issue 10 summer 2011
healthcare manager LET’S WORK TOGETHER TOP MENTOR LIZ PAICE ON THE POWER OF COACHING
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NHS finance: feeling the pinch? Why telehealth is good for you
helping you make healthcare happen
Working together for you The Open University and Managers in Partnership have joined forces to encourage greater participation in health sector education and training. Between us, we offer a wide range of modules and qualifications to make a difference to your life, your career and the people in your teams. Whether you are an Administrator or CEO, Clinical Nurse Manager or Business Manager, there are a range of modules and qualifications that will help develop skills in areas of practice from policy interpretation to research. Our flexible work-based learning fits with busy work and home commitments. Modules are vocationally relevant based on cutting-edge research and learning materials, to ensure that what you learn today, you can apply tomorrow – making an immediate and effective impact to improving levels of care. Did you know? • UNISON/MiP members receive a 10% discount on many of our courses • Learning materials reflect the day-to-day practical issues involved in running a hospital ward or clinic.
Postgraduate options designed with you in mind Postgraduate Certificate in Advancing Healthcare Practice (C92) Postgraduate Diploma in Advancing Healthcare Practice (E46) MSc in Advancing Healthcare Practice (F52) MBA (AMBA accredited) (F61) Professional Certificate in Management (C31) Certificate in Professional Practice in Delivering Public Services (K02) Postgraduate Certificate in Clinical Leadership (K04) Postgraduate Certificate in Professional Practice (Children and Families) (K14) Postgraduate Diploma in Advancing Professional Practice (Children and Families) (E70)
Advance your career www.openuniversity.co.uk/mip
0845 300 8846 Quote: GAMAEG
INSPIRING LEARNING
The Open University is incorporated by Royal Charter (RC 000391), an exempt charity in England and Wales and a charity registered in Scotland (SC 038302).
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issue 10 summer 2011
healthcare manager inside heads up:2 What you might have missed & what to look out for Leading edge: Jon Restell inperson: Christina McAnea, head of health, UNISON inpublic: Gwent Frailty Programme
letters & comment:8 Clare Gerada on GPs’ doubts about the health bill Richard Sarson says the reforms ignore 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.
Teleheath: Encouraging signs from English pilot Interview: NHS mentor of the year Elisabeth Paice NHS finance: crisis at Imperial could go viral Skills for Health: New resources to nurture talent
regulars:20 Legal eye: Getting to grips with TUPE regulations. Tipster: How to tweet effectively Careers: Making personal development plans work MiP regions: Partnership working across the UK
backlash:24
Welcome to the summer issue of healthcare manager, the magazine from MiP (Managers in Partnership), the trade union organisation specifically for mangers working in health and social care. We knew when we were planning this issue that there would still be some uncertainty about how public spending cuts will affect the NHS. We just hadn’t realised there would be more uncertainty, not less. What we do know is that investment in NHS services is being squeezed and organisations are struggling to maintain levels of service. In this issue, Noel Plumridge clarifies the financial pressures facing service providers, and the problems they face trying to balance the books and meet increasing demand. NHS mentor of the year Elisabeth Paice argues that investment in mentoring and coaching is essential and can achieve efficiency savings as well as improve quality of care. Jenny Sims puts the case for telehealth as an essential tool in developing affordable care systems. And of course we have our regular features bringing you news about health policy and the workplace. We hope you enjoy the magazine. Do contact us with any comments you have about this issue or about the health services in general. Marisa Howes Executive editor
issue 10 | summer 2011 | healthcare manager
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HEADS UP
heads up what you might have missed and what to look out for
MiP Conference
MiP 2011
23 November 2011 Congress Centre, London Make sure this date is in your diary for this year’s MiP conference. Public service cuts are biting everywhere. In England, the Government’s proposals for health service reform have been described as “the most radical change to the NHS since its inception”. This year’s MiP conference will provide a highlevel forum to examine and discuss the proposals and what they really mean for managers, patients and frontline staff.
For further information, contact Fiona Gardner on 020 7222 2176 or email MIP@connectpa.co.uk
For more information visit NHS Live at: www.institute.nhs.uk/nhs_live/ introduction/welcome_to_nhs_live.html
Campaigning
Training
Enduring Values of the NHS
A new online training course for carers and peo-
Unison has published Enduring Values, setting out the union’s vision for the
healthcare manager
Executive Editor
Contributors
issue 10 | summer 2011
Marisa Howes m.howes@miphealth.org.uk
ISSN 1759-9784 published by MiP
Associate Editor Craig Ryan editor@healthcare-manager.co.uk
Clare Gerada, Marisa Howes, Andrew James, Liz McCarten, Helen Mooney, Alison Moore, Noel Plumridge, Jon Restell, Craig Ryan, Richard Sarson, Jenny Sims, Martin Shovel, Karen Walker
Art Director
James Sparling
Warners Print, Bourne, Lincs
Design and Production
Advertising Enquiries
Lexographic production@healthcare-manager.co.uk
020 8532 9224 adverts@healthcare-manager.co.uk
All copy © 2011 MiP or the author. Opinions stated are not necessarily those of healthcare manager or MiP.
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Our conference will bring you up to date with the latest innovations in health service delivery and give you a valuable opportunity to join managers, policy makers and other decision takers to find out how health service managers can help to deliver worthwhile change in the NHS.
ple who work with carers is now available via the NHS Live website. Carer Aware, developed by Dudley Council, helps carers and service managers to understand carers’ rights and the support available from local authorities and the NHS. Access is free and users can dip in to any part of the course at any time. Those who complete the full course can test their knowledge and receive a ‘Carer Aware’ certificate. The NHS Institute has dozens of online learning courses available on the NHS Live website, with over 11,000 members now taking advantage of online training and sharing best practice via the site.
Live and learn
issue 10 | summer 2011 | healthcare manager
future of the NHS as part of its ‘Our NHS Our Future’ campaign. Illustrated throughout with real life stories from NHS patients, including that of Unison general secretary Dave Prentis, the document shows how widely loved the NHS is and why we need to ensure it survives for generations to come. Enduring Values reminds us about the values and pledges set out in the NHS Constitution and warns that current government proposals threaten to undermine them. The documents includes international comparisons and a useful myth-buster, including a welcome defence of NHS managers, drawing on academic research by Ian Kirkpatrick at Leeds Business School which shows the NHS is ‘management light’. Enduring Values is wellresearched and a useful way to publicise the good work that healthcare staff do. Copies of the report are available on the Unison website at www.unison.org.uk/ healthcare
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.
HEADS UP
leading edge Jon Restell, chief executive, MiP I am trying to write this column against the din of political deals being hammered out and pork barrels rolling up and down Whitehall. Whatever the outcome of the latest twist in the story of the Government’s health bill, one thing is certain – the position of the NHS will not suddenly change. This reality is dawning on our politicians who hitherto have been mucking up spectacularly. The obsessive and largely unnecessary focus on legislative and structural change remains with us. But in recent weeks more attention has been paid to the state of the NHS in England, its immediate challenges and the many risks created by uncertain policy and the sudden collapse of management capacity, morale and focus in many parts of the system. One change of tack is the cooling of the hostile rhetoric against managers. In a recent speech, the Prime Minister spoke about the important and valuable work of
“Supportive politicians need powerful stories about how individual managers make a difference for patients, clinicians and other staff, and taxpayers.” managers. The London Evening Standard managed to discuss the future of the NHS without attacking a ‘huge swollen bureaucracy’. Most impressively, Andrew Lansley defended his policies in the Daily Telegraph without mentioning managers once. At last, public acceptance that, in the great scheme of things, management costs are a red herring. The louder articulation of the case for managers is another sign of a changing scene. The excellent recent report by the King’s Fund, The Future Leadership and Management in the NHS: No More
Heroes, deserves special praise. MiP has seen much more interest from parliamentarians in the state of management and the risks associated with under-management. For the first time, some are questioning the wisdom of cutting so far and fast and might be ready to argue openly for a slowdown, even a reversal, of management cuts. And this is where you must come in if we are going to make a difference. Abstract arguments and general statistics, important though they are, do not cut the mustard in this debate. Supportive politicians need powerful stories about how individual managers make a difference for patients, clinicians and other staff, and taxpayers. And how lack of management hurts quality for patients, support for staff or efficient use of public money. Wherever you work, if your job matters, you will have a powerful story. Your patients, your staff and the public need you to tell it. Get in touch.
