issue 30 summer 2016
healthcare manager
MARIA KANE MANANGING MENTAL HEALTH IN A COLD CLIMATE plus TALKING THERAPY How managers put Stockport’s doctors back in touch TIME TO GO Having trouble finding the exit door? Your union can help
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issue 30 summer 2016
healthcare manager inside
Craig Ryan Acting editor
heads up:2 Leading edge: Jon Restell inperson: Sheree Axon, director of organisational
Whatever else it is, Brexit is hardly a welcome mat for the NHS’s 57,000 staff from other EU countries.
change and programme delivery, NHS England
comment:8 Sir Simon Wessely: Mental healthcare is still being short changed
features:9 published by
Case Study: How Stockport put GPs back in touch with hospital doctors The HCM interview: Maria Kane, chief executive, Barnet, Enfield & Haringey Mental Health Trust Devo Manc: Where’s the plan for the NHS’s northern powerhouse? Pensions: Tax relief and your NHS pension
Managers in Partnership miphealth.org.uk 8 Leake Street, London SE1 7NN | 020 7121 5146
regulars:20
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.
backlash:24
Legal Eye: Snooping and surveillance at work Tipster: How to clean up your email inbox MiP at Work: Our anti-bullying initiative, plus how MiP can help you get the best redundancy outcome
How many will stick around once we make it much more difficult for them to live and work here remains to be seen. But just days after the referendum, the HSJ reported that some had already decided the UK was no longer the place for them. And there are anecdotal reports from across the UK of NHS staff facing xenophobic and racist abuse from patients and members of the public. That’s very sad and rather pathetic. Staff from across Europe have made a giant contribution to the NHS, especially in recent difficult years, and the service couldn’t operate without them. I’m sure MiP members will do everything they can to give EU staff all the support they need and deserve. In the next few months, we’ll be making some changes to Healthcare Manager as part of a major review of MiP’s communications. Our communications survey has now closed (see page 5), but don’t let that stop you from giving us a piece of your mind. It’s your union, your magazine and your website, so tell us what you want and what you need and we’ll do everything we can to bring it to you. Enjoy this issue and what’s left of the summer!
healthcare manager | issue 30 | summer 2016
1
heads up Our review of news you might have missed, plus what to look out for
Training
MiP Conference 2016
MiP training for link members
Great managers, great workplaces – a positive vision for the NHS
27-28 July 2016, Unison Centre 130 Euston Road, London NW1 2AY
We help our link members to develop new, transferable skills and get more involved in representing the union, working with existing members and recruiting new ones. This two-day course is facilitated by professional tutor Davinder Sandhu, with MiP chief executive Jon Restell and national officer Jane Carter also taking part. It will help you to: ■■ Gain in-depth knowledge of the role of an MiP link member ■■ Recruit new members and explain the benefits of belonging to MiP ■■ Understand MiP and UNISON national, regional and local structures
To register, please contact Laura Anthony on: l.anthony@miphealth. org.uk.
healthcare manager
Design and Production
issue 30 | summer 2016
Lexographic www.lexographic.co.uk
ISSN 1759-9784 published by MiP
Contributors
All contents © 2016 MiP or the author unless otherwise stated.
Acting Editor
Craig Ryan editor@healthcare-manager.co.uk 07971 835296
2
■■ Identify how you can support members ■■ Organise members on the ground ■■ Build confidence in dealing with workplace issues ■■ Address equalities in the workplace ■■ Look after your own wellbeing MiP will cover your expenses for travel and meals and will book and pay for your accommodation. Time off for courses is covered by national agreements and should be readily agreed by line managers. If you have any problems, please let us know.
2016
Join us at our 2016 annual conference. This year, the conference will focus on creating a positive vision for managers as catalysts for high-performing teams in great workplaces, despite the huge pressures on the health service. The MiP annual conference, which is free to attend for all MiP members, provides a great
Andy Cowper, Helen Mooney, Alison Moore, Jon Restell, Matt Ross, Craig Ryan, Dale Walmsley, Sir Simon Wessely, Brian Wilson. Optinions expressed are those of the contributors and not necessarily those of healthcare manager or MiP.
healthcare manager | issue 30 | summer 2016
Wednesday 23 November 2016 Congress Centre, London WC1B 3LS
opportunity for you to exchange your experiences and views, get practical support on the issues which affect you, and hear from a range of speakers and contributors. For more information and to register online go to mip-conference.co.uk or call 020 7592 9490.
Cover image
© Euan Cherry/Photoshot.
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 join our mailing list or receive copies please email editor@healthcaremanager.org.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 them to the editor by email or by post to MiP, 8 Leake Street, London SE1 7NN, clearly marked “For Publication”. We may edit letters for length. Name and address must be supplied, but will be withheld from publication on request.
leadingedge Jon Restell, chief executive, MiP
W
hat do the next three years hold for the NHS, its staff, managers and the public it serves? I recently spent three days at the NHS Confederation conference in Manchester. It’s a good barometer event, even if delegates tend to express themselves carefully. The messages from top leaders like Simon Stevens and Jim Mackey were straightforward: “You’ve done a great job in a difficult year” and “We need more money, but we won’t get any: get used to it.” Of course, they were soft-pedalling on resources before the EU referendum. It will get colder and harder from now on. I joined an HSJ roundtable where trust chief executives were asked what makes today’s problems different to earlier funding crises. The consensus was that everything – money, quality standards and access targets – is nailed down today. What hasn’t changed are the high workloads, the staff shortages and constant organisational change. People understand that this is the boat we’re in. Some other themes from the Confed made an impression on me: ■■ People talked a lot about social care funding, with Stevens suggesting that any new money should go to social care. The relatively few voices representing social care warned that integration was in trouble because NHS commissioners and providers don’t understand social care. ■■ Sustainability and transformation plans (STPs) are the new system magnets in England. Opinions varied widely about what they can achieve and there was much talk about
“MiP will help to shape a more supportive approach to leadership in the NHS and the wider care system.” changes in commissioning structures. System bodies, including the Department of Health, are starting to respond quietly to the board-level vacancy crisis. As one delegate told me, “Frankly, Jon, we’ve run out of spikes… and heads to place on them.” ■■ There was a marked interest in culture change. I chaired a session on creating positive workplaces free from bullying. Other sessions looked at the power of conversations in changing culture and the workforce race equality standard, a year after it came into effect. So what might all this mean for our union? While we campaign for the best, we prepare for the worst. MiP will continue to press for proper funding of both health and social care, but members need to debate whether social care should take priority. We need to defend the role of managers. Access targets may be nailed down in publicly stated policies but few managers expect us to hit them consistently again. Managers are politically exposed in the gap between policy and reality. We need to keep up a steady drumbeat about the positive impact managers and other non-clinical staff have on patient care. The Carter review’s last minute recommendation – made ■■
without any supporting evidence – that administrative costs be cut to 6% shows the problem we face. Too many policymakers fail to recognise the importance of managers’ and support staff’s skills and capacity in delivering sustainability and transformation in our health and care services. MiP will help to shape a more supportive approach to leadership in the NHS and the wider care system. Leaders need a new culture that encompasses career management, skills development, inclusivity and diversity, pay, and the relationship between tenure and accountability. We need to embed good leadership into a workforce strategy that includes a longterm approach to pay and reward. We welcome the growing interest in culture with open arms. Good leadership and line management are critical to improving the working lives of staff and, therefore, patient care. Our partnership approach and perspective as a managers’ union mean that MiP has much to offer. Our reps will become an ever more valuable resource to employers, staff and patients. At the sharp end, we advise and represent hundreds of members every year, protecting their employment rights and improving their working lives. Our support for each member matters most because at the heart of MiP is our belief that managers matter to patient care and they need and deserve employment support and representation. Our team and reps will focus on becoming even more accessible, responsive, expert, dispassionate and empathetic – the five qualities of our service that members tell us matter most.
healthcare manager | issue 30 | summer 2016
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HEADS UP
Unison conference 2016
MiP and Unison plan closer working
MiP national officer George Shepherd (second left) at a joint MiP-Unison event in Ipswich.
Staff shortages are the number one headache facing NHS managers, according to delegates at Unison’s health ser-
vice group conference, held in April in Brighton. MiP held a lively fringe event, chaired by Darren Barber, Unison’s regional convenor for the Eastern Region and branch secretary at the Queen Elizabeth Hospital, King’s Lynn. Delegates debated whether senior managers joining MIP benefited other trade union members and workplace culture, and concluded that managers could shape workplace climate and needed more support – especially those in their first managerial jobs. Delegates also felt that Unison activists needed much more information about MiP and its work, and discussed how MiP members and staff could work with Unison branches on shared issues of concern. The survey and outcome of the fringe meeting will feed into a forthcoming review of the relationship between MIP and Unison.
Trade Union Act 2016
Union bill watered down Unions won important victories in their battle against the government’s Trade Union Bill, with key clauses outlawing the collection of union subs from salaries and restrictions on union facility time, political funds and public sector strikes watered down or withdrawn from the bill. Extreme measures to restrict protest, picketing and social media campaigns by unions were also dropped from the final act, which received Royal Assent on 4 May. Unison general secretary Dave Prentis said: “The final act looks drastically different from when it was proposed last year. And to achieve that, we ran a
4
Dave Prentis: Proud of the campaign against the bill.
campaign to be proud of. Of course we’d rather the bill had never existed, and there is much that is still wrong with it. But ministers have sensibly listened to many of the arguments put to them. They have
healthcare manager | issue 30 | summer 2016
rowed back from many of the proposals that would have placed unbearable restrictions on unions’ ability to function in public sector workplaces across the country.” Read more: bit.ly/hcm3004.
