tag:blogger.com,1999:blog-81541700163080235122024-03-18T02:48:12.732-07:00Data for LBChris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.comBlogger22125tag:blogger.com,1999:blog-8154170016308023512.post-1393224289523994192017-09-03T07:46:00.000-07:002017-09-03T07:49:59.046-07:00A new era? The Southern Health Annual Report and Accounts 2016/17<div class="MsoNormal">
Just over a year ago, <a href="http://dataforlb.blogspot.com/2016/07/failing-and-flailing-southern-health.html" target="_blank">I went through Southern Health’s Annual Report and Accounts for 2015/16</a>, looking mainly at what the figures told
us about what Southern Health was doing and where it was heading. My conclusion
at the time was that the figures showed Southern Health to be failing and
flailing: shrinking; shipping skilled professionals at a rate of knots and
replacing them with unskilled staff; paying executive directors more whilst
paying other staff less; and still forking out a fortune in dubious ‘training’
and ‘consultancy’ contracts. At the same time, the annual report was trying
desperately to fend off and ignore the pressing realities of their situation
and to pretend that everything would be fine if it wasn’t for those meddling
kids/#JusticeforLB/#JusticeforNico/other campaigners/the media/Monitor (sort
of)/CQC (sort of)…the list goes on.<o:p></o:p></div>
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The year 2016/17 has been somewhat, er, turbulent, for
Southern Health, with the Chief Executive, Katrina Percy, departing with a humungous
payout and an almost complete replacement of everyone (both Executive Director
and non Executive Director) on the Southern Health board. This blog looks at
<a href="http://www.southernhealth.nhs.uk/about/performance/annual-report/" target="_blank">the 2016/17 annual report figures</a> to see if there are any signs of changes in
Southern Health’s direction as they moved into the post-KP era.<o:p></o:p></div>
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<b>The money <o:p></o:p></b></div>
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Southern Health is continuing to shrink, for two main
reasons: 1) shuffling off their social care service, TQ21, to other
organisations (why were Southern Health running social care services in the
first place?); 2) continuing to offload learning disability services acquired
during the ‘absorption’ of Ridgeway/Oxfordshire Learning Disabilities NHS Trust
in 2012. By the end of 2017, when services in Oxfordshire will finally transfer
to the Oxford Health NHS Trust, I think this will mean that none of the
Ridgeway services acquired by Southern Health will remain in their hands,
although Southern Health will have pocketed over £8 million in reserves
transferred from Ridgeway and kept the proceeds from the sale of a number of
former Ridgeway properties. To my mind, it is no coincidence that both TQ21 and
the Ridgeway acquisition were driven by the venture capital mindset of Katrina
Percy and the Board at the time. People died
preventable deaths in these services.<o:p></o:p></div>
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Financially, this means that the income to Southern Health
continues to shrink, from £353.9 million in 2013/14 through £330.8 million in
2015/16 to £321.6 million in 2016/17 (a decrease of 9.1% in three years).
Overall expenditure has also dropped over this time period, from £348.5 million
in 2013/14 (when there was an operating surplus of £5.4 million) through £331.6
million in 2015/16 (with an operating loss of -£5.8 million) to £314.4 million
in 2016/17 (a decrease of 9.8% in three years). The income figure for 2016/17
includes a bung of £5.3 million from the Sustainability and Transformation
Fund, resulting in an operating surplus of £7.2 million. It is also worth
noting a final financial gift from Ridgeway in 2016/17 – the sale of the West
View/Home Farm site for £0.8 million.<o:p></o:p></div>
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How does Southern Health spend this income? Some specific
lines of expenditure suggest that Southern Health is still an organisation in
trouble. For example, ‘purchase of healthcare from non-NHS bodies’ (principally
buying inpatient mental health services from private companies such as Huntercombe)
rose from £5.0 million in 2015/16 to £9.1 million in 2016/17. Expenditure on
clinical negligence cases continues to increase rapidly; from £0.6 million in
2013/14 through £1.1 million in 2015/16 and £1.6 million in 2016/17.<o:p></o:p></div>
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As with all NHS Trusts, by far the biggest expenditure is on
staff. Reflecting the continuing shrinkage of Southern Health, spending on all
staff (excluding Directors) continued to drop; from £258.9 million in 2013/14
through £236.5 million in 2015/16 to £225.2 million in 2016/17 (a decrease of
13.0% in three years).<o:p></o:p></div>
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Continuing to buck this trend is expenditure on Executive
Directors. This has increased from £1.0 million in 2013/14 through £1.6 million
in 2015/16 to £1.9 million in 2016/17, a 90% increase in three years. Some of
this is undoubtedly due to changes in the Board throughout 2016/17, where there
are signs of attempts to regularise some of the more outrageous ways in which
Executive Directors (and a select few others) were paid in the Katrina Percy era.
Of course, this doesn’t mean that new Executive Directors are exactly donning
hairshirts and taking vows of poverty themselves.<o:p></o:p><br />
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First of all there is Katrina Percy herself. Including her
pay-off of a year’s salary and pension benefits, she ‘earned’ £295,000 -
£300,000 in 2016/17 (and she wasn’t even there for the whole financial year).
Senior cronies such as the Chief Operating Officer, Chris Gordon (now gently eased to a secondment to, er, NHS Improvement) still raked in as a Director £105,000
- £110,000 from Southern Health in 2016/17 – not to mention an additional
£70,000 - £75,000 in income from Southern Health for his work in ‘other roles’
for them. Whether appointed at the tail-end of KP’s reign or just afterwards,
other Executive Directors include Christopher Ash (Director of Strategy;
£180,000 - £185,000 including pension contributions), Gethin Hughes (Director
of Integrated Services; £185,000 - £190,000 including pension contributions),
Sara Courtney (Acting Director of Nursing and Allied Health Care Professionals;
£165,000 - £170,000 including pension contributions) and Paul Streat (Director
of Corporate Governance; £155,000 - £160,000 including pension contributions). <o:p></o:p></div>
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The new Interim Chief Executive Officer, Julie Dawes, took
home £150,000 - £155,000 in salary and a further £62,500 - £65,000 in pension
contributions in 2016/17. The Interim Chair Alan Yates, appointed by fiat by
NHS Improvement, isn’t doing badly either, taking home £100,000 - £105,000 in
total in 2016/17.<o:p></o:p></div>
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The Director of Operations for Mental Health, Learning
Disabilities and Social Care is Mark Morgan, who seemed to perform a similar
selling off role for Castlebeck after Winterbourne View. Under the KP era he was
being paid eye-watering amounts by Southern Health via his company. The annual
report for 2016/17 reports that he now takes a salary rather than being paid
through this company, although he still managed to rake in £265,000 - £270,000
from Southern Health in 2016/17. A number of other Directors were earning
substantial additional amounts for ‘other roles’ in Southern Health under the
KP era in 2015/16, but this seems to have stopped for four Directors in
2016/17.<o:p></o:p><br />
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For reasons which are not obvious to an outsider like me,
the great survivor of this turbulent period is the Medical Director, Lesley
Stevens, with a total £165,000 - £170,000 (including pension contributions)
from Southern Health in 2016/17.<o:p></o:p></div>
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One of the indicators that NHS Trusts have to report is the
ratio between the highest salary in the Trust and the median salary of all
staff in the Trust. In 2015/16 the median salary in Southern Health was £24,500
and the ratio was 7.6. In 2016/17 the median salary increased to £26,900
(largely because poorly paid workers in the social care TQ21 service no longer worked
for Southern Health). The 2016/17 annual report states that the ratio of
highest paid worker to median salary dropped dramatically to 5.7. It turns out
this is because the Trust decided that Katrina Percy’s income didn’t count
because of the payoff – the ratio would then have rocketed to around 11. The
Trust also decided that the next highest income, for Mark Morgan, didn’t count
either, because he was paid via his company for most of the time (or something
like that) – the ratio would then be approaching 10.<o:p></o:p></div>
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<b>Through the nose<o:p></o:p></b></div>
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Last summer, <a href="http://www.bbc.co.uk/news/uk-england-36922039" target="_blank">Michael Buchanan of the BBC reported the hugeamounts of money</a> being paid by Southern Health to two consultancy companies,
Talent Works and Consilium, both of which were led by people with connections
to Katrina Percy. Trusts have to report in their annual report and accounts total
spending to external agencies in three categories: legal fees; consultancy; and
training/courses/conferences. Much of the gargantuan spending to Talent Works
in particular was categorised as training rather than consultancy, particularly
for the infamous ‘Going Viral’ collection of happenings (I’m struggling to find
a neutral but descriptive term) inflicted across Southern Health.<o:p></o:p></div>
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In 2016/17 are there signs that Southern Health is curbing
its dangerous addiction to consultants, in whatever form? <o:p></o:p></div>
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First, Southern Health spending on legal fees is continuing
to increase: from £1.1 million in 2014/15 through £1.4 million in 2015/16 to
£1.7 million in 2016/17. How much of this legal spending is necessary to work
through the consequences of Katrina Percy’s actions (the annual report states
expenditure of £14,256 to the legal firm Capsticks specifically related to
Katrina Percy’s departure), and how much is engaged in aggressive and
unnecessary actions like the legal bullying involved in the @LBInquest, is
unclear.<o:p></o:p></div>
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Second, spending on training, which had shot up from 2014/15
(£1.0 million) to 2015/16 (£2.7 million), possibly involving recategorising
consultancy spending during that time, decreased slightly to 2016/17, but was
still running at £1.9 million. <o:p></o:p></div>
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Thirdly, spending on consultancy, which had ostensibly
dropped from 2014/15 (£1.5 million) to 2015/16 (£0.7 million), increased again
in 2016/17 to £1.3 million.<o:p></o:p></div>
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Across all three categories, spending increased from 2014/15
(£3.6 million) through 2015/16 (£4.8 million) to 2016/17 (£4.9 million).
Southern Health’s addiction continues under new management.<o:p></o:p></div>
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If you want to look in more detail at who Southern Health
have been paying, <a href="https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in_6#outgoing-656272" target="_blank">this Freedom of Information request has details</a> of exactly
when Southern Health paid invoices to which organisations in 2016/17 under the
three categories of training, consultancy and legal/professional fees. I haven’t
gone through all of this myself (yet), but one thing did jump out at me: even
at the end of March 2017, after KP had departed, Southern Health were still
paying large sums to Talent Works Psychologists Ltd for ‘training’, over
£137,000 in March 2017 alone.<o:p></o:p></div>
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<b>Staffing<o:p></o:p></b></div>
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As I mentioned earlier, Southern Health continued to shrink
in 2016/17, with expenditure on (non-Director) staff also decreasing. What have
the consequences been for the number of staff in different roles employed in
Southern Health? A year ago, it looked to me like the figures were suggesting a
deprofessionalisation of the Southern Health workforce, with from 2014/15 to
2015/16 big reductions in the number of doctors/dentists;
nurses/midwives/health visitors; and scientific/therapeutic/technical staff to
set alongside a big increase in healthcare assistants/other support staff.<o:p></o:p></div>
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What has happened from 2015/16 to 2016/17? As you would
expect from a shrinking organisation, the total Whole Time Equivalent (WTE)
staffing time available reduced again, from 7,282 WTE staff in 2014/15, through
6,468 WTE staff in 2015/16, to 6,028 WTE staff in 2016/17. <o:p></o:p></div>
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However, within these overall figures there are signs of at
least a stalling of the staffing plans of the late-KP era. For example, the WTE
number of healthcare assistants/other support staff, after increasing
drastically from 1,587 in 2014/15 to 2,033 in 2015/16, dropped dramatically in
2016/17 to 1,484.<o:p></o:p></div>
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Other groups of staff that had reduced from 2014/15 to
2015/16 showed signs of small reversals in 2016/17. The WTE number of
doctors/dentists, which had reduced from 238 in 2014/15 to 211 in 2015/16,
increased again to 230 in 2016/17. The WTE number of nurses/midwives/health
visitors, which had plummeted from 2,507 in 2014/15 to 1,748 in 2015/16, had stabilised
at 1,786 in 2016/17. Similarly, the number of scientific/therapeutic/technical
staff, which had dropped from 823 in 2014/15 to 529 in 2015/16, has stabilised
at 557 in 2016/17.<o:p></o:p></div>
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Southern Health is still quite highly reliant on agency
staff (227 WTE in 2016/17 compared to 211 in 2015/16 and 287 in 2014/15) and
Bank staff (350 WTE in 2016/17 compared to 365 in 2015/16 and 461 in 2014/15).
Staff sickness rates are high at 4.5% in 2016/17 compared to 4.8% in 2015/16,
with an average of 11 working days per full-time post lost due to sickness.<o:p></o:p></div>
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<b>Who let this happen?<o:p></o:p></b></div>
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As Southern Health struggles to emerge from the disastrous
reign of Katrina Percy (and unlike when it is applied to football managers, the
word ‘reign’ feels appropriate here), there are so many unanswered questions.
Principally, how was the catastrophic direction Katrina Percy took Southern
Health not only allowed to happen, but actively encouraged? There are so many
people and organisations part of making this happen who have evaded any
scrutiny or accountability. The murky deal for Southern Health to ‘absorb’
Ridgeway brokered by the Primary Care Trust at the time (remember that the
other NHS Trust shortlisted to take it on was Calderstones). The replacement
health service commissioners (Clinical Commissioning Groups) who studiously looked
the other way while continuing to blandly hand over the cash. Oxfordshire
social services commissioners who were so busy protecting their own reputations
they neglected to do their jobs. The whole self-serving shiny panoply of the Health
Service Journal awards circuit. Where were Monitor/NHS Improvement? The CQC? NHS
England? The Department of Health? (who they?). Without #JusticeforLB and other
campaigners wanting accountability and justice at Southern Health, Katrina
Percy would still be in post now rather than <a href="https://uk.linkedin.com/in/katrina-percy-88481258" target="_blank">advertising her wares as aStrategic Consultant on LinkedIn</a>, and I shudder to think where Southern Health (and
the people using its services, and its staff) would be headed. <o:p></o:p></div>
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I’m not privy to the internal workings of these
organisations so I have no idea whether they have engaged in any real
reflection on their role in this disaster, and whether they have changed what
they do as a result. My question to them would be, not only could it happen
again, but is it happening somewhere on their watch right now, and does it look
to them like failure or success?<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com63tag:blogger.com,1999:blog-8154170016308023512.post-91068966373871491572016-07-30T21:58:00.000-07:002016-08-03T00:06:49.295-07:00Failing and flailing: the Southern Health Annual Report 2015/16<div class="MsoNormal">
Every year, Southern Health (as an NHS Foundation Trust) has
to present to parliament its <a href="http://www.southernhealth.nhs.uk/about/performance/annual-report/" target="_blank">Annual Report and Accounts</a>. About two years ago <a href="http://chrishatton.blogspot.co.uk/2014/03/a-public-accounting.html" target="_blank">I looked at the 2012/13 Annual Report</a> to get a sense of what the Trust was reporting about
itself, particularly with reference to their services for people with learning
disabilities. <a href="http://dataforlb.blogspot.co.uk/2014/08/welcome-from-chair-and-chief-executive.html" target="_blank">The 2013/14 Annual Report successfully repelled me</a>, but I’ve
managed to have a look through the 2015/16 Annual Report and Accounts.<o:p></o:p></div>
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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 <a href="http://justiceforlb.org/" target="_blank">#JusticeforLB</a> 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.<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5LoJIjsX5_6ZmVyvwshngs9foPyT0jshY4SaAKI60wZJrTgI-cBhrSiijFN1Ib5mqWrdMkAyMu7pi_RSonCXZiawCROqr630kraR-KUDxiUH6VvwwuRLjOWwMXkkfpjRL9nQNHhywWCY/s1600/Wile+E+Coyote+1.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5LoJIjsX5_6ZmVyvwshngs9foPyT0jshY4SaAKI60wZJrTgI-cBhrSiijFN1Ib5mqWrdMkAyMu7pi_RSonCXZiawCROqr630kraR-KUDxiUH6VvwwuRLjOWwMXkkfpjRL9nQNHhywWCY/s1600/Wile+E+Coyote+1.gif" /></a></div>
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[GIF from http://giphy.com/ ]</div>
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<b>Under pressure<o:p></o:p></b></div>
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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].<o:p></o:p></div>
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Without explicitly saying so, many of the Trust’s 13 ‘Key
Actions’ for 2016/17 [pages 7-8] reflect serial failures, including:<o:p></o:p></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->“Delivering the SIRI and Mortality Action Plan
in response to the Mazars report”<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->“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”<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->“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]<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->“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]<o:p></o:p></div>
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<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->“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”]<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->“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”
[<a href="http://www.dailyecho.co.uk/news/14595468.Psychiatric_unit_faces_EIGHT_MONTH_closure_as_trust_crisis_deepens/" target="_blank">the closure of a major inpatient mental health service, Antelope House, for at least 8 months due to their inability to recruit staff</a>, is just one
illustration of their problems with recruitment]<o:p></o:p></div>
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<b>Money’s too tight to
mention<o:p></o:p></b></div>
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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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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). <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Spending on Non-Executive Directors has stayed fairly static
(£143,000 in 2013/14; £139,000 in 2014/15; £146,000 in 2015/16). <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>When is a consultant
not a consultant?<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="http://www.bbc.co.uk/news/uk-england-36922039" target="_blank">In another superb piece of investigative reporting</a>, 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. <a href="http://www.southernhealth.nhs.uk/news/statement-regarding-the-news-story-about-the-trust-on-the-bbc/" target="_blank">Southern Health put out a statement</a> saying that all their consultancy contracts were fully justified and
procured correctly.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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 <a href="http://dataforlb.blogspot.co.uk/2016/05/march-of-lawyers.html" target="_blank">£1.06 million in consultancy which they provided in FoI requests</a>. 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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Will the last member
of staff left please turn out the lights (Environmental Strategy 12.92)?<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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).<br />
<br />
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%).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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%.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>Candour Crush Saga<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Performance Analysis (page 10)<o:p></o:p></div>
<blockquote class="tr_bq">
“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”.</blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
[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]</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Quality Governance (page 25)<o:p></o:p></div>
<blockquote class="tr_bq">
“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.”</blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
[Either they weren’t actually compliant, or Monitor’s
Framework is rubbish]<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Duty of Candour (page 118)<o:p></o:p></div>
<blockquote class="tr_bq">
“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.”</blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
[So, for Duty of Candour, they didn’t report everything they
should have done but said in their reports that they had]<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Statement of Chief Executive Responsibilities As the
Accounting Officer of Southern Health (page 76)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
[This is part of the CEO’s closing official statement in the
report, and sums up the clash of reality vs spin quite well]<o:p></o:p></div>
<blockquote class="tr_bq">
“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.”<br />
“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.”</blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
[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]<o:p></o:p></div>
<blockquote class="tr_bq">
“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.”<br />
“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.”</blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
[The main lesson learned appears to be how to copy and
paste]<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Failing and flailing<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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:<o:p></o:p></div>
<blockquote class="tr_bq">
“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.”<br />
“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.”</blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<br />
<br />
NB: [Update: I have corrected some of the percentage changes over time from the original version of this post]<br />
<div class="MsoNormal">
<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com8tag:blogger.com,1999:blog-8154170016308023512.post-88777279466174413192016-07-03T03:20:00.000-07:002016-07-03T03:20:02.348-07:00The return of the repressed<span style="font-family: Verdana, sans-serif;">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:</span><br />
<span style="font-family: Verdana, sans-serif;">1) Not meeting with families as part of the review, despite saying he was going to.</span><br />
<span style="font-family: Verdana, sans-serif;">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.</span><br />
<span style="font-family: Verdana, sans-serif;">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.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxjFmPuc2bAqcY3ssyEWGvBaP_CIwgVACLfdeQhcHvGuQGDFK7loe5HnfL_GwCLpI9u6jGLcvHdND7PK_nDKrht2IDwrRPF2T0lY0io74NscewUmTA25rX97TXlRBEIkeoJAmGl3D980o/s1600/012.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxjFmPuc2bAqcY3ssyEWGvBaP_CIwgVACLfdeQhcHvGuQGDFK7loe5HnfL_GwCLpI9u6jGLcvHdND7PK_nDKrht2IDwrRPF2T0lY0io74NscewUmTA25rX97TXlRBEIkeoJAmGl3D980o/s320/012.JPG" width="320" /></a></div>
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;">The main actions arising from Tim Smart's comprehensive review are, er, apparently nothing at all even as, <i>on the same day</i>, <a href="http://www.portsmouth.co.uk/our-region/fareham/woman-s-death-leads-to-fresh-calls-for-action-at-under-fire-health-trust-1-7458003" target="_blank">another Coroner reported shocking Southern Health practices</a> (including retrospectively 'updating' the person's care records).</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;"><a href="http://justiceforlb.org/statement-on-behalf-of-patients-and-relatives-of-southern-health-justiceforlb/" target="_blank">This statement</a>, 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 <a href="https://mydaftlife.com/2016/07/02/tears-rage-disbelief-frustration-and-utter-bafflement/" target="_blank">essential reading</a>.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;">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. <a href="http://www.southernhealth.nhs.uk/news/interim-chairs-review/" target="_blank">The Southern Health statement </a>in full is below, with some of my annotations.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<br />
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<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="text-align: center;"><span style="color: purple; font-family: Verdana, sans-serif;">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.</span></span></div>
<div style="margin-bottom: 1em;">
<span style="text-align: center;"><span style="font-family: Verdana, sans-serif;">It is easier to only imagine the pain rather than actually meeting families to find out about it.</span></span></div>
</div>
</div>
</div>
</div>
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<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">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? </span></div>
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">The 'we' indicates that Tim Smart identifies himself as part of Southern Health, while at the same time providing an 'objective' assessment of it. </span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">It's the next sentence that starts doing the real rhetorical work though. First, the use of <a href="http://chrishatton.blogspot.co.uk/2016/04/the-complexity-complex.html" target="_blank">'complexity'</a> - 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. <a href="http://dataforlb.blogspot.co.uk/2014/08/welcome-from-chair-and-chief-executive.html" target="_blank">This has been a repeated refrain of Southern Health corporate communications</a> 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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;"><span style="color: purple;">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.</span></span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">Note 'my opinion' here - not quite the rigorous application of objective evidence</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">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. </span></div>
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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:</span></div>
<span style="font-family: Verdana, sans-serif;">This introduction screams big changes afoot - 'transform', 'makes changes'. What follows...</span><br />
<br />
<blockquote style="margin: 0px 0px 0px 40px; padding: 0px;">
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
</blockquote>
<span style="font-family: Verdana, sans-serif;">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.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;">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.</span><br />
<br />
<blockquote style="margin: 0px 0px 0px 40px; padding: 0px;">
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
</blockquote>
<span style="font-family: Verdana, sans-serif;">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.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;">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.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span>
<span style="font-family: Verdana, sans-serif;">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?</span><br />
<br />
<blockquote style="margin: 0px 0px 0px 40px; padding: 0px;">
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
</blockquote>
I<span style="font-family: Verdana, sans-serif;">n 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).</span><br />
<br />
<blockquote style="margin: 0px 0px 0px 40px; padding: 0px;">
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
</blockquote>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;"><span style="color: purple;">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.</span></span></div>
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">Is that it? <a href="https://twitter.com/BBCMBuchanan/status/748813946782486528" target="_blank">Tim Smart seems to think so</a>, 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'.</span></div>
<div style="margin-bottom: 1em;">
<span style="font-family: Verdana, sans-serif;">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.</span></div>
<div style="margin-bottom: 1em;">
<span style="color: purple; font-family: Verdana, sans-serif;"><br /></span></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com6tag:blogger.com,1999:blog-8154170016308023512.post-29624576135081366102016-05-13T04:17:00.006-07:002016-05-13T04:17:53.847-07:00March of the lawyers<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">In a previous blogpost for #JusticeforLB, using Freedom of
Information requests I went through how much Southern Health NHS Foundation
Trust spent on external consultancy and legal/professional services in 2013/14
and 2014/15 (see <a href="http://dataforlb.blogspot.co.uk/2015/07/watching-consultants.html">http://dataforlb.blogspot.co.uk/2015/07/watching-consultants.html</a>
). I’ve now got this information for 2015/16 (in two batches because I was
impatient, see <a href="https://www.whatdotheyknow.com/user/chris_hatton">https://www.whatdotheyknow.com/user/chris_hatton</a>
) via the good offices of What Do They Know? and the genuinely efficient FoI
office at Southern Health.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">The previous blogpost goes through a lot of the issues in
too much detail, and I don’t want to repeat all of that detail here. Instead, I
want to talk about some general trends in Southern Health spending over these
three years.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">The graph below shows the total amount that Southern Health
spent on consultancy and legal/professional services (although these categories
seem to be somewhat arbitrary to me) from 2013/14 to 2015/16.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">Overall, in 2015/16 Southern Health spent £2.23 million on
consultancy/legal/profs - 0.7% of their total income of £331 million in 2015/16.
Overall this is down from 2014/15, when Southern Health spent £3.28 million
(0.9% of their total income of £346 million). But still not a trivial amount
when your income has dropped by 6% in two years.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">Looking at the two main categories of spending, the big drop
came in spending on consultancy (from £2.17 million in 2014/15 to £1.06 million
in 2015/16). However, spending on legal/professional services stayed pretty
steady (from £1.12 million in 2014/15 to £1.17 million in 2015/16) and is now
outstripping spending on consultancy. </span><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br /><div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQy24rzgfIIBpsimcy7id76q_t6d_V4di9_8PcQxj2fdt91T-rVpdxFOVme7UlzWce_MF3-4EQOzZeuEIzv7gedkgsx4dDSz9jm4IOPjbfF-Ube4JxlUXhnh-oq5m9Dy8ZRARMY7Yfo6M/s1600/Southern+Health+consultancy+spending.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="258" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQy24rzgfIIBpsimcy7id76q_t6d_V4di9_8PcQxj2fdt91T-rVpdxFOVme7UlzWce_MF3-4EQOzZeuEIzv7gedkgsx4dDSz9jm4IOPjbfF-Ube4JxlUXhnh-oq5m9Dy8ZRARMY7Yfo6M/s400/Southern+Health+consultancy+spending.png" width="400" /></a></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">So who are the lawyers and what are they getting paid for?
