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issue 18 summer 2013
healthcare manager inside
heads up:2
What you might have missed & what to look out for Leading edge: Jon Restell inperson: Paul Worthington, Cwm Taf Community Health Council inpublic: The Cotton Rooms, UCLH
letters & comment:8
Mark Lever: the Care Bill is a small step forward for people with autism
features:10 published by
Managers in Partnership www.miphealth.org.uk 8 Leake Street, London SE1 7NN | 0845 601 1144 Managers in Partnership is the trade union organisation providing support and advice to senior managers in healthcare in the UK on employment matters, careers and management practice. We represent their views to policymakers, employers, the media and the public.
Mark Britnell: integration trumps competition Interview: London Ambulance Service’s new boss Ann Radmore Christina Patterson: are we really listening to patients? Older People: making Francis count
regulars:20
Legal Eye: capability dismissals – reason or excuse? Tipster: coaching for managers MiP at Work: asserting your rights under TUPE
backlash:24
healthcare manager | issue 18 | summer 2013
Welcome to the summer issue of healthcare manager, the magazine from MiP, the specialist trade union for health and social care managers. This issue focuses on the patient voice and how we can listen and learn from patients and families to improve their experience. This is central to Robert Francis’ recommendations for culture change following his inquiry into Mid Staffs. Christina Patterson, former Independent columnist and health campaigner, writes from personal experience of receiving NHS care. Michelle Mitchell from Age UK argues that improving dignity in care for older people is not a complicated recipe. We have an interview with Ann Radmore, recently appointed chief executive of London Ambulance Service, who points out that the Francis Report is relevant to paramedics as well. And we hear from Paul Worthington about the Welsh way of involving patients through Community Health Councils. We also have our regular features on MiP at work, including Legal Eye, which explains the law around capability dismissal procedures. I hope you enjoy the magazine. Do let us have any comments on the content or any other views. Marisa Howes Executive editor
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HEADS UP
heads up what you might have missed and what to look out for
Commissioning in Healthcare and Healthcare Efficiency through Technology Expo 8 October 2013 Olympia, London MiP is supporting both these events, which take place on the same day at London’s Olympia exhibition centre. Both events are free to attend and are CPD certified. Commissioning in Healthcare 2013 is a new event which gives delegates the opportunity to examine the results and challenges of the reforms to date and to debate where improvements in clinical commissioning can be made. The high-level speakers include NHS England chair Malcolm Grant.
Election of MiP national committee
Speaking up for healthcare managers MiP will be holding elections later this year for its national committee. This is an important time to get involved in MiP, and if you would like to play a key role in shaping MiP policy and the direction of the union over the next few years you may want to stand for election. New committee members will be elected to represent the geographical constituencies set out in the table below and will serve a two year term from January 2014 to December 2015. As a member of the committee you will play a key role in making sure MiP policy reflects the views
of our members on healthcare, management skills and workplace relations. You will also be involved in MiP recruitment and organisation, as a key link between the members in your region and the union nationally. The rules for the election, together with the terms of reference of the national committee, will be posted on the MiP website. We will contact members by e-mail with details of the nomination process. If you would like further information contact your national officer (see our website for details) or Martin Furlong on 020 7121 5438.
Nominations open
Healthcare Efficiency through Technology Expo, now in its third year, is an established event for those involved in NHS reforms and focuses on the role of techonology in improving patient outcomes. Delegates will hear from senior policy officials, explore leading edge technologies and share best practice. Speakers will include health secretary Jeremy Hunt.
Timetable for Elections Elections open
For more information please visit www.hettexpo.co.uk or www. commissioninginhealthcare.co.uk
Seat allocation by area
healthcare manager
Executive Editor
issue 18 | summer 2013
Marisa Howes m.howes@miphealth.org.uk
ISSN 1759-9784 published by MiP
Associate Editor
All copy © 2013 MiP or the author. Opinions stated are not necessarily those of healthcare manager or MiP.
18 Oct 2013
15 Nov 2013
Results announced
27 Nov 2013
AREA
SEATS
Northern Ireland
1
Wales
2
Scotland
Art Director
James Sparling Lexographic production@healthcare-manager.co.uk
2
30 Sept 2013
Elections close
Craig Ryan editor@healthcare-manager.co.uk
Design and Production
2 Sept 2013
Nominations close
2
England – each old NHS region (except London)
1
London
2
Contributors
Mark Britnell, Marisa Howes, Mark Lever, Michelle Mitchell, Helen Mooney, Alison Moore, Christina Patterson, Jon Restell, Craig Ryan, Jo Seery, Corrado Valle
Warners Print, Bourne, Lincs
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020 8532 9224 adverts@healthcare-manager.co.uk
healthcare manager | issue 18 | summer 2013
HEADS UP
leadingedge Jon Restell, chief executive, MiP
M
anagers matter more than ever in the health service. This is MiP’s message in the wake of the Francis report. Politicians, unions and others are right to challenge senior managers and hold them to account. I heard
Welsh health minister Mark Drakeford doing just this at MiP’s recent event at the Welsh Assembly. It is good for management, not least because this type of challenge earns managers the right to demand support on the tough issues facing our health and social care system. Challenge demonstrates the importance of management. Here are some of the ways MiP argues that managers matter. There is no monolithic culture in the NHS (and certainly not one set by one or two people in Whitehall). There are as many cultures as there are hospitals and services. Great practice, standards and innovation criss-cross the service – and a great manager is not far from the action. Last week I shared a cab with
“Managers are the ultimate safety net for the interests of patients and the wider public. If no one else is listening to patients then they are. Can you prove this, day in day out?” Andrew Foster, chief executive of Wrightington, Wigan and Leigh trust. He told me about the work they are doing to make staff feel more valued by the organisation, which has lead to a quantum leap in staff satisfaction on this issue. Can you dish dirt like this? We must drag examples of great management into the open all the time. Politicians are running shy of spelling out the interdependent relationship between quality and cost. Arguably they always have,
but now is a bad time for them to stick with the habit. It is up to managers working with senior doctors and other clinicians to spell out what the funding situation means, demand freedom to manage the consequences, and then support frontline teams in finding ways to keep quality as high as possible within the new constraints. Can you tell it how it is and then manage? Finally, managers are the ultimate safety net for the interests of patients and the wider public. If no one else is listening to patients then they are. Can you prove this, day in day out? If managers matter as much as this then they need training, autonomy and resources. Most of all they need respect when they get the job done well. In the coming year MiP will punch home this message. We will tell it how it is – but we will never counsel despair on the NHS or publicly funded healthcare. There is always something great managers can do.
Changed Jobs? Please update your MiP records Thousands of our members have changed jobs over the past few months – either through choice or, mostly, because of restructuring or mergers. Whatever the reason, if you have changed jobs, employer or workplace and if your email address has changed, please take a few minutes to update
healthcare manager | issue 18 | summer 2013
your MiP membership record. You can do it online by logging into the members’ area of the MiP website (www.miphealth.org.uk ) or email us at info@miphealth.org.uk. Thanks.
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HEADS UP
Funding
Leadership
The public remain opposed to changing the way the NHS is funded but may support charging for some treatments and services in particular circumstances, according to a new report by The King’s Fund and pollsters Ipsos MORI. How should we pay for health care in future? published in April and based on two day-long events with members of the public, found participants were reluctant to consider fundamental changes to the current funding model, even when confronted with the scale of the funding challenge facing the NHS. Participants strongly supported the principle that access to health care should continue to be based on need rather than ability to pay, and rejected means testing as a way of controlling future spending. They were also adamant that the quality of clinical care should not be compromised to reduce costs. The research found some support for introducing payments for treatments not seen as clinically necessary, such as cosmetic surgery and elective Caesarean sections, and for those patients thought to misuse services, including people who missed appointments or arrived drunk at A&E. Some participants also supported charges for patients
Most health service professionals think quality of care is not given enough priority in the NHS according to a new post-Francis survey published by The King’s Fund. The survey, carried out with help from MiP and other NHS leaders’ organisations, found that 73% of nurses, doctors and managers thought care quality needed to be given a higher priority, and 40% said the quality of leadership in the NHS was poor or very poor – although this fell to 11% when people were asked about their own service or team. Lack of time and resources were blamed for poor quality care by 40% of respondents and by more than half of nurses. Almost half (48%) of executive directors said ‘organisational culture’ was the biggest to barrier to improving care standards, compared to 28% of NHS professionals overall. Nicola Hartley (pictured), King’s Fund director of leadership development, said the survey showed
Public wary of NHS charges
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requiring treatment as a result of lifestyle ‘choices’, such as smoking or obesity, and for ‘top-up’ services like private rooms. ‘Although difficult choices lie ahead, politicians have been reluctant to discuss the future funding challenge facing the NHS,’ said Anna Dixon, former director of policy at The King’s Fund (pictured), ‘This research shows that people want to engage with these issues.’ Ipsos MORI Chief Executive, Ben Page added: ‘The public have always said they are willing to go to great lengths to protect current NHS services, preferring to exhaust all other options before cutting NHS spending. Whether they appreciate the scale of the financial challenge facing the NHS is another matter.’ For further details of the report, visit: www.kingsfund.org.ukfuture
Professionals call for higher priority for quality care
the NHS still had ‘a long road to travel’ in making care patient-centred. ‘We know that most NHS staff are intrinsically motivated to help people who are at their most vulnerable. It is a failure of leadership if those staff consistently face barriers to treating patients and their families well,’ she added. MiP chief executive Jon Restell said: ‘We were delighted to assist with this important survey which highlights the work needed to make quality of care the top priority for NHS organisations. But we mustn’t be overwhelmed by the scale of our task. While we do need to develop strategies to embed a culture of compassionate care in the NHS, we don’t have to wait for the ink to dry before changing our behaviours. Managers can start now by coming out of their offices and listening to staff, patients and carers.’ The report, Patient-Centred Leadership: Rediscovering our purpose, is available online at: www.kingsfund.org.uk
healthcare manager | issue 18 | summer 2013
HEADS UP
inperson
“We are often referred to as the ‘critical friend’ of the local health boards.”