MiP committee
Zoeta wins FDA equality award
Former MiP chair Zoeta Manning was presented with the Wendy Jones Equality Award at the FDA’s annual conference in May. The award recognises Zoeta’s work to promote equality and diversity, as an NHS manager, a trade unionist and a leader of the health and social care BME network. The award was presented by Scottish TUC general secretary Grahame Smith (pictured above with Zoeta). “Zoeta has the experience and standing to make a major contribution to shaping race and equality policies, at national, regional and local levels,” said FDA president Gareth Hills. “Zoeta has done this in her characteristic, authoritative, calm and eloquent style, which breaks down opposition and always makes way for her innovative, but also pragmatic, solutions.” Zoeta, who remains a member of MiP’s national committee, told conference: “We see a lot more women in management now, which is great, but we are still struggling with BME leadership. I’m going to give you some homework. Do not come here to do nothing. I want you to think about how you can truly improve the diversity at senior management level and create the opportunities that we need to improve the situation.”
HEADS UP
Nursing bursary cuts may backfire Government proposals to withdraw bursaries for nursing students will exacerbate staff shortages in the NHS and could even leave the Exchequer worse off, according to an independent economic analysis commissioned by Unison and the National Union of Students. The research, by London Economics, found the move would increase costs to nursing students by 71% and lead to 2,000 fewer nurses qualifying each year. This could cancel out any savings once the costs of staff shortages and the increased use of agency staff are taken into account.
Scottish elections
MiP members demand funding pledge
Read more: the London Economics report is available from: bit.ly/hcm3002
Members set out communications priorities MiP should concentrate influencing policymakers and the media and recruiting new members, according to a survey of members’ views on the union’s communications work carried out this spring. More than 80% said working to communicate members’ views to politicians and civil servants should be among MiP’s top three priorities, while 56% prioritised the union’s media profile and 42% improving marketing to potential members. Members overwhelmingly wanted MiP to focus its campaigning work on combatting “manager bashing” by demonstrating managers’ contribution to healthcare services, and on “fighting for health managers’ pay, pensions, terms and conditions”. The survey found Healthcare Manager was widely read by members, with 86% reading at least some of each issue, and 54% reading the magazine for more than 15 minutes. Participants identified improved email bulletins, a stronger website and better use of social media as the priorities for MiP’s communications work in the future. The MiP national committee and staff will be taking the recommendations forward over the coming months. The winners of the survey prize draw have been notified.
MiP called on candidates in May’s Scottish Parliament elections to pledge to meet the public’s funding expectations for the NHS and support NHS managers taking difficult decisions “in the face of public unease”. The pledge, drawn up by MiP members, also called for an inquiry into how to maintain health and social care funding in the future. MIP committee member Wayne Gault said: “Our members have seen the increasing difficulties in meeting the
people’s aspirations for a first class NHS, given the available budget. We thought it was really important colleagues had their views expressed during election time, and hopefully someone will listen to them.” Leading Scottish newspaper The Herald backed MiP’s call in its editorial: “If our conversation about the NHS is to be honest, it must, as MiP suggests, include a discussion about the cost of the service and how that cost is met,” said the paper. Read more: bit.ly/hcm3001.
Raw deal on meals Poor quality hospital food poses a threat to the health of NHS workers as well as patients, according to a survey of 4,000 NHS staff by Unison and the Campaign for Better Hospital Food, published in April. Almost a third of NHS staff work night shifts, but half of hospital canteens close before 8pm, forcing staff to rely on fast food or vending machine snacks, the report said. The survey also found that 55% of staff would not be prepared to eat the food served to patients, and 86% said they had received complaints from patients about food prepared by outside caterers. Unison General Secretary Dave Prentis said: “Both staff and patients deserve better. An overhaul of NHS food is needed urgently, and enforceable standards
[should be] introduced so that hospitals can be held to account if they breach them. Takeaways and fizzy pop don’t make for a healthy workforce.” Read more: bit.ly/hcm3003.
healthcare manager | issue 30 | summer 2016
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HEADS UP
Valuing non-clinical staff
Pensions
Retire and return rules stay The Department of Health decided against changing the ‘retire and return’ provisions of the NHS Pension Scheme following representations from the Scheme Advisory Board, which comprises NHS employers and trade unions in England and Wales. Ministers ordered a review of the rules after press reports about the use of the provisions at board level. The SAB will issue new guidance on how the provisions should be used, and MiP will be fully involved. The SAB has also
announced a review of the money purchase AVC scheme, through which members can make additional contributions towards buying an extra pension at retirement or later. The SAB intends to report in the autumn. This year’s annual benefit and total reward statements will be available to view from the end of August 2016. MiP recommends viewing your online statement regularly as it helps to identify mistakes in your pay and service history. For more information about scheme benefits, rules and annual statements visit www. nhsbsa.nhs.uk/Pensions.aspx.
Let’s talk pensions MiP national officer Claire Pullar has been holding information seminars on pensions across Scotland and Northern Ireland, helping members to plan for retirement and get up to date with recent changes in pension arrangements. Claire says many
people do not even have basic information, such as how to top up their state pension so they can claim the maximum when they retire. “There are also some issues for members who are in the section 95 NHS pension scheme and have “opted out”
of paying full national insurance contributions towards the state pension, so it is worth checking and ensuring you are as paid up as possible to maximise retirement funds,” see adds. If you would like to hold an MiP pension seminar at your workplace, email Claire at: c.pullar@miphealth.org.uk. To top up your state pension, visit: www.gov.uk/ statepensiontopup.
MiP chief executive Jon Restell took part in a round table debate in May, as part of the Health Service Journal’s inquiry into maximising the contribution of non-clinical staff to the NHS. Widespread “manager-bashing” in the media “has made us reluctant to draw attention to the non-clinical care spend,” Restell told participants. “And there’s lots of good work to promote: from the porter who makes time to talk to a frightened patient to the clinical coders and finance staff – we should value these as important occupations, as well as simply being jobs.” He called for more investment in skills and training for non-clinical NHS staff. “Intermittently, we discuss with Health Education England the 0.01% of the NHS training budget for non-clinical staff, and we’ll keep pushing on this,” he said. Restell agreed with other participants that the NHS suffered from a negative working culture, too often driven by fear and blame. “Maybe this inquiry should be about not just the nuts and bolts of non-clinical workforce planning, but could also describe the new, more positive working culture that we want to see,” he said.
Pay
SSRB cut out of top pay review The Senior Salaries Review Body (SSRB), which recommends pay levels for senior public servants, refused to recommend a pay award for very senior managers (VSMs) in arm’s-length NHS bodies, after the government excluded it from a review of VSM pay. In its 38th report, published in May, the SSRB said it has been unable to work 6
healthcare manager | issue 30 | summer 2016
with QCG, the company hired to carry out the review. It called on the Department of Health to make clear what pay increase VSMs will receive, and to hold back money for next year if the 1% increase paid to other NHS staff is not awarded in 2016. “The SSRB’s decision not to make a recommendation was extraordinary, if understandable,” said MiP chief executive
Jon Restell. “The government’s poor engagement with the review body shows the relatively low priority given to this small but important group of leaders. It’s welcome that DH and the main arm’slength bodies are talking to us about how to make the best of a bad job, but a more strategic approach to executive pay is our long-term goal.”
MY JOB
inperson
“The NHS still has a traditional employment model – that needs to change and that is where my focus is going to be.”
Sheree Axon, director of organisational change and programme delivery, NHS England. Over the last 25 years Sheree Axon has built a career in NHS management that many would envy. Following a stint in hotel management on an African game reserve, she joined the NHS in 1990 as a band 5 personnel trainee at the then Norfolk Ambulance Service. She worked her way up to director of personnel in just six years, before being headhunted to become director of personnel at Derbyshire Ambulance Service. This is where she got her first experience of “the benefits of working closely with trade union colleagues”, she says. She subsequently helped the service to win an ACAS award for partnership working. Sheree then left the NHS to join Deloitte and Touche as a consultant in change programmes, before becoming an independent consultant for the Department of Health and helping to set up the National Care Standards Commission and the Care Quality Commission. She later returned to the NHS fold, joining the workforce for London programme, led by Ruth Carnell at the London Strategic Health Authority, where she later became programme director for workforce. Sheree currently leads a small team at NHS England which supports NHS organisations and staff who are going through change programmes. “This includes change in the shape of cost reduction and larger system change,” she says. She is also part of a team working to understand better the impact system changes will have on NHS England. “I am looking at the Care Passport, co-commissioning and devolution and what it all means for NHS England,” she explains. Sheree says she chose to come back to the NHS specifically because she wanted work that “connects
back to the patient”. She adds: “My roles have all been about releasing money back into the NHS for patient care. The NHS employs a lot of staff and it’s important that staff make the best possible decisions at the best possible time. It’s also important that costs are properly managed so services are properly funded.” She describes her current job as ”very varied, with the opportunity to shape and influence the way things are done and make a real difference”. One of the key things she is working on is finding ways to get young patients and the public, as well as the families of NHS England staff, more involved in the changes happening across the NHS. Sheree says she works closely with union colleagues on NHS change
programmes and is “very proud” of the relationship she has developed with them. She has also recently spearheaded the launch of a network which aims to support female NHS staff in non-managerial roles. And what of the future? “Over the next 18 months we will be thinking in a lot more detail about the impact of the organisational and planned system changes as policy develops, and there will be robust challenges around that,” she says. She also believes the NHS needs to turn its attention to supporting staff who move through different organisations during their careers. “The NHS still has a traditional employment model – that needs to change and that is where my focus is going to be.” Helen Mooney
healthcare manager | issue 30 | summer 2016
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MENTAL HEALTH
comment Sir Simon Wessely
President, Royal College of Psychiatrists
Getting our priorities right The Mental Health Taskforce, commissioned by NHS England, created a five-year, all-age national strategy for mental health in England to 2020. Its final report, published in February, covered five core themes: an integrated mental and physical health approach; prevention at key moments in life; creating mentally healthy communities; building a better future for mental health services; and, finally, a “seven day NHS”. The last theme refers specifically to emergency care – it does not imply we should deliver the same services every day of the week.
