Dying in Hawke’s Bay, by Mark Sweet and Tom Belford

Not a pleasant topic.

But an inevitable one. And one of special policy importance in Hawke’s Bay, where people over age 65 represent the fastest growing segment of our population. For those afflicted with terminal illnesses like cancer, which often bring unrelenting pain, the final path to death can be especially dire. Special care – palliative care – must be provided to these individuals to ease their suffering (and that of their families) and enable a dignified passing.

In Hawke’s Bay, that has been the mission of Cranford Hospice for more than twenty-five years. During that period, our community has developed both tremendous pride and trust in the care provided by Cranford.

But now that trust has been shaken by a very public dispute between present management, as provided by Presbyterian Support, and former and present clinical staff, who allege that quality of care has suffered in an environment of insensitivity and mis-placed responsibility at best – and bullying and intimidation at worst.

A range of charges have been brought to BayBuzz. We have investigated them through a series of in-depth interviews with knowledgeable parties, as well as reviewing pertinent documents made available to us. Certain parties at the centre of the controversy spoke only superficially with us – notably, Barry Keane, Executive Director of Cranford Hospice; Shaun Robinson, CEO of Presbyterian Support; and Ron Hall, Board Chair, Presbyterian Support.

Our conclusion … Cranford Hospice is broken in spirit, and quite possibly the quality of care provision is diminished as well. Intervention by a responsible body – Hawke’s Bay District Health Board (HBDHB) – is clearly required if issues are to be fully explored, disputes resolved, and public confidence restored.

Here is our story. Supporting documents, some not previously published, can be found on the BayBuzz website, enabling readers to draw your own conclusions.

Palliative Care
To understand the current dispute, a bit of history is required.

In February 2001 then-Minister of Health, Annette King, announced the New Zealand Palliative Care Strategy.

Palliative care was succinctly defined as “the care of people who are dying from active, progressive diseases or other conditions that are not responsive to curative treatment.” The document emphasised that palliative care “embraces the physical, social, emotional and spiritual elements of well-being … and enhances a person’s quality of life while they are dying. Palliative care also supports the bereaved family/whanau.” The Strategy contained nine steps to implement the vision of providing “timely access to quality palliative care services” to all people who are dying.

District Health Boards were given responsibility and funding for implementing the strategy.

In Hawke’s Bay Cranford Hospice had been providing this service already for 20 years and was regarded as a model of palliative care in the community. They were the obvious vehicle to assist the Government’s policy, and the HBDHB contracted Cranford to do the job.

Up until this time Presbyterian Services had taken a hands off management attitude towards Cranford, and from it’s beginning in 1982 the Hospice developed its own culture of caring for the dying.

Jack Mackie was the Director when Presbyterian Social Services Association bought Cranford Hospital from the Royston Trust Board. “Cranford was allowed to develop on its own,” he told Baybuzz, “The PSSA were not involved.”

Jack and his wife Margaret were especially interested in the work of Dame Cicely Saunders at St. Christophers Hospice in London, and her four goals were used as a guide in the development of Cranford:

1. To care humanely for the terminally ill.

2. To provide not merely for the patient’s medical requirements, but also for the spiritual and emotional needs of the patient and loved ones.

3. To give family and friends the opportunity to share actively in the care, comfort and support of the dying individual

4. To make the patient’s final days as painless, happy and meaningful as possible.

From the beginning, the aspirations of Cranford were the same as those which came later in the New Zealand Palliative Care Strategy of 2001. From the outset, Cranford was a community asset. The first volunteers came from women’s groups associated with the churches and from the Country Women’s Institute. Fundraising and donations were the sole source of income, and Jack Mackie ensured that PSS, “did not proclaim involvement.”

With the appointment of Dr Libby Smales as Medical Director in1985, Cranford’s success was assured. She had trained at St. Christopher’s and as Jack Mackie observed, “Libby understood the spiritual aspect of dying, and the importance of family involvement. She created a flat management structure with relationships of equality where communication was easy and everyone was involved in patient care.”

Under the direction of Dr Smales, Cranford matured into a model of best practice in palliative care. Numerous professional articles written by EA Smales, HG Sanders, KL Lum, and AP Denton testify to the reputation of the team.

