Healthcare Manager, Autumn 2017

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issue 35 autumn 2017

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healthcare manager BECAUSE IT’S WORTH IT Help us make the case for more money for the NHS

BECAUSE YOU’RE WORTH IT Why investing in management means better patient care plus MEDICS & MANAGERS Umesh Prabhu on how to work better with doctors

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issue 35 autumn 2017

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

analysis:8 MiP webinar: Getting to grips with STPs

features:10

published by Managers in Partnership

On-call: Why the NHS emergency duty regime isn’t fit for purpose—10 Why the NHS needs more money: Tell us how underfunding affects your patients—12 More managers: New research shows managers add value to patient care—15 Engaging junior docs: An innovative approach at Imperial College—18

regulars:20 miphealth.org.uk Elizabeth House 39 York Road, London SE1 7NQ | 020 3437 1473 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.

Legal Eye: Social media and data protection Tipster: Umesh Prabhu on working with doctors MiP at Work: Agenda for Change pay claim for 2018. Plus: Holding employers to account for outsourced services

the sharp end:24 Dean Royles: Taking the centre forward

Craig Ryan Editor

Much of the debate on NHS funding involves exchanging statistics extrapolated from projections and, frankly, guesswork. But we know remarkably little about how underfunding is affecting patient care on the ground.

This is why MiP’s funding campaign starts from the simple proposition that we need to devote a bit more of our national resources to healthcare, and then aims to explain why. To do that we want to hear your stories about how underfunding affects the services you manage, and how you would use a bit more money to make them better. You can read more about our campaign on page 12.

When it comes to putting money to work, managers are the essential cog in the process. For too long, politicians and commentators – many of whom should and do know better – have got away with depicting managers as a bureaucratic dead weight on the system, as if patient care is a process that, uniquely, requires no management and no support.

But there are signs the tide is beginning to turn. The last election campaign was relatively free of ‘manager bashing’ and, as Alison Moore reports on page 15, there’s a growing body of research showing that having more managers, with better job security, directly and significantly benefits patient care. Maybe some politicians are starting to listen.

MiP will be doing its best to hammer home that message at our Members’ Summit and parliamentary reception on 31 October. I hope to see you there. healthcare manager | issue 35 | autumn 2017

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

MiP Elections

New national committee takes charge in January MiP Committee 2018-2019

Nominations for MiP’s national committee closed on 25 September and, as there were no contested seats, the nominated members will take up their positions from 1 January 2018. The membership of the new national committee is shown in the box (right).

The national committee formulates MiP policies on healthcare, the NHS and workplace relations – including negotiations – and the representation, recruitment and organisation of MiP members.

Committee members are ambassadors of MiP, representing the union on public platforms and talking up issues that matter to you, upholding MiP’s

Anthony Nichols Stuart Quinton Richard Carthew Sandie Belcher Claire Bannister David Cain Jeremy Baskett Zoeta Manning Geoff Underwood Aidan Dawson Gail Thompson Sam Crane

Vacancies: South East Coast South Central Scotland Wales

(seat two) (seat two)

values and maintaining our political neutrality.

The national committee is made up of elected representatives from each geographical area of the UK with co-optees for any areas of healthcare not represented. There are two seats for Scotland, Wales and London, and one seat for each of the other English regions

and for Northern Ireland.

The new committee will elect the MiP chair – a position currently held by Sam Crane from Wales (pictured) – at its first meeting in January. Byelections for the seats in South East Coast and South Central

regions, and the second seats in Scotland and Wales, will be held in the near future.

healthcare manager

Design and Production Lexographic www.lexographic.co.uk

Cover image

issue 35 | autumn 2017 ISSN 1759-9784 published by MiP

Contributors

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

All contents © 2017 MiP or the author unless otherwise stated.

Editor

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

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East Midlands East of England London

North East North West Yorks & Humber West Midlands South West Northern Ireland Scotland Wales

Matthew Limb, Alison Moore, Umesh Prabhu, Jon Restell, Matt Ross, Dean Royles, Craig Ryan, Jo Seery.

Opinions expressed are those of the contributors and not necessarily those of healthcare manager or MiP.

healthcare manager | issue 35 | autumn 2017

© 2017 V I Levi

Print

Captiv8 UK, Lewes, East Sussex

Advertising Enquiries

020 8532 9224 adverts@healthcare-manager.co.uk healthcare manager is sent to all MiP members. If you would like to join our mailing list to receive copies please email us at editor@ healthcare-manager.org.uk.

To find out more about the committee’s work visit the national committee page on the MiP website: bit.ly/hcm3504.

Letters

Letters to the editor on any subject are welcome by email, or by post to MiP, Elizabeth House, 39 York Road, London SE1 7NQ, Letters must be clearly marked “For Publication”. We may edit letters for length. Please supply your name and address, which may withheld from publication on request.

HEADS UP

leadingedge Jon Restell, chief executive, MiP

W

e need to talk about the statutory duties of healthcare bodies.

This column was conceived on a visit to Belfast last week. NHS leaders in Northern Ireland are currently consulting staff and the public about draft savings plans to meet revised targets sprung on them by the Department of Health. In essence, trusts need to save an extra £35m on top of existing plans to save £35m. Funding simply isn’t covering costs and the books won’t balance.

With a budget of just over £5bn, this may sound like small beer. But with only a few months in which to release cash, the impact will be felt directly in patient services. In Belfast, for example, managers need to find another £13m on top of existing plans to save £13m. They are consulting on temporary proposals including stopping the use of off-contract agencies, deferring routine elective care and closing beds, cutting back on domiciliary care packages and placements to residential and nursing homes, and deferring fertility treatment and access to some high-cost drugs.

What an unenviable job for managers faced with implementing proposals that they know will inevitably affect the health and lives of people for the worse. On this occasion, the public and NHS staff do seem to sense that the cause – and therefore the solution – lies with the politicians, and managers are not getting it in the neck. But that could change, as we’ve often seen elsewhere.

What struck me most was how managers were carefully addressing these difficult issues within a statutory framework – principally the duty to provide

“More and more change is occurring under the radar, out of sight of parliament, and more individual decisions are being made which stretch or ignore statutory purposes and duties.” quality care and the duty to break even – and doing so in the wide open.

For NHS managers elsewhere in the UK this story will elicit sympathy and recognition – the four health services have not yet diverged that far. But in England, I wonder if statutory duties are quite as clear as they once were, and as they appear to be in Northern Ireland.

It seems to me that more and more change is occurring under the radar, out of sight of parliament, and that more individual decisions are being made which stretch or ignore statutory purposes and duties.

This is one of the enduring, and depressingly predictable, legacies of the Lansley debacle. A system that was never likely to work, despite some good work in some areas, now needs fixing. As Dean Royles argues on p24 of this issue, accountable care systems and the pressing need for a single voice in the system make it urgent.

But recent memories of the 2012 Act have scared off politicians from meddling with the structures of the NHS for a generation. Even if they had the appetite – and the Tories made provision in their manifesto for tidying up legislation – the focus on Brexit

and the government’s parliamentary weakness makes such meddling impossible.

So well-meaning system leaders and managers have started to fix the system. National bodies are being spliced and diced without any coherent policy. Providers and commissioners are doing their bit to develop accountable care systems, possibly off-piste. As at least one foundation trust chief executive has pointed out, doing what’s right for the local system may not be doing what’s legally expected of your individual organisation.

But everyone has been reluctant, our union included, to embrace another reorganisation of management structures.

I’m a pragmatist, but I wonder if we’re going beyond what’s right and proper. Does it feel right that statutory bodies are having their rules rewritten out of sight of the parliament that set them up (and votes them the money)? What are the risks run by individual managers who, as in Northern Ireland, must make increasingly difficult and controversial decisions?

The encouragement and support we see for managers now won’t be seen for dust if things go wrong. With Fit and Proper Person accusations being thrown around like confetti, managers are being placed in a dangerous position.

We must have openness about what’s happening in the NHS, and give managers who are being asked potentially to go outside the statutory framework genuine and bankable assurances that they won’t be blamed for the consequences of political decisions.

healthcare manager | issue 35 | autumn 2017

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HEADS UP

Employment rights

Unions win new rights to be consulted about workplace changes

Employers will obliged to consult unions on all issues affecting their members at work, including job losses, working hours and holiday pay, following a second

major victory of the summer for UNISON in the courts.

Just two days after the Supreme Court outlawed tribunal fees, the Court of Appeal ruled that unions have

a right to be consulted on all issues affecting members in the workplace, not just those specified in existing laws, such as redundancy and the transfer of workers from one employer to another under the TUPE regulations.

UNISON claimed the ruling will benefit thousands of employees whose rights at work are under threat and means that employers will face greater scrutiny over their treatment of staff.

General secretary Dave Prentis (pictured) said: “This is the second major legal victory in a week for working people.

It means that employees in any workplace where there’s

a union will now benefit from greater protection at work.

“The message to bosses is they will have to treat their staff more fairly over pay and working conditions. If they fail to consult unions then they will be acting unlawfully and could be taken to court.”

The appeal court ruled that UNISON had the right to be consulted by Wandsworth Council over planned job losses affecting parks police.

