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issue 19 autumn 2013
healthcare manager inside
What you might have missed & what to look out for Leading edge: Jon Restell inperson: Karen Dunwoodie, patient experience lead, Airedale NHS Foundation Trust inpublic: Murray Royal Hospital, Perth
Dr Caitlin Palframan: turning good intentions into the better care for breast cancer patients
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.
Telehealth: are we ready for takeoff? Interview: Stephen Dorrell – let’s hear less about structures and a lot more about care. Community Care: how community services are leading the way in reshaping the NHS NHS Sport: healthier staff leads to better care
Legal Eye: take care with settlement agreements Tipster: appraisals don’t have to be painful MiP at Work: supporting a learning culture at work
healthcare manager | issue 19 | autumn 2013
Welcome to the autumn issue of healthcare manager, the magazine from MiP, the specialist trade union for health and social care managers. In this issue we focus on what’s happening outside the hospital environment. Thanks go to Rob Webster, chief executive at Leeds Community Healthcare, for telling us to look at community services to find exciting innovations and real transformation of services: Noel Plumridge finds plenty of change taking place and some real challenges for providers and commissioners alike. We also take at look at the latest innovations in telehealth and hear about the NHS sport challenge. Our interviewee is Stephen Dorrell, the influential chair of the health select committee, who gives his views on management in general and commissioning in particular. We also have our regular features – including Michael West giving his tips on doing successful appraisals. To support breast cancer awareness month, we asked Breakthrough Breast Cancer to tell us what managers can do to help with the early diagnosis and prevention of breast cancer. Enjoy the magazine – and do get in touch if you have any news, views or comments. Marisa Howes Executive editor
heads up what you might have missed and what to look out for
Quality managers delivering quality care MiP national conference 2013 27 November, Congress Centre, London
Special offer for MiP members Once again we have brought together a great line-up for the MiP annual conference on 27 November. We’ve got speakers from the key areas of healthcare policy, including politicians Andy Burnham and Stephen Dorrell; healthcare chief executives David Dalton, Ann Radmore and Lisa Rodrigues; think tank Professors Chris Ham and Derek Mowbray; and MiP’s own chief executive Jon Restell. Channel 4 News health correspondent Victoria Macdonald will
chair the conference. Discussions will include the implications of the reports from Robert Francis, Bruce Keogh and Don Berwick, management standards and the impact on managers’ health and wellbeing of the pressure to improve quality while making huge savings. The programme includes masterclasses and focus groups covering a range of topical issues. It is free to attend for MiP members and is CPD certified. To register visit the conference website at www.mip-conference.co.uk
issue 19 | autumn 2013
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ISSN 1759-9784 published by MiP
All copy © 2013 MiP or the author. Opinions stated are not necessarily those of healthcare manager or MiP.
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Design and Production
MiP is pleased to support this conference for those involved in the transformation and delivery of health and social care services for people with long-term conditions, taking place on 21 January at the QEII Conference Centre in London. Long term conditions account for 70% of health and social care spending, so improving early intervention, clinical provision and rehabilitation is essential to maintaining service levels in the face of grow-
Mike Farrar, Marisa Howes, Helen Mooney, Alison Moore, Caitlin Palframan, Noel Plumridge, Jon Restell, Craig Ryan, Jenny Sims, Neil Todd, Michael West.
Warners Print, Bourne, Lincs
ing demand. This conference brings together over 300 healthcare specialists from across government, and the public and private sectors, to hear the latest thinking on recent policy changes, funding, innovative strategies and new models of care to achieve quality outcomes. MiP members can attend this event at an exclusive rate. Places are allocated by sector and limited in number, so to enquire about your discount, please contact the team on 0161 211 3453 or visit the website: long-term-conditionsconference.co.uk
healthcare manager is sent to all MiP members. All weblinks mentioned are at www.miphealth.org.uk/hcm healthcare manager is printed on uncoated paper with vegetable-based inks. The paper is FSC approved and the cover wrap is biodegradable.
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healthcare manager | issue 19 | autumn 2013
leadingedge Jon Restell, chief executive, MiP
eaders who say one thing but do another soon find they have a trust problem. This can happen when leaders don’t care what they say, don’t know what to say, or don’t know how to say it. More often than not, however, trust gets lost because leaders don’t know how to turn what they say into practice.
MiP has recently talked to politicians throughout the UK. An emerging theme is politicians who have encouraging, affirming things to say about managers but don’t seem to have concrete policies and positions to support their rhetoric. For example, in Scotland health ministers routinely talk about how they value managers, yet they still pursue disproportionate cuts in senior manager posts and, as a recent MiP survey demonstrated, they leave managers feeling that they are treated differently from other staff, especially over pay. But the mood is changing as the scale of the challenge facing health and social care comes into eversharper focus. Quality of care and efficiency dominate thinking with fresh urgency, as people wake up to the reality that management structures
“There is a growing understanding that healthcare needs you! More and more politicians and policymakers are ‘getting’ how important professional managers are.” are not the most important issue. Inevitably, there has been political recoil from the pointlessly seismic Lansley restructuring. This now even includes scorn for those simplistic graphics – in the style of Soviet tractor production figures – showing fewer managers and more doctors. (Comrades, rejoice!) There is a growing understanding that healthcare needs you! More and more politicians and policymakers are ‘getting’ how important professional managers are in the healthcare team, as Stephen Dorrell, your cover boy for this issue, and a politician who has walked the talk, has consistently argued. Our job in the next year is to help politicians and employers walk the talk. First, the voice of managers must
Flu Fighter’s back The annual Flu Fighter campaign aims to further increase uptake of flu vaccination among front line NHS staff to protect patients in their care. healthcare manager | issue 19 | autumn 2013
be at the heart of the debate on future direction. Managers bring a unique view of the system, with their overall concern for strategy, structure, processes, measurement and people. Second, we must champion the workforce, as its values, attitude and skills are central to success. The evidence piles up to show staff engagement, building trust and commitment (through leadership, involvement, security, team working, encouragement, communication and career opportunities) delivers in spades for patient experience, mortality, staff well-being and financial and operational performance. Third, we must ensure through the practical business of day-to-day representation that managers are treated as other staff are treated. The trust, engagement, and commitment of managers matters more than ever, because management matters more than ever – and while words are important, it takes more than words to make people feel trusted, respected and engaged. l never counsel despair on the NHS or publicly funded healthcare. There is always something great managers can do.
Run by NHS Employers with the support of the Department of Health and NHS unions, including MiP, the national seasonal campaign has seen vaccination uptake in healthcare workers with direct patient contact continue to increase, from 35 per cent in 201011 to 46 per cent last winter. All the information you need on
how to run a successful campaign for 2013-14 is available from the Flu Fighters website (www.nhsemployers.org/flu), including the latest news about flu, uptake figures and an updated set of tools and resources. Follow @NHSFlufighter on Twitter for all the latest flu updates and developments across the NHS.
Cash boost for rural Scottish services
NHS Scotland is to spend £1.5m on testing innovative ways to deliver healthcare in remote areas in the face of mounting difficulties with recruiting and retaining professional staff in rural communities. NHS Highland, which has pioneered such innovations as GP teleconferencing and home-based ‘pods’ linking patients with local clinics, will use the money ‘to explore new approaches to building sustainable health and care services’ for the 20% of the Scottish population who live in rural areas. Announcing the scheme during a visit to Campbeltown Community Hospital, Scottish public
health minister Michael Matheson (pictured) admitted the NHS had problems recruiting enough staff in rural Scotland. The scheme ‘will play a vital role in helping to develop long term solutions that meet the healthcare needs of rural communities,’ he claimed. ‘I would expect this to have relevance not only for other remote areas in Scotland, but that it will inform new models for testing in urban areas as well,’ he added. Under the model being developed in Campbeltown, the community hospital and three local GP practices will provide ‘24/7 care’ supported by ‘an enhanced Scottish Ambulance Service response’. Claire Pullar, MiP’s national officer for Scotland, said: ‘We are delighted that the Scottish Government has recognised with further investment the excellence and innovation that employees of NHS Highland deliver time and again with their telehealth programme. This has led to some fascinating innovations and we look forward to seeing what NHS Highland will deliver next.’ Successes and setbacks with telehealth in the NHS – see page 10.
Minister promises better deal for Scottish managers MiP has secured a promise from health minister Alex Neil to improve the pay of NHS managers in Scotland and to review 4
CCG signs up to partnership working
Mike Kavanagh, RCN regional officer, Amanda Lyes, HR Director West Suffolk CCG and MiP national officer George Shepherd.
