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issue 7 autumn 2010

healthcare manager inside heads up:2 What you might have missed & what to look out for Leading edge: Jon Restell inperson: Graham Rich, Boston Consulting Group inpublic: Breakthrough Breast Cancer research unit

letters & comment:8 John McDermott finds himself disorientated by government plans for the NHS

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.

features:10 Risky business: the costs of NHS reorganisation Interview: Sir David Nicholson talks to John Carvel White paper: ten top names gives us their views on the shake-up

regulars:19 Legal eye: what is suitable alternative employment?

Tipster: Polish up your CV MiP at work: MiP pension survey; lessons from the Rose Gibb case; regional white paper meetings

backlash:24

Welcome to the seventh issue of healthcare manager, the magazine from Managers in Partnership, the trade union organisation for managers in health and social care. There’s been a lot of water under the healthcare bridge since our last issue. A new UK government and a new NHS reform in England, and a spending review which will no doubt signal further public spending cuts throughout the UK. All of which provides us with plenty of material for this issue.

We managed to get an exclusive interview with NHS chief Sir David Nicholson, in which he shares his experiences of restructuring and his optimism about the future. You can also read what a range of other stakeholders think about the white paper proposals, while James Gubb from Civitas does the sums to calculate the cost of another reorganisation.

We also have our regular features on working in healthcare, and as this is the autumn issue, we are marking breast cancer awareness month by looking at an exciting new research centre opened by Breakthrough Breast Cancer at the Christie Hospital in Manchester.

Marisa Howes Executive editor

issue 7 | autumn 2010 | healthcare manager

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HEADS UP

heads up what you might have missed and what to look out for

pieces of legislation into a single act, with the aim of simplifying the law and making it easier for employers to comply with discrimination law.

The first wave of implementation of the Equality Act will include new provisions, coming into effect on 1 October to protect disabled people from discrimination and tackle the gender pay gap.

Equality

The summary guides to the act can be downloaded from the GEO website follow our link from www.miphealth.org. uk/hcm.

What you need Insurance indemnity to know about Take cover? the new equality The government is laws considering proposals to

MiP scheme boosts career support for managers MiP has secured funding from the government’s Union Learning Fund for a project to improve and promote learning and development opportunities for the union’s members.

The project is led by Neil Ridwould be the ‘most cost-effective and proportionate means’ of er, who said: ‘This funding is ensuring that all healthcare pro- timely and will allow us to get fessionals have insurance cover. on with delivering careers support to help MiP members at The government welcomed this time of organisational the report but responded cauchange. tiously. ‘The report will require ‘We will be working with emcareful consideration and the ployers and education providgovernment will publish a substantive response in due course, ers and, of course, healthcare managers to provide developafter ministers in all four UK countries have had the opportu- ment opportunities for memnity to consider its content,’ said bers who may be facing difficult choices in the months to the Department of Health. come.’

The full report can be downloaded from

The Government Equality Office (GEO) has published a series of guides to the new equality legislation which takes effect from October, including guides for employers in the public and voluntary sectors.

The 2010 Equality Act, passed in the last weeks of the previous Labour government, brings together nine separate

require all healthcare professionals to take out indemnity insurance as a condition of professional registration, following the publication of an independent review supporting the idea.

The review, led by Finlay Scott (pictured), a former chief executive of the General Medical Council, concluded that it

healthcare manager

Executive Editor

Contributors

issue 7 | autumn 2010

Marisa Howes m.howes@miphealth.org.uk

ISSN 1759-9784 published by MiP

Associate Editor

John Carvel, James Gubb, Marisa Howes, Liz McCarten, John McDermott, Helen Mooney, Victoria Phillips, Jon Restell, Craig Ryan.

Craig Ryan editor@healthcare-manager.co.uk

Print

All copy © 2010 MiP or the author.

Opinions stated are not necessarily those of healthcare manager or MiP.

the DH website. Follow our link at www.miphealth.org.uk/hcm.

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Careers

issue 7 | autumn 2010 | healthcare manager

Further details about the project will be available soon on the MiP website. healthcare manager is sent to all MiP members.

All weblinks mentioned are at www.miphealth.org.uk/hcm

HEADS UP

leading edge Jon Restell, chief executive, MiP You can’t convey in a few words a general sense of the first few months of the Coalition Government without sounding apocalyptic and, frankly, a little unhinged. Better to go calmly through a concrete list of things (predominantly about England – the rest of the UK is preparing similarly challenging lists) that might be relevant to you.

Public sector pay freeze; new ministers; switch in pension indexation from RPI to CPI; John Hutton’s review of public sector pensions (interim report due in September); Rose Gibb’s court case; QIPP; cuts to management trainees; new health select committee; white paper and five consultation papers (heralding – breath deeply – GP consortia, abolition of PCTs and SHAs, new NHS Commissioning Board, scrapping performance targets, including waiting times, making

“We are in a long race. If MiP keeps building, then our capacity to support and protect individual members will build too.”

Monitor an economic regulator for all NHS providers, an axe to the arms length bodies, HealthWatch, new Public Health Service and transfer of health improvement to local authorities); stupid personal attacks on managers by ministers; revised management cuts for PCTs and SHAs of 46% nationally; Transforming Community Services; Will ‘The Other’ Hutton’s review of executive pay in the public sector; end of the job evaluation exercise for Very Senior Managers; proposed changes to tax relief on the pensions of high-earners and maybe not so high earners; first national MARS scheme;

Resignation

Life on MARS? Details of the national Mutually Agreed Resignation Scheme (MARS), under which NHS staff in England may be offered severance pay to leave their jobs voluntarily, have now been published by NHS Employers.

Key points to note are: ■■ The scheme is authorised to run from mid-September to the end of October.

■■ It is aimed at SHAs and PCTs in England to help them achieve their management cost cuts, but trusts and arms length bodies can also apply to implement the scheme. Foundation trusts are able to seek Treasury approval for their own schemes.

consultation for on-call allowances; national HR framework; death of the Audit Commission – and then business as usual.

So far MiP and its members have responded to, or been involved in most, if not all, items on the list – no mean feat. Both the magnificent feedback from members, for example, on pensions and the white paper, and the strong growth in new link members and local organisation, are excellent signs for the next few years. Because, for all the torrential change announced in a few weeks, we are in a long race. If MiP keeps building, then our capacity to support and protect individual members, speak, lobby and negotiate for managers, and develop management skills and values will build too. To the hundreds of you who’ve joined since the last issue of this magazine: Welcome! Get stuck in.

■■ It is a voluntary scheme and is subject to the needs of the service.

■■ It is designed to let people who are not at risk of redundancy leave if they want to, freeing up jobs for people who may be at risk of redundancy but want to stay.

■■ It does not replace the NHS redundancy scheme, which remains as set out in section 16 of the NHS terms and conditions handbook.

■■ It is not a negotiated agreement, although the trade unions were consulted to ensure that it complies with the national MARS principles drawn up by the Staff Council.

The pay circular, which includes the model scheme and the MARS principles, together with some useful FAQs, are available from NHS employers, follow the link at www.miphealth.org.uk/hcm.

issue 7 | autumn 2010 | healthcare manager

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HEADS UP

Pay

Fair pay in the public sector MiP has submitted evidence to the independent review of fair pay in the public sector being conducted by the economist and former Observer editor Will Hutton.

Hutton was commissioned by Prime Minister David Cameron to investigate pay across the public sector and make recommendations on how to ensure that no public sector manager can earn more than twenty times the lowest paid person in the organisation. While the review is independent, the terms of reference are very narrow.

MiP chief executive Jon Restell said: ‘On the whole we welcome this review, which gives the opportunity to stand back and consider the way in which pay is determined and the relationship between pay in the public and private sector.

‘Will Hutton is a well-established economist and commentator on the role of government in the economy, citizenship and management

In its evidence MiP: ■■ Points out that relative pay rates for the highest and lowest paid in NHS organisations are already well within the ratio of 20:1 ■■ Stresses the need for open and transparent systems to determine pay for executive staff ■■ States the need for fair and competitive rates of pay to attract and retain good managers in the public sector ■■ Points out that remuneration covers more than just pay and includes things such as the NHS pension and the workplace culture of teamwork.

principles. He is well-placed to carry out this review and MiP is optimistic that it will be thorough and thoughtful.’

The review will produce an interim report in the autumn, with a final report to the Prime Minister and Chancellor in March 2011.

For further information, see the MiP website at www.miphealth.org.uk.