We know from the excellent My Life My Choice (see <a href="http://mylifemychoice.org.uk/how-much-did-southern-health-nhs-trust-spend-on-connor-sparrowhawks-inquest/">http://mylifemychoice.org.uk/how-much-did-southern-health-nhs-trust-spend-on-connor-sparrowhawks-inquest/</a>
) that Southern Health apparently spent £318,121 (including VAT) just on the
costs of lawyers at LB’s inquest. The FoI tables don’t typically give that
level of detail, but there are some clues.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">First, there seem to be some law firms that do the kinds of
tasks you would expect, for example relating to property (Paris Smith LLP;
Savills LLP) or a whole range of legal stuff (Capsticks LLP; DAC Beachcroft). The
amount that Southern Health pays to these law firms fluctuates over the three
years and adds up to a tidy sum (£236,003 across these four law firms).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">However, it’s not nearly as much as the amount paid to three
other law firms, whose services go under the strategically vague ‘clinical
governance and audit’ category. By far the biggest is Bevan Brittan LLP – from £47,802
in 2013/14 and £44,932 in 2014/15, their income from Southern Health leapt to
£265,522 in 2015/16. Their stance on inquests involving the deaths of people in
public services can be gained from articles on their website such as “Avoiding
a Coroner’s Rule 43 report at an inquest”
(<a href="https://www.bevanbrittan.com/insights/articles/2011/avoidingacoronersrule43reportataninquest/">https://www.bevanbrittan.com/insights/articles/2011/avoidingacoronersrule43reportataninquest/</a>
) and “Under the microscope: a note on inquests and NHS Trusts” (<a href="https://www.bevanbrittan.com/insights/articles/2013/thewideninggyre/">https://www.bevanbrittan.com/insights/articles/2013/thewideninggyre/</a>
), which has the following gem of wisdom:<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: Trebuchet MS, sans-serif;"><span style="background: white; color: #192947; mso-bidi-font-family: Arial;"><br /></span></span></i></div>
<div class="MsoNormal">
<i><span style="font-family: Trebuchet MS, sans-serif;"><span style="background: white; color: #192947; mso-bidi-font-family: Arial;">“There is a
view that if something goes wrong, it is usually somebody’s fault and unless
the mistake is paid for by the person responsible it is more likely to be
repeated. At the same time, post-incident investigations undertaken within the
NHS are usually expected to adopt a no-blame approach. The inquest process
still seems to pay lip-service to both ends of the spectrum. A stock phrase at
the outset of an inquest is that ‘no-one is on trial, least of all the
deceased’. At the same time it is becoming common for inquests involving
healthcare staff to be a trial by ordeal in all but verdict and sentence. And
yet there is little that can be done to protect such staff or the Trust from
gratuitous intimidation, particularly given the cost of a challenge to an
inquest and the likelihood that, even if successfully challenged, it will only
mean the inquest will be repeated.</span>”<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="background: white; color: #192947; mso-bidi-font-family: Arial;"><span style="font-family: Trebuchet MS, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="background: white; color: #192947; mso-bidi-font-family: Arial;"><span style="font-family: Trebuchet MS, sans-serif;">Other new entries for 2015/16 were Hempsons (‘Leading lawyers
for health and social care’ <a href="http://www.hempsons.co.uk/">http://www.hempsons.co.uk/</a>
) – paid £52,147 in 2015/16 by Southern Health, and Weightmans LLP (‘A top 45
law firm’ <a href="http://www.weightmans.com/">http://www.weightmans.com/</a> )
– paid £45,669 by Southern Health in 2015/16. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">On the consultancy side (although boundaries are blurred, to
say the least), the reduction in Southern Health spending is largely accounted
for by the demise of Going Viral, designed by occupational psychology firm
Talent Works (<a href="http://www.talentworksltd.com/case-studies/going-viral-wins-national-award">http://www.talentworksltd.com/case-studies/going-viral-wins-national-award</a>
) - spending went from £908,832 in 2013/14 to £642,272 in 2014/15 to a big fat
zero in 2015/16.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">Other consultancy firms are still being paid large amounts
by Southern Health – by far the biggest is Deloitte, which was paid £65,455 in
2013/14; £285,128 in 2014/15; and a stratospheric £611,721 in 2015/16. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">Local management consultancy buddies Consilium Partners
continue to get regular bungs from Southern Health - £158,250 in 2013/14;
£114,261 in 2014/15; and £103,920 in 2015/16. IRG Advisors (another ‘management
consulting firm’ <a href="https://www.linkedin.com/company/irg-advisors">https://www.linkedin.com/company/irg-advisors</a>
) got £64,893 in 2015/16 (although way down on their £265,599 in 2014/15).
Newcomers PA Consulting (their website seems to suggest they will do absolutely
anything <a href="http://www.paconsulting.com/">http://www.paconsulting.com/</a>
) pocketed £56,056 in 2015/16.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">In what strikes me as an even more sinister turn, we have
MBI Health Consulting – they were paid £25,000 in 2013/14, £296,431 in 2014/15
and £39,600 in 2015/16. What particularly perturbed me was that the 2015/16
amount was, according to the spreadsheet, for ‘LD management’. And even worse,
in 2015/16 Southern Health paid £4,536 to St Andrews Healthcare (yes, <i>that</i> St Andrews), also for ‘LD
management’.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">If I had any sort of role in the governance of Southern
Health, I’d be very concerned about what all these shadowy management
consultancies are doing (quite apart from demanding my money back…). What is
their role in the management of an NHS service? Where’s the scrutiny (they very
rarely appear in Board papers, and don’t seem to ever be called to Board
meetings)? Where’s the accountability? (I know such a question seems naïve to the
point of, I don’t know, something, but how could a person in one of those
consultancies be disciplined for bullying members of staff, for instance, or
for taking a management decision that directly led to a person’s death in the
service?).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">Just to finish off, a couple of snippets that caught my eye.
In 2015/16, Southern Health paid Hampshire County Council £59,459 relating to
Southern Health’s Chief Operating Officer, Chris Gordon. A thickening of the
local web of connections, and a disincentive for Hampshire County Council to
push Southern Health too hard?<o:p></o:p></span></div>
<br />
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">And finally, Southern Health paid £47,280 to Aston
Organisation Development, but £42,552 was paid back. Aston Organisation Development (see <a href="http://www.astonod.com/">http://www.astonod.com/</a> ) is a consultancy
company based on team-based working, and its director is Mike West, guru of promoting
health service cultures to promote high quality care. Southern Health is not
listed as one of Aston’s recent clients on its website. An accounting error, or
one of the parties deciding very quickly that an intervention from Aston wasn’t
going to work out?</span><o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com6tag:blogger.com,1999:blog-8154170016308023512.post-5581671359015721202016-04-29T04:00:00.001-07:002016-04-29T04:00:21.253-07:00Days of judgement<div class="MsoNormal">
<span style="font-family: Trebuchet MS, sans-serif;">The latest (in a long series) of damning CQC reports
concerning Southern Health NHS Trust (see press release here <a href="http://www.cqc.org.uk/content/southern-health-nhs-foundation-trust-still-not-doing-enough-protect-people-its-care">http://www.cqc.org.uk/content/southern-health-nhs-foundation-trust-still-not-doing-enough-protect-people-its-care</a>
) was published this morning. Here are some quotes from this press release,
from Paul Lelliott, Deputy Chief Inspector of Hospitals and Lead for Mental
Health:<o:p></o:p></span></div>
<blockquote class="tr_bq" style="background: white; line-height: 15pt; margin: 16pt 0cm;">
<span style="font-family: Trebuchet MS, sans-serif;">“Since the failings identified in
the Mazars report, this Trust has, rightly, been under intense scrutiny. In
December 2015 it introduced a new system for reporting and investigating
incidents, including deaths. It is too early to gauge the effectiveness of the
new process. However, our inspectors found that the quality of the incident
reports and initial management assessments, conducted both before and after the
introduction of the new procedures, varied considerably.</span><span style="font-family: Trebuchet MS, sans-serif;">“We
found that in spite of the best efforts of the staff, the key risks and actions
to address them were not driving the senior leadership or board agenda. It is
clear that the Trust had still missed opportunities to learn from adverse
incidents and to take action to reduce the chance of similar events happening
in the future.</span><span style="font-family: Trebuchet MS, sans-serif;">I
am concerned that the leadership of this Trust shows little evidence of being
proactive in identifying risk to the people it cares for or of taking action to
address that risk before concerns are raised by external bodies.”</span></blockquote>
<div style="background: white; line-height: 15pt; margin: 16pt 0cm;">
<span style="font-family: Trebuchet MS, sans-serif;">The
CQC’s remedy for this long-standing and dangerous continuing failure of
leadership at the Trust? This:<o:p></o:p></span></div>
<blockquote class="tr_bq" style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">“The Trust has supplied an action
plan setting out the steps it will take to address the concerns identified in
the warning notice and CQC will be monitoring the Trust closely with regards to
its progress. A further inspection will take place in due course to check that
the required improvements have been made and are being sustained.”</span></blockquote>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">Meanwhile, a brief statement from
NHS Improvement says:<o:p></o:p></span></div>
<blockquote class="tr_bq" style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">“We’ve read the Care Quality
Commission’s report and it makes extremely disappointing reading.</span><span style="font-family: Trebuchet MS, sans-serif;">We recognise the seriousness of the
situation at Southern Health and it’s clear that urgent improvement is needed
at the trust.</span><span style="font-family: Trebuchet MS, sans-serif;">We’re currently considering whether
to take any further regulatory action.”</span></blockquote>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy4MExMw_Uk6GMT0c32dEWwDBR3yNlbnQEvC-Ze-XuKozNuNEZFtzx-qeiiyId8P7xmLlU4_JVMpDwKKAmYymLN5bSXxrPIWr6udCGcklTAxSCbFLhVOJpF4yAcWPHGW1cPVC_P19hPUQ/s1600/081.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy4MExMw_Uk6GMT0c32dEWwDBR3yNlbnQEvC-Ze-XuKozNuNEZFtzx-qeiiyId8P7xmLlU4_JVMpDwKKAmYymLN5bSXxrPIWr6udCGcklTAxSCbFLhVOJpF4yAcWPHGW1cPVC_P19hPUQ/s400/081.JPG" width="400" /></a></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;"> [The photo is of 'Days of Judgement', part of the brilliant, brilliant 'Seen and Unseen' exhibition by Laura Ford across the Abbot Hall Art Gallery and Blackwell House in the South Lakes]</span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">Just so the CQC, NHS Improvement,
the Department of Health, and anyone else on the accountability magic
roundabout are clear about what the consequences of their continued
non-participant observation are, this short blogpost goes through how Southern
Health are reporting people’s deaths in their Board papers. It was prompted by
a straightforward question from Mark Neary a couple of weeks ago – do we know
how many people with learning disabilities using Southern Health services have
died an unexpected death since the Mazars report was published? Over a sandwich,
I thought I’d have a quick look. As ever (I should know better by now), I ended
down a malignant rabbit hole of Southern Health Board paper reporting, whether
nothing quite adds up and the overall effect is to obscure rather than illuminate.<o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">Remember, the timescale for this reporting
is recent – Southern Health must have had a draft of the Mazars report in the
summer of 2015, and no end of lesson learning before that, so their reporting
of deaths should be exemplary by this point. <o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">This first graph below (from the
Board papers for 27<sup>th</sup> October 2015) shows how Southern Health were reporting
information on people dying – or ‘Minimising unexpected deaths (Quality account
priority)’. This reports the number of people using Southern Health services
(across all their services) who died an ‘unexpected death’ (the definition they
use for ‘unexpected death’ is unclear) week by week. My reckoning is that
Southern Health reported 103 unexpected deaths from April to September 2015. At
this point (well after Mazars had started work) they don’t report in which
areas of their services the unexpected deaths are happening. And although the
definition states ‘all unexpected deaths are reported as a serious incident
requiring investigation’ this isn’t apparent in other parts of the Board papers
reporting on SIRIs, and the statistically spurious red line representing the ‘not
bothering threshold’ (I’m claiming the copyright on this technical term) is
drawn conveniently just above the maximum number of unexpected deaths in any
one week (‘expected variation – no investigation required’). <o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjW9ZtkXquDn5wrPFSKd2JxvIbY87AvV-rsnvXvfi1hzNSBA12acBAQi3zDK7deET5I1F2TVH_zGRvynZDcatIXSTPxGEh1m4lhw33rP77q0CdH709NSjZL06wBrzG531HG3NpQp9tfBzk/s1600/Southern+Health+board+papers+27+Oct+2015+unexpected+deaths+.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="306" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjW9ZtkXquDn5wrPFSKd2JxvIbY87AvV-rsnvXvfi1hzNSBA12acBAQi3zDK7deET5I1F2TVH_zGRvynZDcatIXSTPxGEh1m4lhw33rP77q0CdH709NSjZL06wBrzG531HG3NpQp9tfBzk/s640/Southern+Health+board+papers+27+Oct+2015+unexpected+deaths+.PNG" width="640" /></a></span></div>
<span style="font-family: Trebuchet MS, sans-serif;"><o:p></o:p></span><br />
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">This way of reporting deaths was
judged to be inadequate, and a new ‘improved’ system for reporting deaths began
on the 1<sup>st</sup> December 2015. In the Board papers across this time
period, I couldn’t find any reporting at all of how many people died,
unexpectedly or otherwise, in the last two months (October and November 2015) that
the old reporting system was operating.<o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">The new, ‘improved’ system produces
graphs like the one below (from the 29 March 2016 Board meeting papers). This
records the total number of deaths each month, and whether internal ‘review
panels’ (heavily criticised in the #Mazars report) have happened or not. By my
reckoning, there were 289 deaths in total from the 1<sup>st</sup> December 2015
to 21<sup>st</sup> March 2016. <o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">Moving from reporting only unexpected
deaths to total deaths is a perfectly defensible thing to do (some ‘expected’
deaths may well be preventable). However, there is now less information available
than before. There is no reporting of how many of these deaths are classified
as Serious Incidents Requiring Investigation (SIRIs), for example. <o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">There is also no attempt to
cross-check the new reporting system against the old one, to enable the Board
to evaluate what impact changes to reporting systems and changes to investigation
processes are having on the number of people dying, why they are dying, and
what the Trust are doing to prevent preventable deaths. Why are the Trust
saying that ‘No historical data…is available’? Do they not know how many of the
people using their services died before December 2015? Or can’t they be
bothered to work it out?<o:p></o:p></span></div>
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<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkoXmmn0roWThhrW0L9tPyYrYJjghpeE7Xzk0vVtRFdib9h5hx9PTnD7LzETZmfWNsGaBeBaCgtsbcpDVoHxfHW9ars5qBPLxC2YRAxZut7tGBcwW1nZa1iiYX35KIX1hoe8jYHsu9U8M/s1600/Mortality+table+Southern+Health+Board+papers+29+March+2016+.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="316" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkoXmmn0roWThhrW0L9tPyYrYJjghpeE7Xzk0vVtRFdib9h5hx9PTnD7LzETZmfWNsGaBeBaCgtsbcpDVoHxfHW9ars5qBPLxC2YRAxZut7tGBcwW1nZa1iiYX35KIX1hoe8jYHsu9U8M/s640/Mortality+table+Southern+Health+Board+papers+29+March+2016+.PNG" width="640" /></a></span></div>
<span style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;"> </span><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">Elsewhere in the Board papers,
there is a table with some more detail on how they report deaths. This does
report how many people died in different areas of the Trust. So, from 1</span><sup style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">st</sup><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">
December 2015 to 21</span><sup style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">st</sup><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;"> March 2016, 28 people using the learning
disabilities service (this includes community-based services as well as
inpatient services) died, and 2 people using their TQ21 social care service
died. Beyond that, all this table reports is how many deaths were subject to
the preliminary investigation stage within 48 hours. Nothing more meaningful (how
many were recorded as SIRIs, for example) is reported here.</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiH-WwITcg3mZHibxcQ9Jg2fBVPcy3_b-pu9Ub0gopX1PkttfdAXJzHkH42qwoQGr8_NGOoJy3Xu0wQKCOfvIfAy36myeEdvLU4PLXVybynM2XbH3cEehn_8PXFuxSp9G1Xh1dSqTMNNrk/s1600/Southern+Health+Mortality+29+March+2016+board+meeting.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="292" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiH-WwITcg3mZHibxcQ9Jg2fBVPcy3_b-pu9Ub0gopX1PkttfdAXJzHkH42qwoQGr8_NGOoJy3Xu0wQKCOfvIfAy36myeEdvLU4PLXVybynM2XbH3cEehn_8PXFuxSp9G1Xh1dSqTMNNrk/s640/Southern+Health+Mortality+29+March+2016+board+meeting.PNG" width="640" /></a></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">At a time when Southern Health know
they’re being watched, specifically on how they report and investigate deaths
in their service, the shoddiness of their reporting beggars belief. They
replace an old, rubbish way of reporting deaths for an even worse way of
reporting deaths. They ‘lose’ two months’ worth of information regarding deaths
from Board and public view. They start from a Month Zero of death reporting in
their new system, and can’t/won’t find any way to track what’s happening over a
longer time period. What really matters to them (what gets counted in graphs
and tables) is how many initial reviews get done in 48 hours, and </span><i style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">nothing else</i><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 15pt;">.</span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">How many people with learning
disabilities using Southern Health Trust have died unexpected or preventable
deaths since the Mazars report (the original prompt for me having a look at
this stuff)? Has this improved or got worse over time? From these Board papers,
we the public (and the Board itself) cannot begin to answer these questions. <o:p></o:p></span></div>
<div style="background: white; line-height: 15.0pt; margin-bottom: 16.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 16.0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">We do know that pretty much since
the Mazars report up until the 21<sup>st</sup> March 2016, 28 people using
Southern Health learning disability services lost their lives. Regulatory ‘monitoring’
and ‘considering’ time (even if this is serious face considering) is long past –
this Trust has dishonesty in its bones.</span></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com3tag:blogger.com,1999:blog-8154170016308023512.post-55024428590268660142016-03-10T08:30:00.001-08:002016-03-10T08:30:45.252-08:00Easy chair<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkes5kqF2dB0_H9l4_8_nugMDwyVGRvf0D4ir8v_-R0g2U3TbyrkWY9klk_o3zCC5zv7Sh3tZULQEYWHe1zQ5mR2chUj_g3ER7vGYem7AgSNDQvef6_drCZHt26s1evFi-yKJapNuXIYY/s1600/Chair.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkes5kqF2dB0_H9l4_8_nugMDwyVGRvf0D4ir8v_-R0g2U3TbyrkWY9klk_o3zCC5zv7Sh3tZULQEYWHe1zQ5mR2chUj_g3ER7vGYem7AgSNDQvef6_drCZHt26s1evFi-yKJapNuXIYY/s320/Chair.jpg" width="320" /></a></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: x-small;">[This picture is from the website http://montazne-hise-on.net/nenavadni-pocivalniki.html]</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Another day, another Freedom of Information request. </span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">A pretty repugnant feature of recent Southern Health practice has been the threatening behaviour of the new Chairman of the Southern Health Board, Mike Petter, towards members of the public in board meetings. How he behaves as Chairman of the Governors (those are the governors that are independent and can hold the Board to account, including sacking Board members like their, er, Chairman - ooh stop it, my accountability sides are hurting) doesn't bear thinking about. </span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Mike Petter's association with Southern Health is long (even going back to its previous incarnation before 2011). Given we're always being told how vastly competitive these senior Board posts are - and let's face it, for this post up to £50,000 a year for a part-time gig must be pretty tasty to a lot of people - I was interested in just how fiercely Mike Petter had to compete to get his job. Such prestige, Vanguard among Vanguards, working with former CEO of the year Katrina Percy, surely it was a comprehensive, searching, Apprentice-style selection process to pick out the Petter plum from the thousands of desperate applicants? So I did a Freedom of Information request to ask a few simple questions, via the excellent WhatDoTheyKnow (see here https://www.whatdotheyknow.com/request/selection_process_for_current_ch#followup )</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">From this (and despite the expensive ministrations of executive recruitment wizards Odgers Berndtsen), we learn that a princely total of 7 people formally applied for the post of Chairman.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Of these, 3 were shortlisted by the 'Appointment Committee' on 22 June 2015. There is no more detail about who was on the Appointment Committee, but a previous (and rather sniffy) response to an FoI request put in by Richard West (see here https://www.whatdotheyknow.com/request/details_of_panel_selecting_chair ) basically says that the Appointment Committee is constituted of Trust governors. </span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Of these 3 shortlisted candidates, 1 withdrew, leaving just 2 people.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">According to the response to my request, "This was then followed by a Stakeholder Day on 29 June 2015, which was made up of Governors, Service Users and Board members". It is not clear what role this played in selection, or how this fed into any final decision, but it seems that the 2 remaining candidates must have been there, as they also 'took part in psychometric testing' on the same day (29 June). A couple of thoughts at this point. First, I would love to know what psychometric tests were done and what the criteria were for evaluating scores on them. Second, a week between shortlisting and final selection is an incredibly short period of time, particularly if they were hoping to attract the sort of highly competent people with busy diaries suitable for a big Trust like Southern Health.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;"> 'Final panel interviews' then took place the next day, on 30 June 2015, with the Appointment Committee and also a shadowy 'External Assessor'. There is no more information about who this External Assessor was, and this information seems to directly contradict what Richard West was told in the response to his FoI request. </span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Overall, this seems a remarkably light process for selecting a Chair of a large, vanguardy NHS Trust. Application form, chat to a few people, a few psychometric tests and an interview, all with people presumably well-known to the successful candidate. </span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">When I was a governor of my kids' primary school we had to appoint a new headteacher. The appointment panel was 3 governors (including me) and two external assessors with considerable and complementary experience and expertise. After shortlisting, the selection tasks included a data task (looking at school attainment data and interpreting it), conducting a short assembly, conducting a lesson, observing and providing feedback on a teacher's lesson, answering questions from pupils on the school council, and a structured interview. The tasks were designed to cover the range of things that a good head teacher would be expected to do, and to get feedback from kids and teachers as well as governors and external assessors. And they really made a difference to who we selected.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">It's almost as if the process to select a Chairman of Southern Health Trust wasn't designed to attract as many high-powered, capable people as possible, and then really put them through their paces to see which one actually had what it takes to be a competent, ethical Chair of an NHS Trust. Surely not...</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
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<br />Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com6tag:blogger.com,1999:blog-8154170016308023512.post-58536993771648702242016-03-01T08:00:00.000-08:002016-03-01T08:00:23.584-08:00The cycle of (no) changeHere's the well-known cycle of change, from the stages of change model of Prochaska and DiClemente (this diagram is from Social Work Tech).<br />
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEdpdr5nJTy57dviOQmWPJFeiko-n1De1KPyM49uNbup7Vf_r2rMK95XBysySs1zwfpoPD23geJG3B-kqRLqJilewYdXu095hm70WH6eQWLnbz1L1mX49edRB8Z5yZ6UFYkiXmTy0dDQI/s1600/Social-Work-Tech-CoC-color.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="491" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEdpdr5nJTy57dviOQmWPJFeiko-n1De1KPyM49uNbup7Vf_r2rMK95XBysySs1zwfpoPD23geJG3B-kqRLqJilewYdXu095hm70WH6eQWLnbz1L1mX49edRB8Z5yZ6UFYkiXmTy0dDQI/s640/Social-Work-Tech-CoC-color.png" width="640" /></a></div>
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Here's the less well-known cycle of no change, from the stages of no change model of Concordat & Disdain (this diagram, er, isn't).<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpEwG95xgz1JbTlRWTNnhuBVDd1pKyy6qmJDnS1T7F1X6n75hXIcfSDrSgvB3ucvypqr8bCyj7dXeuzuqfsJY667NfJ5MssLIb1Xf9OzsdbM7Cr4t7m0qJJhzPIm8lmjDvW70u-I3SIO0/s1600/Cycle+of+no+change.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpEwG95xgz1JbTlRWTNnhuBVDd1pKyy6qmJDnS1T7F1X6n75hXIcfSDrSgvB3ucvypqr8bCyj7dXeuzuqfsJY667NfJ5MssLIb1Xf9OzsdbM7Cr4t7m0qJJhzPIm8lmjDvW70u-I3SIO0/s640/Cycle+of+no+change.png" width="640" /></a></div>
<br />Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com1tag:blogger.com,1999:blog-8154170016308023512.post-55777379415166010012016-01-13T08:26:00.003-08:002016-01-13T09:49:54.285-08:00Don't wanna die before I get oldPublic health types love producing those maps of city transport systems where the life expectancy of people living in Swankyburbdon is vastly better than that of people in Grotshawe just 4 stops along the rapid transport line.<br />
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So, here's my equivalent map for median age of death for people with learning disabilities, in a nutshell. You're welcome.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJi70x7cZE3jj6tDSTP__nchOXN4-wx1MJgNC2xaQgV1NbKo6lII5borbATK_1QcoUF2HgyUMVYyCU_1Q9Ik7e-n5ZlwQ30_tVVGYdxYjI7BorGSiwKVZGNCfidwVtbt2VLIEQnxSt55w/s1600/Median+age+of+death.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJi70x7cZE3jj6tDSTP__nchOXN4-wx1MJgNC2xaQgV1NbKo6lII5borbATK_1QcoUF2HgyUMVYyCU_1Q9Ik7e-n5ZlwQ30_tVVGYdxYjI7BorGSiwKVZGNCfidwVtbt2VLIEQnxSt55w/s640/Median+age+of+death.png" width="640" /></a></div>
<br />Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com4tag:blogger.com,1999:blog-8154170016308023512.post-10418424070044247982015-11-18T09:12:00.000-08:002015-11-18T09:12:25.066-08:00All-purpose statement<div class="MsoNormal">
Well, despite our best efforts this so-called review has been
stuck on the web somewhere [which one is this about? Oh, that one – OK – good
job we did that ‘sad face’ training eh?]. It’s really long and boring with
complicated tables and charts and stuff – not worth ploughing through, to be
honest. We’ve done our own easy-read though cos we’re so down with the kids
[what? It’s not teenagers?], cos we’re in a co-dependent – no – co-producifying
relationship with our <s>meal ticket</s> –
patients [no, they’re not patients any more? What the actual?] service
user-type types. Here it is – just look at that instead.<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEidnxw-ugilf9eTjYrFQmiRFTkTzSjM9qrLdc9y6cQWumbw6bSjdIEgutd5D26MtXEsr_12YfzLc0nSCzX9pXwhwuX5AXuhA5xxg0ISrnmOBGgHY_FIOWFPdPr5lAZV2kg1lqrbdm78jrk/s1600/Smiley.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEidnxw-ugilf9eTjYrFQmiRFTkTzSjM9qrLdc9y6cQWumbw6bSjdIEgutd5D26MtXEsr_12YfzLc0nSCzX9pXwhwuX5AXuhA5xxg0ISrnmOBGgHY_FIOWFPdPr5lAZV2kg1lqrbdm78jrk/s1600/Smiley.jpg" /></a></div>
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<div class="MsoNormal">
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<div class="MsoNormal">
We’re so not bothered about this bollocks [oh, sad face now?].
We’re absolutely gutted that this review was commissioned in the first place
and has seen the light of day. Families, supporters and shit can just do one
[what now?], move on somewhere else far, far away please, and stop bugging me.
