Wednesday, 25 February 2015

I'll take the P please Bob

I don’t know if it’s still going or in what guise, but those of a certain age might remember the kids’ TV quiz show Blockbusters, hosted by Bob Holness. Contestants had to choose a letter to get across the board, with the height of hilarity being for a contestant to smirkily ask “Can I have a P please Bob?” So, on the back of three recent CQC inspections which included inpatient services for people with learning disabilities, here’s a multiple choice quiz to help you work out which of these three organisations are taking the P. One point per question if you identify all three organisations correctly.

CQC inspection reports:

1)      Which organisation’s inpatient services for people with learning disabilities were:
a.       Rated overall as ‘Requires Improvement’.
b.      Rated overall as ‘Requires Improvement’.
c.       Not rated overall as the organisation refused to allow the ratings to be made public

2)      Which organisation’s inspection report included the following:
a.       There were potential ligature points in rooms that people who use services have unsupervised access to.
b.       Care was not always being provided in safe physical environments. At the [unit] and [unit] work was needed to address ligature points… We noted that there was only one set of emergency resuscitation equipment across the two units which was stored on [unit 1]. This meant that if a person on [unit 2] needed this equipment staff would need to pass through three locked doors, posing a potential risk.
c.       Not all wards had resuscitation equipment. There were a number of locked doors, stairs and potentially an unpredictable patient group, which may impact how quickly the equipment arrived where it was needed.

3)      Which organisation’s inspection report included the following:
a.       We found that there were not always enough members of staff to care for people safely. Some staff and patients told us that they did not always feel safe on the wards.
b.      The [organisation] relied heavily on agency and bank nurses to staff the wards. On some shifts none of the nursing staff were permanent employees.
c.       All the services were facing challenges in filling all their staff vacancies, but regular agency staff were being used and safe staffing levels maintained. The [organisation] should consider whether it is safe for staff to start working at the [unit] prior to their disclosure and barring checks being in place.

4)      Which organisation’s inspection report included the following:
a.       Contrary to current Department of Health guidance, nurses sometimes restrain people in the prone (face-down) position as a planned intervention to manage disturbed behaviour.
b.      Seclusion facilities were being routinely used for deescalation and time out and not recorded as seclusion.
c.       The seclusion room on the [unit] did not support patient privacy and dignity as there was no separate area for the toilet which was in full view of a large window. There was poor recording of seclusion on [unit]. Seclusion records we reviewed covered a range of time periods from 15 minutes to nine hours which took place one year ago. The longest period of seclusion had no record of a medical review taking place throughout the whole period. There was no evidence the patient had been given the opportunity afterwards to record their views of their experience of seclusion.

5)      Which organisation’s inspection report included the following:
a.       We found that patients had detailed health action plans which had been informed by a number of assessments. However we found one person who had epilepsy did not have a care plan in relation to this despite having a seizure in 2014.
b.      External professionals (NHS England commissioners) told us they were satisfied with the quality of interventions provided by the staff at [unit].
c.       Just two of 33 records that we reviewed contained a health action plan.

6)      Which organisation’s inspection report included the following:
a.       Patient care and risk was not assessed, planned and managed based on individual needs. There was an emphasis on generic, restrictive risk management processes, including restricting visitors and leave, which are not in line with current Department of Health guidance, the principles of the Mental Capacity Act or the Mental Health Act code of practice.
b.      Concerns were raised about the use of the Mental Capacity Act and the exclusion of relatives from decision making.
c.       Ten of 20 care records that we reviewed showed that staff had not adhered to one or more of the requirements of the MHA.

7)      Which organisation’s inspection report included the following:
a.       We found two cases where the best interest decision had been made before the mental capacity assessment had been recorded.
b.      We checked the T2 (certificate of consent to treatment) and T3 (certificate of second opinion) forms. We found that these were not always accurate. Some specified medication the person was no longer taking, or did not always represent the dosage of medication the person was taking, which was over the British National Formulary (BNF) recommended limit.
c.       Whilst medicines were stored securely, the facilities for the storage of controlled drugs were not in accordance with [organisation] policies.

8)      Which organisation’s inspection report included the following:
a.       People using the services were cared for by staff who were very motivated and supported people with care, dignity and respect.
b.      The great majority of the people who use services that we talked to told us that they were treated kindly and respectfully by staff. The care interactions that we observed supported this.
c.       We observed little activity or interaction between staff and patients on the wards we visited. Some patients told us that they were well cared for and they had no concerns about the staff. Some patients felt angry and frustrated by how they are treated; stating that staff do not listen to them and did not always speak to them with respect.