MiP has signed a groundbreaking partnership agreement with East and West Suffolk CCG. MiP national officer George Shepherd (pictured right) who worked with the CCG and other unions to develop the new partnership arrangements, said: ‘This partnership agreement is an important commitment by East and West Suffolk CCG and ourselves to work together to develop fair employment policies and to make this a great place to work.
existing pay arrangements which the union says are ‘not up to the job’. In a message to MiP’s event for members in Edinburgh (see page 23), Neil said: ‘This settlement will be better than in recent years but I accept that questions will remain about whether the management pay arrangements introduced by the previous administration continue to be fit for purpose. I would like to be able to review elements of these within our vision for an
‘It makes my role a pleasure when you have an employer like this who embraces true partnership working, and respects our opinion as trade unions, and where the joint working ethos is seen as an asset. Amanda Lyes, HR director, has championed the agreement and has adopted a no surprises culture. This is a model approach which other organisations can learn from.’ Further info on the partnership agreement is available on the Social Partnership Forum website: www.socialpartnershipforum.org
integrated workforce.’ Neil added that he understood ‘the concerns that now exist following several years of pay restraint’. MiP chief executive Jon Restell welcomed Neil’s pledge but said the entire pay system needed to be changed. ‘The current pay system for senior managers in NHS Scotland is not up to the job and it could be challenged by people under equal pay legislation.’ healthcare manager | issue 19 | autumn 2013
inperson Karen Dunwoodie, patient experience lead, Airedale NHS Foundation Trust Passionate about people, Karen Dunwoodie describes herself as ‘very much a people person’. After working for what was then the National Union of Public Employees, now UNISON, for 15 years she became a mature student at the University of Cardiff, gaining a degree in industrial relations and psychology. Karen has held various roles in and around the NHS with the chief aim of helping patients and carers get the best experience out of the services they use and trying to make sure their feedback is used and valued. As chief officer for Wakefield Community Health Council for fourteen years before its abolition in 2004, she says her work focused on ways to improve things for patients. ‘It was a fascinating role that covered all aspects of health from acute, to primary care, ophthalmology, dentists, and mental health,’ she explains. After a short time as complaints manager at Leeds Teaching Hospitals NHS Trust, Karen moved into her current role as patient experience lead at Airedale NHS Foundation Trust, where she has worked for the last four years. When she started, the trust had not previously employed someone specifically charged with leading on public engagement – instead the job was attached to that of the deputy director of nursing. ‘My job at the start was to strategically look across the organisation to see what needed to be done to engage patients and what was already being done,’ she says. ‘It was like a giant jigsaw puzzle. There was a lot happening but my job was to bring it all together and it was about making people aware across the organisation about what was happening.’
“The executive team have patients at the heart of what we are doing. I am really pushing at an open door.”
Karen Dunwoodie, left, with Isobel Scarborough, chair of the patient and carer panel, launch a patient experience initiative at Airdale NHS Trust.
Karen was charged with developing a strategy for the trust on patient and public engagement, which included establishing a steering group to look at patient experience. ‘The executive team at the trust very much have patients at the heart of what we are doing and I believe that I am really pushing at an open door and that this is their highest priority,’ she says. Under Karen’s stewardship the trust has also set up a patient and carer panel which meets monthly and give a first-hand perspective on services that are being developed or changed at the trust. ‘The panel decide on the projects they want to take on. Most recently they were involved in looking at end of life care and the Liverpool Care Pathway,’ she says. Recently, the trust has also set up a youth panel, working with schools and youth groups, in order to make
healthcare manager | issue 19 | autumn 2013
sure it was getting opinions and experiences of young people on the services that it provides. The trust, with the help of volunteers, conducts real-time surveys every day, interviewing patients about their experience just before they are discharged. ‘The results of those surveys are inputted into our system and staff can access them at any time,’ she adds. So what does she make of the Government’s new friends and family test? ‘It’s been a massive piece of work and I think staff were expecting that they would get lots of negative feedback but it has actually given people who have had a positive experience the chance to comment where they wouldn’t ordinarily,’ she says. ‘I think it is has served to improve staff morale and it has been a good thing.’ Helen Mooney 5
NHS to go ‘paperless’ by 2018 The government has announced a £1bn fund for investment in new technology to improve patient care and ease pressure on A&E departments, as a first step towards a ‘paperless’ NHS by 2018. Ministers say a paperless NHS would see fewer unnecessary tests and hospital admissions, reduce mistakes with medication and speed up discharge procedures. The government says the initiative will form part of its long-term solution to the rising pressure on casualty departments by cutting down on bureaucracy and freeing up doctors, nurses and care professionals to spend more time caring for patients. Much of the cash will be spent on systems allowing hospitals, GP surgeries and other organisations to access patients’ electronic records, and enabling patients to book GP appointments and order repeat prescriptions online by March 2015. Health Secretary Jeremy Hunt admitted past failures had dented public confidence in NHS IT systems. ‘But rather than imposing a clunky one size fits all approach from Whitehall, this fund will empower local clinicians and health services to come together and find innovative solutions for their patients,’ he said.
‘Technology is key to helping our A&E staff meet the massive demand they face as the population increases and ages.’
David Dalton, Chief Executive of Salford Royal Foundation Trust (pictured) said: ‘I’m really pleased that the government is supporting local IT solutions to local problems – this is so much better than the previous one-size-fitsall approach. Investing in electronic patient records has the power to transform patient care. It has been key to helping us improve safety and drive up standards of care for patients in Salford.’ The initiative follows the announcement in June of a £3.8bn fund to promote joint working between the NHS and social care services in 2015-16. Projects seeking funding from the Integration Transformation Fund must include proposals for better data sharing between health and social care.
Misinformation risks ‘meltdown’ in services The NHS confederation has called for urgent measures to avert a ‘winter meltdown’ in NHS emergency services after a survey of senior managers found less than half expected to meet government targets for A&E waiting times this winter. The Confed said ‘myths and misinformation’ about the state of A&E services were preventing managers from dealing with the problem. The survey revealed that the troubled roll-out of the NHS 111 service earlier this year was not a major factor: instead nearly half of respondents said the rising number of frail elderly people with multiple conditions was the main source of pressure on A&E departments. More than a quarter identified problems with discharging patients and setting up alternative care arrangements as the biggest problem they face. Outgoing NHS Confed chief executive Mike Farrar, said the public
had ‘so little confidence’ in alternative services, they saw A&E as their only option. ‘It’s a vicious spiral,’ he warned. ‘But as if the genuine rise in seriously ill, frail A&E attendees wasn’t putting enough strain on the system, the NHS is also struggling from ill-informed speculation about what is causing the pressures and what services they can rely on to meet their needs.’ Farrar warned the problem was complex and there clearly wasn’t a single solution. ‘There needs to be cultural change in order to introduce seven day a week working in the NHS and social care, and a greater shift of our resources to enhance community services, so patients are treated closer to or in their homes rather than automatically default to A&E when they are ill.’ The report, Emergency care: an accident waiting to happen? is available from the NHS Confederation website at: www.nhsconfed. org.
GPs urged to ‘ask, wait, listen’ The Stroke Association has released a video aimed at helping surgery staff better understand the needs of stroke victims after a survey revealed many had problems communicating with their GP. The survey revealed that one in five patients with aphasia – the most common post-stroke communication disorder – had problems making GP appointments and 43% found it hard to communicate with their doctor. The three minute ‘aphasia etiquette’ video, entitled Ask, Wait, Listen narrated by BBC interrogator-in-chief John Humphrys, has been developed from feedback by stroke survivors with aphasia and
uses simple solutions like offering them the opportunity to express “yes”, “no” or “I don’t understand”. Dr Clare Gerada, chair of the Royal College of GPs said: ‘Patients presenting with aphasia are still quite rare in general practice and so the video is an innovative and simple approach to help GPs improve interactions…by reminding us quickly and easily of the vital things to remember. ‘Anything that enhances communication between GPs and practice staff and their patients with aphasia should be encouraged,’ she added. To view the film and find out more about training and support for patients with aphasia visit www.stroke.org.uk/aphasia.
healthcare manager | issue 19 | autumn 2013
inpublic Murray Royal Hospital, Perth, NHS Tayside NHS Tayside has invested in a new £75m facility at the Murray Royal Hospital in Perth, which has been set up to provide state-of-the-art mental health treatment facilities for the people of Tayside. The new building, which was opened by Scotland’s First Minister Alex Salmond in July 2012 (pictured right), is the first hospital in Scotland to be delivered under the new non-profit distributing (NPD) scheme – a Scottish alternative to the controversial private finance initiative used in England. The NPD model puts a cap on private sector returns, ensures that there are no dividend-bearing shares, and that any surplus is directed back into the public sector. The NPD health programme is set to run until 2017 and the Scottish Government claims it will result in more than £800 million being spent on new NHS construction projects. The new hospital has a total of 102 beds providing psychiatric services for adults and elderly patients along with new old-age psychiatry day services. According to NHS Tayside chair Sandy Watson the new hospital will provide mental health facilities that are ‘fit for the 21st century’. ‘This project, which has had so much input from so many people with a real involvement in the hospital, underlines NHS Tayside’s commitment to the care of patients with mental health problems,’ he said. Construction began in June 2010, with designs created through detailed dialogue with service users, carers, clinical and non-clinical staff, together with a wide range of technical experts. Watson said that the role of art and nature in healing was taken into account in the design with a detailed art strategy drawn up in consultation with stakeholders. healthcare manager | issue 19 | autumn 2013
There had been a mental health hospital on the Murray Royal site since 1827. The first buildings were constructed thanks to an 1814 legacy from James Murray – a labourer who inherited a fortune from his merchant brother – for the construction of an asylum for Perth and its neighbourhood. Since then, a number of buildings have been added to meet the increased need. The new hospital main hub building contains the main reception, café, outpatients department and administrative services. There are three general adult psychiatry wards and three wards for psychiatry in old age, providing a total of 102 beds. All patients in the new Murray Royal Hospital have a single room with en-suite facilities. Around £5m was also earmarked for landscaping the extensive grounds, which
“The role of art and nature in healing was taken into account... with a detailed art strategy drawn up in consultation with stakeholders.”
