Healthcare Manager Autumn 2016 by lexographic

issue 31 autumn 2016

healthcare manager

ALWEN WILLIAMS BARTS: TURNING ROUND THE SUPERTANKER plus RADICAL UNCERTAINTY Brexit and the NHS NO VISIBLE SUPPORT The misuse of suspensions in the NHS

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issue 31 autumn 2016

healthcare manager inside

Craig Ryan Acting editor

heads up:2 In our survey earlier this year, you asked for more case studies, more “hard” information on pay, conditions and legal stuff, and more analysis of workplace issues. We’ll be bringing you much more of that as we move towards what comms people call a “seamless content operation” across the magazine and website.

Leading edge: Jon Restell

analysis:8 Craig Ryan: Brexit and the NHS

features:9

published by

Managers in Partnership miphealth.org.uk 8 Leake Street, London SE1 7NN | 020 7121 5146 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.

Managing better care: How the ‘Once for Wales’ project has transformed staff training. The HCM interview: Alwen Williams, chief executive of Barts Health, on turning round our biggest trust. Hunt’s new pack: Meet the three fresh ministers at the Department of Health. Robots with scalpels: How automated care is spreading through the NHS.

regulars:20 Legal Eye: Where to draw the line between managing poor performance and bullying. Tipster: How to manage a difficult boss. MiP at Work: Misuse of suspensions, plus workplace trends for the next 12 months.

the sharp end:24 Your reports from the frontline: STPs & integration

We’ve introduced two new columns in this issue. In collaboration with national media outlets like the Guardian, The Sharp End (p24) gives MiP members a chance to say what they really think about government policy and its impact on their work (anonymously, of course). In this issue we get an insight into the STP process, and how government rhetoric again falls far short of reality. And our new Analysis column (p8) kicks off with my look at the potential impact of Brexit on the NHS – an issue, that despite my best efforts, remains as clear as mud. From the autumn, we’ll be adding news updates to the website every week, so you won’t have to wait for the next Healthcare Manager to find out about the key workplace issues and what MiP is doing about them. It’s your magazine and your website, so tell us what you’d like to read more (or less) of, and let me know if you want to contribute something yourself. Contact details are over the page.

healthcare manager | issue 31 | autumn 2016

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

Leadership

MiP Conference 2016

MiP sponsors Golden Hearts Award

Great managers, great workplaces

MiP is proud to sponsor the “Great Leaders” category of the Golden Hearts Awards at Hull and East Yorkshire NHS Trust, one of the largest trusts in England. Now in its sixth year, the 2016 award was won by theatre manager Julie Nicholson (centre). MiP national officer Tina Smallwood (above right),

healthcare manager

Design and Production

issue 31 | autumn 2016

Lexographic www.lexographic.co.uk

ISSN 1759-9784 published by MiP

Contributors

Acting Editor

Craig Ryan editor@healthcare-manager.co.uk 07971 835296

who presented the award to Julie, said: “Sponsorship of the awards enables the trust to reward and recognise staff who routinely go above and beyond to provide outstanding care for the very sick and vulnerable people served by the trust. We’ve already agreed to sponsor next year’s award.”

2016

Andrew Goodall (pictured left), chief executive of NHS Wales, and Matthew Swindells (centre), national director for operations and information at NHS England, will be among the keynote speakers at this year’s MiP conference. The conference will be chaired by Anita Charlesworth (right) chief economist at the Health Foundation. Despite the huge

Colin Marrs, Alison Moore, Jon Restell, Matt Ross, Craig Ryan, Jo Seery, Jenny Sims, Steve Smith. Opinions expressed are those of the contributors and not necessarily those of healthcare manager or MiP.

healthcare manager | issue 31 | autumn 2016

Wednesday 23 November 2016 Congress Centre, London WC1B 3LS

pressures on the NHS, the conference will set out a positive vision for NHS managers as catalysts for highperforming teams in great workplaces. The conference will also hear from Wendy Hick, head teacher at Cranmer Primary School in south London and one of the UK’s top leaders in education, about how positive leadership can change the culture within

Cover image

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 us at editor@ healthcare-manager.org.uk.

organisations. The MiP annual conference is free to attend for all MiP members and will be a great opportunity to exchange your experiences, network with colleagues from all over the UK and get practical support on the issues which affect you. For more information and to register online go to mip-conference.co.uk or call 020 7592 9490.

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 may be withheld from publication on request.

leadingedge Jon Restell, chief executive, MiP

ivil servants at the Department of Health have started work on a comprehensive workforce strategy for the NHS. (Let’s hope it covers social care too.) This is very welcome; MiP have been arguing loudly for this for at least three years.

The case for a workforce strategy is now accepted by many NHS leaders and organisations. Simon Stevens has called for a “complete strategy”, arguing that “our future lies in networks and health systems, not go-it-alone institutions. On too many procurement and workforce issues it has felt the opposite of that.” The NAO, Health Foundation, Public Accounts Committee, Nuffield Trust, and even the OECD have all pitched in. But the case was best put by the NHS Pay Review Body, which called for a workforce strategy to “explore all aspects relating to the attraction, development and retention of staff and therefore support staff engagement to deliver wider strategic and operational plans”. Thinking about why no strategy has emerged so far may help us to see the barriers we need to overcome. The Five Year Forward View did not come with a workforce strategy, although one could be implied by making some workforce assumptions. While some individual bodies have specific workforce responsibilities and some have done useful, important things, the national system is fragmented. The DH should take the lead in bringing everything together. Understandably, local employers often resist national encroachment. A comprehensive national strategy must aim to do the right things in the right

“A comprehensive national workforce strategy must aim to do the right things in the right place, not to do everything nationally. Most of the action should take place in teams, boards and local systems.” place, not to do everything nationally. Most of the action should take place in teams, boards and local systems. Culture – people and the way they do things – eats strategy for breakfast, straight from the pan. So why have strategists ignored workforce and created conditions for their own failure? For some, workforce is for someone else to worry about. Others display magical thinking about new people and new roles. Others again don’t buy the link between staff engagement and patient care, or between wellbeing and performance. They believe top down and grip gets things done. And then there are those who do get it but feel powerless to act, or give up because the workforce consequences look too difficult. These strands of thought all need to be addressed. Employers’ commitment to engaging with trade unions is patchy. But unions run through the NHS like Blackpool through a stick of rock, and the junior doctors’ dispute shows that industrial relations can still make the weather. Dialogue with unions on both policy and delivery is essential. Then there’s the big one: pay restraint has marginalised pay as a policy lever to support changes in

productivity and service delivery. The system must push back on pay restraint or, at the very least, prepare for it to end. And what should go into the strategy? Here’s the unions’ latest shopping list – in no particular order: ■■ Making Agenda for Change simpler to explain, understand and operate ■■ A job evaluation system which delivers equal pay for work of equal value ■■ Putting staff wellbeing and engagement at the heart of healthy, safe and high-performing teams and workplaces ■■ Safe staffing levels ■■ Making the NHS an employer of choice with attractive terms, conditions and people management policies ■■ Engagement and partnership with unions, locally and nationally ■■ Effective change management agreed jointly by employers and unions ■■ Equality, diversity and inclusion – delivering a just workplace for all our people ■■ Developing learning and innovating organisations that continuously transform themselves ■■ A focus on leadership at all levels – one in three NHS staff has supervisory responsibility for someone else

MiP is emphasising three themes. First, leadership should be part of the workforce strategy, rather than a separate strategy as now. Second, support staff must receive equal care and attention – because when you kick the back office the bruise appears on the frontline. Finally, partnership between unions, employers and the government is essential. It’s the only way to deliver a workforce strategy that works for staff and the patients they care for.

healthcare manager | issue 31 | autumn 2016

HEADS UP

Campaigns

Fund our NHS The TUC and the NHS Support Federation have prepared a new campaign, “Fund Our NHS”, to press for more money for the NHS and more support for staff. The campaign, which is supported by healthcare unions including MiP and UNISON, unveiled its website in July. The campaign is calling for a five-point action plan to tackle NHS underfunding: ■■ Give the NHS an urgent funding boost, to bridge the £30bn funding gap before 2020-21 ■■ Lessen the pressure for unrealistic efficiency savings, which are causing problems for patients and cuts to services

■■ Set out a long term settlement for the NHS – a commitment to public funding, that will improve planning and give it confidence for the future ■■ Invest in the staff who are the heart of the NHS – through safer staffing levels, pay, training and recruitment and retention ■■ Spend public funds wisely, restore the benefits of a col-

laborative NHS and limit the waste of PFI and marketisation Visitors to the site are encouraged to report incidents and problems caused by NHS underfunding, and staff and patients can record their experiences by taking a fiveminute survey. The site also offers easy-to-read explanations of issues like STPs, infographics, video clips and

many links to evidence on NHS underfunding for supporters to use in letters and emails to MPs. The TUC and the NHS Support Federation are continuing to develop the campaign and website ahead of the official launch this autumn. Sign up to support the “Fund our NHS” campaign at nhsfunding.info.

