Mazars and the Parliamentary Urgent Question

This morning, the Secretary of State for Health Jeremy Hunt responded to an urgent question from his shadow opposite Heidi Alexander on the leaking of the Mazars Report into unexpected deaths between 2011 and 2014 under the care of Southern Health Mental Health Trust.

I don't want to discuss the substance of the report here as it is ably being discussed elsewhere. Rather I wanted to focus on the 30 minutes in the House of Commons.

Because of the current unpublished status of the report, even with Parliamentary privilege, MPs were rightfully careful of their language. Yet the manner of Jeremy Hunt's statement should leave no doubt as to the status held of it by the Government and NHS England. 

Jeremy Hunt's Statement

The whole House will be profoundly shocked by this morning’s allegations of a failure by Southern Health NHS Foundation Trust to investigate over 1,000 unexpected deaths. Following the tragic death of 18-year-old Connor Sparrowhawk at Southern’s short-term assessment and treatment unit in Oxfordshire in July 2013, NHS England commissioned a report from audit providers Mazars on unexpected deaths between April 2011 and March 2015.

The draft report, submitted to NHS England in September, found a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths of mental health and learning disability service users. Of 1,454 deaths reported, only 272 were investigated as critical incidents, and only 195 of those were reported as serious incidents requiring investigation. The report found that there had been no effective, systematic management and oversight of the reporting of deaths and the investigations that follow.

Prior to publication, or indeed showing the report to me, NHS England rightly asked the trust for its comments. It accepted failures in its reporting and investigations into unexpected deaths, but challenged the methodology, in particular pointing out that a number of the deaths were of out-patients for whom it was not the primary care provider. However, NHS England has assured me this morning that the report will be published before Christmas, and it is our intention to accept the vast majority, if not all, of the recommendations it makes.

Our hearts go out to the families of those affected. More than anything, they want to know that the NHS learns from tragedies such as what happened to Connor Sparrowhawk, and that is something we patently fail to do on too many occasions at the moment. Nor should we pretend that this is a result of the wrong culture at just one NHS trust. There is an urgent need to improve the investigation of, and learning from, the estimated 200 avoidable deaths we have every week across the system.

I will give the House more details about the report and recommendations when I have had a chance to read the final version and understand its recommendations, but I can tell the House about three important steps that will help to create the change in culture that we need. First, it is totally and utterly unacceptable that, according to the leaked report, only 1% of the unexpected deaths of patients with learning disabilities were investigated, so from next June, we will publish independently assured, Ofsted-style ratings of the quality of care offered to people with learning disabilities for all 209 clinical commissioning group areas. That will ensure that we shine a spotlight on the variations in care, allowing rapid action to be taken when standards fall short.

Secondly, NHS England has commissioned the University of Bristol to do an independent study of the mortality rates of people with learning disabilities in NHS care. This is a very important moment at which to step back and consider the way in which we look after that particular highly vulnerable group.

Thirdly, I have previously given the House a commitment to publishing the number of avoidable deaths, broken down by NHS trust, next year. Professor Sir Bruce Keogh has worked hard to develop a methodology to do this. He will write to medical directors at all trusts in the next week explaining how it works, and asking them to supply estimated figures that can be published in the spring. Central to that will be establishing a no-blame reporting culture across the NHS, with people being rewarded, not penalised, for speaking openly and transparently about mistakes.

Finally, I pay tribute to Connor’s mother, Sarah Ryan, who has campaigned tirelessly to get to the bottom of these issues. Her determination to make sure the right lessons are learned from Connor’s unexpected and wholly preventable, tragic death is an inspiration to us all. Today, I would like to offer her and all other families affected by similar tragedies a heartfelt apology on behalf of the Government and the NHS.

No-one reading that should take credibly the claims in the HSJ article this morning which ran with the counter claims of a tame academic appointed by Southern Health and having a partial extract of the report shown to them. Still its another example of the desparate lengths the Trust are prepared to go that is in the public arena. NHS England take note.

This was a shocked chamber that listened to and responded to Hunt's statement. There were two questions that reoccurred that need highlighting. 

The first question was when did the Secretary of State know about the concerns over Southern Health. The answer was early 2014. The issue about repeating this question is that there has been a delegation of power from the Department of Health to NHS England through the 2012 reforms. The Secretary of State cannot be hands on as previous secretaries of state were. 

