On March 31st I attended a meeting of the Board of the 2gether trust. All NHS foundation trusts are required to hold board meetings in public, although they are not public meetings in the sense that anyone can participate. Members of public can observe the meeting, and they can submit questions subject to some limitations.
In the context of a Board meeting, a governor is little more than a member of the public. However, by law governors must be sent the agenda of every meeting beforehand, and a copy of the minutes as soon as practicable afterwards. I did receive the agenda for this meeting, and copies of the papers (which ran to 236 pages), but two weeks later I still haven’t seen the minutes. This is, sadly, typical of 2gether.
Of course, all the directors on the Board know that their meetings are public. So to a large extent they are conducted as public relations exercises. Difficult issues can easily be discussed in committee, where there is control over the amount of information that later reaches the Board and public, or they can be discussed in corridors and offices where no minutes are taken at all and it is possible to keep even the non-executive directors in the dark.
Bearing all of this in mind, attending a Board meeting as an observer is remarkably revealing.
A patient story
Since last summer the Board has heard a presentation from a patient at each of its meetings. At least, I think it has — at the time of writing I can’t get hold of minutes for the September meeting even though they were supposed (by law) to have been sent to governors, and they are supposed to be on the trust’s public website.
Anyway, the patient story at this March meeting was told by a young woman who has been attending the trust’s recovery college programme. She gave a talk about her experience of it.
She has an impressive collection of diagnoses, including a personality disorder and an eating disorder, which I take to mean that no one really knows what is wrong with her. She addressed the Board with confidence and humour, as if there is nothing at all wrong with her. Yet she had recently been admitted to a psychiatric hospital for reasons that she didn’t specify. Apparently she and her friend, who also, we were told, “has mental health”, are doing the rounds, giving talks all over the place.
I wondered what it implies for the NHS if the ideal patient with “mental health” is one with no clear diagnosis and no apparent treatment plan, who requires periodic emergency inpatient admission and indefinite support. Is this approach, to use a current buzzword, sustainable? Do we want the non-executive directors of NHS trusts to ask this kind of uncomfortable question at Board meetings? And if they don’t, who will?
Service Experience Report
Governors of the trust used to review this quarterly report, about complaints, concerns, compliments, and that kind of thing, though few of our comments ever made more than a cosmetic difference to it. It was therefore with some nostalgia that I noted clinical issues still dominate complaints (78%). They still aren’t broken down into subcategories to
allow any sense to be made of them.
Appendix 1 to the report is a Red/Amber/Green listing of “organisational learning” going back to May 2013. It looks nice, I thought, but no “organisational learning” in the list relates to what any ordinary person would class as clinical activity — assessment, diagnosis, effectiveness of treatment planning, medication, psychological treatment, inpatient stays, follow-up. They are all about ticking boxes around the periphery.
The report refers to a “deeper analysis” and that the Board’s Governance Committee scrutinises the data, but the Governance Committee report makes no more than a vague reference to clinical risk, and its action plan did not come to the Board.
Issues reported by staff continue to be ignored in the report. (More nostalgia.) If something bad happens, then the patient, a carer or a family member has to report it for it to get any attention there. If a staff member reports it, that doesn’t count.
The staff survey indicates that this report excludes well over a thousand bad things that happened to patients, or that nearly happened to them, and that would have been reported by staff in the quarter.
The report covers Friends and Family Test (FFT) scores, which are assessed by the Trust even though mental health trusts are not yet required to publish them. The Trust’s inpatient services scored +3 overall. (Scores can range from -100 to +100.)
For comparison, Gloucestershire Hospitals Trust’s inpatient services scored +76 overall in January, and the cancer ward in Cheltenham General where I was treated last year scored +100. The report does not make such comparisons.
2gether’s overall score, including community services, was +18 but I can’t set that in the
context of other community services, and the report couldn’t either. No non-executive director mentioned any of these matters. One of them asked a question about FFT data
for previous quarters, and another asked about the difficulty of finding information about carers’ assessments on the Trust’s website.
The trust is taking the line that it finds the results of the NHS Staff Survey “encouraging” even though there is no evidence of any overall change since last year, when you take random variation into account. Although the report claims overall statistical significance, it doesn’t back the claim up with an actual significance level.
I don’t have sufficient access to the data to calculate the significance level accurately, but a rough calculation suggests that the 3 out of 28 key findings that appear to be significant could quite easily (p > 0.16) be false positives thrown up entirely by chance. No director even asked the question.
The new priorities for the trust this year are job-relevant training, satisfaction with quality of work and patient care, and physical violence. These relate to some of the survey’s key findings where the trust came out worst compared to other trusts.
Directors were keen to ensure that last year’s priorities will not be dropped. The recommendation in the report does clearly state that actions already in place are to be continued, but isn’t entirely clear about priorities.
On the key finding about staff communication with senior managers, a non-executive director wondered how staff interpret the phrase “good communication”, and another wondered whether continuing the actions already in place was enough, remarking:
“Shouldn’t we be doing some different things as well?”
A statement about the survey results was sent to staff later the same day, in an internal newsletter that’s also sent to governors. The statement doesn’t acknowledge that good communication between staff and senior management appears to be the Trust’s worst staff engagement problem, compared with other mental health trusts. No director at the meeting suggested that acknowledging the problem might be helpful in solving the problem.
The Chief Executive remarked that analysis of the results by age suggests that older and younger staff are very different, and that local measures are more important than this national survey. My interpretation of the figures is that younger staff report better engagement than older staff in all mental health trusts (and perhaps throughout the NHS), so that this remark is a red herring — it does not explain why 2gether is particularly bad on some key findings.
I’m not convinced by local measures, either. The trust’s local survey of patient experience
only asks questions that are already known to produce good results. Questions that the trust does less well on in the national survey are just not asked in the local one. To me it seems likely that local measures of staff engagement might become similarly futile exercises in self-congratulation. Directors didn’t question the value of local measures in either area.
The glaringly poor staff engagement result from the Children and Young People’s Service
(CYPS) wasn’t mentioned either in the report or in the meeting.
The Delivery Committee is one of the Board’s standing subcommittees. It sends a summary report, not full minutes, to the Board.
Areas of concern to the Committee had included Gloucestershire’s Children and Young People’s Service (CYPS) and Eating Disorders Service (EDS). This is interesting
because both services have caused recent concern in other ways. Directors didn’t comment.
The committee reported that Improving Access to Psychological Therapies (IAPT) is now appropriately resourced, conflicting with what the Council of Governors had recently been told. Perhaps the report meant to say “will be…in 2014-15”. Resolving the conflict between what governors were told and what the Committee was told will be a story for another day.
Overall the meeting was a pleasant one, brisk but not rushed. The focus was on receiving reports one by one and doing a little nit-picking. There was no sense that the Board is where things come together and directors take a strategic view of how this report interacts with that report in a grand scheme of things.
I think non-executive directors should be doing more than just a little nit-picking in holding their executive colleagues to account. And they should be doing it in these public meetings, visible and minuted, so that they themselves can be held to account by the Council of Governors.