Brexit

Unions and employers offer “robust and unequivocal” support to EU staff NHS employers and trade unions have pledged to give support and protection to the 135,000 staff from other EU countries working in the NHS and social care following the UK’s vote to leave the EU on 23 June. In the weeks following the referendum there were widespread reports of racist and xenophobic abuse against NHS staff and police reported a 57% increase in reported hate crime in England, Wales and Northern Ireland. The NHS Equality and Diversity Council (EDC), which brings together employers, unions and patients’ groups, is to lead a co-ordinated response to the equality issues raised by the Brexit vote. This will include tackling discrimination and abuse against staff from other EU countries and those from a BME background affected by the apparent increase in hate crime since

healthcare manager | issue 31 | autumn 2016

the referendum. An EDC paper by Paul Deemer of NHS Employers and Ram Jassi of University Hospitals Southampton said there was “significant anecdotal evidence of a marked impact on EU and BME staff” following the referendum. “This ranges from individual abuse and attacks (both physical and verbal) to the daubing of NHS property with offensive graffiti. The response from the sector has – to date – been robust and unequivocal – with clear and high-profile messages from senior leaders offering support and solidarity with any staff who suffer any form of discrimination.” NHS Employers has opened discussions with other government departments to ensure the interests of the NHS are taken into account in the Brexit negotiations,

and that any new migration policy reflects the “safe staffing” requirements of the NHS. In July, NHS Employers launched a Twitter campaign, “#LoveOurEUStaff”, which attracted more than 10,000 followers in the first month. “The result of the EU referendum has created uncertainty for our European staff and to show our support we want to capture stories and experiences about the great things that are happening across the NHS,” said a spokesperson. “Employers are showing their support in various ways, from events celebrating workforce diversity, to thank you letters from chief executives.” For more information visit the Brexit section of the NHS Employers website at: bit.ly/hcm3101. See also: Brexit and the NHS, p8.

HEADS UP

HSJ Awards

MiP backs staff engagement award MiP and Unison are once again proudly sponsoring the staff engagement category of the annual Health Service Journal Awards. Now in their 35th year, the HSJ Awards have become the most sought-after accolade in British healthcare. The ten trusts shortlisted for this year’s staff engagement award are: Guy’s and St Thomas’, Leeds Teaching Hospitals, Liverpool Heart and Chest Hospital, North Staffordshire Combined Healthcare, Northampton General Hospital, South Warwickshire, University Hospitals Bristol, University Hospitals of North Midlands, University Hospitals of Morecambe Bay and Wrightington, Wigan and Leigh. The winners will be chosen by a panel of senior and influential figures from the sector, and announced at the ceremony on 23 November at London’s Intercontinental O2 Hotel. For further details visit: awards.hsj.co.uk.

Staff from East London Foundation Trust celebrate winning the 2015 HSJ award for staff engagement. (Photo: HSJ Awards)

Transparency

Managers must reveal business interests, says NHS England boss NHS managers may be required to disclose their engagements and financial interests outside the NHS under new proposals which NHS England claims will increase transparency and tackle conflicts of interest. A consultation document published on 20 September, following a review of transparency by NHS England chair Sir Malcolm Grant

(pictured), says managers and other NHS staff should declare engagements such as directorships, self-employment and consultancy work, as well as any gifts or hospitality received over the value of £25. Senior staff may also be obliged to reveal any personal or family shareholdings or business interests “which could give rise to a conflict of interest”, along with positions with charities, voluntary organisations and political groups. However, unlike medical consultants, who will be required to give information on their earnings from private practice, managers will not be expected to declare their actual income from outside interests.

Grant said the proposed new rules would replace the “pretty depressing patchwork” of previous attempts to tackle the controversial issues of outside interests and conflicts of interest. “I think there is a cloud hanging over some aspects of the NHS when it comes to the handling of conflicts of interests,” he said. “The public expect the highest standards of behaviour in the NHS, but we know there are times when the NHS has failed to meet this expectation.” The review also proposes that CCGs appoint a “conflicts of interest guardian” to advise boards on commercial relationships and that all NHS organisations should publish registers of all their hospitality spending. “We are trying to embed the principle that you don’t get taken out for a fancy dinner and ignore it,” Grant said. “One of the critical points here is transparency.” Read the consultation document, Managing conflicts of interest in the NHS, at bit.ly/hcm3102. MiP encourages members to respond the consultation paper by the closing date of 31 October 2016.

healthcare manager | issue 31 | autumn 2016

HEADS UP

Pensions

Unions protest Social partners oppose against “cash restrictions on “retire for pensions” and return” offer UNISON have reported East and North Hertfordshire Trust to the NHS Pensions Board and the Pensions Regulator after it offered nursing staff cash incentives to opt out of the NHS pension scheme. The trust offered higher salaries to new starters and existing staff in exchange for giving up pension rights in a bid to fill 200 nursing and midwifery vacancies. But UNISON said the move was “morally wrong”, against the law and would discourage workers from planning for their retirement. It is illegal under section 54 of the 2014 Pensions Act to “induce” staff to leave a pension scheme or discourage them from joining one. Tracey Lambert (pictured), UNISON head of health in the East of England said the move was clearly a cost-saving measure. “If offering staff more money not to join a pension scheme isn’t an inducement, then it’s difficult to see what is. Every worker deserves financial security in their retirement and staff shouldn’t be encouraged to put short-term gain ahead of long-term security. It’s morally wrong to condemn a generation of mainly female staff to poverty in their old age.” UNISON and other health unions held a protest against the move outside the Lister Hospital in Stevenage on 12 September. A similar offer by the Oxleas mental health trust in south-east London was dropped earlier this year after union protests.

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Employers and unions, including MiP, are opposing Department of Health plans to introduce new restrictions on staff returning to work in the NHS after retirement under the so-called “retire and return” rules. Draft guidance for NHS employers says retired staff returning to work in the NHS in England must agree to work reduced hours and may have their pension payments “abated” if their combined salary and pension exceed their preretirement income. The DH also wants to extend the guidance, which currently applies only to chief executives and executive directors, to all NHS staff. But the Scheme Advisory Board (SAB) of NHS Pensions, which includes

representatives of unions and employers, says the requirement for staff to commit to reduced working hours “may not always be appropriate” and is “contrary to government policy on encouraging experienced staff to remain in the NHS”. The SAB’s response to the draft guidance says: “Preventing employees from working full time simply because they are taking their pension benefits may discourage employees from returning to work altogether and would lead to a loss of skills, expertise and experience.” It also warns that restrictions on “retire and return”, including abatement of pensions, would encourage retired staff to join agencies leading to higher costs for the NHS.

In June 2015, Jeremy Hunt wrote to NHS trusts saying he would be “clamping down on retire and return to ensure that very senior staff cannot gain financially from this at a cost to the taxpayer”. In its draft guidance, the DH says “misuse” of retire and return could bring the NHS pension scheme “into disrepute”. In its response, the SAB says: “In SAB’s view, individuals are not ‘gaining’ financially at a cost to the taxpayer by accessing the pension benefits they are entitled to and by returning to work for the NHS to deliver a necessary job role or service.” Discussions between the SAB and DH over the new guidance for retire and return are continuing.

HEADS UP

Link members

Be part of something bigger

Wear it pink for Breast Cancer Awareness Month! Breast cancer is the most common form of cancer in the UK. One in eight women in the UK will be affected in her lifetime and around 50,000 women are diagnosed every year. This October, everyone can help us promote awareness of breast cancer and raise funds for life-saving research by taking part Breast Cancer Awareness Month – from “wearing it pink” through to sharing real life experiences of breast cancer. This year’s “wear it pink” day will be on 21 October – so dig into your wardrobe for something pink and take part in one the many events around the country to raise funds to fight this cruel and still all-toocommon disease. For more information and a fundraising pack visit wearitpink.org.

Eight MiP members from NHS organisations across England took part in the union’s latest training course for link members in July. They were joined by MiP national officers Pete Lowe and Jane Carter, and the course facilitator, Unison’s Davinder Sandhu. Link members are MiP’s “eyes and ears” on the ground in NHS workplaces. As well as recruiting and organising new members, and providing help and advice, they liaise with MiP national officers and UNISON branches, and help negotiate with employers locally. The two-day course aims to help delegates better understand the role of a link member and employ their existing skills to help members with problems at work, resolve disputes and help MiP to grow. Deborah Porter from Cwm Taf University Health Board, one of the delegates, said she felt “uplifted, energised

and positive” after completing the course. “Pete, Jane and Davinder were excellent, and the whole group of people who attended were great. It was so interesting to meet people from different areas in England and to share their experiences. I really enjoyed it and it made me feel more part of something bigger,” she added. Course facilitator Davinder Sandhu said: “The link member training will develop your skills and knowledge to become active within MiP and support members in your workplace. It will increase your confidence in organising in a union context and signposting around workplace issues. You can develop the role as little or as much as you like to fit around your other commitments.” If you are interested in becoming an MiP Link Member or taking part in a Link Member course, please contact Laura Anthony at L.Anthony@miphealth.org.uk.