It also ruled that UNISON’s rights to consultation under Article 11 of the European Convention on Human Rights, which protects the right to form trade unions, had been breached.

Tribunal fees scrapped in “major victory for everyone in work” Employment tribunal fees were scrapped in July, following a major legal victory for UNISON in the Supreme Court, which ruled the government acted unlawfully and unconstitutionally when it introduced the controversial fees four year ago.

The UK’s highest court unanimously upheld UNISON’s claim that the fees were “inconsistent with access to justice” and prevented people from making legitimate discrimination claims. As well as scrapping the fees with immediate effect, the government will also refund more than £27m in fees paid by workers since the policy was introduced by the then Lord Chancellor, Chris Grayling.

Congratulating UNISON on its landmark 4

healthcare manager | issue 35 | autumn 2017

victory, MiP chief executive Jon Restell said: “This is a stunning win for access to justice and working people. If you still need proof that trade unions are important in this country, this is it. Without UNISON’s tenacious campaign in the courts, the regressive policy on tribunals fees would have remained with us.”

UNISON general secretary Dave Prentis said: “The government is not above the law. But when ministers introduced fees they were disregarding laws many centuries old, and showing little concern for employees seeking justice following illegal treatment at work.

“It’s a major victory for employees everywhere,” he added. “UNISON took the case on behalf of anyone who’s ever been wronged at work, or who might be in future. Unscrupulous employers no longer have the upper hand.”

The seven Supreme Court judges ridiculed the government’s misunderstanding of “elementary economics, and plain common

sense”, and said fees “had a deterrent effect upon discrimination claims, among others”, and deterred people from pusuing genuine cases as well as the so-called vexatious claims the fees were intended to deter.

The Court said UNISON’s evidence showed the fall in claims when fees came in was “so sharp, so substantial and so sustained” that they could not reasonably be afforded by those on low to middle incomes. It also held that fees particularly deterred the kind of ‘low-value’ claims generally brought by the most vulnerable workers.

The fees, which applied to workers in England, Scotland and Wales, were set at £390 for wage and contractual claims, and £1,200 for more complex cases such as unfair dismissal and discrimination claims. Workers wishing to lodge cases at the employment appeal tribunal had to find fees of up to £1,600.

Read the judgment in full on the Supreme Court website: bit.ly/hcm3505.

HEADS UP

Active members, active union

MiP Members Summit 2017 Tuesday 31 October, Westminster Central Hall MiP’s 2017 Members Summit – our new-look annual event for members from across the UK – will be a full day of policy debate, interactive training and practical workshops, with plenty of opportunities to network with other members.

The summit is CPD certified and gives you the chance to: ■■ discuss your priorities for MiP in our ‘System Change’ regional and country forums 09.00

■■ attend ‘Management Life’ workshops led by our lay and professional officers – including experts on equality in the workplace, leadership and career planning, managing people, staff wellbeing, and partnership working ■■ network with other members and allies over lunch ■■ take positive experiences back to your workplace ■■ debate MiP’s policy on pensions, pay, funding and man-

agement standards, in our afternoon ‘Influencing the World’ session ■■ learn from NHS leaders about how MiP and its reps bring benefits for employers and patient care ■■ take positive experiences back to your workplace After the summit, we will walk across to the House of Commons to host a parliamentary reception and lobby MPs

to support our health and care managers.

Please see below for the full agenda at the time of going to press. Speakers and sessions may be subject to change.

The summit is free to attend for MiP members. You can register online at connectpa.co.uk/events/ mip-members-summit-2017, email register@mipsummit.co.uk or phone Connect on 020 7592 9490 for more details.

Registration, exhibition viewing and refreshments

12.15

THE MEMBER JOURNEY: GETTING THE MOST FROM MiP Visit the MiP stall to hear about the full range of benefits you enjoy as an MiP member and how to get your colleagues to join.

PLENARY FEEDBACK SESSION Workshop facilitators report back on three learning points or key insights from workshop discussion sessions A and B.

13.00

Lunch

13.20 & 13.40

Fringe session: Advice on lobbying techniques for delegates attending the parliamentary reception (repeats)

09.45

PLENARY Welcome to the MiP Summit Jon Restell, Chief Executive, Managers in Partnership

10.00

WORKSHOP DISCUSSION SESSION A What’s happening in your region or country, and what do you want MiP to do?

Workshop 1: London

PLENARY SESSION Pay, Terms & Conditions 14.00

Workshop 2: South of England

Jon and Dale will discuss the current valuation of the NHS pension scheme, particularly the issue of tiered contributions. The presentation will help MiP reps to talk to members and colleagues about pensions and give them the information they need. There will also be a chance to get answers to your own questions on pensions.

Workshop 3: Midlands and East of England Workshop 4: North of England Workshop 5: Scotland, Wales and Northern Ireland 11.00

Tea and Coffee

11.15

WORKSHOP DISCUSSION SESSION B Management life Delegates can choose from a variety of discussions led by MiP national officers, nationalcommittee members and guest speakers.

Workshop 1 Equalities: making a great workplace for everyone Workshop 2 Managers matter: how we develop managers and their careers Caroline Corrigan, NHSI’s National Director for People Strategy Workshop 3 Managing people well: new approaches to line management Roger Kline and Joy Warmington, chief executive of BRAP

14.30

PRESENTATION: PAY Led by: Jon Restell, MiP, and Sara Gorton, UNISON head of health Jon and Sara will lead a discussion aimed at developing MiP’s position on the public sector pay cap. We will talk about the Agenda for Change pay claim, the case for a better pay deal for managers, and how we can fund it.

15.00

ACTIVE MEMBERS, ACTIVE UNION Keynote speaker: Dean Royles, director of HR and organisational development at Leeds Teaching Hospitals NHS Trust, and former chief executive of NHS Employers Dean has been an active supporter of trade unions both locally and nationally and believes they play a key role in supporting effective change and improving patient care.

15.15

Workshop 4 Managing wellbeing: what managers can do for staff and themselves Workshop 5 Unions and managers working together: sickness absence and bullying Ashley Judd, deputy director of workforce at Norfolk and Norwich University Hospitals NHS Foundation Trust Harry Seddon, UNISON Branch Secretary Jan Bloomfield, executive director for workforce and communications, West Suffolk NHS Foundation Trust Paul Pearson, UNISON Branch Secretary

PRESENTATION: PENSIONS Led by: Jon Restell, MiP, and Dale Walmsley, First Actuarial

INFLUENCING THE SYSTEM, INFLUENCING THE WORLD A debate on policy propositions Dean Royles, MiP chair Sam Crane, Jon Restell and Sara Gorton will lead a discussion on how MiP members can: Promote investment in managers and their skills Support effective system change Take the lead on making the NHS a better place to work

15.40

SUMMARY AND CLOSE

15.45

Delegates transfer to the House of Commons

16.00

Parliamentary reception in the Churchill Room at the House of Commons,hosted by Karin Smyth MP

18:00

Close of day

healthcare manager | issue 35 | autumn 2017

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HEADS UP: PENSIONS

Unions move to protect New pension rights for special class status

MiP and other NHS unions have secured clarification from the NHS Business Services Authority (BSA), which runs the NHS pensions schemes, that there has been no change to the rules on special class status for staff working for Clinical Commissioning Groups.

The unions intervened after SBS circulated new advice to employers which appeared to suggest that nursing staff working for CCGs were no longer eligible for special class status in any circumstances. Both MiP and

the Royal College of Nursing have received a number of complaints from members whose employers have attempted to remove their special class status in recent months.

Under the existing policy, CCG staff whose job required the qualifications and experience of a nurse, midwife or physiotherapist could retain special class status even when working in a largely management role.

The unions have now received written clarification from the BSA that the policy has not changed: “For clarity, CCGs can decide for themselves whether a member retains special class status up to director of nursing level… and nothing about the criteria has changed.”

The BSA said its advice to CCGs had been intended to avoid the situation where members moving into posts which don’t attract special class status didn’t find out about the change until retirement.

Special class status applies to qualified nurses, midwives and physiotherapists who joined the pension scheme before April 1995, and allows them to retire at 55 with full benefits providing they worked in posts attracting special class status for five years before retirement.

If you think your special class status has been removed unfairly, contact your MiP national officer.

Pension delay another blow to NHS staff, says MiP MiP has condemned government plans to make NHS workers wait an extra year for their NHS and state pensions.

The government announced in July that it planned to bring 6

forward by seven years the rise in the state pension age from 67 to 68. MiP members currently aged between 39 and 47 will now have to wait until they are 68 to pick up both their NHS and state pensions.

healthcare manager | issue 35 | autumn 2017

unmarried partners

Unmarried partners of NHS staff who have died will now be able to claim survivor benefits even if they were not formally nominated by their partner, the NHS Business Service Authority (BSA), which administers the NHS pension schemes, announced in September.

The move follows the ruling by the Supreme Court in February that the previous policy, introduced in April 2008, of only paying survivor benefits to partners who had been formally nominated was unlawful. People affected by the ruling would receive backdated payments, the BSA said.