SMi GP Commissioning conference 12-13 October 2011
Following the ‘pause’ of the government’s Health and Social Care Bill, what has the coalition learnt and what does it mean for the future of the NHS? Join SMi at their inaugural GP Commissioning conference with key representatives from NICE, RCGP, CQC, ABPI, United Medical Consortium and Genzyme. This is the perfect opportunity to discuss overcoming the challenges when the reforms are implemented. Discover what the future of NHS will look like; ■■ understand the role of GPs in specialist commissioning services;
■■ get to grips with accountability issues within GP consortia; ■■ achieve efficiency savings and increase productivity within
your area; ■■ overcome the barriers and ensure the support of the local
communities. This is an essential opportunity to voice your opinion and ensure you are ready for future change in the NHS. Register by 30 June and save £200. Visit www.smi-online.co.uk/gpcommissioningevent5.asp or contact Zain Philbey on 020 7827 6722 or email zphilbey@smi-online.co.uk. issue 10 | summer 2011 | healthcare manager
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HEADS UP
Arts
Arts make a Big Difference in healthcare Managers in Partnership has supported a number of health organisations in producing a report using arts and culture in healthcare settings. Reflecting upon the Value of Arts & Health has been produced by Derbyshire Community Health Services, Leicester City Primary Care Trust and Lincolnshire Partnership NHS Foundation Trust, working with not-for-profit agency Big Difference Company. The document was launched by Glenis Willmott MEP, Labour’s spokeperson on public health in the European Parliament. ‘As a former medical scientist, I have been fascinated to learn about the arts and health proposals,’ she said. ‘The document really does offer a chance to understand the role that the arts can play in healthcare.’ Over the next 18 months, the report’s conclusions will be taken forward by a regional Strategic Working Group supported by an Independent Chair, and working with a Delivery Group Partnership. Geoff Rowe, chief executive of Big Difference Company said: ‘Our priorities include providing training for health and
Left to right: Geoff Rowe, Glenis Willmott MEP and Adam Clarke
social care professionals, exploring a pathways initiative to identify new and existing routes from health to arts, and developing a framework for evaluating the process and its outcomes. We will also consider how and where the work best fits in the emerging health and social care ecology. ‘The document has been launched as the national arts and health picture becomes clearer. Big Difference Company
Elections
Speaking up for healthcare managers
Election of MiP national committee MiP will be holding elections later this year for its national committee. This is an exciting time to get involved in MiP and if you would like to play a key role in shaping MiP policy and leading the union over the next few years you may want to stand for election. New committee members will be elected to represent the geographical constituencies set out opposite and will serve a two-year term from January 2012 to December 2013. As a member of the committee you will play a key role in making sure MiP policy reflects the views of our members on healthcare, management skills and workplace relations. You will also be involved in MiP recruitment and organisation, being a key link between the members in your region and the national union. 4
issue 10 | summer 2011 | healthcare manager
has supported work over the past twelve months on refreshing the organisation charged with supporting the national arts and health community, led by the London Arts in Health Forum and including representatives from all English regions.’ For further information contact Big Difference Company: info@bigdifferencecompany.co.uk.
Timetable for elections
Nominations open 24 August Nominations close 23 September Elections open 10 October Elections close 4 November Results announced 23 November (at MiP national conference) New committee takes office on 1 January 2012.
Seat allocation by area
area seats Northern Ireland 1 Scotland 2 Wales 2 Each English NHS region (except London) 1 London 2
The rules for election will be posted on our website. We will then write to all members with details and to invite nominations. In the meantime, if you would like further information, talk to your national officer or contact Martin Furlong on 020 7121 5438.
HEADS UP
inperson Christina McAnea, head of health, UNISON Christina McAnea, who took over as UNISON’s senior national negotiator for health in April, can count herself as one of the union’s most experienced negotiators. She has worked in the trade union movement for more than 25 years, the majority of that time in UNISON. She comes over to health after working as the union’s head of education for the last seven years, when she led negotiations with employers on behalf of members working in universities, colleges and schools and was instrumental in setting up the school support staff national negotiating body. She’s candid about the job she has recently taken on. ‘I am under no illusion that this is one of the most demanding jobs in the union and this is a tough time for the NHS. The government seems determined to push ahead with plans that will wreck the NHS as we know it, but I’m ready to take on the challenge on behalf of all our 460,000 health workers,’ says Christina. ‘I am taking over as the government is proposing to take the “national” out of the National Health Service...our biggest concern about the government’s reforms is that they will lead to wholesale competition in the NHS with the fragmentation of services allowing the private sector to come in and make a profit out of healthcare,’ she warns. Christina agrees there have always been some services provided by the private sector, but when it means the ‘wholesale breakdown of the model of integrated care provided by the NHS’, which she says the government is proposing, then she says we should all be worried. ‘These reforms will make it very difficult to have something fair to everyone across the system and we will end up with a two tier system with the richest paying for extra care. So although the government will still say there is an NHS it will be very limited and rationed.’
She says that it is her job and that of Unison to make both government and opposition listen to the concerns over NHS reforms and to get the public really ‘riled’ about them. Another challenge facing Christina and her team is ensuring that NHS employers do not attempt to subvert NHS pay and conditions and the hard-fought for Agenda for Change contract while the spotlight is trained elsewhere. She says the strong working relationship between Unison and MiP is invaluable, particularly when Agenda for Change negotiations were taking place, and she hopes to build on this joint working in the future.
“These reforms will make it very difficult to have something fair to everyone across the system and we will end up with a two tier NHS with the richest paying for extra care.”
‘We are very committed to maintaining Agenda for Change and strongly resist any dismantling of it,’ she says. And what of the role of the health team in Unison? Christina is keen to make sure it is outward facing. ‘We need to put the emphasis on supporting branches and regions and finding out what they want from us. We are already seeing the abolition of strategic health authorities and primary care trusts and we need to know what our members want in terms of career development and training for example.’ Helen Mooney issue 10 | summer 2011 | healthcare manager
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HEADS UP
Valuing management
No more heroes... just good managers MiP has warmly welcomed the King’s Fund report, No More Heroes, on the future of leadership and management in the NHS. The report, published in May, criticised the denigration of managers by politicians and in the media and called on the Department of Health to rethink its plans to reduce the number of managers in view of the pressures from budgetary cuts and organisational reform. ‘Denigration of managers and the role they play in delivering high quality health care will be damaging to the NHS and to patient care in the short and long term,’ said the report. As well as debunking many myths about the numbers and costs of NHS managers, the report warned that government targets for cutting management posts were ‘simply arbitrary’ and ‘backed by no published analysis whatsoever’. Jon Restell, MiP chief executive, said: ‘This report deserves to be widely read. It makes crystal clear that management is essential in healthcare. We support the call to reverse the planned management cuts. Politicians need to listen before it’s too late. It’s time to stop denigrating managers and build the management capacity in the NHS that patients, clinicians and taxpayers need. It’s also good to see that the King’s Fund has the guts to say that the NHS might be undermanaged. At a summit launching the report on 18 May, MiP vice chair Rosie Ilett, added: ‘The summit highlighted that leadership and management in the NHS is essential, and needs to be recognised as a critical component in delivering the service and providing quality patient care. The very mixed audience heard many examples of leaders who were unafraid to work across disciplines, to think creatively and to see their work as part of a collective effort.’
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issue 10 | summer 2011 | healthcare manager
Scotland & Wales
Devolved governments set to widen rift with English NHS
NICOLA STURGEON
LESLEY GRIFFITHS
The divergence between the NHS in England and other parts of the UK is set to intensify following elections in Scotland and Wales which saw governing parties in both countries consolidate their positions. Following the SNP’s crushing victory in Scotland, Nicola Sturgeon retained her post as deputy first minister and cabinet secretary for health. Although her department expects to face severe budgetary pressure in the next four years, first minister Alex Salmond has promised to extend the current ‘no compulsory redundancies’ deal with Scottish civil servants to all 160,000 staff of the Scottish NHS. MiP vice chair Rosie Ilett said: ‘MiP members in Scotland look forward to working with the new Scottish Government to continue to deliver quality healthcare across Scotland. All disciplines and professions need to work together in increasingly straitened times. NHS managers are a critical part of the healthcare equation and members expect that their contribution is valued along with all other NHS staff who work to improve patient care and public health.’ In Wales, Lesley Griffiths became health
and social services minister following Labour’s victory in the National Assembly elections, and first minister Carwyn Jones’s decision to form a government without former coalition partners Plaid Cymru. Griffiths replaces left-winger Edwina Hart, who took over the business portfolio. In her first speech as health minister, Griffiths said her priorities for NHS Wales would be improvements in access to GPs and reduced ambulance response times. “We have a shrinking budget from Westminster so we will have to look at priorities and where we can save money but we are not going to go the way of the UK Government – we don’t want to see privatisation,” she said. Sam Crane, MiP committee member for Wales, said: “We have a new minister but I cannot see major changes for some time. We have just had the largest ever restructuring in NHS Wales – integrating trusts and 22 commissioning bodies into seven Health Boards took more than two years to bed in. “With social services we expect to see a push towards more working across local authority boundaries but we have not picked up any noises about changes to local authority boundaries.”