We’ve had some lunches with actual, y’know, important people and they couldn’t
give a toss, so I don’t need to press the emergency golden parachute button. Shame
in a way, part of me was looking forward to that management consultancy
contract and getting away from all these badly-dressed people [focus? What do
you mean?].<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
[Lessons bit now, right?] We’ve learned so many lessons from
this review. In fact, we’re so amazeballs that we learned the lessons before
the, erm, <s>fuck-up</s> <s>incident</s> <s>strategy</s> event
actually happened, so we’ve totally changed while staying the same excellent
service we’ve always been [does this statement sound right to you? Seems a bit
off somehow?]. It’s all my responsibility that I feel with great indifference,
but when it comes down to it it’s all your fault, and I’m feeling really quite
upset that you’ve been so horrid as to question anything I’ve ever done about
anything because it’s really cut into my awards dinners.<o:p></o:p></div>
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<br /></div>
<br />
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I’ll say off, and you put any word you like in front of it
[no, I’m not talking to any effing journalists]<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com5tag:blogger.com,1999:blog-8154170016308023512.post-14647172944638432212015-10-21T06:09:00.002-07:002015-10-21T06:09:20.311-07:00Verita 2: A little less than the truth<div class="MsoNormal">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJ6Oyv0tfbtyVzzjVla4Q6Lisp6ZhRTqiicgeMspusltX3VqoKfvKkobh-tP1GCrToxOAzx23QGw9H6XLH5E7XyLUNSlWKHBQ_VOkT1lo5whOtGZ9jtArmqUAmNTmAg74V2Cqzkw92UMs/s1600/Veritas+stained+glass.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJ6Oyv0tfbtyVzzjVla4Q6Lisp6ZhRTqiicgeMspusltX3VqoKfvKkobh-tP1GCrToxOAzx23QGw9H6XLH5E7XyLUNSlWKHBQ_VOkT1lo5whOtGZ9jtArmqUAmNTmAg74V2Cqzkw92UMs/s1600/Veritas+stained+glass.jpg" /></a></div>
<br />
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>And the end shall be
the beginning…<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
OK, let’s start with the conclusion. Why? Because I suspect
this is what the entire 263 page (including 14 appendices) Verita report of their
“independent review into issues that may have contributed to the preventable
death of Connor Sparrowhawk” is really about (see here for links to the full
report and an easy read summary <a href="http://www.england.nhs.uk/publications/invest-reports/#connsparr">http://www.england.nhs.uk/publications/invest-reports/#connsparr</a>
). The longer and more ‘thorough’ the report, the more likely most people will
be to turn straight to the conclusions and not read the rest. The conclusions,
of course, will no doubt shortly be cited in a Southern Health press release,
alongside some passive-aggressive statements about how this has been a very
distressing and distracting experience for the staff involved, how they will
study the report carefully and learn the lessons for when they ‘absorb’ their
next shockingly bad Trust to inculcate in the modern way, and how everyone can
now Vanguard along, nothing to see here.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The three conclusions in the full report, which I predict
will be front and centre of the Southern Health press release, are as follows:<o:p></o:p></div>
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<i><br /></i></div>
<div class="MsoNoSpacing">
<i>6.70. There is no
evidence that acts or omissions of commissioners contributed to the inadequate
care received by Connor that led to his preventable death. We set out our
rationale for this in our overall conclusion.
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>6.71. Quality
reviews carried out before the acquisition or at the point of acquisition did
not find that STATT had acute clinical, managerial or systems failures. In
contrast, concerns were focused on the non-Oxfordshire part of the former
Ridgeway services where patient safety risks had been identified.<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>6.72. An over
reliance on a ‘business as usual’ approach to this acquisition was not
appropriate. Southern Health should have ensured that any deterioration in the
quality of services could be identified quickly and through processes that
Southern Health could place their confidence in. <o:p></o:p></i></div>
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<br /></div>
<div class="MsoNormal">
So, what evidence is contained within the Verita report that
leads the authors to these conclusions? <o:p></o:p></div>
<div class="MsoNormal">
The authors are at great pains to point out the rigour of
their investigation (57 interviews! Including an interview with Sir Stephen
Bubb! [why???] Stakeholder and focus groups! Over 250 documents, 8,000 pages plus!)
and it has clearly been a major undertaking. It’s a bit of a shame that the
rigour this is intended to convey is undermined by widespread typos and errors
throughout. We also know that in Southern Health crucial documents tend to go
missing or are ‘incomplete’, until mysteriously ‘found’ at the last minute. It’s
also extraordinary that in this “independent” investigation, interviews with many
Southern Health personnel (apparently at their request) were conducted with the
Trust’s lawyer present on the following (to me, chilling) terms:<o:p></o:p></div>
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<i><br /></i></div>
<div class="MsoNoSpacing">
<i>“The solicitor is instructed by the trust
and will be attending the interviews (where requested by staff) in her role as
legal adviser to the trust. In this role, she will be supporting and advising
the interviewees through the interview. If the interviewees so wish, she will
be reviewing and commenting upon any transcripts produced and she will be
taking notes of the interviews. Any notes that she makes may be shared with the
trust. If she is sent any interview transcripts, by Verita or the interviewees,
she will share these and any other comments upon them with the trust. The
interviewees who have asked to be supported in this way are fully aware of the
above points and are in agreement with them.”<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This might be one reason why this report has no redactions –
a welcome improvement in transparency or a sign that everything has been
squared off to Southern Health’s satisfaction?<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
<b>The ‘acquisition’<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What was this Verita review supposed to be investigating?
Here’s the terms of reference in the executive summary:<o:p></o:p></div>
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<i><br /></i></div>
<div class="MsoNoSpacing">
<i>6.1. The scope of
the investigation as laid out in the terms of reference was to:<o:p></o:p></i></div>
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<br /></div>
<div class="MsoNoSpacing">
<i>“Identify
whether there were
any wider system
aspects [commissioning, leadership, management arrangements] that <b>contributed to the
preventable death of Connor </b>[our emphasis].”<o:p></o:p></i></div>
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<br /></div>
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<i>“Review whether, prior to Connor’s death, the local
authority, Clinical Commissioning Group and/or Southern Health NHS Foundation
Trust were aware of:<o:p></o:p></i></div>
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</span></span><!--[endif]--><i>any quality, safety or delivery concerns in
respect of the Short Term Assessment and Treatment Unit</i><i><o:p></o:p></i></div>
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</span></span><!--[endif]--><i>the broader learning disability provision and</i><i><o:p></o:p></i></div>
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</span></span><!--[endif]--><i>to consider whether appropriate action was
taken to address any concerns.”</i><i><o:p></o:p></i></div>
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The report tends to ask questions in roughly chronological
order, starting with: <i>What did Southern
Health and their commissioners know about the quality and safety of services in
STATT before the acquisition?</i><b><o:p></o:p></b></div>
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<br /></div>
<div class="MsoNormal">
My reading of the evidence from commissioners at the time is
pretty damning. They knew that Ridgeway wasn’t great and that it was going
downhill. The chaos of the Health and Social Care Act meant wholesale changes to
health commissioning, and a determination to offload Ridgeway (too small to
become a ‘Foundation’ NHS Trust on its own) on to an ‘absorbing’ Foundation
Trust (see <a href="http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-absorption-of-ridgeway.html">http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-absorption-of-ridgeway.html</a>
). <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
In a weird variant of the “You shouldn’t blog because
transparency makes us panic” logic used against @sarasiobhan, the Verita report
argues that the Winterbourne View expose made commissioners narrow their focus
to parts of the Ridgeway service where they were worried about potential abuse
happening, so forgetting about more mundane bad practice in Oxford:<o:p></o:p></div>
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<i><br /></i></div>
<div class="MsoNoSpacing">
<i>6.24. The
Winterbourne View exposé focused attention on the abuse that had happened there
and on restraint in particular. From Oxfordshire’s point of view, commissioners
had concerns about services in Wiltshire and Buckinghamshire, some of which
related to restraint. Their attention was naturally focused there. By contrast,
Oxfordshire services had experienced fewer incidents so they received less
attention.<o:p></o:p></i></div>
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<br /></div>
<div class="MsoNoSpacing">
<i>6.26. Concerns
about the quality of Ridgeway services tended to relate to those outside
Oxfordshire. Commissioners thought that services in Oxfordshire needed less
attention, although they were acknowledged as being old-fashioned and reliant
on a bed-based model of assessment and treatment. <o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
[Aside: note the rhetorical work being done by ‘naturally’
in 6.24]. So, before the ‘acquisition’ Oxfordshire County Council and health commissioners
knew that the Oxfordshire service was less than great and had an arrogant,
defensive culture, but it wasn’t actively abusive enough for them to do anything
about it. An inspid review in late 2012 (with no health professionals in the
team) and an ‘informal’ 45-minute visit in 2013 (the result of which was Oxfordshire
County Council commenting on the state of the décor in STATT) was the extent of
quality monitoring and action. Er – what are commissioners <i>for</i>?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The executive summary of the Verita report then goes on to
state:<o:p></o:p></div>
<div class="MsoNoSpacing">
<i><br /></i></div>
<div class="MsoNoSpacing">
<i>6.27. As will be
seen in the main body of the report Southern Health had a well thought out
strategy for preparing for the acquisition which from our review of the available
evidence was carried out effectively. This included a wide range of
communication processes and as seen below quality and safety reviews. <o:p></o:p></i></div>
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<br /></div>
<div class="MsoNormal">
To my mind, the ‘evidence’ to underpin this seems mainly to
be Katrina Percy impressing the acquisition panel with general shininess and corporate
bullshit to tell the acquisition panel what they wanted to hear [another aside –
what does the fact that the Calderstones bid was rejected say about that service?].
Some of the evidence cited in the report (the NHS Confederation ‘case study’ of
the acquisition) has been taken off the NHS Confederation website, and an
internal review of Southern Health’s due diligence process noted how it wasn’t
conducted properly (see <a href="http://dataforlb.blogspot.co.uk/2015/08/diligence-negligence.html">http://dataforlb.blogspot.co.uk/2015/08/diligence-negligence.html</a>
). And again, there is strong evidence of commissioners abrogating their
responsibility in their expressed ‘relief’ that Southern Health were going to
come in and ‘sort it all out’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>What did Southern
Health know about the quality of Ridgeway services before the acquisition?<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Well, it turns out they should have known quite a lot. There
were multiple reports on the Ridgeway service related to the due diligence
process Southern Health was doing – most of them financial, but some of them,
given what we now know from the inquest, heartbreaking.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For example, in May 2012 (almost a year before Connor
entered STATT), Ridgeway staff conducted a review of their electronic records
using the RiO system. The Verita report summarises:<o:p></o:p></div>
<div class="MsoNoSpacing">
<i>11.26. The review found
inadequate completion of electronic risk assessment entries and said staff needed
to be trained on how to move from paper records to putting data into the RiO
system. It also recommended developing risk assessments on RiO and other record
keeping issues. <o:p></o:p></i></div>
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So Southern Health knew about this, and it is clear from the
inquest that they did absolutely nothing about it.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Contract Consulting reported in September 2012 on a review
done for the then Strategic Health Authority (dissolved in March 2013) on
quality and governance in Ridgeway. Some lowlights from this review included:<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt; mso-layout-grid-align: none; text-autospace: none;">
<i>“There appears to
have been culture within OLDT that could best be characterised as a combination
of defensiveness and complacency in respect of quality, safety and risk.”<o:p></o:p></i></div>
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<i><br /></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“Some we spoke to indicated that there is a disconnect between senior
leaders within OLDT and the staff delivering or managing the services in terms
of the understanding of quality issues and the assurance that actions needed
have been taken and are fully implemented.”<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Big, honking, warning klaxons for Southern Health.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Good job they’ve got their much-trumpeted mock CQC
inspection system then. One of these was conducted by Southern Health on STATT
in August 2012 (I’m sure the diagnostic radiographer was particularly helpful),
which concluded that everything was basically tickety-boo, with the exception
that:<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“Care plans, risk assessments and treatment plans did not match up; not
all plans were reviewed on the agreed four weekly basis.”<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Again, a crucial issue in the inquest, which Southern Health’s
own quality processes had flagged, specifically for STATT, 7 months before
Connor arrived.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There was also one of the famed matron walk-arounds, done by
Southern Health staffer John Stagg as part of a broader quality and safety
review of Ridgeway written in November 2012. Again, pretty much tickety-boo as
far as specific mentions of STATT are concerned. However, the quality and safety
report, which summarised across Ridgeway services as a whole (and therefore
should be taken to apply to all Ridgeway services, including STATT) are
prophetic in identifying crucial issues relating to Connor’s death. Narrative
conclusions and recommendations are in the Verita report as Appendix I and
Appendix J. I quote these conclusions extensively because they <i>exactly</i> predict the findings of the
inquest – they also predict the findings of the CQC inspection of STATT 2
months after Connor died. Southern Health knew – they knew, and they did
nothing:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
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</span></span><!--[endif]--><i>1. Record
Keeping: Both electronic and secondary
paper file records require to be up to date and matched against risk assessment
and care plans. It was difficult to
ascertain other professional assessments and intervention and there was a lack
of joined up MDT working evident within risk assessments and care plans. The transfer from paper to electronic records
is reported by staff to be difficult and in some areas lacks appropriate
support.</i><i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
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</span></span><!--[endif]--><i>2. Multidisciplinary
Working: There was a lack of evidence to
support adequately integrated MDT/ multi-professional or multi agency care
plans, particularly within community settings.
</i><i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>3. Risk
Assessment & Risk Management: The
overall MDT approach to clinical risk assessment and risk management was poorly
evidenced in some areas. In in-patients
this seemed to be led by nursing staff and in the community risk assessment and
management was very limited indicating a potential lack of adequate risk
management of high risk patients within the community. This was due to poor evidence within
electronic records and a lack of access to secondary files and other
professional/ clinical records. Within
in-patients there was evidence of good risk assessment in some areas, but for
some patients there was a lack of consistent record keeping. There was a common failure to match the
electronic record to the secondary paper file so that the electronic record at
times lacked the detail contained within paper records. The risk assessments did not always evidence
the clinical assessments which would inform risk and risk management.</i><i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
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</span></span><!--[endif]--><i>5. Physical
Health Monitoring: There was evidence of
good practice in some areas where the Health Action Plan (HAP) had been
extended to include more complex health needs…The lack of physical health care
plans could lead to potential risk and where this occurred.</i><i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>7. Clinical
Pathways/ Evidence Base: There was limited
evidence of joined up MDT working which reflected a clinical pathway or
clinical map which identified clinical outcomes to measure assessment and
treatment particularly within community settings. Although in-patient services
followed the ‘in-patient pathway’, it was difficult to ascertain the ‘tool box’
of assessment and treatment processes available to patients according to their
needs and the approach taken by professionals and the team. For example, a patient
with epilepsy did not have a care plan which stemmed from a comprehensive
epilepsy profile which detailed seizures, risks, affect and effect of
medication, the aims for the nurses and the patient in providing care. Expected
outcomes for the patient were unclear so could not be measured/ evaluated.<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
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</span></span><!--[endif]--><i>9. Clinical
Supervision & Management Supervision:
There was evidence that identifies that both types of supervision are
limited due to frequency, regularity, recording and staff training. There were no other methods of clinical
supervision identified other than where a psychologist would be made available
for group supervision following an incident.
Staff reported a lack of reflective supervisory methods and there seemed
to be a reliance on management supervision alone.<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>10. Mental
Health Act/ Mental Health Care: There
was evidence that the MHA is not implemented consistently across all services
in relation to policy for locked doors, policy for observation, policy for
Section 17 leave arrangements (monitoring, recording and signing patients out
for leave and on return from leave). </i><i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>11. Environment: Maintenance in relation to a safe environment
was an issue in some areas but also in relation to ligature assessment and
management. Ligature assessment and
management policy has not been consistently applied across services.</i><i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>12. Medical
Devices: There was inconsistent
management of medical devices in terms of on-site inventory, monitoring,
calibration and maintenance.<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>14. Learning
Out of Concerns: This is an area
reported by staff, some of whom felt that they were not informed of outcomes
from investigations including the learning from disciplinary
investigations. Changes in practice were
not felt to always impact at the staff/ ward level. There was also commentary that staff felt
changes in practice e.g. changes to shift patterns to accommodate breaks (a
positive change) was not evaluated in terms of overall impact e.g. the time
period for hand over and staff meetings.
<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
An update of this report by John Stagg in 31 May 2013 was
based on information from local managers – yes, these would be the local
managers that Southern Health had already been warned about in terms of a
culture of arrogance and defensiveness – concluded:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“Overall this report provides assurance and information that the quality
factors identified within the Ridgeway Partnership (Oxfordshire Learning
Disability NHS Trust) have been or are being addressed effectively.”<o:p></o:p></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i><br /></i></div>
<div class="MsoNormal">
That must be because Southern Health swept in with their
modern ways, viral leadership and finely wrought action plans to sort it all
out, yes?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>What did Southern
Health do?<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There’s a short answer and a long answer (no surprise there,
then). Short answer: fuck all – Southern Health took the money and left
Ridgeway to rot (see my take on this here <a href="http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-part-2-shrinking-estate.html">http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-part-2-shrinking-estate.html</a>
). <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The long answer goes something like this...<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The two main people in Southern Health responsible for the management
of the acquisition, and who were expected to lead the former Ridgeway services
after acquisition, scarpered in early 2013 (indeed, they told senior people in
Southern Health in 2012 that they didn’t want the jobs). The fact that one of
them couldn’t drive didn’t help visibility in the former Ridgeway service.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Southern Health dispensed with the services of their ‘interim
transition director’.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
The new post-acquisition director of the merged learning
disability services didn’t have any experience of services for people with
learning disabilities.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
According to commissioners, after the point of
acquisition, Southern Health stopped talking to them <i>“It felt as if, they won the
bid, they got their contracts, they started in November and then they sort of
disappeared.” </i>An email to
Katrina Percy from a commissioner in February 2013 (a month before Connor
entered STATT) stated:<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“We heard over a week ago that
Amy Hobson has left her post as director for learning disability at Southern
Health, but as yet have received no communication from Southern Health to us as
commissioners, nor to Lucy Butler as joint manager of the Community Teams
service manager.”<o:p></o:p></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i><br /></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“Since the acquisition of
Ridgeway Partnership by Southern Health we have had no contact from senior
managers at Southern Health, have had difficulty arranging meetings with Amy,
and when we succeeded she was unable to attend on the day. My last 2 emails to
Amy remain unanswered. As you are aware from the acquisition process, it is
very important to us to establish a productive relationship and dialogue with
our providers in order to maximise the benefits for our service users from the
contracts we manage. Our impression of Southern Health throughout the
acquisition process was that we could expect to establish a productive
partnership and our experience so far has been very disappointing.”<o:p></o:p></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i><br /></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“Please could you let us know
formally who is now managing the learning disability services that we
commission so that we can arrange to meet with them as soon as possible to
discuss our concerns?”<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
According to Katrina Percy, Southern Health were held up
in doing anything because the commissioners didn’t tell Southern Health what they
wanted. Katrina Percy also “<i>doesn’t
actually do my own emails</i>”.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
Up to April 2013, the ever-changing Southern Health staff
were busy working on a ‘business plan’ which included ‘saving’ at least £1.7
million from Ridgeway’s costs [why this planning wasn’t done before acquisition
is beyond me, but anyway…]. While they were doing this (and not bothering to
talk to the former Ridgeway staff, according to them) Southern Health adopted a
‘business as usual’ approach – as far as I can tell, this seemed to involve
Southern Health treating the former Ridgeway service as if it had always been a
branch of Southern Health and leaving the staff to magically acquire all
Southern Health’s ‘modern ways’ without any assessment of what staff needed,
any training, or any plan to help them.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“As has been explained in a number of interviews, upon the date of
acquisition, Southern Health took the decision to operate the entirety of the learning
disability division services (including the former Ridgeway services) on a
‘business as usual’ basis; i.e. to encourage integration, the acquired services
were treated the same as all of the other services in Southern Health’s
existing learning disability division.”<o:p></o:p></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i><br /></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“This means that those services formed part of the learning disability
division’s ordinary assurance processes to monitor quality, safety and
performance – i.e. there were no extraordinary measures put in place to monitor
the quality and safety of the former-Ridgeway services.”<o:p></o:p></i></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i><br /></i></div>
<div class="MsoNoSpacing">
As Sue Harriman, the acting CEO for Southern Health at
the time (Katrina Percy was on maternity leave) says below, Southern Health
apparently forgot that former Ridgeway staff were people: <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<i>“I think some of it was around
the people part, the softer part, the bit that makes a registered practitioner
fill in a form and to say ‘Is everything is okay?’, ‘Okay,’ when it is not
okay. That bit we had really missed
somewhere in the mix, that this was a group of people who, clearly, felt or
were behaving as if they were totally disenfranchised.”<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
The business plan was launched at Newbury Racecourse
(obviously) in April 2013, when Connor was already on the STATT unit, and it
looks (and looked to the Ridgeway staff) like a wholesale cost-cutting
exercise, with swathes of posts disappearing. Apparently staff weren’t consulted
in advance. The post-acquisition management of Southern Health services was a complete
mess.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b><i>On July 4<sup>th</sup>, 2013, Connor
Sparrowhawk died.<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<b><i><br /></i></b></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiblbeTT7M_PAD1IVQNCYYPwHbaipB2qbc73A_993ji7JiMuCu3U3U1-2CGRMacoqPcvAud4lBWvIvtD9GmJp_tQ1V1_ymxG8N6QYfE-je1jTuOlB0RAtruGvmvZFJaJNQbwbdFYRts23Q/s1600/lb_dude.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiblbeTT7M_PAD1IVQNCYYPwHbaipB2qbc73A_993ji7JiMuCu3U3U1-2CGRMacoqPcvAud4lBWvIvtD9GmJp_tQ1V1_ymxG8N6QYfE-je1jTuOlB0RAtruGvmvZFJaJNQbwbdFYRts23Q/s320/lb_dude.jpg" width="320" /></a></div>
<div class="MsoNoSpacing">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
After a damning CQC report of STATT in September, an
internal review identified problems with the STATT unit that had been obvious
to Southern Health before acquisition and that they had done nothing about:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>Culture<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 54.0pt; mso-list: l3 level2 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><i>The practice of moving senior staff when
problems arose did not assist in maintaining safe, quality services in the
former Ridgeway Partnership. A number of the issues were significantly
stressful and demanding to deal with. SHFT may not have realised the degree of
strain amongst its new senior management team. <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 54.0pt; mso-list: l3 level2 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><i>Senior managers worked hard however their
increasing range of responsibilities led to a reduced level of support and
leadership notably on STATT and JSH.<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 54.0pt; mso-list: l3 level2 lfo4; text-indent: -18.0pt;">
<i><br /></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>Transaction
and post transaction <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level2 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>The lack
of robust local management support for STATT and JSH appears to have continued
since transaction occurred, despite various quality initiatives led by others
not in a direct line management relationship with the ward manager…<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level2 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>The
governance arrangements which prevailed post transaction did not readily enable
communication and a change in culture due to the top down approach, and
apparent lack of empowerment for front line staff. A good example of where the
disconnect became apparent during the investigation was with regards the post
transaction process of review and amalgamation of policies.<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
Yet another internal investigation of management can
perhaps best be summarised in this one line:<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 38.4pt; mso-list: l2 level1 lfo5; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>The
evidence gives the impression of complete chaos leaving staff feeling uncertain
and distressed.<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Responsibility?<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There is much more in the Verita report, but for the
purposes of this blog I want to stop there. This has been a bit of a trawl
through (part of) the evidence, but I thought it was important to do this for
me to see what conclusions I would come to, based on the evidence presented.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The Verita report has this brief discussion that, for me,
gets to the heart of the matter in terms of responsibility for Connor’s death:<o:p></o:p></div>
<div class="MsoNoSpacing">
<i><br /></i></div>
<div class="MsoNoSpacing">
<i>4.8. A quote from
the executive summary of Sir Robert Francis’ report on Mid Stafford Hospital
(which looked at the causes of the failings in care at the hospital between
2005-2009) gives guidance on one aspect of evaluating evidence relevant to this
test:<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>“There is … a
difference between a judgement which is hindered by understandable ignorance of
particular information and a judgement clouded or hindered by a failure to
accord an appropriate weight to facts which were known.” (Paragraph 70) <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>4.9. This insight leads
us to consider:<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l5 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>whether
commissioners and Southern Health failed to seek out information that they
should have known or needed to know to provide a safe service; and<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="margin-left: 18.0pt; mso-list: l5 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><i>whether
commissioners and Southern Health had information that they failed to act on.<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To me, the evidence is overwhelming that:<o:p></o:p></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo6; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->Commissioners knew throughout there were serious
problems with the Ridgeway Trust, and fobbed off their responsibilities on to Southern
Health as quickly as they could.<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo6; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->Well before they ‘acquired’ Ridgeway, Southern
Health knew exactly what the problems were, to the extent that they virtually
predicted the issues contributing to Connor’s death set out by the inquest
jury.<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo6; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->After acquisition, Southern Health left former
Ridgeway staff to fend for themselves, while threatening their jobs and not ‘leading’
(hey, there’s a word) or managing any part of the former Ridgeway service
effectively.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To my naïve brain, it is clear that, using the Francis test,
the actions (and inactions) of both commissioners and Southern Health were
contributory causes of Connor’s death.<o:p></o:p></div>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Throughout the Verita 1 investigation and the inquest, it
has been painfully clear that Southern Health’s strategy has been to pin all
the responsibility for Connor’s death on to the staff working on the STATT unit.
