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.