Healthcare Manager Summer 2014

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issue 22 summer 2014

healthcare manager inside

heads up:2

What you might have missed & what to look out for Leading edge: Jon Restell inperson: Ian Reid, NHS Greater Glasgow & Clyde inpublic: North Yorkshire & Humber CSU

comment:9

Allyson Pollock: how care.data threatens confidentiality

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.

NHS finance: Falling numbers but committed staff Interview: Rob Webster, NHS Confed chief executive Bureaucracy: the other side of the story Complex conditions: tools for developing person centred care

regulars:20

Legal Eye: the dangers of protected conversations Tipster: Giving feedback MiP at Work: How MiP helps members to resolve problems at work

backlash:24

healthcare manager | issue 22 | summer 2014

Welcome to the summer issue of healthcare manager, the magazine from MiP, the specialist trade union for managers working in health and social care.

In this issue Rob Webster, the new chief executive at NHS Confederation, talks about his vision for valuesbased leadership and a lot more collaboration in the NHS, and outlines how the Confed can meet the challenges it faces.

NHS managers seem to be getting it in the neck even more than usual at the moment, so it’s good to read Craig Ryan’s piece which argues that effective bureaucracy enables organisations to function efficiently and fairly. We also have a report on the recent census and survey of NHS finance staff which describes how committed they are to the NHS and argues for a better understanding of this important role in delivering high standards of patient care. And we hear about ADAPT, a new approach to supporting and caring for people with complex conditions which puts them at the heart of the planning process.

And we have our regular features including In Person, which features Ian Reid, who talks about the value of HR as part of the healthcare team.

I hope you enjoy the magazine and do let us have any comments.

Marisa Howes Executive editor

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HEADS UP

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

Leadership

Suffolk CCGs strikes gold Congratulations to MiP national committee member Amanda Lyes and her team from Ipswich and East Suffolk and West Suffolk Clinical Commissioning Groups, who have just been awarded Investors in People Gold standard.

The award recognises an impressive culture of staff engagement and leadership, which have equipped staff to deliver significant improvements to services after just one year of operation. These include a brand new 24/7 stroke service, a new early intervention service for dementia patients, reducing the number of patients having unnecessary hip and knee operations and help for patients to recover more quickly at home rather than in hospital.

Amanda, chief corporate services officer for both CCGs, said: “Delivering the best of healthcare to people in Suffolk can only be achieved by

having a motivated staff which cares about its work. Both our CCGs are committed to ensuring that every member of staff is able and committed to delivering our vision of a long and healthy life for everyone in the county. Every member of staff should be proud of this achievement.”

healthcare manager

Associate Editor

issue 22 | summer 2014

Craig Ryan editor@healthcare-manager.co.uk

ISSN 1759-9784 published by MiP

Design and Production

All copy © 2014 MiP or the author.

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

Executive Editor

Marisa Howes m.howes@miphealth.org.uk

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Lexographic production@healthcare-manager.co.uk

Contributors

Clive Acraman, Iain Birrell, Paul Briddock, Jane Carter, Bob Dowd, Marisa Howes, Helen Mooney, Alison Moore, Allyson Pollock, Jon Restell, Craig Ryan.

Networking

Chain mail CHAIN (Contact, Help, Advice and Information Network) is an online mutual support and intelligence network for people working in health and social care. Originating more than 14 years ago in the NHS Research and Development programme, CHAIN has grown steadily in both scope and scale. It is now international, with national groups in the UK, Ireland, Australasia, Canada, Spain, Italy and Scandinavia, and members in more than 40 other countries.

CHAIN is multi-professional and cross-organisational, and aims to connect like-minded health and social care practitioners, educators, researchers and managers. It is a not-for-profit organisation, staffed by NHS employees and funded by stakeholders including the National Institute for Health Research, NHS Scotland and Macmillan Cancer Support.

The network uses searchable online directories to enable members to identify one another, and uses simple e-mails for networking. Main benefits of the CHAIN membership include: ■■ occasional targeted emails about resources and opportunities relevant to you ■■ a searchable online directory of members and their interests ■■ using CHAIN to broadcast your own questions and messages Membership is free, and you can join the network, update your records or leave at any time.

For further information or to join visit: chain.ulcc.ac.uk.

Print

Warners Print, Bourne, Lincs

Advertising Enquiries

020 8532 9224 adverts@healthcare-manager.co.uk healthcare manager is sent to all MiP members. If you would like to be on our regular mailing list or require copies please email editor@ healthcare-manager.co.uk

healthcare manager is printed on uncoated paper with vegetable-based inks. The paper is FSC approved and the cover wrap is biodegradable.

Letters

Letters on any subject are welcome.

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

healthcare manager | issue 22 | summer 2014

HEADS UP

leadingedge Jon Restell, chief executive, MiP

M

iP is in campaign mode.

Three interlocking themes are coming together in our “Managers Matter” campaign: respect, resources and reward. Respect because we need to value and appreciate the role of managers in the healthcare team. Resources because managers need development, stability and demand matched to capacity. Reward because everyone in the healthcare team deserves fair pay.

The first wave of our campaign concerns pay. You are angry. Why? This year’s pay award for NHS staff was divisive. The incremental system, under which you are paid less while you build up skills and experience, has been transmuted by the DH’s alchemy into “cost of living” increases. Even the “winners” at the top of the pay bands will see their 1% increase melt away in March 2015 – non-consolidated, nonpensionable, nothing. No other group of public servants has been treated this way – everyone else got at least 1%.

MiP members once accepted the need to tighten belts, to do their bit, but now – working harder than ever – they see the pay freeze becoming permanent. The NHS is being funded from the pockets of its own workforce. This is the pinch point. Inflation alone has eroded the value of salaries by between 8% and 12% since 2010. Higher taxes and pension contributions

healthcare manager | issue 22 | summer 2014

“The NHS – and the public it serves – needs fair pay to recruit, retain and engage the best, most caring people in our society.”

have cut take home pay even further. Enough’s enough.

So our campaign first seeks fair pay for all NHS staff — from the highest to the lowest paid members of the healthcare team. Jeremy Hunt must think again about this year’s award. Secondly, we seek the basic and reasonable pay expectation of any employee: a cost of living increase. Private sector settlements are delivering precisely that. Thirdly, it’s reasonable and right that NHS employers – as many have already decided – pay their staff the Living Wage. Finally, we need a sustainable pay system, where, among other things, the Government removes the shackles from the pay review bodies and accepts their recommendations, and public services are organised around sustainable pay arrangements. In the long term the NHS – and the public it serves – needs fair pay to recruit, retain and engage the best, most caring people in our society.

You’ve told us enough’s enough.

The pay campaign starts in England, but its themes will resonate in Scotland, Wales and Northern Ireland. We invite MiP members to join members of all the other health unions to campaign for fair pay. Some unions will consider responsible industrial action, and many MiP members will expect to be asked too. But our campaign will allow you to participate whatever your position, role and preference. Use your influence locally, especially around the Living Wage.

This would affect 35,000 staff – an achievable goal.

Finally, take every opportunity to argue for a sustainable pay system that delivers cost of living increases as a minimum, and bring your distinctive voice to the campaign.

As managers you know sustainable pay is more than extra funding – it requires fundamental changes in the way the health service works.

The staff side needs your voice.

Basta! Ask the Government to change its mind.

Update your details Do we have your correct home address, work address, employer and preferred email address? Please take a few moments to check your membership records and make any necessary changes. Simply log in to the members’ area of the MiP website and follow the prompts to update your details.

Alternatively, please email us at info@ miphealth.org.uk.

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HEADS UP

Patient experience

Wales

NHS satisfaction stable, Goodall is new but worries over A&E Welsh health chief Public satisfaction with the NHS remained stable last year, but is still significantly below the level at the 2010 general election, according to the results of the widely-respected British Social Attitudes survey, published in May. Although 60% remain happy with the NHS overall, this compares to a record high of 70% in 2010. Following last year’s high-profile pressures on the NHS’s emergency services, there was a significant drop in satisfaction with A&E services, from 59% to 53%.

This is the lowest level recorded since since 2008, leaving A&E services as the part of the NHS with which the public are least happy.

Other hospital services fared better, with inpatient services recording a big increase in satisfaction to 58%. Satisfaction with outpatient services reached a record high of 67%.

GPs remain the most appreciated part of the NHS, with 74% satisfied — unchanged since 2012 despite the upheaval caused by the government’s reform of primary care services. In contrast, the public

remain particularly unhappy with social care services, with only 29% satisfied, possibly reflecting the impact of government cuts to council funding.

John Appleby, Chief Economist at The King’s Fund (pictured), said: “Since 1983 the British Social Attitudes survey has provided an important barometer of how the public views the NHS. Public satisfaction in the NHS remains high, although satisfaction with A&E has dropped. This may be due to concerns about waiting times in 2013.”

With a year to go before polling day, the survey found Conservative voters were most happy with the NHS, with 66% satisfied in 2013, up from 63% last year, while satisfaction among Labour voters fell from 63% to 59%.