Paul Worthington, chief officer, Cwm Taf Community Health Council, Wales Paul Worthington has worked in the NHS for 26 years in various planning, operations and commissioning jobs, and for the last eighteen months has been at the helm of Cwm Taf Community Health Council. There are eight community health councils (CHCs) across Wales, which, by and large, geographically mirror the local health boards they have been set up to police, and the local populations they represent. Cwm Taf CHC oversees the Cwm Taf health board and covers both Merthyr Tydfil and the Rhondda Valley, representing around 300,000 people. Before moving to the CHC, Paul worked as health and social care programme manager for planned care at Hereford primary care trust. He says that in England – where the ‘latest incarnation’ of CHCs are the new local HealthWatch bodies – the lack of patient and public voice in the NHS stems from the fact that, unlike in Wales, the organisations do not have the same statutory footing. ‘CHCs in Wales work across a number of different areas and their main job is to hear people’s views on health services and represent those views, so we work closely with local health boards to articulate the patient view,’ Paul explains. He says that CHC members in Wales have the right to visit local health boards either on an announced or unannounced basis at any time. Health boards ‘see it as a positive because lay members give a different perspective on the services that are being provided’, he says. CHCs are funded by the Welsh government but are independent, so although the Government cannot set the agenda for CHCs they do monitor
whether they are delivering on their statutory responsibilities and make sure they do not overspend. ‘Cwm Taf CHC has a budget of £3m and I think we deliver really good value for money,’ he says. Paul’s main task is steering the work of the CHC to make sure that it is meeting its duties effectively. ‘I support our members and am their first point of contact, as well as managing the CHC staff,’ he says. ‘I also do a lot of work outside with stakeholders and will speak to the chair and chief executive of the health board every week to find out what is happening.’ He adds: ‘We are often referred to as the “critical friend” of the local health boards, as we work very actively on supporting their development.’ Paul meets local community groups on a regular basis and promotes the CHC to ensure that people are aware that CHC organisations
healthcare manager | issue 18 | summer 2013
exist and what their functions are. Paul believes the role of the CHCs vastly reduces the chances of a crisis in patient care similar to that in Mid-Staffordshire happening in Wales. ‘The fact that we can visit unannounced at any time means we talk to staff and patients and there is a real opportunity to open up dialogue,’ he explains. ‘We have people walking the wards so we have a better chance of picking up patient care issues.’ Paul says that when working in England, he was struck by the fact that NHS organisations did not seem to know where to go to seek the views of the patients and the public, whereas in Wales they know the CHC is their first point of contact. ‘We are the “go to” people and have been and will continue to be a consistent and constant presence,’ he says. Helen Mooney 5
HEADS UP
Patient care
Francis prompts big expansion of ‘Schwartz Rounds’ A groundbreaking scheme to promote a culture of compassionate care in NHS services, endorsed in the Francis Report, is to be extended with a grant from the Department of Health. Schwartz Center Rounds allow NHS staff to get together once a month to reflect on the stresses and dilemmas that they have faced while caring for patients. Robert Francis QC specifically pointed to the positive impact of the rounds in his report. Monthly rounds are already established in 15 trusts and will now be extended to a further 40 hospitals, and to GP practices, district nurses and community services for the first time. Health minister Dan Poulter said: ‘Schwartz Center Rounds have been shown to help hospital and care staff support each other and learn about how to deal better with tough situations, and spend more time focused on caring for patients in a compassionate way.’ Poulter said a grant of £650,000 would be awarded over the next two years to the
Point of Care Foundation to expand the scheme. Jocelyn Cornwell, Director of The Point of Care Foundation, said: ‘Patients do not always have a good experience of healthcare – sometimes they don’t understand what is happening, their preferences aren’t
taken into account or they aren’t spoken to sensitively. Often, this is because staff feel challenged or stressed by the high pressure environment in which they work.’ Schwartz Center Rounds were developed by The Schwartz Center for Compassionate Healthcare in Boston, USA, following the death of Ken Schwartz, who died in 1995 from lung cancer. Prior to his death, he set up the centres to nurture compassion in healthcare and to encourage healthcare workers to make ‘the unbearable bearable’ through ‘the smallest acts of kindness’. Marjorie Stanzler, Senior Director of Programs for the Schwartz Center for Compassionate Healthcare (pictured), said: ‘Our Rounds programme has been changing the culture in more than 320 hospitals and other healthcare facilities throughout the United States, and we are confident that it will usher in similar changes in the UK.’ See www.theschwartzcenter.org for further information.
Raising concerns
NHS Scotland launches staff complaints hotline NHS Scotland has launched a free, confidential phone line for staff wanting to raise concerns about practices or care standards in Scottish health services. The National Confidential Alert Line for NHS employees, an independently-run service which went live in April 2013, received over fifty calls during its first month of operation. Twenty-three calls anonymously raised concerns about NHS care practices in Scotland while 11 related to per-
6
sonnel or contractual matters. The service also received 19 calls from health workers in other parts of the UK. All of
the concerns raised were passed on to the relevant authority for further investigation. ‘We have created a way that staff can speak to an independent organisation, anonymously, safely and confidentially,’ said Scottish health secretary Alex Neil. ‘I have also been clear that any areas of concern have to be investigated so that lessons will be
learned.’ He added: ‘While the Francis Inquiry focused on NHS England, we can still learn lessons about our NHS by listening to staff and patients and learning from mistakes.’ The Alert Line, run by Public Concern at Work, will also support callers in pursuing complaints with the appropriate regulator when they consider this to be the most suitable course of action. The National Confidential Alert Line number is 0800 008 6112.
healthcare manager | issue 18 | summer 2013
HEADS UP
inpublic
“The £120 cost of an overnight stay compares favourably to the cost of a hospital bed.”
The Cotton Rooms, University College London Hospital NHS Foundation Trust A four-star hotel catering exclusively for hospital patients opened last year around the corner from London’s University College London Hospital NHS Foundation Trust. The Cotton Rooms is the first service of its kind in the NHS and has been built and funded by University College’s charity. The 35-bed hotel near Tottenham Court Road offers hospital patients undergoing daily chemotherapy and others undergoing tests at UCLH a place to stay overnight when they do not need to be admitted to hospital and take up an inpatient bed. Patients can receive hospital treatment during the day then check into the Cotton Rooms afterwards. Dr Jonathan Fielden, UCLH medical director says that although the trust has been paying to put up patients who do not live locally in hotel rooms instead of wards for some time, the Cotton Rooms is the first hotel targeted only at patients and not open to the public. ‘We have worked with a variety of local hotels but we realised that with our own facility we would have a greater degree of control and governance,’ Fielden explains. The UCLH Charity developed, owns and runs the Cotton Rooms and rents rooms to the trust. Hospitals across the UCLH trust have designated ‘core bookers’ within the range of clinical services which use the hotel. These are the only people authorised to book rooms. The charity issues an invoice to UCLH at the end of each month. The £120 cost of an overnight stay at the Cotton Rooms compares favourably to the cost of a hospital bed, which totals around £330 per night. According to Dr Fielden using the Cotton Rooms, or even a commercial hotel room, generates a considerable saving, with any profits generated being used to provide additional grants to UCLH through the charity. He explains that patients can only healthcare manager | issue 18 | summer 2013
check into the Cotton Rooms after the go-ahead from doctors. A care team is on call 24 hours a day and all guest rooms have telephones with direct lines to the hospital switchboard. There is also an alarm by the bedside in case of emergencies so patients can be readmitted to hospital quickly. The majority of patients staying at The Cotton Rooms will be cancer patients, although rooms are available for all patients who have undergone treatment at UCLH, and who need to be close to a hospital but do not require clinical supervision overnight. Many will have travelled long distances for the very specialised care offered by the trust’s hospitals. According to Kirit Ardeshna, consultant haematologist and clinical lead for the UCLH Cancer Centre the Cotton Rooms
allows patients to carry on with ‘normal’ life in an environment where family and children can stay with them. ‘All patients must meet strict criteria and if our medical teams consider that a patient needs to be admitted to hospital then a hospital bed is always provided,’ he explains. Paula Statham, a cancer nurse who helped develop the ambulatory cancer care service at UCLH added: ‘It can be an isolating experience for some patients and we hope the hotel will make it easier for them to carry on with their lives as normally as possible – but with the added assurance that medical help is close by. They can – if they wish – socialise and chat with other patients to share their experiences or invite a relative or friend to stay with them in their hotel room.’ Helen Mooney 7
LETTERS
letters
Letters on any subject are welcome. Please send to editor@ healthcare-manager.co.uk or to 8 Leake Street, London SE1 7NN. We may edit letters for length. Name and address must be supplied, but you may ask for them not to be published.