Libby Smales left Cranford in 2000. Her successor, Kerryn Lum, had been with the hospice since 1988. A change in Presbyterian Support management also occurred in 2002 with the appointment of Shaun Robinson as CEO.

This marked a change in the relationship between PSEC and Cranford which saw PSEC assume more and more control over Cranford affairs until arriving at the situation we have today. Cranford staff are now directly answerable to the CEO of PSEC. When Baybuzz contacted Cranford Director, Barry Keane, he said he couldn’t talk to us without the permission of Shaun Robinson. A far cry from Jack Mackie’s hands off approach.

In August 2007 a Review of Management and Leadership Functions and Structure (Harper/Devine) recommended that: “PSEC recognises the dynamic tension between Cranford and the rest of PSEC, valuing the individuality and uniqueness of the strong Cranford brand and what it offers PSEC while encouraging the development of collaborative innovative organisational wide synergies”. To PSEC this was an invitation to restructure Cranford, and within a year the three top positions were filled by new appointments from outside Hawke’s Bay, old relationships were severed, with many people feeling very badly treated.

The Complaints
“We do not intend to participate in any further debate via the media. We believe that most reasonable people would agree with our decision” is how the PSEC Board concluded an “open letter to assure the public, staff and supporters that they can have total confidence in Cranford Hospice.” (HB Today advert, November 2009) The letter was in response to “articles and correspondence in the media … based on the opinions of a small number of people.”

Doctors Smales and Lum were obviously among the “small number” of people who had “unjustified criticisms,” because two weeks before the PSEC letter they issued a joint statement in which they referred to “a climate of bullying and intimidation” at Cranford. They spoke of the “much admired interdisciplinary team being systematically deconstructed,” and how “Many benefactors are now cautious of their ongoing support.”

When things went sour at Cranford, Libby Smales was an obvious conduit for people’s concerns and grievances. After a year of being constantly asked, “to do something about the destruction of Cranford,” she approached the PSEC Board in September 2008, but her request to, “take with me a number of professional people who had been or were involved with the Hospice,” was declined by Chairman Ron Hall.

Also declined was her request that her presentation be, “to the Board alone, as many of the concerns relate to Hospice management …”

What Dr Smales did present to the PSEC Board was a clear and illustrated picture of dysfunction at Cranford.

• The Inter-Disciplinary Team approach, which fostered co-operation and easy communication was being replaced by an outdated, hierarchical, hospital model, unsuitable to achieving Current Best Practice in Palliative Care.
• Experienced staff were struggling to get what patients need/deserve from inexperienced staff, who were unsure, hesitant, and acting in isolation because of the destruction of the team.
• The cohesive, mutually supportive way of working with GP’s who previously could discuss problems with any of the Inter Disciplinary Team (in house team, Palliative Care Co-ordinator, pharmacist, on call doctor) was lost.

Supporting Dr Smale’s concerns were letters from people involved with Cranford.

From a Napier GP: “I don’t know what to tell patients about the hospice service any more, as I don’t want to raise their expectations … Recently when I rang Cranford to obtain a Special Authority for a mutual patient, I was stunned to hear that there would be no pharmacist available until the next day. Yes I can get a Special Authority myself, but it can take up to two weeks to get a reply … Cranford pharmacists had an excellent system for immediate responses. Palliative Care patients don’t always have two weeks to wait.”

From Medical Staff: “Redundancies and resignations … include hospice manager, principal nurse, medical director, councillor, massage therapist, and two pharmacists. Several staff members have taken stress leave. Many others are expressing levels of stress, distress, and low morale.”

From Senior Nurses: “New medical personnel are inexperienced and and hesitant resulting in poor symptom control. This is often resulting in painful and distressing deaths … the loss (of the Pharmacy team) is putting a huge strain on the team.”

From Kerryn Lum: “Loss of teamwork, insufficient staffing, and loss of trust and goodwill has meant that the excellent pro-active anticipatory care planning for which Cranford was renowned is reduced to reactive crisis, with a slower response time than ever before. Dying patients and distraught families do not have time to wait.”

Presbyterian Support’s response was to commission a review of Cranford by Dr Sandy McLeod, a Palliative Care Physician from Christchurch. Dr McLeod’s report has not been released by PSEC, but what is known is that when he asked staff which regime would they rather be under if they were dying – the old or the new – the majority chose the old. There is no doubt that the restructuring of Cranford has compromised the quality of care, and there is little indication that concerns expressed in September 2008 have been resolved.