As a result of repeated marketisation reforms, the NHS banner contains numerous separate legal entities. The ability to act has to be lawful and consistent. It is, in my opinion, this space that has allowed Southern Health to make 300 challenges which will have been legally argued as required. Here its worth noting Jeremy Hunt's response to Andrew Turner:

The commitment I have from NHS England is that it will be published before Christmas. I am confident that, whenever it is published, it will generate huge media interest, rightly so and partly thanks to the shadow Health Secretary’s urgent question. When the draft report was sent to the trust, it came back with 300 individual items of concern, and it was right for NHS England, in the interests of accuracy and justice, to consider fully all those concerns. It has given me an assurance, however, that, whether or not it can reach an agreement with the trust about its contents, the report will be published before Christmas.

An agreement with the Trust. Yet also note what Hunt said to Heidi Alexander that [w]e will not allow any further arguments about methodologies to stand in the way of the report being published before Christmas. I would suggest that any goodwill within Whitehall towards Southern Health has been burnt up.

The second question was around families not having access to legal aid to challenge NHS bodies. This placed Jeremy Hunt in a difficult position because it isn't his turf but that of the Lord Chancellor Michael Gove and the members asking the question knew that. Hence the line that with a properly accountable NHS with full family involvement that there wouldn't need to be litigation. A sentiment that I would like to see fulfilled as it would be an extraordinary achievement. Until that perfect world, the Ministry of Justice needs to be lobbied in order that the scales of justice are balanced. 

This 30 minutes merely sets the context for future events. Once the report is published then a full debate will follow. This is where the House of Commons can give direction to the Secretary of State and that then empowers NHS England. Publication shifts power balances and serious reports require serious actions.

I would want to see Southern Health broken up, the earth salted and its ashes scattered to the winds. Its board and senior management were too remote and separate from the actual practice of care. Its size and empire (property) building are emblematic of an unfit culture. I believe, based on experience, in rooting management in the community so that values are shared and mutually understood. This sector of the NHS appears aloof and outside of those processes. When the debate occurs, I hope consideration is made on that point.

A clash of ambitions

Today (Tuesday 3rd March) has been an interesting day for the contrast between my morning spent in London discussing the 2nd draft of the Laughing Boy Bill (LBBill), a movement to see enacted in law changes that will improve the lives of people with learning difficulties and/or autism, and this afternoon/evening spent following the debate to set the 2015-16 budget for Birmingham City Council (BCC) where the Labour administration is having to enact £85m of cuts for the next financial year alone.

Now I have considerable sympathy for the position that Sir Albert Bore et al find themselves in. This is unprecedented in terms of scale. Yet some of this has been self-inflicted by successive administrations to favour the city centre development over citywide responsibilities. So in my area of interest, adult social care, Birmingham City Council is underspending comparatively with other metropolitan areas by 2.5% of budget or £39million in cash terms. That is an outlier that is significant by any stretch of the imagination.

It cannot be said with confidence that the budget that will be set today will meet the statutory requirements on the city as the 2014 Care Act comes into effect from April. Its an difficult juxaposition where Whitehall expectations are increased while the grants for BCC are decreased. If the consultation, budget or any service provision were tested legally, BCC would probably have more difficulties than the contingency fund would allow.

Against this, the 2nd draft of the LBBill sits as a statement of intent. In particular, clause 4.4 of the 2nd draft which asserts duties above financial resources. As a principle, this is absolutely right. In practise, if this culture of austerity for local authorities continues, it will inflict more pain on the functioning of any authority. It makes me uncomfortable because I know that 2015-16 isn't the worst point for Birmingham City Council. 2016-17 and 2017-18 will be harder still as the cuts drive deeper. Its against this background that I and others hope that Sir Albert, John Cotton etc will start working with us and others interested parties from May 8th to help the city mitigate the worse aspects of 2016-17 onwards and close that gap with comparable cities. Its a hard road ahead.

Against that, the 2014 Care Act does reduce the ability of local authorities to use financial considerations as a basis for setting who qualifies as having statutory needs. The imposition of national standards does challenge the 1997 Gloucestershire Judgement that local authorities have used to tighten qualification of substantial or critical needs. So clause 4.4 can be said to work with the 2014 Care Act. This will be tested in court soon I suspect.

So the optimism I felt this morning at Monckton Chambers with the diverse and knowledgeable individuals and organisations around the table, both in person and the disembodied voices on speakerphone, has been tempered by the ugly reality that is occurring in Birmingham's Council House.

Yet the ambitions of LBBill has to happen. We cannot compromise on the principle that underpins LBBill that is everyone has the right to live their lives however messy that may be. That it may make local government's life more messy is something we'll have to live with.