to the editor
Thanks for your support I would like to take this opportunity to thank MiP for the wonderful support and publicity your magazine gave to the Courtney Pine concert held on 10 April 2013 in aid of the Mary Seacole Memorial Statue Appeal.
It took place at the Brixton JAMM, was packed out and was a tremendous success! There was some sublime saxophone playing by Courtney together with fantastic performances from The Portraits and Jerry Deeney, and poetry from Zita Holbourne. The magnificent sum of just over £3,000 was raised and we would particularly like to
acknowledge the brilliant support from MiP national officer Martin Furlong. Over £300,000 has now been raised for the appeal from a mixture of donations and sponsorship leaving a further £200,000 to be generated to reach the total required. Our registered charity has just launched a newly designed website at www.maryseacoleappeal.
org.uk so we would love MiP members to take a look. You might also wish to follow our progress via Twitter (@seacolestatue) or on Facebook: www.facebook. com/SeacoleStatueAppeal Professor Elizabeth Anionwu CBE Emeritus Professor of Nursing, University of West London
MiP conference 2013 27 November, London
Preparations are under way for MiP’s 2013 conference, taking place on Wednesday 27 November at the Congress Centre in London.
2013
Once again the focus will be on managers and how your development needs can be met as you deal with the pressures of delivering quality services in the face of rising demand and the continuing financial squeeze. We will reflect on the Francis report and what managers can do to create the cultural change needed to embed the values of compassion, dignity and respect in delivering services. And we will consider what, if anything, can and should be done to maintain high standards for managers. Channel 4 health correspondent Victoria Macdonald will be in the chair with a great line-up of speakers as well as masterclasses, networking tables and exhibition. To register and for further details, visit the MiP website at www.miphealth.org.uk
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healthcare manager | issue 18 | summer 2013
COMMENT
comment Mark Lever
Chief Executive of The National Autistic Society
A second chance to be heard With the Care Bill set to become law, steps are being taken to end the crisis in our social care system. But with squeezed local authority budgets and uncertainty about how much the Government plans to invest in the system, we have serious concerns about what will actually be delivered on the ground for people with autism.
Around one in 100 adults in England have the disability, which affects how they communicate and relate to others. Some need help to carry out basic tasks such as getting washed and dressed and cooking meals, while others need specialist support to find sustainable employment. Currently thousands of adults with autism miss out on essential support because their difficulties aren’t recognised. All too often local authorities set eligibility criteria too high and community care assessors lack the training they need to understand the daily impact autism has on an individual, and so cannot make a realistic assessment of their needs. Joined-up working is vital, because without the right assistance from social care, people with autism face social exclusion and escalating health needs. Research for the National Autistic Society (NAS) found that a third of adults with autism have developed a serious mental health problem because they lack appropriate support. Many people with healthcare manager | issue 18 | summer 2013
autism only receive assistance when they have plunged into crisis. Very expensive and intensive support could often be avoided if low-level options were in place in the first instance. Specific steps were taken to improve the local offer for these adults with the 2009 Autism Act. This landmark legislation achieved cross-party support and set the building blocks in place to deliver better services. However, a recent NAS survey found that, four years on, many of the Act’s requirements still need to be implemented. Too many adults with autism are still waiting, with 70% telling us that they weren’t getting the support they needed from social services. A key duty arising from the Act was for local authorities to work in partnership with clinical commissioning groups to improve access to diagnosis in adulthood. Getting a diagnosis is a critical milestone for adults with autism, helping them to unlock the right support and understand years of not fitting in. Every local area was supposed to have a pathway to diagnosis in place by 2013. But of the 152 English local authorities, our research found that only 63 currently have such system in place. A further 81 are already making progress – it is really important that they deliver too. In 2012, as a result of the Act, NICE published guidelines on diagnosing, assessing and managing autism in adults.
One recommendation was for every area to establish an autism team. Liverpool’s Asperger Team and Bristol’s Autism Spectrum Service illustrate goodpractice working between health and social care, financed through health funding. These teams provide invaluable support to adults with autism including diagnostic and post-diagnostic support, and an on-going programme of training for frontline health and social care staff.The NAS would like more areas to adopt this model. This year, the Government is reviewing the impact of the Autism Act and the NAS has launched the ‘Push for Action’ campaign to encourage local and national decision makers to follow up on the promise of the Act. We’re calling on local authorities, CCGs and Health and Wellbeing Boards to ensure that they are meeting their duties under the Act, assessing the needs of local adults with autism and providing them with appropriate support. We’re also urging the Government to improve local support by providing new funding, better guidance and improved monitoring. We’ve seen great strides forward in some parts of the country since 2009, but progress has been too slow and too patchy. The Government’s review gives people with autism a second chance to be heard. We need to make it count. Views expressed are those of the author and not necessarily those of healthcare manager or MiP.
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GLOBAL HEALTH
Everyone agrees the healthcare landscape faces transformational change, but if we learn from innovation and good practice around the world, we have nothing to fear, says Mark Britnell.
Is there a storm brewing in international healthcare?
After bringing together more than 40 of the world’s leading health practitioners last year, to look at what they thought the future might hold, we at KPMG think there might be. We weren’t surprised to hear their concerns about the challenges ahead. Nearly all of them, when surveyed, predicted moderate or major system change. What did surprise us however were two things – and these form the key themes of our report Something to teach, Something to learn: Global perspectives on healthcare. Firstly, how many leaders thought they would somehow be insulated against these challenges; and secondly, the striking similarities between the way commissioners (‘payers’) and providers are responding and rethinking their strategies. Three-quarters of the global health practitioners we spoke to believed their current business models would be able to withstand the mounting pressures caused by growing and ageing 10
“Our view is that integration trumps competition in terms of delivering sustainable benefit.”
