Over the last few months I have been involved in a campaign that is asking for an independent review of local health and social care services. The campaign was sparked by the local health board – NHS Highland – announcing that both community hospitals in the area will be closed and replaced by a single new hospital. The proposals will leave the most heavily populated area of Skye without any hospital beds or out-of-hours emergency medical care. Services that we have relied on for the last 50 years will be moved 30 – 60 minutes further away.
This is obviously of great importance locally but the issues surrounding the decision to remove these services are universal. They are about the limitations that we put on funding for public services, and they are about the competence of public servants in their use of resources to deliver the services that we need.
Elsewhere on this blog I discuss the problems of funding public services and how we might do it differently, but this is my first attempt at tackling the subject of how we can make best use of the money that is collected and distributed by government for the common good.
What follows is a copy of an open letter that I have sent to members of NHS Highland’s leadership team in which I try to explain why they are failing to provide the services that we need and the importance of a systematic approach to problem-solving and decision-making.
On the 11th of May 2015 I attended a meeting of the Skye, Lochalsh, Wester Ross & Assynt District Partnership (a forum for conversations between NHS Highland and Highland Council to help them develop integrated health and social care services.)
Two members of the public who work with dementia sufferers presented the meeting with statistics that forecast a significant increase in the number of people in the area who will need care because of dementia. They also described the woeful lack of resources to provide current dementia patients with the care that they need. What, they asked, does NHS Highland propose to do about these shortcomings (current and future) in dementia care in particular and mental health services in general?
The next ten minutes were taken up by Kate Earnshaw (District Manager) more or less repeating the nature and extent of the problems with dementia care services. She told us that similar problems exist across Scotland and the UK as a whole, as if this somehow validated the failure to provide care for these people. When pressed on what solutions were being proposed she told us that NHS Highland was “looking at” additional training for some front line staff and “the possibility of” moving some staff from elsewhere to cover dementia care (without telling us what other services would be affected by this redeployment). During this exchange Ms Earnshaw was backed up by her Area Manager, Tracey Ligema.
The absence of any coherent strategy to deal with what is a chronic problem was very striking, all the more so when one of the councillors pointed out that the District Partnership had discussed this in February and May of 2013. The Action Notes from the May 2013 meeting tell us that concerns about resourcing mental health services “had been raised 18 months ago”, which would have been in late 2011.
So, for at least three and a half years NHS Highland has been aware that people with mental health problems and their carers have been suffering from a lack of services but Ms Earnshaw and Ms Ligema are still unable to provide us with anything that looks like a plausible plan to provide what is needed. There appears to be no analysis of what’s required and no list of objectives that, when met, will result in a service that does what we need it to do.
As my knowledge and understanding of the business and performance of NHS Highland grows it becomes increasingly obvious that this unstructured approach to dealing with problems is endemic within the organisation.
I watched a video recording of the proceedings of the Public Audit Committee of the Scottish Parliament on the 13th of May 2015, where senior members of NHS Highland were interrogated by MSPs about financial mismanagement and procedural irregularities. The responses from Garry Coutts (Chair), Elaine Mead (Chief Executive) and Nick Kenton (Director of Finance) left three strong impressions on me.
Firstly, NHS Highland is an organisation that is in a state of continuous financial crisis, struggling to make its books balance at the end of each financial year, periodically robbing one part of the service to pay for another, routinely leaving vacant posts unfilled in order to avoid paying salaries, desperately looking for other ways of not spending money.
Secondly, cost-cutting is the primary objective behind all changes to services across NHS Highland. Mr Coutts’ claim during the session that the priorities of the organisation are “safety”, “clinical need”, and “patient experience” is a risible inversion of the bleeding obvious. The entire Audit Committee session was about financial shortfalls and the need to reduce costs to fit the budget. The chronic lack of mental health services described at the District Partnership meeting is entirely due to a lack of resources. The ongoing and proposed withdrawal of emergency and hospital services from north Skye (“self-evidently a downgrade” according to our local GPs) is forecast to reduce operating costs by £800,000 per year.
Thirdly, NHS Highland’s approach to cost-cutting is unstructured and opportunistic. The strategy of “vacancy retention” is the most blatant example of this, taking advantage of random retirals and resignations to reduce the salary bill. Members of the Audit Committee clearly shared my astonishment when Mr Kenton told them that savings of up to £6 million a year could be made by leaving vacant posts unfilled, and that some could remain unfilled year after year. The reason for staff shortages in mental health, midwifery, out-of-hours emergency care, and so on, is plain for all to see.