The strategy covers many issues on which the Royal College of Psychiatrists (RCPsych) has been focusing for some time, such as perinatal mental health, liaison psychiatry, crisis care and services for children and adolescents. One area where we have yet to see improvement is the health and wellbeing of the workforce. As a Royal Medical College, we strongly advocated that the NHS as an employer should to pay greater regard to this, not just as an end in itself, but because it is associated with better quality of care. Put simply, staff who are over-stretched, under-rewarded (not just financially) and feel vulnerable to being scapegoated for wider service failings, do not deliver good care. Much has been said about how providing specialist care to people experiencing mental distress is difficult, demanding work and requires dedicated, caring individuals. But we are missing a coherent 8
healthcare manager | issue 30 | summer 2016
“This crisis will not be solved by more individual interventions, but by taking a systemwide approach to a system-wide problem.” narrative about why this is the case, let alone what to do about it. Without such a narrative, many interventions may be at best ineffective and at worst harmful. Fruit in the canteen, better cycling lanes (and I speak as a keen cyclist) and practicing mindfulness are all fine, but they are unlikely to address the dissatisfaction and demoralisation seen across the workforce. For obvious reasons, attention has focused on junior doctors recently, but I doubt discontent is limited to one group within one profession. Few would not argue that NHS organisations must demonstrate good practice in the management of mental health in the workplace from now on. But this crisis will not be solved by simply putting more resources into individual interventions, but by taking a truly system-wide approach to a system-wide problem. People say “it’s not about the money”, but more money would certainly help. In February, NHS England committed to helping more than a million extra people and investing more than £1bn in mental health services by 2020-21. This was in addition to the previously announced £1.25bn new funding for children, young people and perinatal mental health care,
and £150m for eating disorders. All well and good, but as Tom Cruise once said, “show me the money”. When I asked a packed meeting of the mental health section of the Healthcare Finance Management Association (HFMA) if they had seen the promised monies for children’s mental health, only one person raised their hand. So we place greater importance on the commitment to hold commissioners to account for increasing funding to mental health – at least in line with the growth in their general allocation. Research by NHS Providers and the HFMA found that only 55% of the mental health trusts surveyed had received a realterms budget increase for 2015-16. The new £2.1bn Sustainability and Transformation Fund will be available to providers for 2016-17. But guess what? Again, there are concerns that mental health providers are missing out. The ‘sustainability’ bit of the Fund – worth £1.8bn – has been ring-fenced to help bring the provider trust sector back to financial balance. The ‘transformation’ part – worth just £300 million – is intended to support the development of new models of care, along with the implementation of policies such as the “seven-day NHS” and improvements in cancer, mental health and prevention. RCPsych is particularly interested in seeing the evolution of new care models in mental health over the next few years. As the Fund rises to £3.4 billion in 202021, we hope resources will be shifted from deficit reduction towards transformation in order to ensure mental health gets the priority it deserves.
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LEADING BETTER CARE: STOCKPORT
In the first of a regular series revealing the crucial role of managers in improving healthcare, Matt Ross investigates how NHS leaders in Stockport reconnected GPs and hospital consultants – improving the speed and quality of patient care.
“When I first started here 15 years ago, we had a lot of formal and informal meetings with GPs,” recalls Dr Ngai Kong, a consultant at Stepping Hill Hospital in Stockport. “We weren’t as stressed out as we are now, and GPs could phone consultants to discuss patients. We’re so time-pressured these days, there’s no time to have a natter. So those easy connections were broken, and nowadays I don’t know the GPs and they don’t know me.” Dr Kong’s experience chimes with that of Julie Ryley, head of primary care development at Stockport Clinical Commissioning Group. Investigating variable referral rates among the CCG’s GP practices, she identified a “disconnect between the consultants and GPs which had been there for quite a few years”. CCG doctors expressed a “need for advice and guidance – not only for the GP, but also to reassure patients”. With informal communication channels between primary and secondary care clinicians weakened by ever-growing workloads and structural reorganisations, GPs were dependent on formal referral systems – piling patients onto growing waiting lists for a consultant appointment. Many patients waited months for an appointment and then,
Dr Simon Woodworth, a GP in Stockport’s Chadsfield practice, with a patient who has benefited from the new system.
on arrival, found they were in the wrong queue and were referred on for tests or passed to a different specialism. As Kong says, in the “binary system – to refer or not to refer – there’s no room for resolving uncertainty in the grey areas”. So Ryley set out to find a way of reconnecting GPs with consultants – and thus of addressing those uncertainties and ensuring that each patient receives the right care. A few months on, consultants at Stockport NHS Foundation Trust and GPs at the CCG’s practices are directly
linked via a telephone advice service; and the early results are impressive. In the eight weeks to 15 April, GPs calling into the service reported that speaking with a consultant had avoided a referral in 59% of cases. In a further 11% they had requested diagnostics – ensuring that consultants had essential test results at hand when outpatients arrive at hospital. “Now patients can get some reassurance without waiting 12 weeks to be seen,” comments Ryley. “And the people who do need to be seen will be healthcare manager | issue 30 | summer 2016
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LEADING BETTER CARE: STOCKPORT
Julie Ryley, head of primary care development at Stockport CCG: “People who do need to be seen, will be seen quicker... So far, I can’t see a negative side to it.”
seen quicker, because the waiting list isn’t full of people whose referral could have been avoided. So far, I can’t find a negative side to it.” The new system, explains Dr Simon Woodworth – a GP in Stockport’s Chadsfield Medical Practice – has been introduced under Stockport Together, a major change programme designed to integrate health and social care, with funding from the Vanguard scheme. “So there’s a background which is about trying to improve interconnectivity and communications, and a strong management drive to not put barriers up,” he says. “There’s an appetite to do things differently.” Woodworth became involved in the project when Ryley recruited him to test a system developed by a company called Consultant Connect. Each GP practice has a dedicated number they can call. Once they have entered the patient’s NHS number and the specialism required, the system calls the consultants listed on the day’s rota, so GPs can explain a patient’s symptoms and seek guidance on how to proceed. “As a GP, it’s time-efficient. Rather than dictating a letter, I make a call – and we save time on administration,” 10
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says Woodworth. “It’s also efficient for the patient: they don’t have to attend hospital for an appointment they wouldn’t gain anything from.” Kong adds that consultants can suggest diagnostic tests to ensure that patients are referred to the right specialism, and give GPs the confidence to prescribe specific treatments – shortening the wait until patients receive treatment by many weeks. The system also asks GPs to record the outcome of each call, logs performance metrics, and saves a recording of each call into the patient’s records. “When you’re talking about the care of a patient, it’s very important to have clarity about what is being said between consultants and GPs,” comments Gill Burrows, the trust’s deputy medical director. “It was important that
“Managers could have let life carry on as normal, but they took the step. They are the unexpected heroes of the story.” — JONATHAN PATRICK