In this context (and bearing in mind that Verita have ‘form’ when it comes to
conducting independent investigations for Southern Health’s precursor which pin
the responsibility for shocking failures squarely on staff, as in this report
on Fordingbridge Hospital in 2008 <a href="http://www.dailyecho.co.uk/resources/files/7412">http://www.dailyecho.co.uk/resources/files/7412</a>
), it’s hard for me to see this Verita 2 report as anything other than a
continuation of the same strategy. I cannot reconcile in my head the evidence contained
in this report and the conclusions it reaches – short of finding video evidence
of Katrina Percy stalking the corridors of STATT with a piece of lead piping I
doubt that any evidence would have been sufficient to make Verita reach a
different conclusion.<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com8tag:blogger.com,1999:blog-8154170016308023512.post-18324341373661476972015-09-21T14:09:00.004-07:002015-09-21T14:09:41.640-07:00Incidental?<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
How can ordinary punters hold public organisations to
account? In the (possibly fleeting) age of the Freedom of Information Act, and
in the more durable age of the internet, the possibilities for finding out
about our public organisations have in some ways radically improved. However, this
new age brings at least two problems. The first is knowing where to look – the multiplication
and shape-shifting nature of public organisations makes hiding information in
plain sight quite easy. The second is trying to understand what the ‘publicly
available’ data actually mean – unless you’re an expert in how the data are
collected interpreting them can be really difficult.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My reason for mentioning these problems is that I’ve only
just remembered about an obscure (to me) national database of information about
the number and nature of ‘incidents’ reported by NHS Trusts. All NHS Trusts
have a duty to report monthly information on patient safety incidents to ‘Patient
Safety’ (now part of NHS England, up until 2012 the DH-funded National Patient
Safety Agency). Their website publishes six-monthly summaries of incidents
reported by NHS Trusts in England, with useful comparative information by Trust
type (e.g. Mental Health NHS Trusts, of which Southern Health is one of 55-57,
depending on the time period) – see here <a href="http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incident-reports/">http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incident-reports/</a>
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If Southern Health are going to make any claims about ‘lessons
learned’, then presumably this should show up in their incident reporting. This
is where the second problem comes up – interpreting incident data is really
difficult. This blogpost briefly summarises the information collected by
Patient Safety in six month chunks from October 2011 (when Southern Health
Trust officially came into existence) to September 2014. Interpretation,
especially when it comes to any ‘lesson learned’, is another matter.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>How many incidents?<o:p></o:p></b></div>
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<b><br /></b></div>
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First, Patient Safety report the total number of incidents
reported by the Trust in each six month period, and the number of incidents per
1,000 bed days (to take into account the size of the Trust) with a comparator
of information from across all mental health trusts. Surely having fewer incidents
is better, right? Well, the National Patient Safety Agency summaries have this
standard line “Organisations that report more incidents usually have a better
and more effective safety culture. You can't learn and improve if you don't
know what the problems are.”<o:p></o:p></div>
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<br /></div>
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The two graphs below show that the total number of incidents
reported by Southern Health Trust vary widely over the 3½ years, with numbers
reducing to Apr-Sept 2012 and rapidly increasing after that. Given the absorption
of Ridgeway in late 2012, an increase in the number of incidents would be
expected in the Oct 2012-March 2013 data, but it is not clear why there are
further increases after that.<o:p></o:p></div>
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<br /></div>
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Does this count as ‘learning lessons’ in terms of incident
reporting? Well, the second graph shows that the number of reported incidents
per 1,000 bed days was also dropping to Apr-Sept 2012, to a much lower level
than comparator mental health trusts. A temporary bump in Oct 2012-March 2013
was followed by a further reduction below comparator trusts throughout April
2013 to March 2014, with a sudden, dramatic increase in Apr-Sept 2014. If
lessons are being learned, they seem only to been learned relatively recently,
and the big fluctuations in incident reporting rates over time do not suggest
steady improvements in incident reporting.<o:p></o:p></div>
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<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>What types of
incident?<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Second, Patient Safety reports the types of incident
recorded by each NHS Trust. In interpreting this information, Patient Safety
state “If your reporting profile looks different from similar organisations,
this could reflect differences in reporting culture, the type of services
provided or patients cared for. It could also be pointing you to high risk
areas. The response system is more important than the reporting system.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The three graphs below report the three most common types of
incident for Southern Health; patient accidents; disruptive, aggressive
behaviour; and self-harming behaviour; with comparative information from all
mental health trusts combined.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Compared to all mental health trusts combined, from April
2012 through to March 2014 Southern Health consistently reported a much higher
proportion of patient accidents, with a sharp drop in April-September 2014.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The opposite is true for disruptive, aggressive behaviour, where
Southern Health consistently reported much lower proportions than comparator
mental health trusts until March 2014, with a sudden sharp increase to
comparative levels in April-September 2014.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
With some fluctuations, Southern Health reported higher
proportions of self-harming behaviour than comparator mental health trusts up
until September 2013 – after this levels are similar to comparator trusts.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As with total incident rates, the proportions of these types
of incident are consistently out of line compared to other mental health trusts
until April-September 2014, with wide fluctuations over time. <o:p></o:p></div>
<div class="MsoNormal">
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaIDWSuwdBArVe2sefK3M1s60dWUhA9Klco4chhJcxmjD-c_bxu9WW9uzt9GrhLwrjuxINVaFhalTmymaHxnsEWuuz8S7DMFz8ZNCt4Zak_NQqbxqDbfxtSwPMUcvFSzbZuZRWOK9BkqE/s1600/LB+blog+4.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaIDWSuwdBArVe2sefK3M1s60dWUhA9Klco4chhJcxmjD-c_bxu9WW9uzt9GrhLwrjuxINVaFhalTmymaHxnsEWuuz8S7DMFz8ZNCt4Zak_NQqbxqDbfxtSwPMUcvFSzbZuZRWOK9BkqE/s400/LB+blog+4.png" width="400" /></a></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgv5CxkouRaNVLpYD5oT5mUgcBwjjYks2QVfg-oEWoq_aeEdWbrXlmNVusR1mbeiSWA6CHOO2fyH4BzVN7w8CBswhsgF9Xoe424QOx6ccVJsDxewUH30cpXe4plNLr4Mn5NpUQ9LeonHvE/s1600/LB+blog+5.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgv5CxkouRaNVLpYD5oT5mUgcBwjjYks2QVfg-oEWoq_aeEdWbrXlmNVusR1mbeiSWA6CHOO2fyH4BzVN7w8CBswhsgF9Xoe424QOx6ccVJsDxewUH30cpXe4plNLr4Mn5NpUQ9LeonHvE/s400/LB+blog+5.png" width="400" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>How much harm do
incidents cause?<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Third, Patient Safety reports information on the level of
harm reported for each incident, from ‘None’ through to ‘Death’. Deaths of
patients do not necessarily have to be recorded as incidents. On harm, Patient
Safety states “Nationally, 68 per cent of incidents are reported as no harm,
and just under 1 per cent as severe harm or death. However, not all
organisations apply the national coding of degree of harm in a consistent way,
which can make comparison of harm profiles of organisations difficult.
Organisations should record actual harm to patients rather than potential
degree of harm.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The graph below shows the percentage of incidents reported
in each category of harm, for mental health trusts as a whole and for Southern
Health. The graph looks a bit complicated, but the main difference is that
incidents in Southern Health are consistently more likely to be reported as
causing ‘Moderate’ harm compared to other mental health trusts. There seem to be
no obvious differences over time.<o:p></o:p></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2WWAOrpnZmB-jLfi_aHTnCU_VQZn8dUCHjChyphenhyphenHRaRPkBHJN0pQFGC9hH5oWtw96sBO9bylO55R_DYnGtz9qD_h1DvJ0kj8uAuoTk5eOlKdmNkbrknMJ653CnnC2tgK7xHEVhi9Q58DLQ/s1600/LB+blog+6.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2WWAOrpnZmB-jLfi_aHTnCU_VQZn8dUCHjChyphenhyphenHRaRPkBHJN0pQFGC9hH5oWtw96sBO9bylO55R_DYnGtz9qD_h1DvJ0kj8uAuoTk5eOlKdmNkbrknMJ653CnnC2tgK7xHEVhi9Q58DLQ/s400/LB+blog+6.png" width="400" /></a></div>
<div class="MsoNormal">
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<div class="MsoNormal">
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<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The number of deaths reported as incidents by Southern
Health are in the graph below. A very low number of deaths reported as
incidents in April-September 2011 is followed by a huge increase in the number
of deaths reported as incidents in October 2011-March 2012, then the number of
deaths reported as incidents successively drops to a very low level again by
October 2013-March 2014. I do not know the total number of deaths occurring
across Southern Health services, so I cannot say whether there are fewer deaths
overall or whether smaller proportions of patient deaths are being reported as
incidents over time.</div>
<br /><div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZM8Tc-kdfr64QbacFaKqhhLcIYQERsVzxCWm-zC493e38MX9zN3otSlUW4M7mV7PbCRzz-6yn5ETY_cSmPWaKeO3ndVr2w3oCkHAtGc1LUXxaVPLx1DaXNj2XCx4n46hKtrLcYZaQcgk/s1600/LB+blog+7.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZM8Tc-kdfr64QbacFaKqhhLcIYQERsVzxCWm-zC493e38MX9zN3otSlUW4M7mV7PbCRzz-6yn5ETY_cSmPWaKeO3ndVr2w3oCkHAtGc1LUXxaVPLx1DaXNj2XCx4n46hKtrLcYZaQcgk/s400/LB+blog+7.png" width="400" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>How quickly are
incidents reported?<o:p></o:p></b></div>
<div class="MsoNormal">
Finally, Patient Safety set great store by the fast
reporting of incidents: “Report serious incidents quickly: It is vital that
staff report serious safety risks promptly both locally and to the NRLS, so
that lessons can be learned and action taken to prevent harm to others.”
Patient Safety report the median length of time in days that it has taken each
organisation to report an incident.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The graph below shows the median number of days it took
Southern Health and comparator mental health trusts to report incidents.
Compared to other mental health trusts, from April 2011 to September 2012
Southern Health were much quicker to report incidents than mental health trusts
generally, but from April 2013 onwards they have been much slower.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjI-8IjIOzSuvilrdUMXo3HcQR6W20Ze72-HtUz80dwCniqCR19QcyiCl3DF5hS6sTfm91WsPFJ09XSwXwVsZpI1YKDOg2zcoNhf50kQMNkPuEGTa5AkdfnE62KBGB8n_G9gV5Ed2uJCEM/s1600/LB+blog+8.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjI-8IjIOzSuvilrdUMXo3HcQR6W20Ze72-HtUz80dwCniqCR19QcyiCl3DF5hS6sTfm91WsPFJ09XSwXwVsZpI1YKDOg2zcoNhf50kQMNkPuEGTa5AkdfnE62KBGB8n_G9gV5Ed2uJCEM/s400/LB+blog+8.png" width="400" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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<b>What does it all
mean?<o:p></o:p></b></div>
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<b><br /></b></div>
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I’m not an expert in patient safety incident reporting, so I
can’t produce an informed interpretation of this information. For rates and
types of incident reported, it looks like there are pretty consistent
differences between Southern Health’s patterns of incident reporting and those
of other mental health trusts up to April 2014 – rather a time lag to be
claiming to have ‘learned lessons’ from Connor’s preventable death (originally
categorised by the trust as due to ‘natural causes’, let us remember). Given
recent increases in the total number and rates of incidents reported, it’s unclear
to me why the number of deaths reported as incidents should have been
decreasing over the same time period. If lessons have been learned about
incident reporting, it is also unclear to me why it should still be taking so
long to report incidents. Another case of publicly available statistics concealing
as much as they reveal?<o:p></o:p></div>
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Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com1tag:blogger.com,1999:blog-8154170016308023512.post-59567354553741859552015-08-11T09:41:00.000-07:002015-08-11T09:42:12.676-07:00Diligence My Arse<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiib3PgSQ8ZrZ2z9NQycuZDfx6biqWH5o5YM2iHWByB_4j5tH2YYvE1gooEZYvK_RVaD5W6lpcGWPNf1Tp8feTvI8-mXqMuuA96kXz-mTl6Q1XXZ0HYWGE2lx1qZfYISuTin3jxVOGhwRI/s1600/013.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiib3PgSQ8ZrZ2z9NQycuZDfx6biqWH5o5YM2iHWByB_4j5tH2YYvE1gooEZYvK_RVaD5W6lpcGWPNf1Tp8feTvI8-mXqMuuA96kXz-mTl6Q1XXZ0HYWGE2lx1qZfYISuTin3jxVOGhwRI/s320/013.JPG" width="320" /></a></div>
<br />
<br />
I've been ruminating on @sarasiobhan's devastating latest news from the police that they are dropping their case of corporate manslaughter on the grounds that Southern Health's negligence has been insufficiently 'gross' (https://mydaftlife.wordpress.com/2015/08/11/true-detectives-injustice-and-the-law/ ).<br />
<br />
One thing among the multitude of crappery that keeps nagging away at me is the due diligence process that Southern Health must have done before they 'acquired' the former Ridgeway Trust. Either this due diligence process unearthed the potential awfulness waiting to happen and they did woefully little about this, or the due diligence was so incompetent that it didn't pick this up.<br />
<br />
[As an aside, the following quotes are from Board papers very soon after the 'absorption' of Ridgeway: see http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-part-2-shrinking-estate.html<br />
<br />
<br />
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“The division is also working closely with corporate services to ensure alignment of business plans e.g. an estates strategy will be developed that will support operational delivery. It is fair that there are both opportunities and challenges in relation to this, particularly on the Slade site in Oxford.” (COO Report, Divisional Update, 28 March 2013)."<o:p></o:p></div>
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<span style="font-size: 13.1999998092651px; line-height: 18.4799995422363px;">“There are also some challenges in relation to the condition of some of the estate, particularly on the Slade site where buildings are now of an age that they need significant refurbishment. The Division will work closely with other Divisions to ensure that joint decisions and priorities are both understood and agreed” (COO Report, Divisional Update, 23 April 2013 - copied and repeated in the 29 May and 23 July 2013 Board papers)."</span></div>
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<o:p></o:p></div>
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End of aside]</div>
<br />
I don't know who it is, but some excellent dude has already done a Freedom of Information request about the due diligence process in the acquisition of Ridgeway. If you go to the Southern Health disclosure log here http://www.southernhealth.nhs.uk/foi/disclosure-log/ and search for FOI615 you will find their response to the FoI request.<br />
<br />
I know my blogs generally invoke nausea, but in a literal rather than OMG sense I'm feeling pretty sick right now. KMPG (twice), Deloittes and an 'in house' team all did elements of this 'due diligence', and there must have been concerns about how it was done as PWC were then commissioned to do a review of the due diligence that was conducted.<br />
<br />
Except for the last sentence, the rest of this post is verbatim from the FOI response, summarising the findings of the PWC review, with sections highlighted that I think are particularly relevant.<br />
<br />
<br />
Findings<br />
<br />
Some initial due diligence was performed in December 2011 by KPMG and, following
the announcement of the Trust as the preferred bidder in March 2012, more
detailed due diligence was performed by KPMG, Deloitte and an in house specialist
Learning Disabilities team. A number of reports were considered by the Trust Board
in May and June 2012 and at other times throughout the period covered by the
review.
KPMG was commissioned by the Trust to provide financial, legal, estates and
workforce due diligence with Deloitte being commissioned to provide a high level
assessment against Monitor’s Quality Governance Framework. <b>In addition, the
Trust’s in-house team also undertook some due diligence procedures at Ridgeway
which, although these did not directly correspond to the requirements as set out in
the manual, consisted of ‘a review to provide assurance relating to quality, safety
and engagement.’ </b><br />
<br />
<b>Since some of the due diligence process took place more than two years ago, a
number of members of staff who were heavily involved in the transaction have left
the Trust</b>. <b>The level of staff change, combined with incomplete central retention of
documents by the Trust, made it difficult to establish a complete picture of events
that occurred during the period covered by the review. </b><br />
<br />
There were 4 main findings from the review summarised below:<br />
<br />
1. <b>There were comprehensive project plans in place for the transaction,
including due diligence, but these were not clearly linked through to the
3
certification that the Board made to Monitor.
</b>The Trust provided the reviewers with a number of documents which
together formed an overall project plan for the transaction, including the due
diligence requirements, governance and timetable. <b>The review of Board
minutes did not find evidence that the plans went, in aggregate, to the Board
for approval</b>, but it was understood from interviews with Board members
that they felt fully informed in relation to the transaction governance, due
diligence and timetable.
The Trust mobilised nine individual project work streams to deliver the
transaction and each work stream had its own set of project plans and action
logs.
The work stream leads met on a weekly basis to discuss progress and there
were monthly programme Board meetings. The Trust’s Investment
Committee undertook detailed scrutiny of the transaction in the year leading
up to the transaction date and made recommendations to the Board. A high
level milestone plan was presented to the Board at its monthly meetings to
summarise progress to date and matters arising.
<b>It was noted that the work undertaken by Deloitte and KPMG covered many
of the areas of the indicative scopes included in the Manual, but it was not
clear whether the Trust had consciously decided that other elements were
not necessary given the scale and nature of the transaction, or whether
commissioning of due diligence on these areas was omitted in error.</b>
In the course of interviews with staff and Board members the reviewers were
told that the Board was comfortable that sufficient work had been
undertaken for it to make the required certifications to Monitor, but <b>the
reviewers were not able to find written evidence within minutes and other
documents that clearly linked the project plan, the due diligence outputs and
the action plans to the certifications made by the Board to Monitor.</b><br />
<br />
2. <b>Some findings within the due diligence report, which were included in the
Trust’s subsequent action plans, also appear in the recent CQC report on
Slade House</b>.
<b>There were key themes within the Deloitte Quality Governance report and
the in-house Quality and Safety Review report that also appear in the CQC
report at Slade House</b>.
<b>These points were captured in the action plans that were prepared by the
Trust in response to the due diligence findings but the fact that these issues
continued to exist at the time of recent CQC inspection indicates that the
action plans were not sufficient to fully, and permanently, address the issues
identified</b>. It was noted that some of the actions, particularly around changes
to service models, may have taken a longer period of time to fully implement
than then interval between the transaction date and the CQC report, and
would have been dependent on commissioner agreement.
4<br />
<br />
3. <b>The implementation of actions identified in response to the due diligence
reviews were not monitored routinely by the Board after the transaction
date</b>.
An action plan developed post implementation was reported to the Trust’s
Quality Improvement and Development Forum in March 2013, five months
after acquisition. This was not presented to the Trust Board.
<b>A number of action plans address the findings of each of the pieces of due
diligence, but it was not clear how the implementation of these plans was
monitored after the transaction date and it is understood that changes in
Trust staff contributed to slippage in the implementation of actions</b>.<br />
<br />
4. <b>Board challenge and debate in relation to the transaction could have been
more thoroughly minuted.</b>
The most cited transaction risks known at the time of the transaction, as
recollected by the individuals we interviewed, were:
Poor financial performance of Ridgeway;
An outdated operating model at Ridgeway;
The geographical distance of Ridgeway from the rest of the Trust; and
The Trust’s management capacity, which was under pressure due to the
ongoing integration work following the acquisition on 1 April 2011 by
Hampshire Partnership NHS Foundation Trust of Hampshire Community
Health Care NHS Trust and also the diversity of services provided by the
Trust.
These risks were evidenced as being presented to the Board during its
meetings between November 2011 and November 2012, however, minuted
discussion was limited.<br />
<br />
<br />
<br />
In a legal sense this might be not be 'gross negligence', but it's disgusting.<br />
<br />
<br />Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com5tag:blogger.com,1999:blog-8154170016308023512.post-31862370031702892762015-07-29T13:28:00.000-07:002016-08-08T00:53:53.909-07:00Watching the consultants<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhls2dROZRBvRAX_8biuq1nGqD52D7LA9VFyjvWVyD7We28gmtG_rNawfASa6eytopH5AZtdkBdxtTdKB0nVkRwLL0q6_sdIGoLIeJuhRUiHEdFX56ILwfl_TAnYvRX2HpM3o-ZR0gxp-w/s1600/Matrix-and-Internet.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhls2dROZRBvRAX_8biuq1nGqD52D7LA9VFyjvWVyD7We28gmtG_rNawfASa6eytopH5AZtdkBdxtTdKB0nVkRwLL0q6_sdIGoLIeJuhRUiHEdFX56ILwfl_TAnYvRX2HpM3o-ZR0gxp-w/s400/Matrix-and-Internet.jpg" width="400" /></a></div>
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<br /></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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
<a href="http://www.nationalhealthexecutive.com/Health-Care-News/nhs-bill-for-consultants-more-than-doubles-despite-government-promises-to-cut-spending"><span style="color: windowtext;">http://www.nationalhealthexecutive.com/Health-Care-News/nhs-bill-for-consultants-more-than-doubles-despite-government-promises-to-cut-spending</span></a>
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:<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“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.”<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“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.”<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“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.”<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“Consultancy firms are unaccountable and can walk away
from bad or damaging advice with no consequences.”<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“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.”<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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 <a href="https://www.whatdotheyknow.com/"><span style="color: windowtext;">https://www.whatdotheyknow.com/</span></a>) I have
information on Southern Health’s spending on consultancy and legal/professional
services for 2013/14 and 2014/15 (available here <a href="https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in#outgoing-384702"><span style="color: windowtext;">https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in#outgoing-384702</span></a>
and here <a href="https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in#outgoing-384702"><span style="color: windowtext;">https://www.whatdotheyknow.com/request/itemised_list_of_expenditure_in#outgoing-384702</span></a>).<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>How much are they
spending?<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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 <a href="http://www.southernhealth.nhs.uk/about/performance/annual-report/"><span style="color: windowtext;">http://www.southernhealth.nhs.uk/about/performance/annual-report/</span></a>).
<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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)…<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Purpose 1: Surfing
the wave of failure<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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<a href="file:///C:/Users/hattonc/Downloads/SHFT%20Annual%20Report%20and%20Account%202014%202015%20-%20FINAL%20VERSION.pdf"><span style="color: windowtext;"> http://www.southernhealth.nhs.uk/about/performance/annual-report/ </span></a>). 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’. <o:p></o:p><br />
<br /></div>
<div class="MsoNoSpacing">
I also wonder about the £106,376 paid to Charlotte
Housden Consulting for “HR advisory services”. As Charlotte describes it on her
LinkedIn page (<a href="https://uk.linkedin.com/in/charlottehousden"><span style="color: windowtext;">https://uk.linkedin.com/in/charlottehousden</span></a>
I just love google…): <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“<span style="background: white; mso-bidi-font-family: Arial;">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.<span class="apple-converted-space"> “<o:p></o:p></span></span></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<span class="apple-converted-space"><span style="background: white; mso-bidi-font-family: Arial;">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. </span></span><o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
In 2013/14, Southern Trust paid out over £18,000 for
“employment tribunal support” – there is no expenditure in this category for
2014/15. <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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: <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“<span style="background: white; mso-bidi-font-family: Arial;">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.” (</span><a href="http://www.bevanbrittan.com/services/medical-law/Pages/inquests.aspx"><span style="color: windowtext;">http://www.bevanbrittan.com/services/medical-law/Pages/inquests.aspx</span></a>).<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
As part of its <s>asset stripping</s> 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’.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Purpose 2:
Reputation management<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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 <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/390638/HANTSPART_Publishable_Summary_Strategic_Plan_1415.pdf"><span style="color: windowtext;">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/390638/HANTSPART_Publishable_Summary_Strategic_Plan_1415.pdf</span></a>),
Southern Health lists two of its ‘weaknesses’ as:<o:p></o:p></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->Regulatory compliance ratings as a result of
quality issues in LD services<o:p></o:p></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]-->Current reputation largely based on quality
issues in LD services<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
[Note that neither of these ‘weaknesses’ are about the
learning disability services actually being crap]<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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). <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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”.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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:<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
2013/14: Procurement
advice – KPMG (£115,397)<o:p></o:p></div>
<div class="MsoNoSpacing">
Board
& Quality Governance Review – Deloitte & Touche (£65,455)<o:p></o:p></div>
<div class="MsoNoSpacing">
2014/15: Financial
& governance assurance services – PWC (£28,800)<o:p></o:p></div>
<div class="MsoNoSpacing">
Financial
recovery & strategy support – Deloitte (£258,128)<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
And of course there is the <s>notorious</s> 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 <a href="http://www.talentworksltd.com/case-studies/going-viral-wins-national-award"><span style="color: windowtext;">http://www.talentworksltd.com/case-studies/going-viral-wins-national-award</span></a>
):<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
“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.”<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Purpose 3: Hobbing
with the nobs<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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’).<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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 (<a href="http://mbihealthgroup.com/operations-improvement-waiting-times/">http://mbihealthgroup.com/operations-improvement-waiting-times/</a>)
says: “ <span style="background: white; color: #363436;">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.”</span><o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
Oh, and according their website their clients include
Monitor, NHS England, and a multitude of NHS Trusts and commissioners.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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 (<a href="http://consiliumpartners.co.uk/about-us">http://consiliumpartners.co.uk/about-us</a>
), who are working with Southern Health in “<span style="background: white; color: #444444;">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’.</span><o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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? (<a href="http://rowlands-associates-inc.squarespace.com/">http://rowlands-associates-inc.squarespace.com/</a>
). 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? (<a href="http://catholicreview.org/article/work/spirituality-aids-nun-trapped-in-elevator-for-three-days-four-nights">http://catholicreview.org/article/work/spirituality-aids-nun-trapped-in-elevator-for-three-days-four-nights</a>
).<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Purpose 4: Maintaining
the Matrix<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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. <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
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. <o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
It feels to me like pretty much all this consultancy
spending is part of a frantic, overwrought attempt to maintain this façade 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.<o:p></o:p></div>
<br />
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<br /></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com99tag:blogger.com,1999:blog-8154170016308023512.post-46522154193155539352015-03-17T16:04:00.002-07:002015-03-18T00:58:29.431-07:00Shrink Wrapped Part 2: Shrinking the (e)state<div class="separator" style="clear: both; text-align: center;">
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<br />
This post carries on where my previous post, Shrink Wrapped
Part 1, left off (<a href="http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-absorption-of-ridgeway.html">http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-absorption-of-ridgeway.html</a>
). These posts were prompted by news that Oxfordshire County Council’s “big
plan” for services for people with learning disabilities in Oxfordshire is
unlikely to include a further contract with Southern Health NHS Foundation
Trust for learning disability services in Oxfordshire (see <a href="http://www.communitycare.co.uk/2015/03/13/southern-health-set-lose-5m-learning-disability-contract-significant-concern-care/">http://www.communitycare.co.uk/2015/03/13/southern-health-set-lose-5m-learning-disability-contract-significant-concern-care/</a>
). If this comes to pass, does Southern Health NHS Foundation Trust get to keep
(and sell off) the sites of its learning disability services in Oxfordshire,
often in potentially lucrative locations? As yet the answer to that question
isn’t clear (to me, anyway). </div>
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However, on the basis that past behaviour is the
best guide to future behaviour, I’ve been looking through Southern Health’s
Board papers for clues about their financial strategy when it comes to learning
disability services in Oxfordshire.<o:p></o:p></div>
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My template for looking at this is the behaviour of an asset
stripping venture capital company, with stages something like this:</div>
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<span style="text-indent: -18pt;"><br /></span></div>
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<span style="text-indent: -18pt;">1) Identify a financially struggling company and
acquire it at a knock-down price.</span></div>
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<span style="text-indent: -18pt;">2) Reduce running costs as much as possible and
don’t make expensive investments into the company.</span></div>
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<span style="text-indent: -18pt;">3) Sell off the assets piecemeal under there’s
nothing left except for any highly profitable elements that can be absorbed
into other company or sold at a huge profit.</span></div>
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<span style="text-indent: -18pt;"><br /></span></div>
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<!--[if !supportLists]--><o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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The first post focused on Stage 1 – the merger/acquisition/absorption
of Ridgeway, and the possible financial incentives for doing that were
sufficiently attractive for 13 initial bidders to pitch for it.<o:p></o:p></div>
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This post focuses on Stages 2 and 3: after the absorption, what
evidence is there in the Board (and other) papers for:</div>
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<span style="font-stretch: normal; text-indent: -18pt;">1) </span><span style="font-size: 7pt; font-stretch: normal; text-indent: -18pt;"> </span><span style="text-indent: -18pt;">Southern Health making serious investments into
former Ridgeway sites (or not),</span></div>
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<span style="font-stretch: normal; text-indent: -18pt;">2) </span><span style="font-size: 7pt; font-stretch: normal; text-indent: -18pt;"> </span><span style="text-indent: -18pt;">Southern Health looking to sell off aspects of
the former Ridgeway estate?</span></div>
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<span style="font-stretch: normal; text-indent: -18pt;">3)</span><span style="font-size: 7pt; font-stretch: normal; text-indent: -18pt;"> </span><span style="text-indent: -18pt;">Southern Health looking to then divest
themselves of responsibility for former Ridgeway services?</span></div>
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<o:p></o:p></div>
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I don’t know why, but for some reason while I was writing
this ‘Right Said Fred’ (the original and best song by Bernard Cribbins, of
course) kept going through my head – probably slightly too benign a vibe, but
anyway, here it is (<a href="https://www.youtube.com/watch?v=r5XX9LX2es4">https://www.youtube.com/watch?v=r5XX9LX2es4</a>
). <o:p></o:p></div>
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<b>We was getting
nowhere, and so we had a cuppa tea<o:p></o:p></b></div>
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<b><br /></b></div>
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Although there is a curious lack of attention paid in the
Southern Health Board papers to the impending absorption of Ridgeway, there is
a focus very soon after on potential financial issues that require attention,
although issues about how good the Ridgeway services are seem to be treated
with some complacency: <o:p></o:p></div>
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“The Learning Disability division now stretches across
Buckinghamshire, Oxfordshire, Hampshire and into parts of Wiltshire and Dorset.
