I rarely write about meetings of the Council of Governors of 2gether NHS Foundation Trust. This is mainly because there’s so much to write about that I shirk the task altogether. Maybe it will be better if I stick to the main issues and ignore the rest. Here are some thoughts about a Council meeting that discussed care plans and the re-appointment of the Chair.
On Tuesday, January 19th, the Council met in the morning. It was frosty and the traffic was terrible on my approach to Gloucester. I was late.
Governors meet in private for an hour before the main Council meeting. At this pre-meeting we might discuss some of the items on the main agenda, and some other things—whatever we want to discuss out of earshot of the public and the directors, and without any minutes (or bloggings!) being taken. It helps us to clarify our thinking and saves some time in the main meeting.
The main Council meeting lasts for two hours. It’s chaired by the Chair of the Trust, and the public can attend. The Chief Executive and several other directors usually attend.
In practice it’s rare to see any members of the public. Other public meetings about mental health usually do attract some members of the public. The lack of attendance at our meetings might be explained by the difficulty the public has in finding out when a meeting is to take place, and what will be discussed.
There was a presentation about care plans. Governors had requested it, because some of us had heard that care plans can be problematic. For example, I’ve heard stories of patients who have found it difficult to get any care plan at all. Another example is a care plan I saw where the patient’s symptoms and medication didn’t seem to match up, and some of the content looked like computer-generated drivel that didn’t really apply to that particular patient.
These impressions are backed up by the results of a national survey commissioned by the Care Quality Commission (but subcontracted to another body to implement). If the survey results are accurate, they indicate large numbers of patients who have problems of one sort or another with their care plans. The latest survey results are due to be published next month, and I might write about them then.
The presentation was given by a non-executive director of the Trust. We (the Council) appoint non-executive directors to provide independent challenge within the Board, while participating as full Board members.
The Council has a statutory duty (that is, it’s the law) to hold non-executive directors to account for the performance of the Board. That’s what we were supposed to be doing at the meeting, holding the non-exec to account for the performance of the Board in relation to the care plan problem.
The agenda item, however, had been given the title, “Assurance around Care Plans within the Trust”, making it sound from the outset as if care plans are just fine.
Most of the presentation was background information. This was useful because some governors might not know much about care plans. If any members of the public had turned up, it could have been useful for them too.
When it got to the question, “How many Service users have a Care Plan?” a little confusion set in. Care plans are recorded in a computer system called RiO, which is supplied by a company based in Sheffield. This system covers all the Trust’s patients, or so we were initially led to believe.
But there’s another computer system called IAPTUS, which is supplied by a company in Bath. This system covers patients using the Let’s Talk service. After some discussion it was established that these patients do not have records in RiO or care plans. The non-exec giving the presentation seemed a bit lost.
We never really found out how many patients are supposed to have care plans, if my memory serves me right, even though one of the slides had the title, “How many Service users have a Care Plan?” It only showed percentages, without explaining what they’re percentages of.
Another source of information about care plans is a local survey that the Trust undertakes itself. At this point I asked why the CQC’s national survey wasn’t included on the slide. I didn’t know it was on the very next slide, but the non-exec giving the presentation didn’t seem to know either. There was some rather confused discussion, which wandered off topic a little.
We somehow got on to the question of whether the survey asks about medication. My recollection was that it doesn’t ask patients whether their medications work. But another suggestion, from a director, was that it does ask patients how they are getting on with their medications. On checking, just now, it looks like I was right. Question 28 asks:
In the last 12 months, has an NHS mental health worker checked with you about how you are getting on with your medicines? (That is, have your medicines been reviewed?)
So it only asks whether there has been a review, not whether the medication works. There’s no question in the survey about whether the medication works. Of course, the questions might have changed in the latest survey, which has not been made public yet, and the director might have been referring to this new survey.
Some of the governors asked interesting questions. For example, one governor asked about how well care plans are implemented, when they exist. The answer wasn’t entirely clear to me. I think the gist of it was that outcomes of treatment are measured separately, not directly in relation to the care plan, but I may have misremembered it.
Another governor asked about the situation where carers need to see a patient’s care plan so that they know what’s going on, but the patient hasn’t agreed to their knowing anything. In this case Trust staff may feel they can’t share information from the care plan with the carer, because it’s confidential to the patient. It didn’t seem very satisfactory.
There wasn’t really enough time to talk in detail about all the issues that came up.
The presentation left me feeling that the Trust had acknowledged there are some problems with care plans, but that the Board doesn’t really understand what the problems are. The Board’s plan seems to be that by doing what they’ve always done, but more so, the percentages will improve.
It seemed to me that in these things there’s probably some kind of 80:20 rule. Most patients (the 80%) are easy to provide care plans for, but at the same time having care plans isn’t very critical for them. A smaller number of patients (the 20%) badly need a care plan, but for these patients it’s difficult to provide a satisfactory one.