MiP national conference 2010

Good management in a cold climate MiP’s fourth national conference takes place on Wednesday 24 November 2010 at Congress Centre, Great Russell Street, London WC1. This year we’ve got Jenni Murray, from Radio 4’s Woman’s Hour in the chair, and guest speakers include Sir David Nicholson, Chris Ham and Lord Victor Adebowale, chief executive of Turning Point. It promises to be a lively event with interesting debates and an opportunity to quiz the keynote speakers. Back by popular demand we will have masterclasses and speednetworking on topical issues, as well as the healthzone where you can check out your own health status. The conference is accredited for continuing professional development. Attendance is free for MiP members, so book now to avoid disappointment.

For more details and to register online visit the conference website at www.mip-conference.co.uk.

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issue 7 | autumn 2010 | healthcare manager

HEADS UP

inperson Graham Rich: Director of health services at the Boston Consulting Group and a former NHS foundation trust chief executive

Graham Rich, a farmer’s son from Devon, studied medicine and completed an MBA after becoming interested in management during his training as a GP. Working at the Department of Health on NHS performance management for two years was a real ‘eye opener’, he says. ‘I would recommend that people… spend some time in national policy formulation or a management role, as it helps to understand the large amount of guidance and policy that is published.’

Graham enjoyed his most recent NHS job as chief executive of University Hospitals Bristol NHS Foundation Trust.

‘During my time at the helm the trust became a foundation trust, we undertook some substantial capital developments and improved waiting times and infection rates dramatically. ‘We used performance management, strategic planning, prudent financial management, improved internal and external communication and a systematic ap-

proach to quality improvement.’

Graham hopes that he contributed to improving patient services by helping frontline staff feel more connected to the purpose of the organisation. ‘A big part of the role of a health service manager is to make the allocation of resources – both people and financial – more rational and transparent. Sometimes it feels like the role of the manager is to act as referee and coach for all sides in the great contest for resources. Most clinicians I know have very good reasons why their particular specialty or sub-specialty interest should double or triple in size. It’s a constant challenge to persuade people that you can do better with the same, or less, resources by reducing waste and having a relentless focus on what makes a difference for patients.’

Graham says the complexity of healthcare means that clinicians need management support. ‘NHS managers bring planning, problem solving,

“Sometimes it feels like the role of the manager is to act as referee and coach for all sides in the great contest for resources.” financial management and organisational behaviour skills to the table which can liberate clinicians’ time to focus on patient care.’ In the recent years, there has been too much emphasis on process targets and not enough on the difference care actually makes to patients. ‘There has been a large growth in management costs within PCTs, partly driven by the world class commissioning agenda. This is now being reversed… and staff in PCTs are feeling under strain as a result. In times of turbulence people actively seek out leaders and so now is the time for managers to step up to the plate, ensure continuity of services for patients and help other staff to navigate the changes ahead.’

Now director of health services at the Boston Consulting Group in London, Graham is convinced there is life after the NHS. ‘Once you have worked in the NHS, you will always remain a member of the family, but you have more flexibility to explore different options,’ he says.

What is his advice for managers looking for work outside the NHS? ‘There are many things people will need to come to terms with – the loss of an amazing pension scheme, the realisation that it is not a job for life and the potential loss of social interaction at work. It’s important for people to separate their own self-image from their job. You are not your job.

Once you are clear what you stand for and what you are good at, it makes it much easier to make the transition with confidence.

‘Given the scale of the service, there will always be opportunities to return to the NHS, and experience outside will make people even more valuable. The French are good at recognizing the value of the revolving door between public service and the private sector and we should embrace this thinking in the UK.’ Helen Mooney

issue 7 | autumn 2010 | healthcare manager

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HEADS UP

Training

Quality

Managing in stressful times

Scotland aims high

Mowbray, who is also visiting professor of psychology at Northumbria University, and stress management expert Alan Bradshaw, available this autumn: ■■ Changing Management Behaviour – increasing the performance and productivity of staff by achieving strong emotional and practical engagement.

■■ The Managers Code of Conduct

– how any organisation can benefit from developing and implementing a Manager’s Code in order to create a positive work culture.

■■ Managing People Under Stress – how to maintain good performance, even in difficult times, at the same time as reducing the levels of stress at work.

Professor Derek Mowbray, director of the Management Advisory Service (MAS) and a contributor to healthcare manager, is running a series of masterclass seminars relevant to NHS managers during this time of change and uncertainty.

There are three one-day workshops, hosted by Professor

The courses are available on various dates between October and December at different locations around the UK. For further details visit the MAS website.

Follow our link from www.miphealth.org/hcm

HR Framework

Treating staff fairly during the transition MiP is engaged in discussions through partnership forums at national and regional level to develop an HR framework to guide the forthcoming organisational change at national,

6

regional and local level in the NHS in England.

This framework will be based on principles that should ensure staff are treated fairly and consistently during

issue 7 | autumn 2010 | healthcare manager

Scottish health secretary Nicola Sturgeon has launched a Healthcare Quality Strategy for NHS Scotland with the ambitious aim of making Scotland a world leader in healthcare quality.

Implementation of the strategy will concentrate on achieving three ‘Quality Ambitions’ based on: partnership between patients, their families and healthcare professionals, avoiding injury and harm, and appropriate and timely treatment.

‘The task facing us all is to ensure the way patients are treated becomes as important to everyone delivering healthcare as how quickly they are treated. The Quality Strategy will enable us to achieve this,’ said Sturgeon.

To help implement the strategy, NHS Scotland will be inviting everyone who works with and for NHS Scotland to become part of a Quality Alliance. A Quality Alliance Board will be established before the end of the year to oversee implementation, to ‘provide challenge’ and report on progress towards the Quality Ambitions.

Further information is available at NHS Scotland follow our link from www.miphealth.org/hcm

the implementation of the objectives of the NHS white paper, the planned reduction in management costs and the outcome of the review of NHS arms length bodies.

Sir Neil McKay is leading this work for the Department of Health and recently wrote to SHAs to set out these objectives and report on progress to date. He stressed the importance of engagement with trade unions at regional

and local level in developing and implementing the principles. SHA chief executives should be taking action now, in discussion with regional social partnership forums, to set up local and regional clearing houses to support the management cost reduction.

Further information is available on the NHS Employers website follow our link from www.miphealth.org/hcm

HEADS UP

inpublic Breakthrough Breast Cancer research unit, Manchester

“With the range of talent we have, we can get our results from the laboratory to patients in the clinic as quickly as possible.”

to develop new treatments for breast cancer and it is great that we are right next door to where those treatments can be tested on patients.’

The unit also works in partnership with the University of Manchester because of the university’s leading reputation for cancer research. Under the directorship of Professor Howell and leading breast surgeon Professor Nigel Bundred, the scientists and doctors based at the unit are working to develop potential treatments that could mean breast cancer patients are treated more effectively and be an important step towards personalised treatment for all.

‘New treatments have helped increase the number Dr Hannah Harrison, one of the scientists working at the Breakthrough Breast Cancer unit, where new of women surviving breast treatments for cancer are being developed. cancer but the sad truth is The Breakthrough Breast Cancer rediagnosed cancer in the UK – nearly that nearly 12,000 women die of the dissearch unit was launched earlier this 46,000 women, including 5,000 in the ease in the UK each year,’ says Professor year under a pioneering partnership North West, and around 300 men are diag- Powell. ‘That’s why we have set up this between the NHS, the University of nosed every year. It accounts for nearly research unit to find treatments which Manchester and the charity one in three of all female cancers, and in could potentially be used for breast cancer Breakthrough Breast Cancer. the UK, one in nine women will develop and many other types of cancer. With the The unit brings together a team of breast cancer at some point in their lives, range of talent we have, we are in a great world-class scientists to find cancer treatand nearly 1,000 die from it every month. position to get our results from the laboraments that work in a totally new way – by The unit is based on the site of the tory to patients in the clinic as quickly as stopping cancer cells through the growth Christie Hospital Foundation Trust in possible.’ and spread of healthy cells. The unit’s Manchester and has developed a special ‘The trust has been very supportive of main focus is to determine how tumours, partnership with the trust. Professor Anour work, I am also Professor of Medical particularly tumour stem cells, interact thony Powell, director of the unit, Oncology at the hospital, and we work with the host and how this might lead to explains: ‘The research unit was set up closely with the clinicians and managers novel treatments for breast cancer. Staff here because it is the home of the Paterson and that integration is crucial, the support are also studying how breast tumour cells Institute for Cancer Research and because of a trust dynamic chief executive in Carobecome resistant to standard therapies it is on the site of the Christie Hospital line Shaw is also very important.’ HM and how resistance might be which is the Royal Marsden of the North.

For more information about the research unit go to: circumvented.

