Incidental?

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.

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 http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incident-reports/

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.

How many incidents?

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.”

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.

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.

What types of incident?

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.”

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.

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.

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.

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.

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.

How much harm do incidents cause?

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.”

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.

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.

How quickly are incidents reported?

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.

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.

What does it all mean?

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?

Diligence My Arse

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/ ).

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.

[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

“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)."

“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)."

End of aside]

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.

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.

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.


Findings

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. 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.’ 

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. 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. 

There were 4 main findings from the review summarised below:

1. 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. 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. The review of Board minutes did not find evidence that the plans went, in aggregate, to the Board for approval, 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. 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. 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 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.

2. 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. 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. 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. 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

3. The implementation of actions identified in response to the due diligence reviews were not monitored routinely by the Board after the transaction date. 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. 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.

4. Board challenge and debate in relation to the transaction could have been more thoroughly minuted. 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.



In a legal sense this might be not be 'gross negligence', but it's disgusting.

Watching the consultants

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

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

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

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

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

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

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

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

How much are they spending?

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

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

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

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

Purpose 1: Surfing the wave of failure

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

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

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

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

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

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

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

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

Purpose 2: Reputation management

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

·        Regulatory compliance ratings as a result of quality issues in LD services

·        Current reputation largely based on quality issues in LD services

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

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

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

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

2013/14:              Procurement advice – KPMG (£115,397)

                              Board & Quality Governance Review – Deloitte & Touche (£65,455)

2014/15:              Financial & governance assurance services – PWC (£28,800)

                              Financial recovery & strategy support – Deloitte (£258,128)

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

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

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

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

Purpose 3: Hobbing with the nobs

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

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

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

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

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

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

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

Purpose 4: Maintaining the Matrix

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

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

It feels to me like pretty much all this consultancy spending is part of a frantic, overwrought attempt to maintain this 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.

Shrink Wrapped Part 2: Shrinking the (e)state

This post carries on where my previous post, Shrink Wrapped Part 1, left off (http://dataforlb.blogspot.co.uk/2015/03/shrink-wrapped-absorption-of-ridgeway.html ). 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 http://www.communitycare.co.uk/2015/03/13/southern-health-set-lose-5m-learning-disability-contract-significant-concern-care/ ). 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). 

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.

My template for looking at this is the behaviour of an asset stripping venture capital company, with stages something like this:

1) Identify a financially struggling company and acquire it at a knock-down price.

2) Reduce running costs as much as possible and don’t make expensive investments into the company.

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.

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.

This post focuses on Stages 2 and 3: after the absorption, what evidence is there in the Board (and other) papers for:

1)  Southern Health making serious investments into former Ridgeway sites (or not),

2)  Southern Health looking to sell off aspects of the former Ridgeway estate?

3) Southern Health looking to then divest themselves of responsibility for former Ridgeway services?

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 (https://www.youtube.com/watch?v=r5XX9LX2es4 ).

We was getting nowhere, and so we had a cuppa tea

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:

“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).

“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).

[Postern House is an inpatient service in Wiltshire where there was heavy capital investment in the year before absorption by Southern Health].

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’:

“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.”

“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).

There are also statements in the strategy about capital investment, with former Ridgeway services mentioned generically but with no specific plans attached:

“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).

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).

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.

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.

Take off all the handles, and the things wot held the candles

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):

“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).

And even at this point, less than six months after absorption, there are ominously worded statements about the Slade site in Oxford:

“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).

It is unclear to me whether the Slade site is being considered as opportunity or challenge.

There are further sinister signs for the Slade site in the 23 April 2013 Board papers, where:

“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).

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 May and 23 July 2013 Board papers. Followers of #justiceforLB might well wonder why this statement disappears from further ‘Divisional Updates’ after this point.

There was more in a similar vein in the 10 Sept 2013 Board meeting, from the acting Chief Executive Officer:

“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”.

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):

“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).

This point of crisis seems to have forced a little more clarity from Southern Health about their intentions for the Slade site:

“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).

By March 2014, the prospects for estates ‘rationalisation’ across Southern Health is becoming more apocalyptic:

“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).

And by June 2014, the specific implications for learning disability services are spelled out:

“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.”

“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).

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).

So Charlie and me had another cuppa tea, and then we went home

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).

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).

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. 

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:

“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).

[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]

This is put in stronger terms in the 25 March Board meeting:

“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).

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).

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?

Southern Health’s 5-year strategic plan, submitted to Monitor, couldn’t be any clearer how things play out, from the SWOT analysis…

[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]

…to the key ‘challenges’ faced by Southern Health’s learning disability services...

…And finally, the entirety of the summary strategic plan for learning disability services (yes, that really is it):

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.

Shrink Wrapped: The absorption of Ridgeway

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 http://www.communitycare.co.uk/2015/03/13/southern-health-set-lose-5m-learning-disability-contract-significant-concern-care/ ).

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?

As @sarasiobhan first suggested last September (https://mydaftlife.wordpress.com/2014/09/01/sunshine-and-shade/ ), 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.

My template for looking at this is the behaviour of an asset stripping venture capital company, with stages something like this:

      1) Identify a financially struggling company and acquire it at a knock-down price.
2) Reduce running costs as much as possible and don’t make expensive investments into the company.
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.

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.

Surely an NHS Trust wouldn’t (and wouldn’t be allowed to) behave like this? Well, let’s see…

Stage 1) Find the limping wildebeest

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.

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 (http://www.lgcplus.com/sponsored-sections/capsticks-social-enterprise/ridgeway-to-be-taken-over-by-non-neighbouring-ft/5040963.article# ). Clearly a limping wildebeest in the pack.

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 http://www.nhsconfed.org/resources/2013/03/service-redesign-case-study-the-southern-health-acquisition-of-ridgeway ). 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 (http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=39988&type=full&servicetype=Inline ) for the absorption to happen in some haste, November 2012, just before Year Zero.

Why was this ‘financially struggling’ Trust so attractive to so many bidders?

First, in the world of NHS absorptions, you don’t have to pay over any cash for your acquisitions.

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.

So, the final accounts for the old Ridgeway Trust for 1^st April – 31^st October 2012 (actually produced by Southern Trust after the absorption and available in the Southern Health Board papers for 29^th May 2013 http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=71931&type=full&servicetype=Inline ) say this:

“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 the wholesale retendering of social care services by Oxfordshire County Council in 2011/2012 [all italics my emphasis]. As a result NHS South Central continued to provide transitional funding whilst the Trust worked with Southern Health to review and refine operating plans ahead of their formal acquisition on the 1 November 2012. Whilst the Trust was able to deliver a financial surplus over the seven months with the help of this financial support, this was slightly less than planned.”

Third, there was some heavy investment in two specific sites before the absorption, amounting to £1.9 million (these quotes also from the accounts):

“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.

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.”

[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?]

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:

“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.

Wadham Court Contracts due to exchange in May 2013

Sellbrook Villa Contracts due to exchange in June 2013

Northview bungalow Being Marketed in June 2013

Lanterns Being Marketed in June 2013”

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.”

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 http://chrishatton.blogspot.co.uk/2014/03/a-public-accounting.html ) reports that fully £8.8 million of this amount was in the form of a ‘revaluation reserve’.

For some reason Mrs Merton’s question to Debbie McGee seems appropriate here: ”So, what first attracted you to the millionaire Paul Daniels?”