For further information please visit www.kingsfund.org.uk

NHS reform

The future is mutual, says think tank A leading right-wing think tank has called on the government to scrap its flagship NHS privatisation programme, “Any Qualified Provider” (AQP), “because it undermines NHS integration and hinders the fight against long-term conditions”.

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Congratulations to Andrew Goodall, recently appointed as the Welsh Government’s new director general for health and social services and chief executive of NHS Wales.

Goodall has worked for the NHS for 23 years and has been chief executive of the Aneurin Bevan University Health Board since June 2009.

Goodall’s new job combines the civil service role of leading the Welsh Government’s Department for Health and Social Services with that of chief executive of NHS Wales.

“Having lived and been brought up in Wales, I feel very privileged to have been offered this national post,” said Goodall.

Sam Crane, MiP vice chair and rep at the Aneurin Bevan Health Board, said: “This is great

ResPublica warned that neither the public nor the private sector could tackle “the lifestyle and long-term conditions that will cause a £19 billion deficit and bankrupt the NHS in a decade”.

The report Power to the People: The mutual future of our National Health Service, says “the solution to the NHS funding crisis lies in radical institutional reform and a return to the NHS’s mutual roots”. It said mutual organisations like friendly societies were best placed to deliver integrated care in the community, which it described as “the holy grail of NHS reform”.

“Health mutuals represent a balanced solution between public and private models…they should play a much needed new role helping to deliver ‘whole-person care’ and making the necessary institutional and

news for the NHS in Wales. I would like to thank Andrew Goodall for his support for MiP during his time here at Anuerin Bevan, and I’m sure he will take that partnership approach with him into his new role. We will miss him in the health board, but I am delighted for Andrew and wish him well in his new role.”

cultural changes that integration of health care services demands,” said the report.

The report said AQP had failed to open up the healthcare market to smaller providers, as ministers had claimed it would, and tended to favour larger commercial providers.

“AQP is not the answer to integrated care, as it merely atomises and fragments care by multiplying the number of bodies delivering healthcare,” said ResPublica’s research manager, Adam Wildman. “In this way, it simply destabilises existing services and damages care pathways. It cannot, therefore, deliver the whole-person care we need.”

For further details visit the ResPublica website at www.respublica.org.uk

healthcare manager | issue 22 | summer 2014

inperson Ian Reid, HR Director, NHS Greater Glasgow and Clyde

“Waiting time targets and the systems that have been put in place to improve patient care across the NHS in Scotland would not have happened without good managers,” says Ian Reid, HR director at NHS Greater Glasgow and Clyde.

He is clear that without good managers the quality of patient care and standards of safety risk being compromised. “Clinicians need to work in partnership with managers to improve patient services and quality,” he says.

Ian has worked in his current job for ten years and will finally retire from the NHS later this year. Reflecting on his career in HR, he thinks the work of managers in the NHS has become much more difficult.

“There’s a lot more pressure in terms of the expectations from patients, the public and politicians — especially on middle healthcare manager | issue 22 | summer 2014

managers,” he says. “As a manager you require a degree of resilience and energy to work in such a public-focused organisation,” he adds.

Ian disagrees with the black and white distinction often made between “frontline” and “back office” in the NHS because he says that most staff are interacting in some way with patients on a daily basis.

“Admin support, catering and facilities staff are all equally important to patient care and how they interact with patients can make a big difference to the experience that patient has of the NHS services they receive.

“We really try to resist the differentiation that is often made between qualified and non-qualified staff as well.”

Ian joined the NHS in 1983 and held a number of positions in personnel with

HEADS UP

“As a manager you require a degree of resilience and energy to work in such a publicfocused organisation.” the Argyll and Clyde Health Board until becoming assistant to the Board’s director of personnel in 1989.

He then went on to become unit personnel manager of Greater Glasgow Health Board’s community and mental health unit in 1992 and was director of HR for Greater Glasgow Community and Mental Health Service NHS Trust from 1994 to 1999.

“My role as HR director now involves lots of workforce planning and development to make sure we have the right numbers and skill mix of staff.

“I spend a lot of time developing education and training programmes for staff and working in partnership with further education colleges,” he says.

Ian explains that he also makes sure that he and his senior team are fully focused on staff engagement. “The role of the HR director in the NHS has changed a lot. When I started the role was about being a custodian of the terms and conditions of service and dealing with grievances and discipline, which is something we still do, but a lot less. Now we are required to develop annual workforce plans and drive recruitment,” he adds.

NHS Greater Glasgow and Clyde has around 300 HR staff looking after more than 38,000 employees. Fortunately, Ian says he has managed to “resist cutting back” on his staff.

“I am fortunate in that I’ve always had chief executives who have seen the value of HR and so I have been able to protect my HR staff.”

So what impact does does he think managers have on the NHS? “If it was not for the management system in the NHS, waiting times and quality would go down and things like Mid-Staffs would start to happen more often.

“I think that with managers and clinical leaders working together you ultimately improve the service and patient care.”

Helen Mooney

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HEADS UP

Culture and leadership

Survey reveals “disconnect” between clinicians and top managers Staff think NHS leadership has improved but employers need to improve their handling of poor behaviour and performance, and deal with a growing “disconnect” between clinicians and top managers, according to the 2014 King’s Fund Culture and Leadership Survey.

The survey of more than 2,000 managers and clinicians, supported by MiP, found that 22% thought the quality of leadership in the NHS was “good” or “very good”, compared to just 14% in 2013. The proportion rating leadership as poor fell sharply from 40% to 28%.

But the survey revealed widespread concerns about the handling of inappropriate behaviour or poor performance, with 43% saying swift and effective action was not taken when problems arose. Even 16% of executive directors agreed.

The King’s Fund said it viewed with concern the growing disconnect between the views of clinicians and executive directors, with board members being consistently more positive about working conditions and culture within the NHS than doctors and nurses. For example, 63% of executive directors believed there was “pride and optimism” among staff, but only 20% of nurses and 22% of doctors felt the same.

MiP chief executive Jon Restell said: “Better views of leadership among staff, compared to last year, is good news and means the focus on leadership is working.”

But he warned that staff expected poor behaviour and performance to

be properly tackled by employers.

“Tolerance for disruptive colleagues is falling sharply as pressures on time, resources and quality grow and grow. We need to invest urgently in the skills of line managers so they can nip problems in the bud, embrace difficult conversations and challenge poor performance.”

To coincide with the survey, the King’s Fund and the Center for Creative Leadership, published a report calling for the NHS to promote “collective leadership” (see box) in place of traditional command-and-control structures.

Nicola Hartley, the King’s Fund’s director of leadership development, urged all NHS organisations to make creating a collective leadership strategy a priority.

“Creating truly compassionate patient services requires collective leadership, where all staff take responsibility for the success of the organisation and this is actively promoted by leaders in the organisation. This requires high levels of dialogue, debate and discussion to achieve a shared understanding.”

“We strongly support the idea of collective leadership,” added Restell.

“Leadership is needed in all staff groups, not just managers, and we need to nurture leaders in every nook and cranny.”

Learning through good practice Wednesday 25 June 2014, Bristol Wednesday 24 Sept 2014, Southampton

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Better together Key points from the report Developing collective leadership for healthcare, by Michael West, Katy Steward, Regina Eckert, Bill Pasmore.

■■ Collective leadership means everyone

taking responsibility for the success of the whole organisation as a whole – this contrasts with traditional approaches focused on developing individual capability.

■■ If leaders create positive, supportive

environments for staff, staff will create caring, supportive environments for patients.

■■ Where there is a culture of collective

leadership, staff are more likely to intervene to solve problems, ensure quality of care and promote responsible, safe innovation.

■■ Organisational performance does not

rest simply on the number or quality of individual leaders — where relationships between leaders are well developed, trusts will benefit from direction, alignment and commitment.

■■ Vision and mission statements must

be translated into clear, aligned, agreed and challenging objectives at every level of the organisation.

Read more about collective leadership and the survey on the King’s Fund website: www.kingsfund.org.uk

MiP’s programme of seminars to help managers develop their skills and resilience is proving very popular.

As part of the programme, MiP has joined with Big Difference Company to host seminars which look at what we mean by “patient voice” and the managers’ role in patient engagement, and how strategies to develop personal resilience can help you deliver challenging work programmes. Facilitated by MiP chief executive Jon Restell and consultant Linden Rowley, the seminars are free to attend and open to all health and care managers.

For more information and to register, contact Anna Peavitt at anna@bigdifferencecompany.co.uk

healthcare manager | issue 22 | summer 2014

HEADS UP

inpublic

“We see ourselves as becoming a hub of development and innovation.”

NHS North Yorkshire and Humber Commissioning Support Unit NHS North Yorkshire and Humber CSU officially opened its doors on 1 April last year, becoming one of the 19 new commissioning support organisations created following the Government’s controversial restructuring of the NHS. Covering an area of over 4,500 square miles, and employing 380 staff, the CSU has nine NHS Clinical Commissioning Groups (CCGs) on its list of clients, and offers a range of services to NHS and nonNHS organisations alike.