are also open for public use in a bid to keep the new hospital at the heart of the local community. The hospital’s new Birnam Day Centre provides facilities for former service users and the site also houses the Strathmore Dementia Service, one of three national demonstrator sites for dementia care in Scotland. The new Murray Royal Hospital is part of a wider £95m project to modernise mental health facilities across Tayside, which also includes the new Susan Carnegie Centre at Stracathro Hospital together with Rohallion, a new secure unit on the Murray Royal site which is jointly funded by Tayside, Grampian, Highland, Orkney and Shetland NHS Boards. Helen Mooney 7
MiP calls for stability and engagement in the NHS The whole healthcare team needs to be involved and engaged in order to improve care and the patient experience, MiP vice chair Sam Crane told the TUC Congress when it met in Bournemouth in September. Speaking in a debate on the future of the NHS, she said: ‘We cannot underestimate the importance of being a learning organisation – as flagged by Don Berwick in his report – and investing in training for the whole team – clinical,
managerial and support staff – so that all staff feel empowered to make suggestions for improvements and feel safe to raise concerns about issues before they become problems.’ Crane warned policy makers to stop messing with NHS structures. ‘We know that we have to develop our staff and our services to make sure we meet the healthcare needs of our communities. But staff need stability and boring continuity instead of continual change to enable this to
happen. So ministers and potential ministers please take note – give us a break from constant re-disorganisation. And please stop knocking our great NHS and those who keep the show on the road 24/7.’ She finished by calling for policy makers to work with the unions to achieve effective change: ‘Let’s move away from the blame culture in the NHS. Give staff the training and support they
need without the threat of criminal sanctions hanging over them. Stop looking for scapegoats and work with us to keep our NHS great.’
Government undermines employment tribunals MiP is wholeheartedly backing Unison’s application for judicial review of the latest attack on employment relations by the government. Changes to the employment tribunal system introduced in August will have a major, detrimental impact on employment relations and the way we resolve disputes. Claimants will now have to pay up-front fees for submitting a tribunal claim. Fee levels vary according to the type of case, but start at £160 plus £230 for a hearing, and range up to £250 plus a hearing fee of £950. For example, the fees for taking a discrimination claim would total £1,200. MiP will pay these fees for our members where we lodge a claim, but it will significantly impact on the way we work and how we resolve disputes with employers. For instance, MiP will sometimes lodge a tribunal claim as a safeguard in case we fail to reach a settlement on a legitimate claim 8
with an employer. High fees make it much more difficult to do this. There will also be closer scrutiny of how the facts are set out in claims and they could be rejected on technicalities without being referred back for clarification. Our solicitors will seek to ensure the tribunal claims are correctly set out, but with more stress on getting the details right first time, we are unlikely to be able to lodge a claim successfully at the last minute. The changes also mean claims will be heard by a single judge, not by a tripartite panel as happens now. Two further procedural changes are expected in Spring 2014 when the government intends to introduce the Early Conciliation Scheme. This will force claimants to submit a form to ACAS before they have the right to take an employment tribunal claim, and introduce financial penalties for employers (although those will be
paid to government, not to the claimant). ‘The government has slipped these changes in during the summer to minimise publicity,’ said MiP chief executive Jon Restell. ‘They undermine the tripartite nature of employment dispute resolution. We will ensure our members’ claims are properly dealt with and cover the fees, but the additional red tape means we will be prevented from submitting claims at the last minute and we will have to ask our members for much more detailed information. ‘Getting the facts straight in employment claims can be a tricky business and people should not be penalised for not getting it absolutely correct first time. There was already provision in the system to prevent vexatious claims. This is nothing more than a cynical exercise to make money out of the misery of working people.’
healthcare manager | issue 19 | autumn 2013
Dr Caitlin Palframan
head of policy at Breakthrough Breast Cancer
NHS must turn gold-standard intentions into gold-standard care In June 2013, NICE published its updated guidelines on familial breast cancer. Three per cent of the population has a family history of breast cancer, but their increased risk means they account for one in five diagnoses of the disease in the UK.
NICE made recommendations to improve the standard of care across the entire patient pathway, which Breakthrough Breast Cancer welcomed as a ‘game-changer’ with the potential to revolutionise the way we prevent breast cancer in the UK, and to reduce the burden of the disease on the NHS. The challenge is taking this potential, and putting it into practice. Two recommendations in particular have the most potential impact on patients at risk of, or living with, familial breast cancer. The first is to offer, for the first time, chemoprevention (riskreducing drugs) to women with a family history of the disease. This represents a valuable new option for women in managing their risk, with massive potential to reduce breast cancer incidence, but its success depends entirely on proper implementation across the NHS. Secondly, but of equal importance, was the recommendation to offer genetic testing more widely, allowing people who were previously not eligible for testing to better understand and manage their personal risk. Knowing
healthcare manager | issue 19 | autumn 2013
your risk of developing breast cancer opens the door to personalised care, but there are infrastructure issues that must be addressed to ensure this step is a success. This is where healthcare managers come in. Implementation of these new guidelines is likely to be challenging, as without a plan to make frontline staff aware of the guidelines, and to give them the confidence to put them into practice, they will be of little benefit to patients. Communication will be central, and begins with primary care: GPs will be involved in the prescription of chemoprevention, so their understanding and cooperation will be necessary to realise the full potential of this innovation. There is still confusion among professionals and commissioners about who is actually responsible for prescribing chemoprevention, and setting the patient pathways for its use. Healthcare managers must step in, take ownership of the issue, and ensure that patients benefit from the promise of these new guidelines. There is little question that wider genetic testing will also prove challenging for the NHS. After years of unacceptably long waits (sometimes two years) for test results, waiting times for NHS genetics services are now acceptable. But implementing these guidelines will no doubt place NHS genetics laboratories under more pressure, and will require them to turn around more tests. Simi-
larly, genetic counselling services will also need to provide enhanced support to more people presenting with a family history of breast cancer. The potential benefits for patients, and for the NHS as a whole, are huge. Breast cancer remains the most commonly diagnosed form of cancer in the UK, with 50,000 women and 400 men facing a diagnosis each year. And as the public become more aware of the role genetics and family history play in an individual’s risk of developing the disease – assisted by high-profile stories such as Hollywood star Angelina Jolie’s – commitment will be needed from NHS frontline staff, with the support of charities, patient groups and healthcare managers, to ensure the NHS is able to meet increased need without compromising the quality of services. NICE guidelines represent best practice, but they are not mandatory and their impact is limited if they are not universally implemented. Breakthrough Breast Cancer works closely with the NICE Guideline Development Group, and is one of the patient representatives advising NHS England on commissioning genetic services. As a result, we are well placed to support healthcare managers in working towards translating these gold-standard guidelines into gold-standard care. Go Pink! October is Breast Cancer Awareness Month. For further details visit: www.breakthrough.org.uk 9
TELEHEALTH & TELECARE
Telehealth and telecare projects are beginning to pay dividends, with collaboration and the willingness to take bold decisions proving the keys to success, says Jenny Sims.
The age of telehealth and telecare may have dawned, but not everyone has woken up to it. Organisations who are willing and able to embrace it are beginning to reap the benefits including ‘doing more for less’, saving time, money and lives, improving outcomes and the quality of health and care services.
