On November 12th I attended another meeting of the South West Governors’ Exchange Network in Taunton. This time mental health was on the agenda, sort of, and as usual it was interesting to meet with and hear from governors of other trusts.
Arrangements for the meeting were little better than last time, and the best I can say on that subject is that there was nothing new to complain about.
The presentation slides will be available on the SWGEN page at Salisbury NHS Foundation Trust, though at the time of writing they are not yet there.
The Chief Executive of Somerset Partnership NHS Foundation Trust gave a packed presentation, mainly about his trust and its achievements, but touching on wider aspects of the NHS. Delegates had a lot of questions, which he hadn’t allowed time for, so the session both overran significantly and left many questions unanswered.
Although a very smooth and plausible speaker, a few of his statements didn’t bear even the most casual scrutiny. For example, he chairs the board of the NHS South West Leadership Academy, and he mentioned that its work includes programmes for governors. But in my time as a governor I’ve never heard of any such programmes. On its website there’s no mention of any at the time of writing, just a bland statement about supporting governor development, with nothing to back it up.
He made much of the NHS Benchmarking network, suggesting that we in the audience could use its data to compare the performance of trusts, and highlighting its value in mental health in particular. So I asked whether the data is public and he immediately became nervous and defensive, admitting that it’s not public and governors can’t generally access it:
“We…need to be careful with benchmarking data. It throws up as many questions…in fact it throws up far more questions than it actually does answer…”
And towards the end of the session someone local asked a question about community hospital beds to provide support for patients after discharge from the acute hospital in Taunton. Again he seemed ruffled by this, saying that there were plenty of community hospital beds, and also that 14 more that had been closed were now going to be restored, which cannot both be true.
This was a mixed performance, therefore, looking good on the surface but at the same time creating an uneasy feeling that all is not quite what it seems. No doubt many of the things he told us are straightforwardly true, but how can anyone tell which ones they are?
The mental health of children and adolescents (CAMHS) came up a couple of times, and he said he thought that the main problem was the four-tier model with its separately commissioned tiers. (Tier 1 means services in the community, for example in schools. Tier 2 is in primary care settings like GP surgeries. Tier 3 is secondary care like that provided by NHS trusts. Tier 4 is specialist centres commissioned by NHS England.)
This may have been been derived from a statement made by the Minister of State for Care and Support, Norman Lamb, to the Commons Health Select Committee back in July, and mentioned in the Committee’s report on CAMHS published last week. But the presenter didn’t credit either the Minister or the Committee, and he didn’t seem to be aware of the reason for their criticism of present commissioning arrangements, which is that there are currently perverse incentives that discourage early intervention and cause pressure on inpatient beds.
A questioner asked why the NHS dealt with mental illness but apparently not with emotions. The presenter, who is not a clinician of any kind, let alone in mental health, somewhat foolishly attempted to give an answer, and his attempt meandered far away from answering the question.
So I eventually intervened to clarify that one of the categories clinicians use to classify mental illness is “emotional disorders”. The emotional disorders include the commonest mental illnesses like depression and anxiety.
It had seemed like a sensible question from someone who, perhaps, didn’t know the first thing about mental illnesses. But I chatted with the questioner during our coffee break, and it turned out not to be the case.
The questioner claimed to be a psychosynthesis counsellor, and if that’s true he would know perfectly well how clinicians classify mental illnesses. I was astounded to realize I had run into another practitioner of a weird fringe psychotherapy that has no evidence-based uses, just as I had at the previous SWGEN event. (Although this one was only a governor, in which position he can do no real harm, while the previous one was employed by the NHS to be let loose on patients.)
Care Quality Commission
A presentation by the CQC’s Head of Hospitals Inspection covered the new inspection regime, which many governors have heard about time and again. I soon stopped paying attention.
Before I stopped, however, one remark drew my attention:
“We are drowning in data in the NHS.”
Then towards the end of the presentation a bullet point on one of the slides said:
“Most services don’t know whether they are effective or not.”
These two things can’t both be true at the same time. I asked whether we would be better off knowing less about what’s going on, or better off knowing more about what’s going on.
The answer I got was that we need more information in some areas and less in others. I left it at that, but later another governor followed up by asking which areas we are collecting too much data in, and the presenter had to admit that she couldn’t think of any.
So we’re not drowning in data, really. We’re gasping for it. (Which is another point the Health Select Committee made about CAMHS.)
A questioner asked about diagnostic overshadowing, but the presenter hadn’t heard of it. Unfortunately the questioner couldn’t explain it very well, and the presenter wasn’t able to elicit the information from her.
