Friday 14 March 2014

A public accounting

A public accounting
Coming up to three weeks after the publication of the independent investigation into Connor Sparrowhawk’s death (aka LB – or Laughing Boy) the fitness for purpose of the NHS Trust responsible, Southern Health NHS Foundation Trust, is becoming increasingly questioned. A series of CQC (Care Quality Commission) inspections reporting very poor standards of care requiring enforcement action across a range of Southern Health services, allied to the health regulator, Monitor “investigating governance concerns triggered by CQC warning notices”, reinforces the sense that all is far from well at Southern Health.

[For all the latest news, as well as an ever-lengthening series of blogs from a wide range of people showing their support for @sarasiobhan and @JusticeforLB and their horror at the way the Trust dealt with LB and his family, please go to ‘The Connor Report’ (we really need a Starsky & Hutch-style theme tune) on @sarasiobhan’s blog here].

In a series of magnificently forensic blogs, @rich_w has gone through the independent investigation report, Southern Health Board minutes and the media appearances of Southern Health staff to raise fundamental questions about Southern Health’s fitness for purpose in the face of repeated poor standards of care across a range of services, with a characteristic pattern of responding that aims to evade responsibility and brush any issues under a (by now surely very large and very bulging) carpet [these blogs can be found under the name ‘arbitrary constant’ in the Connor Report].

Southern Health’s Annual Report and Accounts for 2012/13 are publically available on the Monitor website (see here ), so a combination of my nerdy tendencies and waking up at 4am with jetlag in a hotel room with no tea or coffee led to a somewhat feverish set of tweets as I started looking through the annual report. This blogpost is simply an attempt to put some of these tweetish observations into one place, in slightly more measured fashion.

So why look at the annual report for 2012/13? LB was admitted to the STATT unit on 19th March 2013, towards the end of the period the annual report is reporting on. For me, there are two reasons for looking at the report in some detail. First, it might contain useful information on how the Trust was operating up to the time that LB entered the unit. Second, it might give further clues as to how Southern Health NHS Trust characteristically chooses to present itself and its activity, and whether this is consistent with other observations of how they have reacted to bad news about their services.

I write this blogpost as a citizen, and my analysis of this Annual Report is partial in all senses of the word – I focus on information as it relates to services for people with learning disabilities rather than the operations of the Trust as a whole, and I am partial to #justiceforLB.

Empire State Human
Although the annual report doesn’t foregreound this, it is clear that Southern Health has been a Trust going through considerable expansion in a short period of time. The original Trust was Hampshire Partnership NHS Foundation Trust, which became Southern Health when it ‘acquired’ (page 6) Hampshire Community Health Care on 1 April 2011. It then also ‘acquired’ Oxfordshire Learning Disability NHS Trust in November 2012. Southern Health now provides a huge range of services (their list includes Community Services, Child and Family Services, Adult Mental Health Services, Older People’s Mental Health Services, Specialised Services, Learning Disabilities Services, and Social Care Services) over a wide geographical area.

Clearly Southern Trust is following a determinedly expansionist policy very quickly (why, for example, is an NHS Trust looking to expand its social care provider services), and there are legitimate questions about the extent to which any organisation can handle such rapid absorptions of very different organisations with such diverse responsibilities.

Leadership, governance and challenge
In the introduction, there is a quote from Katrina Percy, the CEO of the Trust (on maternity leave at the time the annual report was written), stating among other things that “…We know that leadership directly impacts quality of care…” (page 4). Given the poor quality of care being found in repeated CQC inspections, does this mean that Katrina Percy has accepted that her poor leadership has ‘directly impacted’ the quality of care at Southern Health? As @rich_w has shown in his analysis of her only media appearance to date in response to the independent investigation report, the answer so far seems to be ‘no’, with a clear pattern of shifting the responsibility on to others. The independent report itself clearly shows a pervasive lack of clinical leadership in the Trust and a lack of anyone taking responsibility for LB’s care, a theme repeated in other CQC inspection reports of Southern Health services. 