9)      Which organisation’s inspection report included the following:
a.       The [organisation] must ensure it supports staff working in the [name of unit] so they have regular line management input, understand the changes that are taking place and receive support in an appropriate style to facilitate them to perform their roles.
b.      Some of the governance arrangement were not fully effective. This is demonstrated by: a failure to recognise and address unsafe night-time cover…; a lack of awareness of and failure to follow [organisation] policies relating to seclusion, segregation and restraint; a failure to provide adequate training for staff in the skills required…; poor adherence to the requirements of the Mental Health Act.
c.       Some staff told us that there was little engagement with senior managers or the organisation`s values. We were told that many of the governance, care and treatment processes were centrally administrated.

Organisations’ press releases:

10)   Which organisation’s press release:
a.       Welcomes the CQC report.
b.      Welcomes the CQC report.
c.       is ‘no longer available’ on the organisation’s website.

11)   Which organisation’s Chief Executive has stated that:
a.       The CQC highlighted positive examples.
b.      There are a number of areas of practice highlighted as good within the report.
c.       It has confirmed that we are right to have confidence that our services are effective, caring and responsive.

12)   Which organisation’s Chief Executive has stated that:
a.       The report also highlighted a number of areas for improvement, which we have already begun to address.
b.      A major programme of work began in the summer to address the negatives and learn from the positive and safe practice found by the CQC.
c.       The inspection has highlighted aspects which can be improved and this resonates with the things we have already identified for improvement in our immediate and future plans. 

You scored:

0-4:        What are you, some kind of person using the service or family member or something? You shouldn’t have been allowed anywhere near this quiz.
5-8:        You seem to be mistaken that inpatient services for people with learning disabilities all have similar fundamental problems.  
9-12:      An excellent score – you’re clearly been paying too much attention to be a commissioner.
13:          Congratulations, you are clearly a Chief Executive in the making!


1)      a or b: St Andrews and Southern Health                                c: Calderstones
2)      a: Calderstones                 b: Southern Health                        c: St Andrews
3)      a: St Andrews                    b: Calderstones                            c: Southern Health
4)      a: Calderstones                 b: St Andrews                    c: Southern Health
5)      a: St Andrews                    b: Southern Health          c: Calderstones
6)      a: St Andrews                    b: Southern Health          c: Calderstones
7)      a: Calderstones                 b: St Andrews                    c: Southern Health
8)      a: Southern Health          b: Calderstones                                c: St Andrews
9)      a: Southern Health          b: Calderstones                                c: St Andrews
10)   a or b: Southern Health and St Andrews                                c: Calderstones
11)   a: Calderstones                 b: Southern Health          c: St Andrews
12)   a: Southern Health          b: Calderstones                                c: St Andrews


The CQC inspection report of Calderstones Partnership NHS Foundation Trust available here (quotes taken from inpatient services report).

The CQC inspection report of St Andrews Healthcare available here (quotes taken from services for people with learning disabilities or autism report).

The CQC inspection report of Southern Health NHS Foundation Trust available here (quotes taken from wards for people with learning disabilities or autism report).

The Calderstones full response to the CQC report is available here The Chief Executive’s statement in response to the CQC inspection is on his blog here (17th December entry)

The St Andrews press release in response to their CQC inspection is available here

The Southern Health press release in response to their CQC inspection is available here

Thursday, 12 February 2015

Flux = Rad

(from The Beano)

On Twitter this morning, Martin Routledge (@mroutled) posted the following in response to David Brindle’s story in The Guardian headlined ‘NHS to shut many residential hospitals for people with learning disabilities’ ( ):

“@GdnSocialCare interested to hear thoughts of @ndtirob @AliciaWood_HSA @GeorgeJulian @chrishattoncedr – beginning of end or…”

I’ve been out and about all day so have mulling on this without much clarity, but rather than clogging up people’s twitter feeds with 100s of ill-formed tweets I thought I’d just do a quick blogpost instead.
I watched the Public Accounts Committee session where Simons Stevens, Chief Executive of NHS England first mentioned the c (closure) word (the full transcript of the session is here ). To be honest, at the time it didn’t strike me as that big a deal, largely because any plan that involved significant numbers of people not being in these services any more (like the, er, Winterbourne View objectives?) would have to mean some closures anyway. 

Just a few observations, issued from different parts of my brain:

[Policy wonk part of brain] 1) The responses to the Public Accounts Committee didn’t contain anything materially new from the NHS England Transforming Care document (which to be fair was only published the week before – see my take on this here but really read the #justiceforLB Herb Audit Office report here ). However, public mention of closures from Simon Stevens (with his ‘NHS Change Day’ lightbulb commitment the following day to ‘help improve services for people with learning disabilities’) raises the public stakes in ways that must be helpful.

