No (NHS) improvement (whatsoever)

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More tales of dismal practice and bullying at senior Sloven levels are arriving in the shed. [Thank you for speaking up]. Apparently Mark Morgan, the Director for Mental Health and Learning Disability has a bit of a tawdry background. A serial interim manager, he was reported to be earning £28,000 a month back in 2014 at the Medway Foundation Trust. His director blurb on the Sloven page states:

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Bit of a funny statement about ‘pending a recruitment process’ but it turns out that Morgan (allegedly) wasn’t appointed when he was first interviewed for the post. Not very confidence inspiring and means he was an interim for longer than necessary [yes, my fingers can barely type these words, the level of absurdity is so extreme.] Prof Hatton was keeping a careful watch on the data and tweeted:

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Mark Morgan was paid just under £300,000 for 8 months work.

[Fill in your expletives here:_________________________________  I’m out]

This afternoon, a 38 page investigation report into the care of a patient at the Ridgeway Trust. This is the assessment and treatment unit that takes Oxon patients now the STATT unit is shut. The harrowing complaint, made by the patient’s mum (terribly difficult woman I’ve heard, and no doubt has “hostile” written all over her son’s files) has 29 items relating to the unit in 2014-15.

The covering letter is from Julie (scores on the) Dawes who must be wondering what she’s wandered into but I’m assuming Mark Interim Morgan must have signed it off. It’s under his remit. A tiny bit of context here for any new blog readers:

In 2013 the CQC failed an inspection of the STATT unit where LB died. It found a hideous set of failings including a lack of therapeutic environment [howl], poor record keeping, no involvement from people using the ‘service’ and so on. 

Today’s report upheld complaints in 13 different categories of complaint:

access to services, communication, discharge, nursing care, failure to follow procedures, record keeping, attitude, clinical care,funding, medication and prescribing, aids and appliances, code of openness and equipment

Some low lights:

  • A lack of active engagement with the patient’s mum.
  • Failure to record incidents on RiO or Ulysses or inform families
  • No therapeutic engagement with patients
  • Little access to the community because of low staff levels
  • A distant and unhelpful psychiatrist at the team meetings
  • Misreporting of the patient’s activities at the team meeting
  • Inconsistent communication
  • Failure to effectively minute meetings or act on action points
  • Trust and NICE guidelines were not followed around medication use
  • No specific care plans or risk assessments around observation levels* and their purpose.
  • No discharge report received ‘because of an administrative error’.

LB didn’t get to the discharge bit. Otherwise this is pretty much a repeat of the failings identified three years ago. Sloven clearly are clueless and have no learning disability and mental health expertise at senior level. They don’t get it and they don’t give a shit they don’t get it. While Dawes is cognisant of the failings the report identifies how can any patient/member of the public have any confidence that the recommendations (listed below) will actually happen? We have been told over and over and over again that lessons have been learned and improvements made.

I’ve nothing else to say about Jeremy Hunt, NHS Improvement, NHS England, Oxfordshire County Council and the Oxon CCG. It’s all been said repeatedly.

The system is clearly broken.

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* This reminds me of LB’s psychiatrist (currently missing in Ireland) who when asked by Paul Bowen to explain the difference between an observation and a ‘check’ at LB’s inquest, said “Ah, now I’d have to really drill down to do this”. These are people’s lives.

Take. what. you. need.

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I was at the Disability Studies Conference at Lancaster a week or so ago where I met a small group of Icelandic academics/self advocates. I was delighted to hook up with them because I love the work of Kristin Bjornsdottir and team. And their campaigning. The George Fox building, where the conference was held, was dotted with these posters…

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Kristin talked about using #JusticeforLB in teaching and subsequently posted this:

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Wow.

Tim Smart resigned unexpectedly (but not surprisingly) today. Both Sloven and NHS Improvement demonstrated what Chris Hatton described as ‘a mulish aversion to honesty’ in their press statements about his resignation.

There is no candour. No honesty. We’re left with a ‘trust’ with an interim CEO, no Board Chair, no Chief Operating Officer, no Communications Director and 8 governor vacancies. Well, and financial irregularities over contracts worth millions. And a dodgy new (or old) made up post for Katrina Percy costing around £250k. And left with a deputy board chair who shared the findings of the Mazars review pre-publication with his teenage son who rubbished the findings on social media.