(Diagnostic overshadowing is when you have an obvious condition, and then you develop a second condition. But you can’t get anyone to take your second condition seriously because all they want to focus on is the first condition. For example, if you are obese and you start getting headaches, your doctor might not take the headaches seriously because he’s so focussed on your weight. Your obesity is overshadowing whatever is causing the headaches.)
This is a bit scary. Anyone involved in CQC inspections should have heard of this very common reason for treatment being refused or delayed, and should know what it’s called. Also, anyone involved in CQC inspections should be able to elicit information from people who aren’t very able to express themselves clearly.
The role of governors in CQC inspections was described only as providing information to the inspectors. It’s normal for the CQC to include governors in the focus groups they run at the start of the inspection process.
In the lunch break I asked the presenter why the CQC didn’t evaluate governors’ role in the trust, as we have statutory duties. She agreed that it would be possible for an inspection report to cover the role of governors, but she didn’t know a case where it had ever happened.
A workshop session on how governors can engage with members of their trusts, and with the public, was led by governors from Gloucestershire Hospitals NHS FT. The results were inconclusive.
One of the presenters, however, described the Forest of Dean Health Forum, and I was impressed. It’s not run by a trust, but governors in the area could (and do) use it as a way to keep in touch with the public. It reminded me of the locality forums run by Worcestershire Health and Care NHS Trust.
One of the core problems is distinguishing between engagement by governors and the trust’s everyday public relations work.
For example, if a trust publishes a newsletter, sends it to members and leaves copies in GP surgeries, is that governor engagement? What if a governor writes an article in the newsletter? What if the trust holds a public meeting where the content is all provided by directors or employees? What if a governor is present and has a minor role? To what extent are any of these governor engagement?
Some governors present seemed to find it hard to understand that for governors to play some minor role in the trust’s everyday PR is not the same as governors themselves engaging with members and the public.
Another core problem is understanding what success looks like. For many trusts, the only real measures of successful engagement simply depend on getting members of the public to fill in membership forms and attend meetings. One of the presenters pointed out that her trust already has 12,000 members and just collecting more of them does nothing for governors.
The whole session seemed inconclusive and unsatisfactory.
A session advertised as “Care of patients with mental illness in all settings” was delivered by a consultant nurse who had been asked to give the presentation at very short notice. Unfortunately he chose not to base the talk on things he has direct knowledge and experience of as a consultant nurse, but instead to spend most of the time on the recent Five Year Forward View from NHS England, and the Crisis Care Concordat initiative. It was mostly very boring indeed.
The Five Year Forward View (PDF), published last month, is NHS England’s attempt to describe where the NHS is heading:
“It sets out a vision of a better NHS, the steps we should now take to get us there, and the actions we need from others.”
Little in the document is really new, but amongst the restatements of the need for various things that we already knew the NHS favours, like “hard-hitting national action on obesity”, and “patients will gain far greater control of their own care”, there are a couple of proposals for new-ish ways in which primary and secondary care (GPs and hospitals) might be combined.
The presenter’s view was that when combining services it will also be possible to combine services for mental and physical healthcare, and that this will be an improvement.
Similarly the Crisis Care Concordat (PDF) restates a lot of things that have been in place for a long time in theory, if not very well implemented, to improve outcomes for people experiencing mental health crisis. It aims to stimulate implementation by getting local organizations to make a joint declaration for their area and to agree an action plan.
At the time of writing, nine months after publication of the concordat, only Gloucestershire seems to have published and registered both a joint declaration and action plan. Fifteen areas have published and registered joint declarations without action plans.
The session improved a little when the presenter stopped presenting and responded to questions, because he tended to respond from experience. However, he did at one point remark that:
“Demand never goes away.”
I pointed out that if services are effective, people recover and don’t come back, giving the example of people presenting at A&E after self harm or attempted suicide. With appropriate and effective care they’ll stop presenting at A&E for those reasons. The demand really does go away.
Too many mental health professionals, I think, have the fatalistic view that every patient is a long-term patient, and I was disappointed that this presenter gave the impression he is one of them.
Overall, this was another fascinating SWGEN meeting. A common thread in the sessions seemed to be the tendency to grasp at a simple maxim, “integrated commissioning”, “drowning in data”, “get more members”, “demand never goes away”, and cling to it even though it’s an obstacle to solving real-world problems.
As far as anyone I spoke to was aware, the south west is the only region that has this kind of meeting. If that’s true, I hope the Foundation Trust Network will pick the idea up and extend it to other parts of the country.