The newly configured services are currently finalising the clinical strategy
and business plan ensuring it is in line with the rest of Southern Health in
developing its services with a 'business as usual' approach. The next 12 months
will see the services undertake a financial recovery plan and a detailed
quality improvement plan that is supported by commissioners and centred on the
needs of service users.” (CEO report, 28 Nov 2012).<o:p></o:p></div>
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“The Chairman sought clarification as to whether there were
any issues, in particular in relation to quality of care. The Chief Operating
Officer noted that there had been no issues to date, largely due to the robust
due diligence undertaken; she confirmed that in relation to the transfer of
patients between facilities, there was no indication of systemic problems… In
relation to the financial recovery plan, the Chairman sought clarification as
to the progress with marketing beds at Postern House. The Chief Operating
Officer confirmed that the Trust needed to fill three more beds, two of which
were likely to be filled soon, in order to reach a breakeven position, and
would then look to further increase the financial viability of the service”
(minutes of 28 Nov 2012, Board meeting).<o:p></o:p></div>
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[Postern House is an inpatient service in Wiltshire where
there was heavy capital investment in the year before absorption by Southern
Health].<o:p></o:p></div>
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General financial plans for Southern Health for 2013/14
involved making substantial cuts at a time of reduced income to generate a
surplus, with former Ridgeway services explicitly mentioned as a location for
‘savings’:<o:p></o:p></div>
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“The Trust’s income will reduce by 1.3% for 2013/14, in line
with the national NHS settlement. Internally we plan to generate £17.8m cost
reductions, to enable the Trust to cover cost pressures including inflation,
and to enable investment in further service improvement and the development of
the capability of our workforce. The financial plan is to generate a surplus of
£4.5m.”<o:p></o:p></div>
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“Corporate and back office services will continue to deliver
both cost efficiency savings and restructuring savings. 2013/14 will be the
third year of a three year plan to deliver savings of 25%, alongside savings
planned following the merger with Ridgeway Partnership during 2012” (Summary of
Annual Business Plan 2013/14; 28 March 2013).<o:p></o:p></div>
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There are also statements in the strategy about capital investment,
with former Ridgeway services mentioned generically but with no specific plans
attached:<o:p></o:p></div>
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“An allocation of £4.0m will be required to fund service
developments/estate rationalisation, including works at the Becton Centre,
Petersfield Hospital, the Bridge Centre and Ravenswood and Learning Disability
units in Oxfordshire & Buckinghamshire.” (Summary of Annual Business Plan
2013/14; 28 March 2013).<o:p></o:p></div>
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A year later, it appears that investment in the learning
disability services estate was still effectively absent: “Sue Harriman reported
on the progress in relation to the turnaround plan for the Learning
Disabilities Division. She noted that the Trust was on plan, or ahead of plan
for delivery of key actions, with the exception of those relating to Estates”
(Board minutes, 25 March 2014).<o:p></o:p></div>
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By the 10 Sept 2013 Board meeting, all parts of Southern
Health were failing to deliver against their ‘cost improvement’ targets, with
the learning disabilities Division forecasting a shortfall of £0.9 million by
the year-end due to ‘unfunded beds in Oxford services’. This forecast had
increased to a £1.1 million shortfall by 25 March 2014 and ended up being £3.54
million over budget (27 May 2014). This was a consistent theme into 2014/15,
with the learning disabilities Division already forecast for an end of year
shortfall of £3.8 million by November 2014.<o:p></o:p></div>
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So overall, there seems to be a picture of a lack of capital
investment in former Ridgeway services, and swingeing expectations of ‘cost
improvement’ (i.e. cutting costs) in learning disability services that were repeatedly
not being met.<o:p></o:p></div>
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<b>Take off all the
handles, and the things wot held the candles<o:p></o:p></b></div>
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It seems always to have been part of the financial plan that
parts of the Ridgeway estate were to be sold off. Before absorption, four
Ridgeway properties (Wadham Court, Selbrook Villa, Northview, Lanterns) had
been identified as ‘surplus to requirements’, although they were only to be
sold after absorption, with the money going into Southern Health’s coffers (these
were eventually put up for sale at a total price of around £1.7 million).
However, it appears that this wasn’t enough, with further ‘estates
rationalisation’ required (allied to a worrying lack of preparedness in terms
of service and clinical leadership):<o:p></o:p></div>
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“3.9. Learning Disabilities: Risk
a) Sustainable cost effective services in 2013/2014 are dependent on business
plans with significant change programmes including estates rationalisation. b)
Divisional leadership has changed and Clinical Service Directors are not yet
established.” (Chief Operating Officer’s Report, 28 March 2013).<o:p></o:p></div>
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And even at this point, less than six months after absorption,
there are ominously worded statements about the Slade site in Oxford:<o:p></o:p></div>
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“The division is also working closely with corporate
services to ensure alignment of business plans e.g. an estates strategy will be
developed that will support operational delivery. It is fair that there are
both opportunities and challenges in relation to this, particularly on the
Slade site in Oxford.” (COO Report, Divisional Update, 28 March 2013).<o:p></o:p></div>
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It is unclear to me whether the Slade site is being
considered as opportunity or challenge.<o:p></o:p></div>
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There are further sinister signs for the Slade site in the
23 April 2013 Board papers, where:<o:p></o:p></div>
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“There are also some challenges in relation to the condition
of some of the estate, particularly on the Slade site where buildings are now
of an age that they need significant refurbishment. The Division will work
closely with other Divisions to ensure that joint decisions and priorities are
both understood and agreed” (COO Report, Divisional Update, 23 April 2013).<o:p></o:p></div>
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So there is a clear recognition that the Slade site is in
serious need of refurbishment, but the opacity of what to do about it is
remarkable, and certainly doesn’t seem to involve actually doing any
refurbishment. The lack of urgency is evident, in that exactly the same
statement is copied and pasted into the ‘Divisional Update’ prepared for the 29<sup>
</sup>May and 23 July 2013 Board papers. Followers of #justiceforLB might well
wonder why this statement disappears from further ‘Divisional Updates’ after
this point.<o:p></o:p></div>
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There was more in a similar vein in the 10 Sept 2013 Board
meeting, from the acting Chief Executive Officer:<o:p></o:p></div>
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“Sue Harriman advised the Board that a post-acquisition
benefits realisation was on-going within the Trust’s Learning Disabilities
Division. She reported that this had identified some successes, but also some
challenges and concerns. She noted the significant financial challenges that
the Trust needed to address, which had been highlighted through the due
diligence process”.<o:p></o:p></div>
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Given all this due diligence and earlier recognition of the
poor state of the Slade site, it’s surprising to me that Southern Health were
apparently so surprised by a damning CQC inspection of these services (followed
by a succession of less than stellar CQC inspections of other Southern Health
learning disability services):<o:p></o:p></div>
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“The Care Quality Commission (CQC) conducted a three day
inspection of services on the Slade House site in Oxford in mid-September. The
inspection identified a number of areas of compliance failure and as such it is
incredibly disturbing that these issues had not been identified internally
through tried and tested governance processes. We have taken the findings from
the draft report incredibly seriously and have ensured these services are safe
and of appropriate quality in the immediate terms whilst fully investigating
and generating organisational learning” (COO Report, 29 Oct 2013).<o:p></o:p></div>
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This point of crisis seems to have forced a little more
clarity from Southern Health about their intentions for the Slade site:<o:p></o:p></div>
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“There are some longer term building challenges particularly
around STATT House, which needs to be balanced against the trust investment
criteria and future commissioning intensions [sic]. In the meantime, these
challenges are being planned for and will be implemented when service decisions
have been made” (Learning Disabilities Division Report to Board, 29 Oct 2013).<o:p></o:p></div>
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By March 2014, the prospects for estates ‘rationalisation’
across Southern Health is becoming more apocalyptic:<o:p></o:p></div>
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“The Trust’s Estate Strategy has been refreshed and is
currently going through an internal ratification process. It continues to
support the clinical strategies, resulting in a proposed reduction of
approximately 13 freehold (circa £6.8m total carrying value) and 11 leasehold
properties over the next two years. This will contribute a further £1.5m of
savings per annum to the total occupancy cost and consequent revenue position
of the Trust. The strategy is an interim refresh and a more radical estate
strategy and rationalisation plan will be developed with the challenge to
reduce the cost of estate by an ambitious target of 20-25%” (Finance Report, 25
March 2014).<o:p></o:p></div>
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And by June 2014, the specific implications for learning
disability services are spelled out:<o:p></o:p></div>
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“Costs within the Learning Disabilities Division exceeded
budget by £748k at the end of May 2014. This mainly results from the divisional
CIP target of £729k for the same period. The Division has had to address issues
involving both the quality and profitability of services and radical action has
been taken where appropriate.”<o:p></o:p></div>
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“Postern House has now closed, relieving recurrent losses of
around £400k per year, with notice also served on community services in Swindon
and Wiltshire. A paper evaluating the viability of John Sharich House is being
progressed. Work is ongoing with Oxfordshire County Council to develop a more
community oriented model which should be more clinically effective and cost
effective, and this forms a major part of the planned redesign of services.
Further options are being explored in Buckinghamshire and in LD Specialised
Services.” (Integrated Performance Report, 24 June 2014).<o:p></o:p></div>
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And
by November 2014, Postern House, together with Hampshire learning disability
sites Westview and Home Farm, were officially declared “surplus to
requirements…and the properties are now being marketed” (Chief Executive’s
Report and Directors Report, 25 Nov 2014).<o:p></o:p></div>
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<b>So Charlie and me had
another cuppa tea, and then we went home<o:p></o:p></b></div>
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<b><br /></b></div>
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The first concrete sign of Southern Health withdrawing from
a former Ridgeway service came in December 2013: “There are ongoing discussions
with Swindon and Wiltshire regarding the future of service provision in these
areas”. Unsurprisingly “The Division recognises some unsettling times for staff
in Swindon and Wiltshire, whilst the future of services is agreed” (Learning
Disability Division update, 10 Dec 2013).<o:p></o:p></div>
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The decision came swiftly, by 25 March 2014: “For some time
the Division has been reviewing its ongoing provision on the community element
of the contract with Swindon and Wiltshire. Presently, we only provide
Psychology and Psychiatry and as such have limited influence on overall
pathways of care, which we do not believe are in the best interest of the
people we look after. Having worked with Commissioners over the last year, we
have served notice on both services, and we will stop providing those services
by 29 January 2015. However, should the pathways become clearer during the
notice period, we remain open to negotiations” (Divisional Reports, 25 March
2014).<o:p></o:p></div>
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More generally, throughout 2013 and 2014 there are
increasing rumbles about the financial performance of the Learning Disabilities
Division within Southern Health, usually attributed to ‘under-occupancy’ of
inpatient units in Oxford and Postern House and/or a move from block contracts
to spot purchasing. </div>
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As far as I can see (at this point the full set of Board
papers is over 200 pages long), the 28 January 2014 Board meeting contains the
first implication that Southern Health considers the whole commissioning model
as unsustainable:<o:p></o:p></div>
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“11.1 The Division continues to face a difficult financial
challenge, and has not yet realised the planned CIP [Cost Improvement
Programme] in year. A significant proportion of the divisional position is a
result of loss of income within in-patient facilities commissioned via ‘spot
purchase’, as such there is no longer guaranteed income for a number of our
units. This commissioning position is unsustainable for Southern Health, who
have a strategy to reduce dependency on beds and increase community services”
(Learning Disabilities Divisional Progress, 28 Jan 2014).<o:p></o:p></div>
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[As an aside, I don’t understand why a strategy of reducing
dependency on beds requires block contracts for, er, beds, but then again I’m
probably not strategically sophisticated enough]<o:p></o:p></div>
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This is put in stronger terms in the 25 March Board meeting:<o:p></o:p></div>
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“The Division has seen a significant underachievement of its
income to date and poor delivery of its CIP programme. This financial
underachievement has been in the main a result of quality issues and mitigation
plans in the LD services provided in Oxford, Swindon, Wiltshire and
Buckinghamshire. Significant service redesign with the planned reduction of bed
based services and investment in community based provision in these counties is
required to ensure financially sustainable services. This requires
Commissioners to re-commission LD pathways and wide-scale system and service
re-design; this creates a significant risk for the Trust if the pace and scale
of change is not acknowledged by all” (Learning Disability Divisional Progress,
25 March 2014).<o:p></o:p></div>
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And, in a final straw: “Southern Health’s current contract
to provide Learning Disability Services in Oxfordshire expires in December
2015. Commissioners have commenced the process of procuring a provider of these
services” (Southern Health Summary Strategic Plan 2014-2019).<o:p></o:p></div>
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So, in a year’s time, what will be left of the former
Ridgeway Trust within Southern Health? This map from a presentation to the
Board by the learning disabilities division soon after absorption shows all the
Trust’s learning disability services at that time. It looks like all the
Oxfordshire and Swindon and Wiltshire services will have gone with, to date,
substantial proceeds from the sale of sites – is there any reason to suppose
that the Slade House site will be any different?<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCdCP94uBE44pI1pqWZWcWlHTbydjUFsdbDtQaG797Q0aPcizHhedR3v3_VZuEa0CiFsnjPbqF2II1Az6OY8mrN20yW0ltat_rtSTByJ798839qgPNOcE1q-bohmvaxcU0wjFGDahQav4/s1600/Southern+Health+LD+Services+map.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCdCP94uBE44pI1pqWZWcWlHTbydjUFsdbDtQaG797Q0aPcizHhedR3v3_VZuEa0CiFsnjPbqF2II1Az6OY8mrN20yW0ltat_rtSTByJ798839qgPNOcE1q-bohmvaxcU0wjFGDahQav4/s1600/Southern+Health+LD+Services+map.PNG" height="297" width="400" /></a></div>
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<o:p><br /></o:p></div>
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<o:p><br /></o:p></div>
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Southern Health’s 5-year strategic plan, submitted to
Monitor, couldn’t be any clearer how things play out, from the SWOT analysis…<o:p></o:p></div>
<div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgY54WAOHHe-U83Yjlwma7KlD-k1lISQHfGe_tjH0jd8xo2sanzKBGgKcvN7crMrWUE4KUCS2DohJ0GXMBA6mWB-jxdWZYjzGJEzrfz_NDFXS66lk1nKZJZi0Cch-Wp_DeG172jYu7zjbE/s1600/Southern+Health+SWOT.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgY54WAOHHe-U83Yjlwma7KlD-k1lISQHfGe_tjH0jd8xo2sanzKBGgKcvN7crMrWUE4KUCS2DohJ0GXMBA6mWB-jxdWZYjzGJEzrfz_NDFXS66lk1nKZJZi0Cch-Wp_DeG172jYu7zjbE/s1600/Southern+Health+SWOT.png" height="372" width="640" /></a></div>
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[I particularly enjoyed the CQC regulatory regime being
identified as a threat; and the typically warped tribute to the #justiceforLB
campaign in a weakness being “Current reputation largely based on quality
issues in LD services]<o:p></o:p></div>
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<div class="MsoNormal">
…to the key ‘challenges’ faced by Southern Health’s learning
disability services...<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2qX2Dk_BYnrrbxMo1BF0VYp6gmFxPauId0ht5tdgl3XZgXjId6RZUOuotVFzNLMHSzDDiZxZSQ86PsLIySg3v8OsYT911DYjMlGwV2CR6i2CJ0CmWUO6AE6mckAAI9pqCqg3XvVzQa14/s1600/SHstrat1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2qX2Dk_BYnrrbxMo1BF0VYp6gmFxPauId0ht5tdgl3XZgXjId6RZUOuotVFzNLMHSzDDiZxZSQ86PsLIySg3v8OsYT911DYjMlGwV2CR6i2CJ0CmWUO6AE6mckAAI9pqCqg3XvVzQa14/s1600/SHstrat1.png" height="251" width="640" /></a></div>
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…And finally, the entirety of the summary strategic plan for
learning disability services (yes, that really is it):<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjk5S3BDRS9hg6TdjgAXByRITTn8xmsfMwxhgt6dJXCKB6uTlDbrZWp4NjK_qbv7HlT1AQYb2__cAQlNrIM4dTp9Gg4r6emwHccRKAew67muX-4_BMirtI23ZgGQ-cYhkQ_n9pyRS8SOvw/s1600/Shstrat3.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjk5S3BDRS9hg6TdjgAXByRITTn8xmsfMwxhgt6dJXCKB6uTlDbrZWp4NjK_qbv7HlT1AQYb2__cAQlNrIM4dTp9Gg4r6emwHccRKAew67muX-4_BMirtI23ZgGQ-cYhkQ_n9pyRS8SOvw/s1600/Shstrat3.png" height="312" width="640" /></a></div>
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A stereotype of a venture capital company couldn’t have done
it better. Who knows the motivations of senior Southern Health personnel when
they decided to bid for Ridgeway, especially given that most of the ‘key
challenges’ must have been obvious from the start? And who knows how they feel
about that decision now? Surely it would be complete moral bankruptcy to take
the proceeds of the Slade site back to Hampshire, rather than those proceeds
being used to support people with learning disabilities in Oxfordshire. One thing
I do know for sure – on their watch, a young man died. And none of the capital
gains in the world are worth that. <o:p></o:p></div>
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Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com3tag:blogger.com,1999:blog-8154170016308023512.post-56153926224096540112015-03-14T00:00:00.004-07:002015-03-14T00:00:57.896-07:00Shrink Wrapped: The absorption of Ridgeway<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhN9tjh6Ax-_H1g5YWtpxGf99dTGYE_rHakgcsi9LG5Vht2KGlFHCB8b2mAQEjY_iKjCFO3OutOuUGkMYEHBFziXedoVY7zV6lyzLDkV2DnpD9C_F93OH48FFEFmrAO6edx2OH_GV9TdJw/s1600/paul-daniels-strictly.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhN9tjh6Ax-_H1g5YWtpxGf99dTGYE_rHakgcsi9LG5Vht2KGlFHCB8b2mAQEjY_iKjCFO3OutOuUGkMYEHBFziXedoVY7zV6lyzLDkV2DnpD9C_F93OH48FFEFmrAO6edx2OH_GV9TdJw/s1600/paul-daniels-strictly.jpg" height="202" width="320" /></a></div>
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As reported by Andy McNicoll in Community Care, Oxfordshire
County Council have been developing a ‘big plan’ for its services for people
with learning disabilities, and it seems likely that this plan does not include
a further contract with Southern Health NHS Foundation Trust for learning
disability services in Oxfordshire (see <a href="http://www.communitycare.co.uk/2015/03/13/southern-health-set-lose-5m-learning-disability-contract-significant-concern-care/">http://www.communitycare.co.uk/2015/03/13/southern-health-set-lose-5m-learning-disability-contract-significant-concern-care/</a>
).<o:p></o:p></div>
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Oh frabjous day! Callooh! Callay! Has the Jabberwock been
slain? And if is has, is it planning to whiffle off back to the tulgey wood
with a big stash of cash in its claws that catch?<o:p></o:p></div>
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As @sarasiobhan first suggested last September (<a href="https://mydaftlife.wordpress.com/2014/09/01/sunshine-and-shade/">https://mydaftlife.wordpress.com/2014/09/01/sunshine-and-shade/</a>
), is it possible that the loss of its Oxfordshire learning disability contract
may result in a financial windfall for Southern Health without any future
hassle from those ‘non-Hampshire’ awkward types? If it loses the contract, does
it get to keep (and sell off) the sites of its learning disability services in
Oxfordshire, often in potentially lucrative locations? As yet the answer to
that question isn’t clear (to me, anyway). However, on the basis that past
behaviour is the best guide to future behaviour, I’ve been looking through
Southern Health’s Board papers for clues about their financial strategy when it
comes to learning disability services in Oxfordshire.<o:p></o:p></div>
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My template for looking at this is the behaviour of an asset
stripping venture capital company, with stages something like this:<o:p></o:p></div>
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<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="text-indent: -18pt;"> 1) Identify a financially struggling company and
acquire it at a knock-down price.</span><br /><span style="text-indent: -18pt;">2) Reduce running costs as much as possible and
don’t make expensive investments into the company.</span><br /><span style="text-indent: -18pt;">3) Sell off the assets piecemeal under there’s
nothing left except for any highly profitable elements that can be absorbed into
other company or sold at a huge profit.</span><!--[if !supportLists]--><o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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This blogpost focuses on Stage 1 – what the papers say about
the merger/acquisition/absorption of Ridgeway. A later post will focus on what happened
after the merger/acquisition/absorption.<o:p></o:p></div>
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Surely an NHS Trust wouldn’t (and wouldn’t be allowed to)
behave like this? Well, let’s see…<o:p></o:p></div>
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Stage 1) Find the limping wildebeest<o:p></o:p></div>
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Part of this story lies far back in the mists of time
(probably around 2010/11). At this point, the plan (bound into the Health and
Social Care Bill 2012) was for ALL NHS Trusts to become Foundation Trusts,
largely on the basis of plans for financial viability.<o:p></o:p></div>
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Ridgeway (also known as the Oxfordshire Learning
Disabilities NHS Trust), a relatively small, specialist learning disability NHS
Trust spread across Oxfordshire, Buckinghamshire, Wiltshire, Dorset and North
East Somerset, was always going to struggle to meet the largely financial
criteria that would enable them to go it alone as a Foundation Trust, and were
running a substantial financial deficit of up to £1 million in 2011/12 (<a href="http://www.lgcplus.com/sponsored-sections/capsticks-social-enterprise/ridgeway-to-be-taken-over-by-non-neighbouring-ft/5040963.article">http://www.lgcplus.com/sponsored-sections/capsticks-social-enterprise/ridgeway-to-be-taken-over-by-non-neighbouring-ft/5040963.article#</a>
). Clearly a limping wildebeest in the pack.<o:p></o:p></div>
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Ridgeway therefore were compelled to seek a ‘merger’ (although
it was more often referred to as an absorption or acquisition) with a Trust
that had already reached Foundation Trust status. My guess is that this was
instigating and managed by the local Strategic Health Authority, South Central
SHA, and they wanted as many loose ends tied up as possible before they went
out of existence in March 2013, in the Year Zero of the Health and Social Care
Act (see <a href="http://www.nhsconfed.org/resources/2013/03/service-redesign-case-study-the-southern-health-acquisition-of-ridgeway">http://www.nhsconfed.org/resources/2013/03/service-redesign-case-study-the-southern-health-acquisition-of-ridgeway</a>
). From 13 initial bids for Ridgeway, 6 were longlisted. These were whittled
down to Calderstones and Southern Health (itself the result of a recent merger),
with Southern Health named as the ‘preferred partner’ for Ridgeway in March
2012 (<a href="http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=39988&type=full&servicetype=Inline">http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=39988&type=full&servicetype=Inline</a>
) for the absorption to happen in some haste, November 2012, just before Year
Zero. <o:p></o:p></div>
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Why was this ‘financially struggling’ Trust so attractive to
so many bidders? <o:p></o:p></div>
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First, in the world of NHS absorptions, you don’t have to
pay over any cash for your acquisitions. <o:p></o:p></div>
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Second, it looks like the Strategic Health Authority pumped
an unspecified amount of money into Ridgeway in its last year, perhaps to
sweeten the deal. <o:p></o:p></div>
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So, the final accounts for the old Ridgeway Trust for 1<sup>st</sup>
April – 31<sup>st</sup> October 2012 (actually produced by Southern Trust after
the absorption and available in the Southern Health Board papers for 29<sup>th</sup>
May 2013 <a href="http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=71931&type=full&servicetype=Inline">http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=71931&type=full&servicetype=Inline</a><span class="MsoHyperlink"> )</span><span class="MsoHyperlink"> say this:<o:p></o:p></span></div>
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<span class="MsoHyperlink"><br /></span></div>
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<span class="MsoHyperlink">“</span>The seven months to 31
October 2012 continued to be a challenging year financially with the Trust
(Ridgeway) finding it difficult to reduce operating costs to match the
reduction in income following <i>the
wholesale retendering of social care services by Oxfordshire County Council in
2011/2012</i> <i>[all italics my emphasis]</i>.