Birmingham's Autism Strategy for Adults consultation launch

It was the 6th World Autism Awareness Day on April 2nd as officially designated by the United Nations General Assembly to raise awareness of autism across all communities and societies. You may not have heard of WAAD but those involved in local government and the NHS across the UK are having to raise autism awareness among their staff. Not for a day but permanently.

The 2009 Autism Act and the subsequent national strategy published in March 2010 Fulfilling and rewarding lives: the strategy for adults with autism in England places statutory duties on local authorities and NHS bodies to develop strategies for increased awareness of autism and adaptation of service provision to enable autistic users to access services easier. The act also calls for reasonable adjustments to remove barriers to access and participation in public life.

And on World Autism Awareness Day at Think Tank, Millennium Point, the Birmingham Autism Partnership Board (BAPB) officially launched its Autism Strategy for Adults in Birmingham 2013-2016 as a consultation document.

Presenting the strategy were councillor Steve Bedser, Birmingham City Council Cabinet Member for Health & Wellbeing, Dr Ashok Roy, Chair of the BAPB who specialises in the psychiatry of learning disabilities, and Jonathan Shephard, Chief Executive of Autism West Midlands. Sitting amongst the audience were senior BCC officers who are grappling with the implications for service delivery from the budget cuts announced up to 2016-17. Dr Roy stated that this was an optimistic strategy. In this age of austerity for Birmingham, optimism is at least a free commodity.

The draft strategy sets out six areas where the BAPB wants to deliver progress: implement training and raise awareness; implement pathways for diagnosis; improve on opportunities for employment & education; improve access to services; improve transitions from childhood; and improve interactions with the criminal justice system.

These are all worthy challenges to pursue in aid of a more inclusive city. While there has been considerable attention to autism in childhood there remains large gaps in the understanding of how autistic adults in society function despite autism being a life-long condition. There were considerable difficulties in obtaining information about adult autistic service users because they often weren't being recorded. For example NHS trusts were particularly weak at information recording although this is changing with the NICE clinical guidelines issued in June last year.

Yet the barriers to inclusiveness for those on the autistic spectrum are not as obvious as say providing an access ramp for wheelchair users. Rather, it requires a cultural shift across service provisions within the NHS and local government to meet the needs of users with an autistic spectrum disorder. This represents some interesting challenges in terms of both recognition of someone on the spectrum and making reasonable adjustments for them by front-line public sector service staff.

It is worth reflecting on this truism: "if you met someone with autism, you met one person with autism". Autism is a developmental disorder where the brain has developed differently which can come from a myriad of physical causes. How someone's autism presents itself is diverse. Having an awareness of autism doesn't necessitate an understanding of autism or identifying what reasonable adjustments should be made when presented with an individual on the spectrum. Recognising a difference is merely the start of a communication process and requires freedom of agency from service staff which may not always be possible if the service provision is proscriptive in nature.

A major challenge to the ambitions of this strategy is the austerity that Birmingham is currently experiencing. Whilst the establishment of the Health and Wellbeing Board required by the 2012 Health & Social Care Act will support the strategy through a specific Joint Strategic Needs Assessment for autism, this remains the most challenging of times to attempt to reconfigure service provision and provide additional services given the cost pressures being experienced.

Yet the process currently being undertaken in preparation for BCC's consultation this summer on Adult Social Care provision from 2014 onwards should be identifying current costs being incurred to the city by those on the autistic spectrum across department budgets where possible. If genuine societal costs can be identified then some modelling can be undertaken to assess the cost-effectiveness of preventative work. This could then be widen out to involve the Police & Crime Commissioner/panel and NHS bodies which would also improve data gathering and assessment. From such work can negotiations for joint funding of preventative services or submissions for central funding take place as proposals could then be evidenced.

Therefore the biggest challenge facing an autism strategy for adults is the quality of information available and the lack of information from certain sectors. Whilst the BAPB has identified areas that will improve the lives of autistic adults if implemented, it does so from an incomplete picture of the city. If by 2016 we have considerably more quantitative and qualitative data from across the public sector then there could be a more informed debate in terms of service design rather than just spreading awareness. Such information would also inform a more detailed level of scrutiny regarding outcomes as they impact the city rather than just internal project milestones and outcomes. 

This strategy document is a welcome step forward for the city's autistic inhabitants and their families. The challenges will be how far the targets and/or aspirations laid out are able to be delivered and whether in 2016 the city has a more detailed picture of the needs of autistic adults within its boundaries. For this strategy to be truly excellent, a specific commitment to information gathering is required for me. 

The consultation runs until the 26th of June and information can be found here.