Consultant Connect store all those calls.” Though both trust and CCG staff could see the potential benefits of Consultant Connect, it would never have got off the ground if health managers hadn’t identified and addressed people’s worries about the new system. “A GP’s concern is that they’re very busy, and if they’re going to make a call it’s important that it’s likely to be answered,” explains Jonathan Patrick, a director at Consultant Connect. “The consultants’ concern is that they might be inundated with calls. And it’s all very well talking about the theory, but does a call really help you to avoid an unnecessary referral? “This is where management comes in, because they have to perform a very skilful dance,” he continues. “Everybody’s interested in people getting the right healthcare at the right time, but the trust wants to make sure its consultants aren’t overworked.” Ryley adds that when the project was first mooted, the trust was on a payment-by-results contract – raising fears that if the system did indeed reduce referrals, the hospital’s income might fall. “The answer was: yes, it could,” she comments. “But consultants already take phone calls from GPs, they receive letters asking for advice – and that time’s not logged.” Using the new system, this kind of advice can be recorded and recognised; and soon the trust moved onto a block-booking contract, giving it a stronger financial interest in dealing with each patient as effectively and as efficiently as possible. To address such practical concerns, Ryley and Burrows recruited a group of clinicians to test and pilot the system – checking its operation, and generating the evidence and confidence to get other medics on board. “Managers can win people’s minds by going through the procedures, doing their business cases, but to win hearts they have to convince everybody that it’s a good idea,” comments Patrick. “Even when you have a good story, that doesn’t mean it’s easy to communicate, and it’s
LEADING BETTER CARE: STOCKPORT
the managers’ job to do that.” These clinical leads included Dr Kong, a specialist in diabetes and endocrinology, fellow endocrinologist Richard Bell and GP Dr Woodworth. Then Ryley and Burrows organised meetings bringing consultants and GPs together: “And we could recount our own experience and reassure people,” recalls Kong. “My colleagues were worried about the time it could take, but it’s only a few minutes and you don’t have to take the call; if you’re busy, it gets passed on to the next person. It’s about finding those little windows of opportunity. A lot of work was needed in the run-up [to the launch] to demonstrate the system and make sure people understood what it’s about.” With the system up and running for four trust specialisms, the performance metrics are reassuring: 76% of GPs are put through to a consultant on their first attempt, with an average wait of 40 seconds, and the average call time is just three minutes 45 seconds. Ryley is, though, trying to persuade GPs to stay on the line after their call to log the outcome. Currently, around half ring off as soon as they’ve received advice. “But unless I’ve got evidence that it’s a useful system, I might not get further funding,” she says. Summing up, Patrick points to benefits on all sides. “For the CCG, there’s less unnecessary referrals so they spend less money. For the trust, the only people on the waiting list are people who need to be there. Consultants have less paperwork. And patients get the right care first time, with no unnecessary trips to hospital.” Dr Woodworth adds that the system has exceeded his expectations and those of his patients: “Waiting two months for a letter to come back drives people daft,” he comments. “Patients want quick, effective communications that tell them what they should be doing and when, and that’s difficult to achieve through the traditional models.” Less tangibly, the system has begun to rebuild those crucial links between consultants and GPs. “There’s a softer
“There’s no time to have a natter. Nowadays, the GPs don’t know me and I don’t know them.” — DR NGAI KONG
benefit: a recognition between GPs and secondary consultants that the relationships that used to exist have been eroded,” says the trust’s Burrows. “It may be more difficult to prove the benefits of reconnecting those two groups, but there’s a clear feeling that renewing those links will ultimately give much better patient care”. The Stockport Together programme, she adds, will “require a lot more integration across the whole of health and social care. And here we’ve seen a real willingness to work differently and across traditional boundaries that has been very encouraging; a much more open attitude from all clinicians to working differently.” Ultimately, this kind of project only produces benefits when clinicians – of different disciplines, specialisms and organisations – come together in the interests of better patient care. But as Jonathan Patrick points out, it would never have been conceived, developed, piloted, tested or delivered without visionary, ambitious and pragmatic leadership by health managers within the CCG and trust. “Without the managers, this project simply wouldn’t have happened, because all the clinicians are far too busy – and God knows how busy they’d be if
they didn’t have the managers supporting them,” he says. “They could have let life carry on as normal, but they took the step and are now sitting on what looks like a very successful project. They are the unexpected heroes of the story.” Asked to name the key figures behind this project, Dr Woodworth replies that the trust’s medical directors “drove it through the business managers within the hospital environment. It was incredibly important to have the foundation trust’s commitment to the idea.” At the CCG, “Julie [Ryley] was the driver behind the project,” he adds. She developed it, championed it, produced the business case, took it to the board. And I sat on her coat tails, as any clinician will with a good manager.” “The best year for the NHS, in terms of hitting all its targets, was 2006,” Woodworth concludes. “And that’s when it had the most managers – so I’m certainly not a convert to the idea that less managers equals a better NHS. And I’m a clinician, not a manager.”
.
A consultant to MiP, Matt Ross is an editor, journalist and change manager.
healthcare manager | issue 30 | summer 2016
11
INTERVIEW: MARIA KANE
With disintegrating community support and tighter funding than ever before, mental health services are near to breaking point. Alison Moore asks one of the sector’s leading chief executives, Maria Kane, how she keeps the show on the road.
Taking a walk through the grounds of St Ann’s Hospital with chief executive Maria Kane reveals as much about her leadership style as interviewing her. In just a few minutes, she stops to help patients who are lost or struggling with kerbs, greets many staff members by name, jokes with several of them, and inquires after the health of another whose foot is in a cast. Kane would probably deny knowing everyone on the rambling St Ann’s site – or at the trust’s other facilities across north London. But the chief executive of Barnet, Enfield and Haringey Mental Health Trust (BEH) is obviously a visible presence for many staff, including those based at remote sites or who work irregular hours. To hear their views and concerns, she holds regular sandwich lunches for a cross section of staff, as well as visiting out-of-hours services. The St Ann’s site may be green and pleasant, but it’s one of Kane’s major challenges. The buildings are no longer fit for purpose and, as the Care Quality Commission (CQC) said earlier this year, hamper the trust’s ability to deliver safe services. A planned redevelopment will have to be funded by the controversial sale of part of the 12
healthcare manager | issue 30 | summer 2016
site for housing. In the current financial climate, Kane sees this as the only way to secure better healthcare facilities. The poor state of its buildings was a factor in the ‘requires improvement’ rating the CQC recently gave the trust. Although there were positive findings too, the CQC highlighted problems common to many trusts in both the mental health and other sectors, including a shortage of permanent staff and excessive use of temporary workers. As an outer London trust, BEH faces the challenge that many people will prefer to travel a few tube stops further to get the increased pay (and perhaps prestige) that comes from working for an inner London trust. The trust’s deficit – forecast to be £12.6m this year, £3.5m above the control total set by NHS Improvement – is another challenge shared with many NHS organisations. But with mental health trusts, cost cutting can have a quick and brutal impact on patient safety. This is “not a comfortable place to be,” Kane admits, and managers have to consider the minimum requirements for a safe service. “It’s about managing risk – probably an increasing risk as the thresholds [for access to treatment] have got higher. “That’s a line we’ve consulted on,” she continues. “We’ve had a lot of
clinical input on it. We try to have sensible conversations about trying to make sure that the resources go to where they make the most difference.” This trust’s deficit persists despite a strong savings record, and some of the lowest costs per referral in London. “Need goes up and finance in real terms is, at best, flat,” Kane says. “You get to the crux where it is no longer doable. That’s where we are. It’s a balance between keeping as lean as we can but also keeping the goodwill of staff.” None of these myriad challenges diminish Kane’s obvious enthusiasm for the job or her appreciation of the sometimes very hard and testing work the trust’s staff do. But she knows that many people’s care will need to be delivered in a different way in the future, and that prevention and early intervention need to come to the fore. With the population of its catchment area increasing by 2% a year, and an ever changing cultural mix, the trust’s services can’t remain static. As well as mental health, the trust runs general community services in Enfield, so the opportunities offered by more integrated services should be significant. For older people, the three Ds – dementia, depression and diabetes – should make a co-ordinated approach to both physical and mental health particularly valuable, potentially
INTERVIEW: MARIA KANE
EUAN CHERRY/WWW.PHOTOSHOT.COM
“You get to the crux where it is no longer doable. That’s where we are. There’s a balance between keeping lean and keeping the goodwill of staff.”