Unions and employers renew NHS partnership agreement The Social Partnership Forum (SPF), which brings together unions and employers in the NHS in England, has published a “refreshed” partnership agreement, which sets out how the partners will work together tackle the biggest challenges facing the NHS.

Under the agreement, NHS England, Health Education England and NHS Improvement have now joined the SPF, alongside the Department of Health, NHS Employers and the trade unions on the NHS staff side, including MiP. The agreement says that the SPF supports “strong and

effective partnership working at a local level with the overall aim of improving outcomes for patients and supporting staff to deliver high quality care”. It points to a “growing body of academic evidence” showing high levels of staff engagement lead to better outcomes and experiences for patients

and improve organisational performance. The agreement binds partners to support the basic principles of the NHS, including maintaining a universal service free at the point of use, accountability to Government and regulators, and a commitment to high quality services and continuous improvement. The partners also agree to work in partnership to avoid redundancies and support staff hit by service changes “at the earliest opportunity”.

healthcare manager | issue 31 | autumn 2016

BREXIT & THE NHS

analysis

Easier said than done CRAIG RYAN Far from “taking back control”, Brexit has plunged the NHS into a period of radical uncertainty, with unpredictable consequences for funding, staffing and research.

A month before the EU referendum, a poll commissioned by the Chartered Institute for Public Finance and Accountancy found that 31% of voters thought Brexit would benefit the NHS and 46% thought it would have no impact at all. CIPFA also polled NHS chief executives and financial directors: 95% thought Brexit would harm the NHS.

These findings reflect the stark division between “expert” and public opinion seen throughout the referendum campaign. Three months on, most experts haven’t changed their minds, but how bad it will get is still anyone’s guess. If all we know is that “Brexit means Brexit”, NHS leaders can only guess what Brexit means for the NHS. Mike Birtwhistle, founding partner at centreright think tank Incisive Health, sees Brexit as a “massive ball of tangled string” which will take years to sort out: “There’s a heck of a task unpicking what health policy and law comes from Europe, and where to have divergence or where divergence doesn’t make any sense whatsoever.” Start with the money. NHS finances depend on economic growth. Despite the stock market recovery and August’s consumer spending spree, economists still expect growth to dip sharply. If Chancellor Phillip Hammond wants to find any new money for the NHS – let alone £350m a week – without crippling other services, he’ll have to raise taxes or let borrowing rip. He doesn’t look like that kind of guy to me. The devalued pound will also hit the NHS where it hurts, making imported goods, particularly drugs, more expensive. Worse still, any further cuts in things like social care, housing and welfare could pile costly new burdens onto the NHS. “The economic uncertainty that Brexit has cre-

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ated is the last thing the NHS needed,” says Helen McKenna, senior policy adviser at the King’s Fund, which has called on the government to “be honest” about whether policy commitments like seven-day NHS services are realistic in the postBrexit funding environment. The NHS has 55,000 staff from other EU countries, with another 80,000 working in social care. While it’s unlikely any will be sent home, uncertainty over the outcome of the Brexit negotiations is threatening to choke off this vital source of skilled staff for the NHS. “With the uncertainty over whether EU staff working in the NHS will be entitled to stay, people are rightfully going to be really concerned and worried,” says McKenna. “I’m sure people will be put off from coming until that’s been clarified.” Even more severe problems face social care, where jobs are “often low-paid and undervalued, so it may be difficult to make exceptional arrangements for bringing people in from abroad,” she explains. The falling pound will also reduce the value of social care wages to migrant workers. “People are thinking about where they want to live and bring up their kids, so it’s a lot to ask them to think about,” Birtwhistle adds. “And these are people who have already shown themselves to be highly mobile.” There could also be a nasty sting in the tail if other EU countries restrict migration from the UK. Exchanging a relatively young and healthy migrant population for elderly Brits returning from the continent would put a huge strain – financially and operationally – on the NHS. If these are managers’ headaches, Richmond House policymakers have plenty of their own. Unless the UK takes the “soft option” of joining the European Economic Area, they face spending years converting thousands of European reg-

BREXIT & THE NHS

ulations and standards into UK law or replacing them with British versions. The working time regulations are probably near the top of any hit-list. Although strongly supported by unions, they remain a bête-noire of both ministers and the Royal College of Surgeons, which claims the regulations hamper doctors’ training programmes. “When you don’t have enough doctors to go round, the idea of asking doctors to work a bit more might be appealing,” Birtwhistle says. “It’s one of these things which is potentially in play again after a long time.” But with doctors’ working hours already the touchiest of issues, this risks opening a very unappetising can of worms. “Our concern is the implications for NHS employment contracts at a time when relations with the workforce are tense,” says McKenna diplomatically. Adding to manager’s staffing woes, ministers may be tempted to toughen further professional standards and language tests for migrant doctors and nurses, says Birtwhistle. “If I were a minister, I’d be thinking about populist things I could do to demonstrate that Brexit is making a difference… I don’t expect managers will go into bat saying we must have more doctors who don’t speak English.” With the European Medicines Agency now likely to vacate its offices in London’s Canary Wharf, the UK faces exclusion from the EU’s new harmonised approach to drug regulation and clinical trials, set to begin in 2018. “If pharmaceutical companies have to apply separately to the MHRA [the UK medicines regulator] and the EMA, this would definitely be more burdensome,” says McKenna. “So there’s a question mark over whether companies will want to do that, and the knock-on impact with regard to our access to drugs.” European workers aside, health researchers have most to fear from Brexit in the short term. The UK netted €3.4bn in EU research funding between 2007 and 2013, but “it’s not just about money,” says Elisabetta Zanon, head of the NHS Confederation’s European office. “It’s also about the possibility of collaborating with colleagues across Europe.” “Will people feel welcome?” asks McKenna. “If you’re coming as a researcher from another country to work in a university here, there’s also the message the UK is sending out. People are understandably going to be thinking twice about coming here when deciding where they’re going to do their research.”

Moving out? European Medicines Agency staff at their headquarters in London’s Docklands.

“When you don’t have enough doctors to go round, the idea of asking doctors to work a bit more might be appealing.” – Mike Birtwhistle

Under threat is NHS participation in the €80bn Horizon 2020 research programme and the newly-established European Reference Networks for collaborative research into rare diseases. A quarter of these networks were to be led by NHS trusts. Outside the EEA, they become mere “observers”, unable even to join the networks they invested so much work in setting up. “Our partners are very anxious, but we can’t provide any clarification,” says Zanon. “Can we invest resources in these initiatives or are we just wasting our time? And what does that mean for our leadership internationally in medical science?” But until ministers set the direction of travel, the tiny Brexit units in the DH and NHS England can only really speculate about scenarios. “There’s a sense that everyone is very reluctant to say anything until they’ve got their marching orders,” says Birtwhistle. And with a third of DH staff due to go by 2020, doubts persist over the shrinking department’s capacity to cope with this daunting workload. “The government’s principal focus will undoubtedly be on negotiating favourable terms for trading and working with the EU,” says McKenna. “But the impact on health and social care must not be forgotten, particularly as these systems are already under considerable pressure.” But Birtwhistle believes Brexit at least gives NHS leaders a chance to rethink things. “Any form of reconsideration brings opportunity. If I was sat in the NHS, I would be thinking, ‘Yes, I’m very worried about Brexit’, but also that I should use this debate to think about what, in an ideal world, I might like to change.”

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MANAGING BETTER CARE: WALES

The “Once for Wales” project has transformed staff training across NHS Wales, cutting costs, raising quality and boosting compliance. Matt Ross spoke to the handful of visionaries who made it happen.