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populations and tightening budgets. It’s a worrying paradox that isn’t confined to healthcare. We carried out research with 3,000 leaders in all sectors and found that the majority, when faced with the prospect of major change, would favour transactional change over transformational reform. However, no other sector faces quite the same challenges in the next five to ten years as healthcare – and the seeming lack of long-term planning is a growing cause for concern. Our report highlights an emerging international consensus on the major trends shaping health system reform: ■■ Payers – whether governments,
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public sector bodies or insurers – are becoming more ‘active’ in looking at value, contracting more selectively, reshaping patient behaviour and moving care upstream to focus more on prevention Providers are rethinking their approach and developing new forms of more extensive and integrated care Patients are increasingly being seen as active partners in their care, rather than passive recipients New approaches to integration show that sustainable change and better value can go hand-in-hand The rise of ‘high growth health systems’, from rapidly developing economies in Asia, Africa and South America, is changing global outlooks – offering huge learning opportunities for all
But in spite of these clear indicators, too few organisations, it seems, appreciate the scale of the challenge facing them and are asking themselves the question, ‘In the future, do we do healthcare manager | issue 18 | summer 2013
GLOBAL HEALTH
things better or do better things?’ The health landscape must, and will, change. Everyone needs to be prepared for that – patients, providers and commissioners – as well as clinicians. We need to take the fear out of transformation, embrace the potential and take people with us. While the paradox persists, getting sufficient joint buy-in for major reform will be extremely difficult. There are plenty of examples of innovation and good practice around the world from which global health systems, including the NHS, can learn. Clinical Commissioning Groups, for example, could glean valuable lessons from some of the international insurers, many of whom are already putting the principles of the ‘activist payer’ into practice – contracting for value and outcomes, and directly influencing patient and provider behaviour. Dutch health insurer De Friesland Zorgverzekeraar (DFZ) has pioneered a commissioning approach which has seen them work with local hospital providers to develop fully integrated care pathways for oncology, pregnancy, elective surgery, complex vascular and elderly care. Our view is that integration trumps competition in terms of delivering sustainable benefit. This, with the patient at the centre, is where the focus should be. GP commissioners need to move quickly, and use smart data about their populations, which allows them to predict future needs and design services around patients. Other health economies are finding new and innovative ways to empower patients. ParkinsonNet, also in The Netherlands, demonstrates how an effective patient education system can alter perceptions about what constitutes value for Parkinson’s patients and, as a result, radically change practitioner behaviour. The programme has already halved the number of hip fractures suffered by Parkinson’s patients and delivered savings of 20m euros. The clear evidence is that organisations which fail to understand healthcare manager | issue 18 | summer 2013
and adapt to this new patient-provider relationship face difficult times ahead. Technology will be an important tool for many as they seek to turn patients from passive recipients of care to active drivers of service delivery. If healthcare is going to harness technological advances to improve access to services and give patients more control over their conditions, it needs to learn quickly from the leading innovators out there. Hospitals too, are changing the way they do business in response to a shift in focus from paying for ‘volume’ to commissioning for ‘value’. The days of healthcare organisations simply ‘transacting’ their way out of trouble, either by growing, merging, or focusing on
“Political leaders will somehow have to commit to transformations that will potentially take longer to bear fruit than the duration of their term of office.” organisational efficiencies, are numbered. Instead, our research shows that providers are beginning to look outside traditional hospital-based models. Integration is becoming the watchword. Hospitals are evolving to become health ‘systems’, closing the gap between primary and acute care, providing access to the full range of health and social care services and taking responsibility for overall population health improvements. One of the current problems in the UK is that the policies don’t incentivise integration, adding complexity to something which should be simplified. This has to change in order to allow the system to transform. That said, evidence of an emerging trend towards integration can already
be seen in the UK. Campus-type examples such as University College London and the Central Middlesex Hospital are the obvious ones, but integrated health and social care models are also being driven by early adopters such as South Devon Healthcare. But these are still isolated examples within an overall international health system still wedded to transactional change. For real transformation to happen, and the evidence is mounting that it must, a new type of leadership will be required. Of course, that leadership needs to start at ground level with the NHS’s greatest asset – the many hundreds of thousands of hard working healthcare professionals who shape service delivery on the frontline. It needs to be supported by a new kind of organisational leadership – one which is bold, visionary and prepared to lift its eyes to see beyond day-today operational delivery. To be successful in these difficult times, leaders will have to find new ways to liberate the talent within their organisations and provide the tools and permission for staff to experiment and innovate. They will also have to be prepared to put aside individual perspectives and focus instead on developing joined-up ways of meeting the collective needs of the populations they serve. Political leaders will somehow have to commit to transformations that will potentially take longer to bear fruit than the duration of their term of office. This won’t be easy. Large-scale change never is, particularly when it involves multiple interests, conflicting priorities and pressing timescales. But, as the evidence from around the world shows us, it is possible. Arguably the most important commodity in international healthcare development today is knowledge. And in a world where knowledge is king, it is an absolute truism that we all have something to teach and something to learn
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Mark Britnell is global head of health at KPMG. 11
INTERVIEW: ANN RADMORE
London’s Ambulance Service is going through radical change as part of its bid to become a foundation trust by 2015. Alison Moore spoke to its new boss – born-and-bred Londoner Ann Radmore.
This winter has been one of the most testing on record for the NHS – and particularly so for anyone involved in emergency care. So her first three months as chief executive of the London Ambulance Service (LAS) might have been a baptism of fire for Ann Radmore. If so, she seems surprisingly calm about the experience and upbeat about the future.
This could be partly to do with the relatively good performance of the service on the key ‘eight-minute’ target, and partly with the news that commissioners are to pump additional money into the service – on top of ‘winter pressures’ funding – to help it recruit more staff and reshape its service. But LAS has also developed a plan for meeting the needs of those who are seriously injured or ill, and deal with the many callers who still need help but whose needs are much less urgent. ‘We believe we can reduce the stress and pressure on our staff and treat these patients better by working in a different way. For me it is about a new phase for the ambulance service, for which this is probably the first step,’ says Radmore. ‘Where we go after that is for future development and discussion. What I’ve 12
said to the staff is that we need to develop together a view of what is the longer-term LAS strategy.’ For cases that are true emergencies that will still mean a blue light ambulance – and the LAS has a good record on this, achieving the eight minute target for the last ten years, and working with a stroke and cardiovascular network which ensures patients go to the hospital best suited to their needs. While the implementation of the NHS 111 service and handovers at hospitals have caused some problems this winter, the LAS seems to be a in a less troublesome position than some other areas. But the less urgent cases – where callers don’t need immediate treatment and transport to hospital – can face a long wait for the right care. In April, the LAS published details of its plans to ensure all patients who ring 999 will have a response within an hour – whether a phone assessment, advice to seek care from another part of the NHS, or face-to-face contact with a paramedic or hospital. By 2015, if the programme goes to plan, the service will offer a completely paramedic delivered service: with a paramedic on every ambulance, together with an A&E support worker, and making full use of its rapid re-
sponse fleet of cars, motorbikes and cycles. To deliver this, the LAS wants to train more support workers to work alongside paramedics on ambulances, improve its rostering so that available staff are closely matched to demand, and look at areas such as rest breaks and annual leave. Some staff will have to change their place of work and emergency medical technicians – who will gradually be replaced by lower grade support workers - may choose to retrain as paramedics. These changes have met with a mixed reaction from staff. Radmore insists all of the elements are in use somewhere in the country although perhaps not all of them in the same place. ‘There is a universal view from staff that things need to change and there is a shared view of where we need to be by 2015,’ she says. All this is a far cry from two years ago when the service announced it was cutting jobs by nearly 20% over five years to save £53m – a target which rising demand has made it difficult to deliver. Radmore says two changes in particular are contentious with staff: rest breaks, with many staff feelhealthcare manager | issue 18 | summer 2013
INTERVIEW: ANN RADMORE
“‘I think there is a real commitment to working in partnership... There is a real ambition around about where we could be in two years’ time.”
been important. They have provided additional funding and have a real understanding of the need for change, Radmore says. ‘There was a belief from commissioners that we would commit to doing it. Was that about my personal leadership? Yes partly. There’s a real focus at board level about these category C [low priority] patients and an awareness that we were not delivering the service we would aspire to – it was not good enough.’
ing they need a ‘quality’ break with proper facilities and no interruptions; and the proposals for mixing paramedics and support workers. ‘We are working with the unions to think through how to address some of the staff concerns,’ she says. She has just spent a week talking to staff in groups about the plans and claims to have found a ‘real appetite for clinical development’. Consultant paramedics and advanced paramedics healthcare manager | issue 18 | summer 2013
could be part of the picture and offer a progression route that has been lacking for frontline ambulance staff. ‘I think there is a real commitment to working in partnership. I’m hearing from staff and some of the unions that some of this is going to be difficult… but there is commitment from the unions to work with us. There is a real ambition around about where we could be in two years’ time.’ But the ‘buy-in’ from CCGs has also
Between her appointment and taking up the job, the LAS board decided to reduce its surplus and spend more money on supporting frontline services. Was that driven by the Francis Report? ‘It was a very mature conversation about how we had a responsibility to balance the books and we had a responsibility around quality,’ says Radmore. ‘I think there will continue to be a challenge for the organisation to balance the two.’ And, post-Francis, quality is as pressing an issue in ambulance services as it is in the acute sector. The board and executive team have already had a couple of discussions about its response to Francis, and these will continue into the summer. One concern is ensuring patients are listened to throughout the organisation. There is already a ‘patient story’ at each board meeting and data is triangulated around quality. The board members recruited as part of LAS’s foundation trust bid – unlikely to be realised until 2015 at the earliest – are also a useful source of information and feedback, she says. 13
INTERVIEW: ANN RADMORE
“I think I have arrived at a moment of huge change in the organisation. If you look at our workforce, increasingly we have women in the front line.”