offering better care and a more holistic approach to patients with multiple conditions. Other services can learn a lot from how mental health services have developed over recent decades. “A lot of the skills needed to help people self-care come from mental health care,” Kane points out. “We have very skilled staff, who are really able to help that motivation, that ability to look for ways for people to help support themselves.” Young people, used to looking at screens, may not want traditional approaches to healthcare, she adds. Although the UK is certainly lagging behind the pace of technological development in healthcare, she warns it is just as important to develop a workforce which is competent to cope with the technology. But even with technological
innovations, mental health care is going to remain a very workforce-focused service, where ongoing relationships and trust are key to realising therapeutic benefits. Kane claims the ethos of care at BEH has very much moved from “what’s the matter with you?” to “what matters to you?”. Patients want to “live, love, do”: they want to have somewhere safe and secure to live, to be connected through relationships, and have something meaningful to do. “These are the sorts of things that give people the resilience to cope with their conditions,” she explains. It may not look like much to ask for – but her teams have had patients who are living in sheds and cars, and the lack of social housing in London is always a challenge, especially with increasing numbers of people living alone. “We need to look at a very extended workforce,” says Kane. “Do we have
mental health workers who can support both mum and children, for example? Who are the people in Surestart or early years’ services?” Seizing opportunities for interventions also means looking beyond the boundaries of traditional services. Could, for example, north London’s Turkish community be offered support through the many barber shops in the area? Their staff are used to dealing with men in very intimate situations – perhaps they might be prepared to open up about how they’re feeling and can be directed to services which could help. Kane feels very strongly about the inequalities faced by people with mental health issues. “We know that someone with a serious mental health illness is [on average] going to die 15 or 20 years earlier than someone without,” she says. “There are certainly [parity] issues in terms of outcomes.” And healthcare manager | issue 30 | summer 2016
13
INTERVIEW: MARIA KANE
Kane warns that many determinants of mental health lie outside the scope of healthcare services and funding, and changes in the rest of the public sector are making things harder. “Some social care has been absolutely decimated. We’re seeing people break down more,” she says. The shortage of housing stock and care homes prepared to take older people who have had a mental health admission also makes it harder to place people back in their communities. “One of the key planks of caring going forward is, what can we do to prevent things developing in the first place? That includes trying to deal with children,” Kane says. “The first 1,000 days of someone’s life are the most important. Are we offering enough care in pregnancy and those early years? We’re very short sighted on this. There is fantastic evidence about investing early, especially around children’s behavioural disorders where the savings are multiples of the cost.” Early intervention can reduce costs later on, when children run into problems at school, such as exclusions, or get involve in crime. “We’re just creating lifelong problems which consume huge amounts of public sector resources as well as the cost to the person themselves,’ Kane says. “Commissioners are often very willing to look at children’s mental health, but the way the system works – when you budget one year at a time – [means] the facility to invest to save, to invest in years one to five to get the returns in years five to 20, does not appear to be there.” she continues. And while there has been money coming through for children’s’ mental health services, it is often earmarked for specified additional activities. With a very diverse population, there 14
healthcare manager | issue 30 | summer 2016
“We’re putting people in the private sector because every single bed is full. This is happening everywhere.” are also different cultural attitudes to unpick. “There may be cultural backgrounds where parents would rather their son is in prison than diagnosed with mental health problems,” Kane says. “It means that our first encounter with someone may be in the back of a police van.” But there are signs of hope. Sustainability and Transformation Plans (STPs) have “enormous potential”, she claims, because of their focus on care, regardless of where it is delivered, and the ability to look at healthcare provision at a population level. “The STP in our area is looking at mental health with a view to investing because we do need to transform. The enablement ethos is probably how we’re going to do this.” With good community services, Kane argues that inpatient services can almost be seen as a tertiary service. “Often inpatients is not the right environment – it’s increasingly for patients who’ve been sectioned, which makes it harder for voluntary patients.” However, Kane’s trust, and many like it, are struggling with a falling bed base while the population is increasing. “We’re putting people in the private sector because every single bed is full. This is happening everywhere. It feels
as if it started two years ago, when we suddenly had a spike in people coming in,” she says. There are many reasons, but the disintegration of community support and the effects of austerity could be the most significant, she says. At the same time, Kane’s trust has familiar problems with delays in discharging people back into the community. Some of these may originate with the NHS, but most are external – housing, for example. “These are the sort of things that mean that the pathway is not as free flowing as we would like,’ she says. Working in mental health can be a tough choice for both managers and staff, but it brings rewards, Kane insists. “Our staff give people their life back – a real meaningful life. It’s not the kind of job that gets you boxes of chocolates and thank you cards. You see people through a time in their lives when they don’t want to be here… they don’t want to be breathing. “I have friends and some extended family members who have had lifelong mental health problems, and for 30 years I have been either a volunteer or a trustee in mental health organisations – I’m currently a trustee of Young Minds. I feel naturally drawn to people who don’t have much of a voice.”
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EUAN CHERRY/WWW.PHOTOSHOT.COM
while there are standards prescribed for much of physical healthcare – such as referral-to-treatment times – she points out that these are only just beginning to creep into mental health services.
DEVOLUTION
Three months after Greater Manchester took control of its health and care spending, Andy Cowper finds the devolution “settlement” is anything but settled.
The devolution of funding for public services in Manchester – widely known as “Devo Manc” – is one of the biggest public policy initiatives of this decade. NHS England chief exective Simon Stevens says it has “the potential to be the greatest act of devolution there has ever been in the history of the NHS”. Yet, although the funding and governance arrangements are clearly codified, it’s very unclear how Devo Manc will work in practice. In researching this article, it’s been difficult to get people to talk on the record about operational strategy or how health, social care and other public services will be delivered in ways that make the budget go further or the care better. Off the record, a different picture emerges. It’s one of widespread concerns that can be summarised in the words of one necessarily-anonymous source: Devo Manc “sounds nice and sounds like the right thing to be doing. Everyone’s very enthusiastic about integrating services on a geographical footprint. That’s all lovely. The only question is about how we make it an operational reality.” Health policy experts agree.
“The ambitious rhetoric about health and social care devolution in Greater Manchester is unambiguous...but it is not clear how this is to be done.”
Professor Kieran Walshe
Writing in the BMJ earlier this year, Professor Kieran Walshe and colleagues said: “the ambitious rhetoric about health and social care devolution in Greater Manchester (GM) is
unambiguous in stating two main aims: to secure the greatest health improvement for the 2.6 million population and to reduce the health inequalities within Greater Manchester and between Greater Manchester and the rest of England. But it is not clear how this is to be done or how devolution will help to bring it about.” Devolution is supposed to improve the health and wellbeing of Greater Manchester residents by preventing ill-health and promoting wellbeing, closing the health inequalities gap, integrating health and social care, and moving care closer to the home wherever possible. Professor Bob Hudson of Durham University has outlined a set of underlying principles on which the Devo Manc initiative is founded: ■■ Greater Manchester will remain part of the NHS and the social care system, upholding the standards set out in national guidance and statutory requirements, including the NHS Mandate and Constitution. ■■ Devolution will enable commissioners, providers, patients, carers and partners to shape the future of services in Greater Manchester together. ■■ The principle of subsidiarity will apply, ensuring that decisions are healthcare manager | issue 30 | summer 2016
15
DEVOLUTION
Manchester devolution timeline 2005:
Association of Greater Manchester Primary Care Trusts established with formal authority to jointly commission health services across the area.
2009:
Greater Manchester given City Region status with powers to establish a combined authority with delegated powers over public transport, skills, housing, planning, and economic regeneration
2011:
Greater Manchester Combined Authority (GMCA) established – the first formal administrative authority for Greater Manchester since the abolition of the Greater Manchester county council in 1986.
2012:
Greater Manchester Association of Clinical Commissioning Groups established, with responsibility for specialised and joint commissioning and developing a coordinated approach to service reconfiguration
2013:
GMCA and the Local Enterprise Partnership issue joint strategy for economic growth and reform
06/2014:
Greater Manchester and government agree £476m of government funding for growth and reform plan.
11/2014:
Devolution Agreement sets out further devolution of powers over planning, land, transport, and fire services, and arrangements for a directly elected mayor from 2017
02/2015:
Memorandum of Understanding agreed for health and social care devolution, covering £6bn a year of NHS spending
06/2015:
Memorandum of Understanding agreed with Public Health England and NHS England on securing a unified public health leadership system to help transform population health
12/2015:
Strategic partnership board approves governance arrangements for health and social care and produces strategic plan
01/04/2016: Strategic partnership board formally takes control of £6bn health and social care spending in Greater Manchester. Source: Walshe et al, BMJ 2016; 352:i1495
made at the most appropriate level. The project will ensure transparency and accountability for services and expenditure. ■■ Organisational forms will be driven by the delivery of shared outcomes. ■■
Hudson is sceptical about the potential impact of Devo Manc. “It is far from clear how much freedom Greater Manchester will have to depart from national policies. This is politically sensitive. On the one hand we are accustomed to the idea of a national health service with acrossthe-board rights, standards and targets, 16
healthcare manager | issue 30 | summer 2016
and the Memorandum of Understanding accepts the need for GM to stick to current national requirements. “On the other hand there will be little point to the devolution package if regional discretion is effectively curtailed. And if, as expected, the model spreads across England, are we ready for the existence of around eight versions of the NHS?” Hudson also questions how regulation will work for Devo Manc. Currently, Monitor and the Care Quality Commission (CQC) inspect and regulate separate organisations and functions,
while devolution requires a joined-up regulatory model. It’s unclear to what extent Manchester can develop its own regulatory system, suited to local circumstances. “NHS providers in GM are calling for ‘a new set of relationships’ with their regulators, but the stance of Monitor and CQC remains uncertain,” Hudson warns. “And if the national regulatory role is curtailed within GM, how appropriate is it for GM commissioners to then ‘mark their own homework’?” Manchester’s devolution was born out of the formation, in 2011, of the Greater Manchester Combined Authority (GMCA). This is made up of the ten Greater Manchester councils, who work with other local services to improve life in the ‘City Region’. The GMCA is run jointly by the 10 council leaders and an “interim” mayor, former Central Manchester MP Tony Lloyd. In May 2017, there will be an election for a GMCA mayor, who will have additional powers and responsibilities. In 2012, the city region’s CCGs entered a formal association, which has lead responsibility for joint and specialised commissioning, and developing a common approach to service reconfiguration. The provider sector also faced a review by the Healthier Together Committees in Common, made up of GPs from the city region’s CCGs. The programme, which began in 2014, covers primary care, joined-up care and hospital services. It has established four ‘single services’ in different geographical areas of Greater Manchester, within which a unified team provides care across several hospital sites. Healthier Together originated in work – started by the strategic health authority and continued by the local NHS England team – to rationalise the region’s hospital services. As the original plans involved downgrading the A&E and maternity units of some hospitals, they were, naturally, wildly unpopular. The Healthier Together plans evolved after public consultation, including the presentation of a rival hospital-led plan in autumn 2014 and an unsuccessful judicial review in January 2016. The Devo-Manc deal was announced
DEVOLUTION
in two stages: in outline in November 2014, with more details following in February 2015. The plan was to devolve control of health and social care spending to a new strategic partnership board, uniting the ten local authorities, 12 clinical commissioning groups, 15 NHS trusts and foundation trusts, together with the local outpost of NHS England, with a budget of £6bn a year. In December 2015, the partnership board approved a single strategic plan for health and social care, Taking Charge of our Health and Social Care in Greater Manchester. This was followed by an implementation strategy in January, setting mainly high-level goals and ambitions, and with only the vaguest sense of direction. It said: “This work is describing how we will take the agreed transformation themes and begin to populate plans which show what will be implemented and in what sequence over the next five years.” It is a plan about making a plan. Mangers In Partnership chief executive Jon Restell accepts that much of the detail about how Devo Manc will operate in practice remains to be clarified. “It’s unclear whether Devo Manc will prove replicable or unique, it’s unclear how much the rest of the NHS should focus on its innovations and challenges. It’s unclear how far Devo Manc will succeed in breaking down well-documented, long-understood barriers between social care, local government and the NHS, and how it can help staff overcome what are often cultural problems in integrating care.” Restell believes there is also a big problem with harmonising staff terms and conditions. “Where we start to integrate services along care pathways, we’ll be bringing into close proximity staff on very different employment packages,” he warns. “There are big differences in what a care worker gets relative to even a low-paid NHS worker on an Agenda for Change contract – not just in pay, but also other conditions. “There’s also the national living wage coming down the tracks – meaning employers will have to raise pay in social care,” Restell adds. “Where will
that money come from? How will higher costs be funded? And how will the Devo Manc organisations integrate staff on possibly very different employment packages?” The question of who will actually be the employer of health and care staff in Greater Manchester may also become important, says Restell. “Sure, we don’t want to muck around transferring employment from body to body, but sooner or later, that could become a barrier. There will be questions in due course whether staff need to be employed in different ways and on different contracts to support these new ways of working and new business models.” Arrangements for staff and trade union engagement remain undecided, and “the potential for strife is high if staff feel they’re being railroaded into new ways of working or into new role definitions without consultation,” says Restell. “If they’ve been trained to do something slightly specialised, and then they’re asked to do something that’s more generic, staff may start to worry about problems with their regulators.” MiP is also concerned at the absence
of a Devo-Manc workforce strategy. “Of course, NHS England’s Five-Year Forward View doesn’t have a workforce strategy in black and white, although one is implicit,” says Restell. “But in Manchester, will trade unions be properly engaged? There is a protocol between the staff side and various agencies, but they are missing a trick if they don’t engage staff and staff-side colleagues in designing the detailed changes to how they provide care.” Perhaps employers simply don’t yet know enough about the final operating model to begin getting staff involved in designing services. But with chancellor George Osborne – a longstanding champion of city regional devolution – apparently heading for the exit, Manchester’s leaders need to set out some more substantive plans. Devo Manc is an ambitious project with a complex and challenging brief, but it will struggle to find support while it looks short of leadership, coherence or concrete progress.