Wow.

What a complete and utter (chilling) shambles. Meanwhile, Jeremy Hunt repeatedly deflects MPs questions with non answers.

It’s more than apparent that the likes of Jim Mackey and gang, the remaining Sloven senior exec and ex-CEO, really need to take what they need. And act accordingly.

Or do one.

 

The talented Mr Martin and viral impact

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I wrote about Talent Works when the scandal of a £300k leadership training contract turned into £5m spoondoonies for Chris Martin and crew first broke. Since then, a few staff members have got in touch to describe their experiences of the training. Not good.

I went on Going Viral while at SHFT. It was compulsory regardless of how busy you were. Insistent on overnight stay in the hotel even though I lived 20 mins away. It was awful. Crap management twaddle. Every session we had to “check in” no thought for people like me who were not comfortable sharing in public. I gained nothing from the whole hideous experience.

Yes I’m embarrassed to admit I’m a Southern Health employee. I don’t have anything to whistle blow, and I’m sure no satisfaction to offer you and similar families but suffice to say there are a lot of us within my immediate colleagues of middle management and below who find no surprises in the latest round of revelations of farcical nonsense. Some of us have been on Going Viral and Gone Viral (there really is no opt out for certain pay bands) and while of course finding some of it interesting and sort of useful (especially meeting clinical staff and even patient advocates and hearing about their challenges) have come away feeling it’s too much corporate nonsense with ice breaking tasks and dreaded role play scenarios.

Apparently it costs £6k per person to attend, is compulsory and you have to stay the night at an expensive hotel. (Sloven spent £135k on accommodation in 2013/4 for staff to attend.)  Here’s the Talent Works partner, Sarah Law, talking about the Going Viral programme two years ago [cringe warning]:

“I know Katrina is really keen for everyone to get the chance to get involved in this...” Yeah. Of course. At £6k a pop. Sadly, she wasn’t as keen for staff to be trained in epilepsy care or to remove ligature risks.

What the training involves isn’t clear. But hey ho. A little look at the Talent Works website reveals more work with Sloven who were one of the pilots for this gig:

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Bizarrely, Talent Works evaluated the pilot themselves (yes, really). Eleven staff took part in the pilot but only 7 provided feedback on it. That, in itself, should get alarm bells ringing somewhere but apparently didn’t. And the farce continues with this nonsense:

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So, there was no way of effectively evaluating whether the pilot was effective or not. Asking people to remember how they felt before doing something is simply ludicrous. One person was apparently worse after the intervention, the others the same and yet this is a ‘successful pilot’. This reminds me of the equally nonsensical appreciative inquiry gig Sloven funded recently. The senior management/exec are clearly not very bright if they keep swallowing this shite. And, as always, NHS Improvement are hands firmly clamped over the ears and eyes shut.

Meanwhile, at Sloven’s annual public meeting last week, the finance bod, Paula Anderson, was asked about the Talent Works contract (from 1:01:46):

She clearly states; It’s fair to say when we’ve looked at it we’re not happy with the procurement process and there are issues with that. Stating the bleeding obvious but there’s definitely no governance issues here, are there Mr Smart?

So a little summary of what is deeply wrong:

  • The contract was originally awarded to the CEO’s mate for £300k.
  • Sloven eventually paid Talent Works over £5m.
  • There is no outcome measure to know if there is any benefit of doing the Going Viral training (and given the leadership failings, I think we can probably say there ain’t much benefit at all).
  • Apparently this doesn’t matter and Talent Works are being funded (by who? NHS England?) to extend their biz across other trusts…

It’s truly, truly obscene. And in one last little joining of the dots, one of Talent Works partners is, erm, the charity set up in memory of Percy’s brother, Iain’s, sailing partner. Another grubby, sordid little tale.