The challenges going forward are multiple. One is working with 32 CCGs, and a significant number of local authorities and trusts, some of which are themselves being reconfigured. CCGs may want to commission additional services tailored to their local requirements on top of the core service. ‘In the past we have tended to say this is the way we do things and that guarantees quality and consistency,’ Radmore says. ‘But I would be confident that our staff are capable of responding to local challenges as well as delivering consistently.’ Radmore highlights elderly and frail patients – often living alone – as a key group where CCGs may seek a localised service. But LAS also has to deal with 18 to 30 year olds who are not well engaged with the rest of the health system and know they will always get a response if they dial 999, she says. The trust is having to think flexibly about recruitment – one potential area could be former military personnel, she says. But whoever is recruited will need to be caring and compassionate as well as being capable of meeting the requirements of paramedic training, which is becoming more academically demanding. ‘As well as trying to recruit to A&E support roles we are trying to recruit to paramedic vacancies. There is a cost 14
premium to living in London and people talk to me about housing costs – and we have staff who live significantly outside London and travel to us.’ Radmore, who joined the NHS as a graduate trainee 30 years ago, may not be the first woman chief executive of an ambulance service – but she is certainly the first to run such a high profile service. A Unison official even blogged about her appointment – which he described as forward thinking and radical – under the title ‘Ambulance Belle.’ ‘I think I have arrived at a moment of huge change in the organisation. If you look at our workforce, increasingly we have women in the front line,’ she says. ‘The age of the workforce is dropping. We require them to have more academic qualifications.’ ‘Some of our lady paramedics are delighted to have a lady boss! It’s a time which feels right. I do think that women should have equal opportunity and I feel that the recruitment process for this job was very open and vigorous. ‘I think the [Trust] chair was looking for someone who understood the NHS as a whole. The ambulance service tends to play into two families – the emergency family and it’s also part of the NHS family. ‘I was confident that I was able to do
what’s needed for the job. I’m not sure that was to do with being a woman – was it to do with my 30 years in the NHS? You could say that the way I will do the job is different because I’m a woman, but then we get into a gender stereotype.’ But one thing is clear: she puts enormous emphasis on listening to what other people have to say. ‘There is something about listening to colleagues, to staff, to patients and making sure we hear all the messages and then triangulate it.’ Listening is ‘a recognition that you don’t know it all,’ she says. Her dedication to the job is obvious: she is trying to spend half a day a week on the frontline or in support services, meeting staff and understanding what they do. ‘She was in on Christmas Day,’ her press officer tells me after the interview. Radmore’s previous jobs included chief executive of NHS South West London and chief executive of Wandsworth PCT. She has worked across both provider and commissioner organisations – including leading on the implementation of the pan-London stroke and cardiovascular service – but says her heart draws her back to service provision. At 53 does she still look ahead to the next job? She says chief executives need to give four or five years at least to a job like hers. ‘I remain passionate about the NHS. I’m a Londoner born and bred, so London feels like where I want to work.’
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healthcare manager | issue 18 | summer 2013
PATIENT INVOLVEMENT
Patient involvement isn’t about committees of patient representatives but simply listening and spending time with the patients you’re caring for, says Christina Patterson.
If you want to make God laugh, as Woody Allen once said, tell him your plans. I certainly had no plans to become any kind of expert on healthcare. I’m still not any kind of expert on healthcare. When I look, for example, at the Health and Social Care Act, which runs for 457 pages, and isn’t, to be honest, a very gripping read, I don’t really understand how anyone can be an expert on healthcare. It seems to me like something you might have to study in some secret seminary where they lock you up for years.
But I do know quite a lot about what it’s like to be a patient. I didn’t ever want or expect to, but when, ten years ago, I found a lump in my breast, I set out on a path that made sure I did. When the surgeon told me it was cancer, I was worried, of course. I was worried about the treatment, worried that I’d have to lose a breast and worried that I was going to die. But I wasn’t worried about the care I’d get. I thought that if you were still quite young, and got something like cancer, you wouldn’t need to worry about the care you’d get. It didn’t, unfortunately, take long to find out I was wrong. I didn’t expect the receptionists to be rude, or the nurses to speak to me as if healthcare manager | issue 18 | summer 2013
“The nursing was so bad I made a vow — that I’d use my voice as a journalist to try to make things better.”
I was a nuisance, or the oncologist to be patronizing, or the plastic surgeon to tell me that he thought my approach to a mastectomy was ‘rather heavy’. I didn’t expect the pathology reports to take six weeks to be sent from one hospital to another, or to find that the mammogram the hospital was meant to have sent was an X-ray of an ankle. But all of these things happened, and I learnt a lot. I learnt that when you’re a patient, the thing that feels to you like a matter of life and death, and which sometimes is a matter of life and death, can just be an unwelcome interruption in someone else’s day. When the cancer came back, six and a half years ago, I thought things would be better. Labour had doubled spending on the NHS and the room where I waited for the results of my biopsy was clean and smart. And at first things did seem to be better. At the hospital I switched to, under something called ‘patient choice’, the receptionists were polite, the surgeons were lovely, and letters for appointments actually arrived before appointments. But the nursing was so bad I made a vow. As I listened to the groans of the other patients, and the buzzers that weren’t answered, I vowed that I’d use my voice as a journalist to try to make things better. 15
PATIENT INVOLVEMENT
So I did. I wrote columns for The Independent. I made programmes about nursing for Radio 4 and a short film for The One Show. And I did a special report on nursing in The Independent, which was shortlisted for this year’s Orwell Prize. I’m asked to speak and write about health quite a lot these days, even though health – or the lack of it – had nothing to do with my work or my plans. I’ve never worked in health, but I’ve talked to doctors, nurses, managers, politicians and, of course, patients. And I’ve learnt that our health service, which is meant to be the envy of the world, is letting far, far too many of the people who use it down. For anyone who works in the NHS, or anyone who reads a newspaper, which is probably all of us, this will not be news. When I started talking and writing about my own experiences in the NHS, I was quite often made to feel that I’d broken a taboo. But things have changed. As report after report has talked about patients left unwashed, unfed and believing they’ve been abandoned, there has been more and more talk about ‘patient-centred care’. When I first heard the term, I thought it was a joke. How could care not be about patients? Surely talking about ‘patientcentred care’ was like saying snow should be cold? But now that I’ve learnt the hard way that you can have care that doesn’t care, I’ve also learnt that you sometimes have to state the obvious. If sticking the word ‘patient’ before the word ‘care’ reminds people that patients are quite an important part of the whole process – are, in fact, the reason they have a job – then let’s stick it everywhere all the time. And yes, let’s state the obvious in other areas too. Let’s, for example, have a Chief Nurse talking about the “Six Cs”. It’s hard to imagine that anyone could become a nurse and not know that it was meant to be about compassion, courage, care and so on, but some nurses do seem to have forgotten this, so let’s spell it out. And 16
let’s, by all means, have ‘patient representatives’ on committees. It’s hard to imagine that all the other people on the committees could have forgotten that it was meant to be all about patients, but if they have, and ‘patient representatives’ help them remember, let’s have them there. And let’s have an ‘independent consumer champion for health and social care’ and call it ‘Healthwatch England’, as, since November last year, we now do. ‘Our mandate,’ says its chief executive, Katherine Rake, is ‘to make sure the voice of the consumer is heard loud and clear’. It will, she told me, ‘need to challenge those who plan, run and regulate services to be better’. Yes, it will, though how isn’t yet clear. There is, as Jon Restell, chief executive of Managers in Partnership (MiP), says, ‘a lot of uncertainty about its role, and how it’s going to work around the country. Its powers,’ he says, ‘are not understood.’ ‘Where patients’ care has suffered,’ he told me, ‘and it’s so bloody obvious, is where it’s not seen as the central point of the work. If we’re going to shift this culture in some places, leaders at all levels have got to say that’s what
“Surely talking about ‘patient-centred care’ was like saying snow should be cold?” we’re here for, and we go out and find patients’ experience and value it.’ Clinicians, says Restell, won’t find it easy since they’re ‘the kind of people who are used to saying what needs to be done’, but they need to learn to ‘welcome’ feedback from patients. The more feedback, he thinks, the better. ‘That,’ he says, ‘is why I’m not opposed to the Friends and Family Test. I think these are valuable tools.’ So do I. In my 10-point manifesto for better nursing, I said I thought all patients should be asked for feedback as
they left hospital, and that all trusts should publish the results. I think patients should always be asked for feedback. In a survey of 8,000 GP practices conducted by MORI last year, patients who said they felt they had a good relationship with their GP, and their GP practice, had much better clinical results than the people who said they didn’t. Kindness, in other words, heals. If you want people to flourish, treat them well.
We don’t yet know whether the Health and Wellbeing Boards set up by the Government last year to ‘improve the health and wellbeing of their local population’ will make things better for patients, or worse.