A BSA spokesman said: ”The implications of this ruling have been considered independently by the public sector pension schemes and we as the NHS pension scheme have decided to change our processes with immediate effect.”

He said the authority would be contacting NHS employers for help in identifying claims for survivor benefits that were rejected as well as people who may have been deterred from claiming under the old rules.

Although no longer a requirement, members with unmarried partners are still encouraged to nominate them, as claimants will still have to provide evidence of their relationship in order to claim survivor benefits.

In a Commons statement, Work and Pensions secretary David Gauke claimed the move would save the government £74bn over the next 30 years, but presented no new evidence of changes to life expectancy to justify accelerating the government’s existing plans to increase the state pension age.

“This is another blow for those MiP members whose NHS retirement age is now

linked to the state pension age,” said MiP chief executive Jon Restell. “This latest move is not prompted by people living longer. That’s unacceptable. We will be letting the Department of Health and NHS employers know what our members think in no uncertain terms.”

For more details on the government’s proposals visit bit.ly/hcm3507.

HEADS UP

Employers urged to set up BME networks NHS England says employers should encourage the setting up of networks for black and minority ethnic staff as part of plans to implement the Workforce Race Equality Standard (WRES) across the NHS in England.

NHS England’s WRES implementation team published the first of a series of

networks already operating across the NHS. It also identifies the specific support needed to ensure staff networks are more effective in engaging staff.

“Whilst some organisations have established networks, others are either at an earlier stage or have none. Although there is still a long way to go, there is evidence of some improvements on which we will build and share what works,” said Yvonne Coghill (pictured), co-director of WRES implementation at NHS England. guides in August, with more planned to follow this autumn. Improving through Inclusion provides evidence of good practice from black and minority ethnic staff

For more information on the WRES and to download the guide, visit england.nhs.uk/wres/, or follow the WRES team on Twitter @WRES_Team.

SSRB

Government to review pay for managers in NHS ‘arm’s length’ bodies The Senior Salaries Review Body has called on the government to consult directly with MiP about a new pay framework for senior managers working in arm’s length bodies (ALBs) of the Department of Health, and backed the union’s call for an across-the-board 1% pay increase.

Ministers accepted the recommendations of the review body’s 2017 report, published on 20 July, and agreed to review the SSRB’s remit, in a move that could see its jurisdiction extended to very senior managers across the whole NHS. The SSRB, chaired by Dr Martin Read, reports annually on the pay of around 360 executive and senior managers (ESMs) working for ALBs – such as NHS England, Monitor, the Care Quality Commission and Health Education England – but does not cover senior managers working for NHS trusts or CCGs. The key points of the 2017 report were:

“We have argued over many years that there should be a consistent approach and framework to very senior managers across the NHS.” ■■ The full 1% available for pay awards under the government’s public sector pay policy should be used for pay awards to ESMs, with employers mandated by the Department of Health (DH) to use the budget in full.

■■ Pay awards should be used to address “recruitment, retention, motivation and service delivery issues, staff performance and current position on the pay scale” as well as to tackle gender disparities and those between different groups of staff with similar responsibilities. How the

available 1% is divided between ESMs should depend on the priorities of each ALB. ■■ The whole budget for performance bonuses should be used to make non-consolidated awards to the top 25% of performers. The review body cliticised the under-spending of the performance bonus budget in the past.

■■ The government should carry out a thorough review of the way pay is determined for ESMs before the SSRB’s next report. The review body recommends either widening the remit group to include all very senior managers in the NHS, or delegating responsibility for ESM pay to individual employers.

■■ The review body explicitly recommends that the DH should consult with Managers in Partnership about the review and whether to widen the remit group.

Welcoming the SSRB’s report, MiP chief executive Jon Restell said: “We’re pleased that the review body has agreed with

MiP’s recommendations on awarding the full 1% for basic increases, using the full bonus pot and deciding on the scope of the remit.”

He added: “We’re opposed to the public sector pay cap of 1%, but there was a real discussion about whether even that derisory increase should be recommended.

So our arguments about an award to motivate ESMs were important.

“Our members were clear in our surveys that they wanted to see all available pay funds used including the bonus pot.

So we welcome the recommendation that ALBs use the bonus pot or explain why not.”

Restell said MiP was looking forward to talks with the DH about the remit of the SSRB within the NHS. “We have argued over many years that there should be a consistent approach and framework to very senior managers across the NHS,” he added.

Read the SSRB’s 2017 report in full at: bit.ly/hcm3506

healthcare manager | issue 35 | autumn 2017

7

MIP WEBINAR: STPs

Analysis Alison Moore reports on MiP’s first webinar, which examined how Sustainability and Transformation Partnerships will affect managers’ working lives and how MiP can support members through the process.

STPs – making your voice heard With STPs becoming the key driver of change in the NHS in England, MiP’s first-ever webinar for members, held on 12 September, was designed to examine how STPs will affect managers’ working lives and what the union can do to make sure members are fully engaged in the process.

MiP chief executive Jon Restell started the 45-minute session by outlining the “very fluid situation” with STPs, where the ground is continually shifting and there are huge variations in progress between different areas. The most advanced areas are already moving beyond STPs towards accountable care systems (ACSs), while others are moving much more slowly.

This varied picture presents challenges for trade unions, Restell explained, as does the fact that STPs affect all types of NHS organisation, whilst previous changes tended to affect only one part. “It does have a kind of breadth to it that I don’t think that we’ve seen before,” he said.

Restell said the picture is particularly complicated because the Lansley reforms mean there is no single voice to consult with on the issues STPs were designed to tackle – half a dozen national bodies might be involved in workforce issues, for example. “There’s no ring to rule them all,” he joked. ‘We’re 8

healthcare manager | issue 35 | autumn 2017

not living in a world where you can strike a deal which gets replicated throughout the service.”

He stressed that while some unions have opposed STPs, MiP takes a neutral stance, seeing them as a mechanism which could result in good or bad outcomes. ‘We’re saving our gunpowder for the outcomes of this planning process,” he said.

“One of the key risks is that it becomes another reorganisation of management structures,” Restell added. “We have a real fear that a lot of what is going on is a restructure which is effectively happening under the radar without any ‘tidying up’ through legislation. That makes it even harder to represent members.”

A poll of MiP members taking part in the webinar found that more than half thought STPs will have a high or very high impact on their jobs, emphasising the importance of MiP being able to support members, both as managers and employees, through the STP process.

Responding to questions from participants, Restell explained the priorities for trade unions over the last six to nine months: arguing for proper funding and investment in STP change plans; pressing STP leaders to engage with staff and give them a leading role in managing change; getting STPs leaders to talk to unions at the appropriate level;

and agreeing protection for terms and conditions.

“Funding and investment for the many changes planned is going to be absolutely critical,” said Restell. “Most of these plans have an air of unreality around them when it comes to capital investment. From the staff side the message has been very clear: there needs to be a set amount of money to invest in the change plans.”

Engagement with unions and staff has been patchy, he added, and there’s an additional problem in working out how to engage with what might be system-wide changes. “There are some emerging structures to allow this to happen at system level,” he said.

Nationally, Restell explained that MiP has been involved in discussions with NHS England about how to ‘derisk’ change and make staff more confident that terms and conditions will be protected. There has also been national guidance on engagement – with the emphasis on early engagement rather than waiting for formal consultation – and discussions at national level about access to NHS pensions for staff who move to non-NHS bodies.

MiP national officer Pete Lowe said many members are caught up in other transformational changes running alongside STPs, such as the introduction of new models of care. He cited the example of Dudley where, as well as the

MIP WEBINAR: STPs

STP, CCGs are facing other significant changes as part of a vanguard.

“For individual members of NHS staff it comes down to asking: what’s the impact on my job? The starting point for all the [MiP] officers is how we can protect that individual member of staff,” he said.

Providers often feel they are kept at arm’s length from much of the STP process, and Lowe expressed concerns that issues are too often viewed in narrow “silos”. Many CCGs have also been facing rapid reconfiguration with increasing impact on members. “It feels like continual churn… it starts with people making that phone call because they are feeling unsure about the impact of change,” he added.

Lowe questioned whether existing consultation processes allow staff to influence what is happening, or whether STP leaders and employers are just going through the motions. He advised MiP members to contact their MiP national officer as early as possible if they want to influence the direction of change.

MiP national officer Jo Spear discussed the position of members in Commissioning Support Units (CSUs) and arm’s length bodies like NHS England, who are increasingly being told their work will be aligned with STPs. How this will affect staff remains unclear.

“What does it mean if your employer is going to align your work with an STP? Do you then need to be consulted about the STP?”, she asked.

CSUs are in a “very challenging situation”, she warned, with members asking legitimate questions about how

ISAVIRA | DREAMSTIME.COM

“For the individual members of NHS staff it comes down to asking: what is the impact on my job? The starting point for MiP is how we can protect that individual member of staff”.

being linked to an STP might affect the future of their CSU or lead to them being seconded to work elsewhere as ACSs are set up. In the southern region in particular, there are also related steps to align the work of NHS England and NHS Improvement which could also affect members’ jobs, she added.

Restell said there is a conflict between the regulation of individual NHS organisations and the collective nature of STPs, warning that some organisations could run into regulatory trouble as they try to achieve the STPs’ aims.

