Healthcare Manager Winter 2016 by lexographic

HCM32_FRONTCOVER.pdf

issue 32 winter 2016

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healthcare manager

SIR ROBERT NAYLOR BEEN THERE, SEEN IT, STILL DOING IT plus GREAT MANAGERS, GREAT WORKPLACES MiP Conference 2016 STPs We really need to talk about jobs TIPSTER: How to run a proper investigation

helping you make healthcare happen

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issue 32 winter 2016

healthcare manager inside heads up:2 Leading edge: Jon Restell

analysis:8 Craig Ryan: What’s happening to redundancy payments in 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.

Great managers, great workplaces: Reports from MiP’s 2016 conference in London. The HCM interview: Outgoing UCLH boss Sir Robert Naylor talks about his 45-year career. STPs: Why we really need to talk about jobs. Joining together: How smart work by nursing and HR staff cut one trust’s vacancy list in half.

regulars:20 Legal Eye: New rules on patient consent. Tipster: How to run a proper investigation. MiP at Work: Action on workplace bullying, plus how MiP rescued one member’s retirement plans.

the sharp end:24 Redeployment: your reports from the frontline.

Craig Ryan Editor

I’ve made something of a career writing for and about unpopular people. I’ve worked with tax inspectors and Whitehall mandarins, but nothing quite matches for unfairness and intensity the flak directed at NHS managers. So it’s a great relief to hear a politician – and a Tory politician too – saying and even doing something positive about NHS management. Jeremy Hunt’s speech to NHS Providers (see p7) was spun in some parts of the media as another attack on NHS “general” managers. It was nothing of the sort. Increasing their intake by 1,000% is a funny way to slap down a professional group. Hunt’s simple recognition that “running a hospital is one of the hardest jobs in Britain today” needs repeating over and over again. Yes, his main headline grabber was that he wanted more doctors and nurses in management jobs. Everyone does. But the very fact that he needs to introduce all sorts of schemes to encourage clinicians into management speaks volumes about how tough the jobs are and the extraordinary skills required. In this issue we bring you coverage of MiP’s 2016 conference – undoubtedly the best I’ve been to. We have the incomparable Robert Naylor in conversation with Alison Moore and Matt Ross on some fantastic work by the recruitment and nursing teams at UCLH. And, after doing Brexit in the last issue, I get to wade through more treacle to try to discover what STPs might mean for managers’ jobs. Have a great Christmas and let’s just hope for the best in 2017! healthcare manager | issue 32 | winter 2016

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

Regional leadership awards

Recognising our outstanding NHS leaders

Above: MiP national officer Andy Hardy (second right) with some of the winners at the South West regional leadership awards. Right: Award winners Bernard Brett (left) and Joanne Clark (centre) with MiP national officer George Shepherd at the 2016 East of England leadership awards.

MiP national officers have been presenting awards to NHS leaders around the country as part of the union’s support for the NHS Leadership Academy’s regional awards scheme. At the East of England leadership awards at Duxford Air Museum

in November, George Shepherd presented the award for leading and developing people to joint winners Bernard Brett, the independent chair of the East of England Clinical Senate, and Joanne Clark, senior occupational therapist at Hertfordshire

healthcare manager

Design and Production

issue 32 | winter 2016

Lexographic www.lexographic.co.uk

ISSN 1759-9784 published by MiP

Contributors

Editor

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

Community NHS Trust. “Bernard introduced a succession planning development programme to support council members in chairing review panels and was recognised as a ambassador for under-represented groups,” said George. “Joanne is always

Andy Hardy, Linda Miliband, Alison Moore, Jon Restell, Matt Ross, Craig Ryan. Opinions expressed are those of the contributors and not necessarily those of healthcare manager or MiP.

healthcare manager | issue 32 | winter 2016

promoting training opportunities and created a training notice board and runs a fortnightly quiz on brain anatomy in her own time.” At the South West regional leadership awards at Bristol Pavilion, MiP national officer Andy Hardy presented the

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leading and developing people award for 2016 to Wendy Kelvin, head of learning and development at Avon and Wiltshire Mental Health Partnership NHS Trust. In the last year, Wendy has organised more than 800 training courses, supported over 100 apprentices and run coaching schemes for 63 staff. “What’s fantastic about the job I do is that in learning and development we have the potential to change people’s lives,” said Wendy. “Being nominated and recognised for delivering a job you believe in and enjoy makes you feel nothing other than pride.” Find out more about the South West leadership awards at bit.ly/hcm3203 and the East of England awards at bit.ly/ hcm3204.

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

iP was an enthusiastic supporter of the Five Year Forward View. Now we see the Sustainability and Transformation Plans as a once-in-a-generation opportunity to change our care system for the better.

Our views are shared by many managers. As one of my colleagues notes in this issue (p16), the vast majority of managers “see the logic of trying to unify the system and address the particular needs of the communities they serve”. And as one of our members, writing in the Guardian, said: “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.” But as members took stock at our conference, it started to look like we might throw away this once-in a generation opportunity. While being optimistic, we have always been realistic and sceptical. No MiP member believes the funding gap of £30bn could be closed by 2020-21 through efficiency gains of £22bn. Not only were the efficiency claims overblown at the time but some of the Forward View’s other assumptions have unravelled. The baseline was out because the NHS started with a £3bn deficit, not a balanced position. There have been cuts to public health and social care services, and some drastic reductions

“Will STPs in the end boil down to another restructure of commissioning and a poorly-executed back office rationalisation? Let’s hope not. Now is the moment to launch a campaign to Save Our STPs.” in capital funding. And all this is before we even think about Brexit and inflationary pressures. And certainly no one now believes that the extra money (whether you choose to believe the government or the Health Select Committee about how much it is) will be anywhere near enough. The extra sum needed is probably closer to £20bn than £8bn, with a sizable extra bucket of transitional funding and more time for transition. These are the financial gaps. But there are other gaps – in stability, engagement and accountability – which could prove just as fatal to STPs. Money woes, regulatory and performance pressures are destabilising more and more providers. Unstable systems generally don’t transform themselves well. Then there is public and staff engagement (and I include engaging with leaders here). With a few notable exceptions, it has simply not been good enough. The perception of secrecy has contaminated the STP brand before launch. And then there is accountability. STPs have done good work in bringing a new kind of conversation to local health

and care systems and analysing the big local challenges. But what happens next is less solid, with many system leaders blithely thinking that we can achieve the impossible. The unreality of some plans begs unavoidable questions about accountability and the capacity to deliver. As a result of all this, political pressure is building. It’s possible to sense the start of a retreat from the big decisions. Many of us are feeling that it’s a bit like Groundhog Day. Will STPs in the end boil down to another restructure of commissioning and a poorlyexecuted back office rationalisation? Let’s hope not. Now is the moment to launch a campaign to Save Our STPs. Here are four campaign objectives: ■■ Honesty as well as optimism from NHS and other local leaders about the money and the scope for efficiency gains. NHS leaders must be clear that despite their best efforts the funding gap will remain. ■■ Stabilising the system, with extra money for social care and NHS community services as a priority. ■■ A full year to allow thorough public and staff engagement, with a political understanding that, after that, local systems will make the tough decisions.

Accountability and delivery mechanisms with bite and bark to implement those tough decisions, a transitional find to support local transformation and decent support for local leaders. Unrealistic? Perhaps. But more realistic than the present hopes for STPs. If we want to grab this once-ina-generation opportunity to change our care system, let’s go for it. Save Our STPs!

■■

healthcare manager | issue 32 | winter 2016

HEADS UP

Leadership

Leadership plan promises “inclusive and compassionate” NHS NHS Improvement has published a new NHS leadership development framework, which pledges to spread “inclusive, compassionate leadership” and foster continuous improvement throughout the NHS. The framework, Developing People – Improving Care, which is supported by MiP, says its objective is “a national

health and care system where people at every level take pride and joy in their work, and where together they have the capability and capacity to deliver continuous improvement in care for individuals, population health and value for money.” Immediate actions include a tailored development programme for STP leaders in

both the NHS and local government, and action to improve recruitment at senior levels and tackle boardroom vacancies. Professor Don Berwick, visiting fellow at the King’s Fund and author of the 2013 NHS patient safety review, said: “What’s going on here is pretty bold, pretty ambitious. Why don’t we increase the

capability of the system, from top to bottom, and use scientific improvement methods to add joy to work and deliver better care to people?” Read “Developing People – Improving Care” online at bit.ly/hcm3206 or join the conversation on Twitter using #AllLeadAllCare.

