SWGEN

cat-SWGENThe South West Governors’ Exchange Network (SWGEN) organizes events a couple of times a year for governors and others from the region’s NHS foundation trusts. An all-day event in Taunton on July 22nd brought together delegates from thirteen trusts to hear presentations about various things of interest to governors, and I attended along with another governor from the 2gether NHS FT.

This long post expands on the notes I took, and on my other impressions.

The venue

The event was held in the conference centre at Somerset College, which provided adequate facilities and a nice buffet lunch. As usual for these places that like to imagine they’re conference centres but haven’t really understood the concept, there were basic problems.

The auditorium, for example, was set out with circular banqueting tables and chairs all around each, so that some delegates would either have their backs to the presenters or have move their chairs and do without any space at a table to write notes.

PowerPoint seemed to be beyond several of the presenters to manage. Either the slides changed too quickly and got ahead of the presentation, or they got stuck on one slide while the presentation went ahead regardless.

Sound amplification was a problem — on and off, so to speak. It worked while presenters stood close to the fixed microphone at the lectern, from where they were unable to see, let alone point at, their PowerPoint slides. When someone in the audience wanted to ask something, a lady with a roving microphone would race amongst the tables and arrive just in time for the final sentence to be amplified. Only one person in the room seemed to understand that it’s a good idea for presenters to repeat the question, avoiding any need for a roving microphone, but he wasn’t a presenter, and even when he got himself a microphone and repeated a question, he was unable to stop the lady racing amongst the tables.

At one point the roving microphone went bad and started producing howls of feedback that drowned out the presenter, so roving lady switched it off and left the room to try and get it fixed. Sod’s Law then resulted in her microphone immediately fixing itself. Her conversation in the corridor with a technician boomed in the auditorium, drowning out the presenter again. Proceedings stalled while someone else left the room to find her and explain how radio mics work.

All of this is normal, of course, as anyone who frequents these so-called conference centres knows.

Somerset College’s innovation in the field of conference centre incompetence is its parking arrangements, which require both a pay-and-display ticket and a visitor’s permit to be displayed in each car. Sending permits to delegates in advance would be too obvious, so they employ a man to hand them out on the day. Unfortunately I arrived just before he did, meaning that I had to leave the event to ask for a permit at reception, and then walk back to my car to put it beside the pay-and-display ticket. I noticed many parked cars that did not have both a ticket and a permit, but at the end of the day as I left, there was no sign that any action had been taken to deter this deviant behaviour.

The NHS

The Chief Executive of a hospitals trust spoke for well over an hour about the “NHS landscape” in which trusts operate, and its current “climate”. The landscape part was as dull as ditchwater, being an overview of the various NHS and other bodies that trusts work with, directly or indirectly.

Some of the slides were somewhat out of date, or sloppy, or a bit of both, incorrectly naming both Healthwatch and NICE, for example. A blurred and unreadable version of the green circle diagram that the Department of Health once published was shown, with an obsolete URL pointing to a website that no longer exists. The URL still works, however, as it redirects you to the national archive’s copy of the web page, and the diagram is still quite useful despite being out of date.

I pointed out that NHS England has recently published a useful guide called Understanding the New NHS (PDF), though it doesn’t mention governors at all and gives the impression Healthwatch has a monopoly in public engagement, an impression that the presentation had also given.

Things got more lively when the presenter started to voice his opinions about key figures in the NHS, past and present, such as Andrew Lansley, Jeremy Hunt and Simon Stevens. His point was that the “old guard” and the new have very different approaches, so that it’s difficult for trusts to come up with the right answers in their strategic planning.

The assumption that trusts’ strategic plans should all reflect the views of key figures in various other organizations wasn’t explained. Even so, it was interesting to hear this CEO’s personal opinions about key figures in the NHS. Whether his opinions are entirely correct I somehow doubt, because at one point he regurgitated the old Labour Party slur that Andrew Lansley’s reforms weren’t announced before the last general election. In fact both Conservative and Liberal Democrat manifestos had extensive sections on NHS reform, so it was unsurprising to everyone except Labour supporters who hadn’t read any other party manifestos when reform became coalition policy. I wonder whether checking the facts behind this presenter’s other opinions might not turn out equally disappointing.

There was a brief discussion about the Better Care Fund (BCF), which, we were told, involves a transfer of funds from the NHS to local authorities. The presenter didn’t really seem to think much of it, but he didn’t really explain why. It was announced just over a year ago, so by now I would have thought there would be some information about how well it’s working.

The presentation returned to its initial tedium with an outline of the CQC’s new inspection processes.

I think basic information like how the NHS is put together and how the CQC operates should be provided for all governors as part of their initial training, and then updated by the trusts as soon as things change. Hearing a presentation about this stuff as if it’s news is a poor way to occupy governors’ time in these rare networking events. Hearing a chief executive’s personal views about things is great, but there wasn’t nearly enough of it in this presentation. Someone in the audience remarked:

“I’m slightly more depressed than when I came into the room.”