‘The fact that it is right next-door to the www.breastcentre.manchester.ac.uk/ breakthrough Breast cancer is the most commonly Christie is brilliant. The aim of the unit is issue 7 | autumn 2010 | healthcare manager

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OPINION

letters

Letters on any subject are welcome.

Please send to editor@healthcaremanager.co.uk or to 8 Leake Street, London SE1 7NN. We may edit letters for length. Name and address must be supplied, but you may ask for them not to be published.

to the editor

A chance to show what we can do Being an NHS Manager was and still is something to be really proud of.

I am a Practice-Based Commissioning Manager whose expertise, along with other colleagues, is needed to help the transition to the new GP commissioning. I am also an executive of the National Association of Primary Care (NAPC).

Some GPs are thrilled and others uncertain of what this future brings. Some may not truly understand yet what this means and others may not yet understand that they will all need to participate and make their contribution to prevent failure. This is why we are here to support them, help guide them through the process and where needed, train them in functions

such as contracting and procurement and how best to commission and get them ready.

I personally agree that the GPs should have the opportunity to lead the commissioning and support many areas of the white paper, however practices need to see patients and put their care first, so they need the expertise to make this happen. Let’s not throw the babies out with the bath water. Having been on the other side of the fence and been the lead manager with a large consortium, I’ve seen how well commissioning can work, as long as you have the right team and the clinicians who want to participate and make a difference. We have a fantastic opportunity here to show the press what great people we are and not that ‘the NHS has failed’.

Jan Dod PBC Manager and Executive of the NAPC

Workplace paranoia and how to to avoid it The Tipster column on mental toughness in the last issue of healthcare manager (Issue 6, Summer 2010) was very timely. It has been interesting that over the last few months, as people get concerned about their jobs, I am noticing some behaviour that is a concern. I have called it workplace paranoia. Or pass the buck syndrome. Behaviour to avoid. Whatever happens to us, we must not become the sort of person we would not like to manage.

We are senior managers and it’s important that we show our professionalism at this time. As the late Jimmy Reid put it: ‘A rat race is for rats. We’re not rats. We’re

human beings’. So I have been planning my own mental toughness regime.

The highest level of professional behaviour is what is now required from all of us.

I have reread the NHS constitution to remind myself what we signed up to and our reasons for doing so.

As the tension rises, we need to make sure we get enough rest, make sure we have a work life balance.

This is a time when we need to do as we would be done by – we are all going to have to make some difficult decisions for ourselves and maybe for colleagues and staff.

For all the employment matrices or psychometric testing in the world, there is nothing that will give us better value than how we know we have dealt with this.

Phillipa Chapman MiP national committee

Keep in touch with MiP Do you receive the News from MiP emails? If you are a member of MiP then you should receive the emails MiP send to all members about once a month – or more frequently at times like these when things are changing rapidly. If you don’t get them it could be because your membership records are not up to date. You can check your details online and update them if necessary on the MiP website. Just go to www.miphealth.org.uk and login to the members’ area. If you haven’t done this before, your username is your MiP membership number and your password is your surname. For further advice contact Billy Turner at b.turner@miphealth.org.uk

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issue 7 | autumn 2010 | healthcare manager

OPINION

comment

“Bevan made it clear that the public sector, not private enterprises, should run our services.”

John McDermott

Equalities and Communications Consultant

The Big Society rings hollow My world-view was thrown into crisis when, in February, the Daily Telegraph ran the headline ‘Tories plan “workers co-operatives” for public sector’. Apparently, an incoming Conservative administration was preparing for nurses, librarians and fire fighters to form workers soviets, drive out bourgeois bureaucrats and occupy buildings.

Now in power, the Tories have set about making their ‘great passion’ a reality, although the language of the ‘Big Society’ has replaced that of cooperatives. Now we are told the public sector is inefficient, unresponsive and stifles the private sector which is itself, of course more efficient and responsive.

Despite statements about ‘ringfencing’ health spending there will be significant cuts in the NHS budget like everywhere else, and this is just the beginning. Andrew Lansley’s plans for GP commissioning threaten to undermine the very structure and principles of the NHS as part of the largest overhaul of the service since its foundation.

And if there’s any doubt about this, let’s remind ourselves of Nye Bevan’s vision for the NHS in 1948. Bevan made it clear that the public sector, not private enterprises – which he called ‘unplannable instruments’ – should run our services.

‘The National Health Service and the welfare state have come to be used

as interchangeable terms, and in the mouths of some people as terms of reproach,’ he said. ‘Why this is so it is not difficult to understand, if you view everything from the angle of a strictly individualistic competitive society. A free health service is pure socialism and as such it is opposed to the hedonism of capitalist society.’

For 30 years the erosion of Bevan’s proudest achievement can be traced through the Thatcherite coup in 1979 and the development and implementation of monetarist policies and ideas until 1997.

Later, the Labour Party ceded ground and took up these ideas, a process most obviously epitomised by the socalled ‘Blairite revolution’ which created New Labour. Today, we have the third and latest stage in public sector reform under the Conservative-Liberal Democrat coalition. They have experienced a meeting of minds on how to use an economic crisis to further attack our public services.

Under the double guise of reducing the national debt and promoting the ‘Big Society’ Cameron wants to divest the state of responsibility for providing public services by punting it to the community and voluntary sector, and giving the private sector greater access to what remains to be delivered under the auspices of the state.

Supporters of this right-wing ideology have been able to seize the political

agenda by connecting its ideas for so-called “reform” – which are better described as reaction – with popular discontent over the public sector.

By deploying a language of progress, choice, freedom and efficiency, they have hijacked this mood and used it to push for their own version of “reform”, which is already sweeping away plans to build more social housing and ensure that councils remain a provider of last resort. And in education, David Willets has told school leavers to ‘lower their sights’, leaving more than 200,000 students who have worked hard for their exam results without university places and little hope of getting a job.

Yet there are real reasons for hope.

Already thousands of people have joined a campaign to save NHS Direct, and anti-cuts rallies are planned to challenge the comprehensive spending review in October. Across the world, colleagues in healthcare are organising en-masse against cuts and closures.

Above all, it’s down to public service leaders (that’s you!) to defend what is good and progressive about our public services, and to go beyond this by offering a positive future vision which can become the new ‘common sense’ in society. Hey, maybe we need to introduce workers’ co-operatives after all

.

Views expressed are those of the author and not necessarily those of healthcare manager or MiP. issue 7 | autumn 2010 | healthcare manager

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NHS REORGANISATION

James Gubb considers the risks and costs of another massive upheaval in the NHS.

The reaction to the NHS white paper, Equity and Excellence: Liberating the NHS, has been mixed at best, with even those broadly supportive of the reforms warning of possible dangers ahead. The number one concern, justifiably, is the abolition of Primary Care Trusts (PCTs) as commissioning organisations and the moving of responsibility for commissioning to consortia of GPs. Particularly at a time of unparalleled financial challenge, this presents significant risk; risk that does not appear to have been subjected to any rigorous analysis.

The first point to emphasise is that the NHS has form when it comes to reorganisation, with at least 15 major structural changes having been identified over the past 30 years.

Typically changes have been rapid.

Many have also often been cyclical, taking the organisation back to a form similar to that of a few years past.

One unfortunate consequence of rapid change is that structures are often in place for too short a time for proper evaluation. However, there is little evidence that reorganisations have produced much, or any, improvement. To 10

issue 7 | autumn 2010 | healthcare manager

take just one example: during the 20 years since a quasi-market was introduced in the NHS, a multitude of organisations have been established to commission healthcare which have then been disbanded within a few years – health authorities, GP fundholders, total purchasing groups, Primary Care Groups, Primary Care Trusts and practice-based commissioners. Studies do not suggest any one form alone has been better than the others, though GP fundholding did look the most promising.

One reason for the perceived failure of commissioning overall is likely to be the disruption and discontinuity resulting from constant change: the ‘illusory search’ for the optimum structure as the NHS Confederation recently put it. The reorganisation of PCTs in 2006 is one example of this. The number of PCTs was reduced in size from 302 to 152, through merging 222 PCTs and leaving 80 PCTs unchanged. Recent analysis by Civitas, looking at Healthcare Commission Annual Health Check ratings on ‘quality of services’ and ‘use of resources’ before and after mergers, showed that the mergers led to: an absolute drop in performance on ‘quality of service’ and ‘use of resources’ lasting at least one year in PCTs that were

merged, compared with improved performance on both indicators for PCTs that were not merged; and a period of three years before the relative performance of PCTs that were merged reached the pre-merger (i.e. 2005/06) levels of those that were not.