Its portfolio of services includes managing strategic projects and service change, procurement, clinical quality, business intelligence, medicines management and financial and corporate services.

The CSU’s clients also include foundation trusts and GP practices, to whom it offers support for complaints services and pharmaceutical medicines management.

MiP national committee member Jeremy Baskett is one of the CSU’s relationship managers. He explains that while the CSU is looking to innovate and develop new relationships with a wide range of clients, CCGs will always be “very, very important” to the CSU. “We have invested very heavily in our relationship management with all our customers,” he explains.

“They will get a dedicated manager who is often embedded with the CCG’s senior management team.”

The CSU recently announced that it was merging with West and South Yorkshire and Bassetlaw CSU from October this year when it will become known as Yorkshire and Humber CSU. Baskett says the mission of the CSU is to deliver innovation and change and believes the organisation will be very active in developing new NHS services.

“We see ourselves as becoming a hub of development and innovation,” he says.

One example of this is an app on safeguarding for children, recently developed by the North Yorkshire and Humber CSU. healthcare manager | issue 22 | summer 2014

The app can tell professionals immediately who are the key contacts for safeguarding in their area, should they need to raise concerns about the welfare of children being cared for by NHS bodies or social services.

The CSU’s medicines management social care support team has also recently launched a web-based resource centre for care providers.

The CSU website hosts a specialist area containing national and local guidance documents, NICE guidelines and recording templates to provide CCGs with the help they need to manage medicines safely in social care settings.

He says that one of the strengths of the CSU is involving the staff of its client organisations in decision making. “This is

where CSUs will really come into their own,” says Baskett. “We can see the bigger picture across a region, which is a bigger footprint than one CCG. “Having economies of scale will be the key thing... our merger has largely been driven by having that,” Baskett admits.

The CSU has also partnered with Attain, a private company which provides personnel to the CSU to help it develop its strategy and commissioning support.

“As time goes on, our resources and what we are able to offer as a CSU will get better and better... customers are looking for added value from the CSU and if the NHS really does want to ‘transform and change’ then this needs to happen,” says Baskett.

Helen Mooney

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LETTERS

letters

Letters on any subject are welcome. Please send to editor@ healthcare-manager.co.uk or to 8 Leake Street, London SE1 7NN. We may edit letters for length. Name and address must be supplied, but you may ask for them not to be published.

to the editor

Let’s punch above our weight The motivation behind the Government’s actions on public sector pay and pensions has little disguise.

MiP has an honourable record of opposing moves to denigrate public service and what some see as moves to end the NHS’s role as a provider organisation.

There is unlikely to be support for strike action

among managers and it’s equally unlikely that it would “break many hearts”.

I would prefer we take the propaganda route. Almost all the media is infused with anti-public sector bias and indulges in misinformation and selective reporting. Let’s counter this by providing the public with balanced information. Let’s challenge the Daily Mail’s hysterical ranting, and the propaganda of the major political parties and media commentators, with the odd fact.

Much of the excellent work done by NHS managers is never covered — not least in

maintaining staff morale and performance in the face of the relentless monochrome negative reporting rather than the kaleidoscope of unreported good news that is the real NHS we know. How long would any organisation of comparable size maintain its credibility faced with the forensic analysis and covert investigation the NHS has endured for the last three years?

Of course, we do make mistakes and every single one should be a source of discomfort for managers and a huge shove towards reflection and improvement.

No manager I work with is

complacent or uncaring.

I suggest our subscriptions would be well used in buying media space to simply and clearly state the achievements of the NHS, as part of a rolling positive campaign rather than a reaction to others citing our faults.

MIP is a small organisation of committed public servants proud of their role in providing a world class public service. I believe we can punch above our weight, using honesty, facts and altruism — something all politicians advocate, but usually for others.

Andy Cole, Somerset

MiP conference 2014: Wednesday 19 November, London

MiP’s annual conference takes place at the Congress Centre in London on 19 November. That’s just six months before the general election, so no doubt the NHS will be in the political spotlight again.

Our speakers will consider the policy landscape for 2015 and beyond and discuss the way forward for health and social care.

NHS managers have been subject to

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unprecedented attacks over the past couple of years and we will be taking issue with those who take cheap shots at them. We will highlight the excellent and essential work that managers do as part of the healthcare team and counter the lies and misunderstandings. We will discuss the state of leadership in the health services, and how we can support and nurture good leaders and attract

and retain a more diverse managerial workforce.

The conference will be chaired by Channel 4 health correspondent Victoria Macdonald and will include debates, masterclasses and networking tables.

MiP members attend free of charge, so book your place now. To register and for further details, visit the MiP website at www.miphealth.org.uk.

healthcare manager | issue 22 | summer 2014

COMMENT

comment Allyson Pollock

Professor of public health research and policy at Queen Mary, University of London.

Why we need safeguards with care.data Data are the life blood of public health and the NHS. Without good data, we cannot plan care for patients and we cannot monitor who needs healthcare, who’s getting it and who’s being denied it. We need data to audit care quality and to intervene when things go wrong.

Public trust in the government’s handling of NHS data is at an all-time low following revelations that data were being sold to commercial organisations. Earlier this year, the BMA, the Royal College of GPs and medConfidential spearheaded a campaign called “OPT-OUT” against the government’s care.data scheme, which aimed to link data collected from GP practices with hospital data.

Since the time of Hippocrates, patient information has been recognised as sacrosanct. Doctors are bound by a special duty of confidentiality, underpinned by law. We visit our doctors when we are at our most vulnerable.

Terminal illnesses, miscarriages, sexually transmitted diseases, domestic violence, unemployment or work stresses are ‘routine’ diagnoses for doctors, but are deeply personal and often tragic for the patient. Knowing that commercial companies could exploit that information will deter patients even further from consulting their doctor.

For over sixty years, the NHS has cherished and protected our data through public ownership and strong legal safeguards. Aggregate data is healthcare manager | issue 22 | summer 2014

“Since the time of Hippocrates, patient information has been recognised as sacrosanct.” used for public interest purposes – by cancer registries, for example — and for compiling public health statistics for healthcare planning, auditing and monitoring. There are no recorded incidents of researchers having abused their privileged access.

But public trust has been undermined by the government’s decision to allow many NHS services to be delivered by companies such as Serco, Group4, Virgin and United Health – even private insurance companies.

What happens to our NHS data when it is collected, stored and used by the private sector? Patients do have to consent, but it will be a brave patient who refuses if they’re told it will help coordinate and plan their care. Optingin will destroy sets of national statistics built up over more than a century and seriously impair research into diseases, treatments and care. Opting-out may have similar consequences.

What is to stop companies selling the data generated through their NHS contracts? The government has refused to answer or even listen to these questions. There are no checks.

Previously, there were just two public interest exceptions to the confidentiality of patient data – known as “Section 251 approvals”: for national statistics and for medical purposes. But the 2012 Health and Social Care Act allowed companies to request the establishment of information systems for their own use. The Health and Social Care Information Centre (HSCIC) can already sell data “in connection with the provision of healthcare or adult social care” — a vague condition easily extended to insurance, marketing, invoicing, and targeting eligible and ineligible patients.

One patient’s data can be used to deny care to another.

So what is to be done? The campaign put forward three amendments to the House of Lords on 7 May. These were: a requirement that patients must consent to data being used for commercial purposes; the restriction of “research use” to public interest and medical purposes, as set out in “Section 251”; and parliamentary — or at least independent — oversight of HSCIC’s operation.

But the government refused to listen and pushed through amendments which favour the commercial sector. We now need a new campaign for legislation that will require the Secretary of State to secure and provide healthcare for all and ensure the public interest trumps the claims of shareholders.

.

Views expressed are those of the author and not necessarily those of healthcare manager or MiP. 9

NHS FINANCE

Paul Briddock reports on a new census and survey which finds that NHS finance staff remain committed to the NHS despite falling numbers and rising workloads.

Although there are fewer NHS finance staff following the Health and Social Care Act changes, they continue to enjoy their jobs despite often difficult working conditions and doubts over how other people value their work.

These are some of the findings of a major census and survey of staff attitudes undertaken by the Healthcare Financial Management Association and the NHS Finance Skills Development Network.

The HFMA’s briefing, The NHS finance function in 2013, sponsored by Managers in Partnership, provides a detailed statistical breakdown of NHS finance staff in summer 2013 and shows an overall 4% fall in the number of finance staff since the last census in 2011.

The change in functions related to the Act — for example the creation of NHS England regional and area teams and new clinical commissioning groups — makes direct comparisons more complicated, with the new census covering a broader range of staff and functions than in 2011. But even with the changes in scope, staff numbers have fallen in absolute terms by more than 600, from 16,368 in 2011 to 15,730.

In the commissioning arena, where 10

there have been specific requirements to reduce running costs, the reduction has been greater. Staff numbers in CCGs, commissioning support units and NHS England area and regional teams fell by 11% compared with 2011 levels in primary care trusts – seen as the closest comparison. Given the changes in role, it is likely that the real reduction in commissioning finance staff is greater than this.