“I remember the bad old days, when people used to do everything separately, and work in competition rather than collaboration,” says Julie Rowles, the joint director for workforce and organisational development at Powys Teaching Health Board. “People were all off developing products with slight variations. But this project has pulled together all those good ideas; all that knowledge and expertise.” Rowles is thinking back to the early 2000s, when each of Wales’s ten health boards and trusts ran their own training courses for the ten statutory and mandatory ‘Level 1’ competences – such as infection control, fire, data protection and safeguarding. Helen Thomas, the deputy electronic staff record (ESR) programme director at NHS Wales, explains that because each employer had its own set of standards, “people moving between organisations – and there’s significant churn across NHS Wales – had to repeat training, as there was no ability to evidence what competence had been achieved.” So every time an employee left one NHS organisation for another, they’d have to undertake another ten training courses – not because their skills were out of date, but because their new employer didn’t recognise the courses run 10

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“Every time an employee left one NHS organisation for another, they’d have to undertake another ten training courses – because their new employer didn’t recognise the courses run by their previous one.” by their previous one. And along with this duplication, there was huge waste in the system: most employers paid external training providers to develop, run and license courses – and every time evolving best practice or new regulations required a course to change, they’d all have to pay a new set of fees. “People were using different learning platforms, and had different names for very similar learning outcomes and courses,” explains Thomas. “There were a lot of licence fees being incurred, and those costs meant we were restricted in sharing content. There was very little doing things once!” Meanwhile, at the national level, the lack of a pan-Wales staff records ‘dashboard’ made it impossible to ensure that the whole workforce was up to date with mandatory training courses. “There was

nowhere the Welsh Government could go to get accurate figures on compliance across Wales,” explains Julie Rogers, the technology enabled learning (TEL) programme manager at NHS Wales Shared Services Partnership. “They’d have to do a ring-round, and they were never comparing apples with apples. It was quite muddy waters!” Enter Paul Schanzer, then leading on e-learning at a Welsh trust. In 2005 “we were all up against the same pressures,” he recalls. “And we all wanted the same thing, but we were going about it in our own ways.” Schanzer saw “the potential – in terms of economies of scale, accessibility, savings – to make e-learning courses available across Wales”. But he couldn’t get funding for a national project, so instead he ganged up with a few like-minded colleagues to build a platform based on the Open University’s open source system. “We were all doing this in addition to the day job, because we knew it would make our lives easier some way down the road,” he remembers. “We shared the same passion; the same vision. We understood what we wanted to achieve.” That goal was to build a single elearning platform, offering a standardised set of courses and linked into a national electronic staff record dashboard – enabling staff to move

MANAGING BETTER CARE: WALES

organisations without repeating courses, and giving NHS Wales clear oversight of compliance across the country. If the NHS owned the course content and delivery platform, there would be a dramatic fall in development and licence fees. Economies of scale would generate further savings, as would the reduction in administrative work; and the ability for staff to carry qualifications between employers would avoid a huge amount of wasted time and money in unnecessary training courses. The project started small, but as the benefits became obvious and budget cuts loomed, national health leaders endorsed and adopted it. “Austerity’s helped – when funds are tight and something’s cost-effective, people jump on it,” says Schanzer. “That forced their hand, and we welcomed them with open arms!” With Helen Thomas and other colleagues, Schanzer developed the system and began engaging with the ten ‘subject matter expert’ (SME) panels, which bring together specialists from each employer.

Each panel would have to hammer out a standard course acceptable to every trust. “We started with the frustrations that everyone was feeling, and offered to help each group get consistent training across the board,” recalls Rogers. “And we worked with them not to force change, but suggesting ways in which we could improve the system.” Asked how they persuaded each SME group to agree a common syllabus, both Rogers and her colleague Karen Price – a TEL manager – are unanimous: “Patience!” Working with one ambitious SME group, the team built a ‘proof of concept’ to show how the system could work. And they compromised on the goal of fully-standardised courses, allowing individual employers to populate 20% of each course with information specific to that organisation. Nonetheless, recalls Rogers, they were often told by SMEs that a particular organisation’s course was simply too specialised and couldn’t be lined up with the NHS-wide offer. “But drilling into the detail, they weren’t that different. We

got to the point in some meetings where we’d go through individual courses slide by slide, and they’d be challenging each other.” Eventually, says Price, their patience paid off: “Now we have good relationships with all of them. Without their buy-in, we wouldn’t have been able to make progress.” The team also threw themselves into communications and consultation work with staff at the ten employers: “They didn’t roll over at any point,” says Rogers. “Some meetings were quite heated, but we always listened to their concerns and came back with an answer. I think they appreciated that.” Asked how the team won over staff such as her Powys colleagues, Julie Rowles is clear: “By ensuring that what they designed met the needs of the service, and taking people’s input on board without being paralysed by it,” she replies. “They’ve made sure that the project delivers – and that’s what wins people over.” With the system up and running, the number of Welsh NHS courses in these healthcare manager | issue 31 | autumn 2016

MANAGING BETTER CARE: WALES

Photo: HPMA

The Once for Wales project team collect the learning excellence award from the Healthcare People Management Association in June 2016. From left to right: Hazel Robinson workforce director, NHS Wales Shared Services Partnership; Karen Price, e-learning project manager; Julie Rogers, TEL programme manager; Helen Thomas programme director, NHS Wales.

competences has fallen from 100 to 10; and now, says Rogers, staff “complete the training once and their record goes with them to new organisations”. Each employee receives automated warnings when they’re due a refresher course, and they can complete them online whenever and wherever’s convenient. That saves a huge amount of time, explains Rowles: “If you’ve got a massive geography like Powys – it can take three and a half hours to travel from top to bottom – online learning is far better than trying to get people together in a room.” Meanwhile, adds Rogers, employers are saving money on licences, course costs and the changes required to keep learning modules updated. “One organisation couldn’t push out training to their staff because they’d paid to develop a course but couldn’t afford the licences,” she says. “With us, there’s no hosting fees; no cap on numbers. Our learning is in date, and we’re producing cost savings that can be reused elsewhere.” At the national level, says Thomas, “we now run a compliance dashboard across all our workforce, so we can identify where the gaps are and ensure those employees meet the requirement.” For the first time, NHS Wales knows with confidence that “all the workforce are trained and competent.” This is obviously good news for patients, comments Rowles – and they also benefit from the staff time previously lost to travel and classroom learning. The number of staff using the system 12

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has shot up from 300 to 20,000 a month since 2014, notes Schanzer. Nowadays he’s head of governance and board leadership at executive skills agency Academi Wales – but he hasn’t left the project, and retains a role as chair of the Learning at NHS Wales Service Management Board. Rebadged as the ‘Once for Wales’ programme last year, the learning platform is now producing useful savings. A 2015 Welsh Government report estimated that NHS bodies are saving staff time worth £1.2m in duplicated courses; avoiding module development and course fees totalling £7.3m; and averting annual costs of over £200,000 in areas such as data reporting, staff records and nearly 2,000 unnecessary immunisations necessitated by inadequate record-keeping. There’s obvious potential to extend the system beyond NHS Wales. “There’s a lot of interest from the wider public sector,” Julie Rogers confirms. “People want to move from externally-hosted learning. One organisation has told us they could save £300,000.” And Julie Rowles points to the value of standardising training as services work more closely together: “think about the integration of health and social services”. Meanwhile, HR managers across the NHS are beginning to notice what’s been happening in Wales: in June, the project won the Chamberlain Dunn Learning Award for Excellence in organisational development at the Healthcare People Management Association’s

annual awards. True to form, Schanzer already has his eyes set on the next horizon. “We’re in the process of splitting the platform, so we have one ESR system for the NHS and another for non-NHS staff: social services, colleges, local authorities,” he explains. Cardiff and Swansea universities are already on-board, while the Welsh Government’s corporate learning and development team are joining soon “and there’s interest from the fire and police services”. “It’s far exceeded our hopes, and now we’re getting recognition from other public organisations that this is the right way to go,” Schanzer adds. And what has he learned during his decadelong mission to create a single training system for every NHS worker in Wales? “Stay true to your vision,” he replies. “Engage with people, at every level and throughout your whole journey – or you set yourself up to fail. And we had that core team: six or eight of us who shared the same passion, the same vision. We could challenge each other, and we knew what we wanted to achieve.” They achieved it. That happened once the weight of NHS Wales got behind the project – but it started with a few switched-on health managers who saw the way to go, and started going there. “The old adage,” says Schanzer. “Proceed until apprehended.””

A consultant to MiP, Matt Ross is an editor, journalist and change manager.

INTERVIEW: ALWEN WILLIAMS

Barts Health is the NHS’s largest trust – and comes with financial and quality troubles to match. Alison Moore interviews chief executive Alwen Williams about turning round the NHS’s stricken supertanker.