Update [23 September 2016]

In addition to the illuminating comments below (including evidence from John Green that the Going Viral course is rubbish), we got sent a copy of a timetable…

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And this analysis:
3 overnight stays, = 6 days lost + 2 days for launch and review + 2 0.5 days for learning sets = 9 days of work lost. On one course, there were three consultants. Assuming they were newly qualified, it would cost around £5.6 of service loss for the 9 days on the course. If at the top of the scale, £7.5k (not to mention the loss of outpatient appointments or the cost of backfill).

 

Talentworks removed their website today. Shortly after their tagline was shared on twitter:

‘Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense’.

Removing your website can only be an admission of guilt…

The Sloven senior exec allowed £5m of public money to go into the pockets of Percy’s mates. For training not fit for purpose. In the meantime, they failed to ensure that staff were trained in the basics and that the environment was safe.

This is sounding increasingly criminal to me.

Down but not out…

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Levels of incredulity at the continuing unfoldings down Sloven way – apparently supported and endorsed by NHS Improvement – have reached crisis point. Even our brilliant, informal, campaign media archivist, is flailing…

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Behind this battering is a peculiar situation which seems to be baffling pretty much everyone apart from the Sloven exec (plus Katrina Percy), NHS Improvement and Jeremy Hunt. Even Simon Stevens, CEO of NHS England, has publicly said Sloven have let down patients and families…

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There is sensible and widespread condemnation of the recent sidestepping of the CEO into a new (or old depending on who and when you ask), part time role at the same salary and perks as a CEO (on top of the other, well documented failings). Including this statement from Philippa Russell on behalf of the National Valuing Families Forum.

The story of Smart’s stint as Interim Board Chair which only started in May is that he apparently commissioned two (yes two) so far mysterious reviews which found that the Sloven board are fit to practice. This was announced on June 30 without any engagement with families (other than an ‘accidental’ meeting with My Life My Choice who have since decided to no longer engage with Smart). The annual board meeting held last week demonstrated woeful engagement with families and patients (forced, as always, to sit through interminable presentations/talk with public question time compressed to barely any time at the end). This seems to last as long as Smart’s patience (if you can bear to listen to the audio recording). Appalling senior action still from a trust who have been in the public spotlight relentlessly for failing to engage with patients and families.

Strangely, Smart has agreed to the secondment of two directors (including the Chief Operating Officer).  Chris Gordon to NHS Improvement and Sandra Grant to another trust or commissioning group. And unilaterally (it appears with NHS Improvement dove from above agreement) agreed Percy’s new or old position.

Just a few questions. [No answers expected…]

  • Why would you insist a board is fine and then allow the secondment of (key) execs when the terrain is rocky?
  • Is there now no Chief Operating Officer or Communications Director alongside an interim Board Chair and CEO?
  • Is anyone at the highest levels of the NHS, in this foul and grotesque tale of abuse, deceit and pantomime, going to find it in themselves to stand up and act with integrity?

I suppose, if nothing else, a necessary light is being shone with a bloody big torch not on only Sloven murkiness but also the gaps, limitations, failings, impotence, pointlessness, corruptness and fatcattery that exist within and among senior NHS spaces. I dunno how you sleep at night.

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Walking back from the original gingerbread protest at Jubilee House earlier this summer.

A cheeky bit of media advice to Smart and gang

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We’re weary in the Justice shed. Weary of the continuing horrors, absurdities, scandals, lies, deceit, cover ups, failures in accountability, delay, obstruction, lack of decency, sense and fairness. Broken Trust, shown this week, was pretty horrific and devastating for families involved to watch. In the spirit of productiveness, and to distract from raging, I thought it might be useful to offer Tim Smart and other senior NHS bods a few pointers in engaging with the media. His interview (and Katrina Percy’s) with David Fenton was an exemplar in how not to. Just a few twitter responses:

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Now I certainly ain’t no expert in media appearances. We have no comms team/resources behind us. In fact the only time I was on local radio before this devastating unfolding, was for work. I forgot the third (stereotypical) characteristic of autism through a rabbit in headlights/fear situ. Deeply awkward and embarrassing at the time. Now just budgie feed.

Here’s the transcript of the interview with Smart with thoughts and suggestions added in red. Please feel free to add further reflections/advice in the comment section below. There is clearly plenty to learn.