Analysis of figures reveals that staff are almost equally split between the 211 CCGs (1,190 staff) and 19 CSUs (1,055). The census shows there were 12,164 finance staff working in NHS trusts and foundation trusts – a 1% reduction compared with 2013.

Provider trust staff make up 77% of the overall NHS finance function.

Some 35% of finance staff are band 7 or above (not including directors), compared with a similar level (34%) at bands 1-4. A further 26% are in bands 5 and 6, with the balance made up by other staff (non Agenda for Change staff at or below band 8D) and directors. This represents a similar grade mix of staff to that found in 2011. However, it is clear that the bulk of the reductions in finance staff have come in bands 1-6, with a 10% reduction in staff in bands 1-4 and a 6% reduction in staff numbers in

bands 5 and 6. This is offset by a small increase in the number of finance staff at bands 7 and above.

Some of the reduction in bands 1-4 results from the greater use of shared services. For example, while some PCTs retained fully in-house financial services, all CCGs have their core transactional financial services provided externally as part of the Integrated Single Financial Environment (ISFE) supplied by NHS Shared Business Services. Half of NHS finance staff work in financial management with 29% working in financial accounting and 19% in financial services.

The NHS finance function is highly qualified, with 43% either qualified with or studying for a CCAB (or equivalent) qualification. More than 60% of the finance workforce are women. However women are less well represented at senior levels: at band 6 and below, women make up 72% of the finance workforce, but only 49% at bands 7 and above.

Building on the headcount figures, the HFMA staff attitudes survey aimed to build a comprehensive picture of the training and development, career paths, values and perceptions of NHS finance staff. More than 900 people responded, primarily from the qualified and student accountant community. healthcare manager | issue 22 | summer 2014

NHS FINANCE

NHS Finance staff numbers 2011-13 Breakdown of change by employer

The sample demonstrated significant levels of NHS experience with more than 40% having five years or more experience in their current organisation.

There was some evidence of a lack of mobility between the commissioning, provider and strategic sectors of the service. About two-thirds of provider finance staff have never worked in a commissioning organisation or at the strategic level. And 58% of CCG, CSU or area team staff have never worked in a provider.

Staff in the main have high levels of job satisfaction. On a scale of 1 to 10, the mean satisfaction score last year was 6.8, increasing further at the higher grades. This is despite long working hours. A quarter of staff said they always worked in excess of their normal hours, while 70% said they worked longer hours at least twice a week. For many this was just part of the finance culture – the need to get the work done – and was often related to specific projects or times of the year when annual accounts or cost returns are due.

While most staff (80%) are keen to stay in the NHS, only 63% expect to see out their careers in the health service. And of these only 34% felt very secure in their current job. healthcare manager | issue 22 | summer 2014

The vast majority of finance staff think their department adds value to their organisations, although a few identified opportunities to improve this value, for example, by moving away from providing historical commentary and towards forecasting and modelling.

But there is a more mixed story to tell on how finance staff believe their role is valued by others. Nearly 90% felt valued by their line manager, and nearly 70% by the board. This dropped to 61% for clinicians, although respondents pointed out that it was sometimes difficult to give a simple yes/no answer to the value placed on the finance role by a group as individual views varied widely.

But just 30% felt valued by their national government health department.

And this fell even further to 18% for patients and 17% for the general public. There were complaints about the negative image of finance staff and managers in general in the press and about the lack of understanding of what finance contributes. Some 43% of finance staff thought their status would be higher in the private sector, compared with just 12% who thought they enjoyed better status in the NHS. Despite this, finance staff were clear why they worked in the NHS. Seven

out of 10 said they were motivated by ‘public sector values’ and 60% by the ‘opportunity to improve services for patients’.

The survey confirms what those in finance already know. Our staff are attracted to work in the health service for the right reasons – they believe in the NHS and want to play a part in improving patient care.

We need to transform the delivery of services in the NHS and finance staff have a major part to play in this. Good financial control is essential to high quality healthcare, but, beyond this, robust finance information can help inform decisions about current and future service options and provide a window on variation. We need better understanding of this important role outside of finance departments. The focus for everyone in the NHS is the patient and ensuring care is of the highest standard possible. But we need greater recognition that achieving this is a team game involving both ‘frontline’ and ‘back office’ staff.

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Paul Briddock is technical and policy director at the Healthcare Financial Management Association. The HFMA’s briefing Transforming healthcare: the role for the finance team, is available from TinyURL.com/mq7vfzb.

11

INTERVIEW: ROB WEBSTER

Rob Webster, the new chief executive of the NHS Confederation, wants to set a new tone in the NHS with values-based leadership and a lot more collaboration. He spoke to Healthcare Manager’s Alison Moore.

Excellence in care comes in many shapes and sizes: for Rob Webster, the new chief executive of the NHS Confederation, it came in the form of a tiny crib he saw on a recent visit to Liverpool Women’s Hospital.

The hospital cares for many women with complex pregnancies, not all of which end happily. Midwives had arranged for a specially-sized crib for premature stillborn babies which would allow parents to photograph their babies without them looking swamped.

It’s one of those small touches that can make a difference at the most difficult times. “The fact that they did that underlines the type of care people are giving every day,” he says, and making a difference to patient care is very much his driver.

Webster, 45, came to the Confed after running Leeds Community Healthcare Trust and, before that, Calderdale Primary Care Trust. He has also worked at the heart of government – in the Department of Health and the Cabinet Office – which led to him being called a ‘policy wonk’ when he moved to a frontline job.

“I loved being a chief executive in the NHS. I felt it was a great privilege,” he says. But it was realising that the sys12

tem needed to do more to support good work locally which made him apply for the Confed job.

“I was working in a system where at a local level we were trying to deliver services to meet people’s needs through a partnership with the council, acute trust and the university. That was a positive choice that we made together. What I did not see reflected nationally was any sense of how that was being supported sufficiently.

“The Confederation provides a system voice in a different way to the Foundation Trust Network which is a voice for providers. I’m a great collaborator. I like to amplify the impact of people being together.”

So what does he see as the immediate challenges in his new role? “There is a leadership tone I want to set which I hope resonates with people in the service. Given where we are and how many challenges the NHS faces, a values based approach to leadership is essential and one that focuses on the system rather than the organisation.

“What I would really like people to recognise is that leaders in the NHS and care are some of the best leaders we have in this country. [They] have

delivered some of the biggest changes and most courageous bits of work in the NHS’s history. Despite all the concerns about the financial position over the last three years we have still delivered. We have got to recognise that NHS leaders and those working in local government have performed incredibly well. But what we now face is another significant challenge that is as big as the ones that we’ve just been through.

The future is going to be a big ask for everybody.

“The second challenge for me is how to really position the Confederation in the NHS to meet the challenges of the 21st century.”

With the NHS facing a perfect storm there is a need to look at the way care is delivered and how that can change, he says. “We know that the public and politicians can be fantastic allies for change but they can also block it.”

So he will be asking politicians to help explain to the public where change is essential and not to be too prescriptive in their manifestos. The response so far has been fairly positive, he says.

But the NHS will also need a vision for the future – a ‘burning ambition’ to match the ‘burning platform’ on which it currently stands. Webster suggests healthcare manager | issue 22 | summer 2014

INTERVIEW: ROB WEBSTER

“I’m a great collaborator.

I like to amplify the impact of people being together.”

the beginnings of this can be glimpsed in, for example, the Future Hospital project run by the Royal College of Physicians. All this work needs to be pulled together as part of a single vision with care ‘wrapped around’ the patient.

“We want politicians to sign up for the vision for change but I don’t expect them to say they agree with the Confederation vision of the future – though they might agree with 80% of it.

We are on this burning platform and over there is the burning ambition but under current conditions we’re not going to get there.

“The third thing is to make the Confederation fit for delivering that. We have a set of fantastic organisations doing really great work under our umbrella.” He mentions the relationship with the National Association of Primary Care, together with the launch of NHS Clinical Commissioners. He wants to build stronger relationships with lohealthcare manager | issue 22 | summer 2014

cal government organisations as well as patient groups.

“If we can do that we will end up with a Confederation which has really strong voices around commissioning, delivering the service and the patient.

That feels as if we could be increasingly powerful. But I want to make sure that we’re always connected to the leadership.”

Leadership is obviously a theme which preoccupies him. “When I was a chief executive I was only accountable for two things – the safety of every patient and the value of every penny. I felt that personally every second of every day, and the chief executives I talk to are the same. Being accountable drives you inwardly to be the best you can. But what we use accountability for in the system is to beat people. I want the system to support you to fulfil your accountability.”

Webster’s view on the proposed ‘fit

and proper person test’ for NHS directors is nuanced. Leaders need to have a set of values aligned with the organisation, he says.

“I think setting standards which reinforce the normal principles of public life and values are good. Whether we need to always legislate for that is another matter. We need to get back to what is the issue at point here.

“As a chief executive I was able to spend time with my staff in people’s homes when [the patients] are most vulnerable, and be completely trusted. I think the issue is trust… we need to work very hard to retain that.”