HEADS UP
“The quality of the leadership has been key in getting the partners totally committed to driving this forward...political backing has also been very significant.”
inpublic Gwent Frailty Programme
Since April, the region of Gwent in south-east Wales has been home to the Gwent Frailty Programme. This farreaching and innovative scheme is based on the premise that people using health and social care want a single point of access to the services they need and want to be able to stay in their own homes as much as possible. A community resource team has been set up which integrates primary and secondary care and health and social care. The aim is for individuals and professionals to use the service through a single point of contact with an experienced and trained professional to triage the situation and to put in place the most appropriate type of support. The service has been built along similar lines to NHS Direct. Gill Lewis, strategic programme manager for health, explains
that the scheme was initially set up in an attempt to reduce delayed discharge from hospital. ‘Both the health board and local authorities spent a lot of time setting out what would be a better system in terms of bringing people out of hospital and addressing the needs of local people in keeping them out hospital,’ says Lewis. The programme is a partnership between the Aneurin Bevan Health Board and Torfaen, Blaenau Gwent, Caerphilly, Monmouthshire and Newport councils. Most recently it has also received funding of £9m from the Welsh Assembly Government’s ‘Invest to Save’ fund. The key aims of the programme are to bring together health and social care professionals to make sure there is access to the right person at the right time, to deliver the correct level of response, which
can change according to how much support is needed at any particular level, and to deliver care in or close to the patient’s home and avoid unnecessary hospital admissions. Programme manager Lynda Chandler says it has been no mean feat to get five local authorities and the health board working together. Charities including Age Concern and staff trade union representatives have also been heavily involved in shaping the scheme. ‘The quality of the leadership has been key in getting the different partners totally committed to driving this forward, it is now key that we work with frontline staff as well to win hearts and minds, political backing both from central and local government has also been very significant,’ says Chandler. In it’s early stages, the programme has focused on facilitating early discharge and providing safe alternative pathways to hospital admission. The team are working closely with GPs to make sure they feel confident in using the system, because if they bypass it and admit people to hospital, the current problems will persist. Ultimately the programme has been set up to save money in the long term. The cost of the project is met from the savings made from the reduced hospital and care home admissions, and savings of up to £1m a year are expected once it is fully up and running. Helen Mooney For more information about the Gwent Frailty Programme visit: www.gwentfrailty.torfaen.gov.uk
Hanging on the telephone? MiP’s telephone numbers have changed to 020 7121 5***, with the final three digits the same as the old number. So the number for Marisa Howes, our executive editor, is now 020 7121 5167. All the numbers are listed at www.miphealth.org.uk/Aboutus. Apologies to anyone who hasn’t been able to get through.
You can check your own contact details on our website and update them if necessary. Login to the members’ area at www. miphealth.org.uk, using your MiP membership number as your username and your surname as your password. The new membership contact is Fiona Thorne, f.thorne@miphealth.org.uk.
issue 10 | summer 2011 | healthcare manager
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LETTERS
letters
comment
to the editor
Please send to editor@healthcare-manager. co.uk or to 8 Leake Street, London SE1 7NN. We may edit letters for length. Name and address must be supplied, but you may ask for them not to be published.
Like it or lump it? I am pleased that the public service trade unions are lobbying hard to protect our interests in response to the Hutton review of pensions. In his report, John Hutton recognised that ‘protecting accrued rights is a prerequisite for reform both to build trust and confidence and to protect current workers from a sudden change in their pension benefits or pension age. It is also right that those closest to retirement will be least affected by any changes to scheme design’. While I welcome this, I would value an undertaking that, should the new scheme be introduced before 17 November 2013, when I will reach 60, my accrued rights under the current pension scheme (the ‘old’ scheme), particularly the lump sum, will be paid to me at the age of 60 (or earlier, if I find myself redundant, as I work for a PCT). So, I will not be forced, even if I remain in the NHS, to wait for payment of the lump sum, on which I am relying to pay off my mortgage, until I reach the new state pension age which is likely to govern the future pensionable age in the public sector. Does anyone else share my concern? Name and address supplied.
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issue 10 | summer 2011 | healthcare manager
Clare Gerada
Chair, Royal College of General Practitioners
Pause for thought The Royal College of General Practitioners is not opposed to reform. The NHS needs to change in order to meet the future demands of patients and rise to the challenges of an ageing population and the provision of quality care in an increasingly complex clinical world. There is much in the Government’s Health and Social Care Bill that we welcome. We support the move to place clinicians at the heart of planning services for their patients and the increased emphasis on professional and patient involvement in health service design and funding decisions. But we also have concerns about the Bill and have written to the Prime Minister listing changes that we feel are needed to protect patients and the principles of the NHS. Topping this list is that the Bill should make it clear that the Secretary of State has a duty to provide ‘or secure provision of’ a comprehensive health service throughout England. We want assurances that commissioners or providers will not be able to charge patients for healthcare services that are currently provided free by the NHS or are recommended by NICE, and that there is clarity as soon as possible about which allocation formula will be used by GP consortia for commissioning hospital care. We also want the Bill to place a duty on Monitor, the NHS National Commissioning Board (NCB) and GP Commissioning Consortia (GPCC) to enable collaboration to provide integrated services to meet patients’ needs without fear of a
“Our preferred model is GP federations, where practices can pool expertise and resources.” competition referral. We feel that as they stand, the reforms promote competition without sufficient clarification about how services to patients will be safeguarded and improved. We believe that provider-side reforms could deal with many of the issues without the need for repeated organisational change or many of the proposed reforms. Our preferred model would be GP federations, where practices can pool expertise and resources to deliver a wider range of services. Several federations have already been voluntarily established and are doing excellent work in improving patient care in their local communities. GP federations can also achieve greater collaboration and partnership working with hospital, social care and third sector colleagues to ensure continuous and seamless care. As health professionals, be it clinicians or managers, we all have a duty to ensure that whatever is finally enacted by the Bill brings about real improvements in the care and services we can deliver to our patients. The stakes are too high not to get this right
.
COMMENT
comment Richard Sarson
Writer, blogger and member of the Parliamentary IT Committee.
Reforms turn deaf ear to patients I am old. I and my contemporaries are NHS ‘frequent fliers’. As patients, we have our views about the efficiency of the hospitals and GPs we often visit. Some of us have been in business all our lives and look with a beady eye on the administrative and IT systems in place. And I look with alarm at the Lansley ‘reforms’, which don’t seem to touch many of the things that need fixing. To start with, having a monster rejig of the relationship between GP and hospital at a time of cuts seems insane. Patient care will inevitably suffer. Even with an end-date of 2013, the upheaval will continue until at least until 2015 – look at how PCTs, introduced in 2002, are still in gestation while they are being axed. And then David Cameron calls a ‘pause’, which will prolong the agony for another two years. So I can expect reduced patient care until 2017, when I will be 87. I doubt that I and my contemporaries will survive the ‘reforms’.
“Having a
monster rejig of the relationship between GP and hospital at a time of cuts seems insane.”
We are just expendable cannon fodder in the political battle – the normal situation for patients, despite the ritual statements by ministers and NHS managers that ‘the patient comes first’. Is the political battle over the Lansley reforms worthwhile? I am puzzled by the onslaught on the PCTs. Are they really so bureaucratic and dreadful? And I have many doubts about whether GPs will be any good at commissioning. Even more puzzling is that no one, but no one, including PCT managers and the New Labour people who set up PCTs in the first place, have jumped to their defence. Are PCT managers just a load of wimps who deserve to be axed? Two of my contemporaries have died from MRSA in the last six months, after being admitted to hospital for treatment for other conditions. It seems to me it’s important not to be admitted to hospital unless absolutely necessary. It’s a nobrainer that telehealth, including remote doctor/patient consultation, can reduce hospital admissions and thereby the number of MRSA deaths. Most of the recent telehealth initiatives have been masterminded by PCTs, not GPs. I feel that GPs see telehealth as a threat to their centuries-old way of practising medicine, so long live the PCTs and the forward-thinking ‘bureaucrats’ who make them up. I doubt that GPs, once they get the whip hand, will be that innovative. On the subject of innovation, why is contact between patients and doctors in the NHS almost entirely email-free, when email has become the communications
medium of choice for most of society? Many of my contemporaries spend much of their time waiting by their front doors for the results of tests or details of consultants’ appointments, when they could have got the same same information by email a week or more earlier, relieving them of the anguish of waiting and maybe even increasing their chances of survival. On hospital websites all I find is email addresses for press or HR enquiries. The excuse for this is ‘security’ or the fact that 40% of the population is still not online. In 2011, the lack of security is a myth and just cover for the Luddite tendencies of clinicians. And the ‘digital divide’ is going to be eliminated by Martha Lane Fox in the next couple of years. OK, there will still be some patients who are only accessible by post, but please don’t give most patients less prompt care because of this small minority. I have found one exception: the Marsden, where patients are offered an email address for the relevant consultant. If they can communicate with their patients in a 21st century way, why can’t other hospitals follow? I could go on, but in short, I see little evidence that the Government or healthcare professionals have thought very hard about what patients really want to see reformed
.