Spear described a highly variable picture: in some areas NHS organisations are sticking to a highly competitive model, while others pursue a more collaborative approach. Attitudes to engagement are also mixed, she said: in London some employers have been very organised about engagement; but in the south-east coast area, engagement has been more “presidential” and unions

are “swimming upstream” when they try to get STPs to prioritise the impact on staff.

But both Spear and Restell highlighted the very real challenges for unions, which tend to be well organised at employer and national levels, but aren’t configured to engage at the STP level.

They agreed that unions may need to “kick the door down” to ensure they can negotiate at the right point.

Restell also explained how the MiP reps initiative, which has seen the first eight MiP reps take up their positions this year, will help to boost MiP involvement at the right levels for STPs. “The two really key messages from us are about getting active, and sharing best practice,” he concluded.

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Watch the full webinar online at bit.ly/hcm3502.

MiP will be running a series of members’ webinars over the coming months. Get in touch at info@miphealth.org.uk to let us know what you’d like us to discuss. healthcare manager | issue 35 | autumn 2017

9

ON-CALL DUTY

Many managers feel the NHS’s emergency duty regime is arbitrary and unprofessional. Craig Ryan reports on growing demands for employers to reform an increasingly broken system.

B

eing on-call is a fact of working life for many NHS managers. Trusts, CCGs and the regional outposts of NHS England all place managers on rotas which mean they can be called into work at a moment’s notice to help deal with emergencies at night or on weekends. These can be major disasters like the Manchester terrorist attacks or the Grenfell fire, or more everyday crises such as A&E being full up, outbreaks of CDiff, road accidents or serious staff shortages.

But there are few hard and fast rules on how on-call duties are assigned and most employers make little attempt to agree terms and conditions with unions locally – or even to consult with staff. In recent months, MiP has seen an sharp increase in complaints from managers about how the emergency regime operates, and the arbitrary and unfair way in which people are placed on-call.

For many managers, on-call duty is a serious additional burden that can have a big impact on family and social life – as well as a detrimental effect on their efficiency in the day job. In some busy trusts, managers can find themselves on-call for one weekend in every three.

As one manager explains: “When you’re the on-call, you can’t travel far from the office, you can’t go away for

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healthcare manager | issue 35 | autumn 2017

“Work-life balance is a joke...After another unforgiving week, you have a 24-hour period of on-call – within an organisation where you will be in trouble if you make what they see as a duff decision.”

the weekend, you can’t have a drink or do things with your kids. And if you’re a single parent, you have to arrange childcare just in case you get called in.”

“Work-life balance is a joke” says another manager who works on-call. “After another unforgiving week, you have a 24-hour period of on-call – within an organisation where you will be in trouble if you make what they see as a duff decision.”

The serious disruption to personal and working lives is compounded by what many managers see as lack of training and proper support for people providing what is, after all, a crucial public service.

For example, many feel they are being asked to make what are, in effect, medical decisions. One manager explains: “The bed manager calls and says, ‘I

have x, y and z cases in A&E, I have no Resus, no ICU beds and all the wards are full. I have a, b and c cases coming in – what should I do?’ The manager on call has no idea of how unwell these patients are. Even if there’s no more capacity in local hospitals, they will not be told to close the department.

“This often happens in the dead of night when you can’t really call anyone for advice,” he adds. “The idea that the clinical staff on site will either be able to advise or be willing to help is often inaccurate for various reasons.”

Most trusts operate a two-tier system for emergency cover, with a “first oncall” manager supposedly supported and advised by a more senior “executive on-call”. In practice, the managers we spoke to said they got little support from senior colleagues. “I’ve been told, ‘you know much more about this than I do, you decide’,” one manager says. “Very few have current or even recent operational experience and they will very often off-load the problem back onto the first on-call.

“Some executives are less than helpful and seriously annoyed to be called – having to call for advice is not simple,” he adds. “I’ve even been told that the job of the first on-call is to protect the exec from having to take calls.”

Many managers feel there is a particular need for better support from

ON-CALL DUTY

clinicians, especially medical consultants. “There needs to be hard and fast rules,” said one manager. “If a junior goes sick and a locum is not found then the consultant must ‘act down’. Arguments at 9pm on a Friday night are exhausting and dangerous – and this could easily be avoided.”

He calls for employers to rota two “first on-calls” at the same time – one a clinician, the other a manager – to give each other moral support and make better use of each other’s expertise. He also suggests staff on the rota should to be given blocks of time off – perhaps three months a year in which they wouldn’t be on-call.

The requirement to maintain on-call emergency cover is laid down in the 2004 Civil Contingencies Act and (in England at least) in mandatory guidance from NHS England. But how oncall is implemented within organisations is supposed to be a matter for local negotiation.

“Just because it’s the law that you have to have on-call cover doesn’t mean that employers can unilaterally breach contracts or agreed terms and

conditions,” says MiP national officer Jo Spear, who is representing several members with disputes over emergency cover duty.

“Too often, everything gets presented as a fait accomplit. People are told, ‘we have to do it, your name’s on the list, off you go’. In fact, Agenda for Change is quite clear that there needs to be a process of negotiation about who’s on the rota and how the rota is run, and that it should be locally determined.”

Spear says a big problem with many employers is the lack of any criteria for selecting people for on-call duty or for who should be exempt. “Without agreed exemptions or criteria, no one can ever win an appeal against being put on-call,” she explains. “You can’t argue that I can’t go on the rota because I’m a single parent, I’m disabled, my mum’s ill, or I already live 30 miles from the office, because, without agreed exemptions, every appeal will fail.”

Spear warns it’s not acceptable for trusts – which are understandably anxious to implement on-call arrangements swiftly – to impose rotas and promise to consult with local trade unions later.

“Once you’re on the rota, most people find it impossible to get off it,” she says.

With NHS England preparing to overhaul its emergency preparedness regime in the wake of recent terrorist attacks, Spear says there is a danger that another set of rules “will be passed down as a diktat from NHS England” to trusts and CCGs without discussion with staff or unions at either national or local level.

Most managers we spoke to thought on-call duty should be professionalised and given to managers who want to do it, rather than dumped almost randomly on staff whose personal circumstances often make them unsuitable for the job.

“Some people love the drama and thrive on it,” says one senior manager who regularly works on-call. “That’s their skill and talent and it’s a great quality and ability to have. Employ them to do the on-call properly. Give them the responsibility, pay and flexible working conditions to do it as well as they can. There will be greater expertise and continuity and more people will be more content with their situation. Most importantly – it will be safer for patients.”

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healthcare manager | issue 35 | autumn 2017

11

NHS FUNDING

MiP is encouraging members to talk about their personal experiences managing NHS services under financial pressure.

Craig Ryan explains the thinking behind the new campaign and talks to two groups of managers at the sharp end of NHS funding cuts.

W

e all know the figures.

The NHS is treating more patients than ever before – emergency admissions, outpatient appointments, elective admissions, GP contacts and prescriptions are all at record levels, following steep rises over the last ten years. At the same time, the money has dried up.

The NHS is experiencing unprecedented austerity, with funding set to grow by an average 1% per year for the whole of this decade – way below the near 4% the service had been used to since it was founded in 1948.

“We believe the NHS needs more money. We make no bones about that,” says MiP chief executive Jon Restell.

“That doesn’t mean the NHS should stop making itself more efficient, or stop reforming itself. But it does mean that politicians need to take the decision to devote a bigger slice of our national resources to healthcare.”

MiP has called for the government to raise healthcare spending over the course of this parliament to the same level as France and Germany – around 11% of GDP. This year, that would have given us around £23bn more to invest in transforming services and providing better care for patients.

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healthcare manager | issue 35 | autumn 2017

“MiP believes the NHS needs more money. We make no bones about that.

But that doesn’t mean the NHS should stop making itself more efficient, or stop reforming itself.”

But to win the argument for better NHS funding we need to talk about people, not just statistics. We need to talk about patients and the services they rely on, and about the NHS staff who do their best to deliver quality care however tough it gets.

That’s why, in the next few months, MiP will be talking to managers across the UK about how funding cuts and rising demand are affecting the services they provide for patients. We want to hear your personal stories (in complete confidence, of course) about what it’s like managing services under financial pressure and how you would use a bit more money to improve patient care.

Are you critically short of staff? Are treatments being withdrawn or restricted? Are staff so overworked the quality of patient care is at risk? Are cuts

to social care blocking beds and using up precious NHS resources? Are clinics being closed or having their opening hours restricted? If so, we want to hear about it.

To kick things off we spoke to two groups of managers working in services under severe financial pressure: community nursing and mental health (see pages 13 and 14). They told us how staff shortages and inflexible funding arrangements have led to treatments being restricted, staff spending less time with patients and transformation plans being put on the back burner. In the coming months, we hope to publish many more stories like these in Healthcare Manager and on the MiP website.

How the funding squeeze hits patient services Faced with funding pressures, NHS organisations have three choices: overspend, improve productivity, or cut services. Regulators will not tolerate persistent overspends and, as the NHS is already one of the most efficient health services in the world, there’s only so much juice you can squeeze out of the productivity lemon. The longer the financial squeeze continues, the more the burden will fall on patient services.