As a result <i>NHS South Central continued
to provide transitional funding</i> whilst the Trust worked with Southern
Health to review and refine operating plans ahead of their formal acquisition
on the 1 November 2012. Whilst <i>the Trust
was able to deliver a financial surplus over the seven months with the help of
this financial support</i>, this was slightly less than planned.”<o:p></o:p></div>
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Third, there was some heavy investment in two specific sites
before the absorption, amounting to £1.9 million (these quotes also from the accounts):
<o:p></o:p></div>
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“Building work was completed on the expansion and upgrade of
the Assessment and Treatment services at Postern House in Marlborough. This was
a major scheme that created six additional beds in a series of phases. It has
also addressed longstanding issues around the fabric of the building, such as
the roof, and improved the patient experience through improvements to the
environment. <o:p></o:p></div>
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The refurbishment and expansion of the Assessment and
Treatment services at the Ridgeway Centre (formerly 309 Cressex Road) at High
Wycombe in Buckinghamshire was completed and opened in September 2012. This
refurbishment programme makes this building a unique facility in the region and
will provide a high quality, safe environment for patients that will be
attractive to commissioners across a wide geographical area. This initiative
supports the ambition to improve the strategic estate whilst delivering a
planned vacation of leased estate thus reducing occupation costs.” <o:p></o:p></div>
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[Quite why the priority for investment was in expending Assessment
and Treatment Units whilst government priorities pointed in exactly the
opposite direction is a question for another day – perhaps building these up so
other, shabbier ones, could be closed?]<o:p></o:p></div>
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A fourth element of the sweetened deal was an initial list
of four buildings that Ridgeway had earmarked for sale but were not actually
sold until after the absorption, with the proceeds planned to go to Southern
Health rather than Ridgeway:<o:p></o:p></div>
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“Ridgeway had a number of buildings that have been declared
surplus to requirement and are disclosed as ‘assets held for sale’ within the
Trust’s Statement of Financial Position. <o:p></o:p></div>
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Wadham Court Contracts due to
exchange in May 2013 <o:p></o:p></div>
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Sellbrook Villa Contracts due to
exchange in June 2013 <o:p></o:p></div>
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Northview bungalow Being Marketed
in June 2013 <o:p></o:p></div>
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Lanterns Being Marketed in June
2013”<o:p></o:p></div>
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It will perhaps not surprise you that “The Trust worked
closely with Southern Health on the development of a Ridgeway Estate strategy
to support the operational requirements of the organisation.” <o:p></o:p></div>
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Finally, at the time of Ridgeway’s absorption by Southern
Health, the value of the Trust’s property, plant and equipment amounted to
£16.8 million. Southern Health’s annual report for 2012/13 (see here for
details <a href="http://chrishatton.blogspot.co.uk/2014/03/a-public-accounting.html">http://chrishatton.blogspot.co.uk/2014/03/a-public-accounting.html</a>
) reports that fully £8.8 million of this amount was in the form of a
‘revaluation reserve’. <o:p></o:p></div>
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For some reason Mrs Merton’s question to Debbie McGee seems
appropriate here: ”So, what first attracted you to the millionaire Paul
Daniels?”<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com2tag:blogger.com,1999:blog-8154170016308023512.post-91789559921345834872014-08-12T10:19:00.000-07:002014-08-12T10:20:59.402-07:00Welcome from our Chair and Chief Executive<div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE26WJB8D1h24yniFTZuqLee0YLRPLJr8J5kGYNQ2Op8AHodvKplQFBd3vPKDvGfzttl7Q3j6zLVo5si_zby-ZldhOgTchxi_7n5l7JLecbDiSRjEPlLDWAlPKsKcN7U9BsIPp1JHZkYk/s1600/tumblr_mky7xysFPK1rqfhi2o1_400.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE26WJB8D1h24yniFTZuqLee0YLRPLJr8J5kGYNQ2Op8AHodvKplQFBd3vPKDvGfzttl7Q3j6zLVo5si_zby-ZldhOgTchxi_7n5l7JLecbDiSRjEPlLDWAlPKsKcN7U9BsIPp1JHZkYk/s1600/tumblr_mky7xysFPK1rqfhi2o1_400.gif" height="192" width="320" /></a></div>
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(from GIFS for the masses http://www.tumblr.com/tagged/evil-smile )</div>
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I started to read the Annual Report and Accounts for
Southern Health NHS Foundation Trust for 2013/14 – available here on the
Monitor website <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/339872/HANTSPART_Annual_Report_and_Accounts_2013-14_1_.pdf">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/339872/HANTSPART_Annual_Report_and_Accounts_2013-14_1_.pdf</a>
<o:p></o:p></div>
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A blogpost on their 2012/13 annual report is here <a href="http://chrishatton.blogspot.co.uk/2014/03/a-public-accounting.html">http://chrishatton.blogspot.co.uk/2014/03/a-public-accounting.html</a>
<o:p></o:p></div>
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I’m afraid I only got as far as the first two pages, the
opening ‘Welcome from our Chair and Chief Executive’. </div>
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Below is why – the plain
text is the ‘Welcome’ in full – the material in square brackets, erm, isn’t.<o:p></o:p></div>
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1. Welcome from the Chair and Chief Executive <i>[it’s not just
the Chief Executive, right, we’re all in it together here at Southern Health]</i><o:p></o:p></div>
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On behalf of the Board of Southern Health NHS Foundation
Trust we are pleased to present the Annual Report and Accounts for the
financial year 2013/14.<o:p></o:p></div>
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When we visit the services <i>[erm, where do the Chair and Chief
Executive work if they are visiting their own services?] </i>we are genuinely
humbled by how tremendously hard our staff work <i>[criticise anything about our service
and you’re criticising these hard working people, you callous bounder] </i>and we
look to encourage and inspire them<i> [we don’t do anything ourselves, we encourage
and inspire] </i>to continually seek to improve the services they provide<i> [notice
guys, ‘they’ provide the services, not us, OK?]</i>.<o:p></o:p></div>
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Although 2013/14 had proven to be a challenging year
<i>[completely unexpected guv, nothing we could predict, no sirree]</i>, we are
grateful for the hard work of our staff in delivering high quality healthcare<i>
[see above – diss us and you diss all those hardworking staff, and besides it’s
them doing the healthcare, not us – we ‘inspire’]</i>, and for the support of our
Governors, patients and community<i> [so it’s not just the staff, it’s everyone –
if you’re not supporting us then you’re not part of any of these groups so bog off]
</i>throughout this period <i>[it’s just a passing <s>period</s> phase]</i>.<o:p></o:p></div>
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We have faced significant scrutiny over the past year<i> [so
much in such a short phrase! ‘faced’ implies that scrutiny is an opponent/enemy?
Also implies that the scrutiny has been imposed from outside rather than being
the result of the actions of the Trust? And why weren’t they facing significant
scrutiny before the past year?],</i> in particular non-Hampshire Learning
Disability Services<i> [it’s those learning disability bastards outside our ‘real’
Hampshire services for ‘normal’ people]</i> and some Mental Health inpatient services
in Hampshire<i> [cough, cough]</i>, but we are confident that the care provided to the
vast majority of the many thousands of patients who use our service is good
<i>[never mind about the few awkward ones where we provide a terrible service,
they’re not like ‘us’ and they don’t count]</i>. We have not always got it right
<i>[er, slightly minimising what the Trust has done?] </i>and there have been
occasions when we have needed to apologise, learn lessons and take steps to
address areas of weakness<i> [if I was being mean I’d suggest that that the Trust needing
to do these things isn’t the same as them saying they’ve actually done them?].</i><o:p></o:p></div>
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The quality of our services is under constant scrutiny and
review by a variety of regulatory bodies, notably Monitor and the Care Quality
Commission<i> [how dare they?].</i> Inspections of our sites have identified a great
deal that is excellent about the Trust <i>[lovely wallpaper]</i>. However, we have
also received a number of warning notices and compliance actions which have required
the Trust to take immediate changes to address the concerns identified<i> [again,
the regulators are the agents here, doing mean things to the poor Trust. No
sense that poor practices in the Trust triggered any of this scrutiny? And
should we have known about these ‘concerns’ that these outsiders drone on about
– of course not!]. </i><o:p></o:p></div>
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As a result of an investigation undertaken in-year, Monitor
has agreed to accept enforcement undertakings submitted by the Trust <i>[this is a
very oddly constructed sentence – doesn’t say anything about why Monitor
imposed an enforcement action, or even that they did this, and it’s constructed
in terms of Monitor acceptance of Trust undertakings];</i> actions to address these
will be delivered in 2014/15<i> [just a blip, nothing to see here, move along]</i>. <o:p></o:p></div>
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In the period since Southern Health was formed in April 2011
we have worked with our partners in health, local authorities and the voluntary
sector to develop our children’s services and have delivered our plans to
implement the national programme for health visiting <i>[nice to talk about
children rather than those difficult people causing us trouble]</i>. We have
expanded the delivery of our high quality cost effective social care solutions <i>[nice
phrasing that will make people’s eyes glaze over, rather than ask why an NHS
Trust is expanding its social care services] </i>and developed a number of
innovative services to support patients who would otherwise be cared for in
inpatient facilities<i> [let’s ignore the fact that some of these inpatient
services have been forced to close because they’re so awful]</i>. We have continued
to advance our community services<i> [advance? running out of thesaurus options?] </i>,
providing integrated physical and mental health for older people, working with
partners to support more patients outside of hospital<i> [we’re finding other people
to do this because we can’t do it ourselves?].</i> We have also made good progress
redesigning our mental health services, enabling more people to be cared for in
the community <i>[we’re closing services and selling off the sites]</i>. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Our commissioning arrangements remain complex with seven
Clinical Commissioning Groups authorised to take responsibility for commissioning
local health services in Hampshire and five Clinical Commissioning Groups
responsible for commissioning the non-Hampshire Learning Disability Services we
provide in Oxford, Buckinghamshire, Swindon and Wiltshire<i> [there’s the ‘non-Hampshire’
yoked to ‘learning disability’ again].</i> The NHS Commissioning Board commission
primary care and more specialist services (including our forensic services) and
Hampshire County Council and Southampton City Council commission health
promotion and public health services<i> [see how complicated it is? You couldn’t
possibly understand so can’t ask us about it].</i><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
During the course of the year we have seen the Trust appoint
a new Non-Executive Director, Mr Mike Sadler; Chief Finance Office, Mark
Brooks; and an Interim Executive Director of Nursing, Allied Health
Professionals and Quality<i> [good to see Quality so central, not like it’s tacked
on to someone’s job title or anything],</i> Jude Diggins; all of whom bring with
them new ideas and a wealth of experience and enthusiasm and who we welcome to
the team.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We have also celebrated success in several areas where staff
and teams have been shortlisted and won awards<i> [phew, glad we’ve got that
awkward stuff out of the way, let’s talk awards. See, there’s so many! What’s
to complain about?]</i> such as:<o:p></o:p></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->The West Hampshire Community Diabetes Team won
the Best IT-Led Initiative at the Quality in Care Awards;<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->The TQTwentyone Team winning the ‘Care Team of
the Year’ award at the South East Great British Care Awards 2013;<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->The Mother and Baby (Perinatal) Mental Health
Service being named the ‘Psychiatric Team of the Year’ at the national 2013
Royal College of Psychiatrists Awards;<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->The Trust winning the Leadership Innovation
category at the Guardian Healthcare Innovation Awards;<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->The Trust being shortlisted for the Provider
Trust of the Year; the Creating sustainable NHS Providers and the Board
Leadership Award in the Health Service Journal Awards.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Also, in a first for Hampshire<i> [our ‘real’ service, folks]</i>,
police services in Southampton are piloting a new scheme that puts mental health
workers in police patrol cars and control centres. This is in an effort to
improve the support available to people in crisis<i> [see, we’re not failing
people in crisis, and we’re in-no-vat-ive]</i>, and preventing the need to take
them into police custody.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Day in, day out staff work tirelessly to deliver excellent
care to patients<i> [again, diss us and you diss all our tireless staff, how
hurtful and cruel of you]</i>, sometimes we get it wrong <i>[again, get it wrong?] </i>but
we are all working to truly understand how to deliver improvements <i>[because
delivering improvements is really, really, really complicated and its beyond
anyone’s understanding – how were we to know?]</i>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Despite the challenges that lie ahead, both foreseen<i> [although
we won’t mention what any of them are]</i> and unexpected<i> [those pesky regulators
in those non-Hampshire services]</i>, our main priorities continue to be on driving
up standards of care and giving patients high quality, safe services<i> [so the
challenges of the Trust providing some terrible services are getting in the way
of the Trust improving their services? Eh?]</i> which improve the health, wellbeing
and independence of the people we serve<i> [yep, we’re just the servants here - job done and on to the next awards ceremony]</i>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
<br /></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com3tag:blogger.com,1999:blog-8154170016308023512.post-36648531261862888582014-03-30T02:05:00.001-07:002014-03-30T02:05:36.132-07:00West Hampshire CCG Board Papers 2013-2014<h1>
West Hampshire CCG Board Papers 2013-2014<o:p></o:p></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As with other CCGs, the West Hampshire CCG (one of three
CCGs in Hampshire) was established on 31<sup>st</sup> March 2013. The reason
for having a look at the Board papers for West Hampshire CCG is that the
headquarters of Southern Health NHS Foundation Trust is in Hampshire.
Furthermore, the NHS Oxfordshire PCT document “Maintaining and improving
quality during transition” (designed to inform newly created CCGs and other new
NHS agencies) specifically stated with respect to Ridgeway (now Southern
Health):<o:p></o:p></div>
<div class="MsoNormal">
<i>5.3.3. NHS Oxfordshire
and all of the direct receiver organisations will not be the lead commissioner
for Southern Health and a relationship needs to be developed with CCGs in Hampshire
to make sure that clinical quality is reviewed to a high level.</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Because of this statement, I thought it was worth looking at
the Hampshire CCGs’ Board papers to see if I could find any Hampshire CCGs
either identifying themselves as the lead commissioner for Southern Health
learning disability services or identifying any other agencies as the lead
commissioner. For example, on at least two occasions the Governing Body papers
for South East Hampshire CCG identify West Hampshire CCG as the lead commissioner
for Southern Health’s learning disability services.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
West Hampshire CCG Board (Governing Body) papers are
available here <a href="http://www.westhampshireccg.nhs.uk/about-us/board-meetings-and-papers">http://www.westhampshireccg.nhs.uk/about-us/board-meetings-and-papers</a>
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for March 2014 Board meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i> <b>Board Quality Dashboard Exception Report Section 3: Southern Health<o:p></o:p></b></i></div>
<div class="MsoNormal">
<i>Six key areas of
concern were highlighted to the Clinical Governance Committee (CGC), which
provide a common theme across all of the services. These were: <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Risk
Assessments <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Care
Planning <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Crisis
Plans <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Care
Programme Approach (CPA) <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Implementation
of service redesign <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>CQC –
non-compliance with standards <o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>Risk assessments, care
plans, CPAs and crisis plans. The concern in relation to assessment and care
planning is that they are often not completed in a timely manner or regularly
reviewed. This can have an impact on the immediate and future care and support
of the individual. Concerns with these issues have been highlighted by SIRI
panels, CQRMs, CQC inspection visits and Commissioners visits. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Implementation of
service redesign . There are some aspects of the implementation of the service
redesign that have been a cause for concern, for example the full implementation
of the Hospital at Home service was not realised in the North. There has also
been an increased use of non-commissioned health beds for people requiring
assessment and treatment; it is worth noting that there may not be a direct
correlation with the service redesign. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>The list below
provides a summary of the assurance methods and processes being utilised by the
commissioner and provider:<o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Area of concern 3. Quality review. </i></b><i>Assurance method/process:<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Monthly
CQRMs have been reviewed and will now be specifically focused on MH/Learning
Disability (LD) services <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>New
quality indicators developed for 2014/15 which are outcome focused <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>CQRM to
include on a twice yearly basis “live patient stories” <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Commissioners
to take part in SHFT’s mock CQC inspections with immediate effect <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>All CQC
reports which fail to meet standards are monitored at CQRM. <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Commissioners
have undertaken a series of clinical visits to all of the MH/OPMH/ LD in
patient units and an unannounced visit was undertaken as a result of the recent
Antelope House inspection visit by CQC <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Analysis
of: unexpected deaths, use of restraint, use of Section 136 suites undertaken
by commissioners <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 20.25pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Robust
SIRI panels include clinical leads and commissioners from CCGs and Wessex Area
Team. <o:p></o:p></i></div>
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<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Area of concern 5. Governance</i></b><i>. Assurance method/process:<o:p></o:p></i></div>
<div class="MsoNormal">
<i>In December 2013
Monitor requested SHFT to request Deloitte to provide assurance and support in
the form of a governance review. This is currently underway and the final
report is due in March to be sent to Monitor. <o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Area of concern 6. Contract</i></b><i>.
Assurance method/process:<o:p></o:p></i></div>
<div class="MsoNormal">
<i>Contract. Commissioners
hold monthly contract and performance meetings with SHFT – this year it has
been necessary to raise a number of formal contract queries – which either have
or continue to be worked through. Concerns remain regarding the use of
non-commissioned beds – commissioners have been invited to an internal SHFT
workshop on 6.3.14 to consider this. <o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><i>Section 3.3: SHFT Risk Summit<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>As previously reported
to WHCCG Board, in January 2014, SHFT received notification from Monitor on 3
December 2013 that they were commencing an investigation due to governance
concerns arising as a result of CQC judgements on the quality of care provided
by the non-Hampshire Learning Disability services of the Trust. The CQC also
raised their concerns with the Oxford Safeguarding Board.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>These included:<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>The
warning notices issued by CQC against six of CQC’s essential standards of
quality and safety after their inspection of Slade House and the Short Term
Assessment and Treatment (STATT) Unit (part of Slade House) in September 2013<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>The death
of a service user at the STATT Unit.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>Monitor held a meeting
with SHFT Trust Board on 10 December 2013. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i> On 19th December 2013 the Wessex and Thames
Valley Area Teams decided that a risk summit should be called to discuss the
long standing and continuous concerns about the welfare and safety of patients
in the non-Hampshire Learning Disability (LD) services in the STATT Unit. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i> The risk summit was held on 8th January 2014
involving both Area Teams, WHCCG, Oxfordshire, Buckinghamshire and Wiltshire
CCGs and local councils. The main focus of the risk summit was on the LD
services provided in Oxfordshire, Berkshire and Wiltshire. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>As a result of the
summit, a meeting was arranged by the Thames Valley Area Team to review the
models for LD provision in the Thames Valley area as the ethos of LD services
within Hampshire is considered to be a more appropriate model which took place
in March 2014. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>WHCCG Learning
disability lead attended the meeting and is producing a summary report which
will be shared at the April CQRM <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>Trust action(s): Progress
reports will be presented to the CQRMs <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>CCG action(s): A
follow up meeting to the Risk Summit will take place on 20th March 2014 which
the Director of Quality is attending <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Finance and Performance Report<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Summary of Southern
Heath’s performance does not mention services for people with learning
disabilities.<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for January 2014 Board meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i> <b>Board Quality Dashboard Exception Report Section 3: Southern Health<o:p></o:p></b></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>3.1 CQC Enforcement actions.</i></b><i>
Enforcement actions were identified by CQC due to major non-compliance with
standards during their visits to Slade House and Antelope House.<o:p></o:p></i></div>
<div class="MsoNormal">
<i>Trust Action(s):
Immediate action plans were put in place to address any immediate concerns.
Further action plans were developed for CQC and shared with the CCG. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>CCG Action(s): <b>Slade House is commissioned by NHS England
via the Wessex Area Team who are monitoring the action plans against compliance
together with Oxford CCG</b> [Bold my emphasis]. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>The action plans for
Antelope House will be reported to the monthly CQRMs until the actions are
closed. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Recommendations: A
visit to Antelope House by WHCCG and SCCCG will be undertaken. <o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>3.2 Monitor Risk Rating.</i></b><i> SHFT
received a notification from Monitor in December informing them that they will
be commencing an investigation due to governance concerns arising as a result
of CQC judgements on the quality of care provided by the Mental Health and
Learning Disability services of the Trust. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Monitor will determine
whether the Trust is in breach of its licence and what, if any, regulatory
action is appropriate in relation to its concerns. <o:p></o:p></i></div>
<div class="MsoNormal">
<i> Trust Action(s): SHFT met with Monitor on 10th
December 2013 in response to this investigation. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>CCG Action(s): WHCCG
will respond to the report from Monitor when produced. Subsequent actions and
recommendations will be monitored via the CQRM. <o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>3.3 CQC Required improvement actions.</i></b><i> Improvement actions were identified by CQC due to <b>moderate non-compliance with standards</b> [Bold my emphasis] during
their visits to Slade House, Melbury Lodge, Antelope House and The Potteries. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Trust Action(s):
Action plans are in place to address these issues. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>CCG Action(s): The
action plans are reported to the monthly CQRMs until the actions are closed. <b>The issues regarding Slade House are being
managed by Oxford CCG and the Local Area Team (NHS England) </b>[Bold my
emphasis].<o:p></o:p></i></div>
<div class="MsoNormal">
<i>A quality and
safeguarding visit was undertaken to Melbury Lodge and assurance was gained
that all actions had been undertaken and there were no care concerns. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Recommendations: A
visit to Antelope House by WHCCG and SCCCG is planned. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for November 2013 Board
meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i> <b>Board Quality Dashboard Exception Report Section 3: Southern Health<o:p></o:p></b></i></div>
<div class="MsoNormal">
<i>3 Southern Health
Foundation Trust (SHFT) (MH/LD and Integrated Community Services) <o:p></o:p></i></div>
<div class="MsoNormal">
<b><i>3.1 Number of SIRIs breaching closure date</i></b><i>: The number of SIRIs breaching their closure date across both the
MH/LD and Community services has steadily decreased and SHFT are on track to
clear these by the end of November. <o:p></o:p></i></div>
<div class="MsoNormal">
<i> 3.2 Commissioners and the provider are reviewing
quality indicators to assess if there are any additional indicators that need
to be added to the dashboard in order to provide a broader view of the Trust. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for September 2013 Board
meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i> <b>Board Quality Dashboard Exception Report Section 3: Southern Health<o:p></o:p></b></i></div>
<div class="MsoNormal">
<i>3 Southern Health NHS
Foundation Trust (SHFT) (Mental Health/Learning Disabilities and Integrated
Community Services) <o:p></o:p></i></div>
<div class="MsoNormal">
<b><i>3.1 Number of SIRIs breaching closure date: </i></b><i>There continue to be a number of Serious Incidents
Requiring Investigation (SIRIs) breaching their closure date across both the
Mental Health/Learning Disabilities and Community services. SHFT have been
asked to clear the numbers breaching by mid-October. This will be closely
monitored by CQRM.<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for 25 July 2013 Board meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i>Board Meeting: Summary of discussions and decisions. </i></b>No mention
of Connor or Southern Health’s learning disability services.<b><i><o:p></o:p></i></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i> <b>Board Quality Dashboard Exception Report Section 3: Southern Health<o:p></o:p></b></i></div>
<div class="MsoNormal">
<b><i>3.1 Monitor Governance Rating</i></b><i>: The governance rating for this foundation trust was amended from
AMBER-RED to AMBER-GREEN in December 2012 following the Trust’s actions to
address previous corporate governance concerns. <o:p></o:p></i></div>
<div class="MsoNormal">
<i> <b>3.2
Number of SIRIs breaching closure date</b>: This has been raised at the
Contract Review meeting with SHFT and will continue to be monitored at this
meeting and at the CQRM when SHFT will be asked for actions as to how they will
bring this under control. <o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for May 2013 Board meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i>Board Meeting: Summary of discussions and decisions. </i></b>No mention
of Southern Health’s learning disability services.<b><i><o:p></o:p></i></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i> Key issues to
note:<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>On reviewing the data
for Serious Incidents Requiring Investigation (SIRIs) reported per
organisation, the CCG’s main Community & Mental Health/Learning
Disabilities services provider, Southern Health NHS Foundation Trust (SHFT),
has significantly higher numbers compared to other providers. This is relative
to the size of the organisation and services provided, however the CCG has been
and continues to follow up the high numbers of pressure ulcers reported. The
number of unexpected deaths for SHFT also appears higher than other providers,
and the Board needs to be aware that this includes all suicides for those in receipt
of care or who have been in receipt of care in the previous six months. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;"><br /></span></b></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for March 2013 Board meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Quality Handover Plan<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Southern Health NHS Foundation Trust <o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Southern Health NHS
Foundation Trust joined with Hampshire Partnership Foundation Trust in 2011 and
has recently acquired the Ridgeway Partnership Oxford Learning Disability NHS
Trust. This means that the Trust is now an extremely large and diverse organisation
providing mental health including medium secure services, learning disability
and community services across a large geographical area. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>In 2011/12, the Trust
received a series of unannounced CQC visits which resulted in issues being
identified at Antelope House, Elmleigh and Ravenswood units. The trust took
swift action to remedy the issues and worked with the PCT Cluster to progress a
programme of unannounced visits. <o:p></o:p></i></div>
<div class="MsoNormal">
<i> The Trust has also inherited an
action plan following a CQC visit to the Ridgeway Partnership Oxford Learning
Disability NHS Trust when non compliance was found in the standard for personal
records. <o:p></o:p></i></div>
<div class="MsoNormal">
<i> The PCT Cluster has been undertaking detailed
work with Southern Health NHS Foundation Trust to understand and ensure there
is timely closure of SIRIs. At the time of writing, there remain 171 open SIRIs
at the trust with the highest trend in SIRIs relating to pressure ulcers. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Scorecard.<o:p></o:p></i></b></div>
<br />
<div class="MsoNormal">
No mention of Southern Health.<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com2tag:blogger.com,1999:blog-8154170016308023512.post-50266535103243180722014-03-30T01:59:00.005-07:002014-03-30T01:59:59.900-07:00South East Hampshire CCG Board Papers 2013-2014<h1>
South East Hampshire CCG Board Papers 2013-2014<o:p></o:p></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As with other CCGs, the South East Hampshire CCG (one of
three CCGs in Hampshire) was established on 31<sup>st</sup> March 2013. The
reason for having a look at the Board papers for South East Hampshire CCG is
that the headquarters of Southern Health NHS Foundation Trust is in Hampshire.
