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

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

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

[GIF from http://giphy.com/ ]

Under pressure

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

Without explicitly saying so, many of the Trust’s 13 ‘Key Actions’ for 2016/17 [pages 7-8] reflect serial failures, including:

·        “Delivering the SIRI and Mortality Action Plan in response to the Mazars report”

·        “Continuing to deliver our quality programme in response to the findings of the CQC comprehensive inspection in Oct 2014 and subsequent inspections in July 2015 and Jan 2016”

·        “Restoring public confidence in the services provided by the Trust by demonstrating delivery of high quality services, and engaging with our service users, their families and our staff” [NHS Improvement enforcement actions, a CQC warning notice and the reasons for the lack of public confidence in Southern Health services are not mentioned]

·        “Transforming the provision of secure mental health and learning disability services within a limited capital budget” [note the lightly veiled pleading for extra capital funding there, even though the acquisition of the former Ridgeway Learning Disability Trust in 2012 came with over £8 million in reserves]

·        “Ensuring the safe transfer of Learning Disability services to new providers in Oxfordshire and Bucks” [this is apparently a “Key Action to introduce new models of care to meet the needs of tomorrow”]

·        “Recruiting and retaining sufficient staff with the skills and competence required to deliver high quality care, and minimise the level and cost of usage of agency staff in line with nationally set targets” [the closure of a major inpatient mental health service, Antelope House, for at least 8 months due to their inability to recruit staff, is just one illustration of their problems with recruitment]

Money’s too tight to mention

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

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

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

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

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

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

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

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

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

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

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

When is a consultant not a consultant?

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

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

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

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

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

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

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

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

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

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

Candour Crush Saga

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

Performance Analysis (page 10)

“The Trust continues to meet its access targets and outcome objectives as defined by its regulator, Monitor. We are pleased that our performance against meeting these measures is consistent and strong, and we will continue to focus on improving further”.

[Two things about this. 1) This performance is the only one in the Monitor dashboard that doesn’t have a quantifiable indicator next to it – Trusts rate their own performance and unsurprisingly Southern Health have rated themselves as ‘Green’ throughout. In fact, throughout the whole 197 pages I couldn’t find any specific evidence about the quality of services for people with learning disabilities, the outcomes of their services, or feedback from people with learning disabilities using their services. 2) You have to wait until page 61 to find out that Monitor have consistently rated Southern Health Red for governance and has been subject to enforcement ‘actions’ throughout 2014/15 and 2015/16]

Quality Governance (page 25)

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

[Either they weren’t actually compliant, or Monitor’s Framework is rubbish]

Duty of Candour (page 118)

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

[So, for Duty of Candour, they didn’t report everything they should have done but said in their reports that they had]

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

[This is part of the CEO’s closing official statement in the report, and sums up the clash of reality vs spin quite well]

“On the basis of the above, I have concluded that some internal control issues were identified in 2015/16, as set out in the enforcement undertakings agreed with Monitor, the warning notice from CQC and the Notice of Imposition to impose an additional licence condition issued by NHS Improvement. As such, it is acknowledged that within 2015/16 not all governance processes were fully effective and as a consequence we cannot declare that all functions have been exercised economically, efficiently and effectively.”
“Notwithstanding this, my review confirms that we have made significant progress to address any weaknesses in the system of internal control, deliver agreed undertakings and to ensure compliance with our provider licence.”

[What made me do a double take was when I was looking through the 2013/14 Annual Report, two years earlier, and found this in the equivalent CEO statement – page 73]

“On the basis of the above, I have concluded that there have been control issues identified in 2013/14, as set out in the enforcement undertakings agreed with Monitor, which identified a failure of governance arrangements within the Trust. Actions have been agreed with Monitor, as part of the undertakings, to address these concerns. As such, it is acknowledged that within 2013/14 not all governance processes have worked effectively and as a consequence the Trust cannot declare that all functions have been exercised economically, efficiently and effectively.”
“Notwithstanding this, my review confirms that the Trust is taking appropriate actions to deliver the agreed undertakings and ensure compliance with the Trust’s provider licence and to address any weaknesses in the system of internal control.”