In its report Understanding Financial

NHS FUNDING

Scares in the community Community nursing services face a triple whammy of funding cuts, rising demand and policy pressure, making them particularly vulnerable in the current climate.

“We’re seeing a steady rise in patient acuity – more older people with multiple conditions, but more pressure not to admit to hospital,” says Jane, a manager working for a trust in a largely-rural part of England. “Caseloads are ridiculous sometimes. We can’t cope with any more workload, but we know the need’s going to keep on going up.”

The impact is is obvious to patients or anyone working in the service, Jane explains, but isn’t necessarily picked up in statistics or inspection reports. “You just can’t do patient-centred care on these kind of caseloads. Nurses can’t spend time with patients when something’s wrong or talk about how they feel. It’s just about getting the tasks done – giving them the medication, changing the dressing, then getting back in the car. That’s not patient centred. It upsets a lot of people that they can’t do their jobs properly.

“More and more we’re limited to serving people who are housebound,” she adds. “We can’t respond to patients outside their allotted appointments. We can’t help them manage their own care. But I think the worst thing is patients want to talk and [the nurses] have to say, ‘Sorry, I’ve got to go.’ That’s heartbreaking.”

Jane says her working days are dominated by staffing prob-

Pressures in the NHS, published earlier this year, the King’s Fund identified six ways in which funding pressures can hit patient care: ■■ Deflection: one part of the system shifts responsibility to another part.

For example: medically-fit patients detained in hospital while awaiting a care package from social services.

■■ Delays: patients wait longer for treatment or diagnosis – the traditional NHS response to funding pressures. For example: unacceptably

lems – pushing important work like staff development, redesigning services and implementing new care models to the margins.

“As managers, we spend most of our time juggling staff, plugging holes, on recruitment and finding agency people and so on,” she explains. Around 20% of nursing posts are vacant at the moment, she says, and the service relies heavily on “pretty variable” agency staff. “We have to keep chopping and changing the people who go in,” she says. “And the patients don’t like it, especially the older ones. They want to see the same friendly face.”

Jane’s colleague Dan, a senior manager at the same trust, says teams are under constant pressure to take patients off the list.

“As soon as we’re starting to get on top of a problem we have to scale back the visits and then stop them altogether,” he explains.

“But the patients are still old and frail and they just don’t understand why the nurses can’t come anymore.”

Dan takes particular exception to the block funding regime, under which community trusts receive a fixed sum for covering a particular area, regardless of the number of patients or the level of need. “The move from hospital to community has already happened. Demand is rising. And we’re still on the same block funding as before. How’s that supposed to work?” he says.

long waiting times for neurology and cataract surgery.

■■ Denial: patients are denied certain treatments because CCGs won’t fund them or providers don’t think they’re worthwhile. For example: a range of NICE-approved mental health therapies are not available to patients in some areas (see page 14).

■■ Selection: treatments are denied to specific groups of patients who don’t meet certain criteria. For example: restricting IVF treatment to women

under a certain age.

Deterrence: barriers are put up – deliberately or inadvertently – that make it harder for patients to access services. For example: reducing the availability of GP appointments or making it harder to book them.

■■ Dilution: the quality of the service provided to patients is reduced, whether planned or not. For example: community nurses and social workers spending less time with each patient (see box above).

■■

healthcare manager | issue 35 | autumn 2017

13

NHS FUNDING

Waiting times can be measured, and policies on denying treatment or selecting patients usually attract publicity. But it’s hard to get a handle on how cuts have affected the quality of services or the impact on patients of deterrence or deflection. There is also a dearth of research on the performance of community and mental health services, where outcomes are harder to measure, and the emphasis on prevention and early intervention means less measurable activity can acutally be a mark of success.

Despite seven years of austerity, we still know remarkably little about how the funding squeeze is affecting patient care. In today’s fragmented NHS, funding pressures interact in a wickedly complex way with changes in demand and still-evolving reforms, making it difficult to predict which services will be worst hit or when the cuts will bite.

Official figures shows average waiting times have reached alarmingly high levels for neurosurgery, cataract removal, trauma and orthopaedics, plastic surgery and ear nose and throat procedures. Research by the King’s Fund research identifies particularly severe pressures on district nursing services, where referral criteria have been tightened and visiting times reduced, and Genital-Urinary Medicine (GUM), where sexual health clinics have been closed and advice and prevention services cut back. Everyone knows about the financial pressure on social care, but there’s very little hard data on how it has affected the NHS services on the ground.

This is why your personal accounts are so important. MiP members are uniquely well placed to tell the story of what’s happening on the NHS frontline.

As managers, you understand where the financial pressures are, you see the impact on a wide range of staff across the whole organisation and you have the ultimate responsibility for providing patient care. With your help, we can build up a clear picture of how the funding squeeze is affecting patient care, and make a far stronger case for investing more money in our NHS.

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If you’d like to tell us your story, email funding@miphealth.org.uk and we’ll get in touch.

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healthcare manager | issue 35 | autumn 2017

Reversion therapy With funding failing to match rising demand for mental healthcare, ambitious plans to transform services and achieve “parity of esteem” with physical health risk coming to nothing.

“We have these very big plans for transformation – recovery-based care, early intervention, prevention, integration with social care and the like,” says Philip, a manager at a mental health trust in southern England. “But we can’t implement them properly without more money.

We don’t have the time, we don’t have the management resource… It’s as simple as that.”

Philip says new government money for transforming mental health services hasn’t yet appeared on the frontline, leaving managers and clinicians feeling they are “desperately running to stand still – but still feeling like they’re slipping back”.

He explains: “We’ve been cutting back on psych beds for years, but we’re not really seeing referrals going down, and we’re getting more detentions [under the Mental Health Act]. Our CRHT [crisis response at home team] have also been reduced, so we can’t really respond urgently – people get a call back hours later rather than a visit, which is what they want and expect.”

His colleague Sue, who leads a multidisciplinary community team, says many NHS-approved therapies just aren’t available locally. “We can give people a consultant appointment if they can wait a

few weeks, or we can give crisis support – but not always as quickly as we’d like.

But there’s nothing much in between.

The ongoing care isn’t always there.

“We had to scale back our early intervention [for psychosis] service, which was very successful, when it was integrated into the main team,” Sue adds.

“I think we’re already seeing an increase in our caseload down the line from that.

I can’t prove it – but you can draw your own conclusions.”

Despite rising workloads, mental health trusts have proved better than acute trusts at keeping their finances in the black, leading to some resentment about the renewed pressure they find themselves under.

“We’ve done our bit,” says Philip.

“We’re more productive. We’re trying to implement all these initiatives – and we know they’re good, they’re right. But you can’t go on getting more efficient forever.

You get to a point where it’s just about cutting back – and not doing the job properly. We’re at that point now, maybe beyond it.”

The names of participants have been changed to protect their identity.

Pictures do not show the actual people interviewed.

MORE MANAGERS?

Far from having too many managers, evidence is mounting that the NHS has too few. Alison Moore looks at the latest studies to show that employing more managers leads to better patient care and more efficient services.

Y

ou walk into your local supermarket. There are long queues at the checkout, the goods you want to buy are not in stock and the staff – when you can find them – can’t offer much help.

You leave, cursing under your breath that the place obviously employs too many managers.

That would be a ridiculous assertion

– and most people would recognise it as such. Yet the NHS is continually attacked for employing ‘too many managers’ – even though the NHS has a smaller proportion of managers than almost any other sector. On top of this, NHS managers are also frequently characterised as overpaid fat cats who could not manage their way out of a paper bag.

That deeply-embedded stereotype

has been hard to shift, but evidence is beginning to mount that managers make a big difference in the NHS – the latest example being a groundbreaking academic study showing a clear link between more managers and improved organisational performance.

The study – which has yet to be published in full – was carried out by researchers from the universities of healthcare manager | issue 35 | autumn 2017

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MORE MANAGERS?

Professor Ian Kirkpatrick of Warwick Business School says his findings call into question many assumptions about general managers in the NHS.

Warwick, Bristol and Leeds, and used data from all acute trusts in England from 2007 to 2012. Some of the work (see box on page 17) was presented at the International Research Society for Public Management earlier this year and in a paper published in Organisation Studies.

Author Ian Kirkpatrick, professor of healthcare improvement and implementation science at the Warwick Business School, admits the group did not expect to find such a strong impact. “Theoretically, I would’ve expected there to be no negative impact of managers but some positive,” he says. “The findings call into question many of the assumptions about the failure of general managers in the NHS.” “This type of research does not explain the mechanisms,” he adds. “All it’s telling us is that there is an association.”

However, Kirkpatrick points out that the outputs the team studied are likely to be influenced by processes and systems – and managers influence these through their role in co-ordinating the work of others within organisations. “These are people who spend their lives managing systems and processes,” he says. “My feeling is that this data now opens up 16

healthcare manager | issue 35 | autumn 2017

the floodgates for more research asking how we explain this contribution and can further enhance it.”