Given the widespread agreement that the reforms to commissioning outlined in the white paper are substantial and will result in fundamental changes to the organisation and delivery of care to patients in the NHS in England (far more, for example, than simply merging organisations as in 2006), the concern must be that both financial and clinical performance will suffer.

This concern is only multiplied by the fact that the NHS is facing an unprecedented productivity challenge.

With near-zero real terms increases in funding over the coming Parliament, in order to meet increased demand for care, the King’s Fund recently estimated that the NHS will have to increase productivity by around 4% per year for the next five years – equivalent to saving around £40 billion over the current Parliament. Ironing out inefficiencies within organisations may well be sufficient to achieve this in the first one or two years, but, after that, radically

NHS REORGANISATION

“There is a very real risk that the ‘new’ NHS will be an even more centralised system than the structure the Coalition Government are intent on dismantling.” new models of care will be needed – not least those that transverse the “divide” between primary and secondary care. It is highly questionable whether the NHS bodies, traditionally very conservative and averse to change, can achieve this while attention is diverted to creating new structures and dismantling old ones (which are expensive pastimes in themselves – the Department of Health is rumoured to have set aside £1.7bn to fund the restructuring). It is certainly beyond what the NHS, and much of the private sector, has achieved in the past.

We must, of course, also consider the likely impact of the proposed new structure for the NHS when it is in place. This, to say the least, is uncertain.

First, there is little evidence to draw on to suggest what might happen. The closest experience the NHS has had to commissioning being led

by GP consortia was probably the total purchasing pilots in 1996-97, the final year of the previous Conservative administration. These showed promise before they were abolished by Labour on coming to power, but the level of achievement between pilots varied widely: small multi-practice pilots, the ability to undertake independent contracting and higher direct management costs were all factors associated with greater success.

Larger volumes of evidence come from GP fundholding, under which groups of general practices held real

budgets for elective care from 1991-97.

GP fundholding was associated with improvements in speed, access and responsiveness of secondary care, reductions in waiting times, slight reductions in referral rates and costs, and widening the range of available services.

However, most studies suggest GP fundholding failed to reduce costs as much as expected, and had little effect on the rate of innovation. Fundholding was also associated with lower patient satisfaction with services. Little research, too, was carried out on the impact of fundholding on health outcomes. Most importantly, GP fundholders were selfselected volunteers for the programme, and tended to be well-organised

practices in middle-class areas, who were enthusiastic about taking on commissioning budgets. There is no evidence to support GPs across the country taking on commissioning as consortia, as proposed by the government.

The second point is there are many additional risks created by uncertainty over the exact form of structures and incentives in the proposed new structure. Here are just a few of them: What system of risk and reward will be implemented for GP consortia to motivate involvement and provide

proper incentives for them to stay within budget and focus on improving outcomes for patients? Will they inherit the historic debt of PCTs? And will commissioning budgets be separate from practice budgets?

How much freedom will the commissioning board allow GP consortia, particularly given the risks in transition are significant? What happens, also, if a consortium does not meet the prerequisites to be authorised by the commissioning board?

How is the commissioning board expected to effectively monitor and define contracts for general practice, dentistry, pharmacy and maternity care – largely outside the contracting influence of GP consortia – particularly given that poor primary care is often the source of problems in the NHS? Evidence from research teams at the LSE and Imperial College suggest competition is bringing real benefits to patients in terms of access and quality of care. How will the commissioning board ensure GP consortia are tendering appropriately and effectively, and supporting patient choice, especially in the face of the BMA’s opposition to the market in the NHS? More widely, given that the commissioning board will ultimately be accountable for NHS spending, that budgets are being tightly squeezed, and that many GP consortia almost certainly will not have the managerial nous to deliver the efficiencies required, there is a very real risk that the ‘new’ NHS will be an even more centralised system than the structure the Coalition Government are intent on dismantling. And the solution will be... more restructuring?

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James Gubb is director of the health unit at the social policy think tank Civitas.

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INTERVIEW

Fresh back from a tour of NHS regions and on the eve of his wedding, NHS chief executive Sir David Nicholson gave an exclusive interview to John Carvel for healthcare manager.

David Nicholson spent the first half of August visiting the ten Strategic Health Authorities across England to gauge for himself the morale of the service in the wake of the announcement by the coalition government that it is to undergo its biggest ever reorganisation.

Speaking on the day after the final visit – Nicholson’s last day at work before his wedding and honeymoon – he says he found the NHS starting to recover from a state of shock.

‘Abolition of PCTs was not in any party’s manifesto and abolition of SHAs was mentioned by the Liberal Democrats, but not by the Conservatives. So of course this was a shock. In the West Midlands they told me it was like going through a bereavement process.’ The stages of mourning often take people through feelings of shock, denial, guilt, anger and depression before they come to acceptance and hope. ‘Right now people are at different stages of that bereavement,’ he says. ‘And for middle managers there are lots of unanswered questions.

‘What I would say is that our people are remarkable. They have taken this massive hit, but they are already 12

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starting to think about how they can make it work. That [resilience] is a valuable asset and you ruin it at your peril.’

I asked if MiP was right to complain about unprecedented levels of manager bashing by politicians, who appear to relish telling the people who will be implementing the reforms that everything they do is rubbish.

‘In every place I have been people have said to me: “Can you please stop the politicians denigrating public sector leadership?” So I have heard it at first hand. And I have felt it myself, as someone who has spent the last 32 years working in the NHS as a manager.

‘None of us take these jobs to be popular. Some criticism comes with the territory. Remember when the Conservatives came to power in 1979.

They had a go at us then. And Blair had a go at us in 1997. They were talking about dismantling the internal market, but the language they used was all about armies of pen pushers. That eventually changed under Thatcher and Blair because they came to understand the truth about what matters.

‘Between 60% and 70% of big changes fail. The determining

characteristic of the ones that succeed is not the brilliance of the vision. It’s the way in which the transition is managed.

So you can have a fantastic vision that never sees the light of day and you can have a poorly formed vision that gets delivered.’

In case we might think Nicholson harbours doubts about the white paper’s vision, he interrupts this theme to praise it. ‘I think the vision behind it is brilliant, but the people who will deliver it are the managers in PCTs, SHAs and elsewhere. That basic truth will emerge. The politicians understand that and hopefully you will see a change in the position of our own [Department of Health] ministers.

‘If that sounds more critical of politicians than I mean to be, I should add something else. Politicians can take credit for big achievements in the NHS: the transformation of outcomes and services for people with cancer; the transformation of outcomes and services for people with coronary heart disease; a revolution in improved access times. Many of us may have thought these matters were important, but it took politicians to give us the ambition to change. I remember when John Reid told us to halve the rate of

INTERVIEW

“Our people are remarkable... they have taken this massive hit, but they are already starting to think about how they can make it work.”

MRSA bloodstream infections. It took the ambition of a politician to be so bold. And now it is taking the ambition of a politician to say we need a step change in commissioning.’

Nicholson adds: ‘There is nothing I am saying here that I have not told the politicians directly.’

So there we have it. With this man, what you see is pretty much what you get. Here is a career-long member

of the NHS tribe, who is willing loyally to implement the government’s proposals, recognising ministers’ right to determine policy while robustly upholding his administrative authority and style of leadership. His confident bearing and demeanour suggest that ministers are prepared to go along with this distinction.

Nicholson’s concern for staff whose posts are about to disappear is rooted in a personal back-story. He says: ‘I have

been “abolished” three times in my NHS career. The first time was in 1983 when I was working in mental health in Halifax, West Yorkshire. They moved [the organisational framework] from sectors to units and my sector was abolished.

We had to compete to get a job in the new set up. First there was a local competition and I was unsuccessful in that. Then there was a regional competition and I wasn’t successful there either. I did think about leaving, but I was young and I thought something would turn up. My last chance was in the national competition when somebody took a chance on me.

He must have thought: this guy didn’t get a job in his own part of the country and he didn’t get a job in his region; there must be something wrong about him. But I was given the chance and ended up in Barnsley, where I was during the miners’ strike.

‘My second time came when Labour abolished the regions in 2001. I’d been regional director for Trent. I had no idea that the regions were going until I read about it in The Guardian. I’d only had the job for a year and a half. We were all taken to a hotel in Birmingham. The regional directors were put in one room and the national directors were put in issue 7 | autumn 2010 | healthcare manager

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INTERVIEW

another. We were left on our own to think what we were going to do. I felt let down.’

This was the period when Alan Milburn, then health secretary, was setting up 28 SHAs, with coordination provided by four directors of health and social care. Nicholson got the directorship covering the Midlands and east of England. ‘That one lasted eight or nine months – from the day I was appointed until the day the post was abolished, a week before Christmas, because Milburn decided to get rid of directors of health and social care.