If you’re looking for the biggest operational challenge in the NHS, running Barts Health Trust is surely it. The NHS’s largest trust in terms of staff and turnover, it has been judged inadequate on quality and finds itself in financial special measures, with a deficit of £135m last year. Turning this behemoth round is going to demand everything even an exceptional manager can throw at it. It’s easy to imagine the job being taken by one of the NHS’s alpha male leaders: a big beast with a strong belief that they know what needs to be done – and the headstrong management style to push it through. Instead, Barts has been led since June 2015 by Alwen Williams, a softly-spoken veteran of NHS management with a reputation for quiet efficiency and a background in running primary care trusts and as a senior executive at the NHS Trust Development Authority. She came into post – initially as an interim – after a highly critical Care Quality Commission report and the departure of the former chief executive. The task she faced can’t be overestimated. The trust was heavily dependent on interim executives and

temporary clinical staff and was well on its way towards the NHS’s biggest ever deficit. Staff morale was rocked by the CQC report and the special measures which followed. The viability and future of Barts itself – formed from a merger of three trusts in 2012 – seemed questionable. Fifteen months on, the picture is starting to change. Some clinical indicators are going in the right direction, its finances – although still horrendous by normal standards – have improved somewhat, and measures of staff engagement are encouraging. With the CQC already returning to some sites, Williams hopes to boost the trust’s standing to “requires improvement”, before aiming for a “good” rating. She says “a real passion and commitment to the NHS” is what attracted her to the job. “They were looking for leadership. In a sense there was a vacuum there. A lot of people knew me as I had worked there before and I was known by local partners – everyone was very welcoming. But the staff were yearning for someone to come in.” Williams has spent around half of her 36-year NHS career in East London, and also lives in the area. Her

children were born in the hospitals which now form part of the trust and she worked for nine years at the Royal London. All of this added up to a “connection” with what were effectively her local hospitals, she says. She also believes working across the NHS system gave her a “vantage point”, which has helped her to work more effectively with other organisations. The challenge for Williams was how to make sustainable changes quickly while taking staff with her. The trust has strengthened leadership by introducing managing directors and local leadership teams at each of its main sites. A traditional NHS approach, involving exhaustive discussions of proposal documents, would have taken months, leading to implementation in the middle of winter. Instead, the system was designed – with staff input – within eight weeks. The changes came in last September, giving them time to bed in before winter – although the structure has been refined since. “The way staff engaged with it and agreed to the changes we made was a real testament to them. We have not really had any challenges,’ Williams says. The trust board has also stabilised, with more permanent appointees replacing the board of interims Williams healthcare manager | issue 31 | autumn 2016

INTERVIEW: ALWEN WILLIAMS

NIKLAS HALLE’N

“These are tough jobs… you don’t come to work here for a quiet life!”

inherited. She is proud of the quality of people the trust has recruited. “At a time when we have been put into special measures, had huge challenges and have made significant organisational change, we were able to attract a high calibre team which is really important in terms of sustainability and long term improvement,” she says. She acknowledges that working at Barts is hard for many people, but suggests it can be the challenge which attracts them: “These are tough jobs… you don’t come to work here for a quiet life!” The same could be said for the chief executive’s role: it was never going to be an easy ride. “Barts is almost a microcosm of all these challenges,” she says. “The real leadership challenge is how to deliver sustainable improvement year in and year out – someone said to me it’s more a marathon than a sprint.” Williams also thinks it’s vital to spread leadership widely across organisations in a way which keeps staff onside. “I’m not sure the NHS needs big charismatic leaders that everyone looks up to to take 14

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every decision. Because it then does not build the leadership culture we’re trying to build at Barts,” she says. “There’s a much better understanding that unless you have your staff onside it’s almost impossible and you end up with lots of short-term measures. For me it is about how do you create an organisation where everyone sees themselves as part of that journey of improvement? Staff have to see they are engaged in being part of the solution rather than being told what to do.” Williams says her career has taught her that high-performing organisations get the same things right: they focus on the patient through the engagement and empowerment of frontline staff, and they focus on strategy – that means on both performance (“delivering good quality services now”) and organisational development. Her high points as a leader include being appointed as CEO of Barts and “leading NHS Tower Hamlets to be one of the best primary care trusts in the

country – as confirmed by our position in the World Class Commissioning assessment,” she says. “My low point was definitely the decision to abolish PCTs, and the subsequent uncertainty and focus on transition to the new structures.” At a time when the idea of hospital chains is gaining traction in the NHS, Williams suggests Barts is a “prototype chain” with leaders at each of its sites. She is determined to be a visible presence in the trust, despite the devolved leadership model, joining roadshows at each site and aiming to give the global picture for the trust while local executives fill in what this means for each hospital. Among Barts’ multiple challenges, those involving the workforce are fundamental: it normally has around 2,000 vacant posts in its 16,000 headcount. There are some signs the trust is turning the tide on recruitment and retention, which would be a vital part of improving care and cutting its deficit. Retention rates are now the third

INTERVIEW: ALWEN WILLIAMS

Reaching for a cricketing analogy, Williams says: “Our run rate is going in the right direction but it is not as fast as we would like. We have brought the underlying deficit down from last year. We had already made a £10m reduction in agency spend but we need to make more. The reality this year is

“We want to be renowned for quality improvement – not just in East London, but nationally and internationally.”

NIKLAS HALLE’N

best in London. The trust has ambitious targets on tackling staff shortages, but its increased use of bank rather than agency staff is making a difference. The trust has its own quality improvement plan, called ‘safe and compassionate’. “We are now starting to develop it into a long term vision… that’s what we want to be renowned for, not just in East London, but nationally and internationally,” says Williams. “Our safe and compassionate plan is about speaking to what was important to our colleagues.” Williams says the trust has “worked at pace” to make changes but a question mark must hang over how long the central authorities will allow it to continue racking up deficits. Williams says the challenge last year was to stabilise the finances and prevent the trust exceeding the £135m control total. It succeeded – which Williams sees as proof that the trust can get on top of its financial problems – but the position remains troubling, to say the least. “The challenge we have in Barts is how do we use our resources effectively and efficiently to support the quality of patient care?” she says. “Clearly we’re not going to get to a surplus this year… it will take another three to four years. Our ambition for this year is to do for financial improvement what we have done for quality improvement.” To that end, the trust has a plan for a 6% cost improvement this year. That’s ambitious, given that most NHS organisations struggle to make 2-3% in genuine, sustainable reductions. The target deficit this financial year is still a jaw-dropping £80m and already looks hard to reach. The trust recently found that it had a larger underlying deficit than it thought, creating a gap in its plans which will be difficult to fill.

that the NHS as a whole is in a challenging position and the Barts numbers are a material part of that. “The narrative for staff is very much around focusing both on money and quality,” she adds. “We ask if they are up for it, and they say ‘absolutely!’” On the quality side, the feedback so far from the CQC has been encouraging. “We’re optimistic that the CQC will have seen improvements,” she says. “From the organisation’s perspective it was a much more positive visit than it had been before, staff felt supported and were able to report to the CQC about improvements we have made. Williams says Barts is “driving cultural change through a very different engagement with our staff” and this has resulted in some of the most encouraging signs of improvement. Barts is using a well-tested technique

– Listening into Action, which has already been used at around 60 trusts. Part of the approach is to do regular staff ‘pulse checks’; at Barts, there has been a significant improvement between the pulse check last September and the one in May. “I think we have some fantastic clinicians. Our job as leaders is to put some of the best systems and practices and governance in place,” she says. Like all chief executives, she has to manage relationships with the centre as well as with staff. Conversations with regulators are “very respectful”, she insists. “I think fundamentally my job as chief executive is to build these really constructive relationships with the rest of the system and get to a place where they understand what we’re trying to do and have increasing confidence [in us]. We can’t be defensive as an organisation, we need to be open.”

healthcare manager | issue 31 | autumn 2016

NEW MINISTERS

Jeremy Hunt survived the Brexit fallout and the change of government, but Theresa May’s new faces at the Department of Health have little or no experience of the NHS. Colin Marrs profiles three ministers who will help to shape the future of health and care in England.

PHILIP DUNNE

MP for Ludlow since 2005, Dunne’s background is in farming and business. He was elected to South Shropshire District Council in 2001, before becoming Conservative leader on the council between 2003 and his election to parliament. He moves to the Department of Health (DH) after a stint as a junior minister at the Ministry of Defence, where he was responsible for procurement. Former colleagues cite his head for numbers as a key attribute likely to help him in his new job as minister of state, where he will take responsibility for regulation, workforce and, crucially, NHS spending. 16

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Before going into politics, Dunne helped to establish the Ottaker’s bookshop chain, starting as a non-executive director before being appointed chairman. He helped to grow Ottaker’s into to a business employing 2,500 staff before it was sold to HMV. “He was a very good pilot of what became a large boat while I did the rowing,” says his co-founder James Heneage. “Philip has a very strong financial skill base and has been a merchant banker. He is numerate and understands numbers but also understands systems and how you add value to a business.” Dunne’s analytical skills are matched by an ability to connect with staff, Heneage adds. “I think it’s his understanding of people that will help him most in his new role. There are potentially some areas of misunderstanding between the medical profession and government that he will be able to help with.” Dunne also served as chairman of venture capital trust Baronsmead 4VCT, which made a number of investments in the healthcare and education sectors, including Create Health, a fertility clinic based in London. A former colleague says: “He quickly understands the

“His understanding of people will help him most. There are areas of misunderstanding between the medical profession and government that he will be able to help with.”

key issues that will drive performance, has an eye for detail, understands the importance of maintaining an independent mind, and takes care to listen to people.” As a member of the Public Accounts Committee from 2006, Dunne was involved in the 2007 report on NHS financial management, which criticised the DH for not tackling ballooning deficits among health trusts. He also took a keen interest in his local health services as chairman of The Ludlow Health Forum, and campaigned for funding for plans to redevelop Ludlow Hospital.