We don’t know whether the massive restructuring of the health service will make things better, or worse. If I worked in the NHS, I think I’d feel I’d seen enough restructuring to keep me going for quite a while. But I do think the Government is right to try to bring all the different bits of the system together in those boards, and I think Jeremy Hunt is right to say that it’s not good enough to have a GP who doesn’t even know your name. When hospitals, doctors, nurses and managers do a good job, it’s always because they haven’t forgotten why they’re there. At Liverpool Heart and Chest Hospital, for example, which was recently praised by the Chief Nurse as an ‘excellent example’ of patient care, members of staff have been encouraged to speak out about any care they didn’t think was good enough, and systems have been changed to meet the needs of patients, not staff. People who do their jobs well want to hear what patients have to say. Any chief executive who responds to a complaint by saying that most patients are happy with the care they’ve had is in the wrong job. Treating the medical needs of a population of 63 million, at a time when public spending is meant to be going down, was never going to be easy. It was certainly never going to be easy when so many people were getting old, healthcare manager | issue 18 | summer 2013
PATIENT INVOLVEMENT
“It is a nt.”
Winners of the Apprenticeship Awards run by Liverpool Chest and Heart Hospital and awarded for their personal achievement and the positive impact they have made on patient care.
eating rubbish and getting fat. It isn’t easy, and it’s going to get harder, but we can still try to do a better job. We can, for example, make sure that anyone who works in the NHS, whether they’re a receptionist, a healthcare assistant, a nurse, a doctor, or a chief executive, is trained to think about the patients’ needs. It would be nice if they could be tested, and trained, for compassion, but they could at least be trained in communication and manners. If John Lewis can train its staff in empathy, then why can’t the NHS? We can also cut out some of the nonsense. Language, as George Orwell knew, matters. ‘Political language,’ he said, is designed to ‘to give an appearance of solidity to pure wind’. Goodness only knows what he would have made of some of the documents being produced by people who work in a field that’s actually called ‘health’. I don’t know why people in health think they have to ‘deliver best practice’ or ‘roll out initiatives’ to ‘end users’. I don’t healthcare manager | issue 18 | summer 2013
know what any of this means. I do know that if you want to change something, you have to be clear about what it is you’re doing, and you have to be able to explain that clearly to somebody else. Good health, like so much in life, has a lot to do with good relationships. If you have a doctor, or nurse practitioner, or district nurse who knows you and who you feel is on your side, you’re likely to feel better, and do better, than if you don’t. If you trust that person, you’re more likely to listen to their advice. And if that person smiles at you, listens to you and talks to you as if you’re a human being who’s having a hard time, and not a name to be ticked off a list, you’ll feel physically better, too. Homeopathy works – when it works – because someone has given you quite a lot of time. Time costs money. Training costs money. District nurses and nursing practitioners cost money. But if we want to cut some of the massive medi-
cal costs that are looming, we’re going to have to invest in a few things first. We need to give more people more time, and we need to give it to them before they get ill. And we need to make sure that bosses learn to treat their staff well. People who feel valued are much more likely to make the people they’re looking after feel valued, too. People who are treated badly tend to behave badly. We can’t afford to have people who behave badly looking after us when we get ill. Yes, when we get ill. Because we all do. We all get ill, we all get old, and one day we all die. You can talk about ‘patients’ if you like. You can talk about ‘patient-centred care’ if you like. But really we’re just talking about people. That’s me. That’s you.
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Christina Patterson is a writer, broadcaster and campaigner. She now speaks widely in the healthcare sector, and can be contacted via her website: www.christinapatterson.co.uk 17
OLDER PEOPLE’S CARE
Michelle Mitchell, charity director-general of Age UK, says the Francis Report must be seen as a catalyst and a road-map rather than a reason for changing how the NHS works for older people.
At a recent health event, someone asked ‘what’s Francis?’ The fact that everyone was taken aback by the need for such a simple clarification goes some way to show how fully the term has entered the common lexicon within healthcare services. There can’t be many days when an NHS manager doesn’t hear or say the word that has become shorthand for hospital failures.
The two inquiries into failures at MidStaffordshire were comprehensive and make often depressing reading. Not only because of the extremely distressing stories they included but also from the uncomfortable sense of familiarity they produce. Even the worst failures they described did not come as a surprise to many people working in the health sector. These were not revelations, but a public airing for what many who work in and around the NHS and social care regularly hear about. Not necessarily endemic, but certainly widespread and in some places entrenched. Furthermore, that the care of older people featured so prominently in the report was 18
“Patients, families and carers have vital insights into what is going wrong and right. Using these insights is crucial to stamping out poor practice”
even less surprising. How do we at Age UK know this? In part, it’s from the many letters and conversations with older people deeply frustrated with the complaints system, or the many times we’ve heard, ‘I know you can’t do anything about my experience, I just don’t want the same thing to happen to other people.’ But even more, a brief audit of reports on a similar theme reveal longstanding problems. The Health Advisory Service 2000 report, published in 1998, promised to set out clear standards of NHS care for the older people ‘for the first time in its
history’. The National Service Framework for older people, published in 2001, promised ‘to ensure fair, high quality, integrated health and social care services for older people’ and spoke of ‘culture change’. In 2011, the Health Ombudsman, in her report Care and Compassion, said the reasonable expectation that an older person and their family may have of dignified, pain-free end-of-life care, in clean hospital surroundings, was not being fulfilled. In between, there has been Hungry to be Heard (Age Concern, 2006); Defending Dignity: At the heart of everything we do (Royal College of Nursing, 2008); On Our Own Terms: The challenge of assessing dignity in care (Help the Aged, 2008); Patients Not Numbers, People Not Statistics (Patients Association, 2009); Waiting for Change (Age UK, 2009), among others. And this is just a recent history. This is not to downplay the significance of the Francis report. Few of the reports above have energised those managing and leading the NHS in quite the same way that Francis has. It will certainly be a lot harder to ignore. healthcare manager | issue 18 | summer 2013
OLDER PEOPLE’S CARE
But there will need to be a committed response from all parts of the NHS to make sure that change actually happens this time. Francis must be seen as a catalyst and a road-map rather than the reason for changing how the NHS works. In the report, Francis talked about how patients were often lost behind the operational imperatives of running a hospital. It would be an odd response if we simply talked about improving hospital care to reflect Francis’ recommendations rather than to meet the needs of patients. In 2012, Age UK, the NHS Confederation and the Local Government Association published a report called Delivering Dignity. The three organisations came together in 2011 to form a Commission on Dignity in Care to start addressing many of the problems later identified in Francis and many times previously in the reports detailed above. The Commission aimed to move beyond diagnosing the problem and towards recommendations for change. Taking evidence from a wide-range of experts in the care of older people and those responsible for overseeing standards in the NHS and social care, the report directed a number of recommendations at managers and senior leaders. Addressing these would go a long way to improving care for older people and to making change in line with the Francis report. Recommendation 3 says: ‘Care organisations should introduce facilitated, practice-based development programmes, to ensure that staff caring for older people have the confidence, support and skills to do the right thing for the people in their care.’ Older people are the majority users of NHS and care services yet we are not convinced that the NHS has sufficient skills and knowledge to meet healthcare manager | issue 18 | summer 2013
“Older people are the majority users of NHS and care services yet we are not convinced that the NHS has sufficient skills and knowledge to meet their needs.”
their needs. This is especially so for those living with complex needs and multiple health conditions. This can make it extremely challenging for staff to deliver the high quality care they want to and risks making stays in hospital harmful or at the very least counter-productive. Managers must take a lead in making sure healthcare settings reflect their users’ needs and make time for training and development in older people’s care. The Commission believes this is equally important with respect to dementia. Recommendation 12 says: ‘Boards and management teams must have robust processes in place to collate feedback and complaints from older people, their families, carers and advocates, as well as staff, so that they can identify emerging risks and respond to them’. Underpinning this recommendation must be a real desire to seek out feedback from patients. It is always worth remembering that campaigning by local patient groups was a significant factor in exposing the failures of Mid-Staffordshire. Patients, families and carers have vital insights into what is going wrong and, just as importantly, what is going
right. Seeking out and using these insights is crucial to stamping out poor practice and must also be the basis for assessing performance. This is not rocket science. Yet one of the consistent frustrations we come across is people’s sense that complaints are not listened to, or that nothing changes when they raise concerns about care on a ward. Recommendation 13 further encourages senior managers and board members to make a personal connection with the people and services they are in charge of. On a simple level, this means going to where patients and families are and talking to them. Many NHS staff and managers complain about not having opportunities to engage with vulnerable patients. Well, they’re already in the building, often in a bed with a call bell that’s not being answered. Much of this exists within a culture in NHS and social care where shared decision-making is not the norm and support to help people care for themselves is sometimes lacking. This displaces patients from a process that is supposed to be all about them. Improving dignity in care for older people is not a complicated recipe. The ingredients: training for staff in the care of older people; a commitment throughout the organisation to patient experience as an essential component of care; and ensuring that patients and the public are active, supported partners in running their services and managing their care. That’s not to say these are easy things to accomplish. In some parts of the NHS, this means challenging longestablished ways of working. But this is not about meeting the demands of Francis. This is about running the NHS to meet the needs of patients consistently and sustainably, and to ultimately restore its whole reason for being.