Then I applied for the job of chief executive of Birmingham and the Black Country SHA. That was abolished in 2005, but by then I had another job.

‘The thing you feel when your job disappears is powerlessness. You change from being somebody who is in control to having control taken away from you. I felt it particularly strongly when I lost the job as director of health and social care. It took me 18 months to two years to get over it because I felt so angry that the system had dealt with me in that way. I’d appointed people to work for me. Some of them had moved house. It was the arbitrary nature of the decision to set us up and then get rid of us that upset me. That is why, whilst I have been chief executive of the NHS, I have been reluctant to do organisational change.’

At this point Nicholson gives a wry chuckle as he remembers that he now finds himself responsible for implementing the biggest organisational change since the NHS was founded in 1948. He moves on to lift the veil on what he said to the SHA chief executives during his recent tour of the regions.

‘I told them to start thinking about themselves in one of three categories.

Maybe your reaction to the government’s proposals is: “I hate all 14

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“The thing you feel when your job disappears is powerlessness. You change from being somebody who is in control to having control taken away from you.”

this. I think it’s awful. The values of this white paper aren’t mine.” In that case, you should go and the human resources system should work out a mechanism to make that happen in a civilised fashion. Maybe your reaction is: “I can see how things will work, but I don’t think I have the energy for the whole project.” In that case, you should stay for a while to help things work [through the transition.] Or maybe your reaction is: “I think this is great. There are real opportunities to benefit patients and clinicians and a want to be part of it.” In that case, the organisation should help you [develop a long-term career in the NHS.]’ Should managers across the service be equally abrupt with their teams?

Nicholson thinks not. He says there are about 100,000 people working in the DH, NHS arm’s length bodies, SHAs and the commissioning side of PCTs. Each will be entitled to a one-to-one discussion with their line manager about their future in the NHS. Nicholson does not want line managers to adopt the line he took with the chief executives by telling everyone who hates the proposals to walk the plank at the earliest opportunity.

‘People with kids and a mortgage may not feel able to move and they should not be forced out,’ he says. ‘It is different for people at the top where those who do not like the direction of

travel can infect the whole organisation.

I would not be as strident as that with everyone.’

Nicholson told the Health Service Journal recently that PCT and SHA managers ‘have performed heroics’.

Why does he think they are heroes and heroines? ‘They delivered unprecedented levels of staff satisfaction. They delivered unprecedented levels of patient satisfaction and public confidence.

They have done all they were asked to do and we have a responsibility to support them. I am genuinely in admiration of them, not only in what they achieved, but also in the way they dealt with the shock to the system that they have just had with commitment to the service and to patients.’

So why is it a good plan to reduce the number of managers by nearly half? And does it make any sense to start getting rid of managers before doing all the work involved in setting up GP consortia and making savings of up to £20bn. Would it not make more sense to do the work first and make the cuts in management later?

Nicholson says: ‘We are talking about a 40% reduction in management costs. In the period 2004 to 2006, we saved £250m [during the introduction of “Commissioning a Patient Led NHS”]. This time we have to save £800m. But remember three things: ‘First, the legislation has to go through parliament. So there is still quite a lot of water to flow under the bridge. Parliament does affect things.

Second, the first time a GP consortium can have a statutory budget is 1 April 2013. That’s quite a long time away. It’s longer than people think. Third, of course we want to get consortia up and running before then, but they will only be able to do so through the skill and innovation of PCTs making that work.’

So why not delay the management

INTERVIEW

Sir David Nicholson, Secretary of State Andrew Lansley and retiring Permanent Secretary Sir Hugh Taylor take questions from DH staff.

cuts until this work is done? ‘If you are going to sustain front-line services with a constant level of resources, you have to attack the cost of the overheads… and management costs have to be a part of that. We increased management costs last year by £200m. No one planned that.” Nicholson thinks it would have been unrealistic to try to defend jobs that were created piecemeal without any obvious rationale. So the immediate goal for 2010-11 is to take out the £200m to get back to the previous level.

The 40% cut over several years would fall disproportionately on consultants and temporary staff, not permanent NHS employees – or as Nicholson puts it ‘contract people rather than our own.’ He says: ‘Management has grown since 2005 when the controls were taken off. Our

aim now is to get back down to the levels of 2003-4.”

Nicholson was unwilling to say whether he envisages he will still be NHS chief executive in two years’ time. There have been reports suggesting that he is on a fixed fiveyear contract that expires in September 2011, but they happen not to be true.

Nicholson, aged 54, is a permanent secretary on a permanent Whitehall contract. The decision about when he goes will be up to him and his political bosses. For the time being he says: ‘I am concentrating on managing the transition and that is so important that I haven’t had an opportunity to think through my own personal position. As soon as I do, I will say something about it.’

On the day of this interview,

Nicholson’s concentration may not have been 100%. He was about to leave the office to prepare for his wedding a few days later to Sarah-Jane Marsh, chief executive of Birmingham Children’s Hospital NHS Foundation Trust. They were due to tie the knot at Belvoir Castle in Leicestershire.

Nicholson recalled advice he was given by Sir Ian Carruthers, his immediate predecessor as interim chief executive. Carruthers said: ‘Never leave the office. As soon as you are away, bad things will happen.’ With a smile on his face, Nicholson said this was advice that on this occasion he was very happy to ignore

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John Carvel is a freelance writer and former social affairs editor of The Guardian

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WHITE PAPER

The coalition government’s plans to reorganise the NHS are widely seen as the most radical since its inception. We ask ten healthcare movers and shakers what they think of Andrew Lansley’s controversial White Paper. Interviews by Helen Mooney.

Andy Burnham Labour’s shadow health secretary

I’ve read the white paper quite carefully and I’ve tried to give it the benefit of the doubt but I find I can’t. It threatens to unpick the fabric of the NHS and is a recipe for fragmentation, marketisation and the development of a postcode lottery. It strikes at the heart of the NHS. The suggestion, for example, that there will be no bail out for NHS organisations raises fundamental questions about the state not supporting the NHS. The scrapping of the 18-week referral to treatment target and the cap on how many private patients can be treated in NHS hospitals need to be seen alongside each other, because it will mean NHS patients once again have to wait longer. It is a worrying and dangerous combination. In terms of NHS managers, I recognise what they have done to improve the NHS over the last few years, they are the unsung stars, they really have done a lot of the heavy lifting to improve the NHS, and to do away with PCTs is an 16

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insult to those managers that care deeply about the health service.

Stephen Dorrell Conservative chair of the Parliamentary health select committee

I think that no one can be against looking at unnecessary processes that don’t add value to the NHS. Close engagement with primary care in the commissioning process is likely to deliver better value and better medicine. The health select committee has chosen to go back and look at commissioning and in my mind a core weakness in the management of the NHS in the last few years has been the failure of the structures to deliver an effective commissioning process. Will GP consortia have the expertise to deliver the whole of the commissioning process? The answer is ‘no’, so it is important to have something beyond local knowledge of commissioning. It is an easy hit to say that the NHS has too many administrators. As one of the largest organisations in the Western world,

to think that it will run itself is nonsense, the NHS needs effective management.

Ultimately equitable healthcare and access to that care revolves around commissioning, value for money and safe clinical care.

Rosie Ilett Deputy director of the Glasgow Centre for Population Health and MiP vice chair

NHS managers feel very concerned and undermined by the proposals because I think the notion that management practice and activities can be done by anyone clearly makes no sense in terms of the role of all staff in the NHS. It certainly devalues the existing skills base across the system and the view that anybody can do management is to misunderstand the complexity of that management.

Commissioning is being presented as a transferable activity but commissioning is complex in itself and needs a whole range of skills. Our view at MiP and my view as a manager is that the system is not just about doctors and nurses but

WHITE PAPER

about the whole group of NHS staff working together. I think that GP consortia commissioning will turn out to be more expensive than PCTs and will fragment the structures that are in place.

Removing managers will cut costs in a crude way but the NHS needs managers and these proposals will be mean the private sector has the potential to come in. This will also have an effect on workforce planning, training and education and how we think about managers as a group of staff.

Gina Tiller Chair of Newcastle PCT

This, I think, is the scariest reorganisation the NHS has seen.

Personally, I’m worried about what it means for patients, as it will have a massive effect on how the health service runs. The privatisation agenda here is not even hidden – it is quite upfront. I understand that Andrew Lansley doesn’t think that PCTs have worked and he has had his ear bent for several years by GPs but that was in different financial times. It is all very well being told the private sector will respond to fill the gap but in the past this has not been the case and I don’t necessarily think it is going to be now.