Furthermore, the NHS Oxfordshire PCT document “Maintaining and improving
quality during transition” (designed to inform newly created CCGs and other new
NHS agencies) specifically stated with respect to Ridgeway (now Southern
Health):<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>5.3.3. NHS Oxfordshire
and all of the direct receiver organisations will not be the lead commissioner
for Southern Health and a relationship needs to be developed with CCGs in
Hampshire to make sure that clinical quality is reviewed to a high level.<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Because of this statement, I thought it was worth looking at
the Hampshire CCGs’ Board papers to see if I could find any Hampshire CCGs
either identifying themselves as the lead commissioner for Southern Health
learning disability services or identifying any other agencies as the lead
commissioner.<o:p></o:p></div>
<div class="MsoNormal">
South East Hampshire CCG Board (Governing Body) papers are
available here <a href="http://www.southeasternhampshireccg.nhs.uk/about-us/gbmeetings.htm">http://www.southeasternhampshireccg.nhs.uk/about-us/gbmeetings.htm</a>
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for March 2014 Governing Body
meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i> Performance Report</i></b>. No
mention of Southern Health’s learning disability services in reporting on the
performance of Southern Health.<o:p></o:p></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Joint CCG Governing Body Report</i></b> (think this is joint between
Fareham & Gosport and South East Hampshire CCGs) contains the following:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<b><i>Southern Health Foundation Trust
Mental Health and Learning Disability Services Exception Report.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Care Quality Commission (CQC) visits. </i></b><i>Out of Hampshire areas visited by CQC include Learning Disabilities
(LD): Slade House and John Sharich House. The Trust has received enforcement
notices in relation to these services and NHS England has subsequently held a
risk summit which identified key work streams to progress, with a follow up
meeting planned for March 2014. The LD service pathway in Oxford is under
review and there are plans to implement the Hampshire model. </i><i><b>Monitoring continues via the Lead
Commissioner (West Hampshire CCG)</b> </i>[Bold is my emphasis]<i> with local CCG quality and vulnerable
adults team input.</i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;"><br /></span></b></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for January 2014 Governing
Body meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Performance Report</i></b>. No mention of Southern Health’s learning
disability services in reporting on the performance of Southern Health. <i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Joint CCG Governing Body Report</i></b> (think this is joint between
Fareham & Gosport and South East Hampshire CCGs): No exception reporting
for learning disability services within Southern Health.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for November 2013 Governing
Body meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Performance Report</i></b>. No
mention of Southern Health’s learning disability services in reporting on the
performance of Southern Health. <i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Joint Quality and Safety Report </i></b>contains the following:<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<b><i>Southern Health Foundation Trust
Mental Health and Learning Disability Services Exception Report.<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>Non-Hampshire Learning
Disability quality concern - A CQC inspection outlined concerns re care for
patients in a residential setting in oxford. In addition a SIRI was reported in
association with LD services, raising concerns around governance. The NHS
Wessex Area Team have met with SHFT to discuss in response to concerns voiced
by commissioners and have agreed a way forward. <o:p></o:p></i></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;"><br /></span></b></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for September 2013 Governing
Body meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
No papers beyond the agenda seem to be available online.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for July 2013 Governing Body
meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Performance Report</i></b>. No
mention of Southern Health’s learning disability services in reporting on the
performance of Southern Health. <i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Quality Report</i></b><i> </i>contains
the following:<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><i>CCQ Joint Quality and Safety
Committee proceedings:<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>An update on the
review of placements following the “Winterbourne View “ report, which
demonstrated that all in & out of area placement review s for Fareham and
Gosport and South Eastern Hampshire patients has now been completed.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><i>Southern Health NHS Foundation
Trust [Provider Quality Report]:<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i>Safety/HCAI/SIRIs. </i></b><i>There
were 5 unexpected deaths in April 2013, all of which occurred within
Psychiatric Mental Health.<b><o:p></o:p></b></i></div>
<div class="MsoNormal">
<b><i>Patient outcomes & risks to quality</i></b><i>. Postern House: This LD unit was transferred over to SHFT from
Ridgeway Partnership earlier this year and has one resident from Hampshire who
was transferred from Winterbourne View. Other issues were raised regarding
staffing. A review has been undertaken by SHFT staff and found there to be no
safeguarding concerns. It is planned to undertake an in-depth review in July/August
to determine the future of Postern House. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i>2012/13 Quality Account.</i></b><i> SHFT have provided the CCGs with an
opportunity to review their Quality Account for 2012/13. The Trust is
congratulated on the improvement against a number of local key quality
indicators namely a reduction in incidents involving patient violence, increase
usage of the structured handover tool, increased percentage of patients with a
physical health assessment, and increased usage of patient reported outcome
measures.<o:p></o:p></i></div>
<div class="MsoNormal">
<i>SHFT also achieved a
reduction in violent incidents in Adult Mental Health, Older People’s Mental
Health and Specialised services and a small increase in Learning Disabilities
and Integrated Community services by the end of 2012/13. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i>Summary of Achievements, Best Practice and Areas Under Review</i></b><i>. </i>SHFT Areas Under Review include: <i>Ridgeway transfer; Restraint policies.<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: 12.0pt; line-height: 115%;">Papers for May 2013 Governing Body
meeting<o:p></o:p></span></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Performance Report</i></b>. Very little mention of Southern Health
services at all – no mention of their learning disability services. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Contracting Update for 2013/14. </i></b><i>Includes the following:<b><o:p></o:p></b></i></div>
<div class="MsoNormal">
<i>SOUTHERN HEALTH
FOUNDATION TRUST MENTAL HEALTH (<b>WEST
HAMPSHIRE COORDINATING COMMISSIONER</b>) [Bold my emphasis]: The Contract
document is largely complete. However, there have been some recent QIPP changes
and utilisation of CQUIN money raised by CCGs which need to be reflected in the
documentation. The expectation is that the contract will be signed by 7 May
2013. <o:p></o:p></i></div>
<div class="MsoNormal">
[Are Southern Health’s learning disability services assumed
to be part of their mental health service in terms of the contracting
arrangements?]<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Joint Quality Report<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><i>Southern Health NHS Foundation
Trust Provider Quality Report:<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i>Safety/HCAI/SIRIs. </i></b><i>The
national reporting and learning system (NRLS) March report shows some
improvement for the period 04/12 to 09/12 but SHFT appears to be in the lowest
25% of all MH and LD trusts for reporting incidents. The trust are reviewing
the data and attribute the fall in reporting to the implementation of a new
data system. Further assurances will be sought. <o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i>Patient outcomes & risks to quality</i></b><i>. Ridgeway: a clinical quality review of all former Ridgeway services
was undertaken prior to merger and an action plan is in place to improve
quality. Concerns remain around the quality of services.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i>2012/13 Quality Account.</i></b><i> SHFT have provided the CCGs with an
opportunity to review their Quality Account for 2012/13. The Trust is
congratulated on the improvement against a number of local key quality
indicators namely a reduction in incidents involving patient violence, increase
usage of the structured handover tool, increased percentage of patients with a
physical health assessment, and increased usage of patient reported outcome
measures.<o:p></o:p></i></div>
<div class="MsoNormal">
<i>SHFT also achieved a
reduction in violent incidents in Adult Mental Health, Older People’s Mental
Health and Specialised services and a small increase in Learning Disabilities
and Integrated Community services by the end of 2012/13. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<br />
<div class="MsoNormal">
<b><i>Summary of Achievements, Best Practice and Areas Under Review</i></b><i>. </i>SHFT Areas Under Review include: <i>Ridgeway transfer; Restraint policies.<o:p></o:p></i></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com1tag:blogger.com,1999:blog-8154170016308023512.post-86484611309388537772014-03-30T01:43:00.003-07:002014-03-30T01:43:23.840-07:00NHS Oxfordshire PCT (sub?) cluster<h1>
NHS Oxfordshire PCT (sub?) cluster<o:p></o:p></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
NHS Oxfordshire “Maintaining and Improving Quality During
Transition” document, March 2013, available here <a href="http://www.oxfordshireccg.nhs.uk/wp-content/uploads/2013/03/Paper-13-Oxfordshire-Quality-Handover-Document-FINALv2.pdf">http://www.oxfordshireccg.nhs.uk/wp-content/uploads/2013/03/Paper-13-Oxfordshire-Quality-Handover-Document-FINALv2.pdf</a>
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Documentation concerning the Oxfordshire PCT before this
date seems to be no longer available online – the website address
oxfordshire.pct.nhs.uk goes to a page stating ‘This website is no longer live’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As far as I can tell, NHS Oxfordshire was a merged collection
of PCTs covering Oxfordshire within the larger Buckinghamshire and Oxfordshire
PCT Cluster. Excerpt from Section 5 below:<o:p></o:p></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>NHS Oxfordshire (NHSO)
[a part of NHS Buckinghamshire and Oxfordshire Cluster] is responsible for the
planning and securing of health services and improving the health for the
people of Oxfordshire. NHSO was formed on 1 October 2006 as part of a national
reconfiguration of Primary Care Trusts to reduce their number from 303 to 152.
In Oxfordshire, five Primary Care Trusts were merged to form a single PCT with
a single Board and management team. The principal place of business for NHSO is
Jubilee House, Oxford Business Park South, Cowley, Oxford. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This document is a close match to the quality handover
document excerpted and reported in the newly forming Oxfordshire CCG March 2013
Board Meeting. However, this document does seem to contain more detail in some
respects.<o:p></o:p></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Executive summary:</i></b> One of the 10 “biggest challenges that
future commissioners in Oxfordshire need to focus on” is:<o:p></o:p></div>
<div class="MsoListParagraph" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Improved
learning from serious incidents with the LD Trust</i> <o:p></o:p></div>
<br /><div class="MsoNormal">
<b><i>Section 1.1: Key issues during transition<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>The key issues for
maintaining quality during transition are as follows: <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To ensure
that during transition the needs of the patient remain the key focus for the
health and social care economy <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To
maintain clear lines of accountability at all times to ensure early warning of
any concerns about the quality of care <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To
maintain clear communication channels with staff and patients and to make time
to listen to what they are saying <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To set up
systems whereby hard and soft intelligence on quality is shared with the
receiving organisations<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Section 2: Transition Lead<o:p></o:p></i></b></div>
<div class="MsoNormal">
Sula Wiltshire (Cluster Director of Nursing and Quality at
Oxfordshire PCT – destination Oxfordshire CCG) was one of two people
“responsible for signing off document”.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Section 5.2: Receiver Organisations <o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 5.2.2.: Oxfordshire CCG<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Key Responsibilities
and Functions <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Commission majority of
NHS funded healthcare services – CCGs will be responsible for commissioning the
majority of NHS funded services including: <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Planned
hospital care; (acute and community hospitals) <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Rehabilitative
care; <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Urgent and
emergency care; <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Most
community health services; <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Maternity,
mental health and learning disabilities services. </i><o:p></o:p></div>
<div class="MsoNormal">
<i>Working together with
other commissioners - CCGs will need to work with each other and with other
local partners. For example, where a number of CCGs each commission a
significant volume of care from the same provider, they may wish to agree
collaborative arrangements that enable them to collectively specify services
and monitor the quality of services. They will also need to actively engage the
local communities, patients and service users whom they serve. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 5.2.4.: Oxfordshire County Council<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Key responsibilities
and functions <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Commission learning
disability services on behalf of Oxfordshire CCG – There is a pooled budget
between OCCG and OCC. Both organisations are responsible for ensuring that the
people of Oxfordshire have access to high quality learning disability services.
This is done via a Section 75 arrangement of the contract. The lead
commissioning role is with Oxfordshire County Council. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Section 5.3: Provider Organisations<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 5.3.3 Ridgeway Partnership (now a part of Southern Health NHS
Foundation Trust) <o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Ridgeway Partnership
was one of the leading providers in the UK of specialist health and social care
services for people with learning disabilities and other long term complex care
needs. The Trust specialises in providing services for adults with moderate to
severe learning disabilities and also provides services to people with milder
disabilities and was the Trust that provided healthcare for Oxfordshire
patients. The Trust integrated with Southern Health NHS Foundation Trust in
November 2012. Southern Health provides community health services, specialist
mental health and learning disability services for people across Hampshire and
its surrounding area. NHS Oxfordshire and all of the direct receiver
organisations will not be the lead commissioner for Southern Health and a
relationship needs to be developed with CCGs in Hampshire to make sure that
clinical quality is reviewed to a high level. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>The Trust offers a
range of supported living, community teams, inpatient, step down and assertive
outreach services across Oxfordshire, Buckinghamshire, Swindon, Wiltshire,
Dorset, Bath and North East Somerset. The lead commissioner for the contract with
Ridgeway Partnership is Oxfordshire County Council. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>Challenges <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>To assess
dignity in care in each area and roll out training to all staff in the light of
Winterbourne <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>To develop
best practice guidelines for dysphagia awareness <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>To ensure
all staff, including senior managers, have had appropriate safeguarding
training <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>To ensure
that effective learning takes place following a serious incident as per duty of
candour guidelines<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Section 6: Quality Profile<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.1: Areas of clinical quality challenges (10 areas listed)<o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Improved learning from
serious incidents within the LD Trust: Staff at NHS Oxfordshire have worked
together with Ridgeway to ensure that best practice is implemented to learn
from any serious incidents so as to avoid the possibility of a situation like
Winterbourne View happening in Oxfordshire. Going forward, this relationship
should continue with the lead commissioner for Southern Health. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.2: CQUIN<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.2.1 CQUIN scheme for 2012/13<o:p></o:p></i></b></div>
<div class="MsoNormal">
No CQUINs listed for Southern Health or related to people
with learning disabilities<o:p></o:p></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.2.2 CQUIN scheme for 2013/14 (‘being negotiated’)<o:p></o:p></i></b></div>
<div class="MsoNormal">
No CQUINs listed for Southern Health. ‘Learning
Disabilities’ listed for Oxford University Hospitals.<o:p></o:p></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.3: Quality Account<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.3.3 Ridgeway Partnership <o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Quality improvement
priorities for 2012/13 <o:p></o:p></i></div>
<div class="MsoNormal">
<i>• To continue to
deliver high quality services that safeguard essential standards for service
users <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Rationale: <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To ensure
that services are built on the development of therapeutic relationships between
staff and service users <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To ensure
that practice is based on the best available evidence. To ensure that staff are
provided with the appropriate knowledge to support service users with this
complex health need <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To promote
the importance of policies, procedures and training in relation to Safeguarding
across the Trust, following the Internal Review of Quality and Safety in
response to the Winterbourne View revelations <o:p></o:p></i></div>
<div class="MsoNormal">
<i>• To improve the
effectiveness of assessment and care planning processes across services <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Rationale: <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To
maintain the continuity of effective assessment, care planning and review
processes in the transition from paper to electronic records. <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>The need
to streamline processes and reduce duplication of paperwork in order to ensure
that all service users receive care based on identified needs and that all
service users are offered the same pathway through services. <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>Within the
Forensic Service, there is a need to ensure that service users are accessing
the right facilities with the right level of security to support reduced length
of stay (QIPP Target) <o:p></o:p></i></div>
<div class="MsoNormal">
<i>• To increase recorded
evidence of service user’s experience and involvement in their own care <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Rationale: <o:p></o:p></i></div>
<div class="MsoListParagraph" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]-->•<span style="font-size: 7pt;">
</span><!--[endif]--><i>To ensure
that the broad range of approaches used on a daily basis to involve service
users in their care are captured in a meaningful way and documented within
their care records. <o:p></o:p></i></div>
<br /><div class="MsoNormal">
<b><i>Section 6.4: National quality metrics<o:p></o:p></i></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This section does not seem to contain any information
regarding Ridgeway/Southern Health learning disability services, even in areas
(e.g. inpatient surveys, staff surveys, friends and family test) where such
measures would be relevant.<o:p></o:p></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Section 6.4.6a - Care Quality Commission (CQC) Inspections, compliance
issues and registration status <o:p></o:p></i></b></div>
<div class="MsoNormal">
<i>Oxfordshire Learning
Disability NHS Trust 2012/13</i></div>
<div class="MsoNormal">
<i>Registration details:
Accommodation for persons who require nursing or personal care, Personal care,
Treatment of disease, disorder or injury, Assessment or medical treatment for
persons detained under the Mental Health Act 1983 <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Warning notices: None <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Current status:
Registered <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Section 6.4.6d - Winterbourne View transition arrangements <o:p></o:p></i></b></div>
<div class="MsoNormal">
<i> In May 2011, a BBC Panorama programme showed
disturbing scenes of people with learning disabilities being abused within a
hospital. Oxfordshire had made 3 placements at Winterbourne View (WBV) and 2
Oxfordshire people were placed there at the time of the broadcast. Oxfordshire
County Council (OCC) has responsibility for commissioning specialist hospital
placements for people with a learning disability on behalf of the NHS, through
the pooled budget and lead commissioning arrangements. Like other hospitals,
WBV was regulated and monitored by the Care Quality Commission. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>Following the
identification of the abuse OCC and NHS Oxfordshire carried out reviews into
the commissioning, placement and monitoring arrangements of these 3 patients.
The NHS Oxfordshire review was reported to Oxfordshire Safeguarding Adults
Board and fed into a series of commissioning assurance frameworks submitted to
the SHA jointly by NHS Oxfordshire and OCC. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>A joint action plan
was completed which set out the actions Oxfordshire Commissioners would take to
strengthen the commissioning of specialist inpatient placements for adults with
learning disabilities. A number of strengths in the current commissioning
system were identified including the very low number of out of county placements.
<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>The implementation of
the action plan was monitored through a steering group comprising of the
Commissioning Manager for OCC, Ridgeway Partnership Trust Senior Management and
consultant psychiatrists, service users and carers and Oxfordshire PCT Safeguarding
lead manager. The main findings from the Department of Health ‘NHS Review of
Commissioning of Care and Treatment at Winterbourne View’ have been identified
and addressed in the NHS Oxfordshire / OCC action plan. <o:p></o:p></i></div>
<div class="MsoNormal">
<i>Post Winterbourne view
concordat actions involved ensuring there was an accurate register of LD
patients in NHS funded care and that quality standards had been met for these
patients. Oxfordshire is fully complaint with the concordat requirements. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>The appointment of the
Director of Quality and Innovation to the OCCG, who has responsibility for the
NHS contribution to this work, and Safeguarding Manager, will ensure the safe
transfer and continued application of the WBV, Department of Health review and
Serious Case Review findings. <o:p></o:p></i></div>
<div class="MsoNormal">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Appendix 2: BOx Board Assurance Framework – Oxfordshire<o:p></o:p></i></b></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Risk 3: Accountable Officer Oxon CCG, and Cluster Director of Quality<o:p></o:p></i></b></div>
<div class="MsoNormal">
Under Monitoring of CQUIN, identifies the following risk: <o:p></o:p></div>
<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">• <i>Limited information where PCT is not lead
commissioner, e.g. learning disabilities (social care), and specialised
commissioning </i></span>
<br />
<div class="MsoNormal">
<br /></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com2tag:blogger.com,1999:blog-8154170016308023512.post-75611475290950615982014-03-30T01:34:00.005-07:002014-03-30T01:34:59.120-07:00NHS South of England/NHS South Central Annual Report and Accounts 2012/13<h2>
Strategic Health Authorities (established 1<sup>st</sup> July 2006;
abolished with creation of CCGs on 31<sup>st</sup> March 2013)<o:p></o:p></h2>
<div class="MsoNormal">
<br /></div>
<h3>
<span class="Heading2Char"><span style="font-size: 13.0pt; font-weight: normal; line-height: 115%;">NHS South of England/NHS South Central Annual Report and
Accounts 2012/13<o:p></o:p></span></span></h3>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Available here <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/253755/South_Central_SHA_Annual_Report_and_Accounts_2012-13.pdf">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/253755/South_Central_SHA_Annual_Report_and_Accounts_2012-13.pdf</a>
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
July 2006 to September 2011, Oxfordshire was covered by
South Central SHA.<o:p></o:p></div>
<div class="MsoNormal">
From October 2011, South Central SHA merged with South East
Coast SHA and South West SHA to become one SHA covering the South of England
(although annual reporting was still produced for each individual SHA).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
SHA responsibilities listed in the section ‘About South
Central’<o:p></o:p></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l3 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Providing
strategic leadership to the local NHS, ensuring national policy is implemented
at a local level <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l3 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Leading on
organisational and workforce development, ensuring the NHS organisations in the
region are fit for purpose and have a workforce to meet the future healthcare
needs of the population <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l3 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Developing
plans for improving health services in their region <o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l3 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Making
sure local health services are of a high quality and are performing well.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>The NHS South Central
SHA region consisted of:<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>8 Primary
Care Trusts (PCTs) which merged to form three PCT clusters<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>8 NHS
Foundation Trusts<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>4 NHS
Trusts yet to achieve NHS Foundation Trust status<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>18
Clinical Commissioning Groups<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This report is almost all accounts, I could not see any
mention of services for people with learning disabilities in the report. The
Chairman and Chief Executive’s foreword states:<o:p></o:p></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>Each report should be
read in conjunction with the SHA handover documents:<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Maintaining
and improving quality during transition: handover document<o:p></o:p></i></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><i>Operational
Handover and Closedown Report<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Unfortunately these documents (or any earlier online
information, e.g. papers for Board meetings) do not seem to be available
online.<o:p></o:p></div>
<div class="MsoNormal">
<b><i><br /></i></b></div>
<div class="MsoNormal">
<b><i>Annual Accounts for NHS South Central 2012/13<o:p></o:p></i></b></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->2012/13 Expenditure: £329.3 million, against
available funding of £368.9 million (‘surplus’ of £39.6 million “will be
available to invest across the South Central health economy in future years”)<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l1 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]-->2011/12 Expenditure: £331.8 million, against
available funding of £386.6 million (‘surplus’ of £54.8 million)<o:p></o:p></div>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the ‘related party’ transactions section of the annual
accounts (section 20), £8.6 million is recorded as an expenditure from NHS
South Central to Southern Health NHS Foundation Trust.<o:p></o:p></div>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com1tag:blogger.com,1999:blog-8154170016308023512.post-63348408313783901892014-03-26T03:40:00.000-07:002014-03-26T03:40:07.772-07:00Info Oxfordshire CCG Board MeetingsThis is a set of excerpts from publically available documents concerning the Oxfordshire Clinical Commissioning Group, mainly drawn from documents relating to Board meetings from the CCQ being set up in March 2013 to the upcoming Board meeting in March 2014. They specifically concern information relating to LB and learning disability services commissioning by the CCG (formerly Ridgeway, then Southern Health). There may be much that I've missed.<br />
<br />
<h1>
Oxfordshire Clinical Commissioning Group<o:p></o:p></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Website address for Oxfordshire CCG is here ( <a href="http://www.oxfordshireccg.nhs.uk/">http://www.oxfordshireccg.nhs.uk/</a>
) – all information below is taken from the website.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The names and a bit of background on Board members are
available here <a href="http://www.oxfordshireccg.nhs.uk/about-us/whos-who/">http://www.oxfordshireccg.nhs.uk/about-us/whos-who/</a>
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Board meetings and papers are available here (<a href="http://www.oxfordshireccg.nhs.uk/get-involved/board-meetings/">http://www.oxfordshireccg.nhs.uk/get-involved/board-meetings/</a>
), although the page it takes you to refers to them as Governing Body meetings.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Next meeting Thursday 27<sup>th</sup> March, 9.30-12.30, <span style="background: white;">Jubilee House, Oxford Business Park South, OX4 2LH</span><o:p></o:p></div>
<div class="MsoNormal">
Website states “<i> </i><a href="mailto:oxon.gpc@nhs.net"><i><span style="background: white; border: none windowtext 1.0pt; mso-ascii-font-family: Calibri; mso-border-alt: none windowtext 0cm; mso-hansi-font-family: Calibri; padding: 0cm;">oxon.gpc@nhs.net</span></i></a><i> </i><a href="http://www.oxfordshireccg.nhs.uk/wp-content/uploads/2014/01/Questions-to-Governing-Body-28-Novemberc-.pdf"><i><span style="background: white; border: none windowtext 1.0pt; mso-ascii-font-family: Calibri; mso-border-alt: none windowtext 0cm; mso-hansi-font-family: Calibri; padding: 0cm;">click</span></i></a><span class="apple-converted-space"><i><span style="background: white; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"> </span></i></span><i><span style="background: white; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">here</span></i><span style="background: white; color: #666666; font-family: "Verdana","sans-serif"; font-size: 10.0pt; line-height: 115%;">”. </span><span style="background: white; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">The website says that answers are provided on its website up to 21 days
after the meeting.</span><span style="background: white; color: #666666; font-family: "Verdana","sans-serif"; font-size: 10.0pt; line-height: 115%;"><o:p></o:p></span></div>
<h2>
<span style="background: white;"><o:p> </o:p></span></h2>
<h2>
<span style="background: white;">Papers for March 2014 Governing Body meeting<o:p></o:p></span></h2>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="background: white;">Minutes of January meeting<o:p></o:p></span></b></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><i><span style="background: white;">Section
12: Quality and Performance Report<o:p></o:p></span></i></b></div>
<div class="MsoNoSpacing">
<i><span style="background: white;">She [Director for Quality and Innovation] noted
concerns around the Learning Disability services run by Southern Health NHS FT
and informed the Governing Body that a risk summit had been held with agreed
actions which included a review of how Learning Disability services are
commissioned to review if these can be more community focussed. <o:p></o:p></span></i></div>
<div class="MsoNoSpacing">
<i><span style="background: white;"><o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><i>Section 13: Clinical Assurance
Framework<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>The Interim Chief
Operating Officer was asked about the working of the CQUIN payments. She noted
that CQUINs must incentivise a demonstrable improvement of quality and these
will be a critical part of the approach to commissioning and contracting. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Chief Executive’s
Report [Chief Exec is an interim Chief Exec, Ian Wilson]<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<b><i><o:p> </o:p>9. Southern Health
NHS Foundation Trust</i></b></div>
<div class="MsoNoSpacing">
<i> </i><i>The investigation
report into the death of Connor Sparrowhawk at Slade House, Headington has</i></div>
<div class="MsoNoSpacing">
<i>been published and
the Chief Executive of Southern Health NHS FT which runs the unit has <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>apologised and
confirmed that work is underway to address the findings and recommendations of <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>the report . <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Along with Oxfordshire
County Council, Oxfordshire Clinical Commissioning Group will work to</i></div>
<div class="MsoNoSpacing">
<i>ensure the Trust
undertakes the recommendations from the review as part of an overall <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>improvement plan. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Finance Report<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt;">
<b><i>2.4 Financial Performance –
Mental Health & Learning Disability</i></b></div>
<div class="MsoNoSpacing" style="margin-left: 36.0pt;">
<b><i>Learning Disability Pool</i></b></div>
<div class="MsoNoSpacing">
<i>The month 11
position is based upon the latest pre JMG agreed figures which are for month <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>10. The forecast
position for the pool in total has remained the same as the previous four <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>months at an
overspend of £1.9m for year-end of which the CCG share is 15.13% or <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>£287k.The overall
forecast overspend is after adjusting the expenditure downwards by <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>£1.2m which
reflects the assumption that there are underspends within Personal Budgets <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>and other budget
areas that can be managed to keep the overspend down. There continues <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>to be a level of
anxiety around whether these assumptions will hold true. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>The underlying
overspend has arisen due to panel allocations in the last two months of <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>2012/13 and the
first part of this year which will impact on the remainder of the year. There
is <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>a degree of
uncertainty in the forecast due to possible changes in the timing of
implementing <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>these packages
although this is being closely monitored. The Pool Manager continues to <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>report that all
packages discussed at panel have been through scrutiny at locality teams <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>before coming to
panel and that the majority of high cost requests were for statutory and /or <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>critical needs. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality and
Performance Report<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Executive summary<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c iii.