Health and social care managers in hospitals and the community need to keep abreast of developments in both fields if they are to cope with staffing and skill shortages, funding cuts and increasing demand for services. Despite considerable barriers to uptake, successful innovative schemes can be found across the UK, particularly in managing chronic conditions and caring for older and vulnerable people, as a recent King’s Fund conference on telehealth (TH) and telecare (TC), held in July 2013, demonstrated. Politicians, health policy analysts, and the technology industry agree that sharing knowledge and best practice is essential for TH and TC to take off. And Scotland has proved pretty good at it, which is why Professor George Crooks, medical director of NHS24 and director of the Scottish Centre for Telehealth and Telecare, is well placed to advise that ‘the key to success is collaboration.’ 10
Indeed, much can be learned from collaborative partnerships throughout Scotland, where telecare is now embedded in health and social care, due in no small part to the Scottish government’s funding of innovative projects such as the Telecare Development Programme which has driven up the adoption of telecare by both health and social services. Projects such as Renfrewshire Community Health Partnership’s (CHP) home telecare service for people with dementia have proven cost and other benefits which could be realised in mainstream services. Between April 2007 and March 2012 the CHP delivered telecare packages to 1,045 vulnerable and older people, including 325 diagnosed with dementia. Dementia sufferers were supplied with
“Many analysts suggest that ‘perverse incentives’ in the way the NHS is funded remain a big barrier to implementing telehealth schemes.”
equipment such as door monitors, smoke detectors, pill dispensers and GPS tracking for ‘buddy support’. Monitored by a 24-hour call service, activation of sensors and alarms resulted in a response from the Community Service Responder Team According to an evaluation by the York Health & Economics Consortium (YHEC), over five years the benefits included fewer delayed discharges, reduced hospital admissions, reduced home care placements, and fewer nights of sleepover care, according to a recently published evaluation of the service. This produced estimated net savings of £2.8 million. For people with dementia, 67% of the savings were from avoided hospital admissions or shorter lengths of stay, with a further 24% from avoided care home admissions. In addition, the YHEC report points out there are user benefits which can’t be measured in money terms: ‘feelings of reduced anxiety, greater independence, improved security and overall better quality of life’. Carers may also benefit from reduced stress and anxiety but this wasn’t measured in the study. ‘Overall the telecare service is performing very well from a qualitative perspective with satisfied users and carers, healthcare manager | issue 19 | autumn 2013
TELEHEALTH & TELECARE
excellent staff and good support from many NHS elements and the police,’ concluded the report. ‘Telecare for people with dementia is cost effective and high quality,’ added Nick Hex, associate director of the YHEC. The report recommended that all community care assessments and hospital discharge plans should include an assessment of the patient’s suitability for telecare. This will help to ensure that patients can benefit when problems are beginning to develop, instead of waiting until their dementia is too advanced and they are unable to learn how to use the equipment. Many studies, including the Department of Health’s prestigious Whole System Demonstrator Programme (WSD) have shown that even if patients and staff have reservations about using technology, familiarity with the equipment usually wins them round. A 2012 RCN eHealth survey of nurses’ attitudes towards telehealth, found that experience of such systems had grown from 55% to 62% since 2010. Of those with experience of them, 85% welcomed and supported the use of telehealth systems. ‘The survey showed that experience of telehealth gives nurses a positive perception of its benefits’ said David Barrett, a nurse and lecturer in telehealth at the University of Hull, which analysed the results. Innovative projects involving mobile devices are also proving effective and popular with users. Mobile telehealth is relatively new, but with management of long-term conditions accounting for 70% of primary and secondary budgets, it’s becoming a useful management tool – enabling patients to be active in managing their conditions. NHS Lothian and North Somerset Community Partnership (NSCP) have both trialled O2’s Health at Home scheme to monitor patients with COPD and heart failure. Patients are provided with a tablet computer connected to the mobile network, as well as ‘smart’ monitoring devices including pulse oximeters, weight scales and blood pressure monitors. healthcare manager | issue 19 | autumn 2013
If a patient’s readings trigger an alert, a clinician is informed. Early findings showed that the average length of hospital stays has decreased by 59% in the small COPD group. Leeds City Council is also using mobile and GPS devices to give more indpendence to frail patients or older people with dementia or other longterm conditions. Users are given a small handset which can detect falls and allows them to contact a 24/7 alarm-receiving centre should they need to. But there are dangers in relying on very specific and intensive tehcnologies like O2’s Health at Home. The company announced recently it was withdrawing the service from the end of 2013. While insisting the global prospects remain strong, ‘the uptake of mobile telecare and telehealth in the UK marketplace has been slower than anticpated,’ said an O2 spokesperson. However, big government funded initiatives such as the Technology Strategy Board, the Dallas programme and 3millionlives, as well as the Academic Health Science Networks and the industry’s Telecare Services are all helping drive TC and TH forward and improve the identification, adoption and spread of innovation in the NHS. But many analysts suggest that
‘perverse incentives’ in the way the NHS is funded remain a big barrier to implementation. Many organisations fear TH and TC will reduce clinical activity, threatening funding and jobs, although TH and TC can result in clinicians seeing as many – or more – patients, and give them more face-toface time with the most needy ones. ‘It’s a real issue. We don’t have a sufficient system of fiscal rewards, a new model of rewards is needed,’ warns Professor Stanton Newman, dean of the School of Health Sciences at City University London, and principal investigator on the WSD project. Many also argue that much of the financial benefit of TH and TC will only be achieved if brave decisions are taken by hospital managers to reduce beds when successful schemes such as the Renfrewshire CHP’s telecare service show they are not needed. Are you brave enough to do that? With the NHS facing a £30 billion hole in its budget by 2020 – you may have to be.
Jenny Sims is a freelance writer and editor specialising in healthcare. Details of the King’s Fund’s Third Annual International Congress on Telehealth and Telecare are available from: www.kingsfund.org.uk. Telecare for People with Dementia, the evaluation report of the Renfrewshire project is available from www.yhac.co.uk 11
INTERVIEW: STEPHEN DORRELL
Stephen Dorrell, health select committee chair and health secretary in John Major’s government, has seen a few NHS reforms in his time. Now, we need less talk about structures and a lot more about care, he tells Alison Moore.
It’s always a bit surprising when a senior politician says there are no significant differences between his party and the opposition on a major policy area. Even more surprising when that area is health – one of the key election battlegrounds and traditionally one of the most politicised policy debates.
But the former health secretary and chair of the health select committee, Stephen Dorrell, believes the strength of passion over the subject does not reflect real differences. For example, when it comes to the private sector providing NHS-funded healthcare, ‘there is very, very little policy distinction between the three major parties,’ he says. Both Conservatives and Labour have accepted the purchaser/provider split, first proposed by a Conservative government in 1990. Since then Labour has gone on to give trusts much more freedom than the Conservatives originally envisaged. ‘With the exception of Frank Dobson, every health secretary since 1990 has followed the same policy,’ says Dorrell. ‘I’m a straightforward Blairite – the Blair model was the Clarke model.’ He points out that the private sector has always had a role in healthcare – whether it’s GPs, elderly care or pharmacists. ‘Peo12
ple forget the majority of patient contact with the NHS is through the private sector – the pharmacist,’ he says. Dorrell – the first MP to chair a select committee covering their former area of responsibility as a secretary of state – is well placed to take a historical perspective on the NHS. He was a junior health minister as far back as 1990 and health secretary from 1995 to 1997, so there’s little he hasn’t seen. At one point in our conversation he winces and confesses he has just advocated something that was being talked about when he was a junior minister – the unspoken implication is that not much has advanced in more than 20 years. But with this long view comes scepticism about the ability of big structural changes to transform the health service. ‘The issue is not how we reorganise management, it’s how we reorganise healthcare,’ he says. ‘I hope we will have rather less talk about structures and rather more about care. If there was a performance management solution we would have stumbled across it by now. We need to focus on the day job.’ But what is that day job? ‘There are two real issues for management of the service and management structure is
not one of the two. The issues are the quality of care delivered and the efficiency with which resources are used,’ Dorrell says. ‘The easy option is to say that quality is not good enough because of not enough resources. But we all know that there are many examples of services that don’t use resources as well as they could if issues are addressed. Efficiency is about reinventing what we do. In the times when money was plentiful it did not happen. Now we have no choice but for it to happen.’ ‘Labour were in office at a time where they could devote significant resource growth to health and care,’ he says. When this growth came to an end, the need to deliver the Nicholson savings emerged. Dorrell has been quite clear in past interviews that this, rather than reorganisation, is the major challenge the NHS must cope with. The demand for 4% annual savings, he says, is twice the average productivity gain in the economy. Dorrell puts tremendous stress on joined-up or integrated care, especially as a means to keep people’s health from deteriorating to the point where they need hospital care. ‘Most people who work in the health and care sector would recognise the argument that we healthcare manager | issue 19 | autumn 2013
INTERVIEW: STEPHEN DORRELL
“‘With the exception of Frank Dobson, every health secretary since 1990 has followed the same policy. I’m a straightforward Blairite – the Blair model was the Clarke model.”
© Andrew Wiard
‘Health and wellbeing boards have two opportunities,’ he says. ‘One is managing a single budget and the other is offering greater local accountability through councillor representation. One of the changes in the 1990 Act which I was uneasy about at the time was the removal of local authority representation from health authorities. I’m strongly in favour of local authority involvement in healthcare.’
need to have a more joined up model that lays more emphasis on supporting people in normal life rather than waiting for them to become acutely ill,’ he says. ‘That delivers better care and probably delivers better care for more people because we are using resources more effectively.’ And he raises the question of why the NHS is still operating with organisational barriers inherited from the time of Nye Bevan – with primary care separate from community healthcare, a solution which was seen as ‘sub-optimal healthcare manager | issue 19 | autumn 2013
nearly 70 years ago’, he suggests. ‘I don’t personally think that the changed services would look the same everywhere. When you look at integrated care in Lambeth and integrated care in Oxfordshire, it will look different.’ And here is another point of agreement with Labour: Dorrell favours what he calls the ‘Burnham plan’ with health and wellbeing boards developing commissioning across health and social care from a single budget. This was, he points out, first mooted by his health select committee.