Views expressed are those of the authors and not necessarily those of healthcare manager or MiP.
issue 10 | summer 2011 | healthcare manager
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TELEHEALTH
Jenny Sims reports on encouraging early findings from the government’s £31m pilot of telehealth schemes in England.
The use of telehealth and telecare may be ‘just another tool’ in the healthcare management box, but it’s the essential one for solving the problem of serving increasing elderly populations with long term care needs. Current staffing systems will not be able to cope. That was a key message from an international congress on telehealth (TH) and telecare (TC) held at The King’s Fund in London in March, which attracted 80 speakers from 10 different countries. Another key message was: act now. Healthcare organisations need to stop waiting for more pilot studies and more expensive, lengthy, Randomised Controlled Trials (RCTs). There is already enough evidence to go ahead with implementing telehealth schemes, or at the very least to start the process. Though many countries can boast success with pilot studies, these have generally been small. There is insufficient evidence on cost savings, and doubt about whether piloted projects could be implemented large scale. But early findings from the Department of Health’s Whole Systems Demonstrator Programme (WSDP), suggest that study results due by the end of June 2011 could be the shot from the starting gun that many have been waiting for. 10
issue 10 | summer 2011 | healthcare manager
Early findings show a reduction in Accident and Emergency admissions, fewer admissions to care homes, more people able to stay in their own homes for longer, and an improvement in the quality of their lives. The findings also stress the importance of interoperability of systems and how that will drive down price. ‘It will provide the solid evidence base we need to show telecare helps people stay independent longer and ties up resources more effectively,’ says Stephen Johnson, deputy director of long-term Conditions at the DH. The three year trial into heart failure, diabetes and chronic obstructive pulmonary disease (COPD) has been the largest and most expensive telecare RCT carried out anywhere in the world. It involved 6,000 patients, 400 carers and 235 GP practices, and examined the effect on both people in the care of social services and on carers. Three very different pilot sites were chosen to reflect urban and rural populations: Newham in east London, Cornwall and Kent – the latter already had an impressive pedigree of successfully proven telecare pilots. In all three sites patients, carers, nurses and family practitioners reported positive experiences in using telehealth, and as a result, Newham and
Cornwall hope to expand it into other services. But Kent has gone much further, by promising to ‘mainstream’ telecare into their health and social services from 1 April this year. It has already commissioned a governing body, the Kent Technology Strategy Board, to bring in all the partners: suppliers, providers, GP commissioning groups, patient groups and other interested parties. A jubilant Hazel Price, of Kent County Council, and programme manager of the Kent WSDP, said: ‘We know the challenges and the barriers, but we know telecare works.’ Kent’s earlier pilot with specialist community matrons using telemonitoring as a triage tool every morning before making their visits, found even the subtlest changes in patients could trigger an intervention. ‘Over six months we saved an average of £1,800 per patient. Rolled out across all long-term conditions this could save £7m – not an amount to be sniffed at,’ adds Price. The trial has reinforced the findings of Kent’s earlier pilots. Giving patients more information about their conditions enables them to ask more pertinent questions, and makes them more confident and empowered to manage their conditions.
TELEHEALTH
One of the lessons learned is that it has been harder to engage top management with telemedicine than clinical care groups. Getting telecare discussed at board level is not easy, says Price. Like others before them, Kent found telecare isn’t suitable for everyone or all conditions, and one size doesn’t fit all. But they are confident it works for heart failure, COPD and diabetes and are now looking to use it in maternity services and for young, unstable diabetics. Many questions remain to be answered, including: who should receive telemedicine equipment? For how long? How should people who misuse equipment be dealt with? And should some people be asked to pay? These are universal problems, and ones Quebec is currently tackling in its state-wide pilot of telecare for its statefunded health and social services. Though it’s proving a great success, as soon as the condition of patients at home have been stabilised, cost constraints mean the equipment is taken back and given to someone else in greater clinical need. But David Levine, chief executive of the Montreal Health and Social Services Agency, says the state is now looking at charging for retention of the equipment for those who want it, while providing a free monitoring service to
analyse the data collected. In the UK, telehealth needs to be ‘embedded and central to clinical practice,’ says Andrew Forrest, deputy director of Cornwall Information Technology Services, which is part of the county’s hospital trust. ‘Our clinicians and community nurses do now see it as a primary way of prioritising their workloads and as part of their toolkit, but we’ve got a long way to go.’ Mainstreaming may be a long way off for Cornwall, but meanwhile they are using their experience and telehealth centre in the county to support other organisations in neighbouring Devon. Stan Newman, principal investigator in the WSDP study, said they had indentified a number of barriers to people taking part in the trial. These included: fears from people that they would be unable to cope with the technology, that they would become hypochondriacs and that they would become isolated from their care professionals. Many others were satisfied with their existing services and didn’t want any changes. Newman believes TC and TH is more about changing behaviour than technology. Global experts agree with him. Jon Linkous, chief executive of the Chief Executive Office, American Telemedi-
cine Association is optimistic. ‘When people see change which is successful it enables them to change.’ Dr Brian Rosenfeld, vice president of Philips VISICU, who has been instrumental in developing and implementing telecare in ICU across the US, says it’s harder to change the behaviour of healthcare professionals than patients, who overcome the psychological barriers to using technology quite easily. Nevertheless, US telecare trials have won over clinicians’ hearts and minds, and a new breed of health care specialist – the ‘intensivist’ – is emerging. These specialists, backed by teams of critical care nurses, monitor multiple screening of patients at home, reducing number of consultations, waiting times and costs. Tele-radiology is another growth area where services are being outsourced, not only across states but across continents, to Europe, South America and Australia because of the shortage of radiologists. Dr Rosenfeld hopes the results of England’s WSDP will now help boost the business case for telecare worldwide. But ‘mainstreaming of telecare is only a matter of time,’ he says. In Massachusetts this could be as early as 2014 for intensive care services, following the success of telecare ICU pilots in the state. Moira Mackenzie, Scotland’s telecare programme manager, is also looking forward to publication of the WSDP study but isn’t expecting ‘any wonderful new revelations’. They already know telecare works, having pump-primed £20m into their Telecare Action Plan which finishes in 2012, and is predicted to save £48m by monitoring people at home. ‘I do expect an addressing of concerns of certain professionals, and it will address the fact that in future we will just not have the staff to deliver services in the way we do now,’ says Mackenzie
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Jenny Sims is a freelance writer specialising in healthcare policy and practice.
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INTERVIEW
Former director of the London Deanery Elisabeth Paice won the NHS mentor of the year award in 2010. She spoke to Alison Moore about how better mentoring, training and team working can bring managers and doctors closer together.
