A public Board meeting of the 2gether NHS Foundation Trust took place in Gloucester on February 27. There were around ten of us in the public seats at the back, apparently including a journalist. The minutes and papers are, or will be, published by the Trust, so I will only comment on some of the things I found the most interesting.
At the last public Board meeting I attended, someone had submitted a question but this time there were no questions from the public. (Anyone in Gloucestershire or Herefordshire, or who is affected by the work of the Trust, can submit a question to the Board and get a written reply, even without attending the meeting.)
The question last time was about how the Trust uses the 2009 National Patient Safety Agency (NPSA) Being Open framework. The text of the Trust’s written reply was given in the minutes this time. I thought the reply was rather too general. It didn’t specifically mention the NPSA’s 10 principles, and it didn’t mention the paper on complaints-handling presented to the Board at that same meeting in December, whose recommendations related closely to the first four of the NPSA principles.
After the minutes of the previous meeting were agreed, it was discovered that no one knew whether one of the actions (a comparison with Mental Health Act governance arrangements in another NHS Trust) had been acted on. What’s more, although the other four actions had been completed, none of the five had a due date. The Chief Executive, Shaun Clee, was critical of this.
The meeting’s main presentation was on the Accreditation for Inpatient Mental Health Services (AIMS) accreditation scheme operated by The Royal College of Psychiatrists. All the Trust’s wards in Gloucestershire are accredited, and three are accredited at the “excellent” level. The scheme is being extended to Herefordshire.
The scheme was criticized for being unreliable, with the results of the peer review process depending on just who the reviewers were on the day. It is not always clear why one ward is “excellent” and another not. The scheme also fails to take into account some important aspects of running a ward. For example, there is no formula to determine staffing levels, length of stay is not factored in, and reducing boredom for inpatients is covered by a different scheme. The scheme’s cost was also questioned, as there seemed to be no good reason to pay fees to The Royal College of Psychiatrists when the Trust could do much the same thing in-house, and when there is increasing overlap with the Care Quality Commission’s standards.
Overall, however, the scheme was thought to be good value. Having the accreditation certificate on the wall improves staff morale.
Chief Executive’s report
The Chief Executive, as always at these meetings, presented a list of national documents and news items that the Trust has to take into account. This time there were 29 in the list, and a few of them were picked out as being particularly significant. A stream of about 30 documents or significant news items rains down on the Trust each month.
The NICE guideline on service user experience in mental health, mentioned again below, was published just before the last Board meeting in December but didn’t appear in the list at either that meeting or this. The list can’t be relied on as a complete record. Also the list gives no indication of what action the Trust will take as a result of each item. So although I think the list is quite a good idea and quite interesting, and it does contain items I would not otherwise be aware of, it’s not completely clear that it’s a useful exercise.
Service user experience
A report on service user experience was presented by the Trust’s Clinical Director for Social Inclusion. It started with a brief outline of the national context, including the Government white paper No Health Without Mental Health from a year ago, and the National Institute for Health and Clinical Excellence (NICE) guidance, Service user experience in adult mental health, from a couple of months ago.
The NICE guidance includes a set of 15 quality statements. For example, the first one is:
People using mental health services, and their families or carers, feel optimistic that care will be effective.
Curiously, the quality statements were not mentioned anywhere in the report, and they were not mentioned in the Board’s discussion, giving the impression that the Trust hasn’t taken any notice of them yet, and perhaps never will. I found this disappointing.
Another thing missing from the picture is recovery, which is surely something service users experience, or hope to. The Trust sloganizes its strategy as ensuring that service users experience its services as:
Caring and Safe
Advancing practice to meet their needs
Respecting their individuality
This formula weasles out of giving any priority to effective treatment or recovery. I don’t think it adequately expresses what service users want to experience from the Trust.
A large part of the report deals with complaints, concerns, compliments and other comments. Some of the figures are hard to interpret because they are not shown in relation to the number of patient contacts, or the population served. There was some discussion of how to report the figures in a more meaningful way.
Just over half of the complaints are categorized as being about clinical treatment, and the next largest category is the attitude of staff. Despite this, the parts of the report that deal with how the Trust responds to complaints do not indicate any ongoing work to reduce complaints in these categories. Examples of complaints in a “You said — We did” format show complaints about clinical treatment and staff attitude being resolved by managers negotiating with the complainant, not by any changes in treatment or attitude. The implication is that these complaints are not found to be valid on investigation, although this is never explicitly stated.
The section on learning lessons from reported service user experience doesn’t mention clinical treatment, the largest category, at all. Under staff attitude it gives just one example of individual learning, and no learning by the Trust.
A highlight for me of the previous Board meeting in December was a report by a non-executive director that made recommendations about the way the Trust handles complaints. They included action to ensure that there is evidence the Trust has learned from each complaint, and to ensure that there is evidence of whether or not complainants are satisfied with the Trust’s response. That report’s recommendations were supported by the Board in December, but not mentioned either in the report or the discussion in February, giving an unfortunate impression of the Board’s attention span.
The Trust’s Delivery Committee had reviewed the many performance indicators that the Trust uses to monitor its work, and the committee reported to the Board. As a Governor of the Trust I was an observer at the committee’s confidential meeting, which I cannot comment on publicly, but the following items were among those it brought to the public Board meeting.
Care planning was causing a problem because the indicator is based on a survey of patients. When asked whether they are involved in planning their care, only two-thirds of patients say they are. The target is around three-quarters, and the Trust stands to lose a bonus payment from NHS Gloucestershire if it misses the target. From the Trust’s point of view involving patients in planning their care is routine, and it is difficult to understand why so many patients don’t say so in the survey. It seems to me there is some risk that staff will increasingly coach patients on how they should answer the survey questions, making the survey pointless.
Another item concerned personality disorder training for staff, another target that the Trust might miss. The idea was that many staff should have basic training in personality disorders. (As far as I can tell, the Trust still doesn’t have a specialist personality disorder service, although it is in NHS Gloucestershire’s 2009 – 2014 strategic plan to develop one.)
More statistics and targets were presented as part of the quality report for the quarter, including statistics on serious incidents and suicides, amongst many other indicators.
A suicide prevention toolkit developed by the National Patient Safety Agency (NPSA) has been implemented, and the Trust reported meeting its target of 100% compliance. This is only of interest because in June last year Gloucestershire LINk said:
The 100% target for the implementation of the NPSA Suicide Prevention Toolkit seems very optimistic to us and difficult to achieve.
I think it reflects poorly on the LINk that it made such a foolish prediction. A LINk is intended to be a way for the opinions of ordinary people in the wider community to influence health and social care, and a remark like that does not seem as if was is based on information from ordinary people in the wider community at all, or indeed on any sound information.
That said, the toolkit is no more than a glorified checklist. It can have no direct effect on numbers of suicides, and there’s nothing in the report presented to the Board meeting that suggests the impact of the toolkit on suicide statistics will be measurable. If it does nothing to prevent loss of life, no one will ever know.
There was some discussion about the idea of publishing a separate report for the public to make the information “more accessible”, keeping the details private for the Board. I didn’t pick up the reason for this, and it wasn’t clear whether Governors (who are mostly members of the public) would have access to the private version.