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1Obviously this interview will have been edited and mucked about with. But the ills and errors were spoken and so available to produce this version. Thoughtfulness, care, honesty, reflection and openness are the very basic ingredients. With knowledge, underpinned by experience, and broader understandings of and engagement with the wider context essential at such a senior level. At a senior level, and on these massive salaries, I’d also expect a clear understanding of media engagement (and the potential pitfalls) and some ease (taught or otherwise) of sitting in front of a camera or microphone.

The third ‘autism characteristic’ I forgot, back in the day, that afternoon at BBC Radio Oxford, was ‘theory of mind’. I was mortified at the time. I resolved to avoid announcing a number of things, in advance of listing them, and to prepare a list of key points in advance. I hope Smart, Percy, and those around and above them, are revisiting the seriously gut wrenchingly awful presentation of Sloven senior culture presented in Broken Trust. And that serious questions are being asked around what has, and continues to happen, at higher levels. 

Unpacking the Smart move

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Blimey. Does anyone know what’s going on? Record breaking levels of absurdity… I recommend watching Broken Trust which was shown last night on BBC South. Just contrast the contributions of the families, public, rebel governors with the performances by Percy and Smart. [A limitation to the programme was it didn’t shine the spotlight on the other, good for nothing, crap execs and non execs (Gordon, Grant, Stevens, Spires and Bezzaman and co) but it was only 26 minutes long…]

To summarise where (I think) we’re at (for the next 12 hours or so…) and not spelling out the crapitude both Smart and Percy demonstrate in this film (and their actions).

  • KP is no longer Sloven CEO.
  • She moved into a “new role” at the same salary and without following HR processes and procedures.
  • She moved because of media attention.
  • She then allowed a film crew to follow her for a day and coax utterly reprehensible reflections out of her.
  • She is “uniquely qualified” for this, so far, unnamed new role.
  • We don’t know what those unique qualifications are, but I think most of the UK population following this sordid little tale would agree, they ain’t jumping off the page and really, we should know if there are any.
  • The new role is now not a new role.
  • It’s part of her old job (CEO).
  • Apparently the part that took 1 day every two weeks.
  • She will be doing this new tiny part of her old job for 12 months on a CEO salary.
  • Smart’s definition of corruption doesn’t include lies, cover ups or deception.
  • Smart’s credentials for trouble shooting a failing trust are looking pretty flakey.
  • He has managed (with the apparent blessing of NHS Improvement) to piss on the lives of families shattered by sustained failings over the last five years.
  • It hurts him to meet bereaved families.
  • A patient left Sloven’s mental health services alive [positive end piece].

We are in Laurel and Hardy territory.

Stay classy y’all.

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Postscript: In case anyone missed it, My Life My Choice have washed their hands of the Sloven leadership (and feature in the programme). Telling it like it is. You delivered nothing.

The Bode files

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Still struggling to absorb the latest leaked documents: two letters from Carol Bode, previous Sloven board chair, to Monitor (now NHS Improvement) flagging concerns in 2011 and to Alistair Burt in July 2016.

The 2011 letter is 9 pages long with appendices. My first response, other than horror, was surprise to read an authoritative, sensible and thoughtful letter. Our communications from Katrina Percy and other Sloven execs have been grim, silly, hot air, lying bullying bullshite. Exemplified by the letter Katrina Percy sent me in August 2014 but also Simon Waugh categorically denying Sloven were monitoring my blog.

The back story is Hampshire Partnership NHS Foundation Trust (HPFT) merged with Hampshire Community Healthcare (HCHC) [Katrina Percy’s stamping ground] creating Sloven in 2011. Senior HPFT bods left and within a short space of time HCHC directors dominated the board. A cheeky little Percy coup d’état with only Helen McCormack remaining from HPFT by 2013. Extraordinary and deeply alarming. Particularly, as Bode raised issues around the expertise of the board two years earlier:

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Not only foundation trust expertise but also mental health and learning disability expertise. Before the Ridgeway takeover… [Howl]

Though carefully worded, Bode also raised issues around Percy’s leadership approach:

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Sadly, there were no fresh eyes. Simon Waugh, the replacement board chair was replaced by Mike Petter, an old mate of Katrina Percy’s from her pre-Sloven days. A now familiar path of rewarding mates with jobs/contracts.