Managers and doctors could take part in mutual mentoring sessions to aid understanding of their different problems and perspectives, the winner of the 2010 NHS mentor of the year award believes. Professor Elisabeth Paice, former dean director of the London Deanery, was praised at the NHS Leadership Awards ceremony, for her work in mentoring individuals and her conviction that ‘humane training makes humane doctors and better patient care’. But she would like to see mentoring used, not only to help individuals, but also to bring together doctors and managers and create a shared understanding of the issues they face. ‘It seems to me that a wonderful idea would be co-mentoring between doctors and managers – especially if both get the [mentoring] training,’ she says, suggesting that it would be ‘jolly interesting‘ to look at how it would work out in groups of senior doctors, managers and also more junior staff. When doctors have attended training sessions together with other staff the outcomes have been ‘like a door opening,’ says Paice. ‘Listening to them coaching each other was a revelation. They were quite confident in helping each other sort out complex issues 12
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which were sometimes very technical.’ There was suddenly a shared understanding of how generic issues – such as dealing with poor performance – could affect an organisation in different areas. Paice sees training as crucial to maximising the benefits from mentoring and helping individuals develop. Paice has been involved in an innovative mentoring scheme run through the London Deanery which has attracted a wide range of participants, with good representation of women and ethnic minorities. More than 850 doctors have applied to be mentored and 300 have trained as mentors – a significant achievement, especially as mentoring has been less developed among doctors than other professions. Embedding mentoring within the NHS would make economic sense, she adds, with worldwide evidence that it can help raise productivity. That could make it an appealing investment in these straitened times. ‘I would like to see it as much a part of NHS life as appraisal has become, and I suspect it would do more to improve performance. But it does need to be developmental, not the traditional model of the senior showing the junior the way things are done around here and shaping them in their own image.’ She believes that relationships between
managers and doctors have improved but the divide ‘has gone very deep white lipped and white nostrilled’. She adds: ‘Managers have quite clearly felt their ability to achieve efficiency and sustainability has been undermined constantly by doctors who can’t see beyond the patient in front of them. ‘Managers are perceived as flying in and not staying around to see the chaos they create. But I do think things are getting better.’ Improved clinical engagement – such as engaging young doctors in leadership projects – has been important in overthrowing these perceptions and stereotypes, she says. At a recent MiP seminar on management skills, Paice introduced the concept of ‘chronic embitterment’, where a combination of long working hours, poor support and making errors can lead to a downward spiral of bad feeling and a sense that the organisation is against the individual. Performance, commitment and enthusiasm are all affected. Although she was talking about doctors, it’s a concept that could easily be reframed for other groups and one which has particular relevance to the tough climate many managers are enduring now. For some doctors this can lead to resentment against managers. ‘This is where some of the “them and us, man-
INTERVIEW
“I would like to see [mentoring] as much a part of NHS life as appraisal has become, and I suspect it would do more to improve performance. ”
agers are the dark side” divide comes in. Managers would not be in the health service any more than doctors if they did not have the passion for improving patient service,’ she says. Mentoring, she suggests, can provide a way out, reducing embitterment and allowing individuals to realise their potential. ‘One of the things that mentoring and coaching does is help people reframe the situation they are in and not see it as so much of a conspiracy against them, and to see why other people are taking a line or behaving in a way which seems inexplicable. ‘It is helpful in stopping these great waves of emotion overcoming you. If you see everyone around you as being malign or career-chasing, it is a very embittering feeling to walk around with. If you understand the situation it is much easier to fit in and influence things.’ Mentoring is a passion for Paice now
but for the last 15 years she has been closely involved in medical education as a dean director and then as acting director of medical and dental education at NHS London. She is known for her work on junior doctors’ hours and the introduction of the ‘Hospital at Night’ programme, which reduced the number of young doctors who were on call overnight and better utilised the skills of other staff. While the 48-hour week has come under attack from some professional bodies, she stands by this attempt to make junior doctors’ lives more civilised. ‘A 48 hour week gives a reasonable amount of time for friends and family, and reasonable balance – and time to reflect and read about the job.’ It has helped juniors go the extra mile and engage more with the leadership and management of the service – something which was hard to do when they were working excessively long
hours, she says. ‘Many junior doctors have expressed an interest in getting involved in this it’s not that amazing when you think that they have a little more time to do these things. They are not ground down.’ And juniors have told her that they get a better view of the whole running of the hospital through the Hospital at Night programme – the breadth, if not the depth, of work is becoming clearer to them. She points out that doctors in other countries become competent professionals without working excessive hours and suggests that the evidence is clear that learning is not enhanced by repeating tasks when excessively tired. ‘My very strongly held view is that people are better doctors if they have a balanced life, especially if you are talking about communication and patientcentredness. One of the things that issue 10 | summer 2011 | healthcare manager
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INTERVIEW
goes badly wrong with doctors is that it if they are so enclosed it’s easy to lose touch with the outside life and the way culture and patients’ expectations change.’ But she is reluctant to be drawn into the debate over how doctors should be trained in the future, saying that the tension is not between service and training now, but between service now and service in the future. If the NHS does not provide adequate training to junior doctors – for example, when organisations are under financial pressure and want to increase the contribution juniors make to service delivery now – the consequences will be felt in the future. ‘Shrugging your shoulders and saying it is a tough time and they will just have to miss their training session and get through this pile of patients…You end up with doctors who become embittered.’ Juniors are an untapped resource for new ideas, she says: ‘I was talking to a group of senior trainees last week and they all had a story to tell about their first month in a new job and the ideas they had about improving the service, none of which had come to fruition because of lack of support or interest in what they thought. ‘But one or two experiences of being slapped down and the desire to champion change is quickly dampened. What if, instead, new trainees were routinely interviewed by senior managers looking for their ideas? Or offered the chance to present their ideas in a Dragon’s Den?’ What doctors fear most is making an avoidable mistake in contravention of the Hippocratic principle of first doing no harm, she says. But such mistakes are most likely to occur when people are working long hours, are sleep-deprived and don’t have supervisors they can easily turn to. These are more potent problems than doctors lacking knowledge or being cack-handed. But much of this is in contrast with strands of the ‘traditional’ medical model, which frequently values what she describes as the ‘lonely hero who sees a clinic with twice as many patients, who 14
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manages the night from hell while on call.’ In fact, the evidence is clear that people who work in teams make fewer mistakes than those who work in isolation, she says. ‘In a team there’s several perspectives – someone will take a different perspective and notice that you have made a mistake.’ She is passionate about the need for women to be helped to combine work with family life and having children, advocating tax relief on childcare to allow them to do this. She worked part-time while her own children were young and then moved back into full-time work as a rheumatologist – one of the specialties with less on-call duties. But at an age when many people are beginning to think about early retirement her career moved into the fast lane as dean. She is now in semi-retirement, combining mentoring with projects for various medical and healthcare bodies including chairing an integrated care project in North West London. Mentoring remains a major part of her work – she works with the London Deanery and currently mentors seven people at different stages of their career in education and healthcare. She is
also doing a diploma in coaching and mentoring. Even now, she says, a lot of her time is spent learning new skills. ‘Everyone needs to be on a journey. I feel I am on a journey to be a really good, diplomawaving coach and mentor. As a coach and mentor, I gain as much as I give from the interaction.’ She believes her experience in coaching has enhanced some of the skills she needs for chairing the integrated care project – ‘trying to understand people’s points of view, challenging limited beliefs, the importance of keeping people focused on the vision and not allowing interpersonal problems to blunt that. ‘There is nothing more satisfying than helping someone sort out a problem they have not been able to sort out for themselves. It is like making a really difficult diagnosis.’ But her emphasis is very much on helping mentees to change and find their own solution – mentoring is not about problem solving for them. ‘I absolutely don’t give people advice,’ she says. Success is when there is a ‘light bulb moment’ which allows the mentee to gain insight and move forward. ‘It draws on the skills I have from 40 years in the NHS - the ability to pick up on what is not being said.’ She was thrilled to receive the mentoring award, which is sponsored by MiP. ‘It was all the encouragement I needed to focus on this as something I want to really master. But I have a long way to go to become an expert in these skills!’ And she has other challenges just as substantial: her three children have provided her with grandchildren who take up much of her spare time. ‘Mondays are childcare – a two-year-old and a three-year-old. The baby on a Wednesday afternoon. And the others for sleepovers. I’m a good granny!’ she says
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NHS FINANCE
The £20bn squeeze on the NHS means even top flight NHS managers can’t feel secure in their jobs. Noel Plumridge finds out why the NHS hot seats are getting hotter.
For the managers of big football clubs, a profession associated with rich rewards but negligible job security, the day of reckoning often comes at the end of a disappointing season. On 15 May Avram Grant of West Ham was summarily dismissed as his club lost its premier league place. A week later, on the other side of London, Carlo Ancelotti of Chelsea was ruthlessly sacked on the final day of a trophyfree season, as his team lost 1-0 at Everton. It’s tough at the top of the NHS too. Just down the road from Chelsea’s grand stadium, at the huge Imperial College Healthcare Trust, the year 2011-12 was only in its first week when the board said goodbye to chief executive Professor Stephen Smith, along with his chief financial officer Tony Graff. The trust, it emerged, had a £40m gap in its £110m cost improvement programme, and NW London commissioners, the trust’s key income source, were pursuing further reductions. Imperial was facing a torrid year, with no realistic hope of promotion to the NHS’s ‘premier league’ of foundation trusts. Whereas Grant and Ancelotti were judged, retrospectively, on their
actual results, Smith’s fate was sealed by the financial forecasts. News of the crisis at Imperial sent a shudder through an NHS inured to high profile departures. Since the coalition government announced, last summer, a root and branch reorganisation that would see the demise of all 151 primary care trusts and all 10 strategic health authorities by 2013, managerial insecurity has been palpable. But the top jobs at big acute hospitals had hitherto been seen as relatively secure. In England they don’t come any bigger than Imperial, the trust created in 2007 to combine St Mary’s Hospital in Paddington, Hammersmith Hospitals, Charing Cross Hospital, Queen Charlotte’s & Chelsea Hospitals and the faculty of medicine of Imperial College London. With an annual turnover of £910m, Imperial appeared immune from takeover – the potential fate of any NHS trust unable to navigate the route to foundation trust status. Professor Smith had built an impressive reputation, particularly for turning the cliché of ‘clinical leadership’ into a practical reality. Imperial wasn’t on the list of NHS trusts perennially struggling for cash. In short, if there was a financial crisis at Imperial, nowhere would be secure.
