial) staff budget considerably, and they’re having such trouble recruiting staff that they are having to temporarily close some of their services. Which staff are being cut?

The Annual Report has a very helpful table of the number of whole-time equivalent (WTE) staff working in Southern Health (page 39). Overall, the number of WTE staff has dropped by 11% in one year, from 7,282 WTE staff in 2014/15 to 6,468 WTE staff in 2015/16.

There are big drops in the number of qualified health staff. The number of doctors/dentists fell from 238 WTE in 2014/15 to 211 WTE in 2015/16 (an 11% drop). The number of nursing/midwifery/health visiting staff dropped from 2,507 WTE in 2014/15 to 1,748 WTE in 2015/16 (a drop of 30%). The number of scientific, therapeutic and technical staff fell from 823 WTE in 2014/15 to 529 WTE in 2015/16 (a 36% drop).

There were also (potentially more welcome) reductions in the usage of agency staff (from 287 WTE in 2014/15 to 211 WTE in 2015/16, a 26% drop) and bank staff (from 461 WTE in 2014/15 to 365 WTE in 2015/16, a drop of 21%).

In contrast, the number of healthcare assistants/other support staff increased from 1,587 WTE in 2014/15 to 2,033 WTE in 2015/16, an increase of 28%. The only other group of staff to buck the downward trend were admin/estates staff: these increased from 1,305 WTE in 2014/15 to 1,370 WTE in 2015/16, an increase of 5%.

It’s no surprise that vacancies constitute 8.5% of the workforce, that the rolling average of sickness absence is 4.8%, or that the staff turnover ratio was running at 18.6% in March 2016. It’s also no surprise that Southern Health’s response rate to the national NHS staff survey, 33%, is 11% lower than the national average.

Candour Crush Saga

Given the state of Southern Health, the Annual Report cannot altogether avoid mentioning Monitor/NHS Improvement enforcement notices, damning CQC reports (including the issuing of a warning notice), the Mazars report, and other evidence of badnesses that have been pushed blinking into the half-light. The relentless spinning of these is more than I have the stomach to share and analyse. But a few quotes stuck out at me in a kind of queasily comic way, so here they are.

Performance Analysis (page 10)
“The Trust continues to meet its access targets and outcome objectives as defined by its regulator, Monitor. We are pleased that our performance against meeting these measures is consistent and strong, and we will continue to focus on improving further”.
[Two things about this. 1) This performance is the only one in the Monitor dashboard that doesn’t have a quantifiable indicator next to it – Trusts rate their own performance and unsurprisingly Southern Health have rated themselves as ‘Green’ throughout. In fact, throughout the whole 197 pages I couldn’t find any specific evidence about the quality of services for people with learning disabilities, the outcomes of their services, or feedback from people with learning disabilities using their services. 2) You have to wait until page 61 to find out that Monitor have consistently rated Southern Health Red for governance and has been subject to enforcement ‘actions’ throughout 2014/15 and 2015/16]

Quality Governance (page 25)
“During 2015/16 the Trust was compliant with using the Monitor Quality Governance Framework as a guide for good practice. In June 2015 Deloitte LLP undertook a follow-up review to their 2014 assessment of the Trust. One of the key issues highlighted was that the Quality Governance Strategy did not link to the Quality Improvement activities underway in the Trust, was not ‘reader friendly’ and did not represent a five-year-plan.”
[Either they weren’t actually compliant, or Monitor’s Framework is rubbish]

Duty of Candour (page 118)
“In our Quality Reports for 2013/14 and 2014/15 we reported our compliance with Duty of Candour. The data provided was in relation to our contractual reporting requirements with commissioners. These required us to report to them on whether there had been initial contact made with patients or their families after an incident had taken place. We recognise that this does not constitute the entirety of the requirements under Duty of Candour and this should have been made clear in our reports.”
[So, for Duty of Candour, they didn’t report everything they should have done but said in their reports that they had]

Statement of Chief Executive Responsibilities As the Accounting Officer of Southern Health (page 76)