I felt that way, too. It’s not the first time I’ve heard a supposed NHS “leader” give a downbeat presentation about how difficult things are, and not the first time that I’ve wondered whether this is the kind of leadership the NHS needs.

West of England Academic Health Science Network

The WEAHSN is one of 15 networks set up by NHS England but managed very much at arm’s length. They don’t even get to use the NHS brand logo. The AHSNs bring together NHS organizations and universities to work with commercial partners to develop new healthcare solutions, improve healthcare quality and promote patient safety, all in a local setting — which is why there have to be 15 of them.

The presentation was given by WEAHSN’s Director of Quality, whose giggly and jargon-ridden style contrasted sharply with the previous presenter. I need only say that in her world everyone is:

“passionate about what they do”

…for you to be able to extrapolate and predict much of the content of her presentation.

The AHSNs operate collectively in some ways, as well as pursuing their separate local priorities as determined by their members. I found this a bit confusing and so did other delegates. Another confusion was that I vaguely remembered being told that 2gether is not part of an AHSN, but the presenter was confident that 2gether is a member of the WEAHSN. I was wrong. When I investigated the matter I found that 2gether is a member of the AHSN but not part of an AHSC (Academic Health Science Centre), which is something completely different.

I was concerned that AHSNs will collect scientific evidence about matters of great interest locally and then hide the evidence from the public. The presenter assured me that governors will have access to the evidence even though the public won’t, but it’s not clear how this will work in practice. I wonder whether AHSNs will function as a way for NHS England to hold healthcare data where it is out of reach of the Freedom of Information Act.

We were told that WEAHSN will have an online video channel on the website. It doesn’t seem to exist yet. There are a few possibly related videos on YouTube, but they are quite old and I didn’t see an actual channel. It seems likely that the channel will be public, if it’s to be hosted on YouTube.

A case study of the use of magnesium to protect against some cases of cerebral palsy was described. Within WEAHSN this project is known as PReCePT.

While magnesium has been used for complications of pregnancy for a very long time, maybe 30 years or more, its value in protecting against cerebral palsy has long been controversial. Some earlier scientific studies had concluded that it’s useless. I was disappointed that neither the presentation nor the WEAHSN website explained this scientific background, and that the website doesn’t link to any primary evidence for or against, or to any reviews of the evidence.

Anyway, a Cochrane review in 2010 concluded that magnesium does have a protective effect. It’s administered into a vein as a solution of magnesium sulphate (“Epsom salt”), but the magnesium is the active ingredient. The PReCePT project aims to increase its use by developing information for clinicians and patients.

A peculiar thing about this case study is that it doesn’t appear to involve universities of commercial partners at all. Also, if magnesium is beneficial in this way it’s beneficial throughout the whole country. A delegate commented:

“It sounds like bureaucracy to me.”

On reflection, perhaps the real issue here is that the existing national bureaucracy centred on NICE doesn’t work because it’s too unresponsive to new evidence of consensus like this Cochrane review. Although no one could argue with the good intentions of the PReCePT project, it seemed an odd choice to show off WEAHSN.

Holding non-executive directors to account

Holding non-executive directors to account for the performance of the Board is one of the statutory duties of any council of governors, but no one knows exactly how to go about it. A presentation by one trust’s head of corporate governance waffled around the subject without ever getting down to brass tacks. Indeed, to some extent it was a calculated distraction from the statutory duty.

A great deal of the presentation was background information, but the core of it came down to a series of rather vague checklists. For example, a good board meeting was described in terms of seven bullet points. The trouble is, the points trivialized the work of a board of directors of an NHS healthcare provider. An electrifying and transformative board meeting might easily fail several of the checkpoints, while a dull and ineffective meeting might very easily score seven out of seven.

Only one of the checkpoints mentioned non-executive directors, and it said simply:

“NED challenge…”

In my view this fails to distinguish between challenge that’s just mindless nit-picking and challenge that goes to the heart of the issues facing the trust. One of the habits of low-performance boards is that they evade issues instead of addressing them, and one of the techniques of non-execs who collude with this kind of behaviour is to challenge the execs on trivial matters so as to look good, take up time in the meeting and distract observers. The presentation evaded this issue.

A case study told of a fictitious new governor, Gill’s first six months. After becoming a governor, Gill becomes concerned about cleanliness and catering at her local community hospital, sets up regular meetings with the manager there, and volunteers for a variety of development and inspection roles. There’s no mention of the board at all in any of what she does.

Gill’s only involvement with the trust is operational. She has no contact with the board, no knowledge of how it’s performing, and no opportunity to hold non-execs to account for it. She’s an utter failure in contributing to the statutory duties of her council of governors, yet she was presented to us, presumably, as a role model.

Based on remarks from various delegates, the indications were that many trusts have governors who are much more involved with their boards than Gill. At the same time, there were indications that governors of some trusts don’t get far beyond duplicating the role of Healthwatch in inspecting front-line operations and being a channel for patient feedback.