“Imperial wasn’t on the list of NHS trusts perennially struggling for cash. In short, if there was a financial crisis at Imperial, nowhere would be secure.” Yet now Imperial had four executive director vacancies – the posts of commercial and strategy directors were already unfilled – and Ernst & Young arriving to help sort out the mess. And speculation about a merger with the Chelsea and Westminster or the Royal Brompton, each already foundation trusts, soon began. Two parallel processes are currently squeezing the NHS, making the managerial work of chief executives like Professor Smith more complex and challenging than at any time in the last 20 years. The first is a major restructuring of the NHS in England, seemingly the brain-child of secretary of state Andrew Lansley, opening up the provision of NHS treatment and care to competition from ‘any willing provider’, and replacing primary care trust commissioners issue 10 | summer 2011 | healthcare manager
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NHS FINANCE
PROFESSOR STEPHEN SMITH
with consortia of (sometimes reluctant) GP practices. Unloved by many of the people upon whom its success relies, and with HM Treasury increasingly alarmed at the prospect of £60bn of public money being handed over to vaguely-defined consortia under equally vague accountability rules, Lansley’s Health and Social Care Bill is currently stalled in the House of Commons. On 4 April, faced with opposition from many of the GPs whom Lansley was levering into a commissioning role, and perhaps into carrying the blame for hospital closures and the rationing of treatment, the secretary of state announced the government would ‘take the opportunity of a natural break in the passage of the bill to pause, to listen and to engage with all those who want the NHS to succeed.’ Now, following the spectacular collapse of the Liberal Democrat vote in the May elections, it appears the legislation may not move forward for some time. Nick Clegg insists major amendments are needed and a return to the committee stage would be appropriate. Lansley’s personal credibility has been severely, perhaps fatally dented. His bill 16
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is, at last, the stuff of inter-party politics, and in a very public way. Meanwhile, however, the serious and often brutal business of trimming £20bn from the NHS budget continues in the background, generating the pressures at Imperial and elsewhere. This is the second and more immediate squeeze on NHS managers, though it has had a lower public profile so far – not least because ministers insist that £20bn can be saved without harming frontline services. £20bn is an estimate of the cost, in an era of minimal financial growth, of the NHS absorbing three longacknowledged pressures: ■■ population growth, estimated at around one million per year – though this assessment has been challenged and the 2011 census may tell a different tale ■■ the cost of an ageing population, with more people living well into their 80s and 90s – albeit often not in sound health as long-term illness proliferates ■■ the cost of allowing NHS patients access to improved medications and medical technology as they become available. In turn this drives the hard targets demanded of NHS managers in 201112. The headline requirement is a 4.0% ‘cost improvement’, as set out in the NHS operating framework for 2011-12: The national efficiency requirement in 2011/12 is 4 per cent and the uplift for pay and price inflation is assessed at 2.5 per cent… Tariff prices for 2011/12 also reflect the four per cent efficiency requirement: two per cent is embedded in tariff design with the remaining two per cent offsetting the pay and prices uplift resulting in a final tariff adjustment of 0.5 per cent. Now 4% is challenging enough in hospitals, which have relatively fixed cost structures. Some two-thirds of a hospital budget is typically tied up in salaries. Millions more are committed to site costs, even where the Private
Finance Initiative hasn’t added its own special layer of rigidity. During the three years prior to 2011-12, it might have been possible to offset the cost improvement target against growth funding: between 2008/09 and 2010/11 the NHS was still receiving growth funding of 4.0% per year. But those days are gone. But a 4.0% cost improvement isn’t the whole story. Economists suggest 2.5% understates the inflation hospitals face in 2011-12, as fuel and energy costs rise rapidly and pay costs remain uncertain. Meanwhile commissioners, who also need to balance their books, are steering more patients towards treatment outside hospital – a longterm policy aim – and are delaying or denying treatment for certain conditions. For instance, if you need a hip or knee replacement, you may, depending on where you live, be told to lose weight before an operation will even be considered. Sheltering behind the euphemism of ‘demand management’, commissioners are blocking hospitals’ attempts to offset savings targets by simply increasing their throughput, and hence their income. There’s also mounting evidence that primary care trusts are withdrawing funds into contingency reserves, topping up the 2% they are required to withhold in 2011-12 to cover the costs of change. PCTs in the East of England and in London are retaining a minimum 0.5% contingency fund; the suggestion from NHS West Midlands is 1%. The killer blow for 2011/12, however, lies in a succession of “technical” changes to the payment by results funding mechanism. Each appears reasonable enough, yet in combination they represent a major shift in the balance of power within the system in favour of commissioners. These changes are: ■■ maintaining a 30% “marginal tariff” for additional non-elective procedures ■■ the non-reimbursement of emergency admissions within 30 days of discharge ■■ allowing commissioners and
NHS FINANCE QUEEN CHARLOTTE’S & CHELSEA HOSPITAL, PART OF IMPERIAL COLLEGE HEALTHCARE TRUST
providers to agree variations from the national published tariff price ■■ plus a series of adjustments to thresholds for short-stay and longstay tariffs Taken together, these changes escalate the implied efficiency gain required in 2011/12 to some 6.5% for acute trusts, or 6% for non-acute trusts. This is the reality behind a 27 April letter from Monitor, the independent regulator of foundation trusts, to would-be new foundation trusts. Unless an acute trust like Imperial Healthcare can achieve a ‘downside case’ cost improvement of around 6.5%, not just this year but in each of the next four years, it cannot become a foundation trust. Which is where the spending curbs
and the aspirations of the Health and Social Care Bill come together. What’s the logic of recalibrating the tariff system in favour of commissioners? It’s partly that a funding system designed to encourage extra activity no longer fits NHS needs: the waiting lists of 2003-04 are a distant memory and so is the funding growth of the Blair years. And it’s also that the government’s vision of the future NHS is of a commissioning organisation, buying in patient care from a mixed market of providers. Sir David Nicholson, the NHS chief executive, has already been appointed head of its new commissioning board. And, more pointedly, no GP consortium wishes to inherit a deficit on its opening day. Perhaps time for a little discreet rebalancing? Meanwhile, the big deal about foundation trust status is that, in the words
of the 2011/12 Operating Framework: All NHS trusts will become NHS foundation trusts (NHS FTs) by the end of 2013/14… NHS trusts will be held to account at regional and national level for achieving the updated timetables submitted to the Secretary of State at the end of 2010. It will not be an option for organisations to decide to remain as an NHS trust, rather than become, or be part of an NHS FT. Subject to legislation, by 1 April 2014 all NHS trusts will cease to exist. There are currently 137 active foundation trusts, with a further ten applications being considered. Which leaves slightly over a hundred NHS trust boards facing either heroic cost-cutting over the next three years, or a future spent sleeping with the fishes. Under the Health and Social Care Bill as it currently stands, Monitor acquires a duty to promote competition. Scope to offer dozens of ‘failing’ NHS trusts for merger or takeover, whether with existing foundation trusts or with commercial enterprises, might just be convenient. It would also sit neatly with that other long-term Treasury objective – scaling down the cost of public sector pensions. Trust directors are losing their jobs not because of financial mismanagement, but because boards, loyal to their local NHS hospitals, hope newcomers might steer them to a promised land that sadly seems increasingly illusory. And not just chief executives: thousands of hospital staff, both clinical and non-clinical, are losing their jobs as NHS providers feel the pinch. Professor Smith’s career will now take him to Singapore. Like Carlo Ancelotti and Avram Grant, top managerial talent is rarely sidelined for long. But these are gloomy times for most managers at NHS trusts
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Noel Plumridge is a freelance writer specialising in healthcare management and finance, and a former NHS financial manager.
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SKILLS FOR HEALTH
Karen Walker unveils new resources to help retain and nurture management talent in the NHS and wider public services.
For all of us working in the public sector these are uncertain, turbulent and challenging times. Managers in the NHS, like others in public services, are now facing the reality of job losses and many organisations, including SHAs and PCTs, are putting in place packages of support to help staff over what will be a difficult time of transition. However, the challenge is not just one for individual staff or even for individual organisations, but for the whole of the health sector and indeed beyond that to all public services. The paradox we face is that this is exactly the time when the experience and talent of NHS leaders and managers will be needed most.