The Management
In January 2008 Shaun Robinson, CEO of PSEC, announced the recruitment of a new leadership team at Cranford.

Barry Keane, Executive Director, Dr Mike Harris, Medical Director, and Sandra Sanderson, Nursing Director. Keane and Harris worked together at Arohanui Hospice in Palmerston North. Dr Harris was relatively inexperienced in palliative care, and yet to qualify as a Palliative Care Specialist.

Barry Keane comes from a nursing background, and is currently Chair of the Palliative Care Advisory Group, which signals his pre-eminence in current palliative care trends. His enthusiasm for the Liverpool Care of the Dying Clinical Pathways was recognised at the outset.

Sandra Sanderson was recruited from Scotland, where she worked as a palliative care co-ordinator with a background in nursing leadership, education, and facilitation, all within palliative care.

Our interviews indicated that another major player in the restructuring of Cranford was Diane Keip. Keip comes from a hospice nursing background in the South Island and was employed by Cranford, when Kerryn Lum was Medical Director, to help implement the HB Palliative Care Strategy, which Lum and her colleagues had developed.

Keip developed a close working relationship with Shaun Robinson, giving her access to confidential information, which caused distress to those involved. She now holds the position of Palliative Care Planning and Funding Manager with HBDHB, and is the primary day-to-day monitor of Cranford’s performance … relied upon by senior management to reassure that “all is well.”

With Shaun Robinson micromanaging, the new leadership team soon changed the culture of care that had characterized Cranford.

Many people BayBuzz spoke to pointed to Robinson and Keane as the protagonists most responsible for creating a culture of distrust and fear.

Numerous incidents were related where staff have been treated with disrespect and intimidation. Many are convinced there was an orchestrated campaign of ‘constructive dismissal’ where abusive behaviour was employed as a weapon to move along old time employees. Only in past weeks has an employment action brought by three Cranford nurses been settled by mediation.

And recently, in a letter written to HB Today (but rejected), Richard Grey, husband of Sue Grey, until recently a nurse at Cranford, with decades of experience, said:

“If the reorganisation is not going smoothly, management often react with an increase in discipline to assert their management role. The staff then believe that they are not respected, are being threatened, intimidated and can feel very insecure. This leads on to a down turn in morale, increase in sickness, more involvement in disputes and unions, along with a loss of employees. As well as increased costs and possible reduction in the services offered.

Much of the above was already beginning to occur whilst my wife was in employment at Cranford, so I strongly advised her to leave soonest. On reflection, the correct decision, even though she, as are the remaining Cranford nurses, felt torn by the strong bond of loyalty, commitment and allegiance first and foremost to their patients and then to their fellow colleagues.”

The clash of cultures, between the old Cranford and the new, is not just a matter of management styles, but also of systems and philosophy. In a presentation entitled Rethinking Palliative Care Provision, Barry Keane asks, “But where have we come from? Reactionary movement – Cottage hospice – Charity base – Culture of ‘specialness.’” He then asks, “Has the nature of Hospice development been one of the barriers to progress?”

He obviously thinks so. Indeed, nurses at Cranford have been admonished not to refer to Cranford as “a Hospice … it is a Palliative Care Unit.”

Palliative care provision with a diminished hospice role would appear the direction Cranford is being steered, with an emphasis of spreading care for the dying more broadly by providing training to Health Providers in palliative care, including the Liverpool Care of the Dying Pathway (LCP). ”

Over the last 12 months, 1100 staff in resthomes and hospitals have received specific training in the care of the dying through the Liverpool Care of the Dying Pathway project,” states Ron Hall in his open letter. Barry Keane describes LCP as “a tool designed to be used in settings other than a hospice, which enhances the skill and confidence of practitioners, and the quality of care.”

Listening to Barry Keane speak passionately about, “ensuring best practice in palliative care for the dying being available to all in need,” is hard to reconcile with the allegations of his insensitive management style. It’s unfortunate his tenure at Cranford has been mired in so much controversy, but from what Baybuzz has heard from the parties dealing with Keane, he has brought it on himself.