Agenda for Change

Unions demand end to pay cuts

Unions have called for a real-terms pay rise for NHS staff in 2017 and action to tackle unfairness and inconsistencies in the Agenda for Change (AfC) pay system. NHS unions, including MiP and UNISON, submitted a four-point claim for 2017 in their evidence to the NHS Pay Review Body: ■■ a “fair pay award” which at least

healthcare manager | issue 32 | winter 2016

matches the rise in the cost of living ■■ a realignment of the AfC pay scales to

ensure consistency across the different nations of the UK ■■ restructuring of Bands 1 to 3 and action to ensure other staff don’t have their award reduced to fund payment of the higher minimum wage ■■ a comprehensive workforce strategy with fair reward as a key element

The unions’ evidence says NHS staff have seen their take-home pay cut by an average of 12% in real-terms since 2010, with pay restraint expected to continue for the rest of the decade. The evidence included results from UNISON’s 2016 pay survey, in which 21,000 NHS staff, including MiP members, took part. It found that 63% felt worse off than last year and 59% were relying on unsocial hours payments to get by. Only 7% said morale at their workplace was “high or very high”, while 65% said morale had fallen in the last year. The survey also found that 70% thought there were not enough staff in their unit to do the work required, and over half had considered leaving the NHS within the last year. The unions will give oral evidence to the review body in early December and its report is expected to be published in February. Unions will submit separate evidence for staff in NHS Scotland, after the Scottish Government asked to delay the pay review process until after November’s Autumn Statement. Read UNISON’s evidence to the NHS Pay Review Body for 2017 at: bit.ly/hcm3205.

HEADS UP

Pay

MiP calls for end to secrecy on trust chairs’ pay

MiP has called on the government to be more open about the pay of trust chairs and non-executive directors after the Health Service Journal revealed that ministers had approved inflation-busting pay rises for 22 trust chairs. “We’re concerned about the apparent secrecy surrounding these pay decisions,” said MiP chief executive Jon Restell. “We only know about them because the HSJ made a freedom of information request. Pay, especially for senior postholders, should be determined in the open.” Restell said MiP had “no problem in principle” with pay rises for trust chairs and other non-employee board posts, which were often hard to fill, but criticised the government’s failure to extend the same approach to NHS staff. “There are many recruitment problems in the NHS, including the employee posts on trust boards, such as chief executives and finance directors,” Restell added. “Staff have been told for years to stick with the pay freeze, that there is no money to reform Agenda for Change and so on. This will go down badly with them.”

SSRB

MiP gives evidence to Senior Salaries Review Body MiP has called for an across-the-board pay rise and a comprehensive leadership and workforce strategy for senior managers working in arms-length NHS bodies (ALBs) in its evidence to the Senior Salaries Review Body, which is preparing its 2017 report. The SSRB, chaired by Dr Martin Read (pictured), recommends salary levels and pay arrangements each year for around 360 executive and senior managers (ESMs) above Agenda for Change grades, working in ALBs such as NHS England, Health Education England and NHS Improvement, as well as some Commissioning Support Units and ambulance trusts. The review body does not currently cover senior managers working for provider trusts, CCGs or other local commissioning bodies. Appearing before the SSRB in October, MiP chief executive Jon Restell set out the union’s main recommendations for the 2017 pay round: ■■ the 2017 pay award to be calculated by dividing 1% of the paybill equally among qualifying ESMs (those with “exceeded” or “met” performance ratings), resulting in proportionally higher awards for lower paid managers ■■ a comprehensive leadership and work-

force strategy for senior managers in ALBs, to be developed as part of the planned operational review of the new ESM pay framework ■■ key stakeholders such as MiP should be closely involved in the planning and delivery of the operational review ■■ a sector-wide discussion about extending the SSRB’s remit to cover senior managers’ posts in the wider NHS In supplementary evidence, MiP argued that the case for a 1% across–the-board rise was “overwhelming”. It pointed to the Department of Health’s own evidence showing that take-home pay for ESMs has already fallen by 20% since 2009. With inflation already at 1% and expected to rise further next year, anything less would mean a further significant decline in ESM pay, the union said. “It would damage morale and staff engagement, reduce the attractiveness of senior posts in ALBs in comparison to elsewhere in the NHS, and send a very negative signal about the value placed on the work of this small but important group of managers,” said MiP chief executive Jon Restell. Restell called for talks on extending the remit of the SSRB to all senior NHS managers above Agenda for Change grades. “Pay and conditions for very senior managers in the NHS has been determined for too long by short-term, tactical considerations of political presentation,” he said.

Does your employer take part in the Workforce Equality Index? Stonewall’s Workplace Equality Index (WEI) is an evidence-based benchmarking tool used by employers to assess their achievements and progress on LGBT inclusion in the workplace. UNISON is running a short survey for members (including MiP members) to give their views on the WEI and how it can be used as part of the union’s equality work. If your organisation participates in the WEI, visit bit.ly/hcm3207 to take part in this short survey.

healthcare manager | issue 32 | winter 2016

HEADS UP

Job evaluation

Obituary

Because you’re worth it

Trade unionists and NHS workers from around the country were saddened to hear of the death of UNISON president Eric Roberts in November, after a brief struggle with cancer. Born one of five boys in Litherland, Liverpool, Eric left school to work as an instrument repairer, before working as an apprentice baker, confectioner and wine waiter. After seeing an ambulance shooting down Oxford Street, he joined the London Ambulance Service, in which he served for 42 years until his death. Of his work in the ambulance service, Eric said: “I love it. I love the people, I love the service, I love the health service.” He was an active trade unionist and became the branch secretary of NUPE’s North West London ambulance branch. He was the first secretary of the London ambulance branch following the creation of UNISON and the first ambulance worker to be elected president of UNISON. Dave Prentis, general secretary of UNISON said: “I will miss his honesty. I will miss his infectious personality. But most of all I will miss his friendship. Eric Roberts was a good man who gave so much to so many people.” Eric was also a member of MiP’s management board and sat on many appointment panels for national officers. Jon Restell, chief executive of MiP, said: “Eric was a big personality who knew how both to challenge and support, all with great good humour. He was on your side. We’ve lost a great friend and supporter.” Our thoughts are with his children Jack and Rhian, family, friends and colleagues.

healthcare manager | issue 32 | winter 2016

Eric Roberts

With STPs set to bring sweeping changes to posts and job descriptions across the NHS, delegates at an MiP conference workshop discussed how to protect the integrity of the job evaluation system. “Job evaluation is the core of Agenda for Change, it’s what the whole thing rests on,” explained Helga Pile (above), UNISON’s lead for job evaluation on the NHS Staff Council. She described how the partnership approach – with unions and employers agreeing how jobs should be fairly evaluated and graded – was under threat. “People are not getting training, employers are using outside consultants with no experience of the NHS or Agenda for Change, and they’re looking for shortcuts, not evaluating all

the factors and not doing consistency checking,” she said. She warned that employers were vulnerable to equal pay claims if they didn’t apply the job evaluation scheme properly. MiP national officer Claire Pullar (below) described how so-called “desktop” evaluations, “done by one person in a darkened room”, with no consistency checking and no appeals, often resulted in posts being unfairly downgraded. She shared the example of a public health consultant who was transferred to a local authority during the

Lansley reforms. The outside consultant evaluating the job made numerous mistakes and even added up the final score wrongly, resulting in the post being downgraded to Band 8D – a potential loss of £18,000 in salary. “It looks as though they were trying to downgrade the job and this was not a very subtle way of doing it,” said Pullar. “Looking at it properly, he’s comfortably into Band 9. But they wanted to reduce his pay with immediate effect.” One MiP member from a London trust said downgrading was “rife” where she worked. “People were systematically downgraded and it was put to them ‘you either take this or there will be nothing for you’. So people took it and two years later the problems with it are really emerging.”

Correction – Incisive Health In the article on Brexit in the last issue of Healthcare Manager (“Easier said than done”, HCM32, p8) we referred to Incisive Health as a “centre-right think tank”. In fact, Incisive Health is an independent health policy consultancy with no political alignment. Its founding partner is Mike Birtwistle, not “Birtwhistle” as printed. We apologise to Mike and Incisive Health for these errors.

HEADS UP

Leadership

MiP welcomes Hunt’s “vote of confidence” in NHS management

Ben Birchall/PA Wire/PA Images

“Running a hospital is one of the most difficult jobs in Britain today, and we see in our NHS some of the most outstanding leaders in Britain today.”

MiP has welcomed Jeremy Hunt’s announcement of a ten-fold increase in NHS management trainees as a “vote of confidence in NHS management”. But the union warned that politicians need to do more to end “manager bashing” and attract more clinicians to top management jobs. Hunt’s speech to NHS Providers conference on 30 November was probably his most significant since he unexpectedly retained the post of Health secretary in the post-Brexit reshuffle. He announced several new policies on management and clinical leadership in the NHS, including: ■■ doubling the intake of non-clinical graduate management trainees to 200 a year in 2018, rising to 1,000 by 2020 ■■ an urgent review of professional regulations for doctors and nurses to ensure that clinicians are encouraged,

rather than discouraged, to take up management jobs ■■ the NHS Leadership Academy to send 30 students a year to “worldleading” universities as part of a fasttrack programme for clinicians aspiring to senior management positions ■■ a review by Health Education England of whether clinical leadership should be a specialism in its own right ■■ a new MBA from 2017 for senior NHS professionals, to be run in partnership with leading UK universities “Running a hospital is one of the most difficult jobs in Britain today,” Hunt said. “But in the face of the pressures we face, we see in our NHS some of the most outstanding leaders in Britain today.” Hunt pointed out that the proportion of clinicians in senior management jobs in the NHS is, at 54%, low by international standards. It is hardly surprising that “we underexploit the talent” available in the NHS, he said, when one in ten chief executive posts are filled by interims or on a fixed-term contract basis. He said the NHS may have made “a historic mistake” in the 1980s by “creating a manager class who were not clinicians rather than making more effort to nurture and develop the management skills of those who are”. He claimed his new programme would create “space for an outstanding new generation of leaders from both clinical and non-clinical backgrounds, while more properly exploiting the huge talents of our female and BME workforce at the same time”.