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Andy Cowper is editor of Health Policy Insight and comment editor of the Health Service Journal. healthcare manager | issue 30 | summer 2016
17
PENSIONS
Dale Walmsley explores how pensions tax relief affects you as a member of the NHS Pension Scheme.
R
ocket science and brain surgery are often considered the most difficult subjects to understand. Now we can add the continually-changing pensions tax system to that list. The current pensions tax relief system can broadly be described as Exempt-Exempt-Taxed, or EET, which describes the tax rules on the three stages of pension saving: 1. Paying in contributions: EXEMPT* 2. Investment returns on contributions paid: EXEMPT* 3. Receiving pension income: TAXED*
You don’t pay tax on your own contributions One of the biggest incentives to save in a pension scheme is the tax relief on member contributions. The higher up the tax bands you are, the more tax relief you’ll get. This is evened out to some degree because member contributions are tiered by pay. As the graph (below left) shows, the more you earn in the NHS, the more you pay into the scheme. While tax relief applies to member contributions paid in, some of it may be clawed back if the Annual Allowance is breached. We will explore this later
*Up to prescribed annual and lifetime limits, known as the Annual and Lifetime Allowances
Overall limit on pension savings The Lifetime Allowance (“LTA”) is a limit
Combinations of service, pay and pay increases where pension saving breaches the AA in 2016/17
£2,500
£140,000
£1,875
£105,000
members’ contributions £1,250
£625
employers’ contributions
£0 £190,000
healthcare manager | issue 30 | summer 2016
£170,000
18
£150,000
£130,000
£110,000
£90,000
£70,000
£50,000
£30,000
£10,000
Pay over 2016/17
Pay over 2015/16
Member contribution (per month)
Who pays for monthly member contributions
on the pension savings you can build up over your lifetime, above which a tax charge will apply. The LTA covers all pension saving – in the NHS Pension Scheme, other workplace pension schemes and personal pensions. The LTA reached a high of £1.8m before being reduced to £1.25m in the 2015-16 tax year. For 2016-17 the LTA was reduced to £1m, with rises linked to the Consumer Price Index from 2018-19 onwards. Each £1 annual pension taken on retirement is assumed to be worth £20 over the lifetime of the pension, with additional cash taken valued on a £1-for-£1 basis. This means that the £1m LTA will be breached where
£70,000
5% pay increase, fully protected 1995 Section member 10% pay increase, fully protected 1995 Section member 5% pay increase, moved from 1995 Section to the new scheme 10% pay increase, moved from 1995 Section to the new scheme
£35,000
£0
5
10
15
Years of service
20
25
PENSIONS
members retire on a pension over £50,000 per year. Two types of protections are on offer to avoid penalising those who’ve already saved “too much”. Fixed Protection 2016: The LTA of £1.25m is retained but no more pension saving can take place beyond 5 April 2016 or the protection is lost. Individual Protection 2016: An ‘individual’ LTA applies, equal to £1.25m or the value of all pension savings at 5 April 2016, whichever is the lower. In this case, the member can carry on pension saving but any excess saving above the protected LTA may trigger a tax charge. Annual limit on pension savings The Annual Allowance (“AA”) is a limit on pension savings you can build up in any one year, above which a tax charge may apply. More pension savers are being caught by this tax charge as the AA has reduced dramatically in recent years from £255,000 to £40,000. Any unused part of the AA from the previous three years may be used to offset future years where the allowance is breached. The AA covers all active pension saving in the NHS Pension Scheme – including Additional Voluntary Contributions (“AVCs”) and Additional Pension. The value of a year’s worth of pension saving in AVCs is straightforward; it’s simply equal to the amount of contributions paid in. The value of a year’s worth of normal pension saving in the NHS Pension Scheme is less easy to work out. It is measured as the real increase (by “real”, we mean above CPI inflation) in the value of pension benefits earned over the year. Each £1 annual pension earned is assumed to be worth £16 over the pension’s lifetime, with additional cash on top valued on a £1-for-£1 basis. There are four main factors which will affect the value of pension saving: ■■ length of pensionable service
pay pay increases ■■ level of benefits in the scheme ■■ ■■
The right-hand graph on page 18 shows that it isn’t necessarily just the highest earners in the NHS who may breach the AA. A long-serving member on pay of around £50,000 may breach the AA after receiving a significant pay increase. The AA was already complicated enough, but further complexity was introduced last year. Where income, including the value of pension savings, in a year is over £150,000, the AA will be reduced below £40,000, and can be as low as £10,000. There are two income tests which determine whether the AA is reduced from 2016-17 onwards: The AA tax charge STEP 1: THRESHOLD INCOME
Taxable income excluding pension contributions
Up to £110,000
Over £110,000
AA stays at £40,000
go to step 2
STEP 2: ADJUSTED INCOME
Taxable income including the value of pension savings
Up to £150,000 AA stays at £40,000
Over £150,000 AA is reduced by £1 for every £2 above £150,000 (min AA £10,000)
The amount by which a member breaches the AA is added onto their taxable income for the year, which essentially means that the tax charge is calculated on a member’s marginal
income tax rate. The tax charge can be settled in two different ways. ■■ You pay up-front: Using a self-assessment tax return. ■■ Use “Scheme Pays”: You may have guessed it, but this means that the scheme pays your tax charge. The downside is that the member’s benefits (but not any dependant’s benefits) are reduced at retirement. This is only available if the tax charge is over £2,000. An example Helen was in the 1995 Section for 20 years and moved to the new scheme when it was introduced in 2015. Her pensionable pay increased from £100,000 to £120,000 in April 2016. The value of Helen’s benefits increased over the year from around £505,000 to £635,000. Allowing for assumed 2% CPI inflation, this was a real increase of around £120,000, which is well over the AA of £40,000. However, Helen has also breached the two income tests described above: 1. While her NHS pay, less member contributions (of 14.5%), is under £110,000 she has received private rental income of over £12,000, which takes her ‘threshold income’ to £115,000. 2. Including pension savings over the year of £120,000, this takes her ‘adjusted income’ way over above £150,000 and her AA is reduced to just £10,000. If Helen doesn’t have any unused allowances from previous years, her AA tax charge would be over £50,000. Helen might be wondering if it is worth her while staying in the NHS Pension Scheme. Due to the level of benefits earned, it probably is. Triggering a tax charge does not necessarily mean the scheme is no longer beneficial.
