On October 26th I attended a meeting of the Board of Directors of the 2gether NHS Foundation Trust, as a member of the public. The bundle of papers for the meeting was unusually slim, and there were unusually few directors present. However, the Trust’s Chair, Baroness Fritchie, had returned following the illness that prevented her from chairing the last Council of Governors meeting.
There were unusually many iPads at the meeting, as the Trust had issued them to directors in order to save paper. The planned agenda was rearranged so that a presentation on Making Every Contact Count (MECC) could be moved to the end. As I had recently seen this presentation at a Council of Governors meeting, I didn’t stay to see it again.
Papers for the meeting, and the minutes, will as usual be published in the Board Papers area on the Trust’s website, or failing that, on request.
Substance misuse services
As reported in the press, NHS Gloucestershire’s choice of the charity Turning Point as preferred bidder for its “Roads to Recovery” drug and alcohol programme will mean that 2gether will be handing over its substance misuse services to the new provider from April 2013. It was noted that 2gether has a good record in this field, and the bid had only just been lost on a narrow points difference. A separate bid for similar services in prisons, in partnership with charities Independence Trust and Nelson Trust, had been won.
15 Steps and the Safety Thermometer
It was announced that the Trust will be rolling out the dreadful 15 Steps Challenge, a tick-box approach to first impressions of hospital wards. I rolled my eyes.
Oddly, the Trust is less enthusiastic about another initiative, the Mental Health Safety Thermometer, and it will be lobbying for changes before implementing it. Maybe not oddly, on second thoughts, because the safety thermometer is likely to have contract and financial implications while the 15 steps are not.
Care Quality Commission
From remarks made at the Board meeting, there seemed to me to be indications of a common thread relating to record keeping in the adverse comments made in this latest report and previous CQC reports about the Trust, which I might investigate when the report appears. It was acknowledged that record keeping is a persistent cause of problems, and the Trust’s computerized clinical records system, RiO, was mentioned in this connection, a director remarking:
“I think RiO is a wonderful system, but…”
An independent investigation
NHS South West, before it merged into NHS South of England, had commissioned an independent investigation into the care and treatment of Darren Roberts, a former patient of the Trust who is currently serving a life sentence for the violent murder of his partner, Jenny Young, in Cheltenham in 2008. In their report, investigators had made 25 recommendations, resulting in an action plan with 80 actions for the Trust.
Some concern was expressed that information about a former patient’s history had become public through the publication of the report, even though he had given consent that the investigators access his medical records, even though the jury at Bristol Crown Court had not thought that his mental state had made him unaccountable for his actions, and even though many details have already been reported in the press. I don’t see any good reason for secrecy in such circumstances.
It seems to me that the report’s recommendations are weak, concentrating on procedure instead of outcome. Many of the recommendations are along the lines of:
“The Trust should ensure that staff are aware of…”
The report does not present specific evidence that staff were unaware of these matters in 2008. The recommendation that, “The Trust should ensure that all eligible carers receive a carer’s assessment” is impossible to achieve, because carers are entitled to refuse assessment, and many of them do. From April, several of the recommendations will no longer apply to the Trust, because it will have handed over its substance misuse services in Gloucestershire.
Community Treatment Orders
The use of Community Treatment Orders (CTOs, Section 17A of the Mental Health Act) in preference to leave of absence (Section 17) was discussed, as it had been in a previous Board meeting that I attended. The Trust’s Lead Governor remarked that cultural issues might be inhibiting change, and that:
“I’m conscious that this is an issue that has been discussed for the last yonks, in this organization…”
The matter was again referred back to the Trust’s Mental Health Act Scrutiny Committee. I wonder what it will take to achieve clarity on this, whether external audits with contractual penalties are the only way, and if so what that says about the cultural issues.
Health of the Nation Outcome Scales
A system of outcome measurement known as HoNOS (Health of the Nation Outcome Scales) was discussed. There was concern because an audit had revealed that only around a third of the Trust’s eligible patients had complete HoNOS records of the start and end of treatment (if I understood it correctly).
The Director of Finance and Commerce pointed out the importance of outcome reporting for the future, particularly in relation to Payment by Results. She also mentioned that further outcome measures are in development, so that the Trust needs to do better with HoNOS before two or more other measures come along.
By the way, HoNOS involves ticking twelve boxes to rate the patient on a scale of 0 – 4 on such things as behaviour and mood, together with a diagnostic category. One of the things that the Improving Access to Psychological Therapies (IAPT) programme has demonstrated is that it is possible for clinicians to administer simple ratings scales of this kind routinely, achieving high rates of compliance with the reporting requirement.
HoNOS differs from the IAPT measures in that it records a clinician’s assessment, while IAPT’s are patient-reported outcome measures (PROMs). I suspect that the addition of a PROM to HoNOS could improve compliance by involving patients in recording their own outcomes.