NEW MINISTERS

NICOLA BLACKWOOD

Born in Johannesburg, South Africa, Blackwood was elected as MP for Oxford West and Abingdon at the 2010 election. Previously, she worked as a parliamentary researcher for Andrew Mitchell, who was then shadow secretary of state for international development. She worked with Mitchell on Project Umubano, a Conservative party initiative aiming to raise awareness of global poverty and find ways to tackle it on the frontline. During that time, Blackwood visited DAVID MOWAT

Another MP from the 2010 intake, David Mowat takes responsibility for primary care as junior minister for community health and care. He also covers the controversial area of NHS transformation, where he will be responsible for helping to implement Jeremy Hunt’s pledge to provide seven-day services. His other responsibilities include the thorny issue of integrating health and social care. Some see Mowat’s wide-ranging brief – and the abolition of a dedicated social care minister – as a downgrading of

“It’s a great myth about civil servants that they like to fashion a minister. They like a minister with clear views and Nicola has those.” Rwanda with more than 100 Conservative volunteers to help with social and health projects. Mitchell says the experience will help her greatly in her new role. “Nicola was very good on health-related issues,” he says. “She is extremely clever and has a real understanding of poverty, ill health and the connection between the two.” In 2013, as a member of the Home Affairs select committee, Blackwood demonstrated her crusading credentials by spearheading the Childhood Lost campaign – also backed by leading children’s charities – which aimed to tighten the law on sex offenders. This work led to greater powers for the police to place restrictions on people convicted of

“Why have an NHS board if it cannot manage change and do the right thing? That is why big organisations have senior managers who are paid lots of money.” social care within the department. Social care consultant Mike Padgham, who also chairs the Independent Care Group for York and North Yorkshire, says: “I have long felt that social care should have its own secretary of state but supposed that a minister post was as good as it got. To see this removed is disheartening, to say the least.” Mowat, MP for Warrington South, should have no problem getting to grips with the numbers. After a period as an RAF cadet pilot, he qualified as a chartered accountant, subsequently joining global technology consultant Accenture. He became a partner in 1989 and helped build the business headcount from 400 to

sexual offences. Blackwood was elected chair of the Science and Technology select committee in June 2015, leading work on the UK’s response to Ebola and on digital skills, and pressing for a good settlement for science in the 2015 spending review. One official who worked with her says: “She has an eye for detail and can digest a lot of information very quickly. She had an interest in science and was very passionate about science, technology, engineering and mathematics.” Mitchell says her knowledge will stand her in good stead as junior minister for mental health services and public health. “Public health is a subject that she knows well and understands on an international and national stage. I think civil servants are pleased when they get a minister with that knowledge because they don’t have to act as a college of further education. It’s a great myth about civil servants that they like to fashion a minister. They like a minister with clear views and Nicola has those.”

more than 15,000. His last position at the company was as global managing partner, responsible for a turnover of £500m. Mowat’s financial experience led to his appointment as parliamentary private secretary to the Treasury financial secretary, where he served from 2012 to 2016. His involvement in health matters within parliament has been relatively limited, although he has had some exposure in his role as a board member of the Parliamentary Office for Science and Technology. In a limited number of interventions on health from the floor of the House of Commons, Mowat has complained about the problems of introducing a new funding formula for public health. In 2014, he asked: “Why have ACRA [the Advisory Committee on Resource Allocation] if we are not going to do what it says, and why have an NHS board if it cannot manage change and do the right thing? That is why big organisations have senior managers who are paid lots of money.” He has been critical of spending on alternative therapies within the NHS – a view which, if the rumours are to be believed, conflicts with Jeremy Hunt’s own.

healthcare manager | issue 31 | autumn 2016

ARTIFICIAL INTELLIGENCE

Artificial Intelligence, machine learning and robots are set to transform the delivery of healthcare as we know it. So where are the hot spots in the NHS? Jenny Sims investigates.

ike kids with new toys, many clinicians, nurses and patients can’t wait to get their hands on the latest healthcare technology. Not only are clinicians collaborating with digital technology designers to develop systems and products, but more and more patients are raising funds to help buy expensive equipment and train NHS staff to use it. But let’s start with robotic surgery and a big success story. The da Vinci robot has revolutionised surgical treatment by making it possible for surgeons to perform The da Vinci robot, showing the patient-side component (left) and surgeon console (right). minimally-invasive surgery with greater precision and Hospital in Middlesbrough, part of South about the success and popularity of the da Vinci robot not only among surgeons, control than ever before. Tees NHS Trust, would currently be theatre staff and other team members, Da Vinci robots are now being widely holding at least a couple of golds and a but also with patients. used in hospitals throughout England silver. “It’s been an exciting opportunity for and Wales since NICE made robotics the Silver for being the second hospital in all of us, learning new surgical techgold standard for prostatectomy procethe UK to offer robotic thoracic surgery. niques. Robotic surgery allows surgeons dures, finding that “the robot gives fewer Gold for being the first to use it for removto have improved vision and a greater side effects and better clearance of the ing a tumour from the main airway of a cancer”. Many of the 50 NHS robotics lung. And a second gold for being the first, level of precision than the use of concentres are now forging ahead and using in April this year, to use a robot to carry out ventional surgical techniques,” he told Healthcare Manager. robots in other operations. a “diaphragm plication” – an operation to “Feedback has been very positive If there were Olympic medals for intro- repair a paralysed diaphragm. from patients, they like only having to ducing new robotic surgery procedures Trust medical director and consultant spend one night in hospital, it’s a less into the NHS, the James Cook University urologist, David Chadwick, waxes lyrical 18

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ARTIFICIAL INTELLIGENCE

invasive procedure and recovery is speedier,” he said. In fact, patients were so well-informed they were coming to the hospital and asking for robotic surgery even before South Tees had the da Vinci – and choosing to go elsewhere to hospitals that were already using it. “Patients want state-of-the art treatment,” said Chadwick. And with the help of patients’ fundraising through the South Tees Hospitals Charity, the hospital has been able to carry out robotic surgery since 2014. Since then South Tees has carried out more than 350 robot operations, using da Vinci six days a week, and is continuing to expand its use to new specialities. Wales has a similar success story. With £2.5bn funding from the Welsh Government, a regional robotic surgery service has been set up across several health boards – Cardiff and Vale, Abertawe Bro Morgannwg, Aneurin Bevan and Cwm Taf. In addition, a patients’ charity, Prostate Cymru, and a sports management company have raised money to train the surgeons. Meirion George, head of operations and delivery for the surgical clinical board at Cardiff and Vale UHB, said: “We are making better use of valuable NHS resources as patients need shorter hospital stays, freeing up beds for others.” Elsewhere in the NHS, robots are increasingly used in a variety of different ancillary settings. In 2015 South Glasgow University Hospital spent £1.3m on a fleet of robot porters – automated guided vehicles which move medical supplies, linen, food and water around the hospital. And Doncaster and Bassetlaw Hospitals is one of many to use robots to dispense and store medicines. A real insight into how AI and machine learning are going to revolutionise the diagnosis, treatment and delivery of healthcare was given recently by Mark Suleyman, co-founder of Google DeepMind Health (DMH), a British AI company acquired by the US technology giant in 2014. In July, Suleyman told the King’s Fund’s Digital Health and Care Congress in London that he wants to build apps “to put information in the palm of a

South Glasgow University Hospital takes delivery of fleet of robot porters.