[This is part of the CEO’s closing official statement in the report, and sums up the clash of reality vs spin quite well]
“On the basis of the above, I have concluded that some internal control issues were identified in 2015/16, as set out in the enforcement undertakings agreed with Monitor, the warning notice from CQC and the Notice of Imposition to impose an additional licence condition issued by NHS Improvement. As such, it is acknowledged that within 2015/16 not all governance processes were fully effective and as a consequence we cannot declare that all functions have been exercised economically, efficiently and effectively.”
“Notwithstanding this, my review confirms that we have made significant progress to address any weaknesses in the system of internal control, deliver agreed undertakings and to ensure compliance with our provider licence.”
[What made me do a double take was when I was looking through the 2013/14 Annual Report, two years earlier, and found this in the equivalent CEO statement – page 73]
“On the basis of the above, I have concluded that there have been control issues identified in 2013/14, as set out in the enforcement undertakings agreed with Monitor, which identified a failure of governance arrangements within the Trust. Actions have been agreed with Monitor, as part of the undertakings, to address these concerns. As such, it is acknowledged that within 2013/14 not all governance processes have worked effectively and as a consequence the Trust cannot declare that all functions have been exercised economically, efficiently and effectively.”
“Notwithstanding this, my review confirms that the Trust is taking appropriate actions to deliver the agreed undertakings and ensure compliance with the Trust’s provider licence and to address any weaknesses in the system of internal control.”
[The main lesson learned appears to be how to copy and paste]

Failing and flailing

From what I’ve read, it looks like Southern Health is a Trust in the hands of a Board that is frantically trying to balance the worsening books by divesting itself of a host of services recently ‘acquired’ (while keeping the reserves and estate self-offs), and shrinking and deprofessionalising the workforce (while paying itself more). The Board seems to be in denial of reality (why are contracts being cancelled? why don’t staff want to work for them?), seeking to ward off external assessments of what it’s doing via action plans, deflection, spin, and denigration. It feels like a vicious circle, and I worry both for people using their service and the staff trying to hold things together.

There was one dose of reality in the Annual Report, in the feedback provided by Healthwatch Oxfordshire (other feedback went as far as expressing disappointment, but mainly understanding of the ‘challenging year’ Southern Health had experienced because of that pesky external scrutiny). Seems a fitting place to close this extremely long post:
“Given the findings of the CQC that the improvement work undertaken in the last year has not been consistent across the trust, and that the governance around improvement, and learning from incidents is wanting, I wonder how Southern Health aims to reassure patients and the public that these quality priorities will be realised.”
“Since the ‘big plan’ consultation we have heard very little in the way of feedback about Southern Health, so it is difficult to assess whether or not the quality priorities identified for 2016/17 address the concerns of patients, service users and their families other than the concern that there’s consistent, negative news about the quality of Southern Health.”

NB: [Update: I have corrected some of the percentage changes over time from the original version of this post]

Sunday, 3 July 2016

The return of the repressed

In a typically inept and offensive manouevre, Tim Smart, the 'Interim Chair' of Southern Health (parachuted in with a seemingly choreographed pirouette by NHS Improvement), released a statement advertising the conclusions he has drawn from his 'comprehensive review'. The timelines of @sarasiobhan and @JusticeforLB outline some of the dimensions of this offensiveness:
1) Not meeting with families as part of the review, despite saying he was going to.
2) 'Inviting' families to a meeting with him and the relevant government health minister, Alistair Burt, at very short notice, which changed date, time and city a number of times.
3) Despite the meeting being apparently to share the findings of his review before it was publicly announced, as far as I can tell the statement was released while Tim Smart was in this meeting with families.

The main actions arising from Tim Smart's comprehensive review are, er, apparently nothing at all even as, on the same day, another Coroner reported shocking Southern Health practices (including retrospectively 'updating' the person's care records).

This statement, read out by Richard West (@Richard39450952), sums up comprehensively why Tim Smart's conclusions are wrong and dangerous, and I highly recommend you read it. This from @sarasiobhan is also essential reading.

In this post, I just want to quickly take a look at some aspects of the statement through the lens of what we might call the return of the repressed. By this I mean that the evident truth of what has happened and is happening at Southern Health is obvious, but this truth cannot be acknowledged as more and more frantic attempts are made to brush this truth under a (bulging) carpet. The result is complete self-contradiction and incoherence. The Southern Health statement in full is below, with some of my annotations.