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19
LEGAL MATTERS
legaleye Jo Seery explains the law on dismissal on grounds of capability. There is anecdotal evidence of an increasing number of claims of unfair dismissal on grounds of capability. This could be a result of the economic climate, particularly redundancies due to cuts in public services.
NHS restructuring and more private sector involvement may also lead to more unfair dismissals, as employers seek to dismiss employees on grounds of capability instead of making them redundant. Those with a disability and older workers are particularly vulnerable, if employers make stereotypical assumptions about their capability. Capability is defined in section 98(3) (a) of the Employment Rights Act 1996 as: “capability assessed by reference to skill, aptitude, health or any other physical or mental quality.” In cases of capability dismissal, an employment tribunal has to consider whether the employer held an honest and reasonable belief that the employee was incapable or incompetent, had reasonable grounds for that belief and that it was reasonable, taking into account all the circumstances – including the size and administrative resources of the employer – for the employer to dismiss the worker. The employee is judged against the standards required by their current job or the duties they have been transferred to, and the onus is on the employer to provide evidence of poor performance. In most cases, the line manager’s views will carry significant weight. However, this must be supported by documentary evidence of the performance concerns. Appraisals are often the key source 20
of evidence for both employer and employee. It is therefore crucial that employees who do not agree to their appraisal, the targets set or any assessment of their performance between formal appraisals, put their disagreement in writing, setting out the reasons and attaching any supporting evidence. This will make it easier to challenge an employer who later relies on the appraisal as evidence of incompetence. It is a good idea for employees to keep a record of positive comments about their work, so they can show
“It is crucial that employees who do not agree with their appraisal put their disagreements in writing.” that the standards which are subject to capability proceedings have been accepted in the past. Performance pay increases may also be useful evidence. Employer procedure Employers should follow a fair procedure before dismissing for capability. There should be a proper and fair assessment of the employee’s performance and identification of the problem. The employee should be given a warning of the consequences of failing to improve and a reasonable chance to improve. Other than for gross incompetence, or such unsuitability for a job that the employee is incapable of change, failure to give a warning is likely to render a dismissal unfair. Warnings don’t
automatically lapse at the end of an improvement period, but if an employee is led to believe that their performance is no longer being monitored, it may be unfair to dismiss them for poor performance without further warning. There are no hard and fast rules about what is an appropriate improvement period. A tribunal will look at the nature of the job, length of service, status, past performance and the extent of poor performance. The employer and employee should agree “SMART” targets (specific, measurable, achievable, realistic and time bound) before the improvement period starts and if the employee doesn’t agree to a target they should put their concerns in writing and suggest alternative terms for improvement. Most unions will have negotiated capability performance procedures and employers must follow them. Employers may try to dismiss an employee for gross misconduct to avoid the capability procedure. But misconduct is limited to carelessness, negligence or idleness. Where there are no agreed capability procedures the employer must comply with the ACAS Code of Practice on disciplinary and grievance procedures. Finally, while an employer is not obliged to provide training, if they implement a new system or promote an employee to a new role without adequate training, then a dismissal on capability grounds could be unfair.
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Jo Seery Thompsons Solicitors Legaleye is not intended to provide legal advice on individual cases, and MiP members in need of personal advice should immediately contact their MiP rep.
healthcare manager | issue 18 | summer 2013
TIPSTER
How to be a good coach Coaching has been shown to be the best way to increase employee engagement, which in turn is closely correlated with outstanding performance. So, what do you need to do to be a brilliant line manager coach? Jenny Rogers explains. Be clear what coaching is
main reason that most organisational change initiatives fail. Listen for metaphors and ask how the person feels about the situation. Accept what they say without trying to offer ‘therethere’ words. So they might cry? And...?
Coaching is not therapy nor is it about passing on your wisdom to a grateful employee. It’s a highly skilled way of raising people’s self-awareness so that they make better choices and think for themselves. It’s not about being ‘nice’ or ‘soft’. It’s a new tough but respectful way of holding people to account.
7 Explore choices and consequences Ask, ‘What are your own ideas about possible solutions?’ Then, ‘What are the up-sides and down-sides of each?’ That way the coachee can usually see for themselves what will work and what would never meet the goal.
2 Stop offering advice Directing and telling, even when done charmingly, is the worst possible way to improve performance because it just creates resistance or helplessness – we stop listening. Essentially, we believe what we tell ourselves. Advice is disempowering 99% of the time and the manager frequently ends up dealing with problems which have been delegated upwards – i.e. having to do the work that the employee should be doing. This is why so many senior managers are stressed.
3 Become a brilliant listener You can’t coach if you believe you already know the answer. Give up pretending to listen, give the person 100% of your attention – no sitting behind the barricade of your desk, sneaking looks at your watch or casting longing glances at your mobile.
4 Set a clear goal Don’t let the ‘coachee’ get away with vagueness: ‘I thought you could help me with this problem’. Which problem? Ask: ‘How exactly can I help you with this given the time we have today?’ Or: ‘What would be a good outcome from this conversation for you?’ If it’s your
healthcare manager | issue 18 | summer 2013
8 Offer coaching-style feedback
agenda, be clear what outcome you want: ‘I’d like us to think through what we do about the cost over-run – we’ve got 20 minutes, is that OK with you?’
5 Ask powerful questions Learn the difference between a question that provokes fresh thinking and one that gets the same old response. Coaching is about wise, not clever, questions. Coaching questions are short and begin with ‘what’ rather than ‘advice-in-disguise’ questions such as, ‘Have you thought about doing X?’ A coach says: ‘What have you already tried?’ or ‘What do you think you might have contributed to this problem?’
6 Explore the emotions Emotion governs most of what we do, so never be afraid to respectfully explore feelings. Failure to do so is the
Don’t balk at tough feedback – when you do it ‘coaching style’ you increase the chances that the person’s behaviour might improve. Separate fact from opinion. We’re looking for observation not lofty judgement, so don’t say, ‘Your contributions at meetings are pathetic’. Do say: ‘I noticed you only spoke twice this morning, each time very briefly and I found it hard to hear what you were saying.’
9 Hold people to account Don’t let the coachee leave a coaching conversation without agreeing what they will do and how you will both review what has happened.
Ask for feedback yourself How’s your own self-awareness? Ask staff for feedback: what do you do that makes life easier or more difficult for them? An executive coach for 22 years, Jenny Rogers works with senior leaders in government and the NHS, and writes extensively about coaching and leadership. For more information visit www.JennyRogersCoaching.com
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MiP AT WORK
ENGLAND
NHS transition in England – the next steps The new structures created by the Health and Social Care Act in England have been running since 1 April. Over 11,000 staff have been made redundant during the transition process. A lot more face an uncertain future as the new organisations bed down. Many will go through post-transfer restructuring and there are doubts about the long term viability of some smaller CCGs and CSUs.
The ‘rationalisation’ saw the work and staff of 152 primary care trusts and 10 strategic health authorities shifted into over 300 national, regional and local bodies, plus the shift of much of public health into local authorities. This fragmentation of services means MiP has got its work cut out in looking after the interests of these members in the months ahead. We are building on the good partnership working developed during the transition. MiP is represented on the national partnership forums for the new
national bodies, and we will ensure that managers’ views and interests are represented. MiP has allocated lead responsibility for each of the national bodies to a national officer (see table). They will represent MiP on the national partnership forums and raise any concerns on behalf of our members. Although there is no national bargaining forum for CCGs or CSUs we have appointed a lead officer for these employers. MiP also has a network of link
members who keep us in touch with members in their organisations and their concerns. If you think you may be interested in getting involved, please speak to our national officer in your area (see the MiP website for details), or email Martin Furlong on m.furlong@ miphealth.org.uk If you need personal advice or representation with your employer, you should still contact the national officer in your area. The lead officers will provide support and escalate issues to the national level as appropriate.