Welcoming Hunt’s speech, MiP chief executive Jon Restell said: ”The ten-fold increase in the number of non-clinical management trainees by 2020 is bold. Good for Hunt. It’s a vote of confidence in general management, HR, finance and other disciplines in the NHS. “But the government must also do more to hold on to the managers it’s already got. A fifth have gone since 2010, and that’s a lot of skill, experience and dedication lost to the NHS at a crucial time.” Restell said MiP has always supported moves to increase the number of chief executives from clinical professions and the proportion of leaders who are women and from BME backgrounds. “But are we really talking about doctors here? Many nurses and allied health professionals have always gone into general management, because it offered better career progression and more money.” Restell warned that regulation was unlikely to be the biggest barrier to doctors becoming chief executives. “With boardroom salaries in relative decline after five years of pay freeze, pay will certainly be an issue for senior doctors,” he said. “Tenure risk, from unmanageable regulatory and performance pressures, will also be a disincentive – the average tenure of an NHS chief executive is now just 18 months. “The way to get more doctors to become chief executives is to make the post of chief executive more attractive for everyone,” he added. “Overall, this speech has some pretty positive policy on leadership. Our analysis of the vacancy problem at board level differs sharply from the government’s. But we can work with this – it’s possible that government may finally be taking management as a resource seriously.” Read Jeremy Hunt’s speech in full at: bit.ly/ hcm3202. See also Philip Dunne’s speech to MiP’s 2016 Conference on p9.

healthcare manager | issue 32 | winter 2016

REDUNDANCY PAYMENTS

analysis

What’s happening to NHS redundancy payments? Less than two years after new NHS redundancy terms were agreed, the Treasury has forced unions and employers back to the negotiating table. Craig Ryan reports. It’s hard to imagine a worse time to throw the NHS redundancy arrangements up in the air, but that’s what the government is doing. Employers and unions will spend the next nine months negotiating new redundancy terms for the NHS in England, just when the uncertainty and upheaval facing NHS staff has never been greater. The NHS Staff Council, which brings together employers and unions at national level, has begun negotiations within a framework set out by the Treasury in September. This comes on top of measures already in the pipeline to clawback payments to staff on over £80,000 who return to work anywhere in the public sector within a year, and to cap all public sector redundancy payments at £95,000. The Treasury’s five “criteria” for negotiations are: ██ Reducing the standard “tariff” for redundancy payments to 3 weeks per year of service (currently 4.35 weeks in the NHS) ██ Capping payments at 15 months’ salary (currently 24 months in the NHS) ██ Reducing the maximum salary for calculating payments to £80,000 (this is already the maximum in the NHS following changes agreed in 2015) ██ Limiting the use of redundancy payments to fund early access to pensions (such “employer top-ups” were removed from the NHS scheme in 2015) ██ Tapering redundancy payments for staff nearing retirement age That’s the bad news. The good(ish) news is that there is a strong chance of improving on these terms in negotiations. 8

healthcare manager | issue 32 | winter 2016

As things stand, even the Treasury estimates its proposals will save just £250m, less than 0.25% of the NHS budget. But they could still mean substantial cuts in redundancy entitlements for many MiP members. For example: ██ A band 8b manager on £57,640 with ten years of service would see their redundancy payment fall from around £48,000 to £33,000; with 30 years of service, it would be cut from £115,000 to £72,000. ██ A band 9 manager on £99,437 with ten years’ service would see their entitlement fall from around £67,000 to £46,000; with 30 years’ service, the government’s cap would kick in and they would receive £95,000, compared to £160,000 now. Obviously, MiP and Unison will be doing everything in their power to make sure that doesn’t happen. The recent settlement in the Civil Service, negotiated by the FDA and other unions, shows there is plenty of scope to improve on the Treasury proposals. For example, it improves the cap on redundancy payments to 18 months’ salary and the maximum salary for calculation to £149,950.

“The Treasury has torn up existing agreements at the worst possible time,” says MiP chief executive Jon Restell. “Employers and unions need the flexibility to negotiate redundancies. With STPs and the effects of the funding crisis, no one needs this – not employers, not staff and certainly not the NHS as a whole.” UNISON deputy head of health Sara Gorton says NHS unions will be pressing for savings already made in the NHS to be taken into account: “NHS staff will feel particularly aggrieved as they have only recently concluded a set of changes to the way the scheme operates in England. “It won’t be lost on staff that a ‘policy’ which started with tabloid attacks on ‘fat cat’ executives has morphed into a threat to cut terms and conditions for the vast majority of the NHS workforce,” she adds. MiP will also use the negotiations to press for a comprehensive NHS redeployment package . “As we saw with the upheaval created by the Lansley reforms, it’s crazy that the NHS doesn’t have a better system for redeploying staff displaced by service changes, or any interest in aligning change to maximise redeployment opportunities,” says Restell. “Millions of pounds have been wasted on unnecessary redundancies and employing consultants. We need to make sure we don’t repeat the same mistake with STPs.” Negotiations have already begun and are expected to continue until June 2017. MiP will be fully involved in the discussions and will keep you informed every step of the way.

For a fuller analysis of the new redundancy proposals and what they mean for MiP members, visit the MiP website: bit.ly/hcm3201

MIP CONFERENCE 2016

At MiP’s 2016 conference on 23 November, delegates from across the UK gathered in London to debate, network with colleagues and hear from some of leading figures in today’s NHS. Here are some of the highlights from an inspiring and productive day. Conference reporters: Alison Moore and Craig Ryan.

“Let’s reset the rhetoric about NHS managers”

n his first public speech as health minister Philip Dunne promised to “reset” the political rhetoric about NHS managers, improve workplace culture and tackle bullying in the NHS.

Dunne said he recognised there was a stigma attached to NHS management, which was too often seen as “the dark side” by clinicians. “I think we do need to reset the dialogue a bit here, reset the rhetoric,” he told delegates. “I don’t personally subscribe to the view that a manager is bad and a doctor is good.” Dunne said it was “bizarre” that the NHS recruited so few graduate trainees. “We need to act now to improve the pipeline of leadership talent and support leaders if we are to protect health and social care for the future. I see this as a key priority for my time in the Department of Health.”

He warned that bullying was a shared, complex and pressing problem which impacted directly on patient care. “That’s why I think it’s so important and why it’s such a priority for me. It’s essential to tackle not only the pathology of bullying itself but also how organisations might create the positive cultures within which bullying no longer happens.” Dunne also promised “to apply some pressure” to ensure mental health services were given “parity of esteem” in the NHS. “I think it’s right that we’re held to account for our rhetoric on this – it’s been a clear commitment of the new prime minister,” he said. conference photographs © Stefano Cagnoni

healthcare manager | issue 32 | winter 2016

MIP CONFERENCE 2016

“The NHS depends on managers like Sandie”

iP chief executive Jon Restell told delegates the very survival of the NHS depended on managers working under intense pressure and “walking a tightrope between compassion and resources”. Restell spoke about a day he spent with MiP member Sandie Belcher, acute care co-ordination centre manager at South West London and St George’s Mental Health Trust. “That day I spent at Springfield Hospital won’t leave me in a hurry,” he said. “It affected me deeply… Acute psychiatric healthcare gives you life at its most raw, saddest, and most uplifting.” Restell described how Sandie and her team worked under intense pressure to manage emergency admissions across five London boroughs. “I can only describe what I felt as pride and awe,” he said. “And I remember wondering if I could even start to do this job.” Restell warned NHS leaders not to repeat the mistakes of the Lansley reforms during the next round of upheavals triggered by STPs. “People like Sandie will lose their jobs. The NHS will lose their skills, and will need to re-hire and plug the gaps at huge cost. And people like Sandie will lose their focus on the job in hand,” he said. He also called on employers to consider what they could do for managers like Sandie: “Give her a do-able job, train her, listen to her, reward her fairly, and treat her with compassion and justice.”

healthcare manager | issue 32 | winter 2016

our workforce experts discussed the challenges facing the NHS – including bullying, employment rights and pay – and how we can make the NHS a better place to work. Dr Madeline Carter (pictured, centre) of Newcastle University explained that it was important to tackling bullying as an issue of organisational culture rather than individual actions. “Managers shape culture. They are really critical,” she said. Effective organisations had top management who “walked the walk” and engaged with staff. She suggested job descriptions should include reference to managers’ role in creating a better workplace culture. Victoria Phillips (second left) head of employment rights at Thompsons Solicitors, said Brexit was a looming challenge which could sweep away many employment rights, such as limits on working time and protection for workers transferred under the TUPE regulations. The question for the government was to decide “which of these rights they care most about to find Parliamentary time to protect”, she said. “It’s very important for managers to start that dialogue with trade unions and get their collective view on how some of these issues will be resolved.” Jon Skewes (second right) policy director at the Royal College of Midwives, said the most pressing problem was the

level of funding for health and social care which meant finance was “crushing everything” at the moment. Skewes explained that unions were calling for the NHS Pay Review Body to award rises 1% above inflation, rather than 1% in total. But pay was not the only issue. “We know midwives and many other groups are suffering intensification of work,” he said, and employers were less willing to consider flexible working arrangements. Sheree Axon (right) director of organisational change at NHS England, said 400 staff had been through one of its support programmes for women managers. A thriving women’s network, backed by trade unions, was supporting women with professional and personal development in an increasingly fragmented system. “We all have a contribution to make. We have a fantastic voice and we don’t want to be overlooked,” she said.