The proposal to centralise hospital services on Skye is a more subtle example of opportunistic cost-cutting. By all accounts the hospital building at Broadford is in poor condition and needs to be replaced. This is the opportunity that NHS Highland has been waiting for to close the hospital in Portree and move everything that it can possibly get away with to Broadford. The beauty of this opportunity is that a brand new hospital in Broadford will be built using central government money, can be advertised as an “upgrade”, and sold as such to anyone who has a hazy understanding of the geography and demography of the island, including the Health Secretary. All while freeing up £800k from the annual budget which will help to fill the black hole that is the annual deficit for running Raigmore (the area’s general hospital in Inverness).
The opportunism of NHS Highland’s cost-cutting is egregious but the lack of structure, the lack of rigour in identifying needs and developing solutions for delivering health and welfare services within a limited budget, is unforgivable. People are suffering for lack of care and your failure to manage change in a systematic way is directly responsible for that suffering.
I sometimes use the attached diagram to help my clients get a grip of the process involved in getting something done, and show how important it is to close the gap in understanding between the people in charge of a project and those who will have to live with the end result of it. The diagram is valid for any sort of change and each step of the process occurs to some extent in every case, even if the participants don’t realise it and take the steps in random order. Such unconscious, random participation, however, almost always ends in failure.
Let’s refer to the diagram, taking the redesign of hospital services in Skye, Lochalsh & South West Ross as an example.
If, as claimed, the purpose of the redesign project is to improve local services, then NHS Highland should be able to provide:
– records of interactions with stakeholders to assess requirements
– a definitive list of requirements
– evidence of interactions with stakeholders in the development of design concepts
– a clearly-defined design concept that will fulfill the requirements
– evidence showing development of the design process that led to the decision to build a new single hospital in Broadford and how this element of infrastructure fits into the overall design and contributes to fulfilling the requirements
At a meeting on the 10th of January in Portree I asked Garry Coutts and Gill McVicar (Director of Operations) to provide me with any such documentation – anything that could support their claim that these steps in the design process had been taken in advance of the decision to centralise services in Broadford. What arrived several weeks later were some documents relating to the public consultation process, some of which might have been valid elements of a properly structured design process but, in isolation, are of little value. Crucially, no list of requirements was provided.
If NHS Highland’s priorities really are safety, clinical need, and patient experience then its proposed redesign of hospital services on Skye is at risk of being a catastrophic failure. The logic of the design process has not been followed and the understanding gap – between the doers and the done-by – is dangerously wide. To those of us at the sharp end of this redesign it is blindingly obvious that safety, clinical need and patient experience are all going to be adversely affected by centralising hospital services in Broadford. So either NHS Highland has been spectacularly incompetent in meeting its stated objectives or the redesign has a different purpose to the advertised “service improvement”.
As soon as we unpick the obfuscatory language of “hub and spoke” and “step up, step down beds” it’s clear that this redesign is an exercise in cost-cutting. With that in mind, if we go back to the diagram and define the project as “cutting operating costs by reducing the number of hospitals on Skye from two to one”, then the rest of the process starts to make sense. The concept that has been developed is to close both existing hospitals and build a single new one. The high-level design decision to build the new hospital in Broadford has been taken because it offers the biggest operational cost savings, and we’re now in the detailed design phase for that building.
I emphasise that last phrase because what we’re dealing with here is a building project, the primary purpose of which is to reduce operating costs. NHS Highland is now, retrospectively, trying to fit our services into the new model of a single hospital. Only now are workshops being run to explore clinical needs and other things like transport. These things should have been considered at the very start of the redesign and incorporated into the list of requirements, defining exactly what the project aimed to deliver in terms of service provision.
These two cases, failure to provide dementia care and withdrawal of services from north Skye, are but two examples of NHS Highland putting the cart before the horse: the budget before provision of services. This reversal of priorities is where you have gone wrong. We all know that public sector budgets are under pressure but the scope for using what’s available to provide the very best possible service is being undermined by NHS Highland’s perpetual panic about money and shambolic approach to problem-solving. Grasping at opportunities to cut costs and then trying to patch up services around the things that have been cut isn’t merely an illogical approach to service provision, it’s inhumane.
If any of what I have written here rings true, please show that you are interested in making amends by immediately requesting that the Health Secretary commissions an independent review of the redesign in Skye & Lochalsh. A review will give us comfort that the services will be designed around our needs, and you might learn something about requirements-gathering and its importance in determining the direction of a design project, lessons which could be used to provide us with a functioning mental health service.
If, on the other hand, you are unable to see the extent of your failure, if you cannot understand the need to introduce a systematic process for addressing problems and delivering solutions based on the needs of the communities that you serve, then please step aside and let others take on the job. People are suffering as a result of your incompetence and we cannot allow that to continue.