In her letter to Alistair Burt, after Smart’s board judgement on June 30 this year, Bode states:

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If only Monitor had listened and acted… These pages could still be filled with hilarious anecdotes.

You fucking bastards.

PostScript: Thank you for trying, Carol. And thank you to the peep/s who send us these documents. There remains nothing like transparency and candour within official channels.

When troubleshooting goes bad…

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Blimey. More documents pinging mysteriously into the Justice shed. Including a letter written by the then Sloven board chair to Monitor (now NSH Improvement) raising serious governance concerns in 2011. [Yes. Really]. At first graze, a dense, detailed, informed, harrowing and enraging addition to an apparently unlimited evidence pile highlighting Sloven governance failing.

I’m typing this post listening to Laura Veirs. A vague balm. Rich and I have spent the last three days since the faux announcement of Katrina Percy’s (yet to be properly confirmed) ‘resignation’ in a harsh and agitated space. It’s not about her, as a person. It was never about her as a person. Blimey. She didn’t make it to the Connor Manifesto. But it’s becoming more and more about her. 

Percy failed to lead effectively. We all know that. The board failed, and continues to fail, as an executive board. The Council of Governors remain split between an enlightened minority and the waste of space rest. There remains a consistent and shocking lack of competence, authority, knowledge and sense among both the board and council. Backfilled with a frenzied focus on reputation and apparently unlimited funds to buy in whatever spurious consultancy or legal support they think will magic away the disorder that surrounds them.

Deeply depressingly, the documents leaked to us today were shared with Tim Smart to provide context to his review of the board. Now we don’t know (I don’t think anyone really knows) what Smart based his (30 June) judgement of the board on. We do know he scathingly dismissed the Mazars review during the meeting with My Life My Choice and we now know he must have dismissed the serious concerns raised by the board chair back in 2011.

We also know he agreed to the very recent secondment of Sandra Grant and Flash Gordon to new pastures (as well as gifting Percy a substantially reduced role on a CEO salary). Why you would give a board under serious scrutiny a clean bill of governance health and then start seconding execs five minutes later is a mystery. Oh. Unless you finally, and belatedly, realise the board is as grubby as they come.

Indeedy, it’s probably about time some of the spotlight shifts to Smart and Jim Mackey (the CEO of NHS Improvement My Arse). What this pair of muppets are doing is beyond me. Did they really not anticipate the inevitable backlash against such offensive and scandalous news? Did Smart not realise erasing all whiff of failure in Percy’s leaving statement, blaming press interest, would simply enrage and inflame? What an almighty pigs ear of executive and regulatory ‘action’.

Ironically, one of the biggest failings here is candour and transparency. From where we’re sitting, it appears Smart made the wrong judgement on June 30 because he is incapable of listening. Days later Michael Buchanan broke the news about dodgy contracts. Patient deaths are clearly nothing compared to doshing your mates £millions for going viral nonsense. Once Roy Lilley was on Radio 4 condemning the spiralling of a £300k contract to £5m, the writing was on the wall. Failing governance a go go.

Instead of a clean sweep, an acknowledgement of failings – of letting down hundreds of patients and their families, of a board gone bad – Smart, Mackey (and Hunt?) ballsed it up. Big time. Generating more media attention and public outrage than the publication of the report revealing that Sloven investigated less than 1% of the unexpected deaths of learning disabled people over four years. A report that led to the appointment of Smart as the troubleshooting interim chair.

What a stinking mess. Do the right thing someone. Please.

The Smart and Percy Show

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Rich and I are on leave at the mo. A funny space of walking, a weekend away in Finland (me), going to FrightFest with Will and Owen (Rich), catching up with friends and family and more walking. Yesterday Tom left for a day out at Legoland with Yellow Submarine. Lying in bed, vaguely (not) making day plans (around work stuff) we heard the Sloven CEO’s resignation was imminent. Within 10 minutes there was official announcement.