“Managers need to be brilliant”

atthew Swindells, national director for operations and information at NHS England, told conference that NHS managers need to

MIP CONFERENCE 2016

“Empower everybody”

iP brought together NHS leaders from Wales, Scotland and England to discuss the opportunities and threats from the devolution of NHS services. NHS Wales chief executive Andrew Goodall (pictured, left) said the 2009 reconfiguration of services in Wales had brought greater accountability and a very strong ethos of partnership working. The small size of Wales – with just 10 chief executives – “gives us an opportunity to have action and momentum,” he said. But there was also a lot of public scrutiny which could translate into a very visible focus on managers’ actions, he added. Malcolm Summers (centre) head of staff governance at NHS Scotland, said reforms in Scotland would involve the majority of care being provided locally, with centres of excellence for complex care. “There is a focus on safe staffing and

putting that on a statutory basis,” he said. Summers saw working with trade unions in partnership as the way forward for NHS Scotland, with each health board having an employee director on the board. “It’s about recognising that we are all under pressure but there is a lot that we can do collectively,” he said. NHS Confederation chair and former health secretary Stephen Dorrell (right) argued that devolution in England was not primarily driven by the need to reorganise NHS services. The NHS needed to “come down off the hill”, he said, and see itself as part of the patchwork of public services serving communities. NHS leaders must now move beyond rhetoric about integrating services and “challenge ourselves on how we can make it real,” he said. “Why is it that we still think there is something different between primary and community health services? If we can’t join those up, then we really are lost.”

endy Hick, head teacher at Cranmer Primary School in Mitcham, south London, gave an inspiring talk to delegates about how real staff engagement and a positive, reflective approach can turn struggling organisations around surprisingly quickly. Hick helped her previous school, Manorfield Primary in Tower Hamlets, escape from special measures and achieve an “outstanding” rating from Ofsted in less than eighteen months. “Normally, people go in and take a troubleshooting approach, they look to get a quick fix,” Hick told delegates. “I took a very different and more considered approach. I thought what am I going to do to raise the morale of the staff at this school?” “Our main focus was not to look at what was going wrong, but first to look at what was going right,” she explained. “I think that was the crux that really changed their perception of me as a leader, and of the approach that I was going to take. I could immediately see it from their body language. “It’s fair to say Ofsted and the local authority were surprised by my approach,” she recalled. “But when they started to see the impact it was having – and quite quickly – they turned their views around. And they’re now starting to use that approach in a lot of other schools.”

be “strong, resilient and brilliant” to meet the challenges posed by the Five Year Forward View and the integration of health and social care. He said the NHS had made “spectacular progress” since the 1980s, when people had had to wait 12 to 24 hours in A&E and up to two years for a nonurgent operation. While the NHS was doing “fantastic work every day”, he acknowledged life for managers was particular tough at the moment.

STPs had brought people from health social care together, often for the first time, he said. But such partnership working required “egos to be checked in at the door” and more open engagement with patients and staff. “We need to move from senior management doing this to engaging the public. We need to widen it to a conversation with the people who are doing the work. And we need to widen it to a conversation with the voluntary sector.”

He warned the next stage would be tough, “with more noise around STPs and more difficult conversations”. Swindells played down the significance of competition in the future development of the NHS. “I don’t think incentivising hospitals to admit more people through A&E is the brightest thing to do now. “We are not expecting [Payment by Results] to be a significant part of how we plan the next two years contracting.”

healthcare manager | issue 32 | winter 2016

INTERVIEW: SIR ROBERT NAYLOR

The doyen of NHS management, UCLH’s Sir Robert Naylor, talks to Alison Moore about his 45-year NHS career, the prospects for aspiring leaders, and how he still hopes to have a hand in the NHS’s future.

Few NHS leaders can offer as wide a range of perspectives on NHS management as Sir Robert Naylor. In over 30 years as a chief executive – the last 16 at University College London Hospitals Foundation Trust (UCLH) – he has seen more than a dozen health secretaries come and go, the ebb and flow of good times and austerity, and both centralisation and decentralisation fall in and out of fashion. Now in his mid-sixties and just a month after stepping down from running UCLH, he’s thinking about what he can do over the next 15 years. And the answer seems to be anything but retirement. His current project with NHS Estates involves identifying property that can be sold off to raise £2bn for reinvestment in services and provide 26,000 new homes. The review is national but strongly focused on London, which accounts for 60% of the value of property under review. This also involves looking at ways to make progress on a number of high-profile London developments which he says have become “stuck in the system”. Naylor is also involved in a number of overseas enterprises. “The challenges in 12

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“I don’t think people really understand how lonely the role of the chief executive is... you don’t have a peer group of people you can talk through your problems with and you can’t pass them on to the chief executive.”

healthcare are pretty much the same around the world,” he says. “The answers are fairly common, but people have different nuances… Certainly, in relation to the management of hospitals, the answers are pretty much the same.” For example, there is a huge gap in professional training and development in healthcare in the Middle East, he explains, in part because many doctors working there were trained abroad. Naylor helped set up one company that offers continuing professional development (CPD) by flying in eminent British doctors to hold masterclasses in the Middle East. A radiology company – set up while he was at UCLH – is about to be sold, reaping a windfall profit for the trust. Following in the footsteps of his father and uncle, Naylor joined the NHS as a graduate trainee but could easily, he says, have ended up working in a different sector. “I applied for a number of graduate programmes and the NHS came up first!” Training in those days was more like an apprenticeship, he explains, with a mix of education and time spent on the “shop floor” – often in quite menial jobs. This was an advantage in his later career, as no one could claim “you don’t know what these jobs are like”.

NIKLAS HALLE’N

INTERVIEW: SIR ROBERT NAYLOR

One example was working as a nursing auxiliary on an elderly care ward, looking after dementia patients. “They are very challenging jobs. You don’t appreciate that until you’ve done it,” he says. “I’ve always had an affinity for the porters and the domestics because I know how hard their jobs are.” He adds that this experience taught him that a trust chief executive has to “represent the interests of the people who work there”. Naylor has a reputation for speaking truth to power – something which doesn’t always guarantee a long career as a chief executive. He admits he has been lucky not to be as dependent on his NHS job as many others: property investments have given him an alternative income stream. “Some people have commented that my job was easier because I had other sources of income. I agree that I could be more outspoken in my views because my children’s education and mortgage payments were not always on the line. It does help if you have a degree of financial security,” he says.

“It helps you to make the right decision rather than one that may be popular or expedient. So, often it’s easy to compromise because a difficult decision is more likely to cost you.” Naylor believes many chief executives struggle with feeling isolated, especially early in their jobs. “I don’t think people really understand how lonely the role of the chief executive is,” he says. “Before you become the chief executive you always have a peer group of people you can test out and talk through your problems with, and if it’s a difficult problem you can pass it on to the chief executive.” Unlike running a supermarket or a bank, which is “pretty one-dimensional”, he says, running a hospital is multidimensional, requiring chief executives, “at the political heart of the NHS”, to balance many competing – and sometimes conflicting – priorities. “You have to be seen to have honesty and integrity and to be fair and balanced; that way you naturally achieve followership,” he explains. “You can

often avoid failure by getting the people who work for you to collectively own the decision. You have to develop particular skills to manage the business. Within the highly political environment of the NHS, every mistake you make is open to public scrutiny and the media.” He warns that the NHS’s failure to pay its leaders “anything like” as well as the private sector, and the lack of investment in leaders generally, mean the NHS doesn’t get as many good leaders as it needs. “We need chief executives who are better remunerated than the current position otherwise clinicians won’t take these roles,” he says. “I often say you only have to manage the money, the people and the quality – but effectively that’s everything.” Naylor’s approach has been to get the “frontline” involved – particularly doctors. “The one thing I did at UCLH of overriding importance was getting the staff engaged in understanding the decision-making of the trust, in particular by identifying the leaders of various healthcare manager | issue 32 | winter 2016

INTERVIEW: SIR ROBERT NAYLOR

groups of staff,” he explains. This included asking doctors to nominate candidates for clinical and medical director posts. Growing your leaders in this way is worthwhile but not a quick fix, he says: “It takes you five years to identify the right people and train and develop them to become effective.” What is his message to the would-be leaders of today? “I would advise them to put a lot of time into networking, particularly with their peers both in and out of the NHS. One thing you can be sure of in these jobs is that you are going to be challenged and it could lead to your demise as a chief executive. On those occasions you need to rely on the investment you have put in with these people. “I can think of a number of chief executives who, if they had invested more time in networking, might have had a second chance,” he adds. He cites his own experience at UCLH as proof of this. When the wonderful but very pricey new hospital was opening, a sudden bill for £40m materialised, leaving the trust’s financial position looking bleak. “I can think of many organisations where either the chief executive or the chair would have been sacked. But because of our reputation people had confidence in us, that we could sort it – which we did,” he says. He also cites particular concerns about bullying and harassment, which seem to be on the rise in the NHS. He argues it’s important to distinguish between justifiable pressures to raise standards and pressuring people in a discriminatory and personal way. “I find it one of the most difficult areas. There is a fine line between aspiring and achieving, targets and objectives, and bullying and harassment. You often find that organisations criticised for this are those with the best results,” he says. Many of these organisations are in urban areas, where life is particularly stressful and health services are under particular strain, he says. “The higher the standard you aspire to, the more likely it is that people feel under pressure which may feel like they are being bullied and 14

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harassed.” Despite these stresses and strains, Naylor remains an ardent supporter of the NHS model. “I’m more convinced than ever before that the NHS is the best healthcare system. In terms of what you get for your investment, it’s better than anywhere else in the world,” he says. He challenges the doomsayers who claim the NHS is in a worse state than ever before, pointing out that when he started at UCLH, it was operating out of crumbling hospitals with three-year waits for cardiac surgery. That position has changed, both at UCLH and around the country. “But the expectations of the public have increased exponentially,” he warns. “People complain when they have to wait 18 weeks. Less than 16 years ago, they were waiting three years for outpatient appointments.”