[The main lesson learned appears to be how to copy and paste]

Failing and flailing

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

There was one dose of reality in the Annual Report, in the feedback provided by Healthwatch Oxfordshire (other feedback went as far as expressing disappointment, but mainly understanding of the ‘challenging year’ Southern Health had experienced because of that pesky external scrutiny). Seems a fitting place to close this extremely long post:

“Given the findings of the CQC that the improvement work undertaken in the last year has not been consistent across the trust, and that the governance around improvement, and learning from incidents is wanting, I wonder how Southern Health aims to reassure patients and the public that these quality priorities will be realised.”
“Since the ‘big plan’ consultation we have heard very little in the way of feedback about Southern Health, so it is difficult to assess whether or not the quality priorities identified for 2016/17 address the concerns of patients, service users and their families other than the concern that there’s consistent, negative news about the quality of Southern Health.”

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

The return of the repressed

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

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

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

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

Tim Smart, Interim Chair of Southern Health NHS Foundation Trust, said: Following my appointment as Interim Chair on 5 May 2016, I am today publishing a summary of a comprehensive review of the issues and a recommended course of action.

I would first like formally to extend my deepest apologies to the individuals and families who have been deeply affected by recent events. I can only imagine the pain they are suffering.

It is easier to only imagine the pain rather than actually meeting families to find out about it.

I was appointed to make an objective assessment of the reasons behind the failings at Southern Health and the best way forward for the Trust, its patients and its staff.

There were failings in Southern Health. 'Objectivity' implies that previous or alternative assessments are 'subjective' and therefore 'emotional' and not to be trusted. This immediately rules out the domains of injustice and families' distress as irrelevant.

In the last six weeks I have reviewed the available evidence. I have met with many individuals and organisations, including patients, families, staff and Governors. I have also initiated an independent Board Capability Review.

Linked to the point above, presumably the 'available evidence' was only the 'objective' evidence - and the track record of Southern Health in relation to making evidence available is, er, questionable, shall we say? 

I am confident that we are making progress, and I know that our staff are doing everything they can to deliver high quality care. But it is clear that some of our more complex services feel less connected to the organisation.

The 'we' indicates that Tim Smart identifies himself as part of Southern Health, while at the same time providing an 'objective' assessment of it. 

It's the next sentence that starts doing the real rhetorical work though. First, the use of 'complexity' - professional shorthand for 'We don't have a clue what's going on but we can't admit it so you punters won't understand it either'. I fail to see why services for people with learning disabilities and services for people with mental health issues are more complex than the wide range of other services that Southern Health provides, like community diabetes services or the management of chronic pain. That these services feel 'less connected to the organisation' is an odd and revealing phrase - so these 'complex' services (the ones causing the trouble) are not a core part of Southern Health but are more or less connected to it. This has been a repeated refrain of Southern Health corporate communications for some time - there is a core of 'real', 'good' services and there is 'non-Hampshire' bad stuff which was taken on through some sort of mistaken act of kindness, apparently.

It is my opinion that the Board of Southern Health should have spent longer in its early years creating an integrated, patient focused, operationally efficient culture. Before it did that, it acquired the Ridgeway Partnership despite understanding the risks. Ever since, the Executive team has been too stretched to guarantee high quality services everywhere that Southern Health operates. To resolve this failure changes are being made to the Board.

Note 'my opinion' here - not quite the rigorous application of objective evidence

To my mind, this is quite damning in its assessment of a strategic and operational failure at Southern Health, driven by the CEO and the Board. In its early years (led by, erm, you know who) they were inefficient, all over the place, and not concentrating on the people they supposedly serve. They knowingly 'acquired' Ridgeway knowing that they weren't ready or able to manage it properly. 'Too stretched' attempts to distance the Board from responsibility (the not enough resources line), but it was and is within the power of the Board to increase those resources to make them less stretched (unlike many of their staff, who presumably really are stretched but have no power to change this). It is also worth remembering that at various points the Board restructured themselves to have fewer rather than more people on it. 

On the basis of the evidence before me, I am recommending that Southern Health transform the way in which it delivers services, and makes changes to the structure and strength of its leadership team:

This introduction screams big changes afoot - 'transform', 'makes changes'. What follows...