To promote discussion we were invited to prioritize three issues faced by a fictitious trust, and to formulate questions to ask the board about them:

  • Traffic congestion and parking
  • A new inpatient unit that makes the parking problem worse
  • The CQC says maternity and end of life care services require improvement

Unfortunately the case study was poorly defined, and few of us felt we understood what we were supposed to do. There was no final consensus, but several people took it as given that the trust must jump when the CQC says jump, the council of governors’ statutory duty to members and the public being neither here nor there. The case study didn’t have anything whatsoever to do with non-execs, and none of the discussion groups set any importance on non-execs’ role.

We were finally given a handout page headed listing five suggested questions that governors of this fictitious trust could ask the board. None of them had anything to do with the role of non-execs, and none of them held anyone to account for anything.

For example, the only one of the five that contains either the word “performance” or the word “account” is this two-part question:

“What is the Board’s assessment of the performance of the new inpatient facility in relation to plan? How does the board account for any differences?”

This asks about the performance of the facility, not the performance of the board. And it asks the board to account for differences between plan and actual, not to account for its own performance.

This is why I used the phrase “calculated distraction” above.

Infection control and prevention

A final presentation described infection control and prevention in an acute hospital, where CDIF (Clostridium difficile) infection fell by 82% in three years and deaths related to CDIF have been eliminated.

Interestingly, the presenter gave the impression that the trust’s board did nothing to reduce infection rates until forced to by government policy and the threat of the Department of Health arriving to take over management of the problem.

Once they were forced to, they adopted all the measures they could. The presenter freely admitted that none of the methods they used were novel, and that probably none of them is more responsible than any other for their success — a multifactorial approach was key. However, when pressed, she said she thought that controlling antibiotic prescribing was probably very significant, and someone in the audience remarked that GPs had been involved in this aspect of things, too.

A new infection threat called CPE (carbapenemase-producing enterobacteriaceae), possibly better known by its American name, CRE (carbapenem-resistant enterobacteriaceae), is becoming the focus of attention, despite all the measures already in place for CDIF. Apart from the problem of spelling its name, which the presenter suffered from quite seriously, the various organisms in this category are a problem because they have a way to neutralize the most powerful antibiotics, making them very dangerous, with reported death rates as high as 50%.

The presenter also said at one point that these bacteria “kill” the carbapenem (the antibiotic, which isn’t actually alive, of course). Perhaps she was simply assuming a kind of poetic licence, but it sounded unscientific, or else deeply confused. The science behind the whole situation could have been explained a bit more, I thought, but on the whole this was an interesting presentation to end the day.

Networking and the SWGEN

I met a couple of interesting people at the event.

One woman said she worked part-time for the NHS in mental health. I asked her what she actually does and she said she’s a psychotherapist. So I asked her what kind of psychotherapist — CBT, family therapy, psychodynamic… and she said she can do all of those. Well, that’s highly unlikely, so I asked her what therapy she’s qualified in, and she changed the subject.

Then we got back to what she actually does, and she described working with mothers and children. I said that sounded like family therapy, but she said it wasn’t. So I asked what kind of therapy it is, and she said it’s dyadic therapy. I hadn’t heard of that, but I asked her if she’s qualified in it, and she changed the subject. Hmmm…

It turns out there’s a fringe therapy called dyadic developmental psychotherapy (DDP), but it’s not usually abbreviated to dyadic therapy and the woman I spoke to doesn’t appear to be listed as a practitioner on the DDP website. DDP is the brainchild of an American psychologist, as so many fringe therapies are. It doesn’t appear to be represented at the UK Council for Psychotherapy, as so many fringe therapies aren’t. It doesn’t appear to be recommended by NICE for anything. There’s an old saying, caveat emptor, “Let the buyer beware!”, but if you’re a troubled parent of a troubled child, and you turn to the NHS for help, you probably don’t think of yourself as a buyer, and you may not know how to beware.

Another woman I met told me that all psychiatric drugs cause people harm. They shouldn’t ever be prescribed. Not at all. And she didn’t tell me this just once, but over and over again. It was hard to get her to stop. Someone suggested I should just have said, “Shut up!” I hadn’t thought of that.

Then, in a break, I encountered her again. This time she was recommending mitochondria therapy (or something like that), over and over again. Unfortunately I’d already forgotten the previous advice just to say, “Shut up!” and for a second time it didn’t occur to me.

The event ended with a few short speeches, and ideas for future meetings were invited. I didn’t participate, but a few people suggested having a mental health topic for next time.

On reflection, what I’d really like is an event based on different perspectives from acute, mental health and ambulance trusts on a topic that concerns more than one type of trust. One such topic is mentally disturbed patients, and psychiatric liaison in general. A police view might also be interesting, and section 136 of the Mental Health Act, with decisions about whether to use A&E, a dedicated place of safety or police custody, is a complex area that’s been in the news recently. Other such topics might be self-harm and parasuicide, maternal mental health and stroke.

 

 

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About Rod

Chairman of the Gloucestershire charity Suicide Crisis, Vice Chair of Relate Gloucestershire & Swindon, and an enthusiast for public involvement in the NHS.
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