Although the research focuses on acute and specialist trusts, Professor Kirkpatrick suggests it might hold true for other areas of the NHS as well. However, he warns that the extensive organisational disruption of recent years might make it hard to replicate the research in the primary care sector.

By using data from 2007 to 2012, the researchers may have captured a relatively stable period of “business as usual”, at the tail end of a period when NHS budgets were growing. “The conditions have changed. The pressure the NHS faces now probably distorts the picture. Looking at this earlier time might give you a better picture of what difference managers make,” Kirkpatrick explains.

MiP chief executive Jon Restell agrees that the pressure on managers has increased: “It could be that these managers in this period of time [during the study] were successful because their focus was on the patients and staff. If we distract them, we imperil that good work.”

As the NHS tries to drive down costs – including management costs – the research backs up the findings of previous studies, which have not been widely acknowledged. For example, the King’s Fund 2011 report Managers in the NHS reviewed the evidence and concluded that “it is at least possible that higher management costs deliver better performance”.

And research by Professor G Ross Barker from the University of Toronto, in the same year, found that higher performing healthcare organisations worldwide tended to have longer serving leaders.

More recently, the Health Service Journal reported a strong connection between the tenure of trust leaders and Care Quality Commission ratings: ‘outstanding’ trusts tended to have chief executives who had been in position for many years – in several cases, over a decade. Perhaps not surprisingly, trusts rated as inadequate had often had several chief executives in a short time.

So, what are the messages for the NHS and for politicians? “This has implications for policy, resources and workforce,” says Restell. “This is a very direct link between management activity and quality and safety.”

To capitalise on the benefits, the NHS must recognise the value of management and change the rhetoric about managers, he adds. “It could be because there’s a culture of management bashing and a tendency to see back-office functions as a cost rather than an investment. That particular culture around managers creates a lack of interest in the value of managers’ work.”

The research should prompt politicians and system leaders to think again about the value that managers can add across the range of their activities and in meeting key NHS priorities such as reducing spending on agency staff or reducing bullying, Restell says.

Attitudes towards management numbers might also need to change, he suggests: “What does this mean for numbers, job design and support for managers? If line or team management is this important, then the design of these jobs and the training and development needs to be rethought.”

MORE MANAGERS?

By way of example, he points to managers who are expected to be ‘on call’ for emergency duty, but who receive little training or support in performing a crucial role where they often have to think on their feet and intervene to ensure patient safety. Given the evidence that effective managers can make a real difference to frontline care, isn’t it worth investing in the training and support they need to do the job properly?

But the ingrained view of managers often put forward by the media and politicians is likely to be a barrier to recognising their value. Professor Kirkpatrick says he is always astonished by how entrenched unsympathetic views of managers are in the media. His message for those in power is: “Try to move away from the simplistic view that managers are the scapegoat and re-educate the public and the media. Take seriously the possibility that managers, given the right support and resources, can improve services.

“If parties started with the premise that management is on the whole a good investment rather than constantly seeking to backtrack on that commitment, it might facilitate things,” he adds.

For example, given the evidence that longer tenures in post enhance the value managers add, Kirkpatrick suggests that government could take action to improve retention and reduce high turnover, which could also start to tackle the embedded notion that managers are a “bad thing”.

Nigel Edwards, chief executive of the Nuffield Trust, agrees healthcare management is often seen negatively. “Why would good managers not make a difference?” he says. Although Kirkpatrick’s study only looked at hospitals, Edwards says there is “other good evidence about the quality of middle management and frontline supervision improving the working experience of staff”.

Edwards says the relatively narrow definition of managers used by the Kirkpatric study may even underestimate the impact of managers by excluding some middle-ranking roles. “The ward manager may be one of the people making the biggest difference in terms of efficiency,” he suggests.

“One of the things they have not

How managers add value Key findings from the study by Warwick, Leeds and Bristol universities ■■ an increase in the proportion of managers from 2% to 3% leads to a 3% per cent improvement in trust efficiency and a 2% improvement in patient experience scores ■■ higher levels of managers in a trust (the manager to staff ratio) was correlated with improved infection rates and hospital experience score ■■ When average levels of pay and stability among managers are higher, managers have an even stronger positive effect on patient experience and efficiency (as measured by the trust’s performance on the reference costs index) ■■ there is a ‘tipping point’ past which the impact of additional managers on infection rates and patient experience begins to reduce. But this is not the case with efficiency, where performance continues to rise Further details on the full report, when published, will be available on the MiP website: miphealth.org.uk

looked at here and may be an issue is flat or hierarchical structures and if they make a difference,” Edwards adds.

“What can be striking about some NHS organisations is how many levels there are between the board and the frontline.”

He suggests more hierarchical structures might get worse outcomes: “Managers might need to be fairly close to the front line to make a difference.”

Mike Chitty, head of applied leadership at the NHS Leadership Academy, says findings that longer tenure for managers improve performance probably reflects good working relationships and trust built up with other partners in the local health system.

But he warns that new chief executives are sometimes given ‘almost impossible jobs’, such as taking on trusts with multiple problems. ‘Our newest chief executives are picking up some of the most difficult turnaround jobs,’ he says. ‘When they fail in that job it doesn’t mean that they are a failure. We’re talking with newly appointed chief executives about how we support them for a decade or more.”

No senior manager can suddenly have 20 years more experience in the role, says Chitty, but the academy is working on how some of the benefits of long tenure, such as building good relationships, can be accelerated.

But he does question whether long tenure is always a benefit. “The kind of management and leadership that has got us to where we are now may not be the kind of leadership we need for the next 10 to 15 years,” he says.

Managers in these intensely demanding roles also need better support. Michael Watts, development adviser at NHS Improvement, is involved in a number of leadership programmes, including one on collective leadership, developed with the King’s Fund and three pilot trusts (resources and key lessons from the programme are available to download from bit.ly/hcm3501). “There are a number of offers out there across the system to support managers at whatever level – however long they have been in post,” he says. “We’re going to continually look at what we are offering and try to improve it.”

“A lot of trusts who come to us saying they have no option but to get external people to support them. We want managers in the system to feel empowered and supported to make decisions,” adds Watts.

Restell asks whether one day the concept of a “safe staffing level” for managers might be as widely accepted as it is for nursing staff. If that ever happens, we will know that the value of managers has finally been recognised.

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healthcare manager | issue 35 | autumn 2017

17

MANAGING BETTER CARE: IMPERIAL COLLEGE

Everyone wants to involve more clinicians in managing the NHS, but junior doctors are a notoriously difficult group to engage.

Matthew Limb spoke to Imperial College about an innovative scheme that’s already bringing results.

S

enior managers in NHS trusts have a key role in setting the right tone and culture within the organisation, and an increasingly important part of that is building trust and improving communications with frontline medical staff.

“I feel that this is essential in creating an environment that’s open, honest and set up to deliver the high-quality care we aspire to,” says Claire Braithwaite, director of operations for medicine and integrated care at Imperial College Healthcare NHS Trust in London.

Evidence suggests engaged medical staff enjoy increased job satisfaction, and have lower rates of absenteeism and burnout – leading to better safety outcomes and a better patient experience.

But every workplace is different and the needs of staff groups vary, so finding a workable approach can be challenging.

Braithwaite says she realised two years ago that the trust had to improve trust and communications with staff generally. “Our staff and GMC survey results weren’t brilliant,” she admits.

And according to James Hatcher, a former junior doctor and now a consultant at the trust, “a lot of junior doctors felt, rightly or wrongly, they were not listened to for certain things”.

Braithwaite led a programme to improve engagement with junior doctors, a group that is often hard to engage because of the short nature of rotations.

“The outline plan was to ask some

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healthcare manager | issue 35 | autumn 2017

“We got a view on life that I’d never heard before, of the reality of what it’s like on the frontline of clinical care.”

CLAIRE BRAITHWAITE junior doctor representatives to come and sit on our divisional management committee to help in day-to-day running of the division,” she explains. “We had a number of major change projects coming up that would have a big impact on junior doctors and we needed their help and support to make sure we got that right.”

The trust set up four junior doctor representative posts, paying each an additional £3,000 a year to improve engagement and contribute their expertise to decision-making. This involved drawing up what Braithwaite admits was an initially “vague” job description and adverts

aimed at tempting “willing people” to take part.

The strong response provided managers at Imperial with new insights into how to improve engagement.

“We got a view on life that I’d never heard before in terms of the reality of what it’s like on the frontline of clinical care and how some of the things we were doing affected people in a way that I’d not quite appreciated,” says Braithwaite.

The first challenge for the newly-appointed representatives was to work out the best way to engage and start conversations with junior doctors generally.

The new junior doctor representatives attended the divisional management committee and the quality and safety committee, and had equal status with other members. Braithwaite says opening up the committee for the first time to staff who had no management training was very important and “covered off what we felt was a blind spot in terms of decision-making”.

An example of this approach in action was the reconfiguration of acute medicine services at Imperial’s St Mary’s Hospital to meet new standards for reviewing and assessing patients arriving through A&E – changes which required extra consultant cover.

“In order to make that work in a way we wanted, we needed to do some quite significant redesign of the junior doctor rotas and one of our junior doctor reps

MANAGING BETTER CARE: IMPERIAL COLLEGE

took the lead on doing that, helping to set up all the engagement and consultation meetings,” says Braithwaite.