Equally worrying is what is happening in terms of public health, the strides we have made in reducing health inequalities I worry are going to be lost as public health moves to local authorities and has to compete with GP consortia. We are handing massive amounts of public money to people that don’t even work in the NHS – GPs are private contractors.

Many GPs will not want to be accountable officers and someone else will have to manage the money, which is where the role for the private sector will come.

I just don’t think PCTs have been given a chance; the oldest PCT is only ten years old. I’m sure there is more that PCTs could have done but I don’t think dismantling the system is the way to achieve effective patient care.

“The NHS is our priority. That is why the Coalition Government has committed to increases in NHS resources in real terms each year of this Parliament. The sick must not pay for the debt crisis left by the previous administration. But the NHS is Secretary a priority for reform too. Investment has not been matched by of State for reform. So we will reform the NHS to use those resources far Health, more effectively for the benefit of patients.

Andrew Lansley

12 July 2010

The Government’s ambition is for health outcomes – and quality services – that are among the best in the world.

We have in our sights a unique combination of equity and excellence.

With patients empowered to share in decisions about their care, with professionals free to tailor services around their patients and with a relentless focus on continuously improving results, I am confident that together we can deliver the efficiency and the improvement in quality that is required to make the NHS a truly world class service.”

Charles Alessi GP at The Churchill Practice in Kingston-uponThames

I think this is the best thing to happen to the NHS for many a year. PCTs are not representative of the view of their constituents like GPs, and putting commissioning back onto the frontline is a good idea. However, the devil will be in the detail in terms of what happens. If the level of reward given to GPs for making changes and innovating is right then it will work, but the contracts will have to be as fair as possible to avoid a postcode lottery. There is still a question over where the provider arms of PCTs will sit, at the moment they are moving to the acute trusts which is the worst place for them because the business is completely different. This could be an opportunity to get them back into primary care, however it will be challenging to get GP consortia to take on these services. Financially it will depend on how this is managed but I’m sure somebody has done the sums and decided that this is affordable. Former PCT managers could help to administer GP consortia but I don’t believe that they should do it by right. There is also the question of central commissioning functions, how will they fit into this new

world? GPs will also have to change from what they are to much more corporate individuals, this will be a real challenge and we will need strong GP leaders, the Department of Health needs to develop that leadership.

Professor Julian Le Grand Professor of Social Policy at the London School of Economics and senior policy adviser to Tony Blair from 2002 to 2005.

This is basically a continuation of the Blair reforms. I am not one of these people who think this is a revolution; I think it is an evolution. The chief change has been the move to GP commissioning. I was always a supporter of GP commissioning, or GP fundholding as it was known, and I tried to persuade the Labour Party not to abolish it, which they did, although it was somewhat reintroduced through practice based commissioning which never really took off.

GP fundholding worked because it reduced the number of hospital referrals, prescription costs and brought in innovation. GPs are close to the patient and are knowledgeable where PCT managers find it difficult to be. The average GP consortium will be better at commissioning than PCT commissioners; howissue 7 | autumn 2010 | healthcare manager

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WHITE PAPER

ever, it will depend on the size. Research on GP fundholding showed that they needed a population of at least 100,000 to get the appropriate level of risk pooling.

Anna Dixon Director of policy at the King’s Fund

This is a radical and ambitious set of reforms and these are difficult and testing times in which to implement them.

The financial challenge that the NHS faces is very challenging given the changing demographic pressures on the NHS and the very tight squeeze that will be placed on social services, and there are a lot of questions still to be answered about how it will all work together. Where will accountability and power lie? There are a lot of risks to a system which patients and the public are already pretty satisfied with. There are risks in trying to implement this system, not least the risk that people will take their eye off the ball if there is no clear accountability and there is the danger that as money gets tighter patient safety may slip. Some groups of GP commissioners will seize these opportunities and probably do a good job but many more GPs are not in a position to take on this responsibility and will need a lot of support, and it will be a question of ensuring accountability for how the money is spent and how they get more for less and better value for money for the NHS

“Where will accountability and power lie? There are a lot of risks to a system which patients and the public are already pretty satisfied with.”

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Andrew Cozens Local Government Association’s strategic lead for health and social care

From a local government point of view this represents an opportunity to play a stronger part in how the NHS is commissioned locally, but there are still lots and lots of questions on how it will work. In terms of the public health function transferring to local government, this is a journey that we have been on for some time with nearly 70% of public health directors who are already jointly appointed. Between the new National Public Health Service and public health in local government, public health will have a voice at practically every level. In terms of the introduction of GP consortia I am particularly keen that pooled budget arrangements around mental health, vulnerable adults and those with learning disabilities are not lost. However, local government could also be in a position to offer commissioning support to consortia or commission jointly and we are keen to have a good relationship with commissioners.

Colin Walker Policy and campaigns manager for mental health charity MIND

From a mental health point of view there is a lot of wait and see what comes out of the consultations on the white paper.

However, the most dramatic thing is the shift of £80bn of funding to GP consortia. From our standpoint a lot of what happens will depend on the training and knowledge of GPs in mental health. The experience of the NHS for people with mental health issues is nearly always tied up with their first contact with their GP, some of whom are not aware of the complexity of mental health as an issue. As GPs form consortia we will be concerned about the nature and quality of the mental health services that are provided.

Some might be good and some might have limited knowledge of mental health issues, which could mean a postcode lottery. The worst-case scenario will be that some GP consortia fail to provide any positive mental

health services at a local level in some areas.

Katherine Murphy Director of the Patients Association

We welcome the broad direction of the government’s proposals. It’s clear that to have an effective health service patients need a degree of choice and useful information, and the recognition of the role of clinicians in that is long, long overdue; now it is about turning laudable goals into real gains for patients – we need real actions. The health secretary has gone on record saying that we will have an information revolution but where will the money come from for that? And do they know the information patients really want? I don’t think so… Patients want information about their local hospital, about their consultant, about the clinical team, about the surgeon and about infection rates, not just in the hospital but in the ward that they are going to be admitted to, and they want to easily understand that information so it can be of use to them. It’s really important that the government is not talking about patient choice for its own sake, but that the outcome of choice should be of benefit to patients and it should benefit patients fairly. I also question whether creating GP consortia is really just reinventing the commissioning wheel or whether there will be any sustainable change. Ultimately as the changes are rolled out we need to know that the patient voice is at the centre

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LEGAL MATTERS

legaleye With the NHS braced for job losses it is important to understand the choice between redundancies and alternative job offers.

The obligation on an employer to offer suitable alternative employment in redundancy situations is much misunderstood.

While the employer is under an obligation to look for a suitable alternative job, an employee who unreasonably refuses an offer loses their entitlement to a statutory redundancy payment.

Clearly the difficulty lies in what constitutes a suitable alternative.

Ultimately, it comes down to the circumstances of the case and to some extent what is mutually agreed by the employer and employee.

The sole criterion for what constitutes a reasonable offer is its “suitability”. So, while an employer can quite reasonably argue that a more senior position may not be suitable, it is the employee who decides whether a more junior position is acceptable. The decision to accept demotion is one that many employees are facing. But it is their decision, not their employer’s.

If an employment tribunal were

“The decision to accept demotion is one that many employees are facing.

But it is their decision, not their employer’s.”

asked to decide whether the alternative job was suitable, it would have to judge whether the job matched the individual. It’s not just about the type of work to be performed, but the terms of employment, such as salary and hours, responsibility and status. Location is, of course, relevant. If a job is located miles away and presents massive transport problems for the employee, it is unlikely to be an attractive offer.

Unless there are mobility clauses in contracts, employers cannot require employees to work elsewhere. As an employment appeal tribunal said in one case, ‘commuting is not generally regarded as a joy’.

Employers are obliged to search for suitable alternative employment.

Although they are not required to offer it, if they don’t, the redundancy could be unfair dismissal. They should not limit the search to the same section of the organisation in which the employee worked. But it is probably going too far to require them to search among associated employers.

The employee must be given sufficient information about any new job – including pay prospects – so that they can make an informed decision. If the post is suitable, but the terms are not, then this can make the dismissal unfair.

The issue that most frequently arises when a job offer is made and the

employee wishes to reject it and claim the redundancy payment, is whether the rejection is unreasonable. It is for an employer to show that an employee was unreasonable in rejecting an offer, not for the employee to prove that they were being reasonable.

A tribunal would have to consider the employee’s reaction, looking at it from their point of view, according to the facts as they appeared at the time the decision had to be made.

Finally, employers must follow statutory rules in making an offer. They must make the offer after the notice of redundancy was given and before the redundancy notice period ends. And the new role must take effect at some point within four weeks of the old job ending.