And with the NHS about to embark on some of the most fundamental changes ever seen, trust is going to be particularly important. “We have to be able to demonstrate that we are a set of fit and proper people. We have to be trusted with something that is incredibly precious, not just to the people receiving the service but to Britain — if 13

INTERVIEW: ROB WEBSTER

“It’s always interesting to invite people from outside to come and have a look – they recognise the quality of people we have.”

that doesn’t sound too pious.

“We have to get into a position where the staff we employ and the leaders we select reinforce values-based leadership. The idea is that when we have bad apples who shout at people, bully and try to shut up whistleblowers, they become the exception and they stand out.”

This extends to the non-NHS organisations the Confed works with, he says, where the question will be, do their values match those of the NHS? “The NHS does not have a monopoly on values. Lots of private sector organisations are fantastic values-driven organisations.”

The issue of incompetent leaders is more difficult, he admits. There is the question of who judges incompetence, and also a tendency to blame people rather than the system when things go wrong.

“As a trust chief executive I got ten times as many compliments as complaints. But we don’t talk about positive things – we’re British.”

But how is the NHS going to find the resilient and diverse group of leaders it needs? “Sometimes we beat ourselves up on where we are on equality 14

and diversity,” says Webster. “We’re ahead of most FTSE 100 companies.

But there is enough evidence that there is discrimination.”

When he worked in the Yorkshire and Humber area, research showed that BME staff did not feel they had opportunities to progress, whereas white people felt both that they did and that BME colleagues did as well.

“We need to sort it out. It can’t be allowed to continue. Different leadership creates strengths. We need to create the conditions where we have the best leaders possible to meet the toughest challenges.”

He does not call for positive discrimination but stresses instead the importance of talent development programmes. “I can’t not be white, middle aged and a bloke, but I can be passionate about [the need for change].”

More generally, Webster fears clinicians could be put off coming forward for top management jobs. “The tone around the chief executive leadership means... people are saying why would anyone want to do this? We could be speaking more positively about being chief executives in the NHS.” More clinical leaders are emerging, he suggests, with some fantastic indi-

viduals coming through in CCGs. Depending on how a manager is defined, four out of five managers in the NHS are already clinicians, he points out.

He adds that the NHS reforms set out to deliver three things – accountability, improved outcomes, and the clinical leadership of change. “The agenda that we have and the way that we describe it has to be attractive to clinicians.” He suggests that deciding how to get the best clinical outcomes has to be a clinically led process – and that will enable “the money to drop out”.

But he agrees that managers are always going to get a rough ride from politicians and the press. “We have to recognise that manager-bashing will always be a political reality. In the run up to the election I don’t expect there will be any back slapping.

“But it’s always interesting when you invite people from outside to come and have a look – they recognise the quality of people we have.” Webster was particularly pleased to invite Sir Stuart Rose (ex-M&S boss and now adviser to Jeremy Hunt) to the Confederation conference.

The drivers for quality have to come from inside rather than just from regulation, he says. He points out that Mid Staffs was preceded by other care failings – Bristol, Maidstone and Tunbridge Wells, Winterbourne View.

“We have to be constantly vigilant about how this might happen. The way we make sure it does not happen is creating the right culture and values.

What frustrates me is that if we talk about the positives people think we are denying the negative.”

He is particularly positive about his regular visits to the frontline when he was chief executive at Leeds (usually working in a support role, doing “the grubby stuff”) which he is trying to continue at the Confederation. “The discretionary effort we get from [frontline staff] is superb,” he adds. “The NHS is made up of people, it is not made of buildings or drugs or kit.”

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healthcare manager | issue 22 | summer 2014

BUREAUCRACY

Blaming phantom “bureaucrats” for the ills of the NHS and other public services blinds us to the value of a good bureaucracy, says Craig Ryan.

Bureaucrats are famously faceless, but they’re usually invisible too. Who are these obstructive pen-pushers, these clock-watching jobsworths, getting in our way? You? Your colleagues? Your boss? Your chief executive? Have you noticed that whenever someone attacks bureaucracy, in the NHS or elsewhere, like Macavity the Mystery Cat, the bureaucrat’s not there?

American academic Charles Goodsell, who bravely wrote a book called The Case for Bureaucracy (2004), said: “Bureaucracy, institutionally, is said to sap the economy, endanger democracy, suppress the individual and to be capable of embodying evil. It is denounced on the right by market champions and public choice theorists and on the left by Marxists, critical theorists and post-modernists.”

For decades, “bureaucrats” have been everyone’s favourite scapegoat.

For politicians and much of the media, blaming bureaucratic phantoms is a way to avoid responsibility for failed policies and ideologies, or to duck the tough political decisions. Why admit your billion-pound NHS reorganisation was ill-conceived when you can blame “bungling bureaucrats”? Why deal with the awkward reality that markets

healthcare manager | issue 22 | summer 2014

“Precision, speed, ambiguity, knowledge of files, continuity, discretion, unity, strict subordination, reduction of friction and of material and personal costs — these are raised to the optimum point in the strictly bureaucratic administration.”

Max Weber

sometimes fail when you can blame interference from Whitehall or Brussels? Why face the facts about funding NHS care for an ageing population when you can just promise to slash “red tape”?

Professor Julian Birkinshaw of London Business School works with managers on streamlining their organisations. “I always push back when they say bureaucracy is the problem,” he says. “‘What exactly is going wrong?’ I ask them. Bureaucracy is a convenient bogeyman, as it can mean anything bad about big companies.”

So, if everyone agrees bureaucracy is a bad thing, why is it so hard to get rid of?

In the early 20th century, the German economist and sociologist Max Weber made the first academic study of bureaucracy. He concluded that bureaucracies were hierarchical, based on rules and procedures, upwardly accountable, functionally departmentalised, deliberately impersonal and employed people on the basis of technical qualifications.

Few business schools would quarrel with Weber’s description of bureaucracy, even today.

“Precision, speed, ambiguity, knowledge of files, continuity, discretion, unity, strict subordination, reduction of friction and of material and personal costs — these are raised to the optimum point in the strictly bureaucratic administration,” wrote Weber.

Try reversing Weber’s attributes and see where that gets you in, say, a hospital, a government department or even a tech multinational. It’s only when we try to imagine life without bureaucracy that the reasons for its survival become clear.

We complain that bureaucracies offer impersonal, “bog-standard” services.

Bureaucracies do usually try to treat clients or customers according to a 15

BUREAUCRACY

consistent set of rules, principles or criteria. But how else do we want to allocate NHS treatment, school places or benefit payments? According to the whims and prejudices of individual public servants? First-come-first-served? The ability to pay fees or bribes?

We need bureaucracy to make sure that “personal” does not become arbitrary, discriminatory or wasteful. In an A&E department, this usually means treating people according to urgency.

Using a “bureaucratic” procedure, such as triage, results in more personalisation not less. “Bureaucratic” requirements for professional qualifications and standards help to ensure that good post-natal care, for example, does not depend on chancing across a “good” health visitor rather than a bad one.

We complain that bureaucrats are feather-bedded in their secure jobs. But effective administration benefits from experience and a degree of continuity in leadership. But despite a mountain of evidence that rapid management turnover diminishes the performance of healthcare organisations, the average NHS chief executive lasts just 20 months in the job.

Twenty years is more like it, according to Ross Baker, professor of healthcare management at the University of Toronto.

He studied several top healthcare organisations for the King’s Fund 2011 Leadership Commission, including Henry Ford Healthcare in Detroit, Jönköping Council in Sweden and our own Heart of England foundation trust in Birmingham.

Baker concluded that the highest performing organisations were “likely to have long-serving senior leaders, and transitions that preserve their achievements”.

We complain about “jobsworth” bureaucrats, unwilling to go the extra mile, use their discretion or take risks.

But clearly defined responsibilities and lines of accountability are important, especially when the public expect someone to “own” their problem and take responsibility for sorting it out.

It’s World Cup time, so let’s try a football analogy. When the 2014 Premier League Manager of the Year, 16

Tony Pulis, joined Crystal Palace last November, the club were rooted to the bottom of the league. Six months later, without a single new player, Palace finished eleventh, winning five of their last eight games. To what does Pulis attribute this remarkable turnaround?

“The most important thing was ironing everything out on the training ground so everybody knew their role,” Pulis told the BBC. “Wherever the ball is, they know where they should be, they have to be there and if they’re not there it will cause problems.

“The reason why we’ve achieved what we have is because everybody has done what we wanted them to do to the best of their ability. If anybody marches away from that and starts doing what they think is right for them, and not right for the team, then the team will collapse and be similar to what it was before I took over.”

We complain that bureaucrats waste money. But our public bureaucracies are hardly indulgent towards staff or the people they deal with. (I used to go to regular meetings at the Treasury, where tea and biscuits were served in

“The reason why we’ve achieved what we have is because everybody has done what we wanted them to do to the best of their ability.”

Tony Pulis, Crystal Palace Manager

regulation “Treasury green” cups. There were always exactly the same number of biscuits as attendees at the meeting.