The QIPP agenda and the achievement of £15-20 billion of efficiency savings will require strong and bold leadership. At the same time expanding patient choice, personalisation, ‘any qualified provider’, the growth and diversification of the market and the increasing contribution of communities and the voluntary sector mean rethinking the way services are delivered. These are challenges in which experienced and skilled staff have an important role to play and retaining capacity and capability will be crucial. Without this the NHS will achieve less than it is capable of. With 24,000 management jobs at risk, the loss of this talent could have a real impact not just on our ability to manage the reform agenda but on the longer term delivery of services and, ulti-
Skills for Health is the Sector Skills Council for all healthcare sector employers: NHS, independent and third sector. Since 2002, it has been working with employers to get the right people, with the right skills, in the right place at the right time. It is the authoritative voice on skills issues for the healthcare sector and offers proven workforce solutions and tools, with the expertise and experience to use them effectively. To find out more about Skills for Health’s competence-based approach to workforce transformation and how it can help you drive up productivity and quality visit www. skillsforhealth.org.uk
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mately, the experience of service users. These are also staff in which substantial investment into their training and development has already been made and we cannot afford for that to be ‘written off’. We need to look beyond the immediate job losses and find solutions which will help us not just retain but also develop the skills we need at this crucial time in a way that enables continuing improvement across the NHS and wider public services. But this cannot be about just more of the same. Instead we need to help people develop and use their skills in different ways to meet new priorities. Doing this in a meaningful way means: realigning the skills and abilities of staff to fit with changing work opportunities and the challenges presented by market diversification, economic constraints and structural change ■■ supporting morale and retaining engagement with skilled staff whose roles are in transition and who are at risk of being lost from public services ■■ continuing to maintain and develop services for the users of public services with a workforce that is under pressure and often reduced in size ■■
SKILLS FOR HEALTH
Managers in the NHS have a wealth of transferable skills and experience. We need to make sure that these are not lost and that we do not see valuable and talented people disengaged from the sector. As the skills council for the healthcare sector, Skills for Health has an important role in helping to retain and develop management and leadership talent. To this end we have been working with Skills for Care, Skills – Third Sector and a range of other partners to develop a solution across not just health, but also social care and wider public services. Recognising that there is a real need to be filled, this crosssector coalition is developing an innovative new service – a social market place – to connect talented people with transferable skills to these new opportunities. Called ‘Workonit.org’ we are developing a web-based initiative that will offer individuals an innovative package of services based around five platforms. All of these platforms have been designed with the future needs of public services in mind: Shop for work – a jobs board which extends beyond the NHS to all public services. ■■ Enterprise – a space to help grow ■■
opportunities, particularly for people looking to establish or grow a small business or micro-enterprise, looking for short-term contract work, or for people willing to offer pro bono support as a way of gaining experience or developing new skills. ■■ People to people – offers professional networking opportunities with access to offline events and activities enabling people to keep in touch and make the most of any opportunities for employment, developing partnerships and career development. ■■ Skills – supporting people to develop the skills they need to take advantage of new and emerging career opportunities. People will be encouraged to undertake a self assessment of their skills and will be directed to the most relevant skills development opportunities. The focus is firmly on helping people to develop the skills they will need for the ‘new world’. ■■ Think piece – a way for people to keep in touch with the healthcare sector, this is a space for narrative and discussion on emerging policy and services, taking advantage of social media like Facebook and
Twitter to stimulate discussion and debate. The initiative is much more than just the traditional jobs site that we are all familiar with. Instead the focus is on bringing together a range of different services into a one-stop shop for people looking for support as they take the next steps in their working lives. Our aim is to establish a real sense of community, recognising that everyone’s journey at this time will be different. The website and the services it will offer are currently under development but registration, which is free, is open now at www.workonit.org. There is no doubt that in the future we will all need to think much more creatively about how we work and how we approach our career and skills development. We hope that this initiative will go some way to helping us all to think in that different way and grasp the opportunities on offer
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Karen Walker is director of policy at Skills for Health
issue 10 | summer 2011 | healthcare manager
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LEGAL MATTERS
legaleye Andrew James gets to grips with the complex rules protecting employees who are transferred to new employers. With the coalition government’s reforms set to turn many parts of the NHS over to private companies to commission or provide services, the rules around the Transfer of Undertakings (Protection of Employment) regulations (TUPE) and how variations of contract and dismissals can be justified will be under greater scrutiny by trade unions than ever. The TUPE regulations are designed to protect employees’ terms and conditions when a business or undertaking, or part of one, is transferred to a new employer. Employees who are employed by the transferring employer immediately prior to the transfer and who are ‘assigned’ to the relevant grouping of employees should transfer to the new employer under TUPE. Except for pension rights, terms and conditions transfer and are enforceable against the new employer, but there is no defined period of protection for terms and conditions. Variations of employment contracts will be void if the sole or principal reason for a change in the contract is either the transfer itself or a reason connected with the transfer that is not an ‘economic, technical or organisational’ (ETO) reason entailing changes in the workforce (Reg 4 (4)). In other words, the new employer cannot change contracts in a TUPE situation if the change is by reason of the transfer or a reason related to it, unless the reason is an ETO one. Likewise a dismissal in a TUPE situation will also be automatically 20
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unfair where the dismissal is by reason of the transfer or a reason connected with it, which is not an ETO reason entailing changes in the workforce. Where the dismissal is not so related, the normal rules on unfair dismissal and statutory dismissal procedures still apply. The difficulty with the TUPE regulations and the case law on them is that there is no satisfactory or statutory definition of an ETO reason. Employers can usually use ‘economic, technical or organisational’ reasons to justify both variations to contract and to dismiss workers as long as the change entails ‘changes in the workforce’. This means, for example, a change in job description, a change in job functions or a change in the number of employees. A wish to harmonise terms and conditions is not a valid reason for changes. Dismissal due to redundancy will generally count as an ETO reason but a fair process must be applied to both transferring employees and the existing workforce. The employer cannot just sack the transferring employees. In the case of Nationwide Building Society v Benn in 2010, the EAT said the change in functions performed by employees can relate only to the functions exercised by transferring employees. There is a legal debate as to whether the scope for transfer-related variations to contracts complies with the European Acquired Rights Directive, which aims to regulate transfers of undertakings within member states by ensuring that terms and conditions are
maintained for the employees affected. In 2006, the then Department of Trade and Industry produced guidance on how to determine whether a variation in a contract is by reason of the transfer itself or a reason connected with the transfer. The DTI guidance says: ‘Where an employer changes terms and conditions simply because of the transfer and there are no extenuating circumstances linked to the reason for that decision, then such a change is prompted by reason of the transfer itself. However, where the reason for the change is prompted by a knock-on effect of the transfer – say, the need to re-qualify staff to use the different machinery used by the transferee – then the reason is “connected to the transfer”.’ Despite this guidance, deciding whether a reason is transfer related or not remains as difficult to apply in practice as ever. In a time of unprecedented public austerity, unions will have to be even more vigilant about attempts by employers to make adverse changes to terms and conditions following a transfer, where such changes are unlawful under TUPE
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Andrew James Thompsons Solicitors Download the DTI guidance from: www.bis.gov.uk/files/file20761.pdf 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.
CAREERS
Making a plan Liz McCarten makes your personal development plan work for you. As you read this, the government may still be in ‘listening’ mode about NHS reforms. Maybe there’s a pause for reflection – or not. And just maybe there’s a clear sense of direction. For senior managers in health services, life is very turbulent not only because of the uncertainty about the final shape of the legislation, but also because of the very real cuts and challenges managers already face. With so many pressing concerns about the future of the NHS, things like performance reviews can seem irrelevant. But this is when it’s really important to make sure that your review is done, that both you and your line manager take it seriously and that you use it constructively. It’s also important for the
future that the NHS fully understands and uses the wealth of talent and experience provided by its senior managers. The personal development plan (PDP) is a crucial part of your own career planning. You need to set aside some time away from the fire fighting and take a good look at your experience and strengths. Look at your previous year’s PDP to see how you are perceived and what your objectives were for the year. Given all the changes, your mediumterm ambition may be quite different from the steady progress through a known structure which might have seemed sensible a year ago. The point is to make sure that you deal with the reality of your situation, take control of it and use the PDP to maximise your
opportunities. Talk to a trusted colleague or to MiP if you need a sounding board or help to develop your ideas. There may be opportunities, albeit finance permitting, for you to access training through your employer. Additionally, MiP’s Union Learning Fund project offers regional masterclasses and discounts for Open University study, and is adding new learning opportunities all the time. Now’s the time to get the skills you need for your future – and that of the NHS
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Liz McCarten works on MiP’s learning and development proejct. See the MiP website for details of masterclasses and OU study.
Tipster: Make better use of Twitter Social media expert Martin Shovel (follow him @MartinShovel) separates the twits from the top tweets
USE A DEDICATED TWITTER APPLICATION Some people give up on Twitter because they find its website clunky and frustrating to use. For a more enjoyable and productive Twitter experience, use one of the many free dedicated Twitter applications instead.
2 TWEET FROM A SMARTPHONE Tweeting from a smartphone is a great way to make the most of your time. It will transform occasional spare moments into Twitter opportunities.