If the employer fails in these steps then the employee’s rejection will not be unreasonable

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Victoria Phillips Head of Employment Rights Thompsons Solicitors

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CAREERS

Future Proofing Liz McCarten on staying in control in uncertain times.

For many professionals reading this, the next few months at work are unlikely to be like anything they have experienced before. The government’s white paper, Equity and Excellence: Liberating the NHS, promises a radical overhaul of the health service with implications for staff at every level.

So what can you do to ensure you are prepared to deal with this change?

At a policy level there will be lots of exciting opportunities as well as serious challenges ahead. For some people, this could be the chance to move into a new area or to get involved with a project which may long have been dear to your heart. It certainly looks like there will be no areas unexamined by this shake-up, which can throw up opportunities for those who are ready and alert.

Clearly, there will be a great deal of enforced change as well, and healthcare managers may well find

themselves subject to the dual pressures of formulating and promoting that change as well as dealing with its ramifications for their own roles.

That means you need to remain clear-sighted about your own personal position while being objective about the wider picture. It’s fine to be concerned about what will happen to you – and even better to be prepared. The first thing is not to panic. When things become uncertain, it’s easy to spend a lot of time speculating about the future.

Often the final result is quite unlike what you may have imagined or feared, so try to stick to practicalities and certainties. Spend some time reviewing your CV (see below) and considering your future options.

Try to think about what aspects of your role you would like to retain or do more of in the future, what you would really like to stop doing, and what new things you might like to try. Do this in isolation from what you hope or fear

your new role might be, so that you can really think about what would be the most satisfying job for you. Then you can work on trying to make that a reality. If and when you have to compromise, you will be clear about your priorities and you will have a way to measure whether what’s on offer meets your aspirations.

Make sure that you stay aware of what’s going on, not only in your immediate environment, but also in areas which might be of interest or use to you in the future. For some people reading this, the next couple of years may see a complete or partial change of career – and if that’s what’s going to happen, you need to be in control of the outcome

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Liz McCarten is director of Careerworks and will be working with MiP to deliver our learning and development strategy (see page 2).

Tipster: Sort out your CV Your CV is one of the most important ways for you to sell yourself – and you need to have a fresh look at it to make sure it’s doing its job

 PRESENTATION The traditional CV says ‘Curriculum Vitae’ at the top, followed by your name and contact details. This dated approach isn’t the best way to sell yourself. Start with your name as the heading, and put the most relevant things about you up front. People want to see quickly and clearly how you fit the role they’re offering. Your contact details can go at the end. Aim at filling two or three pages – don’t end halfway through a page as it looks like you’ve run out of things to say.

 CONTENT Think about what aspects of your working life are relevant to the role you

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are applying for. You should adapt your CV to make it as closely matched as possible on each occasion. Make sure you go through the person specification to ensure that each area is addressed somewhere on your CV. Don’t put in hobbies, primary school, clubs and interests unless there is a compelling relevance. Everyone loves reading, films and going on holiday and a weird hobby might make you stand out for the wrong reason. Get a friend to give you their honest opinion of your CV – and consider their advice.

 practicalities Never, ever name your CV as “CV.doc”.

This may seem like a trivial point, but

for anyone who handles a large number of CVs when a job is advertised, it’s really irritating. The first thing your recipient has to do is open and rename your file, which is a waste of their time and can lead to errors. Name the file “your name.doc”.

 CHECK IT OVER Get someone to proof read your CV once it’s finished and make absolutely sure you get the basics right. Spelling errors undermine your professionalism, particularly if you make a howler in the name or job title of the person to whom you send your covering letter.

PENSIONS

Fair and affordable Marisa Howes reports on MiP’s survey of members’ views on the future of the NHS pension scheme.

One of the coalition government’s first announcements was a review of public service pensions. They want to ensure that they are sustainable, affordable and fair in the long term. Which would be fine, except the announcement was accompanied by scare stories about the burden on taxpayers now and in the future.

John Hutton, who is carrying out the review, has invited all interested parties, including MiP, to submit evidence for his interim report. To make sure our submission reflected managers’ views, we carried out an online survey and got a massive response.

Our survey gives a very clear message: managers are fed up with being the scapegoats for the economic problems the country faces and they warned of the impact on recruitment and retention if the NHS pension is cut.

Here are just some of the points raised by our members, which we have passed on to Hutton.

The NHS scheme has just been reviewed and amended The overwhelming majority of respondents were clear that the NHS scheme is affordable and sustainable. They said it has just been reviewed and employees’ contributions have increased to make it affordable for the foreseeable future, with a cap and share mechanism built in to ensure future affordability. Crucially, these changes were arrived at through discussion between employers and unions. As one respondent said: ‘It is affordable but requires a significant contribution from members. It is not weighted in favour of high earners and in that respect is democratic.’

The NHS pension is crucial for recruitment and retention The pension scheme is important to attract and retain skilled staff in the NHS. Respondents emphasised that pensions are part of the total pay package for NHS staff, and as such they are affordable. As managers, they would find it much more difficult to attract talented candidates if the pension was devalued. ‘A public service pension is part of the package that attracts workers to jobs,’ said one. ‘The private sector pays bonuses.’ And the NHS would find it more difficult to keep them: ‘Reducing the pension benefits at this time will have a significant negative impact on staff morale that should not be underestimated.’

The cost of the NHS pension is fair Many respondents were fed up with being labelled as a drain on taxpayers’ money. They said they make a fair contribution to their pension from their salary, and the employer makes a fair contribution so that NHS staff can expect a decent pension on retirement. As one respondent put it: ‘The vast majority of NHS staff do not earn huge salaries, and should not be demonised because of their pension provision. Through 32 years of public service I have never felt so much of a pariah as in recent months.’

The objectives to guide public service pensions in the future The message from our survey was that pension provision should be guided by principles of fairness and affordability, consistency and trust, with joint funding by employer and employee contributions. Many said public sector em-

“The vast majority of NHS staff do not earn huge salaries, and should not be demonised because of their pension provision... I have never felt so much of a pariah as in recent months.” ployers should lead by example in making good provision and argued against levelling down to match poor provision elsewhere. ‘The objective should not be to weaken good pension provision but to strengthen poor ones.’

No rushed decisions Our respondents warn against making rushed changes to a pension scheme that was deemed to be affordable just a short while ago. ‘It would seem prudent to actually plan a long term strategy for public sector pensions and debate with a view to implementation, if ready, in 2012.’

The number and quality of the MiP survey responses clearly show how much healthcare managers value the NHS pension and how passionately they oppose any attempts to devalue that pension. MiP will make sure those opinions are heard

.

MiP has also made a submission to the Treasury consultation on changes to pension tax relief. This and the full submission to the Hutton review are available from the link on the MiP website: www.miphealth. org.uk

issue 7 | autumn 2010 | healthcare manager

21

MiP AT WORK

Court battle leaves space for negotiation Rose Gibb vs Maidstone and Tunbridge Wells NHS Trust The case of Rose Gibb caused a huge storm of controversy that lasted for three years. But what about the complex legal case that ran often unnoticed under the storm? And does it hold any wider lessons for NHS managers and their employers when negotiating departure terms?

Ms Gibb became chief executive of Maidstone and Tunbridge Wells NHS Trust in November 2003. In 2006, a number of patients died after an outbreak of C Difficile. A report into the outbreak by the Healthcare Commission the following year was highly critical of the trust’s leadership.

The trust’s remuneration committee unanimously decided to keep Rose in post and Rose wanted to stay to defend herself. However, the Strategic Health Authority (SHA) disagreed.

The SHA held sway and, after taking legal advice, the trust decided to pay Rose £250,000. Under a compromise agreement, Rose agreed not to pursue any internal grievance, bring any legal claims against the trust, make any damaging statements about the trust or disclose the substance of the agreement.

Although both parties signed the agreement, the Department of Health instructed the Trust in October 2007 to pay only six months’ notice – £75,000 – and to withhold the compensation part of the payment. Ms Gibb challenged that decision and MiP asked Thompsons Solicitors to act for her.

If public bodies exercise their powers unreasonably, courts can decide that they acted beyond their power (or ultra vires), in which case whatever they did 22

issue 7 | autumn 2010 | healthcare manager

will be void.

In the High Court, the trust argued that it had been “irrationally generous”, and that it did not have the proper authority from the SHA and the Treasury, so the agreement was ultra vires and therefore void.

The judge agreed, and also found the trust had miscalculated the likely costs and liabilities of a dismissal. It had been wrong to consider past service. It had recklessly assured her the payment was properly authorised, but there was no loss as a result.