The transfer of public health into local government led to upheaval but was justified, he says. But he is more circumspect on other aspects of the 2012 Act and has previously suggested the rhetoric on all sides has been ‘grossly overblown.’ The jury is out on CCGs, he says, but despite his comments about having single commissioners he supports the local/national split in commissioning exemplified by CCGs and NHS England. ‘We can’t have local commissioning doing paediatric heart surgery and you can’t have a national plan for physiotherapy. There has to be a balance and the balance between NHS England and CCGs will evolve. It’s not black and white, it’s shades of grey.’ Dorrell sees a key role for commissioners in upholding quality after the uncomfortable questions raised by the Francis Report on Mid Staffordshire and the Keogh report into mortality rates at 14 trusts. ‘What happened in Mid Staffordshire was a particularly egregious example, but there are departments which NHS insiders would not go into,’ he says. ‘It’s the NHS’s dirty secret. We know 13
INTERVIEW: STEPHEN DORRELL
“I don’t accept that argument that the NHS model can’t be sustainable...but we have to make the system more transparent.”
that there are significant quality issues in parts of the system. This double challenge of quality and finance needs to be the key focus. ‘If you have to sign a cheque with the public purse for the commissioning of healthcare you have to ask yourself the question, “Does the care I’m commissioning meet efficiency and quality standards?” I agree it’s not simple but because something is not simple is not a reason for not doing it. If it was easy someone would have done it by now. ‘How do we do it? Through the spotlight on outcomes data. It’s about engaging the professionals in this process because, when we talk about outcomes data, people say it’s fine in cardiothoracic, it’s more difficult in psychiatry. But if you get a group of psychiatrists in the pub on a Friday night they will tell you who’s no good. There are ways of measuring quality even in these difficult areas.’ But Dorrell is reluctant to condemn commissioners who fail to intervene when there are problems at hospitals – such as those at Whipps Cross hospital in east London, highlighted by a recent highly critical CQC report. ‘Quite often it is did they know or ought they to know?’ he says simply. 14
Openness and transparency will be key going forward. ‘I don’t accept that argument that the NHS model can’t be sustainable,’ he says. ‘But I do think that it can’t be sustained if it runs a secret world where it is not accountable to the people who pay for it. We have no choice but to make the system more transparent. That may require facing some uncomfortable truths, he warns. ‘It is about matching reality to rhetoric - delivering the promise.’ Dorrell has led the health select committee in producing a number of scathing reports, and some evidence sessions which have been obviously painful for the high-level NHS people involved. But he is unwilling to enter into anything which even hints at managerbashing. ‘One needs to recognise that all management in the public sector raises difficult challenges because the risks are asymmetric. There is a great tendency to blame failure rather than celebrate success. The public sector is nowhere near as good at celebrating success as the private sector is. That’s true of all public sector management but particularly of the healthcare system. ‘Ministers need to recognise the value and specific difficulty’ of good management in healthcare, he says. He points to the ‘accountable officer’ role
of the new NHS England chief executive – whoever it will be – as important in making them responsible for the whole of the commissioning budget. That, one suspects, might be the focus of grillings from Dorrell’s committee over the next few years. Responsibility and accountability across the whole system is something Dorrell is clearly keen on. Registered healthcare practitioners obviously have professional obligations about raising concerns, but the concept of managerial responsibility is more subtle and elusive. His support for the proposed ‘fit and proper person test’ seems less than fulsome: ‘It’s occasionally just worth considering the counterfactual – what’s the case for an unfit person?’ he says. ‘Sometimes it’s important to separate the surrounding noise from the substance. I’m not in favour of trying to invent a series of professional obligations for managers.’ But managers do have a specific obligation when they are spending public money, he says. ‘If they are concerned that there is not sufficient information around quality or it does not represent best value they should not sign the cheque.’ Should they then be protected if they raise such concerns? ‘Yes.’ But it’s a tough life for managers, he admits. ‘Managers are there in order to deliver the promise of high quality and good value. Provided they do that, I think managers are entitled to support,’ he says.
healthcare manager | issue 19 | autumn 2013
Community services, for so long the Cinderella of the NHS, are becoming the cutting edge innovators that will shape the rest of the service, says Noel Plumridge.
Although the NHS headlines in recent months have been dominated by troubled acute hospitals – from Stafford to Barrowin-Furness – and overworked A&E departments, the managerial focus has continued to swing quietly towards non-acute care. Two buzzwords dominate: “integration” and “transformation”.
We want integrated, not fragmented, care. Boundaries and demarcation squabbles between partner organisations so often become the source of delays, system failures, high transaction costs and patient and user frustration. In the English NHS, two decades of market rhetoric and competition, backed since 2004 by tariffs which encourage hospital admission rather than community care, have only served to reinforce such dislocation. And we want transformation. The relentless grind of annual savings targets, coupled with a pattern of service transfer away from acute hospital settings, render whole system efficiency not just desirable but essential. Managers schooled in the models and mantras of improvement science – the gospel according to Don Berwick – understand that what is needed is step change rather than incremental gain.
healthcare manager | issue 19 | autumn 2013
Rob Webster, chief executive of the Leeds Community Healthcare NHS Trust, highlights the needs of a 21st century health system. ‘You can’t be cured of most long term conditions or of being old. The system needs to make a volte-face. Services need to start with people’s lives and aspirations, with integrated support to deliver them.’ Webster emphasises that with community services the power balance is different to hospital care and failures in dignity, care, and compassion are mostly absent. And most NHS care already happens outside hospital: around 300 million GP appointments a year, compared with around 20 million A&E visits. ‘We have a massive opportunity in England’, he insists, ‘to harness these resources and drive innovation and improvement. Other countries would love to have a system of registered list-
“The practical implication is that 21st century general hospitals will be radically different, and much more closely bound to primary and community care.”
based general practice and community services on the scale we have.’ So what sort of step change, and how do we achieve it? Two key questions follow. The first concerns the nature of an “integrated” or “transformed” health system: what exactly would success look like? (And, by extension, what would it mean for the status quo: in particular, what are the implications for already-struggling yet much loved general hospitals?) The second is whether commissioners or providers are best placed to lead the radical changes we need. Provider-led innovation continues to thrive. Norfolk, for instance, has engineered extensive integration between NHS and social care, allowing home care packages that span what traditionally has been a major divide. Teams are co-located and co-managed. The community matron, managing long-term conditions, has emerged as an especially useful role, working with individual patients to co-ordinate governmentfunded services ranging from housing to medication. Such innovation also extends across traditional NHS boundaries. Crucially, Norfolk’s community matrons have the confidence of GPs, relieving pressure on primary care practices. Meanwhile Norfolk Community Health & Care NHS 15
in place, and plans to enhance it using social care data. ■■ fully integrated health and social care teams supporting patients. This is already in place for district nurses and social workers; the next stage is to include community matrons and intermediate care. ■■ supported self care on a massive scale, with commissioned neighbourhood networks supporting older people who may, for instance, get a “social prescription” for company. Rob Webster links Leeds’s success to a structure of relationships - the Leeds Innovation Health Hub – that involves all local and national health partners in the city with the council, the universities and the private sector.
Michael Scott, chief executive of the Norfolk Community Health and Care Trust.