If someone didn’t turn up, the number of custard creams was adjusted accordingly.) In fact, bureaucrats are accused of being penny-pinching almost as often as they’re accused of profligacy.

Truly catastrophic waste often comes from too little bureaucracy rather than too much. With government IT projects, attempts to cut “bureaucracy” through “management by contract” have resulted in a lack of in-house expertise and an inability to control costs. Likewise, neither the Whitehall nor City Hall bureaucracies were able to control the incredibly complex public-private partnerships for the London Tube, which piled up losses estimated at £20 billion by the time they were wound up in 2006.

In 2000, against civil service advice, ministers decided to contract out the Individual Learning Accounts scheme and dispense with the “bureaucratic” accreditation of training providers. When it was wound up mere months later, fraudsters had siphoned off more than a third of the £290m spent on the project.

You can see where this is going. With bureaucracy, the flipside of every vice is a virtue. The time-serving jobsworth with a “computer-says-no” mentality, who is penny-pinching and resistant to change is also an experienced manager, who knows her job, is properly accountable, treats people equally according to the rules, juggles competing priorities, is prudent with her employer’s money and takes evidence-based decisions.

In cost terms, the NHS appears to be a relatively efficient bureaucracy.

Whether it spends a “staggering” 13.6% of its budget on administration, as The Guardian’s Simon Jenkins claims, or just 8%, as the King’s Fund says, it compares well with the world’s most successful company, Apple, which spends around 30%. So is there any evidence that the NHS is over-managed?

The King’s Fund doesn’t think so. It estimates that only 4.8% of NHS staff are managers, compared to around 16% in the economy as a whole. Since healthcare manager | issue 22 | summer 2014

BUREAUCRACY

1997, the NHS budget has more than doubled in real terms, but there are only 25% more “bureaucrats”. The King’s Fund’s NHS Leadership Commission found “appreciable evidence” that the NHS was, if anything, “under-managed”, despite being “overburdened with administrative tasks” — many imposed by the very politicians who complain about too much bureaucracy.

It’s not as if bureaucracy is unknown in the private sector.

Indeed, large corporations like General Electric, UBS and Apple have whole “universities” dedicated to training staff in the company way of doing things.

This sounds very much like a bureaucracy, however much that might be at odds with the company’s image.

Bureaucratic structures have actually been proliferating as more firms — especially banks and insurance companies — have moved away from decisions based on personal relationships, experience and instinct towards relying on protocols, procedures and models. The algorithm — which dominates much modern business decision making — is a very bureaucratic mechanism indeed. It’s just an automated one.

Just because the top managers wear jeans doesn’t mean the firm doesn’t have a bureaucracy. Corporations like Apple, Google and Microsoft have welldeveloped bureaucratic structures built around tight brand guidelines, design templates, programming protocols, rigorous standards and extensive testing and verification. They are bureaucratic in ways that work for healthcare manager | issue 22 | summer 2014

them, harnessing bureaucratic structures to support the more creative aspects of the business.

New technologies are developing new forms of bureaucracy. The web

itself is really a digitised bureaucracy, with its hierarchies of documents, strict protocols such as HTML 5, clearly defined roles and functions, and the emphasis on authority and knowledge encapsulated in Google’s algorithms for producing and ranking search results.

Modern management thinking — like complexity leadership and “whole system” leadership, recognises that the bureaucratic and creative leaderships must work together for either to function properly. Large and necessarily bureaucratic organisations like the NHS need to find ways for the two aspects of leadership to talk while giving each other the breathing space to do what they do best. The BBC is a supremely bureaucratic organisation, but it would be a

harsh critic who said it hadn’t managed to function creatively over the years.

In their book, Leadership in the Twenty-First Century, Gregory Dess and Joseph Picken (2000) said that the challenge for today’s leaders is “to loosen up the organisation — stimulating innovation, creativity and responsiveness, and learning to manage continuous adaption to change — without losing strategic focus or spinning out of control”. That remains the challenge for today’s NHS leaders.

For all their faults — and some recent setbacks – we still tend to trust our traditional bureaucracies more than private corporations and much more than political institutions.

Regular surveys, like British Social Attitudes and IPSOS MORI’s polls on British institutions, consistently rank the NHS, the BBC, the military, the courts, the police and even the monarchy (well — it’s certainly hierarchical and procedural) as the most trusted insitutions in the country, and those the British people are most proud of.

In The Case for Bureaucracy, Charles Goodsell wrote that “good bureaucracy is indispensable to a free society, a democratic polity, and a capitalist economy… the ability to vote governments out of office requires a reliable administrative apparatus.”

It’s probably asking too much to urge public servants branded as bureaucrats to wear the label with pride, but being indispensable to freedom, democracy and prosperity is nothing to be ashamed of.’

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Craig Ryan is a freelance writer and associate editor of Healthcare Manager.

Read Craig’s blog at: www.craigryan. eu/blog 17

PERSON CENTRED THINKING

Clive Acraman and Brian Smith explain how the NHS can develop a more personalised and cost-effective approach to caring for people with complex conditions.

There are powerful legal and ethical reasons for providing people with quality information so they can better manage their health and wellbeing, and make fully informed decisions about their treatment and care. Yet, according to NHS England’s 2013 GP patient survey, only 3% of patients had a written care plan in place. This is despite the Francis Inquiry highlighting the lack of patient involvement in care decisions and the need to create a patient centred culture in the NHS.

In our conversations with NHS and social care managers we often hear about the challenges faced by people living with dementia, and other conditions which make communication difficult, and the extra support they need.

Unfortunately, the information emanating from staff working on wards and in community settings is rarely person centred and often lacks insight into the challenges these patients face.

We are told about people displaying ‘challenging behaviours’. People who appear highly confused and in a state of agitation are said to be ‘wandering all over the ward’, ‘creating a nuisance for other patients’, or ‘trying to escape’.

People who struggle to articulate their wishes and feelings verbally, and so express themselves differently — and often with great emotion — are de18

scribed as violent, aggressive and uncompliant. While the implicit messages given by staff can appear negative, they are not meant to be. The managers we meet understand the frustration and anxiety of staff whose vocation is to care for people with compassion and treat them with dignity and respect.

Unfortunately, the same staff often report feeling overwhelmed, undervalued and under-resourced.

Of course, the challenges reported by health and social care staff are also the day-to-day experiences of many families, friends and care workers who provide the majority of care in domiciliary settings.

The reality we face is stark. People living with complex conditions account for two-thirds of total health costs.

People are living longer and the number of people with complex care needs is projected to rise by 50% over the next 20 years. Therefore, the need to invest in enabling and supporting a more personalised understanding of people who use health and social care services could not be more urgent.

To get care and support right we need to understand the limitations of the treatments and services currently used to manage distress, including psychotropic medication and continuous one-to-one supervision and monitoring (“specialing”).

We need creative, sustainable solutions

to ensure we can meet the complex needs of people who present as distressed. At the heart of this is supporting staff to increase their understanding and to deliver simple, cost-effective, person centred interventions.

ADAPT This is why we have developed ADAPT (Alleviating Distress by Applying Person Centred Thinking), a tool to help successfully support people in any care setting when they are expressing distressed behaviour. ADAPT is an inclusive, considered approach which recognises the impact of distress, while highlighting the need for co-production of care plans to achieve positive outcomes. It incorporates three simple steps: understanding, engaging, and caring and supporting.

Understanding The first step is to understand who we are supporting. Family, friends and carers can explain the person’s ‘usual’ personality, helping us to know when they are well and when their behaviour is unusual, and to appreciate and recognise the person’s qualities, strengths and individual resources, which can be used to support them. This helps us to identify potential causes of distress, to set aside any preconceived ideas and examine the presenting behaviour analytically. healthcare manager | issue 22 | summer 2014

PERSON CENTRED THINKING

PERSON CENTRED THINKING TOOLS

help people to move from a state of distress to feel comfortable, safe and secure by understanding what is important to individuals and how they wish to be supported wherever they are on the spiral.

PERSON FEELS DISTRESSED

WE UNDERSTAND

WE ENGAGE

WE PLAN

WE SUPPORT

PERSON FEELS COMFORTABLE, SAFE AND SECURE

At this stage it is helpful to record what the person is trying to communicate: what is happening around them when they present as distressed? What do we think the behaviour means?

What is the person’s behaviour telling us? And how should we respond?

Engaging The second step involves staff, the patient and the people close to them engaging together in a ‘family meeting’ to co-produce a personalised care and support plan. Engaging with the patient’s friends and people who know them well helps us to understand their social history, daily routines and behaviours. Methods of communication are often the most important things we need to know on admission, or when we initiate a service following a referral.

This method of engagement meets the duty placed on commissioners by the Health and Social Care Act to involve individuals, their carers and rephealthcare manager | issue 22 | summer 2014

resentatives in decisions about their care and treatment. The family meeting also explicitly meets the commitment in the 2010 white paper Liberating the NHS to greater patient choice and control through an “information revolution”.