The Court of Appeal disagreed. At stake was the reasonableness of the trust’s decision, not whether it was a financially prudent settlement. The trust “had to consider a series of matters not all of which were clear-cut or implied financially precise outcomes”.

Importantly for employers and MiP members, the Court of Appeal spelled out that an employer could consider past service and the difficulties that an employee might have in finding another job when settling severance terms.

It said, “the constraint of rationality will not close the door on some degree of generosity for the sake of good relations and mutual respect between

employer and employee”.

Of course, each case stands on its own merits, but these findings are helpful. They don’t require employers to be generous, but equally employers can’t say they are only allowed to offer the bare legal minimum. Negotiation has a bit more space.

The Court also agreed that Rose had signed away employment rights, after her employer’s reckless assurances about the compromise agreement. This aspect of the case throws light on a difficult issue in negotiations. Severance payments to senior managers – including those working in foundation trusts – are tightly controlled. Can you be certain your employer or its lawyers have got the right authority? Probably not, but it might be worth seeking written assurances about proper process before leaving your job.

Finally, executives in difficult jobs might take more comfort from the conclusion that compensation of £250,000 was not “outlandish” for the “arbitrary termination of a career which it was unlikely Ms Gibb would be able to resume or resurrect”.

The trust did not appeal

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16332 MIP ad 213(h) x 110(w):Layout 1

Getting to grips with the white paper

31/8/10

13:11 Page 1 MiP AT WORK

These are uncertain times.

MiP members debated the white paper and expressed their anger at the language used about managers by ministers, in meetings around England in July and August.

The Yorkshire and the Humber members’ network met in Leeds the day after the white paper was published, followed by meetings at PCTs including Brent, Bristol and Leicestershire.

Other key themes from the meetings, which will feed into MiP’s response to the white paper consultation, included: the massive risks in the government’s plans; concerns about GP consortia; governance and capacity of GP practices; fears about losing the NHS as an organisation; the loss of quality and financial control; and the future of public health in local government.

On the employment front, members discussed social enterprise options; vacancy freezes and overwork; Transforming Community Services; management cuts; staff with marketable skills already leaving; patchy information and communication from PCT to PCT; TUPE rights; the need for quality and best practice for career support; uncertainty about mutually agreed resignation schemes; the threat to the pension scheme; joint working and other campaigning with other unions.

Members agreed ways to strengthen partnership working with employers around the White Paper and many new link members came forward

Reduce the uncertainty.

Join MiP. One thing is for certain in such times – you need support.

MiP is the UK’s only trade union organisation that solely represents healthcare managers.

We provide an influential voice, personal support and employment advice, management skills and access to leadership networks.

Our experienced team of employment professionals is on hand to offer one-to-one confidential advice, negotiation and representation and fast access to legal resources.

Join MiP today. Visit www.miphealth.org.uk/joinus

.

For more information about becoming a link member contact Martin Furlong, national officer for recruitment and organising: m.furlong@ miphealth.org.uk

helping you make healthcare happen

issue 7 | autumn 2010 | healthcare manager

23

backlash

Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@ healthcare-manager.co.uk.

by Celticus

Out-sauced

I

t’s tea trays at dawn in Essex, where the trust is preparing to ‘vigorously defend’ a £2.3m writ from catering giant Compass, which claims the trust was too hard on its failings while running the hospital canteens. The MidEssex Hospitals Trust fined Compass subsidiary Medirest £46,000 for proffering outof-date tomato ketchup and £85,000 for supplying superannuated chocolate mousse, as well as £95,000 for operating a fridge at the wrong temperature and £23,000 for using a spoon to prop open a fire door.

Compass’s lawsuit says the trust ‘systematically made unreasonable and/ or unjustified deductions’ totalling £700,000. Despite such onerous demands, the company is still claiming another £1.68m for the profit it would have made out of the rest of the five-year contract, which it terminated itself in October 2009.

The Living Dead

C

elticus has been interested to read the online musings of “Dr Custodes” (we suspect this is not his real name), a GPturned-manager working for a PCT indentified only as ‘the Black Tower’.

Surveying the scene after the July Revolution, he records: ‘In primary care I have colleagues who are

24

scouring the white paper and subsequent publications for the section called ‘Shifting the Blame to GPs’...

But, rather like the film The Sixth Sense, I can see dead people and some of them don’t know they’re dead.’

Read more of Dr Custodes’s tales of woe at community. healthcarerepublic.com/ blogs/tales_from_the_black_ tower.

You cannae change the laws of physics

C

elticus is grateful to Dr Martin McShane for more trenchant observations on the postwhite paper landscape.

‘Going into any big change…

I have also learnt to always think of the formula, as applicable as a law of physics, which states that for any project there are three variables: fix two and the third becomes defined.

The three variables are: the resource you dedicate to the project, the time to complete the project, and the quality of the outcome. By 2013, we must have GP consortia up and running whilst slashing management support by 45%. The time-scale seems fixed, the resource allocated seems apparent; the big question is – what does that bode for the quality of the outcome?’ Dr McShane blogs, ocassionally but thoughtfully, on the BMJ site at: blogs.bmj.com/bmj/ category/martin-mcshane/

issue 7 | autumn 2010 | healthcare manager

Surf’s up

T

o Cornwall, the surf capital of Europe (weather permitting), where a pilot scheme to assess the value of ‘surf therapy’ for mental health patients is getting underway.

Surfers have long extolled the mental and physical benefits of catching the waves – now those benefits are to be formally evaluated by the local NHS. The project will use professional surfers (yes, there are such people) to run one-to-one lessons for 20 young people with mental health needs. Project leader Joe Taylor said: ‘They have funded a pilot scheme for six weeks, and after that time we will produce a report to evaluate whether it has had any impact on their mood and wellbeing.’

Fingers crossed for an Indian summer, then.

Life is tweet

T

he search for our favourite NHS tweet of the summer found

PCTs particularly active, twittering health messages on everything from stinging marine insects to how to cope with England’s embarrassing World Cup exit against Germany.

Celitcus isn’t keen on Lincolnshire PCT’s idea of a night out: ‘Are you out in Lincoln on Saturday night?

Watch out for Chlamydia testing during 9pm-1am on the High Street.’ And we were alarmed by this plea from North Norfolk Hospital: ‘May we politely ask people not to walk across the helipad. That is all.’ But you’ve got to admire the same trust’s optimism in this message: ‘Busy day ahead.

Expecting 200 people to attend dementia event we’re holding… this afternoon.’

Our winner came from Havering PCT with its tweet encouraging men to look out for signs of testicular cancer, posted in the #worldcup feed: ‘Keep your eye on the ball – Robert Green should have, and so should you.’

LESSONS FROM HISTORY: PART I We trained very hard, but it seemed that every time we were beginning to form up into teams we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress, while producing confusion, inefficiency and demoralisation.

Gaius “Petronius” Arbiter (c27–66 AD) the Darzi-esque ‘judge of excellence’ at the court of the Roman emperor Nero.

SDO Network SDO Network

The Service Delivery and Organisation Network

The Service Delivery and Organisation Network supports NHS managers to use health services research to improve and develop the services they manage.

Membership of the SDO Network is free to all NHS organisations, and members can access a range of services including: • themed learning events and publications • chief executives’ forums

‘Exposure to research strengthens managers’ ability to successfully innovate’ Ron Kerr, chief executive, Guy’s and St Thomas’ NHS Foundation Trust

To find out more and to join, email sdonetwork@nhsconfed.org or visit www.nhsconfed.org/sdonetwork

• support in conducting and sourcing the latest health services research.

The SDO Network is funded by the NIHR Service Delivery and Organisation research programme (NIHR SDO)

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27/08/2010 13:01

EE i P S FR M R R BE FO EM M

MiP national conference 2010

Good management in a cold climate Wednesday 24 November • Congress Centre, London WC1

keynote speakers include conference chair:

Jenni Murray

BBC journalist

Chris Ham

Chief Executive, The Kings Fund

Lord Victor Adebowale

David Nicholson

Chief Executive, Turning Point

Chief Executive, NHS England

In these times of public spending cuts, healthcare managers are under pressure to deliver higher quality with fewer resources.

The annual Managers in Partnership conference gives you the opportunity to join managers, policymakers and other decision makers to debate challenges we face: How can managers work in partnership with GPs, other clinicians and patients to ensure effective commissioning and delivery of services?

What does the Big Society and devolution of power to a more local level mean for health service delivery?

How can we meet the challenges ahead with less money and fewer managers?

places are limited: register online and download a full agenda at

mip-conference.co.uk or telephone 020 7592 9490 sponsored by

helping you make healthcare happen

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03/09/2010 11:31:44