Scattered throughout the annual report are indicators that all has not been well at Southern Health in terms of leadership, governance and challenge (pages 27-51). For example, during 2012/13 there was an extraordinary turnover of personnel at Board level, which sends danger signals to me about the extent to which the work of the Trust in 2012/13 was subject to proper scrutiny. Over the course of 2012/13, five out of eight Non-Executive Directors left the Board, to be replaced by only three Non-Executive Directors – two Board meetings in the year had only three or four Non-Executive Directors in attendance.

In addition, during 2012/13 the Director of Finance and Corporate Services left the Trust (the former Chief Operating Officer and the Medical Director left the Trust during 2011/12). The Commercial Director and Director of Health Technology Outcomes posts were also downgraded from Executive Director status in 2012/13 as part of plans to reduce the size of the Trust Board (despite an expanding Trust remit).
This adds up to an unstable Board with a cadre of Directors with no longer-term knowledge of the Trust.
Despite (or because of?) this instability, the Board was happy to self-certify to Monitor that it was compliant with Monitor standards on Access to Care: Learning Disabilities for every month in 2012/13 (Quality Report page 50) – a slightly surprising finding given the lack of evidence they have concerning people with learning disabilities throughout the Trust (see below).

There are also hints that the Council of Governors for the Trust was also in turmoil in 2012/13; “In the latter part of 2011/12 we identified issues surrounding our corporate governance arrangements which meant we did not meet the terms of the Trust Constitution”. The Council of Governors “did not include the requisite majority of public Governors or a minimum of one Staff Governor from each staff category” (page 31). Of the 38 places for Governors in the revised arrangements, fully 10 places were not filled during 2012/13.
As an indicator of the active involvement of Governors, try this statement: “The draft Quality Account was sent to Governors on 9 April 2013 asking for comments. No comments, suggestions or amendments to the content or layout were received.”

Money – that’s what I want 
The annual report paints, in its terms, a positive picture for Southern Health’s finances. So, after taking everything into account, Southern Health ran an ‘operating surplus’ of £1.5 million in 2012/13 (page 21). Their financial plans for 2013/14 (page 24) project a 5% cut (sorry, ‘challenging cost improvement programme’) but an increased operating surplus of £4.5 million.

It might also be worth mentioning that the ‘absorption’ of Oxfordshire Disability NHS Trust added £16.3 million to Southern Health’s accounts (page 21), including £8.8 million of ‘Revaluation Reserve’ (page ii of Appendix C).

Personally, the aggregate renumeration of the CEO, Katrina Percy, increased from £160,000-£165,000 in 2011/12 to £175,000-£180,000 in 2012/13 (page 56). There’s a revealing table on page 57 (prefaced by “We are obliged to disclose…”) which states the salary of the highest paid Director in the Trust compared to the median salary of a full-time staff member in the Trust. In 2011/12, the CEO’s renumeration was £165,000-£170,000 compared to a median salary of £26,264 (so the CEO was earning 6.4 times as much as the median staff member in the Trust). In 2012/13, the CEO’s renumeration had gone up to £175,000-£180,000 while the median staff salary had gone down to £25,255 – the CEO was now earning 7 times as much as the median staff member in the Trust. The CEO’s pension pot (in cash equivalent transfer value – page 58) also increased from £306,000 in 2011/12 to £369,000 in 2012/13.

The unbearable invisibility of being a person with learning disabilities in Southern Health
At various points throughout the annual report, Southern Health reports on its success in gaining positive feedback from people using its services. So on page 10, there is a one-page up-front table of Southern Health’s achievements in 2012/13. One of these achievements is “We achieved the 95% target for responses to our patient experience survey”. However, “Information for learning disabilities…is not yet available as some modifications to the survey procedure are required” (Quality Report page 24).

Similarly, 9 out of 10 clinical divisions in the Trust provided evidence of using patient reported outcome measures in their services. “The exception was the Learning Disabilities division which highlighted that it was hard to use such measures with their service users.” (Quality Report page 23). There were no specific plans to develop these in 2013/14.