“It’s obvious that the amount of money we spend on healthcare is significantly less than the European average. If we want to maintain our position in the world rankings we need to invest more money.” But that does not mean he’s blind to the problems with the system today, or uncritical of what is happening. “I think all parties have to be honest about what can be delivered with the money that is voted for by Parliament,” he says. “It’s obvious that the amount of money we spend on healthcare is significantly less than the European average. If we want to maintain our position in the world rankings, we need to invest more money. The NHS needs money, but equally I think the NHS can become much more efficient.” Opportunities to improve the model have been missed, he believes. He points out that, during the mid-Blair years, extra money ended up being spent on salaries rather than reform. And he regrets that foundation trusts, which

he played a role in establishing, have lost their freedoms even over assets and capital. He has repeatedly said that if 10% of hospitals are in deficit, the problem is likely to be with the trusts, but if 90% are in deficit, the problem probably lies with the system. “The trouble is, if you bail out hospitals when they overspend, it’s going to encourage them to overspend even more,” he warns. Ultimately, the government will have to write off some of the debts, he says, even if that makes some trusts which stay within budget feel disgruntled. He suggests the NHS should be moving towards accountable care organisations (ACOs), combining hospitals and primary care in one organisation. And trusts need to be incentivised to deliver the Five Year Forward View, he says. “We might end up with 100 ACOs that replace trusts… it would incentivise hospitals because they would be responsible for the whole patient pathway. So it would make sense to sell a building to invest in primary care. But sometimes the most challenging issues are cultural and it takes five years to change that in a meaningful way.” Although Naylor’s decision to leave UCLH was announced last autumn and he was expected to step down earlier this year, he remained in post until the appointment of new chief executive Professor Marcel Levi. “It’s a natural time to move on,” he says. “From when I left school, it took me 15 years to become a chief executive. I was in Birmingham for 15 years as a chief executive and then 15 years at UCLH. I thought, I’ve got 15 years left in me to hopefully make a difference in a non-executive career. “If I had my time over again I would definitely do the same. It has been an enormous privilege – I have no regrets. Healthcare is such a rewarding environment to work in – rewarding for a number of reasons, but in particular because the vast majority of people you work with are highly dedicated and really want to get up in the morning and make a difference.”

SUSTAINABILITY AND TRANSFORMATION PLANS

Sustainability and Transformation Plans may save the NHS or drag it further into the mire. Yet staff and patients have been shut out of the conversation so far. Craig Ryan takes a first look at what STPs might mean for managers working for the NHS.

TPs are the flipside of the Five Year Forward View. The 5YFV’s broad vision for the NHS was breezily optimistic, but STPs are – or will be – all about the grinding detail of realising it. In these 44 hastily cobbled-together “footprints” the stark reality of what £22bn in efficiency savings really means for the NHS will play itself out. As the King’s Fund recently observed, STPs started out as being all about new care models, integration and public health but “the emphasis from national NHS bodies has shifted over time to focus more heavily on how STPs can bring the NHS into financial balance (quickly).” Most STPs have now found their way into the public domain one way or another. But it’s as clear as mud what they mean for people working for the NHS. Most of the STPs I’ve read have little to say about the impact on the NHS workforce, and engagement with staff and their trade unions – as with patients and the public – seems to have been minimal at best. “You’re looking at extremely superficial, strategic and high-level stuff at the moment, there’s no nitty-gritty about what it’s going to mean for the people

of this area and staff who work for the NHS,” says Steve Smith, MiP’s national officer for the South Central region. He says discussions at regional level

on the STPs in Berkshire, Oxfordshire and Buckinghamshire (known as “BOB”)

and Solent have not got beyond talking about eye-watering deficits and “high level aspirations” like giving pharmacists the power to dispense. “Obviously, there must be discussions going on about what that means for staffing levels, service changes and hospital closures, but they’ve not been shared with either the staff representatives or the public,” says Smith. A similar story emerges almost everywhere – with the shining exception of Suffolk and North East Essex, a relatively small STP centred on Ipswich and Colchester. Here, following talks with unions, Ed Garrett, chief executive of two of the three CCGs within the footprint, has gave an undertaking to staff that there will be no compulsory redundancies as a result of the STP. “This should be seen as a standard setter,” says George Shepherd, MiP national officer for the East of England, who played a leading role in the talks. Garrett’s promise is rooted in a history of constructive engagement in Suffolk, Shepherd explains. “The partnership agreement we signed two years ago means we’ve built a very strong relationship with the CCGs, and this assurance comes from the involvement of the staff side at an early healthcare manager | issue 32 | winter 2016

SUSTAINABILITY AND TRANSFORMATION PLANS

“You’re looking at extremely superficial, strategic and high-level stuff at the moment, there’s no nittygritty about what it’s going mean for people.” MiP national officer Steve Smith talking STPs at the South Central Social Partnership Forum

stage in the STP process.” MiP chief executive Jon Restell explains that employers only have a legal duty to look for suitable alternative employment – as an alternative to redundancy – within the same organisation, even when job losses are a result of a multi-employer STP process. “If people fall out of the tree, we need some sort of outside-the-employer intervention to match them up with suitable jobs elsewhere within the STP footprint or even the wider region,” he says. Shepherd has called on employers to put a block on external recruitment and “ring fence” new jobs to maximise redeployment opportunities for existing staff across the region. “If there are jobs available and there are people at risk of redundancy, they should be given the first chance to apply for them,” he explains. “That seems a common sense approach, even if they’re in a different STP. HR leads at regional level need to be talking to each other about this.” Finding alternative jobs is particularly tough for very senior managers, says Corrado Valle, MiP national officer for the North West. In Central Manchester, three CCGs are being merged into a single commissioning body, potentially displacing several executive directors. “Quite simply, the higher up the management chain you are, the harder it is to be redeployed,” he explains. Across the North West, details remain sketchy, but the direction of travel is clear, says Valle. “Back-office mergers, reducing duplication to zero – the name 16

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of the game is to save as much money as possible.” Cheshire and Merseyside STP is typical, with plans to merge procurement, recruitment, occupational health and training. “This is happening across CCGs but providers are starting to have similar conversations,” he adds. NHS England and NHS Improvement have put great pressure on CCGs and providers to merge back office services. At the end of November, four STPs – North West London, Kent, Essex and Greater Manchester were chosen as “pathfinder” STPs – charged with developing blueprints for other STPs to follow. All four had included back office mergers in their STP submissions, but only Essex quantified the savings it expects to make – £10.5m a year, but only if upfront capital funding is available. Specific plans for merging clinical services – and especially for closing hospitals – were largely kept out of the initial plans submitted to NHS England in October. Health minister Philip Dunne told MiP’s conference in November to expect

“significant political resistance” to the next phase of STPs as the pattern of reconfigurations becomes clear. “I understand why the powers that be are anxious to avoid those conversations, because that’s when communities get defensive,” says Smith. “At the moment, it’s all just tootling along under the surface like a torpedo and most people just don’t know anything about it.” We do know that one of the five big acute hospitals in South West London will close. With St George’s deemed safe, the fate of the hospitals in Croydon, Epsom, St Helier and Kingston hangs in the balance. Jo Spear, MiP national officer for the South East, says it’s very hard to see redundancies being avoided in the bigger London STPs, but no one knows where the axe will fall. “There is movement but it’s very slow. And it’s very slow because NHS England put the kibosh on anything that looks like detail,” she says. “Sutton Council published the STP against NHS England advice, raising

“Movement is very slow because NHS England put the kibosh on anything that looks like detail... Most of the information is coming from councils, not from the NHS. That speaks volumes, doesn’t it?” MiP national officer Jo Spear