Trust has been commissioned to run community paediatric nursing across the county. Investment in community services is seen as the route to reduced hospital admissions. It is now in the process of establishing community-based services for older people, including older peoples’ centres and medical consultants: a radical change in a largely rural county where many older people live far from hospitals. Michael Scott, chief executive of the Norfolk trust, argues the source of innovation has been his own community services linking with like-minded others: GPs, social care staff and the voluntary sector. He says the myth that community services are a sleepy backwater persists mainly because of the money: ‘We don’t get incentivised. Plus, it’s perpetual reorganisation.’ He hopes foundation trust status will offer much-needed stability. The Leeds trust, meanwhile, uses a system wide approach built around three guiding principles: ■■ risk stratification of all patients – with a bespoke risk stratification tool 16
Other community providers are transforming the traditional services they offer. In West Yorkshire, the Locala Community Partnership, a social enterprise (which describes itself as ‘part of the NHS family’), has trimmed the average length of stay in intermediate care from 24 to 16 days, essentially by offering seven-day therapist input. Locala has also increased the number of community nursing appointments it provides each year from 270,000 to 410,000, while simultaneously reducing the nursing headcount by 8%. Robert Flack, Locala’s chief executive, attributes these improvements to the power of information. ‘We set out to create a performance culture’, he explains. Significant investment in ‘agile technology’ has been the engine for Locala’s transformed productivity. Not financial information, not service line reporting, but solid performance data. Locala faces the same efficiency pressures as the rest of the NHS, yet it is the philosophy of quality improvement rather than a quest for savings that underpins its innovation. And technical innovation isn’t limited to activity data. Central to Locala’s new way of working is using the power of video technology to simplify care for anyone with internet access. If you have a camera on your
computer or tablet, you needn’t come to hospital, or get visited, so often – and that’s better for everyone. Flack insists that modern care of the elderly, seen through the eyes of the Kirklees community, is about getting services into a person’s life, not getting that person into hospital. But what does that mean for the hospital? Squeezed between an ever-tighter tariff regime and medical advances – in equipment, in pharmaceuticals, in support – that allow care closer to home, smaller general hospitals are failing. Some, like Hinchingbrooke in Cambridgeshire, have been sized up by commercial providers. Elsewhere, particularly around the periphery of big cities, there are whispers that we have too many hospitals, and some closures are inevitable. The type of transformation being pioneered in Leeds, Norfolk, West Yorkshire and elsewhere is umbilically linked to the politically challenging question: what is the future of the general hospital? No sane MP wants a local hospital to close. Lewisham, in south-east London, is only the latest “downsizing” proposal to provoke public demonstrations. “Save our hospital” remains an emotive cry. If the managerial answer is fewer hospitals, the practical implication is that 21st century general hospitals will be radically different, and much more closely bound to primary and community care. The remorseless logic for care of the frail elderly, people with long term conditions and end-of-life care, is a system of “inreach” into the hospital, when necessary, from an integrated community service. “Payment by results”, obsessed by cold surgery and hospital throughput, is being called into question but, less prominently, so too is the “ownership” of general hospitals. Soon competitive tendering, with CCGs pursuing lead providers for services, may result in the de facto control of smaller hospitals by integrated community providers. The frail elderly are increasingly being recognised as a group with specific needs. Pressures in hospital A&E departments during 2013 have also highhealthcare manager | issue 19 | autumn 2013
lighted how significant frail elderly people now are to hospital workloads. Long-established demographic trends – more people living longer – and cutbacks in social care now position casualty departments, and the ambulances that serve them, as the NHS safety net for older people. People with long-term illnesses also have specific needs that cut across conventional care boundaries. This applies equally to potentially life-limiting conditions, such as respiratory illness or heart failure, where the locus of care has for years been moving away from hospital, and to musculoskeletal conditions like arthritis and lower back pain which generate so much of a GP’s workload. The value of specialists – in diabetes nursing, for instance, or in extended scope physiotherapy – has long been recognised. But increasingly the focus is on creating a capable and coherent service for the chronically ill, rather than shoe-horning them into generic health provision. So might future transition to genuinely integrated services be led not by visionary providers but by commissioner demands? Many eyes are closely following developments in Cambridgeshire, where the Cambridgeshire and Peterborough CCG – one of the largest in England – is seeking a patientcentred service for older people. According to the CCG, the preferred approach is to move away from payment by results and block contracts and use a ‘year of care’ budget for older people. The commissioners’ timetable envisages a contract starting in July 2014, running probably for five years with potential for a further two years. The financial value, says the CCG, is around £150m per year. Cue a month of outrage about “£1bn privatisation plans”. Yet consider the CCG’s success criteria: ‘care organised around the patient’, ‘services which are sensitive to local health and service need’, ‘a move beyond traditional organisational and professional boundaries, so front-line staff can work effechealthcare manager | issue 19 | autumn 2013
tively and flexibly together to deliver seamless care’, and reductions in avoidable emergency admissions, readmissions and extended stays in acute hospitals – all within ‘an organisational solution… which can demonstrate strong leadership, sound governance, resilience…’ The intended service for older people in Cambridgeshire, pursued by commissioners, doesn’t appear so very different to that already emerging via provider leadership in other parts of the country. Some sceptics suggest squeals of anguish over privatisation only seem to arise when hospital doctor jobs are involved. But there is a deeper doubt: not about Cambridgeshire’s intent, but about imposing such change through tendering. One chief executive of a social enterprise, which successfully manages integrated community services in southern England, likens the frequent retendering of community services to ‘modern slavery’. ‘There’s a battle’, she says, ‘and the winner takes the staff and enslaves them to their regime. Then there is another battle and a different winner takes the staff and enslaves them to their regime.’ The inevitable outcome, argues the chief executive, who asked to remain anonymous, is caution: ‘Staff engage-
ment has a massive impact on quality of service, commitment and continuity of care. What happens if staff are passed from pillar to post? The answer is they don’t know whom they work for; they have loyalty only to their local team, and transformational change, corporate values and improvement become almost impossible. You create a siege mentality where keeping your head down is the best chance of survival.’ But the vision remains strong. Rob Webster spells it out: ‘For me, the real thing we need to do is apply the same approach to older people that was seen in mental health services in the past. In a decade or so, I would want people to be shaking their heads and wondering “did we really keep all of these older people in hospital?”, because supported self care, and community provision is the default. With brilliant hospital services free to be able to cope with the short term needs of the acutely ill.’ Community services are driving NHS transformation: of that there is no doubt. Not just internally, but across health and social care. Whether this process will in future be led by innovative providers or by demanding commissioners may be played out in the months ahead.
SPORT IN THE NHS
The success of the NHS Sport and Physical Activity Challenge shows helping staff to become healthier and more active improves efficiency and leads to better patient care, says Mike Farrar.
The recent report Going for gold: Inspiring results for workforce health, wellbeing and performance highlights the success of the NHS Sport and Physical Activity Challenge. Our analysis shows clearly that there are significant benefits to individuals, to organisations and to patients from taking effective, supportive action to promote the health and wellbeing of staff through sport and physical activity.
In 2009, the final report of the independent NHS Health & Wellbeing Review, led by Dr Steve Boorman, made clear the potential gains for the NHS from improving staff health and wellbeing. Equally there is clear evidence that physical activity has benefits for both physical and mental wellbeing. It was recognised, from the Boorman Review, that too few staff were meeting physical activity recommendations, and that increasing activity was likely to have a range of benefits for individuals and for the NHS as a whole through the better health of its workforce. These include improved retention and recruitment, reduced sickness and absence and its attendant costs, more effective working and better quality care for patients. Building on this, in 2010, NHS chief 18
executive Sir David Nicholson challenged NHS managers to improve staff health and wellbeing, using the inspiration of the London Olympic and Paralympic Games as an opportunity to get NHS employees actively engaged in sport or physical activity as part of, or associated with, their NHS employment, by the time the Games arrived in 2012. Since then, many organisations have been working to get NHS employees actively engaged in sport or physical activity. Across the country, many thousands of NHS staff have been walking, cycling, running and dancing their way to better wellbeing, and many NHS bodies have been reporting reductions in staff sickness and improvements in morale and team working – all fundamental ways for the NHS to improve its performance both as an employer and as a provider of vital services. The Challenge consists of a range of sport and physical activity programmes designed to maintain and promote a healthy lifestyle and encourage staff to get more physically active. The focus is on NHS people challenging each other and themselves to increase their involvement in fun and physical activity and improving their health and wellbeing. This means staff
can be better role models for patients and results in better patient care. The Challenge has two main elements – national activity and local responses. At a national level, key activities included: ■■ raising the profile of the programme and creating a ‘national NHS movement’ ■■ creating and maintaining momentum through a website and regular updates ■■ creating and promoting a number of national partnerships ■■ recognising success through an accreditation scheme ■■ using the website and updates to promote good ideas and provide further encouragement and support The national programme was supported by the London Organising Committee of the Olympic Games (LOCOG) and Jonathan Edwards, the former British triple jumper gold medallist, sits on the steering group. The programme provides support and information about how to set up sports and physical activities within the NHS, providing easy, cost-effective and fun ways to improve staff health and wellbeing. All NHS bodies were encouraged to set up their own local programmes. healthcare manager | issue 19 | autumn 2013
SPORT IN THE NHS
KEY OUTCOMES from the NHS Sport and Physical Activity Challenge
220 organisations are taking part (excluding organisations outside the NHS who participated in locally run NHS programmes) at least 17% of NHS staff have taken part (excluding staff participating in mass participation events such as the NHS Fun triathlon) 68 NHS organisations have been awarded an accreditation certificate
NHS organisations have found a number of benefits from participating in the Challenge and increasing levels of physical activity among staff, many of whom reported they were not previously meeting the recommended levels of activity. Many programmes aim to become sustainable by encouraging staff to try a programme and then continue it. For instance, Great Ormond Street Hospital’s staff evaluation found that: ■■ 77% of respondents did not previously meet the recommended minimum of five to eight half-hour sessions of exercise a week ■■ 70% have taken up more exercise as a result of taking part in the challenge ■■ 83% have felt benefits to their health and wellbeing as a result of these activities, including more energy, weight loss, reduced stress, a sense of wellbeing and more social interaction.