clinician’s hand”. To this end, he’s keen to work in partnership with the NHS, and has appealed for ideas from NHS staff for the company to develop. “All our clinician-facing tools will be led by doctors and nurses,” he explained. “All of our existing projects have been brought to us by frontline staff and they will continue to be involved at all stages of our research development and user testing.” DMH is currently involved in two major NHS projects with London hospitals which Suleyman believes will deliver huge benefits to patient care as well as cost savings to the NHS. Suleyman says he was approached by Pearse Keane, a consultant ophthalmologist at Moorfields Eye Hospital, to explore how machine learning could help analyse scans to provide a better understanding of eye disease and speed up diagnosis of serious conditions, such as age-related macular degeneration (AMD) – which affects 250,000 people in the UK – and diabetic retinopathy. Moorfields carries out more than 3,000 optical coherence tomography (OCT) scans a week. These are highly complex and require specialised training to analyse, and there are often significant delays in diagnosis and treatment. It hopes that using AI to collect and analyse the data will help to standardise diagnoses and prevent sight loss in some patients. Suleyman says he hopes to publish some results at “the back end of this year”. Meanwhile Moorfields’ website

has published a Q&A for patients aiming to reassure them about data protection and patient confidentiality. Concerns about confidentiality have led to controversy over another DMH project, the collaboration with London’s Royal Free Hospital to develop an app to improve the detection of acute kidney injury (AKI). AKI affects more than one in six inpatients and can lead to prolonged hospital stays, admission to critical care units and, in some cases, death. The Streams app developed by DMH immediately reviews blood test results for signs of deterioration and sends an alert – and the results – to the most appropriate clinician via a dedicated handheld device. The data sharing agreement with the Royal Free gives DeepMind and access to patient information for five years up to 2017. DeepMind says the patient data is encrypted and safe, and that patients can opt out of sharing data at any time. However, the NHS’s Data Guardian, Dame Fiona Caldicatt, is considering whether to publish new guidance on such agreements. Suleyman expresses the lofty ideal that part of his company’s core mission is “to use the technologies we develop to make the world a better place and to tackle some of the world’s tougher social problems”. AI enthusiasts claim faster diagnoses will free up doctors and nurses to give more time to the more seriously ill patients, rather than replace existing staff.

healthcare manager | issue 31 | autumn 2016

BULLYING

legaleye Jo Seery examines where the law lies on bullying and harassment when dealing with poor performance. Carrying out appraisals is often a challenging process for managers, particularly when difficult conversations about poor performance are required. There has been a recent increase in MiP members reporting that they have been accused of bullying and harassment when tackling poor performance. Such accusations can have severe implications – including suspensions or unpleasant, protracted investigations, so it’s important that managers understand how the law deals with accusations of bullying. ‘Bullying’ is not defined in law but is described in the ACAS guidelines on bullying and harassment at work as “offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power through means that undermine, humiliate, denigrate or injure the recipient”. While most people will recognise extreme cases, when it’s less obvious there is a thin line, often open to interpretation, between what is and what’s not bullying. A manager may feel they are being completely fair by pointing out poor performance and attempting to put in place measures to rectify the problem. Indeed, this is part and parcel of the job. However, this same process may make the employee feel they are being singled out for criticism, victimised and undermined for no reason. There are a number of ways in which managers can address poor performance while doing their best to avoid allegations of bullying. Managers should always ensure that 20

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conversations about poor performance are dealt with privately and confidentially – they should never take place in front of other members of staff. It’s also important to prepare evidence of poor performance before the discussion. This could be from previous appraisals, measures of performance against targets or examples where the employee has fallen short of expectations. Where targets or standards have been set, check that the employee has agreed these and, where they are not being met, that the employee is aware of concerns about their performance and has received support and guidance. Lastly, all criticism should be constructive. While this may seem obvious, it is not always easy to do and a member of staff is far more likely to feel victimised if they feel that they are being criticised without any evidence or suggestions on how to improve their performance. Managers should ensure that the reason for any criticism has nothing to do with the employee characteristics protected under the Equality Act 2010: age, disability, gender (including

“While most people will recognise extreme cases, when it’s not completely obvious there is a thin line, between what is and what’s not bullying.” gender reassignment), race, religion or belief, sex, and sexual orientation. While a manager may not be taking any of these into consideration when criticising poor performance, an employee may nevertheless believe that the reason for any criticism is because of a protected characteristic and claim that they have been subject to harassment. Unlike bullying, harassment is defined in law as: “Unwanted conduct related to a relevant protected characteristic, which has the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual.” Even if the harassment is unproven, an allegation can still do serious damage to a manager’s reputation. We recommend that workplaces should have a clear policy aimed at avoiding bullying and harassment, which staff can access easily. Training should also be provided on the policy, the procedure for reporting accusations and how any complaint should be taken forward. If you are accused of bullying at work, your first port of call should be your union. Your MiP rep or national officer will be able to give you expert advice on your case and inform you on the next steps to take to protect your reputation against spurious allegations.

Jo Seery is an employment rights professional support lawyer at 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

Managing your boss An aggressive, incompetent or bad-tempered boss can turn even the job of your dreams into a nightmare. But storming out or taking revenge isn’t the way to go. Craig Ryan gathers some tips for “managing upwards” – and perhaps turning the situation to your advantage. 1. DON’T LEAVE

7. IT’S (USUALLY) GOOD TO TALK

If you’re otherwise satisfied with your job, use the situation to develop your skills and become a better manager yourself. If something else – your job description, workload or the organisation itself – is at the root of your unhappiness, tackle those issues first. And if your boss’s behaviour amounts to bullying or serious abuse, you need to make a formal complaint. But take time to talk through your options with your MiP rep or a trusted colleague first.

Sooner or later, you’ll probably have to talk to your boss about their behaviour. Plan what to say and how to say it. Keep it constructive and concentrate on the impact on your work and your team – not their personal deficiencies. If they get angry, offer to come back when they’ve calmed down. And try to leave the meeting with an agreed plan of action.

8. TAKE THE CREDIT You are likely to get credit for succeeding in working with a difficult boss where others have failed. If your boss tends takes all the credit for your success, show them up by going out of your way to praise the other members of your team for their contributions.

2. MAKE A PLAN Don’t let things fester – you need a plan. Work out your own objectives first. Do you just want to smooth things over until you or your boss move on, or are you looking to build a long-term working relationship? Are you also trying to protect colleagues or change the policy of the organisation or department? Try to plan for every situation – even down to the words you will use when talking to your boss.

3. WHAT’S MAKES THEM TICK? Try to understand why your boss is difficult. Micromanagers may simply be inexperienced, or they may have a deep-seated fear of losing control. Procrastinators might just be disorganised, or they may be terrified of making wrong decisions. Dictators may just be insecure, or they may really think they know it all. In each case, the behaviour may be the same but the causes and solutions are different.

4. WORK AROUND WEAKNESSES Think of your manager as a difficult patient – you’ve no choice but to work with them for now, so use your skills to diffuse potential conflicts. If your boss is a micromanager, keep them well informed. If they don’t like hearing bad news, try proposing one or two solutions at the

same time. If they can’t deal with people, offer to handle difficult meetings for them.

5. KEEP CALM Try really, really hard not to lose your temper with your boss. Just pausing for a few deep breaths can automatically produce a calmer, more reasoned response. Bad-tempered people are usually predictable, so work out your boss’s “triggers” and plan your responses. And remember, silence can be very effective – people soon feel silly getting angry on their own.

6. ACCENTUATE THE POSITIVE Wholly bad managers don’t usually last long. Try to identify and play to your managers’ strengths – you could ask for their advice or suggest they take the lead on something they’ll do well. Always reinforce good behaviour. For example, making a point of thanking a micromanager when they do give you some responsibility is likely to encourage them to do it more often.

9. KEEP RECORDS If problems persist, start a dairy and note all contacts – good and bad – with your boss as soon as you can afterwards. Write down how they made you feel and the effects on your work and your team. Keep copies of emails and other written communications, and store them offsite so you can access them at home if necessary.

10. GOING NUCLEAR If nothing works, consider making a formal complaint. Talk to your MiP rep at the earliest opportunity, and make sure you’re prepared for the worst outcome. And remember – all your efforts to build a better relationship with your boss won’t have been wasted – they will significantly increase the chances of your complaint succeeding. Craig Ryan (@CraigA_Ryan) is a writer and associate editor of Healthcare Manager. healthcare manager | issue 31 | autumn 2016

SUSPENSIONS

You deserve more support when everything’s on the line Investigations and grievances can often drag on for months or years, creating uncertainty and stress for everyone involved. Steve Smith calls for a more supportive approach from NHS employers. “I didn’t think anyone would care what I had to say.’’ “This is a pack of lies and I’ve been suspended: I can’t believe it.” “I’ve been judged and sentenced already.” “At last: someone on my side.” “Thank you for listening.” Those are just some of the more memorable words from the many MIP members who have recently found themselves caught up in grievances or investigations, often with scant support from their employers. As MiP national officers, my colleagues and I advise senior healthcare managers on all aspects of investigations and grievances: those considering or lodging a grievance; those who are the subject of a grievance; those asked to be witnesses; those interviewed; those responding to disciplinary charges or accusations; those taking part in hearings and outcome meetings; and, finally, those dealing with the fall-out. It gives MIP an informed and rounded perspective on the most challenging work situations, where career prospects, professional and personal integrity are often on the line. And it is clear from that perspective there is a systemic void 22

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“The clear misuse of a neutral act” Across the UK, MiP national officers and reps are reporting a surge in cases of NHS managers being suspended, often on flimsy or spurious grounds and even in contravention of employers’ own HR policies. In the NHS, staff should only be suspended as a last resort. But there are growing signs of suspensions being used without due cause and sometimes on the basis of a single, unsubstantiated allegation. MiP national officer Steve Smith has been helping one clinical manager who lodged a grievance against her employer and found herself suspended the next day as a result of unrelated allegations for which the trust presented no evidence. “This is clearly a punitive, retaliatory act,” says Steve. “The accusations against her do not merit an ongoing suspension. The trust’s policy requires suspension if the member’s attendance at work ‘poses a risk to patients, colleagues or the trust’s financial security’. Needless to say, the trust has not justified that or related the suspension to that policy. “This is a clear misuse of a supposedly neutral act – suspension – by senior managers and HR staff who know better than this,” adds Steve. “MIP has already instructed solicitors on the matter and we’re simply waiting for the trust’s investigation to play out before beginning legal action on our member’s behalf, if it proves necessary to do so. This sort of institutional bullying can’t and won’t go unanswered.”