SUSTAINABILITY AND TRANSFORMATION PLANS

concerns about its content and the way it’s being conducted,” she adds. “Most of the information has been coming from councils, not NHS organisations. That speaks volumes, doesn’t it?” In this game of musical chairs, when the music stops even those managers who are sitting down may find themselves in different seats with a different employer’s name on their payslip. And finding a suitable perch will be made even more difficult by the lack of a national or even regional framework for redeploying people or moving them between the NHS and local government. “Organisations’ practice in grading jobs under AfC varies enormously,” Restell explains. “We’re finding new jobs are being graded poorly, and new structures are being presented without job descriptions or grades. People are asked to make decisions about moving with very little information. And this is going to be happening all over the country at the same time.” Shepherd says STPs require a common approach to job evaluation and consistency checking. “Even if there’s no redundancies, they’ve still got to make savings and we’ve seen jobs being downgraded even when the core goals and responsibilities are the same.” With the integration of health and social care, Spear warns that STPs risk repeating the chaotic transfer of public health staff to local authorities seen during the Lansley reforms. “NHS England has been talking about memorandums of understanding on staff being transferred,” she says. “But everyone forgets and people just end up on the terms and conditions of whatever organisation they get put into. “The MoUs for public health staff were largely set aside,” she says. “The workforce lead for one of my public health areas said she’d never heard of it, she’d never seen it, we didn’t sign it, so it doesn’t apply to us. But it does apply to them. The process was supposed to be overseen by Public Health England, but that didn’t happen in practice.” “The assurances people are given aren’t worth the paper they’re normally not written on,” adds Restell. “People are promised, if they take a temp job,

“They may be lean and efficient organisations, but how manageable will managers’ workloads be? If they’re enormous, you tend to end up far removed from what’s happening on the ground.” MiP national officer Corrado Valle

they’ll still be able to apply for the substantive post. Then things change and they’re told, ‘Actually we can’t do that anymore – sorry.’ People have taken one for the team without realising it.” Of course, patient care will inevitably suffer as skilled and experienced managers leave and those that remain lose their focus on the job in hand. “Even people who understand what’s going on are overwhelmed by the speed of the change,” says Spear. “And the concern I’ve got is that we will lose organisational memory and the ability to handle skilfully these and future changes.” Valle warns that bigger organisations, thinly staffed with managers, may become more remote from frontline services – the opposite of the government’s intentions. “On the one hand they may be lean and efficient organisations, but on the other, how manageable will managers’ workloads be? If they’re enormous, you tend to end up far removed from what’s happening on the ground.” He says the “the vast majority” of managers he speaks to “see the logic of

trying to unify the system and address the particular needs of the communities they serve. Potentially, the single hospital in Manchester will be a good thing. But the implementation is chaotic and piecemeal, and being done without realising what happens in one area has an effect on another.” It’s often claimed that STPs have brought people together across health and social care who have never met before. But, ironically, the 44 STPs themselves seem to have retreated into silos, with little sign of regional or national coordination – over redeployment or anything else. The King’s Fund sees STPs as “a complex workaround” addressing the fragmented post-Lansley structures of the NHS “which pull the system away from collaboration”. It has called for a national “45th STP” to set out how STPs “will work together to provide a consistent and clear approach to supporting improvements in local areas”. “It’s a bit like the first inception of CCGs,” says Valle. “Because they were a legal entity in their own right, they decided they didn’t need to talk to their neighbours. They commissioned completely different stuff even though they were next door to each other.” MiP has joined other health unions, led by UNISON, in calling for a slowdown in the pace of change to allow for proper consultation with patients and staff. Writing to NHS chief executive Simon Stevens, UNISON head of health Christine McAnea proposed a “national compact”, to be mirrored at regional and local level, on the workforce consequences of STPs – including how redundancies and redeployments will be handled. This can’t come soon enough. The two groups most affected by STPs – patients and staff – have thus far been locked out of the process. Secrecy and lack of consultation can only provoke opposition to what may be perfectly desirable and sensible changes. “It’s like the Lansley reforms all over again,” says Shepherd. “They weren’t engaging with patients, they weren’t engaging with staff, and lots of big mistakes were made as a result.”

healthcare manager | issue 32 | winter 2016

MANAGING BETTER CARE: RECRUITMENT

With NHS pay frozen, it’s becoming ever harder to recruit nurses and midwives in the capital. But at UCLH, managers have transformed the trust’s recruitment operation – and cut the vacancy rate by more than half. Matt Ross reports.

Until recently, London’s most prestigious hospitals had escaped the worst of the nursing shortage. With fewer nurses being trained, the 1% cap on public sector pay rises and fast-rising transport and housing costs, there was fierce competition for staff in the capital. But teaching hospitals offering the 20% central London pay premium had still been able to recruit. Then things changed, and UCLH – a cluster of five hospitals around the Euston Road – felt the squeeze. “We’d enjoyed quite good times,” recalls Julie Hogg, the trust’s deputy chief nurse. “Then we got a little bit behind the game: we’d been living on our brand, and recruitment hadn’t had the energy and focus that it needed. Other organisations began attracting people who we might have brought in.” Staff shortages were “impacting on patient experience as well as staff experience,” Hogg adds. “If you haven’t got enough nurses, you can’t respond to patients’ needs as quickly as you’d like.” But, says Faith Thornhill, a senior nurse, RCN lead and chair of UCLH’s trade union committee, it was only when UCLH introduced an electronic rostering system that staff saw “the evidence that showed the level of vacancies across all staff groups. That was a massive shock.” In February 2015, UCLH’s vacancy rate 18

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The directors began gathering ideas from all sides – and taking them seriously. “They were very dynamic meetings; lots of ideas were thrown around, and all of them were discussed. Staff were listened to.” in nursing and midwifery reached 16%. “This situation couldn’t carry on,” Thornhill adds. Director of nursing Flo Panel-Coates and workforce director Ben Morrin, who’d both joined the trust the previous year, set up a taskforce – bringing together senior nurses and allied health professionals (AHPs), union reps, and staff from the HR, communications and education departments – and began redefining the challenge. This wasn’t just an HR problem. “Our key learning was bringing in medical and scientific leads, because they were the primary customers,” says Morrin. The two directors began gathering ideas from all sides – and taking them seriously. “They were very dynamic meetings; lots of ideas were thrown around, and all of them were discussed.

It was a very safe environment,” recalls Thornhill. “Staff were listened to. We weren’t just token union reps; we were integral to the work.” Soon, things were moving fast. Rather than recruiting staff as vacancies arose, the trust began using historical data to predict demand and build a pipeline of suitable candidates. It committed to paying all staff the London Living Wage, and is “working with contractors to encourage them to pay it too,” says Morrin. And it invested in a “careers clinic”, where staff interested in moving into different specialisms could access training and seek relevant jobs within UCLH. The clinic gave staff a way to develop their careers without leaving the trust, and provided a clearing house that hastened recruitment and strengthened nursing career paths. “Managers gained because they didn’t have to go through a full recruitment process; nurses gained because they could change career direction or experience a different specialism; and patients gained because we could keep valuable nurses in our teams,” explains Thornhill. Meanwhile, says Morrin, UCLH’s recruitment marketing was rebuilt around “a new communications platform, designed and led and facilitated by frontline clinical staff”. Working with an advertising agency, nurses created a poster campaign using photos of serving

MANAGING BETTER CARE: RECRUITMENT

“Everevious one.”

UCLH workforce directer Ben Morrin (third from left) with staff from the recruitment and nursing teams who worked on the trust’s recruitment initiative.

staff. The trust set up an enquiries system to put potential recruits in direct contact with existing staff who could help answer their questions: “People based in other parts of the world are matched up with staff from the same country or who’ve gone through the same journey,” says Morrin, “so you’re speaking to people like you.” The taskforce didn’t have to wait long to get results. Within a year UCLH had 551 more nurses and midwives on the payroll, and the overall vacancy rate had fallen to 6%. Meanwhile, the careers clinic produced a 127% increase in internal promotions and transfers and, along with the predictive recruitment strategy, cut hiring timescales by 25%. The resulting reduction in the use of agency staff has cut overall costs by more than £3m annually, says Morrin. Patients too are feeling the benefits. “We’re not struggling with low staffing levels, which can put standards of care at risk,” says Thornhill. “And bank and agency staff are excellent nurses, but with permanent staff we can maintain the continuity of care which supports high standards. They know the policies, the procedures and the patients.” The taskforce’s work was recognised when UCLH won the Recruitment and

Talent Management Award at this year’s CIPD People Management Awards, attracting interest from other trusts keen to learn from the project. This opportunity to spread the word has “been one of the most rewarding aspects,” says Morrin, adding that the lessons are being shared through the citywide partnership Capital Nurses. Morrin hopes to get the vacancy rate down to 5% – leaving enough wriggle room to bring in specialist staff when required – but he warns that the wider London jobs market for nurses and AHPs is becoming ever tighter. “Too little has been done to ensure that national supply is right,” he says. At national level, Hogg explains, “there’s a need for “proper workforce planning and making sure that we train enough nurses – particularly in the specialities where there are chronic shortages, like neo-natal nurses, sonographers”. The loss of bursaries for nursing training won’t help, she adds. Then there’s Brexit. “The future of good medical staff will rely on us getting the best from the global jobs market,” says Morrin, pointing out that 15% of UCLH staff were born in continental Europe. “Across the world, the best healthcare relies on globally diverse

professional groups, and the NHS will fall behind if it can’t rely on that. It’s important that we speak up for open labour supply. Immigration controls could affect us very significantly.” Asked about the lessons from UCLH’s recruitment work, Hogg replies: “Listen to the people who work in your organisation, and use the experience of your staff to improve development opportunities and campaigns. Our nurses, doctors and managers came together with real executive support. And you have to invest to save.” The project is set to yield £1.46 for every pound invested by the end of the financial year, Morrin adds. For Thornhill, a key lesson is that “if you work in partnership with the trade unions, you’ll gain the engagement of staff across the organisation – and once staff are engaged, you’re halfway to success. So work constructively with us, rather than seeing us as a challenge.” In the longer term, Morrin argues that trusts must begin working together on recruitment: “Collaboration is more important than competition – but we’re set up for competition.” He believes NHS organisations should use the opportunity presented by STPs to build “common campaigns, common recruitment. If we do that, everybody will win.” But nobody will win, he warns, unless the government makes the right decisions on medical training and immigration controls. “If higher education institutions aren’t given the right financial backing, and government doesn’t liberalise international supply… we’ll be in a more challenging rather than a less challenging position.” By bringing staff together and tapping into the expertise of medical leads, UCLH managers have tackled the immediate recruitment challenge – saving money and improving patient care. But the NHS’s ageing nursing workforce, inadequate national training provision and the looming cloud of Brexit “add up to difficult times ahead,” Hogg concludes. UCLH has done what it can to solve its problems; now the government must pick up the baton.