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Dale Walmsley is a consultant with First Actuarial, a consultancy with expert knowledge of the NHS Pension Scheme, which offers independent financial education to employers and staff. For further information, email: dale.walmsley @firstactuarial.co.uk.
healthcare manager | issue 30 | summer 2016
19
SURVEILLANCE
legaleye Brian Wilson on what you need to know about workplace surveillance and social media snooping. The development of digital recording technology and the prevalence of smartphones means both employers and employees are increasingly using surveillance footage in the workplace. Generally, employers use CCTV to record the activities of staff in the workplace, but in some cases they may monitor employees externally. Meanwhile, employees are increasingly – and often covertly – using smartphones to record meetings with managers or conversations with colleagues. These developments present challenges for workers and managers alike, so it’s important to properly understand the law in this area. Social media: Widespread use of social media inevitably means that what would previously have been private conversations are now posted online, often for all – including employers – to see. Workers have been dismissed for using social media at work or because of content they have posted online outside working hours. But in our experience, many employees are still ignorant of the risks involved. The Employment Practice Data Protection Code says that employers must show there is a good reason for monitoring employees’ social media activity and consider other less instrusive ways of achieving their goals. They must also ensure workers know they are being monitored and why. Section 7 of the Human Rights Act states that public sector employers must adhere to Article 8 of the European Convention on Human Rights, which provides an individual 20
healthcare manager | issue 30 | summer 2016
with a right to respect for his or her private life, and to Article 10, which provides a right to freedom of expression. Although these give workers a legal recourse, they can also support an employer’s case. An employer may be permitted to monitor their employees’ social media activity if they can justify it as being in the interests of protecting the health, morals or rights and freedoms of others. They may argue that comments by employees have infringed the rights and freedoms of others by damaging the employer’s reputation, or that comments about colleagues, for example, amount to harassment. Using social networking sites at work may be a breach of the employer’s internal policy. However, where there is no policy, disciplinary action – including dismissal – may be unreasonable. Covert recordings: The use of secret recordings by employers is difficult to justify, except in exceptional circumstances and when authorised by senior management. Covert monitoring could be used, for example, for the prevention or detection of a crime. The Employment Code states that it should form part of a specific investigation and should never be used in areas that workers would genuinely and reasonably expect to be private. One case involved an employee who was recorded playing squash when he should have been at work. An appeal tribunal held that the employee did not have a reasonable expectation of privacy, as he was in a public place, playing squash in his employer’s time – which amounted to him being, fraudulently, engaged in his own business while
being paid by his employer. Generally, if an employee has secretly recorded an internal meeting or hearing with the employer, a tribunal will consider whether the evidence is relevant, but only if the employee was present when the recording was made and a transcript has been provided to the tribunal. Covert recordings of the employer’s private discussions will not usually be admissible if the employee was not present when the recording was made. However, the balance of public interest between preserving the confidentiality of private discussions and admitting relevant evidence could be adjusted if, for example, the case relates to allegations of discrimination and the recording is the only evidence of this. Employees should also ensure they are familiar with their terms and conditions of employment and their employer’s policies, as the recording of disciplinary meetings may expressly be prohibited. If an unauthorised recording came to light, it may be deemed to be an act of misconduct. Even if the issue arises after the employee has been dismissed, the employer could still argue that the employee’s breach of contract means it is ‘just and equitable’ for a tribunal to reduce the amount of any compensation to be awarded for unfair dismissal.
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Brian Wilson is an employment rights lawyer with Thompsons Solicitors. Legaleye is not intended to offer legal advice on individual cases. MiP members in need of personal advice should immediately contact their MiP rep.
TIPSTER
How to manage your inbox There’s no single “right” way to deal with email overload, but experts agree on some basic steps. Follow these tips from Craig Ryan and you should be able to find a method that works for you. 1 DECIDE WHAT YOU USE EMAIL FOR
all notifications – how do random interruptions help you to manage your time? And it’s fine to keep longer emails for reading later, but remember to acknowledge receipt if the sender expects a response.
Email is a tool, how you use it is up to you. Do you want to read news and blogs in your email? Do you find updates from your social media accounts useful or annoying? Do you really need daily briefings or will a weekly digest do? It’s your inbox – decide what should be there and get rid of everything else.
8 ALLOCATE TIME FOR DEALING WITH EMAIL
2 SEND FEWER (AND BETTER) EMAILS If you send fewer emails to fewer people, you’ll get fewer replies. Be clear and concise in the emails you do send and limit them to one topic per message. And don’t bother people who really don’t need to know.
3 KEEP YOUR INBOX (REASONABLY) CLEAR You shouldn’t fret about reaching “inbox zero”, but experts agree that an inbox with years of unsorted and unread messages will harm your productivity – and will be a daily or hourly reminder of your inefficiency. Try to keep your inbox for new messages and those you genuinely intend to read later. Archive important emails and delete everything else. If your backlog is unmanageable, declare “email bankruptcy” and just dump everything into the archive. You can always use search to find it later.
4 BE RUTHLESS WITH THE DELETE KEY Get rid of ALL promotional emails. You don’t need them now, and we have Google for when you do. Delete “updates” after a day or two – life’s too short to bother with old news. Use searches to bulk delete emails by sender or subject (start with “out of office”).
5 ORGANISE YOUR EMAIL Folders are the key to keeping your inbox under control. You could have folders for everything, or just for big current projects, with a general archive for everything else. But keep it simple! If you find yourself dithering over where to put a message, your system needs simplifying. Keep a dedicated folder for messages you’ve sent which require a reply. Just blind copy (BCC) the original email to yourself and set a rule to file it automatically in an “awaiting reply” folder.
6 TAKE ACTION There are really only four things you can do with an email: deal with it, delegate it, delete it or defer it (the “four Ds”). If you can deal with it or delegate in under two minutes, do it straightaway. If you can’t, add it to your to-do list and file the message. But use a dedicated folder for messages that just need a reply, rather than bother putting them on your task list.
7 DON’T LET EMAIL CONTROL YOUR LIFE You decide what’s urgent. Turn off
Make a routine and stick to it. Read messages no more than three times a day and shut down your mail app when you’re done. I try to avoid reading emails and get on with some real work for the first hour or so, but it’s up to you when you do it. If colleagues demand immediate responses, ask them if they would mind you interrupting a meeting with them to read and reply to emails.
9 CONCENTRATE ON YOUR MOST IMPORTANT EMAILS It’s likely that less than 5% of the emails you receive will be important, so deal with them and you’ll be fine. Create a sample of your important messages by flagging them as they come in. After a month or so, try to identify some common criteria or keywords. You can then set up a smart folder or saved search to see your most important emails at a glance.
10 FIND WHAT WORKS FOR YOU Forget trying to find the perfect email management system. It doesn’t exist. What matters is finding something that works for you in this job and at this time in your life. Spending an hour or two reviewing how you handle email every six months will save you time and a whole lot of grief down the line. Craig Ryan (@CraigA_Ryan) is a writer and associate editor of Healthcare Manager.
healthcare manager | issue 30 | summer 2016
21
MIP AT WORK
WORKPLACE CULTURE
Let’s banish bullying from the NHS once and for all MiP is leading a national initiative to tackle bullying and harassment, which undermines managers’ work and damages their careers. Jon Restell explains how the programme is shaping up. MiP is at the heart of a piece of partnership working which aims to reduce the persistently high levels of bullying in the NHS. More than a fifth of staff have reported bullying by managers or colleagues in recent NHS staff surveys, and more than 40% say they have witnessed it. We know that a culture of disrespect harms staff wellbeing and, as the Carter Review recently emphasised again, can severely impair organisational effectiveness. But the fact that bullying also damages patient care is less often discussed. International research shows that disruptive and disrespectful behaviour by healthcare professionals leads to an unsafe culture – distraction from clinical work, errors, withdrawal, burnout, reputational damage and more people leaving. Staff are less likely to admit mistakes, raise concerns or work effectively in teams – with obvious implications for patient care and safety. On the initiative of health minister Ben Gummer, the NHS Social Partnership Forum (SPF) is planning a new campaign to tackle bullying in the NHS. I am leading this work as co-chair of the SPF’s Workforce Issues Group (WIG). We have already staged a workshop facilitated by NHS Employers in November, a ministerial roundtable in February and, most recently, an interactive session at the NHS Confederation in Manchester. Madeline Carter of Newcastle University is helping NHS unions and employers to work with the available data. Her own research and evaluation of other evidence suggests the NHS should take a broad-ranging, strategic 22
healthcare manager | issue 30 | summer 2016
“Disruptive and disrespectful behaviour can lead to an unsafe culture – distraction from clinical work, errors, withdrawal, burnout and reputational damage.” approach, with interventions targeted at different levels. At the organisational level we need to concentrate on: a positive work climate; leadership; conduct codes; policy; monitoring; recruitment and selection; formal investigations; and job design. At the team level we should focus on: team-building; mediation; conflict management training; multisource feedback; and bystander action. And at the individual level we are targeting: well-designed, relevant training; coaching and mentoring; informal support; and therapeutic approaches and counselling. In the past, we’ve tended to create a framework of policies and training within which individuals can challenge bullying. These are still important but insufficient without organisational interventions by employers and a positive work culture. As we argued in a blog post for the NHS Confederation, “there needs to be recognition that bullying is an organisational issue, not just a conflict between individuals”. Partnership working can deliver where top-down diktat has failed, because we can make a much stronger call to action. Small groups of policy wonks working at speed won’t deliver as effectively as an
inclusive, long-running conversation involving people from all over the system. A key principle of the campaign is that NHS organisations should decide on their own ambitions. Rather than setting another target from the top, the campaign will support organisations to deliver their ambitions with best practice and monitoring tools. Boards and union representatives in NHS organisations will be asked to pledge (probably in autumn 2016) to foster a learning culture and to commit to build a workplace where staff are trusted and supported, where bullying and harassment are tackled, positive behaviours role-modelled, and staff are supported to challenge negative behaviour. The SPF agrees that leadership, accountability and measurement are the key ingredients for success. Leadership is particularly critical. Research shows that leaders affect culture by role-modelling, rewarding, condoning, ignoring and punishing certain behaviours. Two of the biggest barriers to reporting bullying are the belief that nothing would change and that leaders would not take any action. Our campaign is a work in progress and still faces several hurdles, not least persuading system leaders – the DH, system managers, commissioners, regulators, professional bodies and trade unions – that building a culture of respect is an issue for them as well as for organisations, teams and individuals. We must also link our campaign to other work on discrimination and productivity. I’m very positive about the work so far and pleased that MiP has made a big contribution to tackling an issue that affects a growing number of our members, both as employees and managers.