– namely the lack of support offered to the people involved. By support, I don’t mean warm words and the phone number of the Employee Assistance Programme. I mean tangible, helpful, person-centred support for everyone involved. I’m absolutely certain that HR professionals and line managers are acting in good faith in the overwhelming majority of cases, but too often the gap between intent and outcome remains significant. For example, suspension from duty is, in legal terms, a ‘neutral’ act. Yet from the perspective of people who are suspended it invariably feels punitive. If employers truly want to fulfil their duty

of being supportive, then a much more creative and sparing approach to suspensions is needed. And for staff accused of inappropriate conduct? The gap between the default presumption of innocence unless proven guilty and the lived experience of MIP members is wide and needs to be bridged. Too often, I hear health professionals talking about how they have been arbitrarily cold-shouldered or not supported by their peers, or left wholly reliant on their trade union for advice and support because their employer is, in the words of one member, “nowhere to be found”. But rather than merely assign blame, I

MIP AT WORK

MIP CASEWORK

Trouble at scale and pace Jon Restell looks at the challenges ahead for the union’s work in supporting members with problems at work. thought I’d offer three initial suggestions for improving matters. 1. Unless there is a weight of evidence showing that an individual’s presence at work is dangerous, poses a risk to patient safety, the organisation’s finances or is likely to lead to someone interfering with an investigation, suspension should be the last and not the first resort. We need a much more evidence-based approach, with shorter suspensions and proper use of redeployment options. 2. We need to recognise that real people are by default involved in challenging, confrontational, stressful and adversarial situations. Careers, employment prospects and reputations can be at stake, which means all parties involved need practical institutional support and guidance, such as a named HR contact to walk them through policies, procedures and outcomes. 3. The challenging and difficult nature of these situations involving suspensions, investigations and grievances is always exacerbated by elongated timescales, lack of communication and the fear of an unknown outcome. Sticking to hearing and investigation timescales (which are always set out in policies!), agreeing subsequent actions, being as transparent as possible and advising all parties regularly are all ways to reduce or mitigate the stress and adverse impact these difficult and stressful situations.

Steve Smith is MiP national officer for north-west London and south central England.

At our annual planning event the MiP team identified the key trends with which members will need the particular support of the union. Members in nearly all organisations face continual cuts and workforce uncertainty. In England, the STPs will drive widespread organisational change through the health and care system. The planning of integrated and devolved services will give way to implementation, and this is when the implications for job security and employment conditions will become clearer to staff and their unions. Questions of employment status and the continuity of employment will be central to workforce discussions, especially as commissioning leads to re-tendering and fragmentation of services. The pace of mergers and acquisitions of providers will quicken. There are considerable challenges for MiP’s collective representation of our members. Unlike earlier systemwide transformations, there will be no national timetable and the form of change will be different for both providers and commissioners in different parts of the country. We will also have to deal with an incoherent workforce strategy, with national responsibilities scattered and duplicated across a number of system bodies. The NHS’s financial problems will continue to hit managers and other staff. As care quality, financial performance and waiting times suffer, managers will get the blame. Organisations

will use dismissal – often with the misuse of disciplinary and performance management procedures – to shift attention from their own responsibility for what is happening. As Steve Smith writes opposite, our representatives are already reporting more and more instances of poorly managed investigations, trumped-up or inflated disciplinary charges, and the inappropriate use of suspension. Financial pressures are also toxifying workplace culture and creating unsustainable workloads, with serious consequences for wellbeing and mental health. There are growing fears about another serious service failure like MidStaffs. One unhelpful trend is the hollowing out of experienced, permanent HR staff, leading to a growing aversion to risk and over-reliance on lengthy and often damaging formal processes. The third key trend is the further chipping away of terms and conditions. The redundancy cap and clawback provisions are expected to come into force in the next year. The Treasury and NHS Improvement continue to interfere in settlement and contractual decisions, hamstringing the ability of MiP and employers to reach sensible and fair outcomes. Employers appear to be offering more and more new staff non-Agenda for Change terms, and some examples of employers offering inducements to leave the NHS Pension Scheme. There is also much poor practice in the assessment of suitable alternative employment during re-organisations and in the job evaluation process, leading to the incorrect downbanding of posts and staff. The team and our national committee will agree action to respond to these trends in the next two months.

healthcare manager | issue 31 | autumn 2016

THE SHARP END: YOUR REPORTS FROM THE NHS FRONTLINE

To get your views out there, MiP is working with its members to have your stories published in the national media. This one appeared in the Guardian. Can you help produce the next?

The government must commit to its own agenda B

ringing together health and social care is crucial to sorting out the problems in the NHS, and could unlock all sorts of benefits for patients. But to make these reforms successful, the government needs to provide more clarity about how they’re going to work – then to demonstrate commitment to its own strategy. I work in programme management for a Commissioning Support Unit: we support CCGs and other organisations on matters such as finance, IT, service transformation and change management. Recently I’ve been supporting our local system to develop a Sustainability and Transformation Plan (STP) – which bring NHS bodies together with councils and community providers to produce a five-year strategic plan to improve care and find the very ambitious savings required of us. The benefits of STPs could be huge. The whole system is short of money, and we have a growing and ageing population with increasingly complex needs: to have any chance of sorting this out, we must integrate health and social care services – and STPs have sparked some real collaboration. We’re bringing together people who’ve been plugging away at different aspects of the same problem for years, and there’s huge enthusiasm. We had a difficult start, though, because NHS England made up the policy on the hoof. Late last year, work had started across England on Local Digital Roadmaps: by April, we were required to submit plans to transform and connect the IT of NHS and social care bodies within our geographical ‘footprint’. Then at Christmas, we were suddenly asked to produce an STP by June. It wasn’t clear how STPs were to line up 24

healthcare manager | issue 31 | autumn 2016

with Local Digital Roadmaps, and in some areas their footprints aren’t coterminous – which is daft. NHS England’s guidance was fragmented, emerging in bursts while

we worked, often leaving us little time to respond to new requests. Still, we hit the deadline, expecting a written response in July; but as of late August, we haven’t heard back. NHS England are constantly telling us to work “at pace and at scale”. It would be helpful if they worked at the pace that they expect of us! A second big challenge with STPs is their lack of a formal structure or leadership. ‘Volunteer’ chief executives lead STPs alongside their day-jobs, and the organisations involved report to their own boards – which have a legal responsibility to protect their own bottom lines. So plans that are good for the whole system can lead to individual organisations losing income, which may put boards in conflict with STP ambitions. I think the government should create formal structures that will enable STPs to appoint full-time leaders, make the necessary strategic decisions and, crucially, move money around

the system to where it’s needed. System-wide reforms may also involve controversial changes such as closing A&E departments. Sensibly, NHS England requires strong public and patient engagement before these decisions are finalised: when we don’t get people’s buy-in, the result is protests, judicial reviews – and delays that we can’t afford. So we need to start consulting on our plans and having an open conversation with the public. But NHS England says we can’t publish our STPs – presumably because it’s worried about negative headlines. I think we have a duty of candour here, and NHS England says we must move ‘at pace’; yet we’re barred from explaining our plans. That’s a problem. STPs are really helpful in driving collaboration; in integrating health and social care; in creating a climate for change. But they need the right management structure to make system-wide decisions, along with the freedom to publish and consult as they see fit. And I’d like to hear much stronger signals from NHS England that they’re committed to this model – that it won’t be swept away in yet another round of top-down reforms. Then people will recognise that this is for real, and commit themselves to the agenda – and we’ll be able to use reforms to make the savings asked of us, even as we improve services for patients.

The Sharp End gives MiP members the chance to tell politicians and civil servants how their policies affect your work and your organisation. If you’d like to work with a reporter on your own story, email us at thesharpend@ healthcare-manager.co.uk. Anonymity is guaranteed.

Our pledge to you

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We have more experience of winning personal injury and employment claims than any other firm â&#x20AC;&#x201C; 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.

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MiP ANNUAL CONFERENCE 2016 Great managers, great workplaces â&#x20AC;&#x201C; 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