It can also bring significant reductions in costs, as highlighted by the Wanless Report. Information, combined with the right support, is the key to better care, better outcomes and reduced costs.

The outcome of a family meeting is a personalised care and support plan which begins with a positive statement explicitly describing who the patient is and how they wish to be supported.

The interventions they require from their family, friends, carers and professionals, and the purpose and desired outcome of the intervention, are all recorded and agreed.

Caring and Supporting When implementing the plan it is vital that everyone does what they agreed

to, at the time and in the place they agreed to do it. This consistent approach is essential to success. The process of planning personalised care and support is organic, continuous and fluid in nature. This provides a structure to support learning and reflection and ensure appropriate continuity of care.

A personalised care and support plan is never complete; it should be reviewed and updated regularly. As recommended by Francis, when a person no longer requires intervention, their plan must remain alive to ensure that the right information is available to the right people at the right time and in the right place, should they require additional care or support.

Effective planning ADAPT is a simple, non-technical, cost effective approach. Using person centred thinking, it draws together all the relevant people and develops the necessary competencies to produce successful, sustainable interventions with people who present as distressed.

Planning with people is often viewed as a time-consuming luxury. However, taking two hours to truly understand a person can save many thousands of pounds by avoiding one-to-one ‘specialing’, additional unwarranted assessments, unnecessary interventions and medication with significant adverse side effects.

Effective planning will ensure we can deliver on Francis and that patients get the information they need, delivered with sensitivity and due regard for them as valued individuals, capable of coproducing the interventions that will best support them.

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Clive Acraman has 30 years experience of delivering health and social care services with children, families and adults. Brian Smith is an occupational therapist with 25 years experience, specialising in people living with complex conditions. For more details about ADAPT, visit: www.planningwithpeople.org.

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LEGAL MATTERS

legaleye Iain Birrell updates us on new provisions allowing employers to hold ‘protected conversations’ with their employees.

In July 2013, new provisions came into effect allowing employers to talk to workers “off the record” to arrange settlement agreements.

These “protected conversations” represent yet a further shift in the balance of power away from staff towards employers. Healthcare managers need to be aware of the new provisions and their impact on themselves and their staff.

The Government’s rationale for introducing the new provisions was that businesses wanted to be able to talk to their staff about sensitive employment issues, such as retirement and maternity leave, but were worried that the details of what they said could result in legal claims against them. Effectively, the Government decided this was too legally daunting for employers and they needed protection from their own workers.

Before the introduction of ‘protected conversations’, employers could speak to their staff “without prejudice” and the conversation could not be disclosed as evidence in an employment tribunal or court. However, “without prejudice” only applied if the conversation formed part of negotiations for any settlement agreement and when there was a genuine attempt to settle an existing dispute.

If there was no dispute, then the conversation could not be held “without prejudice”.

With “protected conversations” the requirement for an existing dispute is removed. An employer can now talk to a worker about sensitive and important employment issues, safe in the knowledge that the details will be withheld from any ordinary unfair dismissal tribunal.

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The provisions are particularly damaging for workers wishing to pursue a case of constructive dismissal. An employer could hold a sensitive conversation with a worker which has the effect of destroying the working relationship and leads to worker’s resignation — yet the crucial conversation could not be used as evidence in an employment tribunal. Of course, while most employers will not abuse the new provisions, there

will unfortunately be some who do.

Thankfully, some crucial safeguards for employees are still in place.

Conversations cannot be “protected”, and therefore kept out of a tribunal, where they relate to discrimination and some forms of unfair dismissal.

Moreover, there are numerous pitfalls for employers when attempting to make a settlement agreement. An employer can easily find themselves unprotected if there is impropriety or procedures are not followed correctly.

ACAS has produced Settlement Agreements: A Guide, which lists various examples of what might be deemed “improper” behaviour by employers. For example, an employer putting undue pressure on an NHS manager to sign an agreement would be regarded as improper behaviour. As a general rule, ten calendar days should be allowed for an employee to consider the terms of an agreement, unless agreed otherwise. In addition, all forms of harassment, discrimination and victimisation while negotiating a settlement agreement are listed as inappropriate behaviour. However, whether or not the employer has actually acted improperly will always be for the employment tribunal to decide.

Although there is no statutory right to be accompanied by a trade union representative in a protected conversation meeting, paragraph 13 of the ACAS code of practice on settlement agreements states: “Whilst not a legal requirement, employers should allow employees to be accompanied at the meeting by a work colleague, trade union official or trade union representative. Allowing the individual to be accompanied is good practice and may help to progress settlement discussions.”

Any healthcare manager approached by their employer regarding a settlement agreement should contact their union representative immediately for support and advice on the process

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Iain Birrell is a member of Thompsons Solicitors’ Trade Union Law Group.

Legaleye is not intended to provide legal advice on individual cases, and MiP members in need of personal advice should immediately contact their MiP rep.

healthcare manager | issue 22 | summer 2014

TIPSTER

Giving feedback Giving feedback is all about helping your colleagues, not criticism or blame, says Bob Dowd.  INTENT

5 A DESC JOB

Consider your ‘intent’ and think it through carefully before you start any feedback session. As long as you are committed to helping the person concerned, then you will should be OK.

You may be familiar with a form of feedback like the DESC script: Describe the exact behaviour; identify the Effect or impact on you or others; Specify the change you are looking for; and Check it out for understanding. This also chimes with another technique for positive reflection, often used for interviewing purposes: ‘STARS’. This means thinking about the Situation/Task, or ‘challenge’, they faced; the Actions or behaviours they used; the Results or outcomes of their efforts; and the Skills, tools or techniques they used. STARS is particularly useful for helping people to reflect positively and develop their confidence.

2 FEEDBACK, NOT CRITICISM Be careful to distinguish between praise, criticism and feedback. Praise — comments such as ‘well done’, ‘you communicated well’ and so on — are helpful, but are not feedback. Criticism is simply and lazily pointing out a negative.

Feedback is ‘future facing’, more explicit, and focuses on actual behaviours or actions. Michael Polanyi argued that learning needs to be explicit: we can’t replicate “you chaired the meeting well”, but we can replicate “you summarised actions after every agenda item”.

6 ON REFLECTION

3 ACCENTUATE THE POSITIVE Talk about what they “did well” or what they “could do differently” rather than “what we messed up” or “where we went wrong”. In David Kolb’s learning cycle (www.simplypsychology.org/learningkolb.html), comments like these are the essential links to consolidate learning between the ‘Reflective Observation’ and ‘Abstract Conceptualisation’ stages (think about Kolb’s cycle as a ‘continuous improvement’ process). The ultimate aim is to help your colleague to learn to use these questions themselves.

healthcare manager | issue 22 | summer 2014

7 FEELINGS Be aware of your own feelings as well as theirs. If either of you are experiencing a disabling emotion, such as anger or distress, take some time out. It’s more helpful to express your feelings when you are not actually experiencing the emotion, as part of describing the effect or impact of their actions. Use your own words, and say “I felt…” or “I was…” rather than “you made me...” This applies equally to positive feelings, such as “I was really pleased...”

8 FOLLOW UP Make sure you follow up on feedback, especially if you have taken the time to challenge unhelpful behaviour — it’s a great opportunity to give genuinely positive feedback if they do make changes. This underlines the importance of feedback as an ongoing dialogue.

9 PRESENT OPTIONS Involve them in creating “options” (plural) for how things could be done differently in the future. Note the word “could” — “should” implies that there is only one way (your way?) of doing things.

 YOU ARE LEARNING TOO Treat giving feedback as a learning experience for yourself – both to consolidate good practice (remember your own neural pathways!) and to reflect soon afterwards on how you handled the feedback session. This will help you to feel more comfortable with your own feedback skills.

4 USE IMAGERY Be perfectly clear and explicit about “what good looks like”, using strong imagery or visualisation. Neuroscientists believe that we learn through practice or strong, vivid imagery – both help to create neural pathways which enable us to “access” appropriate actions or behaviours more easily. Small actions or behaviours (“micro-narratives”) gradually build up to a macro-narrative about our self-perception, belief, image or identity.

by identifying and articulating what you could have done differently.

Help yourself by getting used to reflecting first. Jim Collin’s metaphor in his book Good to Great about “looking in the mirror” when things don’t work, and “looking out of the window” when things go well, holds good for giving feedback.

It’s useful to “model” feedback yourself

Bob Dowd is a lecturer at Liverpool University Centre for Continuing Education, working on leadership and organisational development. He can be contacted at bobdowd@liv.ac.uk.

21

MIP AT WORK

What do members expect from MiP? MiP MEMBERS’ SURVEY

Marisa Howes reports on the findings of MiP’s members’ survey 2013.

MiP commissions an annual independent survey of members to gauge satisfaction with our services. We followed up the 2013 survey with some in-depth interviews using “appreciative inquiry” to better understand what we do well and spread the good practice throughout the organisation.

Many thanks to the members who responded to our survey. The response rate of 5%was lower than 2012, but understandable given the pressures managers are under. It was a good representative sample, with responses from all regions and nations.