A Trust target of 100% of service users having a care plan that has been developed with them and/or their main carer did not seem to have been audited in learning disability services (Quality Report page 25).
Possibly due to the recent ‘acquisition’ of Oxfordshire Learning Disability Trust (the name of this former Trust varies slightly throughout the Southern Health Annual Report), the Quality Report states that “Information from the former Oxfordshire Learning Disability Trust is not included in these performance reports as it makes it difficult to show progress against targets originally set by Southern Health” (page 8). Figures for learning disability services are also not provided for medicine reconciliations (“the numbers are very small” Quality Report page 10), and the use of the Patient Safety Thermometer in adapted form for people with learning disabilities was going to be piloted in February 2013 (data anyone?; Quality Report page 13).

It is worrying that most of the major tools cited by Southern Health as markers of their quality are not being used with people with learning disabilities in the service, with no clear plans for ensuring this happens in the future.

Ooh matron!
The annual report makes much of its quality assurance procedures. The annual report is liberally sprayed with statements like “We are committed to using robust evidence as the basis for improving care” (page 11).
As one example, the upfront table of Southern Health’s ‘achievements’ on page 10 states “We achieved our target of matron walk rounds using a structured handover tool”, and this ramblin’ matron appears on a number of occasions as a key plank of Southern Health’s quality assurance processes. However, as we now know (and as Southern Health personnel have effectively admitted in their media appearances) these matron walk rounds were completely ineffective at spotting poor practice and doing anything about it.

I was also surprised to read (page 62) that Southern Health in 2012/13 had conducted no less than 198 internal mock CQC inspections. Again, given what actual CQC inspection reports are finding in relation to some of Southern Health’s services, it is unclear what the point of these mock CQC inspection reports is. Interestingly, most of the recommendations coming out of these mock CQC inspections were around staff training, supervision and support (page 63).

During 2012/13, 17 CQC inspections were conducted, of which three inspections resulted in concerns being raised (page 63). The Trust’s gloss on this is on page 66, “All three services have fully implanted action plans to resolve all issues raised by CQC therefore the Trust declares it’s self [sic] as compliant with the CQC registration requirements.”

Overall, there seems to be a dangerous combination of ineffective quality assurance procedures which are not recognised as such by the Trust. Do these quality assurance procedures really encourage honest and open critique and challenge, with the determination to improve services as a result?

You’ve got to accentuate the positive, eliminate the negative, and latch on to the affirmative, don’t mess with Mr In-Between
Although Southern Health presents their information as showing a consistently positive picture, there are some indicators that might have given a more reflective organisation cause for concern, or at least pause for thought. I also have some concerns about the style in which some of the information is presented,
For example, the Trust received:
·         398 complaints in 2012/13, up from 342 in 2011/12 (a 16% increase)
·         475 concerns in 2012/13, down from 554 in 2011/12 (a 14% decrease)
·         1511 written compliments and letters of thanks in 2012/13, up from 854 in 2011/12 (a whopping 77% increase)
The Trust also state that they implemented a revised Complaints policy – from the figures above, it seems that this revised complaints policy has mainly resulted in a massive increase in compliments!

Another example concerns data from the National Staff Survey (pages 16-17). Among other things, it reports that:
·         90% of Southern Health staff reported errors, near misses or incidents witnessed in the last month in 2012, compared to 96% of Southern Health staff in 2011.
·         74% of Southern Health staff reported working extra hours in 2012, up from 69% of Southern Health staff in 2011.
Neither of these statistics are mentioned in Southern Health’s textual gloss of ‘particular achievements’. The increased staff absence rate (from 4.3% in 2011/12 to 4.6% in 2012/13) is not really mentioned either (page 18).

On page 26, the Trust reports that is has put in place a whistle-blowing policy, but reports no data concerning if it has ever been used.

Appendix A (the sustainability report) contains a minor but revealing example of tricky stats. Page 1 reports the number of assaults to NHS staff in Quarters 1, 2 and 3 of 2012/13 (345, 377 and 380 respectively). It then goes on to say “The total number of incidents represents 66% of the previous year’s total figure indicating a significant reduction in the number of incidents”. So it looks to me like they’re comparing figures for 9 months of the year in 2012/13 to figures for a full 12 months of the year in 2011/12 and claiming a big reduction. If the Trust is prepared to present misleading statistics in this minor example (at a constant rate projected for the whole year, there would still be a smaller reduction from 2011/12 to 2012/13), it severely reduces my confidence in the way they present the rest of their figures.