Tim Smart, Interim Chair of Southern Health NHS Foundation Trust, said: Following my appointment as Interim Chair on 5 May 2016, I am today publishing a summary of a comprehensive review of the issues and a recommended course of action.
I would first like formally to extend my deepest apologies to the individuals and families who have been deeply affected by recent events. I can only imagine the pain they are suffering.
It is easier to only imagine the pain rather than actually meeting families to find out about it.
I was appointed to make an objective assessment of the reasons behind the failings at Southern Health and the best way forward for the Trust, its patients and its staff.
There were failings in Southern Health. 'Objectivity' implies that previous or alternative assessments are 'subjective' and therefore 'emotional' and not to be trusted. This immediately rules out the domains of injustice and families' distress as irrelevant.
In the last six weeks I have reviewed the available evidence. I have met with many individuals and organisations, including patients, families, staff and Governors. I have also initiated an independent Board Capability Review.
Linked to the point above, presumably the 'available evidence' was only the 'objective' evidence - and the track record of Southern Health in relation to making evidence available is, er, questionable, shall we say? 
I am confident that we are making progress, and I know that our staff are doing everything they can to deliver high quality care. But it is clear that some of our more complex services feel less connected to the organisation.
The 'we' indicates that Tim Smart identifies himself as part of Southern Health, while at the same time providing an 'objective' assessment of it. 
It's the next sentence that starts doing the real rhetorical work though. First, the use of 'complexity' - professional shorthand for 'We don't have a clue what's going on but we can't admit it so you punters won't understand it either'. I fail to see why services for people with learning disabilities and services for people with mental health issues are more complex than the wide range of other services that Southern Health provides, like community diabetes services or the management of chronic pain. That these services feel 'less connected to the organisation' is an odd and revealing phrase - so these 'complex' services (the ones causing the trouble) are not a core part of Southern Health but are more or less connected to it. This has been a repeated refrain of Southern Health corporate communications for some time - there is a core of 'real', 'good' services and there is 'non-Hampshire' bad stuff which was taken on through some sort of mistaken act of kindness, apparently.
It is my opinion that the Board of Southern Health should have spent longer in its early years creating an integrated, patient focused, operationally efficient culture. Before it did that, it acquired the Ridgeway Partnership despite understanding the risks. Ever since, the Executive team has been too stretched to guarantee high quality services everywhere that Southern Health operates. To resolve this failure changes are being made to the Board.
Note 'my opinion' here - not quite the rigorous application of objective evidence
To my mind, this is quite damning in its assessment of a strategic and operational failure at Southern Health, driven by the CEO and the Board. In its early years (led by, erm, you know who) they were inefficient, all over the place, and not concentrating on the people they supposedly serve. They knowingly 'acquired' Ridgeway knowing that they weren't ready or able to manage it properly. 'Too stretched' attempts to distance the Board from responsibility (the not enough resources line), but it was and is within the power of the Board to increase those resources to make them less stretched (unlike many of their staff, who presumably really are stretched but have no power to change this). It is also worth remembering that at various points the Board restructured themselves to have fewer rather than more people on it. 
On the basis of the evidence before me, I am recommending that Southern Health transform the way in which it delivers services, and makes changes to the structure and strength of its leadership team:
This introduction screams big changes afoot - 'transform', 'makes changes'. What follows...

1)    Following the outcome of the Board Capability Review, I am satisfied that whilst the Board should have acted in a more united way, I have found no evidence of negligence or incompetence of any individual Board member. As we progress with delivering the strategic plans for the organisation, consideration will be given to the findings of the Board capability review and further strengthening of the Board will be required to ensure the best balance of skills and expertise.
This might be called the 'Murder on the Orient Express' defence - in this story each person only stabbed the victim once each, so none of them individually could be counted as responsible for a murder. So a collective, corporate negligence (as we saw in LB's inquest) cannot be used to hold anyone to account. The thought that collective catastrophic incompetence and negligence should have a collective solution, i.e. removing the entire Board, does not seem to occur.

Being a 'disunited' Board also seems strange as the one issue to pick out - if anything, the Board are too united, not allowing anyone to prick their unreality bubble.