“It helped us to understand what would help junior doctors, even around timing of meetings and things like that. Therefore, the process went much more smoothly than I think it otherwise would have done.

We ended up with something we were happy with and, most importantly, the people who were going to work on those rotas were also happy with.”

The representatives also came into their own by helping to improve internal communications during the recent national junior doctors dispute, resulting in “more informed” discussions on the management committee, and better understanding among junior doctors of the trust’s view on the strikes and how they would affect services.

“I think what could have been a very difficult situation actually passed of much more smoothly because we already had a forum to have a dialogue with people we knew reasonably well,” says Braithwaite. “It helped us to identify what some of the operational challenges were going to be and put contingencies in place in order to work around them.

So difficult issues were much more straightforward to tackle and talk about.”

Hatcher, one of the very first reps on the programme, says it was especially effective in preparing him for his new job as a consultant in infectious diseases and medical microbiology at the trust. “It helped me to understand the systems

you don’t get involved with on a dayto-day basis as a junior doctor,” he explains. “That gave me lots of contacts and it was inspiring to talk to people outside my small specialty.

“I was able to grow and learn with regard to my management experience and leadership skills,” he adds. “I was able to voice opinions but also to make those connections with other people to drive change and different ideas. That two of our reps are now consultants at Imperial – both have leadership roles within the organisation – I think in itself kind of demonstrates what a success it’s been.”

The trust has received more applications for rep posts each time they’ve been advertised and the appointed reps come from a wide variety of grades and specialties.

Braithwaite is keen to get reps involved in new projects, with one rep now reviewing the trust’s complaints process.

The idea is to work out how better to use clinical teams to support patients in getting issues resolved before they make a formal complaint.

Junior doctor reps are also helping to deliver a pilot project to improve the quality of clinical coding, conducting an analysis of stress levels among junior doctors and redesigning the senior house officer role at Charing Cross Hospital.

Braithwaite says the trust has shown it has both listened to and acted upon junior doctors’ concerns.

Although she admits the trust could

DAVE GUTTRIDGE THE PHOTOGRAPHIC UNIT

have implemented some projects without the rep model, both she and Hatcher agree change has been more successfully implemented as a result of the scheme.

“A significant amount of time and effort goes into planning and implementing our engagement strategy and the introduction of the junior doctor representative role was an important part of this,” says Braithwaite. “We’ve been tracking staff engagement scores and things that come through on the GMC survey and generally those things are moving in the right direction.”

The division achieved its highest ever engagement scores, both overall and for training grade doctors, in the 2016 NHS

“It was inspiring to talk to people outside my small specialty.”

JAMES HATCHER Staff Survey. The GMC survey results for the division have also improved on previous years.

“It’s difficult to know whether these projects would have happened anyway or how successful they may have been with or without a junior doctor,” says Hatcher. “But if you are retaining staff that then take on leadership roles by engaging them earlier as junior doctors, that’s a real success, because it’s the path we really want to develop in clinical medicine in the NHS.”

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Matthew Limb is a freelance journalist and regular writer for the BMJ. healthcare manager | issue 35 | autumn 2017

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SOCIAL MEDIA

legaleye Jo Seery explains how the courts approach cases involving the use of social media, focusing on human rights, contract law and data protection.

Social media is now an everyday part of our personal and working lives. As a result, the distinction between what is private and what is public can become blurred.

This has consequences for both the employee and employer. Inappropriate social media use by an employee could amount to misconduct and lead to disciplinary action including dismissal.

Equally, employers who access an employee’s private social media account may be infringing their human rights.

Human Rights The Human Rights Act 1998 provides: ■■ the right to respect for private and family life (Article 8) – this is a qualified right and only applies where there is a reasonable expectation of privacy ■■ the right to freedom of expression (Article 10) – this right is also qualified, and can be interfered with for the protection of health or morals and the reputation, rights and freedoms of others In Barbulescu v Romania an employer asked an employee to create a Yahoo account to respond to clients’ inquiries. The employee used it to send and receive personal messages. After monitoring his account, the employer dismissed him, and his claim that his rights to respect for private and family life under Article 8 had been breached was ultimately rejected by the court.

However, this case does not mean that employers are free to monitor employees’ private communications.

Whether the right to a private life is infringed depends on whether the employee has a ‘reasonable expectation’ of privacy. In this case, the employee’s contract specifically forbade the 20

healthcare manager | issue 35 | autumn 2017

personal use of work computers.

Where an employee makes a public comment about their employer, even outside work, and the employer subsequently objects, a court is unlikely to find that the worker’s right to freedom of expression has been breached. But if the employer is not mentioned by name, courts may consider that there has been no damage to their reputation.

Contract Employers who monitor employees’ use of social media where the employee has a reasonable expectation of privacy may be in breach of the implied term of trust and confidence if they have acted unreasonably and without proper cause.

Data Protection Where an employer accesses an employee’s personal data they must comply with the Data Protection Act 1998 (DPA), which is intended to provide safeguards on the use of personal data.

The Information Commissioner’s Office has produced an Employment Practices code, which gives detailed guidance on monitoring at work. In short, it recommends that employers: ■■ carry out an impact assessment which clearly sets out the business reasons for monitoring ■■ inform staff about the nature and extent of monitoring, and how long information will be retained ■■ consider if monitoring is proportionate and whether alternative means of achieving the business reasons were available ■■ only carry out covert surveillance of social media activity in exceptional circumstances, e.g. when there is evidence of a crime being committed

Balancing rights and protections The best way to balance the rights of employees with protection for employers is to formulate a clear social media policy. The policy should be widely publicised and all staff trained on it. A good social media policy should include the following: ■■ What use of social media is allowed in the workplace and when ■■ Whether certain sites can be used in work time and for what purposes (e.g.

Linkedin) ■■ Whether an employee is required to have separate accounts for personal and professional use, guidelines on their purposes and what each can be used for ■■ What comments are acceptable and appropriate ■■ What sort of material can be posted ■■ What kind of conduct – taking into account the impact on colleagues, clients, customers and the organisation’s reputation – may lead to disciplinary action or dismissal Employers should also make clear that using social media to harass colleagues because of a protected characteristic (such as age, disability, pregnancy and maternity, race, religion or belief, sex and sexual orientation) is unlawful under the Equality Act 2010.

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Jo Seery is a professional support lawyer with Thompsons Solicitors. For employment law expertise and advice from Thompsons, visit: thompsonstradeunion.law

Legaleye does not offer legal advice on individual cases. MiP members in need of personal advice should immediately contact their MiP rep.

TIPSTER

Working with doctors With patient demand rising as the funding noose tightens, relations between doctors and managers can become strained. But it doesn’t have to be like this. Umesh Prabhu shares his tips for working more effectively with your medical colleagues. For more advice, visit the MiP website.

1. RESPECT EACH OTHER

junior doctors, GPs and so on. I just asked them five questions: Who’s the best consultant? Who’s a nice human being? Who’s a good team player? Who do you want to see as the leader? And why? Everyone knows my mantra by now: “happy staff, happy patients”. It’s a leader’s job to create a culture of staff happiness.

Doctors and managers are both under severe pressure for different reasons.

Doctors struggle to provide the best care but there isn’t enough money. Managers struggle to manage budgets and meet targets. To work together, doctors and managers must understand each other’s difficulties and needs. That means we need to respect, listen to, engage with, praise, value and challenge each other.

8. DON’T BE INTIMIDATED Some doctors are a nightmare to manage but they’re very easy to inspire and lead.

Try to listen to doctors and engage them, – leave “management” to the clinical directors. Don’t be intimidated into avoiding talking to doctors about how your organisation is run. If you open a dialogue, you may be surprised how co-operative even difficult doctors can be.

2. GET TO KNOW DOCTORS Go and meet the doctors in your organisation individually. Ask them, “What’s your plan? What do you want to do? How can I help you improve patient care?” I believe around 80% of doctors are reasonable and easy to deal with. The rest may be cynical and resistant to change, but most can be helped – only 1-2% are actually bad doctors. Get the most co-operative and engaged doctors on your side – let them tackle the more difficult ones. And avoid talking to doctors in a group; the herd mentality takes over and only the most vocal people will talk.

3. TALK THE SAME LANGUAGE Most doctors and nurses don’t think about resources and aren’t trained in finance – they instinctively think only about patient safety. So you need to change your language. Don’t tell doctors you want to save money, tell them you want to use resources effectively to improve the quality and safety of services. And then ask them: how can you help?

4. SHOW DOCTORS THE EVIDENCE Doctors like data. If you tell me, “Umesh, you’re wasting money, we’re going to do X”, I won’t co-operate. But doctors are fiercely competitive and if you show me the financial and performance data, I’ll be interested and will help you solve the problem. But make sure you’ve got your figures right: doctors won’t trust you if you give them inaccurate data more than once or twice.

9. TAKE RESPONSIBILITY 5. ASK DOCTORS FOR HELP Like most people, doctors hate being told what to do. But if you respect doctors and ask them for help, they will melt in front of you. And they will tell you how to do it.