[Policy wonk part of brain] 2) The Public Accounts Committee seemed fairly aghast that some of the big failures of the original programme (which seem to me largely commissoners and providers of these places swaggering up to the DH in best Horrible Histories rap style and chanting “You gonna make me?”) basically have been left unaddressed, with NHS England taking the rap but at the same time tiptoeing round commissioners, service providers, social care generally (who they?) and the Ministry of Justice rather than tackling them head on. As John Lish noted in a superb analysis of the session ( ) the question of funding yielded no satisfactory answers, and without this being addressed what’s going to be different from first time round?

[Perhaps what I can call the #justiceforLB part of my brain] 3) A really striking thing for me from the session is the technocratic language world that senior people seem to live in (see Mark Neary’s blogpost for more on this and other issues ), and that more ‘cleverness’ may not be what’s essential here to drive through fundamental change – now is the time for people with learning disabilities and families to be really in charge, with access to undoubted necessary cleverness that will work under their direction.

[#justiceforLB brain] 4 and last) These services are not going to give up without an almighty fight, and NHS England had better be ready for the streetfighting required…

Exhibit A: Findings from the Learning Disability Census show that they’re already digging in to defensive positions to protect themselves (see ), for example the number of people ‘not dischargeable’ due to behavioural risks to self or others or mental illness increasing by a whopping 80% from 496 people in 2013 to 895 people in 2014.

Exhibit B: Reacting to a news story about the closure of Calderstones NHS Trust (partly on the back of a fairly damning CQC inspection report ), a story in the Lancashire Telegraph showed the range and scale of opposition to any potential closure ( ), including:
  •            the local MP Nigel Evans (“There is always going to be a need for secure units, so I don’t see how every patient can be released into the community quite frankly. And I don’t really see the benefit of moving patients to smaller units around the country, as I’d still say there’s a need for big and more centralised institutions so that economies of scale kick in. My belief is that Calderstones is essential.”)
  •           the local councillor Terry Hills (“There have been concerns historically about patients ‘getting out’ of the site, but I don’t think there have been any issues for a while. I wouldn’t say Calderstones is an asset to the village, it’s just been there for many many years. Undoubtedly it would have a big impact were it to close, as they employ a lot of people, but my main concern is where would the patients go?”)
  •           and the local Clinical Commissioning Group (“We are not aware of any plans to close the trust at all, however we are monitoring the situation very closely, noting that the trust is nationally recognised as a specialist forensic learning disability service”.).

Exhibit C: This week, the CQC published another damning report of a ‘specialist service’, this one private, St Andrews. For their services for people with learning disabilities and/or autism, every single area was rated as requiring improvement (see ). The overall summary is shocking in the range and fundamental nature of the failures in these services.

St Andrews have, of course, ‘welcomed’ the CQC reports (see ). And Manjit Darby, Director of Nursing and Quality for NHS England (Central Midlands), said: “We welcome the CQC’s report into St Andrew’s Healthcare. We have been working actively with St Andrew’s and its health partners to ensure improvements to services and are pleased to note the areas of good practice and progress made to date. As the CQC identifies, there are some areas still requiring improvement and we will continue to work with St Andrew’s to address these for the benefit of patients.”
Calderstones Hospital started as “accommodation for imbeciles and epileptics”, with building starting in1907 ( ). St Andrews started life as the Northampton General Lunatic Asylum in 1838 ( ). They’ve survived two world wars, the creation of the NHS and deinstitutionalisation. Cleverness is important, but people up for the fight are essential. If these providers will be singing this ( ) we need people who will sing this (  ) – written and performed by @KatharineChrome.

Wednesday, 4 February 2015

Reconfiguring support for people with MP (Member of Parliament) syndrome: A cost-effective proposal for the 21st and a 1/2th century

Image from


People with MP syndrome (or P-WiMPS) are a small but highly resource intensive cohort of people in England. There are currently 650 people identified with MP syndrome in England, all of whom are supported in a single specialist day facility in London, popularly known as the House of Commons. There are also a much larger number of people with proto-MP syndrome (otherwise known as Prospective Parliamentary Candidacy), some of whom go on to develop full-blown MP syndrome. An equivalent number of people with MP syndrome recover from the syndrome, although a disproportionate number are at risk of later developing the closely related Peer Spectrum Disorder. On the same site as the House of Commons, there is also a national specialist centre for the assessment and treatment of Peer Spectrum Disorder, known as the House of Lords. Together (with smaller community-based facilities such as Portcullis House) these make up the Westminster Foundation Trust.

