The Secretary of State’s Desk

Woman businesswoman under stress missing her deadlines


“The rational response of an appointed NHS CEO is not necessarily to improve the long-term performance of the hospital, but instead to minimize the amount of bad news that ends up on the Secretary of State’s desk.”



This is just one conclusion to academic research,  ‘The Impact of CEOs in the Public Sector: Evidence from the English NHS‘ published by the Harvard Business School.

The paper, available here, authored by leading academics Dr Katharina Janke
(Lancaster University), Prof. Carol Propper (Imperial College & University of Bristol) and Prof. Raffaella Sadun (Harvard Business School) is supported by detailed, statistical analysis, which mere mortals would not pretend to understand.

The conclusions are enlightening and should be essential reading for the Secretary of State for Health & Social Care, his Junior Ministers and officials, along with the Boards of NHS Improvement and the Care Quality Commission.  Essentially:

“We find little evidence of CEOs being systematically able to change the performance of these organizations. We also do not find evidence that a change in CEO brings about an improvement (or even just a change) in performance.”

The paper proffers two possible explanations [abbreviated and paraphrased]:

“Lack of CEO effects is consistent with top managers chasing political goals, not policies that might improve hospital performance. The rational response of an appointed CEO is not always to improve long-term performance, but to minimize the bad news landing on the Secretary of State’s desk: this may explain why there is a CEO effect in remuneration, unassociated with observed performance, but with receiving public honours. The political nature of the NHS may lead to negative sorting (reluctance of high performers to seek CEO appointments). 

“Hospitals are large complex organizations, in which highly trained (and hard to monitor) individuals run separate, interconnected production processes. Top Management may find it difficult to engage in co-ordination and getting a large number of actors, who traditionally have not worked together, to work co-operatively. A possible interpretation of our finding is that the organizational inertia of a large hospital is often too strong for a CEO to impact performance.”

These conclusions are remarkably similar to expert (unscientific) analysis of Southern Health’s recent reply to a letter from Suella Braverman MP to the Secretary of State. A press release and Southern Health’s response are available here→.

The expert analysis is here→.  The similarities with the conclusions of the Harvard Business School paper are clear. For example [abbreviated and paraphrased]:

“I am also mindful that there is a political and PR exercise at play here.

“[Directors] have forgotten that the letter was addressed to the SoS. They address the points made as though it were directed to them as criticism and write what I feel is a very defensive letter. A better approach would have been to build on what was said and commit to what they could do with £5m to invest in the areas identified, or indeed suggest where the outcome could be improved by investing it differently. They simply don’t see this opportunity; they see this as a threat to their position and authority. Clear arrogance on their part I would suggest in that they know best. 

“They are dismissive about the points on GP training and the deployment of Medical Examiners essentially saying its someone else’s job to deal with those. Everyone is aware these are not Trust specific issues, indeed the work requires all parties to play their part and work as a team. Saying it’s for someone else to do is very much old school “pass the parcel” mentality which indicates there is much more to do to change the culture.

“Overall, the response doesn’t say a lot. It’s all aspirational. Very little is tangible in terms of specific results that can be expected to be seen by a specific time. 

“The first two pages of the [Trust’s]  reply are all spin and waffle. It tells us very little about what the customer can expect by way of improvements. It tells us there’s a new board, a focus on training staff in a QI methodology, a focus on improving patient and carer engagement, a new organisation structure and an improved culture. No detail as to what this will mean to the customer.  

Regarding the second explanation, we know Southern Health is a large complex organization, in which hard to monitor individuals who run separate, interconnected production processes. It is difficult to engage in co-ordination and getting a large number of staff , who traditionally did not work together, to work co-operatively. As we have said before, transforming an NHS Trust is more difficult than turning around an ocean liner.

When will the Secretary of State’s desk look like that of Russian Tsar Nicholas II in his office in Livadia Palace, Crimea – 4 family photo’s, 6 sheets of paper and a large tome?

figure of tsar Nicholas II in Livadia Palace


Triangle of Care

The combined hands, are forming a triangle

The Triangle of Care™¹ is not a difficult concept – it’s just common sense. Yet how many Mental Health & Learning Disability Consultants and other clinicians ignore it?

We reported the Inquest into Ellie Brabant’s death just three months ago. Yet this month, we attended the Inquest into Maria (‘Joey’) Duarte’s death. She died at the same Southern Health NHS Foundation Trust unit (Antelope House) just 2.5 months after Ellie.

Ellie and Joey had two things in common – extremely supportive families – and the same Consultant Psychiatrist, Dr Obed BekoeYet were the families involved in their care?

NO! Dr Bekoe admitted he had not engaged with Joey’s family because he felt she had capacity and she had not requested it.

Dr Bekoe: As a Consultant Psychiatrist, an Expert Witness, an RCPsych Examiner, an Educational Supervisor and a Medical Appraiser, exactly what part of the Triangle of Care™ do you not understand?

Patients don’t have to ask about family engagement: they should be offered it. Capacity in a patient with suicidal thoughts should not be assumed.

