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
http://mydaftlife.wordpress.com/the-report/].
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].
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.
Commissioners
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.
