On December 19th I travelled to Hereford in driving rain for a public Board meeting of the 2gether NHS Foundation Trust, the mental health trust for Gloucestershire and Herefordshire. According to Monitor, the independent regulator of foundation trusts, Board meetings do not have to be held in public, but meetings of the Council of Governors do. 2gether chooses to hold public Board meetings, mostly in Gloucester but a proportion in Hereford. Oddly, the Trust appears to make no special provision for the public to attend its Council of Governors meetings.
On entering at the venue, the Shire Hall, which looks like an ancient Greek temple from the outside, I was disconcerted to find police and lawyers milling about what was clearly a law court. It turned out the meeting was in a room at the back. The Board had met in private in the morning before reconvening in public in the afternoon.
No member of the public public turned up. By that I mean that although there were about half a dozen of us in the public seats at the back of the room, all but one were already known to Baroness Fritchie, who chaired the meeting, and the one person she didn’t already know was a representative of a group she knew.
I won’t go into detail about all the content of the meeting, because Trust publishes the agenda and papers online and the minutes will be published in due course.
Openness and complaints
The agenda always includes provision for formal questions from the public, and one had been submitted about the Trust’s implementation of the guidance on openness from the National Patient Safety Agency (its Being Open framework). The question was handled fluently but only briefly, with a full written answer to follow, as the questioner was not present. Again, however, the questioner was not public public, but someone well known to many people at the meeting.
The Being Open framework is all about incidents that affect patient safety, and:
Saying sorry when things go wrong
My recollection of the reply is that it didn’t specifically address patient safety incidents and saying sorry, so it will be interesting to see whether the written answer does.
A later agenda item (14, paper H) concerned the Trust’s handling of complaints, which is closely related to openness about incidents. One of the complaints audited by a non-executive director referred to poor communication from the Trust, although the audit also found improvements such as offers to discuss the complaint with someone from the Trust early on, and an empathetic tone in letters sent to complainants.
Amongst various recommendations resulting from the audit, one was to try harder to discover whether complainants were satisfied with the Trust’s response, because this was often unclear, or at any rate unrecorded. In discussion a good point was made that satisfaction with the process and satisfaction with the outcome may be different things, so that they should be determined and recorded separately.
For me, this item about complaints handling was the high point of the meeting. I thought the written report was concise, the recommendations sensible and the discussion fruitful. It was disappointing, though, that no one made the connection with the NPSA guidance mentioned earlier.
Mental Health Act
An item (10, paper E1) about the Trust’s policies and practices in relation to the Mental Health Act 1983, as amended by the Mental Health Act 2007, ran into a spot of bother when directors tripped up over the legal terminology.
The 2007 amendment introduced Community Treatment Orders (under section 17A of the Act) for people who are considered to need compulsory treatment but who do not need to be detained in hospital. Previously, such people would have to be detained in hospital (“sectioned”) and then given leave to go home (under section 17 of the Act) without actually removing the legal compulsion on them to be treated. Clinicians now have to decide which of the two available sections, 17A or 17, is best for each patient.
It had been discovered that to some extent clinicians in Herefordshire tend more to use section 17A community treatment orders, while clinicians in Gloucestershire tend more to use section 17 leave. This was not identified as a problem, but just something that should be monitored.
The problem was with the teminology. The Act uses the terminology longer-term leave to mean leave that lasts more than seven days. Community treatment orders are only appropriate in these cases. The Act uses the terminology extended leave to mean leave that is extended without a return to hospital, for example weekend leave that is extended for another day. Community treatment orders are not appropriate in these cases. The Board paper confuses the terminology, sometimes using the term extended leave inappropriately and sometimes implying that community treatment orders are an alternative to leave in general, which they are not.
Then it got worse when another director tried to clarify, but he emphasized the inappropriate terminology extended leave when he should have used the terminology longer-term leave. He also implied that section 17 leave is required for a detained patient to leave the ward for any reason, (when the Act clearly states that it applies to the hospital as a whole, not a ward), and he implied that a clinician’s decision on whether to use leave or a community treatment order in any particular case is always clear-cut, (making it seem to anyone who can put two and two together that the difference between Gloucestershire and Herefordshire could only be caused by incompetence).
This was a storm in a tea-cup, really, as the difference for patients is slight, and the problem mainly a problem of statistics, but it illustrates that the Trust’s work is complex, so that directors need to be well-briefed and scrupulously accurate in order to avoid embarrassment, particularly on matters of law, and particularly in public meetings.
Overall, the meeting gave a good impression of the Trust and its Board.
Other positive notes that I haven’t dwelt on were the efforts made to emphasize Herefordshire’s inclusion in what was until fairly recently a Gloucestershire trust, and the cracking pace of the meeting, which breezed along without ever seeming to curtail discussion.
Other negative notes were a rather dull and perfunctory report of the Delivery Committee’s work (11, paper E2), and a disturbing remark in the discussion on training (13, paper G) to the effect that private companies are “stealing” staff the NHS has trained for its exclusive use. This seemed to me to be a stone better not thrown from the glass house of an NHS that relies so much on staff trained in poorer countries, who arguably need them more than we do. Also, I am aware how much of their own money some people spend to gain qualifications for entry-level NHS jobs in some of the healthcare professions.
Finishing a little early, the meeting released me to find the rain had stopped and the sun had dipped below the clouds for a while before setting, making the journey home much more pleasant than the journey there. I’m looking forward to the next public meeting on February 27th in Gloucester.