London Eye: Fait accompli

The documentation was fairly conservative – saying there will be more work done before any merger of North Middlesex University Hospital Trust and the Royal Free London Foundation Trust. 

But the most recent board papers for both trusts show Royal Free boss Peter Landstrom is already accountable officer for NMUH.

Obviously this is weird, as normally the accountable officer is the chief executive, and the listed chief executive is Nnenna Osuji, former medical director of Croydon Health Services Trust. 

It was only last April that NMUH confirmed that Dr Osuji had been made accountable officer as well as chief executive – having joined the trust in 2021 – and had taken over the AO role from the then Royal Free chief exec Caroline Clarke.

But now it’s back to a Royal Free CEO as accountable officer for NMUH. NMUH this morning said Dr Osuji had only been AO while the Royal Free recruited a new CEO. The press office confirmed that Royal Free boss Peter Landstrom (announced in October) was made NMUH AO in November.

No one has ever explained why the Royal Free chief exec should be accountable officer for NMUH on-and-off since the departure of Maria Kane in 2021.

It doesn’t look like something you’d do if you were considering all the options; it looks like a long-standing fait accompli. A full business case has yet to be presented to both boards.

On his appointment last year, one of the things the Royal Free announcement highlighted in Mr Landstrom’s career was his leading on the takeover by Western Sussex Hospitals FT (a well-regarded trust) with Brighton and Sussex University Hospitals Trust (less well regarded).

Why does all this matter?

Because fairly recently NMUH said the merger was a bad idea.

A paper presented to its board in 2018 said it would be a risk to “stability, local accountability and highly valued services particular to our local communities”, adding “the advantages of RFL membership would be substantially dwarfed by the disadvantages it would have on North Mid and its local populations”.

No one has been clear about what might have changed in the meantime. If anything, problems at the Royal Free have become more apparent.

It’s not clear whether Dr Osuji would want to stick around as site manager at NMUH rather than full CEO of a trust. She had been linked in some quarters to the chief exec job at Homerton Healthcare FT, where there was a vacancy as Louise Ashley retires, but this was filled by another candidate. 

The missing 400

To hear it described in London, you’d think the Right Care, Right Person programme was all sweetness and light.

Sure, the re-routing of a significant number of emergency calls about mental health patients from police and to the NHS appears on trust risk registers, but the health service side seems relatively sanguine.

But the national body for ambulance trusts has a different view. Ambulance providers often run the call centres as well as the flashing lights and the head of their professional body has major concerns.

Association of Ambulance Chief Executives boss Daren Mochrie wrote to the Parliamentary health committee saying there was a lack of clarity on a significant cohort of patients.

Mr Mochrie wrote: “Since the roll out of RCRP, the LAS believe that they are receiving circa 400 incidents per month relating to concerns for welfare originating from healthcare professionals (often referred to as patients absent without leave).

“These incidents aren’t easily triaged and are often calls that do not require a frontline ambulance response. The LAS are working closely with NHSE regional team, hospital trusts and mental health trusts to agree the actions they should take prior to calling on another agency to respond. But nationally it is of concern to us at AACE that ambulance services are seen as the new ‘default’ response which speaks to our message that it serves nobody if what was undoubtedly inappropriate police demand becomes inappropriate ambulance demand.”

In June, a London coroner raised concerns about a possible gap in the service under the arrangements for mental health patients who run away while on escorted leave.

Officially, admitted patients have to be escorted outside trust grounds in order to smoke. The Heather Findlay case saw just this scenario. When Ms Findlay absconded (telling her accompanying healthcare assistant “I’m sorry I have to do this to you”) and was later found dead, RCRP had not started in London.

But coroner Mary Hassell said the “Affinity protocol” between the Met and, in this case, East London FT, which preceded RCRP, was similar.

She said: “From the evidence I heard [it] allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.”

It is not clear how Affinity and RCRP overlap, or which trusts have adopted it. ELFT is already signed up to Affinity. Central and North West London FT’s January board papers suggest they are going to sign up to it (as part of a discussion of RCRP more generally).

It’s also not clear whether all London MH trusts are signed up to Affinity, and how that sits alongside the London mental health concordat and RCRP.

Ms Hassell wrote: “Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.”

Funding the LAS for the extra work involved in RCRP is also unclear.

NHS England London would not confirm how much extra it will cost the trust to field the extra work RCRP involves.

Mr Mochrie did have data for that and told the Parliamentary committee the estimated costs were £4.7m in 2024-25 and £6.8m in 2025-26.

What wasn’t clear, he said, was who was going to pay for it. “As yet, this new activity is unfunded by Integrated Care Boards and to be fair to them they have received no additional funding to reflect the transfer of work from the police.”

This story was amended at 15.40pm on February 21 2024 to make clear who had replaced Louise Ashley at the Homerton