1)    Following the outcome of the Board Capability Review, I am satisfied that whilst the Board should have acted in a more united way, I have found no evidence of negligence or incompetence of any individual Board member. As we progress with delivering the strategic plans for the organisation, consideration will be given to the findings of the Board capability review and further strengthening of the Board will be required to ensure the best balance of skills and expertise.

This might be called the 'Murder on the Orient Express' defence - in this story each person only stabbed the victim once each, so none of them individually could be counted as responsible for a murder. So a collective, corporate negligence (as we saw in LB's inquest) cannot be used to hold anyone to account. The thought that collective catastrophic incompetence and negligence should have a collective solution, i.e. removing the entire Board, does not seem to occur.

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

2)    I know there is interest in the Chief Executive of the organisation and  I can confirm that Katrina Percy will continue in this role. However, until now she has been too operationally focused in her role. She will shift her focus to delivery of the future strategy of the Trust which I believe needs to be accelerated. The Executive team will be restructured, to allow a more concentrated effort on the day to day delivery of high quality, safe services for patients. This will require a much more outward looking Board, which will at the same time put absolute priority on improving the quality of services provided.

This is where the incoherence becomes screamingly obvious. The statement earlier gives examples of massive strategic and operational failures in taking over Ridgeway and before, and the 'evidence' (whether Tim Smart counted it as such or not, such as the Mazars report) overwhelmingly points to an incompetently operationally managed organisation (this is putting it kindly). As CEO, Katrina Percy was also responsible for (and at the time very happy to paint herself as leading) the big strategic decision to 'acquire' Ridgeway. So, she was responsible for massive strategic failures while, at the same time, presiding over continued operational failure.

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

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

3)    It is clear to me that the Trust needs to change the way it delivers services because currently it operates across too broad a spectrum of clinical services and too wide a geography. The plan is for Learning Disability Services provided by Southern Health in Oxfordshire to be transferred to Oxford Health NHS Foundation Trust as soon as agreement is reached. Other changes will occur.

In other words, the 'bad', troublesome parts of Southern Health (services for people with learning disabilities, especially outside Hampshire) are to be cut away (although the Oxfordshire services decision was taken by the commissioners, not Southern Health, some time ago). Again this is consistent with the long-running Southern Health narrative about their 'core' services, and basically will try to undo the acquisition of Ridgeway (although with Southern Health retaining an awful lot of moolah from this acquisition).

4)    I will establish a Steering Group to further develop and accelerate implementation of Southern Health’s strategic vision for the future, alongside the soon-to-be published Sustainability and Transformation Plan (STP) for Hampshire and the Isle of Wight. The Steering Group’s first task will be to commission a review of the way Southern Health’s services are organised. This will be led by clinicians and commissioners, and it will result in the future form of Southern Health being changed.

Another day, yet another review. If Katrina Percy's future is in strategy, it is unclear why a Tim Smart-initiated strategic Steering Group is necessary (again, to constrain her from actually making any decisions?). Also interesting that, despite his opening lines, no patients or family members are to be on this Steering Group.

Based on my experience and the evidence presented I am confident that these recommendations will see an improvement in the running of the Trust and most importantly in the care provided to patients. We must acknowledge, however, the failures that have occurred in the past and I again unreservedly apologise for this.

The way forward is complex and difficult and success will be dependent on excellent team work within Southern Health, and first class collaborative working with all local stakeholders, patient groups, provider organisations, commissioners, regulators and staff. Southern Health provides good and essential services to a very large population. The Board must now work together to ensure that care quality continues to improve.

I would like to extend my thanks to all of those individuals and organisations who have lent their time and commitment to this important review process.

So we have failures 'that have occurred in the past' (erm - Coroner's inquest evidence Tim?) but that still need Southern Health to have patient care as their highest priority. We have a radical way forward for Southern Health that is likely to involve them returning to the services they were delivering 5 years ago. We have catastrophic failures of strategy and the way Southern Health provide services that none of the Board were individually responsible for. We have operational failures presided over by a CEO who was spending too much time on operations, but the CEO is not responsible for them. We have a major strategic failure in the 'acquisition' of Ridgeway that was led by a CEO who is not only apparently not responsible for this decision, but who is going to spend more time on strategy. We have an 'objective' review that appeals to the authors' opinion and experience.