A consultant to MiP, Matt Ross is an editor, journalist and change manager. healthcare manager | issue 32 | winter 2016

PATIENT CONSENT

legaleye Linda Millband runs through what managers need to know about new rules on patient consent. ‘Informed consent’ must be given before a medical professional can perform any treatment or procedure on a patient. For consent to be valid, it must be both voluntary and informed – the patient’s decision cannot be influenced by anyone else and they must have full details of the risks of treatment and any possible alternatives. A doctor must also determine whether the patient has the capacity to make this decision by themselves. The process wasn’t always like this. Previously, under the Bolam test, which relied on doctor’s “duty of care” towards the patient, there could only be a finding of negligence if there was no respectable body of medical opinion which supported the doctor’s actions. In the case of Chester v Afshar, the courts prioritised the need for a doctor to inform the patient of risks arising from surgical procedure, superseding the process of only having to show that their conduct would have caused the patient harm. Mrs Chester’s disc protrusion surgery carried a 1-2% risk that the procedure could worsen her condition. The court ruled that, since she had not been informed of this in advance, the doctor had breached the duty to obtain valid consent for the procedure. The Supreme Court’s 2015 ruling on Montgomery vs Lanarkshire Health Board made futher changes necessary. Doctors must now ensure that patients are aware of any “material risks” involved in a proposed treatment, and of reasonable alternatives. Material risks occur when a “reasonable person” in 20

healthcare manager | issue 32 | winter 2016

the patient’s position would find the risks to be important in their decision – in this case, the risk of injury to either the mother or baby of a vaginal delivery birth. Nadine Montgomery experienced complications during delivery which meant her son was born with cerebral palsy. Ms Montgomery believed her doctor, Dr McLellan, had not disclosed the risks of shoulder dystocia, a form of obstructed labour, or discussed the possibility of an elective caesarean. If he had, Ms Montgomery said she would have elected to have a caesarean which would have reduced the chance of her baby being born with cerebral palsy. As a result of the ruling, doctors, and other healthcare professionals, are now under a clear duty to take reasonable care to ensure that patients are aware of all material risks. The Royal College of Surgeons (RCS) has published new guidance on consent following the court’s ruling. The key principles are as follows: ■■ The aim of the consent discussion is to give the patient the information they need to decide what treatment or procedure (if any) they want. ■■ The discussion has to be tailored to the individual patient, and requires time to get to know them well enough to understand their views and values. ■■ All reasonable treatment options, along with their implications, should be explained. ■■ Material risks for each option should be discussed with the patient. A risk is “material” if a patient could reasonably be

expected to find the risk significant in their particular case. ■■ Consent should be written, recorded on the form and signed. ■■ A record of the discussion should be included in the patient’s case notes. This is important even if the patient chooses not to undergo treatment. From a legal perspective, it is vital that healthcare professionals understand how to conduct such discussions. Not having written proof of consent weakens the doctor-patient relationship and leaves professionals and managers open to legal challenges and litigation. Patient consent must be underpinned by three key factors. First, a clinician must decide that the patient has the capacity to make a decision about their care. This means complying with the Mental Capacity Act 2005 (England or Wales), the Adults with Incapacity Act 2000 (Scotland), or the Mental Capacity Bill 2015 (Northern Ireland). Second, consent must be given voluntarily, without influence from anyone else. Third, the patient must be made aware of all key information to infom their decision. Managers should ensure these guidelines are followed to significantly reduce the chance of any legal repercussions from treatment given to a patient.

Linda Millband is national practice lead for clinical negligence at Thompsons Solicitors. Legaleye does not offer legal advice on individual cases. MiP members in need of personal advice should immediately contact their MiP rep.

TIPSTER

How to run a proper investigation Have you been asked to investigate a colleague’s conduct or performance? MiP national officer Andy Hardy sees NHS investigators make the same mistakes over and over again. Here’s his tips for avoiding costly and career-damaging pitfalls. 1 WHY ME?

7 CONSIDER ALTERNATIVES TO SUSPENSION

Many people don’t realise how pressurised, difficult and time consuming investigations can be. Consider carefully whether you’re right for the job. Are you impartial? Do you have any prior involvement? Do you have the experience? Are you senior enough? What support will you get from HR? Consider the impact on your day job – investigations can drag on for months or even years, especially if you end up in front of an Employment Tribunal or the GMC. Are you prepared for that?

Employers often suspend senior managers as a panic response to any accusations. Although it’s supposed to be neutral, suspension invariably feels punitive to the person suspended, and makes it almost impossible for a senior manager to return to work even if they are subsequently exonerated. So it’s in both their and the organisation’s interests to use it only as a last resort. Think about redeployment to another post or site instead.

2 TERMS OF REFERENCE

8 PREPARE FOR A GRILLING

Make sure you get rock solid terms of reference. It needs to be crystal clear what’s being investigated, who’s involved and how the investigation will be conducted. If the terms of reference are vague or inaccurate, insist on rewriting them yourself or seek advice on doing so. It’s better to walk away than risk your professional reputation running what will inevitably be a sub-standard investigation.

The employee’s trade union rep will press you hard on both the evidence and the way you conduct your investigation. Remember, this is never personal – they would do the same on your behalf if the boot was on the other foot. Prepare to be grilled very hard by a barrister if you go before a tribunal or the GMC. And if you’re criticised in the ruling, it could be on the web for ever and a day.

3 BE NEUTRAL AND IMPARTIAL Don’t confuse your role with that of the disciplining officer. You’re not there to prove the employer’s case, but to make a neutral and impartial assessment of the facts. Remember, the accused person’s union reps and/or lawyers will try to undermine your credibility as an investigator, so don’t make it easy for them!

4 CHECK THE BASICS Verify all the basic facts about the case. For example, if someone is accused of not doing part of their job, check their job description to see if they’re really responsible for doing it. Make sure you have accurate contact details for everyone involved. I’ve seen a number of investigations and investigators derailed

because confidential details were sent to the wrong person.

5 DON’T TAKE THINGS AT FACE VALUE Is the evidence credible? Is there any substance to the allegations? Check the records – is there evidence of a pattern of behaviour? And don’t ask leading questions. I once defended a member falsely accused of sleeping on shift. Instead of asking if anyone had actually seen the member sleeping, the investigator asked witnesses if they were aware he was sleeping. That will get you a hammering from any trade union official or barrister worth their salt.

6 DON’T GO FISHING Your job is not to dig up dirt, or show that the person under investigation is a bad employee. Stick to the specific allegations in your terms of reference; you have to show evidence of solid reasons for any deviation from them. Remember, you cannot make a smoking gun – if the evidence isn’t there, there’s no case to answer.

9 KEEP IN TOUCH Employers have a duty of care towards people being investigated. There’s nothing worse than sitting at home for months on end, not knowing what’s going on. Make sure someone from management is contacting them at least once every two weeks, keep everyone informed on progress and stay in regular touch with the union rep dealing with the case – they want a fair investigation too!