2)    I know there is interest in the Chief Executive of the organisation and  I can confirm that Katrina Percy will continue in this role. However, until now she has been too operationally focused in her role. She will shift her focus to delivery of the future strategy of the Trust which I believe needs to be accelerated. The Executive team will be restructured, to allow a more concentrated effort on the day to day delivery of high quality, safe services for patients. This will require a much more outward looking Board, which will at the same time put absolute priority on improving the quality of services provided.
This is where the incoherence becomes screamingly obvious. The statement earlier gives examples of massive strategic and operational failures in taking over Ridgeway and before, and the 'evidence' (whether Tim Smart counted it as such or not, such as the Mazars report) overwhelmingly points to an incompetently operationally managed organisation (this is putting it kindly). As CEO, Katrina Percy was also responsible for (and at the time very happy to paint herself as leading) the big strategic decision to 'acquire' Ridgeway. So, she was responsible for massive strategic failures while, at the same time, presiding over continued operational failure.

It seems pretty clear that she is being ushered off to a quiet corner office to do meaningless 'strategic' things (the carousel of shiny bullshit events, no doubt accompanied by more awards ceremonies and leadership blogging) because she can't be trusted with anything real to do. As many have pointed out, how an organisation can have a Chief Executive who isn't responsible for what the organisation actually does is, erm, an interesting managerial conundrum.

And although the Board is fine, apparently it will need a completely transformed Board which, while being too operationally focused before, will now put absolute priority on improving the quality of services provided. And no-one needs to step down - so more people will be added to spare their blushes. Good job the NHS is awash with cash, eh?

3)    It is clear to me that the Trust needs to change the way it delivers services because currently it operates across too broad a spectrum of clinical services and too wide a geography. The plan is for Learning Disability Services provided by Southern Health in Oxfordshire to be transferred to Oxford Health NHS Foundation Trust as soon as agreement is reached. Other changes will occur.
In other words, the 'bad', troublesome parts of Southern Health (services for people with learning disabilities, especially outside Hampshire) are to be cut away (although the Oxfordshire services decision was taken by the commissioners, not Southern Health, some time ago). Again this is consistent with the long-running Southern Health narrative about their 'core' services, and basically will try to undo the acquisition of Ridgeway (although with Southern Health retaining an awful lot of moolah from this acquisition).

4)    I will establish a Steering Group to further develop and accelerate implementation of Southern Health’s strategic vision for the future, alongside the soon-to-be published Sustainability and Transformation Plan (STP) for Hampshire and the Isle of Wight. The Steering Group’s first task will be to commission a review of the way Southern Health’s services are organised. This will be led by clinicians and commissioners, and it will result in the future form of Southern Health being changed.
Another day, yet another review. If Katrina Percy's future is in strategy, it is unclear why a Tim Smart-initiated strategic Steering Group is necessary (again, to constrain her from actually making any decisions?). Also interesting that, despite his opening lines, no patients or family members are to be on this Steering Group.
Based on my experience and the evidence presented I am confident that these recommendations will see an improvement in the running of the Trust and most importantly in the care provided to patients. We must acknowledge, however, the failures that have occurred in the past and I again unreservedly apologise for this.
The way forward is complex and difficult and success will be dependent on excellent team work within Southern Health, and first class collaborative working with all local stakeholders, patient groups, provider organisations, commissioners, regulators and staff. Southern Health provides good and essential services to a very large population. The Board must now work together to ensure that care quality continues to improve.
I would like to extend my thanks to all of those individuals and organisations who have lent their time and commitment to this important review process.
So we have failures 'that have occurred in the past' (erm - Coroner's inquest evidence Tim?) but that still need Southern Health to have patient care as their highest priority. We have a radical way forward for Southern Health that is likely to involve them returning to the services they were delivering 5 years ago. We have catastrophic failures of strategy and the way Southern Health provide services that none of the Board were individually responsible for. We have operational failures presided over by a CEO who was spending too much time on operations, but the CEO is not responsible for them. We have a major strategic failure in the 'acquisition' of Ridgeway that was led by a CEO who is not only apparently not responsible for this decision, but who is going to spend more time on strategy. We have an 'objective' review that appeals to the authors' opinion and experience.
Is that it? Tim Smart seems to think so, if his response to @BBCMBuchanan is anything to go by. But apparently some of the things he was told by families while the statement was released have given him ('feigned'?) pause for thought, and Alistair Burt's response to a TV reporter (sorry - can't remember who or the link - I'll update the blog if I can find it) was a rather curt and repeated 'This is not concluded'.
The sheer incoherent nonsense of this statement is obvious for anyone to see. The truth is there, and no carpet is big enough to hide it. Do we want the truth? We can handle the truth - it's the health 'system' that seemingly can't.