Many NHS bodies embraced the Challenge and can demonstrate significant numbers of staff getting involved and giving very positive feedback about the nature of the Challenge. This is key to enabling NHS bodies to meet national priorities, including supporting better health and wellbeing among staff with its concomitant benefits for morale, team working and reduced sickness rates, and a better patient experience. The setting up of a national movement – the Challenge – has given NHS bodies impetus to take action: although some Trusts were able to build on their existing health and wellbeing activities, for many the Challenge provided the impetus to take the first steps in creating an organisation-wide programme aimed at getting staff more active using sport and other forms of physical activity. Organisations have also obtained
value for the NHS by using the Challenge to forge new partnerships within the NHS and with external bodies in the public, private and not-for-profit sectors. For instance, NHS Somerset formed partnerships with 152 local sports and physical activity related businesses which provided the NHS staff taking part with discounts, special offers and special events. We are now working to grow a ‘national’ NHS movement for staff sport and physical activity, create more mass participation events and develop a sustainable business model to secure longterm investment. We have recently launched an NHS Health and Sport consultancy service to support NHS organisations in improving staff health and wellbeing. NHS staff are in an almost unique position in being able to demonstrate the benefits of taking the NHS’s own advice – that being active is one of the best ways of improving and maintaining physical and mental wellbeing – as well as being fun and a great way to build networks and support.
Leeds Community Health’s cycle challenge involves cycling 874 miles – the distance from Land’s End to John O’Groats – over four weeks. healthcare manager | issue 19 | autumn 2013
Mike Farrar is the outgoing chief executive of the NHS Confederation and national NHS Champion for Sport and Health. Download the full report from: www.nhsconfed. org..For more information contact Sue Henry, NHSSportandhealth@hotmail.co.uk 19
legaleye There’s more to settlement agreements than just a change of name, says Neil Todd. A legally binding contract to end an employment relationship on agreed terms is now known as a ‘settlement’ – rather than a ‘compromise’ – agreement.
So what’s in a word? As legal documents, the two are very similar. Both are entered into voluntarily. Both are legally binding contracts. Both waive an individual’s rights to make a claim on issues covered by the agreement to an employment tribunal or court. But the difference is more than semantics. Indeed, it could hardly be more fundamental. Settlement agreements have been introduced by the government because employers wanted greater scope to initiate termination discussions without risking a claim for unfair dismissal. Previously, it was only when there was an existing employment dispute that an employer and employee could enter into discussions about settling that dispute on a “without prejudice” basis. This meant, in turn, that only statements made in a without prejudice discussion, which were made in a genuine attempt to resolve an existing dispute, were prevented from being put before a court or tribunal as evidence. However, section 111 of the Employment Rights Act has now been amended so that “pre-termination negotiations” – to discuss a potential settlement agreement – cannot normally be referred to as evidence in an unfair dismissal claim in any circumstances. This will protect employers who offer a settlement termination payment even when there has been no previous dispute between the employer and employee. 20
This allows employers to ‘pop’ the termination question secure in the knowledge that the discussions are, in effect, secret and cannot be used against them later. There are some exceptions to the application of section 111A. Claims that relate to an automatically unfair reason for dismissal such as whistleblowing, union membership or asserting a statutory right are not covered by the confidentiality provisions. Neither are claims made on grounds other than unfair dismissal – such as claims of discrimi-
“Employers can ‘pop’ the termination question secure in the knowledge that the discussions cannot be used against them later.” nation, harassment or victimisation and claims related to breach of contract or wrongful dismissal (a dismissal which is in breach of contract). The only other exceptions to the application of 111A are if anything was said or done at the meeting which was improper or connected with improper behaviour. In these circumstances an employee will be able to rely upon what was said or done in the meeting in a tribunal or court. One example of this would be an employee not being given enough time to consider an offer and an employer saying – before any form of disciplinary process has begun – that if the employee rejects a settlement proposal, he or she
will be dismissed anyway. The ACAS guide to settlement agreements makes clear that, for a settlement agreement to be legally binding, the employee must have received advice from a relevant independent adviser, such as a lawyer or a trade union representative. It also recommends that employees should be given a minimum of 10 calendar days to consider the proposed conditions of the agreement. The problem, however, is that there is no guidance on what the offer should contain. Employees who lack confidence may be pressurised – simply by negative feedback on their work – to leave on derisory terms. Employees and their representatives should remember that they have every right to refuse a settlement agreement. They can tell the employer to use a performance management, disciplinary or grievance process instead, where the employer will have to follow a fair process or risk a claim of unfair dismissal. However, once an employee signs a settlement agreement, it will be impossible to do anything about it unless it falls into one of the exceptions outlined above, such as a claim relating to an automatically unfair reason for dismissal or the employer being shown to have behaved ‘improperly’. On this basis it looks like impropriety may well become a new battleground in employment law.
Neil Todd 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 19 | autumn 2013
Appraisals to look forward to Michael West, professor of organisational psychology at Lancaster University shares his tips for making appraisals something to relish rather than dread. APPRAISAL IS A CONVERSATION People should leave the conversation believing they can do their job better and feeling valued, respected and supported by you and the organisation. A helpful, focused, forward-looking and, above all, appreciative conversation will ensure you both come to relish the opportunities appraisal gives.
2 YOUR ROLE The appraiser’s role is to listen, encourage, explore and probe, to find ways of helping, and to enable growth, development, innovation and proactivity. Empathise with difficulties and work out how to support the person in their job more effectively. Take every opportunity to celebrate and appreciate their contributions.
3 PREPARATION It’s vital that you both prepare by thinking through the questions below and drafting clear objectives for the next year, focusing on improving quality and performance.
4 REVIEWING PROGRESS The best starting point is to discuss progress against last year’s objectives. Set the tone by celebrating the person’s achievements. Adopt an ‘Appreciative Inquiry’ orientation throughout in order to be motivating and effective. Probe for what helped them to succeed and what can be learned from that. Ask about what impeded progress and what you can both do to remove such obstacles. Performance and behaviour problems should have been addressed throughout the year and should not be introduced for the first time in the appraisal.
healthcare manager | issue 19 | autumn 2013
5 SETTING OBJECTIVES This is the most powerfully motivating element of the appraisal conversation. Look at the proposals the appraisee has brought. Objectives should focus on effectively implementing innovations or improving quality and performance. They should be limited in number (five or six maximum), specific and challenging. Specific objectives are far more motivating and helpful than ‘do your best’ vague goals. Research shows that performance tends to improve when goals are more challenging, except when they are clearly unattainable.
6 RECOGNISE PROGRESS Setting challenging objectives means you should not expect people to achieve all their objectives. They will simply resist setting challenging objectives next time round. Celebrate and recognise progress towards goals not just attaining them.
7 SUPPORTING PROGRESS Discuss the support the appraisee needs to successfully progress towards their objectives in the coming year. With lashings of celebration and appreciation, it’s easier to ask, ‘What didn’t go so well? Why? What can we learn or change as a consequence?’ Ask about your role, what you can do to help and anything you do that hinders them. How can you best reinforce helpful behaviours and reduce or avoid unhelpful ones? Take time to explore the answers openly and in depth so you can learn to support the appraisee’s work more effectively.
8 TRAINING AND DEVELOPMENT Discuss how you can together make this a year of really exciting learning and growth for the appraisee. Make sure you are talking about high-quality learning opportunities rather than just going through the motions.
9 LOOKING AHEAD Ask the appraisee about their growth or career aspirations for the next five years. ‘What do we need to be planning or implementing to make that happen? What other issues would you like to talk about?’ Give plenty of time to these questions rather than just treating them as a polite way to wrap up the meeting. You both need to summarise the actions you will take, with clear timescales and allocated responsibility.
SAY THANK YOU Finish by acknowledging the appraisee’s substantial contributions and how valuable they are to the team and the organisation as a whole. Pick up on the special qualities they bring to the team. Make sure you emphasise how important their contribution is to you personally as a team leader. And remember to emphasise how their contribution makes a difference to patients and the public, as well as to their colleagues.
More information can be found on Michael West’s blog www.nhsemployers.org/PlanningYourWorkforce/ Organisational-Development/ProfessorMWDoODblog/ Pages/ClearobjectivesinNHS.aspx
MIP AT WORK
Supporting a learning culture NATIONAL
Marisa Howes reports on MiP’s initiatives to support skills development for members and to promote workplace learning for the whole healthcare team.
If we didn’t know it already, the three big reports on patient safety triggered by the failings at Mid Staffordshire – from Robert Francis, Bruce Keogh and Don Berwick – all highlighted the need for healthcare organisations to be learning organisations. These and other evidence clearly show that a strong learning culture which supports broad skills development can improve health outcomes for patients. It also helps employees in their personal development, career progression and job satisfaction.