10 THINK ABOUT THE END FROM THE START However straightforward the case seems, you could still end up before a tribunal. So, keep asking yourself, “could I justify this to a tribunal judge?” A badly handled investigation could seriously damage the organisation – and your career too. healthcare manager | issue 32 | winter 2016

BULLYING

Unions and employers pledge to build better workplace culture The social partners are launching a joint initiative to tackle the scourge of bullying in the NHS. The NHS Staff Survey regularly finds that around a quarter of NHS staff feel they have been bullied within the last year. At MiP conference in November, 32% of delegates said they had experienced bullying by managers or colleagues, while 12% said they had been accused of bullying. It’s clear that this is as much of an issue for managers as for anyone else in the NHS. The Social Partnership Forum (SPF), which brings together employers, unions and ministers at national level in England, has agreed a collective call to action on bullying. It sets out what NHS organisations should do to tackle workplace bullying when it occurs, and to develop the supportive workplace culture where bullying and harassment don’t take place. This includes “developing positive cultures, led from the top”, building “skills and management styles to tackle bullying” and making sure “managers have time to manage”. It also sets out a range of evidencebased actions that have been proven to reduce bullying. The SPF aims to achieve a “measurable change” in the national statistics on bullying by 2020. Madeline Carter of Newcastle University (left), who is working with the SPF on the anti-bullying initiative, told delegates at MiP’s conference in November that it was vital that bullying was seen as an organisational issue rather than

healthcare manager | issue 32 | winter 2016

How effective organisations tackled workplace bullying Effective Organisations

Ineffective Organisations

Recognised bullying is organisational issue; owned problem

Saw bullying as conflict between individuals; a personality clash

Proactively analysed data

Lack of measurement and collation/ monitoring of data

Anticipated negative behaviours but dealt with them quickly and informally

Only aware of formal grievances

Equipped managers with skills needed to effectively manage conflict (especially if new to the grade)

Managers lacked skills and willingness to deal with problems

Recognised strong business case for addressing bullying (turnover, absence, etc)

Business case not made; metrics not available/collated

Top management ‘walked the walk’ – acting as role-models for positive behaviours and challenging inappropriate ones

Senior managers avoided tackling, covered up or excused bullying

Senior leaders engaged with staff – aware of issues early and proactively resolved

Senior leaders not visible to staff

Source: Rayner C, McIvor K. Research report on the dignity at work project for Amicus/DTI 2008.

one of individual behaviour. “Managers shape culture, they are really critical,” and effective organisations had top management who “walked the walk” and engaged with staff, she said. She suggested job descriptions should define managers’ responsibilities for creating a supportive culture within organisations (see table above). MiP chief executive Jon Restell, who co-chairs the SPF group working on the

initiative, said: “Bullying harms patient care, so tackling it is core to the work of the NHS. We’re asking employers, unions and system bodies to talk to each other about creating good workplaces and tackling bad behaviour. With intense pressure on staff and resources we must be vigilant about our values.” Tackling Bullying: a collective call to action will be published in December and will be available from the MiP website: miphealth.org.uk

MIP AT WORK

MIP CASEWORK

Get the pension you’ve worked for You plan your future around your pension, so mistakes can really throw a spanner in the works. Craig Ryan spoke to one MiP member about how the union helped rescue his retirement plans. Pensions are hard. In the NHS, with several different schemes and many arcane rules, even the supposed experts can get it wrong. When they do, your union can help you to navigate the system and get the pension you’re entitled to. In 2012, Paul (not his real name) decided to take redundancy from a PCT that was being wound down as part of the Lansley reforms. As a former mental health nurse, he had “special class status”, which meant he had the option to take his full pension at age 55 instead of the usual 60. “I was 51, so I decided to take my chances of finding a job somewhere else to fill the gap until I could get my hands on my pension,” Paul explains. “So you can imagine, I went to great lengths to establish with the NHS Pensions Agency the impact of accepting a redundancy package on my special class status and my ability to take my pension unreduced at age 55.” But getting a straight answer proved tough. It took several months, and even an exchange of letters between the chief executives of Paul’s PCT cluster and the Pensions Agency, before his position was confirmed in writing: provided he didn’t rejoin the NHS pension scheme, Paul’s right to retire at 55 wouldn’t be affected if he took redundancy. After leaving the PCT, Paul took an interim job before moving south to work in London. “I planned my whole life, including my family’s, around the fact that I was going to retire at 55, even to the extent that we lived in the North West and we sold up and moved down to the south coast,” says Paul. “So we made lots of decisions based on all this advice from the pensions agency.” But when he moved to another trust

“Without the union’s help I would probably still be waiting for a hearing with the pensions ombudsman, which can take years and years.” six months later, Paul got a nasty shock. His new payroll department discovered that the Pensions Agency had removed his special class status and increased his pension age to 60. Paul recalls: “I then spent a couple of months to-ing and fro-ing with the Pensions Agency, and they wrote to me saying ‘the advice we issued in 2012 was erroneous. We apologise, but your normal pension age is 60’.” Paul contacted MiP national officer Jo Spear, who drafted in UNISON’s national pensions officer, Alan Fox, to help Paul with the first stage of the Pension Agency’s two-stage dispute resolution

process. This proved unsuccessful. “The outcome was basically, it’s tough, we apologise, but it is what it is,” says Paul. “At the first stage, I completed all the paperwork myself, with some help from Alan, but basically I got on with it,” Paul explains. “At the second stage, Alan completed all the documentation and got the union’s solicitors, Thompsons, involved.” This time the Pensions Agency found in Paul’s favour. “Basically, they’ve put me back to the position I thought I was in in 2012, which means I’ve been able to apply for my pension and take up a part-time role,” says Paul. If the decision hadn’t been reversed, Paul would have had to work five years longer than planned and would have missed pension contributions for the years he had opted out of the scheme – on the agency’s own advice. “Naturally we’re delighted for Paul as this outcome really does make a significant financial and work/life balance difference for him,” says Alan. “This is another example of why being able to seek UNISON assistance is so vitally important for MiP members.” MiP national officer Jo Spear says mistakes and unfair decisions are all too common with NHS pensions. “They can affect your career decisions even while you’re still working, so speak to your MiP rep if you think something’s wrong. Mistakes can often be rectified if you get the right support.” “Without the union’s help, and the legal support they were able to pull in around me, I think the outcome of the second stage would have been the same as the first,” adds Paul. “As I sit here now, I would probably be waiting for a hearing with the pensions ombudsman, which can take years and years.”

healthcare manager | issue 32 | winter 2016

THE SHARP END: REDEPLOYMENT

MiP is working with its members to get your stories from the NHS frontline published in the national media. This one appeared in the Guardian. Could you help produce the next?

Stepping down but staying on W

into delivery. Working there, some people eventually move into senior roles elsewhere in the system. But many, wounded by their treatment and unsure of their chances in the job market, use the role as a springboard into interim work; the NHS is desperately short of skilled, experienced leaders, so it pays them £1,000 a day to plug gaps in its management structures. Many people offered one-year jobs at

JOHN LEVERS

hen I had to leave my role as a senior manager, I discovered that the NHS has a well-used but little-known system for easing people out of top jobs. And I learned that it doesn’t work well for anyone: trusts, our healthcare system, managers, patients or the taxpayer. It’s quite common for senior leaders to have to step down, even when there are no performance issues and they haven’t risked patient safety. Sometimes, people simply end up in jobs that aren’t right for them. And just as often, managers faced with difficult change projects take on tasks that prove impossible to accomplish. My case is typical. Individual hospitals are being grouped together in larger organisations, centralising specialist care and closing some common services with overlapping coverage. And the timetables for these ambitious reforms are sometimes built around political cycles, rather than good medical care or change management. So I ended up overseeing a major change programme – but the deadline was unrealistic and we couldn’t recruit enough experienced medics. We eventually got things under control; but system leaders wanted a change of leadership, believing that would draw a line in the sand and signal a fresh start. In the private sector, I’d have been given a fat pay-off and sent on my way. But in UK public healthcare it’s not acceptable to spend taxpayers’ money that way, and departing managers have nowhere else to go: the NHS is the only game in town. So I was offered a sideways move into a national role at NHS Improvement: the agency responsible for improving practice across the health service. I soon learned that most such roles are one-year contracts, where people do useful work that is rarely followed through 24

healthcare manager | issue 32 | winter 2016

NHS Improvement would be willing to take a less senior job with their current employer, if it meant a permanent job and the chance to stay in the locality. But few are offered this option, and there’s a stigma attached to dropping grades. It’s seen as a sign of personal failure, and there’s an expectation that careers only ever go upwards – which, in these days of long careers and merging organisations, isn’t realistic. Political and system leaders need to recognise that these people still have skills the NHS needs. Failing in an impossible job is a verdict on the job, not the person. These managers are trying both to

keep their staff happy and push through the systemic changes required by national policymakers. The NHS needs to reform, and ministers have a democratic mandate to reshape the system; but currently, the best way to protect your career is to keep your head down, build support among your staff, and resist risky reforms. It seems obvious that if the NHS wants people to be ambitious in these very difficult jobs, it shouldn’t push those who run into trouble into temporary non-jobs – and thence into an interims market where the NHS must rent their skills back at exorbitant cost. Instead, national leaders need to do everything they can to retain good managers by offering them permanent employment in less high-profile roles. Then people would be more willing to take on the most difficult jobs, and there would be less gaps in management grades. That, in turn, would cut the interims bill and improve continuity in organisations that can ill-afford excessive staff costs and unstable leadership. The current system evolved to protect NHS staff whilst facilitating necessary leadership changes, but it’s hugely wasteful – of talent as well as money. It will take courage from politicians and the Department of Health to be more open, both about the flaws in our redeployment processes, and about the pressures that brought us to this point. But the benefits will be felt by patients and taxpayers as well as NHS managers and policymakers. 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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Thompsons Solicitors has been standing up for the injured and mistreated since Harry Thompson founded the firm in 1921. We have fought for millions of people, won countless landmark cases and secured key legal reforms.

We have more experience of winning personal injury and employment claims than any other firm 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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Managers are an essential part of the team delivering high quality, efficient healthcare. MiP is the specialist trade union for healthcare managers, providing expert employment advice and speaking up on behalf of the UKâ&#x20AC;&#x2122;s healthcare managers. Join MiP online at miphealth.org.uk/joinus

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