Another example concerns serious incidents (Quality Report page 15). In 2012/13, 372 serious incidents were reported in the Trust, although following clinical review 36 of these incidents were downgraded, leaving a total of 337 [sic]. The 337 is presented as “a decrease of 5% compared to 2011/12 (353).

From these 337 serious incidents, none were considered to be “Never Events” (the term for serious patient safety incidents considered largely preventable”.

Or try this one – the number of patient safety incidents that have to be nationally reported (Quality Report, page 45). The report says that the number of patient safety incidents nationally reported went down from 5704 in 2011/12 to 5106 in 2012/13. Looks like good news, except that the percentage of these incidents that resulted in severe harm or death increased from 1.26% in 2011/12 to 1.94% in 2012/13. By my calculations, I think this means that the number of patient safety incidents resulting in severe harm or death increased from 72 in 2011/12 to 99 in 2012/13: these figures are not cited in the report.

The picture for people with learning disabilities
Where information is available for people in the Trust’s learning disability services, the overall picture is of a worrying disconnection of the learning disabilities services from the rest of the Trust.

For example, a reduction in patient violent and aggressive incidents resulting in physical injury was reported for almost all areas of the Trust’s services, although there was a slight increase in incidents in learning disability services (Quality Report page 9).

The implementation of an early warning scoring system to spot physical deterioration in patients actually decreased over time in Trust services (including services for people with learning disabilities) (Quality Report page 12).

The Trust set itself a target of 100% of inpatients with learning disabilities to have a physical healthcare assessment – although this target wasn’t met (at 96% in 2012/13) this quality indicator was not planned to be repeated in 2013/14 (Quality Report page 22).

The most detailed picture of Southern Health’s services for people with learning disabilities comes from an audit of 35 patient records in 2013 (compared to 41 patient records in 2012), all of inpatients with learning disabilities in the former Oxfordshire Learning Disability Trust services (Annex 4, pages 66-70). In 2013, 32 out of 35 people audited had a risk assessment recorded, compared to 30 out of 41 people in 2012. However, fully 100% of audited records included the patient’s name and date of birth (hooray!).
Of the following components of the core assessment for inpatients with learning disabilities, the following percentages of audited records actually had them recorded:
·         Mental health:                     85.7% 2013          (55% 2012)
·         Behaviour:                          91.4% 2013          (55% 2012)
·         Physical health:                   91.4% 2013          (57.5% 2012)
·         Social connections:             71.4% 2013          (50% 2012)
·         Housing:                             65.7% 2013          (45% 2012)
·         Finance:                             48.6% 2013          (25% 2012)
·         Occupation/activity:            45.7% 2013          (15% 2012)
·         Employment/training:          48.6% 2013          (20% 2012)
·         Risk:                                  91.4% 2013          (77.5% 2012)
·         Substance & alcohol:         82.9% 2013          (37.5% 2012)
·         Service user strengths:         2.9% 2013            (10% 2012)
·         Carers assessment:            28.6% 2013          (0% 2012)

In most areas the proportion of people having risk assessments is increasing, but in most areas they are still a long way from 100% and in one area (assessing service user strengths) an already very low percentage decreased still further in 2012/13 to 2.9%. Family carer involvement in assessments was also very low in 2012/13, at 22.9%. Although it is difficult to infer a great deal from these data, it looks like learning disability services were being encouraged to increase their record-keeping in a narrow range of areas (mental health, physical health, behaviour, risk) while being much less assiduous about the whole range of other areas of people’s lives that would be crucial in maintaining community, social and vocational connections and working to help people move back out in as short a time as possible. And of course, the independent investigation report and the CQC inspection report show how such record-keeping was chaotic, unrelated to the support of people in the service, and conducted by staff at the expense of spending time with people in the service.