If this is indeed the situation, then it’s relatively easy to get the percentage of patients with care plans up to 80%, but the 20% of patients who badly need care plans still won’t have them. Of course, I’m using the numbers 80 and 20 only for illustration, but the real numbers aren’t far off.
To fix the care plan problem for that difficult 20% of patients who badly need them, the Board would have to identify exactly what the problems are, so that it can address them with innovation and creativity, not just by doing more of the things that haven’t worked so far.
I was surprised, on reflection, by the whole approach. The Trust is essentially a medical organization, so you’d think that the medical model of treatment informed by diagnosis would be the prevalent way of thinking. But even though there are clinicians on the Board, when there are identified problems with care plans there seems to be no attempt to diagnose them and base the treatment on the diagnosis.
For these reasons I suspect that the Board is performing poorly on this issue.
At the meeting we were supposed to hold the non-exec to account for the Board’s performance, but instead all we got were some vague assurances about management procedures. We didn’t discuss the Board’s performance, and we didn’t hold the non-exec to account for it.
Re-appointing the Chair
The Council of Governors appoints the Chair of the Trust for a three-year term. At the end of that term, the Council can simply re-appoint the same person for another three years if it chooses to. Otherwise there has to be a recruitment process for a new Chair.
It’s not quite as simple as that, though. The Council has a subcommittee called the Nominations and Remuneration Committee (N&R). When the Chair comes up for possible re-appointment, N&R meets in order to consider that matter and make a recommendation to the Council. N&R can’t decide the matter for itself. Only the Council can decide. So I’m not entirely sure why N&R has to make a recommendation first, but that’s how it is.
Anyway, our Chair’s term of office ends at the end of March, she is eligible for re-appointment, and she has indicated she’s willing to be re-appointed. So N&R met, and it recommended that she be re-appointed. The simplest thing would have been for the Council to accept the recommendation and re-appoint her.
That didn’t happen, though, and the reasons it didn’t happen are a bit subtle.
At N&R there were four governors present (and I was one of them). Two voted to re-appoint the existing Chair, one voted against and one abstained. The vote was carried, therefore, but without an actual majority of those present being in favour of it. This made it difficult for the Council simply to go along with the N&R’s recommendation without giving the matter full consideration.
The N&R meeting had only recently been held. If the Council had decided not to re-appoint, then there would not be time between that decision and the end of March to run a recruitment process to find a replacement Chair. This, too, made it difficult for the Council simply to go along with the recommendation without giving the matter full consideration, because it might look as if the Trust had delayed the N&R meeting in order to force the Council simply to re-appoint.
Governors were also mindful that hastily organized meetings and other administrative difficulties with the business of the Council have frequently been a problem. There were, additionally, some other difficulties with this particular decision that I’ll not go into here. Anyway, as a result there was a feeling that, in a matter so important as the re-appointment of the Chair, enough was enough and the Council couldn’t allow itself on this occasion to overlook the way the Trust had handled things.
There was a lengthy discussion.
One governor made the suggestion, which was accepted by nearly everyone else, that there were really two quite separate issues. One was the procedure for deciding whether or not to re-appoint. The other was whether the current Chair is the right person. The first thing to deal with would be the procedure issue, leaving aside the person issue for the time being. Once we are sure that the procedure is OK, we can come back to consider the person.
A couple of people present didn’t really get it, and tried to address the person issue there and then, but they were pretty much ignored.
The Trust Secretary tried to address the procedure issue with reference to guidelines from Monitor, the regulator of foundation trusts. Unfortunately he seemed unprepared and overstated the case. For example, at one point he claimed that Monitor’s guidance is statutory (that is, the law) but Monitor itself doesn’t claim this. At another point he listed criteria that Monitor says should be used to decide whether to re-appoint, but it wasn’t clear whether Monitor didn’t just provide them as examples of the kind of criteria that might be used. I thought the Trust Secretary’s unpreparedness was surprising, because he had been present at the N&R meeting and could see where the whole thing was headed.
The Chief Executive suggested that failing to re-appoint would cause uncertainly that could have far-reaching consequences for the Trust and for healthcare generally in the area the Trust serves. I thought this a bit far-fetched, especially as the Trust had caused some of the very problems that resulted in governors questioning the wisdom of re-appointing without full consideration.
But then the Chief Executive came up with a brilliant suggestion that everyone went along with. We would start again with another N&R meeting, which would consider the matter afresh and make another recommendation, and then we would hold an extraordinary meeting of the Council to make the actual decision.
This will allow N&R to consider and address first the process issue, and then the person issue, and then the Council as a whole can give the matter full consideration, and we’ll have a decision. W00T!
In case you’re wondering whether the extraordinary meeting of the Council will be in public, at the time of writing I don’t know. I can’t think of any special reason for the public to be excluded. When I know for sure I’ll add the information to this post.