Is that it? Tim Smart seems to think so, if his response to @BBCMBuchanan is anything to go by. But apparently some of the things he was told by families while the statement was released have given him ('feigned'?) pause for thought, and Alistair Burt's response to a TV reporter (sorry - can't remember who or the link - I'll update the blog if I can find it) was a rather curt and repeated 'This is not concluded'.

The sheer incoherent nonsense of this statement is obvious for anyone to see. The truth is there, and no carpet is big enough to hide it. Do we want the truth? We can handle the truth - it's the health 'system' that seemingly can't.

March of the lawyers

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 http://dataforlb.blogspot.co.uk/2015/07/watching-consultants.html ). I’ve now got this information for 2015/16 (in two batches because I was impatient, see https://www.whatdotheyknow.com/user/chris_hatton ) via the good offices of What Do They Know? and the genuinely efficient FoI office at Southern Health.

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.

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.

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.

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.

So who are the lawyers and what are they getting paid for? We know from the excellent My Life My Choice (see http://mylifemychoice.org.uk/how-much-did-southern-health-nhs-trust-spend-on-connor-sparrowhawks-inquest/ ) 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.

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).

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” (https://www.bevanbrittan.com/insights/articles/2011/avoidingacoronersrule43reportataninquest/ ) and “Under the microscope: a note on inquests and NHS Trusts” (https://www.bevanbrittan.com/insights/articles/2013/thewideninggyre/  ), which has the following gem of wisdom:

“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.”

Other new entries for 2015/16 were Hempsons (‘Leading lawyers for health and social care’ http://www.hempsons.co.uk/ ) – paid £52,147 in 2015/16 by Southern Health, and Weightmans LLP (‘A top 45 law firm’ http://www.weightmans.com/ ) – paid £45,669 by Southern Health in 2015/16.

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 (http://www.talentworksltd.com/case-studies/going-viral-wins-national-award ) - spending went from £908,832 in 2013/14 to £642,272 in 2014/15 to a big fat zero in 2015/16.

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.

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’ https://www.linkedin.com/company/irg-advisors ) 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 http://www.paconsulting.com/ ) pocketed £56,056 in 2015/16.

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, that St Andrews), also for ‘LD management’.

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?).

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?

And finally, Southern Health paid £47,280 to Aston Organisation Development, but £42,552 was paid back.  Aston Organisation Development (see http://www.astonod.com/ ) 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?

Days of judgement

The latest (in a long series) of damning CQC reports concerning Southern Health NHS Trust (see press release here http://www.cqc.org.uk/content/southern-health-nhs-foundation-trust-still-not-doing-enough-protect-people-its-care ) 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:

“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.“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.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.”

The CQC’s remedy for this long-standing and dangerous continuing failure of leadership at the Trust? This:

“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.”

Meanwhile, a brief statement from NHS Improvement says:

“We’ve read the Care Quality Commission’s report and it makes extremely disappointing reading.We recognise the seriousness of the situation at Southern Health and it’s clear that urgent improvement is needed at the trust.We’re currently considering whether to take any further regulatory action.”

 [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]

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.

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.

This first graph below (from the Board papers for 27^th 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’).

This way of reporting deaths was judged to be inadequate, and a new ‘improved’ system for reporting deaths began on the 1^st 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.

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^st December 2015 to 21^st March 2016.

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.

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?

 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^st December 2015 to 21^st 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.

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 nothing else.

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.

We do know that pretty much since the Mazars report up until the 21^st 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.

Easy chair

[This picture is from the website http://montazne-hise-on.net/nenavadni-pocivalniki.html]

Another day, another Freedom of Information request. 

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. 

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 )

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.

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. 

Of these 3 shortlisted candidates, 1 withdrew, leaving just 2 people.

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.

 '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. 

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. 

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.

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...

The cycle of (no) change

Here's the well-known cycle of change, from the stages of change model of Prochaska and DiClemente (this diagram is from Social Work Tech).

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).

Don't wanna die before I get old

Public 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.

So, here's my equivalent map for median age of death for people with learning disabilities, in a nutshell. You're welcome.