In August, the NHS Social Partnership Forum launched the Learning for Life campaign to support a culture of learning. We have 22
produced an online toolkit, available on the Social Partnership Forum website, which gives organisations the information, advice and tools to help them develop high quality local learning programmes. The emphasis of the campaign is on support staff, but a good learning programme will address the development needs of all staff, including managers. In fact, line managers have a key role to play in developing and sustaining an effective learning programme in their organisation. Good quality appraisals, personal development plans and skills development are essential components of effective team working, which in turn has a positive impact on patient experience and the quality of health
outcomes. If you need more facts and figures to show the value of workplace learning, check out the toolkit. MiP and other health unions have worked in partnership with the new NHS Property Services organisation to produce a union learning agreement, which was launched in September. Simon Holden, Chief Executive of NHS Property Services, said: ‘Having worked at every level in the NHS, I recognise the huge part that training and development has played in my career. We are committed to being an employer of choice and empowering our staff to achieve their potential. Over the coming months we will be introducing a new performance management process and a variety of training, ranging from powerful appraisals to improving core skills.’ ‘All four of our union partners are well placed to promote the benefits of the union learning agreement and their extensive practical experience will enable us to deliver, in partnership, the life-enhancing benefits of training to all our staff.’ MiP hopes that managers will become involved, either as union learning representatives or by giving active support to staff to encourage them to become learning representatives. Managers can also help themselves by helping others. Workplace learning champions, like learning representatives, provide support and guidance to learners. The role benefits the champions as well as the learners: healthcare manager | issue 19 | autumn 2013
MIP AT WORK
MiP members build resilience at leadership event “Line managers have a key role to play in developing and sustaining an effective learning programme.”
they receive training to support them in their role and get the satisfaction of contributing to the workforce development in their organisation. Two linked initiatives are the ‘digital champions’, who encourage and support people to get the most out of the internet and digital technology, and maths champions, who support people to develop their maths skills. MiP is also supporting a pilot project to develop an NHS online mentoring scheme and several MiP members have signed up to be mentors. The project targets young people aged 16 to17 living in deprived areas. It aims to raise awareness of the range of careers available in the NHS. Mentors use their personal experience and knowledge to raise the aspirations and motivation levels of mentees through online discussions. They also receive web-based training and can attend other professional development webinars free of charge. In Scotland, MiP has launched an online training programme in healthcare manager | issue 19 | autumn 2013
partnership with Glasgow’s Stow College and the TUC. They have developed an online course on the NHS pension scheme and participants can also access other Union Learn courses. (See Healthcare Manager issue 18 for details.) As well as working in partnership with employers and other unions to support training and development for the healthcare team, MiP also provides its own masterclasses specifically for managers, helping to develop communications and leadership skills. These are advertised on our website. The next masterclass takes place in Birmingham on 16 October and is facilitated by Big Difference Company, the community organisation working to promote better healthcare. The programme, ‘Learning through good practice’, explores themes that came out strongly in the Francis report – the need to develop effective patient and staff engagement and the need for effective team working – and considers how you can develop personal resilience to manage your workload. Let us know of any other ways we can support your skills development, including topics for future masterclasses.
For more information about: The Learning for Life campaign see the SPF website at www.socialpartnershipforum.org Learning champions and learning agreements contact Sean Ruddy on firstname.lastname@example.org MiP masterclasses: see the MiP website miphealth.org.uk or contact Sean Ruddy.
MiP hosted another successful event for Scottish members in Edinburgh in September. There was a great buzz, with over 40 members networking and discussing a range of topics and highlighting the issues they want MiP to take forward. Workshops covered workplace culture, TUPE, pensions and an update from Europe. MiP chief executive Jon Restell (pictured) led a discussion on personal resilience. Deborah O’Dea and Mark Smithers, of Problem Resolution, gave a presentation on mediation and how it can be used to address complex workplace problems arising from relationship difficulties rather than employment rights. In these circumstances, the use of mediation rather than traditional grievance procedures can provide a much more successful resolution, which can be accepted by all parties concerned.
If you are based in Scotland and would like one of these workshops to be presented locally contact MiP’s national officer for Scotland, Claire Pullar on email@example.com.
Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@ healthcare-manager.co.uk.
backlash by Celticus
Toil and trouble
elticus hears dark rumours about something nasty being cooked up for GPs in Richmond House. Jeremy Hunt’s September attack on the 2004 GP contract – negotiated by that well known soft-touch Dr John Reid – looked like a softening-up exercise for his new contract. Those in the know say Hunt’s plans are heavily ‘market orientated’. Unencumbered by evidence, the SoS said the 2004 contract caused the A&E crisis because it ‘undermined the personal link’ between GPs and patients. Given their commitments to CCGs, LMCs and HWBs, and forming Umbrella Provider Companies to bid for Local Enhanced Services – not to mention preparing to take their practices to market – it’s a wonder GPs have time to see patients at all.
Give and ye shall receive
ore than 200 NHS contracts, worth some £2.5bn, have been contracted out since April alone, according to research by the NHS Support Federation, with Nuneaton’s George Eliot Hospital the latest up for grabs (incidentally, George Eliot is due to be ‘outsourced’ in April 2015 and serves three Tory marginals – where are you Dr Richard Taylor?).
The vast majority of these contracts (84%) have gone to private sector firms, so NHS bidders and charities must be doing something wrong. Perhaps they could learn from the owners of successful bidders like HCA, Care UK and Circle Health, and make a timely donation to the Conservative Party. That’s probably illegal now, but surely ministers can slip a quick clause into the Lobbying and Campaigning Bill to level the playing field?
HUNT PICKS FIGHT WITH GPs
Can I go to A&E now?
eathers were ruffled in the private healthcare sector by a caustic report from the Competition Commission, slipped out in August. The commission says prices in Britain’s private hospitals are too high and quality isn’t consistently monitored. It accuses providers of manipulating markets, a lack of transparency and restrictive practices – such as making ‘loyalty payments’ to doctors (kickbacks to you and me). BUPA and AXA also come under fire for not using their purchasing clout to get a better deal for patients. High costs, dominant providers and restrictive practices? It’s just what critics used to say about the NHS. John Reid liked to quip that he was introducing private providers into the NHS to bring them up to NHS standards. Perhaps he wasn’t joking after all.
ne of the hospital providers criticised was Hospital Corporation of America (HCA), which owns the Gamma Knife facility at London’s Barts Hospital, and was recently awarded a contract to treat NHS brain tumour patients. HCA is no stranger to financial misdemeanours: in the early 2000s it was forced to pay more than $880m to the US government after pleading guilty to 14 felonies including fraudulent billing to Medicare and paying illegal kickbacks to doctors. Civil law suits cost the firm around $2bn. But HCA bosses were back in court in 2005, when 11 senior executives were sued for insider trading and false accounting. HCA eventually settled out of court for $20m.
The other side
r Kate Grainger is a 31-year-old registrar for elderly medicine working in Yorkshire, who is terminally ill with a rare and aggressive form of sarcoma. In her superb blog, she reflects on current NHS issues and her experiences as she approaches the end of her life. Kate’s posts are often moving, always insightful, and offer a (as far as I know) unique perspective on today’s NHS. She has also written two books, The Other Side and The Bright Side, with all proceeds going to Yorkshire Cancer Centre Appeal in Leeds. You can follow Kate on Twitter (@DrKateGranger) and read her blog at www.drkategranger. wordpress.com.
healthcare manager | issue 19 | autumn 2013
The added va lue of membership
Members of MiP have access to a range of benefits provided by our partner organisation through UNISONplus. More often than not, these benefits will be on an exclusive basis with leading companies. But it isn’t only excellent terms and value for money we look for in a potential Partner. The products or services they offer have to be among the ‘best in class’. They must share our values and deliver a high quality service, including straightforward call-handling and easy-to-navigate websites. On the UNISON website you’ll find full details of all the criteria we look for, before we award companies with our official Partner accreditation. All you have to look for when you are looking for a name you can trust is the UNISONplus logo. For more information visit www.unison.org.uk and click on the UNISONplus logo or call MiPLink tel 0845 601 1144. You could save the cost of your subscription many times over and guarantee yourself the value for money that you and your family deserve.
EE i P S FR R M ER B FO EM M
MiP national conference 2013
Quality managers delivering quality care Wednesday 27 November Congress Centre, London WC1B 3LS keynote speakers include conference chairchair Conference
Victoria Macdonald Health Correspondent Channel 4 News
Rt Hon Andy Burnham MP Shadow Secretary of State for Health
Dame Julie Mellor DBE Health Service Ombudsman
Rt Hon Stephen Dorrell MP Chair, Health Select Committee
Zoeta Manning Chair, MiP National Committee
This year’s MiP conference focuses on quality managers delivering quality care. The Francis Inquiry gave the NHS notice to improve quality and safety in healthcare and the importance of patient and staff involvement. The Keogh and Berwick reports reinforced this message. What is the managers’ role in achieving cultural change? How does the pressure to improve quality and make huge savings impact on managers’ health and wellbeing? Other speakers include: • • • • •
Jon Restell, Chief Executive, MiP David Dalton, Chief Executive, Salford Royal NHS Annie Ingram, Director of workforce, NHS Grampian Prof Derek Mowbray, Director, Management Advisory Service Prof Elisabeth Paice, Chair, NW London Integrated Care Management Board
• • • • •
Chris Ham, Chief Executive, King’s Fund Ann Radmore, Chief Executive, London Ambulance Service Dr Peter Lees, Medical Director, Faculty of Medical Leaders and Management Lisa Rodrigues CBE, Chief Executive, Sussex Partnership NHS Trust Gill Bellord, Director of Employment Relations, NHS Employers
places are limited: for more information and to register online go to
mip-conference.co.uk or telephone 020 7592 9490 helping you make healthcare happen