The day became a media thing. A heightened media thing. Reminiscent of the day of the vindictive cow caller. My phone kept pinging. We were a bit half arsed in our responses and hit or missed Sky News, Huw Edwards, Radio 5 Live, Radio 4 PM, BBC News… ITV Meridian and the Daily Fail just pitched up at home. The cheeky scamps.

It turned out the story was the usual Sloven spin and deceit (with the apparent approval of NHS Improvement). Percy was retaining her salary to do some made up nonsense. Truly extraordinary. Both Percy and Smart blame media attention [I know] for making the chief exec role untenable. The personal media attention levelled at Percy apparently. Mmm.

Not sure anyone was simply gunning for her. Take this piece, for example:

Notwithstanding this point, failing to acknowledge well known and longstanding failures in their statements is deeply offensive. Smart, who has scrambled egg on his face in a big way having endorsed Percy and the board only weeks ago, lists her “successes” in a blatantly fake, arse covering way:

Great resilience, devotion, well suited to lead the trust (and to do vital work with GP leaders), ensured joined up working with health and care organisations, leaving the trust financially sound… and blahdy blah.

Joined up working? Like greedily devouring Oxfordshire learning disability provision, leaving it to rot, allowing people to die [die] and then losing the contract…? How could you write this shite?

Now, we ain’t rocket scientists but both Percy and Smart seem to be talking from a leaving hymn sheet in their statements. Percy signs off:

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While Smart states:

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You don’t wish people all the best at work if you’re staying. Or thank someone for their years of service when they ain’t leaving. So it appears that we will continue to pay Percy’s inflated salary indefinitely while she does, erm, very little. [Chris Gordon in the above piece has already been seconded to NHS Improvement in a you could not make it up move… bizarrely leaving the hapless Medical Director on the board. The person who turned up to LB’s inquest without even doing the most basic homework about the Trust].

What is truly sickening is we all know this is complete bollocks. And it seems there is nothing we can do about it.

The reality is Katrina Percy failed as a leader. And her executive team failed alongside her. As Paul Kemp tweeted earlier, this is what she leaves behind.

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‘Second victims’ and calling a boat a boat

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I’ve lost count of the number of scratchy NHS related tweet exchanges I’ve had with certain human factor fanatics over the past three years. Blooming tedious and always brings in the flying monkey types who don’t engage or discuss but just retweet the too often cultish, Stepford Wifey, non speak.

Sigh.

On a vaguely related note, there has been ongoing discussion over the past two days around ‘no blame’ cultures and accountability. I’ve kind of tried not to get involved but every now and again words like ‘witch hunts’, ‘equal parties’ and the like make me chip in. Earlier today the concept of ‘second victims’ cropped up. Second what…?

Blimey. Turns out there is a body of research around health professionals being ‘second victims’ when a patient is harmed. A concept introduced 16 years ago in the BMJ by AW Wu and apparently uncritically accepted as a ‘thing’. The US based paper shared earlier has the following findings and conclusion around the impact of ‘adverse patient events’:

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Six stages that conveniently sidestep any engagement with responsibility or accountability. What is astonishing – in this paper, I’m sure in the broader ‘second victim’ literature and in the twitter discussions I’ve been involved in or followed as a lurker – is the cosy, untouchable, (sadly too often smug) portrayal of healthcare professionals’ working practice being beyond scrutiny. No accountability (or heaven forbid, criminal prosecutions), here thank you. Move along now. We’re doing our holier than thou, extra special work. If anything goes wrong, we need help to start to enjoy our work again.

And zip all reflection about those  left brutalised by the death of their child, parent, grandparent, family member or friend…

The fakery and indulgence around this second victim nonsense is laid bare in the conclusion of the article where the authors state:

Regardless of sex, professional background or years of experience, all participants in our study easily recalled the immediate and ongoing impact of their specific career jolting event.

A career jolting event is nothing like experiencing the preventable death of a loved one. Please don’t ever pretend it is.

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Tama on vene [translation from Finnish: this is the boat].

Postscript: I’m not ignoring or denying that healthcare staff may/must be devastated by the death or serious harm of a patient here. It simply ain’t comparable to the experiences of families.