Best practice is clear and unequivocal:

Triangle of Care 6


“In line with good practice, practitioners should routinely confirm with people whether and how they wish their family and friends to be involved in their care generally, and when looking at information sharing and risk in particular.”²



In short, a patient’s capacity is irrelevant – clinicians should discuss family engagement with patients routinely – not wait for patients to ask. Even in respect of capacity, good practice suggests:

“If a person is at imminent risk of suicide there may well be sufficient doubts about their mental capacity at that time.”²

Is this not common sense too? In CRASH’s opinion, for example, there must be doubts about the capacity of anyone, who sits on a railway bridge for five hours threatening to throw himself off – much less a person known to be mentally unwell. Yet, another Southern Health Consultant Psychiatrist thinks not. 

The Consensus Statement on Information Sharing

Unrelated directly to The Triangle of Care™, the Department of Health, Royal College of Psychiatrists and others issued a ‘Consensus Statement‘ in January 2014 as part of the suicide prevention strategy for England. It aimed (inter alia) to improve information and support for families concerned about a relative, who may be at risk of suicide.

The General Medical Council, Nursing and Midwifery Council and Health and Care Professions Council confirmed that the advice and policies set out in the Statement are consistent with their guidance on consent. The Information Commissioner’s Office confirmed that it is consistent with the Data Sharing Code of Practice. Read more→Conceptual mental health or positive thinking triangle arrow word cloud isolated background. Collage of optimism, psychology, mind healthcare, thinking, attitude balance or motivation text

So why, five years later, are some Members of the Royal College of Psychiatrists not compliant with good practice in this respect and why did Southern Health only learn about it in 2019? 



There were multiple other similarities between Ellie and Joey’s deaths, for example:

  • The same Responsible Clinician, Dr Obed Bekoe.
  • Total failure to work with a very supportive family.
  • Identical ligature point – top of a door.
  • Similar ligatures – clothes.
  • Observations, when expressing suicidal thoughts, too infrequent and carried out by junior staff.
  • Allowed leave from Antelope House despite concerns about their well-being. (Joey was a voluntary patient but could have been sectioned.)
  • Both passed like parcels between various Southern Health Teams and multiple Responsible Clinicians without proper handovers/communication/care plans/risk assessments.
  • Questions about medication.
  • Failure on at least one occasion to record suicidal thoughts.

There were a couple of common problems indentified at the Inquest:

  • Junior staff blamed rather than senior staff taking personal responsibility (with the honourable exception of the male senior nurse, who gave evidence in person).
  • A page from shift handover notes missing from Coroner’s bundle – revealed by the senior nurse. Yet again Southern Health lacks diligence in preparing Inquest documentation … and yet again the moment passes without any consequences for them. A deliberate act or simply incompetence?

In short, total failure in clinical management, family engagement and Inquest preparation.

side-way-smiley-face-emoji (rediced) 2

On a positive note, Southern Health officers and staff  were soberly dressed and conducted themselves appropriately at Joey’s Inquest. There was no laughing and joking as witnessed at Ellie’s Inquest.


Lynne Hunt, Chair of South Health’s Board of Directors, said:

Pic by Samantha Cook Photography, 30th March 2016. Portraits taken of board members at Dorset HealthCare University NHS Foundation Trust, Sentinel House, 4-6 Nuffield Road, Poole BH17 0RB.

Our own investigations and the coroner’s conclusions revealed missed opportunities. Joey’s death has led to meaningful and ongoing changes to make Antelope House, and indeed all our whole trust, a safer place.”

All good stuff (and some improvements were not ‘quick fixes’) but Joey’s family could well ask:

“What steps were taken to implement the simpler improvements, which were clearly required immediately after Ellie Brabant’s death?

“The Board did not report any of the clinicians involved in Ellie’s death to their regulators? Will the Trust report those involved in both deaths to regulators or – failing that – will they be disciplined internally, retrained and supervised?

Elsewhere, Greater Manchester Mental Health NHS Foundation Trust received a second gold star for its commitment to the national Triangle of Care™ initiative. (Alarmingly at the time, only one of four mental health trusts in the country to do so.)

West London Mental Health NHS Trust committed to putting it in place during 2018.

And finally, on the website of Kent and Medway NHS and Social Care Partnership Trust:

“The Triangle of Care™ guide was launched in July 2010 by The Princess Royal Trust for Carers (now Carers Trust) and the National Mental Health Development Unit to highlight the need for better involvement of carers and families in the care planning and treatment of people with mental ill health.”

To paraphrase the Princess Royal herself, after nine naffing years the Triangle of Care™ is still not in place at Southern Health or nationally and after naffing five years, Consultants are not compliant with good practice set out in the Consensus Statement.   

And here’s a couple of images found on the website of Avon & Wiltshire Mental Health NHS Partnership NHS Trust – awarded a second star in 2015:Triangle of Care 2


Triangle of Care 3













When will Southern Health NHS Foundation Trust achieve similar recognition?


¹ Triangle of Care – Trade mark number UK00003054307 (Carers Trust)

²  Consensus Statement on Information Sharing