Learning disability: Concerns about Southern Health increased following a <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>CQC investigation.
Two inpatient facilities are currently closed to admissions. There has been a
coordinated response to the issues at Southern Health by Wessex and Thames
Valley Area Teams alongside CCGs. This work is on-going. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><br /></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Full report<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c iii Learning
disability <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i> </i><i>Learning
disabilities services are commissioned through a section 75 agreement with OCC.
Concerns remain over the safety culture of the inpatient learning disability
services run by Southern Health. Despite established concerns about the quality
of care in inpatient services for people with learning disabilities, the
required improvements did not come about following the transfer of Ridgeway NHS
Trust to Southern Health NHS Foundation Trust. Furthermore there is some
evidence that the change in leadership led to a decline in morale and a
worsening of the situation.</i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>In September 2013,
an unannounced visit from the CQC found serious failings in the <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>STATT unit in
Oxford. The unit was immediately closed to admissions and all patients have <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>subsequently been moved
out. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>A risk summit has
been held as a result of concerns raised and follow up actions are in <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>place and a further
meeting planned. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>The SIRI closure
meeting for the incident in which a young man died in the STATT unit in <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>July 2013 was help
on 26 Feb. Following requests from OCCG SHFT commissioned an <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>independent
company, Verita, to carry out the investigation. The report found that the <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>young man’s death
was preventable and detailed a range of failings in the unit. The trust <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>has accepted the
findings of the report. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Commissioners in
Oxfordshire and Buckinghamshire have continued their suspension of <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>placements in the
Ridgeway Assessment and Treatment Centre in High Wycombe until a <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>programme of
improvements has been completed. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Thames Valley Area
Team of NHS England is coordinating a commissioner wide review of <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>future service
needs. All Oxfordshire patients who are currently in Southern Health inpatient <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>learning disability
facilities are being closely case managed. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><br /></i></div>
<div class="MsoNoSpacing">
<o:p></o:p></div>
<h2>
Papers for January 2014 meeting<o:p></o:p></h2>
<div class="MsoNoSpacing">
<o:p> </o:p><b>Chief Executive’s
Report [Interim Chief Exec Ian Wilson]</b></div>
<div class="MsoNoSpacing">
No mention of Connor or services for people with learning
disabilities<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality and
Performance Report<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<b><br /></b></div>
<div class="MsoNoSpacing">
<o:p> </o:p> <b><i>Executive
summary</i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c ii Learning
Disability: Concerns about Southern Health have increased following a CQC
investigation. Two inpatient facilities are currently closed 14/07 January 2014
4 of 45 to admissions. There has been a coordinated response to the issues at Southern
Health by Wessex and Thames Valley area teams alongside CCGs. This work is
on-going. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><br /></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Full report<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c iii Learning
disability <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>On 27 November the
CQC published its inspection report on Slade House, which comprises 2 inpatient
units for people with learning disability and mental health issues and/or
challenging behaviour. In total there were 6 enforcement notices, and the
remaining core standards were failed with ‘moderate’ concerns. Both STATT
(Short Term Assessment and Treatment Team) and John Sharich House remain closed
to admissions. The greater number of concerns relate to the STATT unit. All the
patients have now been moved out of STATT. Southern Health has put in place a
turnaround team to work intensively with the Slade House units in order to
bring them up to the required standards. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>This closure to
admissions has meant that commissioners have had to place patients in the Ridgeway
Centre in High Wycombe, which is an inpatient assessment and treatment unit run
by Southern Health. Despite a positive CQC report, commissioners have had
on-going safeguarding concerns about the Ridgeway Centre and the decision has
been made not to place in the unit. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Learning disability
services are commissioned by Oxfordshire County Council through a section 75
pooled budget. OCCG is working closely with Oxfordshire County Council, to design
an alternative model of service for this patient group. There has been a
coordinated response to the issues at Southern Health by Wessex and Thames
Valley area teams alongside CCGs. This work is on-going. A risk summit was held
on 8 January 2014. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><br /></i></div>
<div class="MsoNoSpacing">
<o:p></o:p></div>
<h2>
Papers for November 2013 meeting<o:p></o:p></h2>
<div class="MsoNoSpacing">
<o:p> </o:p><b>Chief Executive’s
Report [Chief Exec Stephen Richards]</b></div>
<div class="MsoNoSpacing">
No mention of Connor or services for people with learning
disabilities<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality and
Performance Report<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b><i>Executive
summary<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c ii. Learning
Disability: Concerns about Southern Health have increased following a CQC
investigation: OCCG attended a meeting with Southern Health Executive Team on
16 October. The meeting was organised by NHS England Wessex area team. The
Chief Executive set out assurance of the actions being taken to address the
concerns. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Full report<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c iv.
Learning disability. Concerns remain over the safety culture of the inpatient
learning disability services run by Southern Health. Southern Health has commented
on the enforcement notices which the CQC proposes to issue on the STATT
inpatient service in Oxford and their comments are currently being considered
by the CQC prior to publication. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>OCCG attended a
meeting with Southern Health Executive Team on 16 October along with the other
commissioners of the non-Hampshire LD services. The meeting was organised by NHS
England Wessex area team. The Chief Executive set out assurance of the actions
the trust are taking to address the quality concerns which have been identified
by both commissioners and by the CQC. Commissioners are providing a coordinated
response to this and are setting out the outcomes which they will expect from
these services. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
</div>
<h2>
Papers for September 2013 meeting<o:p></o:p></h2>
<div class="MsoNoSpacing">
<o:p> </o:p><b>Chief Executive’s
Report [Chief Exec Stephen Richards]</b></div>
<div class="MsoNoSpacing">
No mention of Connor or services for people with learning
disabilities<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality and
Performance Report<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Executive summary<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 2 d ii.
Learning Disability – Southern Health: OCCG continues to work with the <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>provider to address
concerns over their safety culture. </i><o:p></o:p></div>
<div class="MsoNoSpacing">
<o:p></o:p></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Full report<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 c ii.
Learning disability.<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>OCCG continues to
work with Southern Health to address concerns over their safety culture. The
Wessex team is coordinating a commissioner-wide approach to issues with
learning disability assessment and treatment services. The performance notice
raised by OCC about the use of physical restraint is currently being addressed
by Southern Health.</i></div>
<div class="MsoNoSpacing">
<br /></div>
<h2>
Papers for 25 July 2013 meeting<o:p></o:p></h2>
<div class="MsoNoSpacing">
<b>Chief Executive’s
Report [Chief Exec Stephen Richards] [reporting first 100 days of Oxon CCG]</b></div>
<div class="MsoNoSpacing">
No mention of Connor or services for people with learning
disabilities<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality and
Performance Report [the first integrated quality and performance report for
Oxon CCG]<o:p></o:p></b></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>[No executive summary]<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Full report<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<i>Section 3 d i.
Southern Health.<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>LD services are
commissioned through section 75 agreement with the CCG and Oxfordshire County
Council (OCC). <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>There are concerns
about the safety culture and quality of patient care in specialist inpatient
‘Assessment and Treatment’ services for people with a learning disability and
mental health issues. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Since 2011 there
have been concerns about the way in which serious incidents requiring
investigation (SIRIs) have been investigated by the Ridgeway Partnership. The
concerns were around the organisational response to incidents and specifically
that they appeared to suggest the lack of a robust safety culture within the organisation.
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>It was hoped that
when The Ridgeway Partnership NHS Trust was acquired by Southern Health NHS Foundation
Trust that concerns would be addressed. However OCCG and OCC have not been ufficiently
assured that the required change has taken place. Currently Oxfordshire are not
placing patients in one Southern Health Assessment and Treatment Service and
there are conditions in place around placing patients in a second service of
this type. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Many of the SIRIs
involve the use of physical restraint. This is a high risk area which requires
a clear organisational approach, strong leadership and close supervision. At
OCCG’s request, OCC has issued a performance notice to Southern Health around
the management of physical restraint. The notice requires that the trust
develops and implements a code of practice for restriction and restraint. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>OCCG and OCC have
been working with Southern Health and continue to do so. OCCG continues to
monitor Southern health SIRIs in services used by Oxfordshire patients closely.
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<h2>
Papers for May 2013 meeting<o:p></o:p></h2>
<div class="MsoNoSpacing">
<b>Chief Executive’s
Report [Chief Exec Stephen Richards]</b></div>
<div class="MsoNoSpacing">
No mention of services for people with learning
disabilities<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality Report<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<i>Section 2 5.
Southern Health <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i> 5.1 Safety culture in learning disability
services <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Since the abuse
uncovered at Winterbourne View by the BBC’s Panorama, there has been an
increased focus on learning disability services, and in particular inpatient assessment
and treatment services for people with learning disability and mental health
issues. Learning disability services in Oxfordshire are commissioned under a section
75 agreement by Oxfordshire County Council. In 2011 NHS Oxfordshire (NHSO)
raised concerns about the safety culture within what was then the Ridgeway Partnership
NHS Trust. In particular there was a concern about the way in which the <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>trust responded to,
and investigated, SIRIs. In November 2012 the Ridgeway Partnership became a
part of Southern Health NHS Foundation Trust (SHFT). NHSO, and latterly OCCG,
had hoped that Southern Health would quickly address our concerns about the
safety culture within the learning disability services. However, progress
towards this aim has been slow. OCCG continue to work closely with SHFT to ensure
a robust safety culture is established. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<h2>
Papers for March 2013 meeting<o:p></o:p></h2>
<div class="MsoNoSpacing">
<b>Chief Executive’s
Report (Chief Exec Stephen Richards]</b></div>
<div class="MsoNoSpacing">
No mention of services for people with learning
disabilities<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b>Quality Handover
Document<o:p></o:p></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><i>Executive summary<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
One of the 10 biggest challenges identified for future
commissioners is “Improved learning from serious incidents within the LD Trust”.<o:p></o:p></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b><i> Full
report<o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Section 5.3.3.
[Provider Organisations] Ridgeway
Partnership (now a part of Southern Health NHS Foundation Trust) <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>Ridgeway
Partnership was one of the leading providers in the UK of specialist health and
social care services for people with learning disabilities and other long term
complex care needs. The Trust specialises in providing services for adults with
moderate to severe learning disabilities and also provides services to people
with milder disabilities and was the Trust that provided healthcare for Oxfordshire
patients. The Trust integrated with Southern Health NHS Foundation Trust in
November 2012. Southern Health provides community health services, specialist
mental health and learning disability services for people across Hampshire and
its surrounding area. NHS Oxfordshire and all of the direct receiver
organisations will not be the lead commissioner for Southern Health and a relationship
needs to be developed with CCGs in Hampshire to make sure that clinical quality
is reviewed to a high level. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>The Trust offers a
range of supported living, community teams, inpatient, step down and assertive outreach
services across Oxfordshire, Buckinghamshire, Swindon, Wiltshire, Dorset, Bath
and North East Somerset. The lead commissioner for the contract with Ridgeway
Partnership is Oxfordshire County Council. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Challenges <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>• To assess dignity
in care in each area and roll out training to all staff in the light of Winterbourne
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>• To develop best
practice guidelines for dysphagia awareness <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>• To ensure all
staff, including senior managers, have had appropriate safeguarding training <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>• To ensure that
effective learning takes place following a serious incident as per duty of candour
guidelines <o:p></o:p></i><br />
<i><br /></i>
<i><br /></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>Section 6.3.3.
[Quality Account] Ridgeway Partnership <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>Quality improvement
priorities for 2012/13 <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>• To continue to
deliver high quality services that safeguard essential standards for service users
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>Rationale: <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o To ensure that services are built on the development of therapeutic
relationships between staff and service users <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o To ensure that practice is based on the best available evidence. To
ensure that staff are provided with the appropriate knowledge to support
service users with this complex health need <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o To promote the importance of policies, procedures and training in
relation to Safeguarding across the Trust, following the Internal Review of
Quality and Safety in response to the Winterbourne View revelations <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>• To improve the
effectiveness of assessment and care planning processes across services <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>Rationale: <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o To maintain the continuity of effective assessment, care planning and
review processes in the transition from paper to electronic records. <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o The need to streamline processes and reduce duplication of paperwork
in order to ensure that all service users receive care based on identified
needs and that all service users are offered the same pathway through services.
<o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o Within the Forensic Service, there is a need to ensure that service
users are accessing the right facilities with the right level of security to
support reduced length of stay (QIPP Target) <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>• To increase
recorded evidence of service user’s experience and involvement in their own care
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>Rationale: <o:p></o:p></i></div>
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<i>o To ensure that the broad range of approaches used on a daily basis to
involve service users in their care are captured in a meaningful way and
documented within their care records. <o:p></o:p></i></div>
<b><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ansi-language: EN-GB; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span></b>
<br />
<div class="MsoNoSpacing" style="text-indent: 36.0pt;">
<b><span style="color: #365f91; font-family: "Cambria","serif"; font-size: 14.0pt; mso-ascii-theme-font: major-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: major-bidi; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast; mso-hansi-theme-font: major-latin; mso-themecolor: accent1; mso-themeshade: 191;"><o:p></o:p></span></b></div>
<h1>
<span style="font-size: large;">
Excerpts from Southern Health Foundation NHS Trust Annual Report 2012/13
(available here <a href="file:///C:/Users/hattonc/Downloads/HANTSPART%20Annual%20%20Report%20and%20Accounts%202012-13%20(1).pdf">file:///C:/Users/hattonc/Downloads/HANTSPART%20Annual%20%20Report%20and%20Accounts%202012-13%20(1).pdf</a>
)</span><o:p></o:p></h1>
<div class="MsoNormal">
<b><i>Quality Report pages 40-41</i></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<b><i>Commissioning for Quality and Innovation
framework (CQUIN) <o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>A proportion of
Southern Health income in 2012/13 was conditional upon achieving quality
improvement and innovation goals agreed between Southern Health and any person
or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the Commissioning for Quality
and Innovation payment framework. Further details of the agreed goals for
2012/13 and for the following 12 month period are available online at: <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>www.gov.uk/government/news/commission-for-quality-and-innovation-scheme-data-available
<o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>In 2012/13 income
totalling £5,446,826 million was conditional upon the Trust achieving quality <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i>improvement and
innovation goals. In 2011/12 income totalling £0.886 million was conditional
upon the Trust achieving quality improvement and innovation goals, of which
payment of £0.772 million were received. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<i><o:p></o:p></i></div>
<div class="MsoNormal">
There is a table of CQUINs on page 41 of the Quality Report
– cannot copy the table but it includes (as well as CQUINs for three other
commissioners that specifically mention learning disability services):<o:p></o:p></div>
<div class="MsoNormal">
<i>Commissioner: Oxfordshire<o:p></o:p></i></div>
<div class="MsoNormal">
<i>Service Area: Learning Disabilities<o:p></o:p></i></div>
<div class="MsoNormal">
<i>Scheme: Improving access to general
healthcare for adults with learning disabilities<o:p></o:p></i></div>
<div class="MsoNormal">
<i> Service user
involvement<o:p></o:p></i></div>
<div class="MsoNormal">
<i> Prison liaison<o:p></o:p></i></div>
<div class="MsoNormal">
<i> Dysphasia<o:p></o:p></i></div>
<div class="MsoNormal">
<i>Available £: £153,974<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>Quality Report pages 54-55<o:p></o:p></i></b><br />
<b><i><br /></i></b></div>
<div class="MsoNoSpacing">
<b><i>Joint Feedback Statement from Oxfordshire
County Council and Oxfordshire Clinical <o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<b><i>Commissioning Group <o:p></o:p></i></b></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Oxfordshire
Clinical Commissioning Group (OCCG) has reviewed the Southern Health NHS
Foundation Trust Quality Account for 2012-13. There is evidence that the Trust
has relied on both internal and external assurance mechanisms to produce this
report. OCCG is satisfied that the Account meets the nationally mandated
criteria for a Quality Account and that the document does not contain any
inaccuracies to the best knowledge of the CCG. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Oxfordshire CCG’s
comments are confined to Southern Health NHS FT services which were previously
provided by the Ridgeway Partnership NHS Trust. The contract with Southern
Health NHS FT for learning disability services is managed by Oxfordshire County
Council under the section 75 agreement. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Oxfordshire CCG is
pleased to see the Southern Health NHS FT’s approach to quality and look
forward to Oxfordshire learning disability services realising the benefits of
the integration. We hope that the integration with Southern Health will address
the concerns expressed last year by NHS Oxfordshire about the lack of emphasis
on continuous improvement of LD services and the lack of information to
demonstrate quality. <o:p></o:p></i></div>
<div class="MsoNoSpacing">
<br /></div>
<div class="MsoNoSpacing">
<i>Oxfordshire CCG
will work together with Oxfordshire County Council and Southern Health NHS FT
to </i><i><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">ensure
that the learning disability services in Oxfordshire are not isolated from the
rest of the Southern Health NHS FT and are therefore able to develop a culture
of continuous improvement. OCCG will continue to seek assurance that a robust
safety culture is developed and evidenced. </span></i></div>
<br />Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com1tag:blogger.com,1999:blog-8154170016308023512.post-49519033414997412742014-03-24T03:26:00.002-07:002014-03-24T03:31:15.653-07:00CCGs with (and without) data returns to NHSE Transforming Care Programme 31 Dec 2013<div class="MsoNormal">
<b><span style="font-size: 14.0pt; line-height: 115%;">From NHSE Summary Analysis for
Transforming Care, summary data for 31 December 2013<o:p></o:p></span></b></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 4.65pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 436px;">
<tbody>
<tr style="height: 15.0pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="height: 15.0pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-size: 12pt;">CCGs
with completed return to NHSE (158 CCGs)<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EASTERN CHESHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH CHESHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 3;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS VALE ROYAL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 4;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WARRINGTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 5;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST CHESHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 6;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WIRRAL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 7;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS DARLINGTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 8;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS DURHAM DALES, EASINGTON AND
SEDGEFIELD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 9;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HARTLEPOOL AND STOCKTON-ON-TEES
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 10;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH DURHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 11;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH TEES CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 12;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BURY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 13;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HEYWOOD, MIDDLETON AND ROCHDALE
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 14;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS OLDHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 15;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WIGAN BOROUGH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 16;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BLACKPOOL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 17;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CHORLEY AND SOUTH RIBBLE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 18;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST LANCASHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 19;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS FYLDE & WYRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 20;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GREATER PRESTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 21;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LANCASHIRE NORTH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 22;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST LANCASHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 23;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HALTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 24;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS KNOWSLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 25;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LIVERPOOL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 26;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTHPORT AND FORMBY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 27;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CUMBRIA CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 28;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NEWCASTLE NORTH AND EAST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 29;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH TYNESIDE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 30;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTHUMBERLAND CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 31;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH TYNESIDE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 32;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SUNDERLAND CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 33;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST RIDING OF YORKSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 34;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HAMBLETON, RICHMONDSHIRE AND
WHITBY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 35;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HARROGATE AND RURAL DISTRICT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 36;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HULL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 37;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH EAST LINCOLNSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 38;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH LINCOLNSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 39;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SCARBOROUGH AND RYEDALE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 40;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS VALE OF YORK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 41;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BARNSLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 42;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BASSETLAW CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 43;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SHEFFIELD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 44;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS AIREDALE, WHARFEDALE AND CRAVEN
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 45;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CALDERDALE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 46;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LEEDS NORTH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 47;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH KIRKLEES CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 48;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WAKEFIELD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 49;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS COVENTRY AND RUGBY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 50;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HEREFORDSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 51;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS REDDITCH AND BROMSGROVE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 52;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH WARWICKSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 53;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH WORCESTERSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 54;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WARWICKSHIRE NORTH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 55;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WYRE FOREST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 56;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BIRMINGHAM CROSSCITY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 57;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BIRMINGHAM SOUTH AND CENTRAL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 58;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS DUDLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 59;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SANDWELL AND WEST BIRMINGHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 60;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WALSALL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 61;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WOLVERHAMPTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 62;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EREWASH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 63;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HARDWICK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 64;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS MANSFIELD AND ASHFIELD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 65;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NEWARK & SHERWOOD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 66;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH DERBYSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 67;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NOTTINGHAM CITY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 68;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NOTTINGHAM NORTH AND EAST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 69;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NOTTINGHAM WEST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 70;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS RUSHCLIFFE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 71;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTHERN DERBYSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 72;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GREAT YARMOUTH AND WAVENEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 73;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS IPSWICH AND EAST SUFFOLK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 74;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH NORFOLK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 75;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORWICH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 76;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH NORFOLK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 77;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST NORFOLK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 78;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BASILDON AND BRENTWOOD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 79;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CASTLE POINT AND ROCHFORD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 80;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS MID ESSEX CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 81;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH EAST ESSEX CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 82;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS THURROCK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 83;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST ESSEX CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 84;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BEDFORDSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 85;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST AND NORTH HERTFORDSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 86;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HERTS VALLEYS CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 87;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LUTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 88;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS MILTON KEYNES CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 89;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NENE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 90;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST LEICESTERSHIRE AND RUTLAND
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 91;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LEICESTER CITY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 92;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LINCOLNSHIRE EAST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 93;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LINCOLNSHIRE WEST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 94;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH LINCOLNSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 95;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH WEST LINCOLNSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 96;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST LEICESTERSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 97;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CANNOCK CHASE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 98;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST STAFFORDSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 99;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH STAFFORDSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 100;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SHROPSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 101;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH EAST STAFFORDSHIRE AND
SEISDON PENINSULA CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 102;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS STAFFORD AND SURROUNDS CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 103;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS STOKE ON TRENT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 104;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS TELFORD AND WREKIN CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 105;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BATH AND NORTH EAST SOMERSET CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 106;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GLOUCESTERSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 107;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SWINDON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 108;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WILTSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 109;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BRISTOL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 110;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH SOMERSET CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 111;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOMERSET CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 112;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH GLOUCESTERSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 113;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS KERNOW CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 114;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTHERN, EASTERN AND WESTERN
DEVON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 115;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH DEVON AND TORBAY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 116;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS ASHFORD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 117;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CANTERBURY AND COASTAL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 118;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS DARTFORD, GRAVESHAM AND SWANLEY
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 119;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS MEDWAY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 120;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH KENT COAST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 121;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SWALE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 122;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS THANET CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 123;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST KENT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 124;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST SURREY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 125;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EASTBOURNE, HAILSHAM AND SEAFORD
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 126;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HASTINGS AND ROTHER CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 127;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HIGH WEALD LEWES HAVENS CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 128;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH WEST SURREY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 129;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SURREY DOWNS CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 130;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SURREY HEATH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 131;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS DORSET CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 132;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS ISLE OF WIGHT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 133;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTHAMPTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 134;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BARKING AND DAGENHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 135;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BARNET CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 136;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BEXLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 137;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BRENT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 138;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BROMLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 139;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CAMDEN CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 140;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CENTRAL LONDON (WESTMINSTER) CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 141;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CROYDON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 142;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EALING CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 143;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS ENFIELD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 144;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GREENWICH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 145;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HAMMERSMITH AND FULHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 146;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HARINGEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 147;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HARROW CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 148;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HAVERING CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 149;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HILLINGDON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 150;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HOUNSLOW CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 151;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LAMBETH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 152;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LEWISHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 153;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NEWHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 154;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS REDBRIDGE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 155;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS RICHMOND CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 156;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTHWARK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 157;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SUTTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 158;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WALTHAM FOREST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 159;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WANDSWORTH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.75pt; mso-yfti-irow: 160; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border: none; height: 15.75pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 326.8pt;" valign="bottom" width="436"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST LONDON CCG<o:p></o:p></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-size: 12.0pt; line-height: 115%;">CCGs with a data return
but no identified patients (11 CCGs)<o:p></o:p></span></b></div>
<br />
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 4.65pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 303px;">
<tbody>
<tr style="height: 15.0pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border-left: none; border-right: none; border-top: solid #BFBFBF 1.0pt; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH SEFTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NEWCASTLE WEST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS ROTHERHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 3;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BRADFORD CITY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 4;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BRADFORD DISTRICTS CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 5;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST SUFFOLK CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 6;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTHEND CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 7;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CORBY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 8;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS ISLINGTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 9;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS KINGSTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 10; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 227.55pt;" valign="bottom" width="303"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS TOWER HAMLETS CCG<o:p></o:p><br />
<br />
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-size: 12.0pt; line-height: 115%;">CCGs with no data
return (42 CCGs)<o:p></o:p></span></b></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 4.65pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 341px;">
<tbody>
<tr style="height: 15.0pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border-left: none; border-right: none; border-top: solid #BFBFBF 1.0pt; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; mso-border-top-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BOLTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CENTRAL MANCHESTER CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH MANCHESTER CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 3;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SALFORD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 4;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH MANCHESTER CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 5;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS STOCKPORT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 6;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS TAMESIDE AND GLOSSOP CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 7;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS TRAFFORD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 8;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BLACKBURN WITH DARWEN CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 9;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS EAST LANCASHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 10;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HALTON CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 11;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS ST HELENS CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 12;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GATESHEAD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 13;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS DONCASTER CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 14;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GREATER HUDDERSFIELD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 15;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LEEDS SOUTH AND EAST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 16;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS LEEDS WEST CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 17;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOLIHULL CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 18;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CAMBRIDGESHIRE AND PETERBOROUGH
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 19;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BRIGHTON AND HOVE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 20;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS COASTAL WEST SUSSEX CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 21;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CRAWLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 22;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS GUILDFORD AND WAVERLEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 23;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS HORSHAM AND MID SUSSEX CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 24;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS AYLESBURY VALE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 25;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS BRACKNELL AND ASCOT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 26;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CHILTERN CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 27;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NEWBURY AND DISTRICT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 28;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH & WEST READING CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 29;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS OXFORDSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 30;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SLOUGH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 31;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH READING CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 32;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WINDSOR, ASCOT AND MAIDENHEAD CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 33;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WOKINGHAM CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 34;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS FAREHAM AND GOSPORT CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 35;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH EAST HAMPSHIRE AND FARNHAM
CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 36;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS NORTH HAMPSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 37;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS PORTSMOUTH CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 38;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS SOUTH EASTERN HAMPSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 39;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS WEST HAMPSHIRE CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 40;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS CITY AND HACKNEY CCG<o:p></o:p></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 41; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-bottom: solid #BFBFBF 1.0pt; border: none; height: 15.0pt; mso-border-bottom-alt: solid #BFBFBF .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.9pt;" valign="bottom" width="341">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
NHS MERTON CCG<o:p></o:p></div>
</td>
</tr>
</tbody></table>
<br />
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
</div>
</td>
</tr>
</tbody></table>
Chris Hattonhttp://www.blogger.com/profile/05299821560069281510noreply@blogger.com0