The Problem

Despite recent Government attempts to modestly reduce the number of people with MP syndrome using the House of Commons, numbers have remained largely static at around 650 people since 1801 ( ), as regularly documented in the Dimblebum Election Night Census. The number of people with Peer Spectrum Disorder treated in the House of Lords has fluctuated greatly over time, from a maximum of 1,330 people as recently as 1999 to the current 774 places ( ).

The Westminster site is composed of a large Victorian complex that is no longer fit for purpose – both the House of Commons and the House of Lords do not have sufficient bench space for collective vocational ‘taster’ activity sessions in their respective ‘chambers’. Despite heavily subsidised meals and regularly prescribed ethanolazine, high further PRN doses are administered on a daily basis. The overcrowded nature of the Westminster site also makes the provision of seclusion rooms problematic.
Despite the specialist nature of these settings, unacceptable levels of challenging behaviour, albeit with different profiles, are present in the House of Commons and the House of Lords. In the House of Commons, prevalence rates of Oppositional Defiant Disorder can approach 50% and rates of hyperactivity, attention seeking and verbal aggression are even higher. Incidents of physical aggression requiring the attention of the police and verbal aggression outside the institution have also occurred, and patients are liable to mass debate with little apparent provocation. In the House of Lords, nonorganic hypersomnia is the most common disorder. The presence of TV cameras within the Westminster site has resulted in widespread public revulsion at the practices happening within it.

Past attempts at deinstitutionalisation have not been successful. Whilst people with MP syndrome notionally still have homes in their local communities (known as constituencies), Westminster can be hundreds of miles from these ‘constituencies’. P-WiMPS in practice spend so much time in ‘temporary’ residential placements near the Westminster site (the longest of these placements can last for decades) that connections to their ‘constituencies’ can become tenuous and their ‘home’ communities hostile.

There is also increasing public concern about the quantity of hard-working taxpayers’ money being spent on these services. In 2012/13, the net cost of administering the House of Commons was £201 million ( ). Placement fees charged for P-WiMPS (typically broken down into ‘salaries’ and ‘expenses’ included £103 million in ‘expenses’ in 2013/14 ( ). As the ‘salary’ component of P-WiMPS’ fees vary so much, a total is difficult to determine ( ), but is estimated to exceed £45 million per year. This results in a total unit cost for P-WiMPS at the Westminster site of £537,076 per person per year.

People with Peer Spectrum Disorder are currently being treated at a somewhat lower unit cost. The total cost for the House of Lords for 2012/13 was £88 million ( ) - a unit cost of approximately £114,000 per Peer per year.

The Proposal

As Nigel Evans, a person with MP syndrome himself, has pointed out, “There is always going to be a need for secure units, so I don’t see how every patient can be released into the community quite frankly. And I don’t really see the benefit of moving patients to smaller units around the country, as I’d still say there’s a need for big and more centralised institutions so that economies of scale kick in.” ( )

Given the unsuitability, high refurbishment costs and high market value of the current Westminster Foundation Trust site, this proposal aims to achieve economies of scale through relocation to a more suitable site.

This site has been identified as RAF Binbrook ( ) in Lincolnshire. A former airfield, this site already has the essential features for cost-effective support for both P-WiMPS and P-WiPSD, including a well-maintained barbed wire perimeter fence. Existing watchtowers will be converted to remote-controlled ‘Hey there buddy, just making sure you’re Okely Dokely’ Nodes, which will be monitored from highly specialised staff in the former air traffic control tower (amphetamines will be provided to facilitate cost-effective shift patterns).

The current house-like atmosphere of the Westminster site will be preserved in two architecturally thrilling open plan corpuscules, where residents can flow freely between their bunk beds, the toilet and the food troughs. To celebrate both the old and the new sites, these will be named the Hangar of Commons and the Hangar of Lords.

Nissen huts on the site will be preserved in their current states of picturesque dereliction for use as ‘Time To Yourself’ havens of seclusion. Behavioural management will be state of the art, using equine pharmacological transfer technology – in a wholly new development to the UK, Xylazine will be routinely placed into the food troughs and the water supply. Residents will also have the opportunity for vocational training under the exciting new ‘Frack With a Garden Trowel’ scheme and will grow their own food through the ‘That’s a Turnip for the Books!’ programme.

Support from Antisocial Investment Inc (“You’ll believe a vulture can smile”), allied to the sale of the Westminster site and the closure of all ‘constituencies’ and temporary residential placements, will allow Westminster Foundation Trust to be transformed into Saint Binbrook’s Corp. We are confident of the success of this model of provision, and are already exploring further potential sites with the Nuclear Decommissioning Authority.