Moving from bullshit to substance in NHS Foundation Trusts

I mentioned the Trust I used to work for in a previous post. It has been found inadequate four times by the CQC, although currently rated as requires improvement. As with Ofsted (see recent report from Education Committee) there are concerns about the way CQC is working, for example, because of single word ratings and the expertise of inspectors. I commonly find it difficult actually to understand what CQC reports are saying about services because of their lack of narrative. They can appear superficial and formulaic. There are concerns about their accuracy, completeness and depth of analysis. They don’t always make clear what services need to do to improve. 

Still, Norfolk and Suffolk Foundation Trust’s (NSFT) first inadequate rating was not surprising. CQC was probably looking for a Mental Health Trust to rate inadequate, as it had been created to give all Trusts a rating and hadn’t yet found a Mental Health Trust to rate inadequate. NSFT was the first and only inadequate Mental Health Trust in its first round of inspections. The Trust had been through a programme of radical redesign without proper consultation and chaotic implementation. I’m not convinced CQC really understood what was happening when they inspected but interviewed staff who were in turmoil. This led to the inadequate rating.

I was a governor at the time. In December 2012 I was observing the Trust Board meeting and spontaneously stood up and interrupted the meeting with a fellow governor because the non-executive directors (NEDs) bounced the CEO in the meeting into saying that the radical redesign would be implemented. The NEDs were unhappy about how long the Chief Operating Officer was taking to finalise the plan for the Trust to be in the lead of the charge to meet the Nicholson challenge, named after the then NHS CEO, for the NHS to make £20 billion efficiency savings. The Chair said the radical redesign was going ahead nonetheless and we had to sit down. This was before there had been the promised consultation, which never happened, about the plan.

Unfortunately the CEO resigned in June 2013. He was probably the only person who could have kept the radical design process together. Instead I witnessed the most chaotic implementation imaginable. I was, therefore, present as a governor, together with a roomful of concerned people, in November 2013 at the launch of the Campaign to Save Mental Health Services, which continues to this day in its campaign. Lurking in the background at the meeting was the interim CEO, who unfortunately that same month refuted that the Trust was in crisis.

Nonetheless the NEDs continued with their gung-ho attitude that the Trust had made major steps forward in forming NSFT by the merger of Norfolk and Waveney Mental Health NHS Foundation Trust and Suffolk Mental Health Partnership NHS Trust in January 2012. In fact they saw it as a takeover of Suffolk by Norfolk and Waveney, which technically it was. Nonetheless, I argued as a governor for the headquarters of NSFT to be in Ipswich, rather than Norwich, which of course did not happen.

The NEDs recruited a replacement CEO in March 2014. He was CEO at Norfolk Community Health and Care NHS Trust (NCH&C) and took up his post at NSFT later in the year. Personally I was not convinced he was the best candidate for the post, but it’s the NEDs that appoint a CEO not the governors, and clearly the governors had to ratify the appointment. I think he was probably sold a ‘pig in a poke’ by the NEDs that they were hoping to also take over NCH&C, which would be ideal for them because he had been CEO there. A few months after him starting in post, CQC gave the Trust its first inadequate rating in February 2015 following an inspection the previous October. I'm not convinced he was aware that this was what he had inherited.

I came to the end of my terms of being a governor in 2015, although I continue to be a member of the Trust. A CQC report published in October 2016 following an inspection in July 2016 regraded the Trust to needs improvement. The following year the Trust was again regraded inadequate, with the CEO resigning just before the report was published. A warning notice under S29A of the Health and Social Care Act 2008 was issued following the inspection in July 2017. The Chair of the Trust left earlier than expected in November 2018 and was followed by the publication of a third inadequate CQC rating. 

The new Chair in January 2019 was already Chair at North East London NHS Foundation Trust (NELFT), which had an excellent CQC rating and she took on both roles. This was despite the governors having already appointed a replacement Chair. They were pressured to change their decision and the constitution of the Trust was changed to allow the new Chair to be appointed. The CEO she inherited was working towards splitting the Trust but he left, having been stopped in his tracks, when the new Chair insisted that the Trust remain a single organisation. She then appointed a new CEO, who had worked at NELFT in the past, although not as CEO. 

The CQC rating was changed to needs improvement in January 2020, following an inspection in October/November 2019. The CEO retired in March 2021. His replacement, who had also worked at NSFT and previously at NELFT, was appointed but withdrew his application when it emerged that parts of his CV were falsified. Although there was an interim CEO, the Chair, even though she was leaving, insisted on making a CEO appointment before she left and the COO was promoted to CEO in September 2021. I questioned whether this should happen, by asking in a public board meeting why an appointment could not wait until a new Chair was in post. The Chair told me that NHS East of England were supporting her in doing so.

I had retired from clinical work in July 2019. Nonetheless I continued my membership as a public rather than staff member. I continued to have some contact with colleagues with whom I used to work. The information I was receiving made me express my concern about the deterioration in services in Great Yarmouth and Waveney, where I used to work, in a Twitter thread in November 2021. I formally asked a question at the Council of Governors in December 2021 about why the Chair was stating that the Trust was one of the fastest improving Trusts in the country, when that clearly did not seem to be the case to me. I was so dissatisfied with her answer that I followed it up with a letter, which she eventually answered in January 2022 after she had left. I had also tried to engage with the lead governor on the telephone asking the Council of Governors to act but we ended up shouting at each other, for which I have subsequently apologised, but I don’t think it would have made any difference if I had kept my cool. As far as I was concerned the Chair did not properly engage with any of my concerns expressed in the letter. I had anticipated that the Trust would again be found inadequate in its next inspection and called for the resignation of the Chair, the two Vice Chairs, the Senior Independent Director and the lead governor in a tweet. As predicted, the Trust was again found inadequate in a report in February 2022 following inspections in November to December 2021. The CQC had already again initiated enforcement action before the Chair left at the end of 2021.

The new Chair duly came into post and managed to help the Trust obtain a CQC needs improvement rating in a report in February 2023 and the threat of enforcement was removed, following inspections in September and November 2022. I thought it was important to keep pressure on the Trust, even with a new Chair, and had been with the Campaign on their lobby of parliament in July 2022 (see EDP report and my Twitter thread). I called for the resignation of the CEO, and he eventually left in September 2023 (see EDP report). I do not think this was because of my campaigning, although MPs we met on our lobby of parliament questioned whether this was necessary. Personally I had no doubt and raised the matter in May 2022 with the two vice Chairs, as technically the appointment had been made before the Chair came into post. I was told the CEO had the full confidence of the Board and that they couldn’t help me any further. I suspect his performance at the Norfolk Health Overview and Scrutiny Board (HOSC) in September 2023 was a factor in his going. At the same meeting HOSC called for a public inquiry, as has the Campaign persistently and consistently for some time. An answer is still awaited from the Secretary of State although an inquiry is being resisted by the Trust and the two local Integrated Care Boards.

Personally I have become more confident that the Trust can turn itself round with its new CEO after the intervention of NHS England. Other campaigners remain more sceptical and they continue to think a public inquiry is necessary. This is not surprising considering the sorry saga I have related here. The Trust is also facing a criminal investigation (see EDP report).

By the way, I’m not being rude when I use the term ‘bullshit’. The technical definition is explained in another previous post.