In terms of interventions, the following were recorded in the audit (all these are required by NICE guidelines):
·         De-escalation:                                   54.3% 2013          (43.9% 2012)
·         Managing disturbed behaviour:          77.1% 2013          (48.8% 2012)
·         Physical intervention:                         51.4% 2013          (34.2% 2012)
·         Seclusion:                                            2.8% 2013            (73.1% 2012)
·         Observation levels:                            45.7% 2013          (39% 2012)
·         Physical health:                                  57.1% 2013          (51.2% 2012)

The trends on recorded interventions are in some respects welcome (particularly the reduction in seclusion), although an increase in physical intervention (and what actually happens within the category of ‘managing disturbed behaviour’?) is concerning.

Reflecting the method used for this audit, which did not directly evaluate the quality of services, particularly in terms of the experiences of people who were staying there or their families, the summary of key findings (despite statements such as “It is not always clear whether the absence of Care Plans reflects clinical need”) focuses its recommendations almost exclusively on improved record keeping rather than improving the quality of the services.

One of the levers that service commissioners have is the Commissioning for Quality and Innovation Framework (CQUIN). This is basically where commissioners set targets for an NHS Trust to meet, with extra money attached if they are met. For Southern Health in 2012/13, five commissioners set six different CQUINs. Four of these CQUINS concerned Southern Health’s learning disability (or mental health and learning disability) services, and in total these four CQUINs were worth £2.6 million to Southern Health. For example, Oxfordshire commissioners had a specific CQUIN about learning disability services, including “Improving access to general healthcare for adults with learning disabilities; Service user involvement; Prison liaison; Dysphasia” (I’m assuming this is dysphagia?) (Quality Report page 40).

Clearly, more than one commissioner had the health of people with learning disabilities in their minds when it came to Southern Health. It is also clear that Oxfordshire commissioners had real concerns about the learning disability services being ‘acquired’ by Southern Health, as they state in their feedback statement (Quality Report page 54), which is worth quoting at some length:

“Oxfordshire CCG is pleased to see the Southern Health NHS FT’s approach to quality and look forward to Oxfordshire learning disability services realising the benefits of the integration. We hope that the integration with Southern Health will address the concerns expressed last year by NHS Oxfordshire about the lack of emphasis on continuous improvement of LD services and the lack of information to demonstrate quality.”

“Oxfordshire CCG will work together with Oxfordshire County Council and Southern Health NHS FT to ensure that the learning disability services in Oxfordshire are not isolated from the rest of the Southern Health NHS FT and are therefore able to develop a culture of continuous improvement. OCCG will continue to seek assurance that a robust safety culture is developed and evidenced.”

So commissioners were worried about the quality of the learning disabilities services being ‘acquired’ by Southern Health, and there was a sizeable financial incentive for Southern Health to report to commissioners that these services were OK.

Duck-billed platitudes
The annual report is stuffed full of aims, values, strategic objectives, masses of initiatives that they’re taking very seriously, and so on. Partly this is a function of the somewhat chaotic and fast-moving policy environment that any Trust is having to negotiate at the moment. But having read through it, the lack of connection or consistent thread through this welter of totes initiativeballs is really striking – I didn’t get a clear sense of which bits of the Trust were doing what, who was responsible and how it all worked. One section that really pulled me up was the section on “Our response to the Francis Report” (pages 12-13), mainly because it contained a succinct list of the themes identified in the Francis Report:
·         Negative culture
·         Professional disengagement
·         Patients not heard
·         Poor governance
·         Lack of focus on standards of service
·         Inadequate risk assessment of staff reduction
·         Nursing standards and performance; and
·         Wrong priorities

For all the strategies, briefings, listening exercises and priorities described in the annual report, pretty much all of these themes (and more) were present in STATT when LB was admitted there. This is why more words from Southern Health about learning the lessons, moving on, strategies, actions and all the rest of it sound so unconvincing – this annual report is full of them, but they didn’t mean that LB was treated with the bare minimum of care, expertise and respect which we all expect (and for the most part get) from our NHS. Southern Health are going to have to work a lot harder than more duck-billed platitudes.


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