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MIP AT WORK
CASE STUDY
Please release me, let me go Sometimes the NHS is hard to leave for the wrong reasons. Two senior managers tell Craig Ryan about their exhausting battle to secure redundancy rights and how MiP helped them to leave on the right terms. Organisational change creates damaging uncertainty for everyone, especially people who don’t know whether they will be staying or going. For them, it’s hard to do your job and impossible to plan for the future. Yet, too often, the NHS redundancy process is dogged by incompetence, indecision and inexplicable delays, piling stress onto staff who want to leave and damaging morale and efficiency. Senior NHS managers David and Kathy (not their real names) initially applied for voluntary redundancy in November 2014 after their arm’s-length NHS body was involved in a major reorganisation. “We saw the writing on the wall and there were all sorts of pressures on redundancy rights which were becoming apparent,” says David. Deciding to give up their careers after around 35 years in the NHS was a significant step for the two managers and their team, making the subsequent delays particularly stressful for them both. Management deferred their applications several times without explanation. As their settlements were likely to exceed £100,000, approval from the Department of Health was also needed – “a difficult, laborious, closed-door process”, Kathy says, which dragged on for several months. “We really didn’t know what was going on,” adds Kathy. “We got hints that things were being approved at higher levels, we were getting green lights, virtually being told to clear our desks – then nothing happened. We were stuck between a rock and a hard place, excluded from communications regarding the next steps for the organisation, but still
without a decision about what was happening to us.” After more than a year of indecision, David and Kathy contacted MiP national officer Pete Lowe. “Pete was able to give us an outside perspective, drawing on his knowledge of similar situations across the country” says David. “He told us not to get hung up on our individual situations… and to look at what sort of collective action we could bring to add more weight.” Pete arranged regular telephone conferences with Kathy and David, and repeatedly pressed their case informally with management. MiP also raised the issue of delays to redundancy settlements at national level. In March 2016, despite management having previously agreed that no suitable alternative employment (SAE) was available for David and Kathy, both were suddenly called for interviews for vacant posts for which they had no suitable
experience. “We knew exactly who would get the grade 9 job and it wasn’t me,” explains David. “But by attending the interview I would’ve been admitting it was SAE.” Such an admission could have jeopardised his redundancy rights if he had then refused one of the lowergraded posts in the same line of work. Pete helped David and Kathy to write responses explaining why the posts weren’t suitable, including a form of words which ensured they didn’t waive their redundancy rights. “To me, that was a breakthrough,” says David. “Heading that one off at the pass at the eleventh hour was a very important role that Pete helped us with.” Just three weeks later, David and Kathy were told their redundancy had been approved and both finally left the organisation in April 2016. “Without a dedicated managers’ union like MiP, there would’ve been little incentive for the employer to address our members’ concerns in the way they eventually did. And I think our regular telephone and email updates gave [David and Kathy] confidence in the support they were receiving from MiP.” But this sorry tale isn’t quite over. At the time of writing, neither Kathy nor David’s financial settlements have been finalised. “We’re not likely to receive any money for four or five months. If it wasn’t for friends I would literally be going down the food bank,” says David. “Unless my pension is resolved soon, I’ll be asking the union to take this over from me because I’m exhausted by the whole process,” he adds. “Just knowing I can get some assistance and perspective on this is very calming and comforting. So, we’ll keep paying our subscriptions – there’s no reason for us not to.”
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healthcare manager | issue 30 | summer 2016
23
BACKLASH
backlash
Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@ healthcare-manager.co.uk.
by Celticus
Something for the weekend
I
Brexit blues
G
eorge Osborne abandoned his fiscal targets in the wake of the Brexit vote, raising hopes of some financial relief for the NHS – especially as Brexit leaders repeatedly promised extra cash for the NHS during the campaign. But don’t hold your breath. With a recession now widely expected, the Brexit government may indeed allow borrowing to rise, but only to shore up the crumbling tax receipts and pay the higher welfare bills that recession brings. As for the supposed savings from leaving the EU, if they exist at all, they’re unlikely to materialise before 2019. If, as expected, Brexit exacerbates staff shortages and pushes up agency costs, while the falling pound makes many supplies more expensive, there will be no silver lining for the NHS.
24
f you need evidence about staff shortages in the NHS, it doesn’t come any starker than this. In June, Leeds Teaching Hospitals was forced to email its entire junior medical staff asking for volunteers from any discipline to take weekend shifts working in its A&E department. The trust, which has around 30% of A&E posts vacant, said agency and locum staff had declined work at the hospital even after it offered to pay above the locum cap. The Royal College of Emergency medicine reckons there’s a shortage of 1,000 A&E consultants alone across England. And this isn’t just about pay, it’s also a failure of workforce planning, with 25% of A&E training posts left vacant last year. It’s not only Brexit that needs a plan.
New wine, old bottles?
N
ews that seven trusts in Yorkshire and Derbyshire are to form a “federation” gives Celticus a sense of déjà vu. The trusts, all members of the Working Together Vanguard, will hand control over some services to the Federation board, chaired by Sheffield Teaching Hospitals chief executive Sir Michael Cash. The whole kit and caboodle will
healthcare manager | issue 30 | summer 2016
operate under the direction of the local Sustainability and Transformation Plan board, also chaired by Cash. All very joined up and integrated. It just needs a better name. “District Health Authority” has a nice ring to it, don’t you think?
Tangle teasing
L
ike every other Whitehall department, the DH faces the laborious task of going through all the EU regulations and directives on its patch to see which should be repealed or replaced with UK versions. This could take years. Unlike directives, which are incorporated into UK law, EU regulations on things like medical devices and medicines apply directly and will lapse once we leave the EU. One possibility being chewed over is a simple law to freeze the existing regulatory regime unless parliament decides otherwise. Brexiteers eager for a bonfire of regulations won’t like it, but it would help reduce much of the uncertainty now hanging over the NHS and the healthcare and pharma industries.
Picking up the tab
T
he public have woken up to the severity of the NHS cash crisis and would prefer to pay higher taxes rather than see services cut or charges introduced,
according to the latest results from the British Social Attitudes (BSA) survey. 96% said the NHS has funding problems, with 32% saying problems were “severe” (up from 19% in 2014). While 41% favoured higher taxes to fund the NHS, only 15% supported charges for GP or A&E treatment and just 26% thought the service should live within its exsiting budget.
Leadership vacuum
P
lunging staff morale poses a bigger threat to the NHS than the financial crisis, according to leading healthcare expert Nigel Edwards. The chief executive of the Nuffield Trust and Healthcare Manager columnist warned that staff shortages, disputes with the government and workplace bullying have created a “toxic mix” in the NHS. “Once the psychological contract with staff is broken, it may be impossible to reverse,” Edwards said. In a glib response, the DH said “good leadership” was the most important ingredient in improving staff morale. Few would argue with that, but with so many board level and chief executive posts vacant, and ministers sharpening the knives for more management cuts, it’s hard to see how leadership is being taken seriously at the top levels of the NHS.
Our pledge to you
Project7_Layout 1 07/09/2015 16:11 Page 1
Thompsons Solicitors has been standing up for the injured and mistreated since Harry Thompson founded the firm in 1921. We have fought for millions of people, won countless landmark cases and secured key legal reforms.
We have more experience of winning personal injury and employment claims than any other firm – and we use that experience solely for the injured and mistreated. Thompsons pledge that we will: work solely for the injured or mistreated refuse to represent insurance companies and employers invest our specialist expertise in each and every case fight for the maximum compensation in the shortest possible time.
The Spirit of Brotherhood by Bernard Meadows
www.thompsons.law.co.uk
0800 0 224 224
Standing up for you
MiP ANNUAL CONFERENCE 2016 Great managers, great workplaces – a positive vision for the NHS Wednesday 23 November 2016
2016
Congress Centre London WC1B 3LS
FREE TO ATTEND FOR MiP MEMBERS Join us at our 2016 annual conference. This year, the conference will have a strong focus on a positive vision for managers as catalysts for high-performing teams in great workplaces, despite the huge pressures on the health service. The MiP annual conference provides a great opportunity for you to exchange your experiences and views, get practical support on the issues which affect you, as well as hear from a range of speakers and contributors.
for more information and to register online go to
2016
mip-conference.co.uk or call 020 7592 9490