The majority of respondents said MiP had performed well or excellently against its three main goals — speaking up for healthcare managers (65%), 22

providing individual and collective representation (62%), and providing opportunities for members to develop their knowledge and skills (51%).

Although not as highly as representation, members rated skills development as important and we have increased the number of seminars around the country which may influence the score.

While MiP members are generally happy with our work on their behalf, with just 8% not satisfied, we still want to improve our performance further.

A quarter of respondents had been represented on a personal basis by an MiP officer in the last two years.

This was a return to the levels of 2011, after higher levels in 2012 during the

major upheavals in the NHS in England. But it is still a considerable proportion of members, especially when added to those who contact us for general advice and information.

Of those who had direct representation from MiP, the majority said the experience was excellent (30%) or very good (26%), with 20% saying it was satisfactory and 24% that it was below their expectations or not satisfactory. Our plans for the next year aim to improve the experience of all our members.

With personal representation, the top priority for most respondents was having speedy access to a national officer, followed by feeling assured that the officer has a high level of competence, followed by feeling supported, cared for and kept informed.

We interviewed some members with a good experience of representation, using some elements of appreciative inquiry, to find out what our officers do well.

Speedy access to national officers Interviewees said that MiP’s initial response times were generally very good, often just a few hours. A response within 48 hours, or 24 hours for pressing cases, was considered generally acceptable.

Follow-up contact with officers was also important. Members particularly appreciated officers who acknowledged messages (even if they couldn’t deal with them straightaway), gave regular progress reports and delivered on commitments, such as attending healthcare manager | issue 22 | summer 2014

MIP AT WORK

meetings or writing documents. Members reported a good experience when they felt they had enough time and attention from their officer.

High level of competence Interviewees reported a high degree of satisfaction when they felt confident in the officer’s skills and expertise. One remarked on the skilful way that their officer focused on facts, detailed analysis and checking what had been said.

Interviewees also prized the skills of officers who used reflective practice and coaching in preparation for hearings. They also valued straight talking and objective advice, where officers were sympathetic but honest about the options available.

Feeling supported and cared for Members want to feel they “own” their case, with support and direction from the officer. As one respondent put it: “I knew the direction but [the officer] knew how to get there.”

Members appreciated officers who listened effectively, showed empathy and interest in their case, but were willing to challenge unrealistic expectations in the member’s best interests.

‘I felt looked after and cared for, yet they were always objective and suggested other options if that was the best approach,’ said one.

So the perfect MiP national officer is knowledgeable about employment law and contracts, an expert negotiator, and a skilful coach who responds promptly to requests for help. He or she maintains contact, listens and empathises but provides realistic and objective advice.

MiP’s national officers are our USP and our inquiry has helped us understand what our members value most about their service. The majority of those we have represented have the highest praise for our services but we need to be more consistent. We will use this valuable feedback to inform our staff development to improve our service to members. And don’t wait for the survey to give us your feedback.

Contact us on info@miphealth.org.uk

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healthcare manager | issue 22 | summer 2014

Helping members get on with their lives MiP national officer Jane Carter shows how MiP can help members resolve problems at work, often without having to go through formal processes.

At MiP we often hear from members who need to resolve a problem at work but ‘don’t want to make a fuss’.

One such member is Fiona, a service manager in her 40s who has been working in the NHS for over 15 years. She is a very committed professional who gives her all to achieve good quality patient care — a typical NHS manager and MiP member.

When Fiona contacted MiP she was working in a mental health trust in a band 8A role. Her permanent post had been deleted in a restructure three years earlier. Since then, she had undertaken a series of project roles, despite repeated promises of suitable alternative employment. Eventually, not having a permanent role made her ill with workrelated stress. She realised she needed to do something to resolve the situation and that’s when she contacted me.

I listened to Fiona’s whole story and advised and coached her on her next steps, using my knowledge of employment law, the employer’s policies, contractual terms and duties of care. I helped her to think through the pros and cons of a range of options, including seeking a permanent substantive role (possibly at a lower band) and arguing that a redundancy position continued to exist as her employer had failed to find her suitable alternative employment. Fiona said afterwards that these conversations

with her MiP rep were the first time she felt someone had listened to her since her post had been deleted.

We agreed a course of action and I arranged an informal meeting with her manager and the HR director to explore options. I set out Fiona’s case, highlighting the prolonged period of anxiety in which she had worked and its effect on her health and wellbeing.

Following the meeting, the employer offered Fiona a redundancy payment.

They also accepted that they had not treated Fiona well and the chief executive apologised to her. My calm and firm advocacy impressed Fiona’s manager and HR director and both have since joined MiP. Because we managed to resolve the issue informally, Fiona did not have to go through the stress and anxiety of the formal grievance procedure – something she was very grateful for.

She knew she could not have made her own case effectively, given her lack of experience, poor health and her strength of feeling about it.

I could say this is all in a day’s work for an MiP national officer, but it’s a joy to use my skills and expertise to represent members like Fiona and help them to resolve problems and get on with their lives.

.

You never know when you might run into problems at work and need confidential, expert advice and assistance. If you’re not a member already, join MiP today. You can join online at www.miphealth.org.uk or ring Laura on 020 7121 5146 for an application form.

23

backlash

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

by Celticus

Funny money

W

ith the NHS scrimping for every penny, claims by the BBC’s Panorama in March to have found £5bn down the back of the sofa got everyone’s attention.

Unfortunately, its report on fraud in the NHS turned out to be, well, a bit of a fraud itself. The research, by Portsmouth University and BDO, an accountancy firm specialising in (surprise, surprise) “fraud reduction”, employed what we’ll politely call an “unusual” methodology. Rather than actually research fraud in the NHS, they collected data from six countries since 1997, calculated an average percentage lost and applied it to the NHS’s £110bn budget.

Hey presto, £5bn a year! The baffling question is, as the UK was one of the six countries, why not use the actual UK figure (the DH’s best estimate is £229m) instead of extrapolating from an average of irrelevant ones?

Looks like another case of a solution provider in search of a problem.

Serious money

L

et’s talk some real numbers. The Economist reports (31 May) that the US healthcare system lost between $82bn and $272bn to fraud in 2011. That’s somewhere between half and one-and-a-half times the NHS’s entire budget.

24

And this is not some dodgy extrapolation, but a serious study by Don Berwick, who actually used to run the system as head of Medicare and Medicaid. Fragmentation and profiteering makes some fraud inevitable, and mindless complexity makes things worse, says Berwick.

(Medicare, for example, has 140,000 different billing codes, including nine for attacks by turtles). Even The Economist, hardly an apologist for the NHS, concludes: “Whatever its defects, Britain’s single-payer National Health Service is much simpler, much cheaper and relatively difficult to defraud.”

Bare necessities

H

ats off to those intrepid warriors for justice, the Taxpayers’ Alliance, for “uncovering” another £46m (0.04% of the NHS budget) spent on “unnecessary” NHS jobs, which turns out to

mean anyone involved in communications, equality or “green” work. Never one to spurn a cut-price cliché, TA chief Jonathan Isaby fumed that the money spent on these 1,129 posts would be better spent on “real doctors, not spin doctors”. Of course, the report tells us more about the the TA than about the NHS. The anti-equality agenda and climate change denial we expect, but why Isaby, a former Telegraph and BBC hack who claims to be Westminster’s “first professional blogger”, is so opposed to “communication” remains a mystery.

Simon says

T

he Guardian’s Simon Jenkins jumps aboard the bandwagon (7 May), professing to be shocked that the NHS spends a “staggering” £15bn on “administration”.

(How does he distinguish “administration” from anything else the NHS does?

Presumably, a surgeon’s biro is “administration” but a scalpel isn’t). “Change has become a ruling obsession… there must be more change managers than heart surgeons”, Jenkins complains, before going on to urge another massive reorganisation. Then, after listing some selective bad news about the NHS, Jenkins concludes, without a trace of irony, that “all the NHS news seems bad”. We know different. Send your good news stories directly to Simon at simon.jenkins@ theguardian.com.

Thanks for nothing

A

nother week, another “thank you” letter from Jeremy Hunt, full of warm words about “your amazing efforts”, “all your hard work”, “your willingness to go the extra mile”, even “the goodwill that exists in the NHS”. But like those disappointing birthday cards from distant aunts, there’s no money inside. And not one single word of apology, or appreciation for the fact that, once again every member of the NHS staff is working harder and longer for less money. We know Hunt won’t change the Treasury’s austerity mindset, but he might’ve gone the extra mile himself and acknowledged the financial sacrifice all NHS staff make. After all, it’s the thought that counts.

healthcare manager | issue 22 | summer 2014

e

insuranc

holidays

The added va lue of membership

s

mortgage

savings

motoring

finance

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.

It’s not just doctors who make it better.

Managers are an essential part of the team delivering high quality, efficient healthcare.

MiP is the specialist trade union for healthcare managers, providing expert employment advice and speaking up on behalf of the UK’s healthcare managers.

Join MiP online at miphealth.org.uk/joinus

helping you make healthcare happen

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12/11/2013 17:25