Shaun Robinson declined to speak to BayBuzz about “issues” at Cranford, quoting Ron Hall’s letter as PSEC’s “final word on the matter.” He did however reply to a written question:

Has the CEO of PSEC any comment to make about the management structure ‘bedding in’ process?

“Given the stable and close knit culture within a traditional hospice like Cranford, organizational development and change can be difficult for staff, volunteers, leadership and the community… As a result of this situation, communication between some key clinical staff was adversely affected leading to some negative impacts on staff morale. Since that time additional effort has gone into communications and team development; workshops and meetings have been held with staff and volunteers to address their concerns about change and to work together on the way forward – this is an ongoing process. While change is always hard, the reality in February 2010 is a growing sense of positiveness within Cranford and a desire to keep progressing palliative care for the people of the Hawke’s Bay.”

Also the “reality” in February 2010: The situation remains sufficiently “negative” that a mediator has been brought in to help rebuild morale. So, while Robinson speaks of “growing sense of positiveness” and Mr Hall proclaims all is well, employment actions and mediator involvement suggest otherwise.

The DHB
The complaints are too numerous, too widely-known, too widely-shared, and too credible to be dismissed. Certainly the ‘open letter’ from Presbyterian Support is an inadequate response to widespread public apprehension.

In view of this, one might think that the Hawke’s Bay DHB, provider of 70% of Cranford’s funds and the contractor (through PSEC) of its services, might inquire vigorously and independently into the matter. Not so.

BayBuzz interviewed a member of DHB’s senior executive team, Ken Foote, General Manager of Planning, Funding & Performance. Mr Foote expressed nothing but confidence in PSEC, who he repeatedly discussed as a “contractor” satisfactorily delivering “outputs.” When issues were raised publicly last November, Foote said he and his team made inquiries of PSEC management and came away reassured that “there were no concerns in terms of quality of care affecting patients.” This is the message he passed to the DHB Board.

Said Mr Foote: “We have expressed our support for Cranford… We remain confident in the level of care… We have no cause for concern about the delivery of the contract and the quality of care.”

He noted that DHB’s contract is with PSEC and how they deliver their services is up to them … “unless we felt there was some threat to the organization that could make that contract difficult to deliver.” Clearly, DHB, through Mr Foote, sees no such threat. Why? Because PSEC has assured them there is none!

A routine “audit” of Cranford’s performance begins this month as part of a normal three-year cycle of evaluation of service contracts.

Recommendations
BayBuzz recommends these steps.

1. First and foremost, as 70% funder and possessor of requisite expertise, HBDHB, with active oversight by Board, must investigate the situation fully and issue a public report indicating findings and any recommended actions.

The aforementioned “audit” can feed into this (as should the McLeod report), but cannot substitute. We believe the review team should include appropriate management & clinical senior officials (including some not in the cozy loop between DHB and PSEC), plus some elected Board members. The latter are necessary to signal a high level of concern by those directly accountable to the community and to reinforce the credibility of findings. The report should be discussed with the interested public in an open forum sponsored by DHB.

2. In this process, the management role of Presbyterian Support should be re-considered. Clearly the dysfunction at Cranford is linked to the management approach imposed by PSEC. As a community asset, Cranford is funded by our taxes and donations, and deserves to be run directly by a Board with one mission and with requisite experience coming from the community.

3. An evaluation program should be instituted to systematically ascertain the views of families whose loved ones have been treated at Cranford. If it can be done for hospital patients, it can be done as a sign of respect and concern for the families of those who die after hospice care. And of course to improve practices where necessary for the benefit of future patients.

4. The HBDHB must also take a more proactive role is educating the public about the HB Palliative Care Strategy, and specifically on how and where this care will be provided. In 2009, 499 patients were referred to Cranford. But clearly not all the terminally ill are or will be cared for at Cranford Hospice, whatever the public perception … both because the numbers will skyrocket, and because this is not the preference of all patients. So what does the future scenario look like? The public should be clear about this.

5. Finally, the Hawke’s Bay community needs to place its present funding relationship with Cranford “in escrow” until these issues are dealt with fully and publicly. The community has been tremendously generous to Cranford Hospice over the years. But unquestioning generosity would now be irresponsible until some substantially greater accountability and public responsiveness is brought into play.

Find supporting documents at www.baybuzz.co.nz/issues/health/cranford