3 USE TWITTER SEARCH Use Twitter’s powerful search function to help you find topics – and people – that interest you.
4 TWEET AS YOURSELF People make relationships with people. So, ideally, tweet in your own name.
If you have to tweet on behalf of an organisation, your twitter settings will allow you to supplement your username –the name of your organisation – with your own name.
5 TWEET REGULARLY Twitter does not have to be timeconsuming: little and often is the key to success.
6 TAKE THE PLUNGE! The only way to get the hang of Twitter is to start tweeting. Twitter is a bit like the Wild West: there are few hard and fast rules. Twitterers en masse make them up and change them as they go along, which is part of the fun!
7 INTERACT Engage with other twitterers. Simply broadcasting to them is boring and will have them reaching for their unfollow buttons.
8 RETWEET Retweeting other people’s tweets is a double blessing: it gives you material to tweet; and it warms up your relationships with the people you retweet.
9 BE POLITE Be interesting, be controversial; but avoid getting involved in heated exchanges. It also pays dividends to thank people when they retweet your tweets and links.
BE PATIENT Establishing yourself on Twitter will not happen overnight. There will be times when you think you’ve cracked Twitter, and others when it leaves you flummoxed. But, if you are prepared to get stuck in and risk making the occasional mistake, your Twitter expertise and confidence will develop fast. And you will reap the rewards.
issue 10 | summer 2011 | healthcare manager
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MiP AT WORK
Mergers in Partnership MiP link members and officers around England are heavily involved in discussions to protect and promote partnership working in these times of unprecedented organisational change. Here we report from three of our regions.
Yorkshire and the Humber Speaking at a regional summit on partnership working in Yorkshire and the Humber, MiP national committee member Robert Quick (pictured) shared experiences of developing employment partnerships in tandem with the major service mergers taking place in Rotherham, South Yorkshire. Robert, associate director of people services at Rotherham NHS Foundation Trust, described how management has worked in partnership with the trade unions to merge community services in Rotherham with the acute services provided by the trust. The new much larger organisation covers a population of around 300,000 people in the urban steel town of Rotherham and the rural and semi-rural areas bordering north Nottinghamshire and the former mining communities of the Dearne Valley. 22
issue 10 | summer 2011 | healthcare manager
‘Partnership was not going to be an afterthought,’ Robert told delegates. ‘It was seen as a priority 12 months before the merger date of 1 April 2011. Working closely with the HR team in the PCT, and crucially with key union reps, we set up a series of meetings and workshops to explore the models of partnership working that we would like to see working in the area.’ ‘Part way through this process, the trust was awarded contracts to take on the management of community services in Bassetlaw and community dental services in Doncaster. A second workshop was held involving trade union reps and managers from Bassetlaw, facilitated by former trade union expert Tony Chandler, who went on to lead a workshop, to assist the unions in their visioning of the project.’ Robert, presenting jointly with the Chair of the Rotherham Community Health Services, said that creating a partnership was especially difficult in the current challenging environment. ‘But with cuts and job losses, we need partnership even more. The real challenge is to recognise the cultural differences between organisations, but also we all share the common values of the NHS and a patient-centred service.’ West Midlands MiP and the other health unions in the West Midlands are working to make the restructuring of local NHS services as fair as possible for staff. As elsewhere in England, PCTs in the West Midlands are working in clusters, and are now appointing staff to cluster-
level positions. MiP national committee member Zoeta Manning (pictured) is working with the other unions and employers to ensure the appointment process is fair and transparent. They will use the lessons learned from the process of appointing the executive teams to agree a standard for appointing the rest of the cluster team. Zoeta’s own PCT has combined with others to form the Birmingham and Solihull Cluster. They have already set up a cluster-level joint negotiating committee, with Zoeta and two MiP link members from other PCTs speaking up for managers. ‘We were able to build on the great partnership relationship we already had in the West Midlands,’ said Zoeta. ‘This meant we could act very quickly to set up this new group to represent our members’ interests in the new organisation. I am proud of the role that MiP
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These are uncertain times.
has played in getting this group off the ground.’ North West In the North West, the partnership forum is exploring ways to sustain local and regional partnerships through the current and future restructuring, and to ensure trade unions and employers can continue to have effective and meaningful consultations as new structures emerge. One model would be to develop partnership forums at the level of PCT clusters, which can deal with consultations on the key high-level employment issues that have an impact across the cluster, while supporting joint negotiating committees at local level to deal with local issues. Jim Keegan, MiP’s national officer for the region, said: ‘To date our discussions on the re-organisation of the service have reflected all that is best in partnership working and we’ve been successful in developing and agreeing fair and effective employment frameworks and protocols against the background of an uncertain and everchanging national scene. ‘We remain committed to continuing and developing this with the PCT clusters and are working on plans and options for maintaining regional partnership working beyond the closure of the SHAs next June. We’ve seen what partnership working can deliver and the Government would be well advised to provide the support to enable this to continue.’
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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
helping you make healthcare happen
issue 10 | summer 2011 | healthcare manager
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backlash
Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@ healthcare-manager.co.uk.
by Celticus
Palace coup
A
ccording to top Tory blogger Tim Montgomerie (who knows about these things) the Secretary of State for the Time Being has already been supplanted. ‘We should now think of Cameron as Secretary of State for Health,’ he tweets. ‘The PM, not Lansley, will be selling the govt’s NHS policies’. But it may take a while for the PM to grasp the finer points of his new job. Like commissioning and contracts, for example. In his big U-turn speech on 7 June, Cameron claimed that, in the NHS, ‘whenever you’re ill… you can walk into a hospital or surgery and get treated for free. No questions asked.’ Really? You just try it, Dave.
Pax Romana
E
merging half-formed (or half-baked) from the mist of confusion thrown up by Cameron’s speech came shadowy
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figures who will be known as ‘clinical senators’. These ‘healthcare professionals’ will come together to discuss (presumably in Latin) ‘the integration of care across a wide area’, much as their Ancient Roman counterparts met to discuss ‘integration’ of a different kind across even wider areas. But before you rush out to get measured up for a new toga, remember the fate of those Roman senators who defied the leader’s will. They were executed on the Senate steps and then dragged off to the Tiber with a hook through their throats.
Talk to the hand
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hat did it all mean? No use turning to the Department of Health which seemed to be whistling with fingers in its ears. Three days after the prime minister ripped up the health bill, trampling through red lines and deadlines alike, the ‘latest news’ on the DH website was ‘Diagnostics waiting times and activity data, month ending 30 April 2011’. The PM’s great speech wasn’t even mentioned. A search for the elusive ‘clinical senators’ drew a blank. And they were still showing a Mr Lansley as SoS. Do keep up!
Some pots are bigger than others
L
issue 10 | summer 2011 | healthcare manager
ots of press outrage after a number of NHS chiefs were ‘outed’
(by Conservative Central Office, apparently) as being over-endowed in the pension pot department. The government likes to use size of the prime minister’s remuneration package as a benchmark for top jobs in public service, but the PM benefits from special rules that mean his pension is based on a notional salary far higher than the salary he actually earns and on which he pays contributions. This means the PM can build his pension pot two or three times faster than NHS staff. So, with a generous MP’s pension on top, he won’t have to put in 40 years’ loyal service to build up a decent pension. Well, it gives you something to aim for.
Heads Up
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nd why not? You’ve earned it. According to the Commonwealth Fund, which regularly surveys international health systems, the NHS is the most efficient system in the world, and the second best rated overall, behind only Holland’s (the US came bottom of the pile). At the same time, far from being the bloated bureaucracy of ministerial myth, the King’s Fund report found ‘appreciable evidence’ that the NHS is undermanaged. Undermanaged and efficient? Let’s hope ministers don’t take that the wrong way.
Heads Down
I
f you’re worried that Ed Miliband and John Healey (he’s Labour’s health spokesman by the way, pictured above to jog your memory) have been quiet of late, they may only be following the sage advice of Paul Corrigan, Tony Blair’s (still) highly respected health adviser. Asked how Labour should respond to the government’s NHS reforms, Professor Corrigan urged them to follow the advice of the Duke of Wellington: ‘When opposition generals are making a mistake I make it as a rule never to interrupt them.’
Follow the leader
F
inally, Celticus was pleased to see that MiP chief executive Jon Restell (@Jon_Restell) has been named by the Health Service Journal as one of the top healthcare policy tweeters. ‘Full of good sense,’ says the Journal. Most of the time, anyway.
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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.
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It’s not just doctors who make it better.
Healthcare managers are passionate about delivering effective healthcare. In fact, it couldn’t happen without them. That’s why they deserve specialist representation. MiP is the only trade union organisation dedicated to providing personal support and employment advice, management skills and networks, and an influential voice for the UK’s healthcare managers.
helping you make healthcare happen.
www.miphealth.org.uk