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Employer MiP lead officer NHS England Pete Lowe NHS Trust Development Agency Corrado Valle NHS Property Services Andy Hardy Health and Social Care Information Centre Jo Spear Health Education England Marisa Howes Clinical Commissioning Groups George Shepherd Commissioning Support Units Jane Carter Public Health England and Lianne Brooks National Joint Council sub committee for public health (local government)
SCOTLAND
MiP launches online training program Claire Pullar, MiP national officer for Scotland, has been working with the trade union education department at Glasgow’s Stow College and the TUC to develop an online training programme for MiP members in Scotland. 22
Speaking to members, it became clear to Claire that many of them wanted online training courses and materials, so that they can fit training in with their hectic work and family lives. So she contacted Brian Corrigan at Stow Col-
lege and the programme took off. In response to demand from members, the group has now produced an online pensions course which will be launched in October. The course will help participants
healthcare manager | issue 18 | summer 2013
MiP AT WORK
TUPE
Achieving harmony on terms and conditions MiP national officer Corrado Valle describes how he helped a member to assert his rights under TUPE legislation A few months ago I received a call from MiP member James, who was worried that his employer was trying to erode his employment rights. James is a senior finance officer who transferred from a PCT to an acute hospital, which had successfully bid to take over community services in his area. The transfer was carried out in accordance with the Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE). Some time later, his employer told him that some of his terms and conditions would need to change to bring them into line with the trust’s policies. In particular, they wanted to radically reduce the period of pay protection he would be entitled to and change his entitlement under the sickness absence policy. James knew that the TUPE regulations provided some protection for him and did not believe that his employer was acting in accordance with the regulations. So he rang me for advice. We agreed that he should lodge
a grievance to establish the facts of the matter and to find out why the employer was trying to change these terms and conditions. Was there an economic, material or organisational reason, unconnected with our member’s transfer, which would justify the changes? I accompanied James to the initial, informal stage of the grievance procedure with the appointed officer and HR. During the discussion it was agreed that there was no justification for the change to terms and conditions and that in fact the employer wanted to harmonise terms and conditions for all staff. We agreed that the grievance should be set aside, and no changes made to James’ terms and conditions. We did, however, agree that it was reasonable to harmonise the terms and conditions for all staff, but that this should be done through consultation with the trade unions, not on an individual basis. Those discussions are now taking place within the trust’s negotiating committee, and staff will be
properly consulted about any proposed changes. James was pleased with the result MiP achieved for him. His rights have been preserved for the time being, and he knows that if and when changes are brought in, they will be subject to formal consultation involving everyone in the trust. He is realistic and knows there will have to be some give and take in the process of harmonisation. But he feels more confident of a fair and consistent outcome. So we achieved a fair settlement and James did not have to stick his head above the parapet by instigating formal grievance procedings in order to do so. I think he would agree that we achieved a harmonious outcome.
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You never know when you might be affected by change or run into problems at work and need some confidential expert advice and assistance. So if you are not yet a member, join MiP today and get peace of mind. You can join online at www. miphealth.org.uk/joinus
mme in Scotland understand the NHS pension scheme and the impact of the Hutton reforms on pensions. By the end of the course, participants should feel confident that they understand how their pension is calculated and what effect changes in working pat-
terns – such as reducing hours or early retirement – would have. Participants in the programme can also access other Union Learn courses, such as an Equalities Diploma and an Employment Law Diploma. Before anyone can par-
healthcare manager | issue 18 | summer 2013
ticipate in the online learning programme, they need to complete a Get Ready for ELearning (GREL) course. This ensures that everyone participating in the programme has a basic level of IT proficiency and a working knowledge of
‘Moodle’, the database used in further education for online courses.
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For further information about the programme, contact Claire Pullar on c.pullar@miphealth.org.uk. For further information about Union Learn visit the website: www.unionlearn. org.uk
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Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@ healthcare-manager.co.uk.
backlash by Celticus
Desperate Dan?
W
ho’s to blame for the near 50% increase in visits to A&E since 2004? Health minister and ex-hospital doc Dan ‘100-hours-a-week’ Poulter blamed GPs for taking advantage of their generous new contracts and ‘going home early’. Another health minister, Anna Soubry, pointed the finger at women doctors working part-time. But maybe the guilty party is right under their noses. As the King’s Fund’s John Appleby tried patiently to explain, the Department of Health itself changed the data series in 2004 to include walk-in centres and minor injury units for the first time. If you look at the broken-down figures (and you can on John’s blog: www.kingsfund. org.uk/blog/2013/04/areaccident-and-emergencyattendances-increasing) admissions to major (‘Type 1’) A&E units have changed little since 2004. Waiting times, however, are a different matter: showing a significant rise beginning, well, in 2010. We can’t think why. But it was around then that Dr Dan deprived the NHS of his superhuman services and became an MP.
Foreign bodies
U
ndeterred by the facts, Tory MP Chris Skidmore loudly claimed that A&E
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departments were being clogged up by sick and accident-prone Eastern Europeans. The NHS doesn’t even keep statistics on the nationality of A&E patients, so where did he get this from? Maybe all these ex-communist Poles, Czechs and Hungarians are nostalgic for hours spent queuing and waiting around on hard plastic chairs. Skidmore did quote some Nuffield research which found more migrants were registering with GPs, but left out the important bit: ‘We found that the group of probable immigrants used hospital care relatively rarely – in fact, admission rates were around half that of English-born people of the same age and sex.’ ‘Nuff said.
Facing both ways
I
t would be unkind to say Sir David Nicholson doesn’t know if he’s coming or going but, in his recent interview in the HSJ, he did sound more like someone on the way in than the way out. He’s promising one more strategy in the coming months – a ‘case for change’ that would ‘liberate’ the NHS to ‘experiment’. NHS England is ‘very interested in thinking about the integration of commissioning and provision’ and is even questioning ‘whether the foundation trust is the right model for all providers
A&E DELAYS: Poulter crackS down ‘I’ll take that, thank you. You haven’t got time for lunch.’
in the NHS’, according to Nicholson. ‘We’re interested in the nature of the NHS being created. We’re not a regulator of commissioners,’ he insisted. Presumably, this was all news to Jeremy Hunt. The SoS’s recent letter to chair Malcolm Grant insisted that NHS England is not ‘the headquarters of the NHS in England’, that it’s ‘not responsible for the oversight of providers’ and ‘the purchaser-provider split remains’. At times like these, it’s good to see the NHS top brass all pulling in the same direction.
In the red
N
ews from France, where the inspection générale des Finances is worried that borrowing
by French hospitals is out of control. Apparently, those sparkling new hospitals gracing French towns have landed the French health system with a €24bn mountain of debt, up from €9bn just ten years ago. No such worries at Hospices de Beaune in Burgundy, where the €40m upgrade of the hospital is entirely self-financed. The hospital benefits from the annual sale of fine Burgundy wines from surrounding vineyards, much of it Grand or Premier Cru, raising millions of euros every year. Sadly, not an option open to cashstrapped NHS managers: Côte de North Staffordshire or Domaine de Barking and Havering are unlikely to sell so well.
healthcare manager | issue 18 | summer 2013
Working together for you The Open University and Managers in Partnership have joined forces to encourage greater participation in health sector education and training. Between us, we offer a wide range of modules and qualifications to make a difference to your life, your career and the people in your teams. Whether you are an Administrator or CEO, Clinical Nurse Manager or Business Manager, there are a range of modules and qualifications that will help develop skills in areas of practice from policy interpretation to research. Our flexible work-based learning fits with busy work and home commitments. Modules are vocationally relevant based on cutting-edge research and learning materials, to ensure that what you learn today, you can apply tomorrow – making an immediate and effective impact to improving levels of care. Did you know? • UNISON/MiP members receive a 10% discount on many of our courses • Learning materials reflect the day-to-day practical issues involved in running a hospital ward or clinic.
Postgraduate options designed with you in mind Postgraduate Certificate in Advancing Healthcare Practice (C92) Postgraduate Diploma in Advancing Healthcare Practice (E46) MSc in Advancing Healthcare Practice (F52) MBA (AMBA accredited) (F61) Professional Certificate in Management (C31) Certificate in Professional Practice in Delivering Public Services (K02) Postgraduate Certificate in Clinical Leadership (K04) Postgraduate Certificate in Professional Practice (Children and Families) (K14) Postgraduate Diploma in Advancing Professional Practice (Children and Families) (E70)
Advance your career www.openuniversity.co.uk/mip
0845 300 8846 Quote: GAMAEG
INSPIRING LEARNING
The Open University is incorporated by Royal Charter (RC 000391), an exempt charity in England and Wales and a charity registered in Scotland (SC 038302).
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Healthcare managers are passionate about delivering effective healthcare. In fact, it couldn’t happen without them. That’s why they deserve specialist representation. MiP is the only trade union organisation dedicated to providing personal support and employment advice, management skills and networks, and an influential voice for the UK’s healthcare managers.
helping you make healthcare happen.
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