Managers don’t involve doctors enough in decisions about finances and meeting targets, but doctors are very bright and like solving complex problems – so don’t waste the skilled resources at your disposal.

6. TRAIN DOCTORS AND MANAGERS TOGETHER I believe teaching doctors to be good leaders is the key to transforming the NHS, but you must train clinical and general managers together and within your own organisation. At Wigan, basic leadership training was mandatory for anyone who wanted to be a clinical leaders. We spent eight days training them in behaviour, leadership, clinical governance, team working, patient safety, finance and value for money, change management, good HR practice, and having difficult conversations.

7. FIND THE BEST LEADERS Handpick your leaders by talking to nurses,

Be honest about what problems you can solve and take responsibility for raising those you can’t with more senior managers or the board. Patient safety and quality of care is everyone’s job. A robust system of clinical governance is very important – it means everyone is accountable for their behaviour and everyone gives feedback and support.

Too much NHS management is reactive – responding to problems with sanctions, blaming and shaming – when we should be proactively listening to staff and supporting them to make changes.

10. GIVE DOCTORS A SENSE OF BELONGING To many doctors, trusts feel like remote bureaucratic institutions. So it’s vital for the board to make themselves visible and available. At Wigan we invited junior doctors and consultants to contribute to board and other important meetings and helped them to understand how dificult managers’ jobs are. When even the most junior doctor feels they can go to the medical director, you’ll know you’re getting the culture right.

Umesh Prabhu was medical director at the multi-award winning Wrightington, Wigan and Leigh Foundation Trust from 2010 to 2017. healthcare manager | issue 35 | autumn 2017

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MIP AT WORK

PAY

Shout to the top For the first time, MiP and other healthcare unions have submitted a formal pay claim on behalf of all NHS staff on Agenda for Change directly to the Treasury.

In September, NHS unions, including MiP, broke with tradition and submitted a pay claim directly to the government on behalf of more than one million health workers across the UK. Although pay for NHS staff on Agenda for Change has been nominally set by an independent pay review body since 1986, unions believe the government’s 1% cap on public sector pay rises means NHS pay is effectively determined by the Treasury.

In a letter setting out the formal pay claim, unions called on chancellor Phillip Hammond to earmark funds in the November Budget for a 3.9% pay rise – in line with inflation as measured by the Retail Price Index. The claim also calls for an additional flat-rate rise of £800 for each member of staff – to restore some of the pay lost over the past seven years and to tackle the scourge of poverty pay in the NHS. The unions argue that the RPI is a better measure of the rises in the cost of living facing NHS workers as it includes housing costs, which are excluded from the government’s preferred measure, the Consumer Prices Index (CPI). In August the CPI stood at 2.9%.

NHS managers on Agenda for Change, along with almost everyone else who works for the NHS, have suffered real terms pay cuts of around 15% since 2010 because of the government’s harsh pay policies, the unions say.

“We believe the government has undermined the role of the independent pay review body and severely restricted its ability to make recommendations.

Health unions are therefore seizing the initiative today and going directly to the government,” said MiP chief executive Jon Restell.

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healthcare manager | issue 35 | autumn 2017

Public “right behind” NHS pay claim The unions’ campaign for a decent pay rise for NHS staff was given a boost by a new poll in September which showed overwhelming public support for ending the government’s cap on NHS pay.

The poll of over 2,000 people by ComRes found that 84% supported removing the 1% cap on pay rises for NHS staff, while 83% supported increasing pay for all NHS staff to meet or exceed the cost of living as measured by the RPI, currently 3.9% The public also strongly backed moves to restore some of the losses NHS staff have suffered after seven years of severe pay restraint, with 69% supporting the unions’ demand for an additional flat-rate £800 for all NHS staff. The poll also found that 77% of people thought low pay was a reason why many staff were leaving the NHS, and 74% thought it deterred young people from choosing NHS careers.

MiP chief executive Jon Restell said: “The public backs the main planks of our pay claim. This is the same public that values and relies on the care provided by NHS staff. The ball is now in the government’s court. It must respond meaningfully to the pay claim, which the public are right behind.”

For full details of the survey results visit the ComRes website at bit.ly/hcm3503.

“Managers in the NHS know how the cap has hit their own pay, and that of their staff. They see the damage it’s doing to NHS services by making it harder and harder to recruit and keep good staff. Patients need the best staff and our staff need a fair pay rise,” he added.

UNISON head of health Sara Gorton said that meeting the unions’ claim would help struggling hospital trusts to attract new recruits and hold onto experienced staff. “Continuing with the pay cap will further damage services, and that affects us all,” she warned. “The government must give the NHS the cash it needs so its entire workforce gets a decent rise, without the need for more services to be cut.”

Following the announcement of pay awards above 1% for police and prison officers in early September, Gorton warned against a selective lifting of the

“Continuing with the pay cap will further damage services, and that affects us all.”

SARA GORTON UNISON, HEAD OF HEALTH cap in the NHS. “All public servants, no matter where in the country they live or what job they do, deserve a proper pay rise,” she added.

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MIP AT WORK

CASEWORK

Out of sight, out of mind When employers outsource services like payroll and staff benefits, it can be hard to hold them to account when things go wrong. One senior manager speaks to Craig Ryan about her frustrating and costly experience with her employer’s leased car scheme.

Paying people the right amount at the right time is perhaps the most basic duty for any employer. Yes, complicated tax rules mean pay isn’t always straightforward – but employers have a responsibility to sort out mistakes as efficiently as possible, and not put hardworking staff under the additional stress of financial uncertainty. That’s what payroll departments are for. Sadly, not all NHS employers take this responsibility as seriously as they should.

Lucy, a manager working for a community trust, was persuaded to join a new “salary sacrifice” leased car scheme after her employer ended its previous salary deduction scheme. “They produced this lovely booklet where you could go through and choose your car, and it explained how it all worked,” explains Lucy. “I found out afterwards, there was a tiny, tiny line that said something about considering the HMRC tax rules for company cars, but that wasn’t included in the financial illustrations, and I had no idea at the time of the impact it would have on me.”

With salary sacrifice schemes, you agree to reduce your salary in return for a benefit, supposedly resulting in lower tax and national insurance payments. Generally, such schemes only reward employees when the benefits are tax free – childcare, for example – but with taxable benefits like company cars, employees can find themselves seriously out of pocket.

“I didn’t understand why I suddenly had loads of tax to pay,” says Lucy. “It was significantly different from the salary deduction scheme in several ways, but nowhere in the financial information did it tell me this, so I was unable to accurately compare the two schemes.”

After two years, Lucy downgraded to a

smaller car to save money. Despite immediately updating her details with HMRC, a series of errors by her payroll department – outsourced to NHS Shared Business Services (SBS) – led to unpredictable changes in her monthly pay.

“I was getting tax codes issued every few weeks, and my tax allowance was whittling down to virtually zero,” explains Lucy. “Every year for the last four years, my pay has been incorrect because of errors made by SBS.” In the midst of all this, Lucy took time off work for an operation and an employment break to care for a sick relative. “It was an incredibly stressful time for me and I thought I just don’t need this now,” says Lucy. “I was trying to get my employer to take this seriously. I shouldn’t have had

to deal with this on my own. I felt very let down by them and by SBS.” In March, Lucy decided to withdraw from the scheme and hand back the keys to her car – a move which landed her with an additional £800 penalty.

MiP national officer Jo Spear, who has been supporting Lucy, says such cases are now depressingly common. “We’re seeing this throughout the NHS – the outsourcing of services like payroll and occupational health to cheap but incompetent providers. What makes these cases particularly frustrating for staff is the hands-off attitude from employers when things go wrong.”

As a union rep, Jo was not allowed to to talk directly to HMRC or SBS, but helped Lucy to work out her options and put pressure on her employer to take responsibility for the failings of its payroll provider.

Jo is also talking to the local staff side to see how the policy change on lease cars – which affects mainly managers like Lucy – came to be approved.

“The employer can’t evade their responsibilities to staff just because they’ve contracted the service out,” says Jo. “They have to take up the issue with SBS and make sure something’s done about it, as well as investigating why it happened in the first place.”

Lucy’s employer has now “escalated” her case and agreed that her pay will be closely monitored for the next 12 months.

But Lucy says she will still be “on tenterhooks” when she opens her first payslip after returning to work in November. “I need to feel assured that they will get this right in the future, and they’re not just going to hope it will be right and then apologise afterwards – which is what’s been happening.”

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If you’re experiencing problems with outsourced payroll or other services, speak to your MiP rep or national officer as soon as possible. healthcare manager | issue 35 | autumn 2017

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THE SHARP END: SYSTEM CHANGE

Dean Royles, director of HR and organisational development at Leeds Teaching Hospitals, calls for a more streamlined system to run the NHS in England.

e in the NHS are constantly trying to deliver better services with flatlining resources. In previous years, I have lobbied for better funding, but we know that we could also work more efficiently and effectively.

The frontline NHS workforce is dedicated to improving patient services and reducing waste. There are many good examples of major efficiency savings and new ways of working which have begun to scratch the surface of this funding gap.

Unfortunately, our efforts to make fundamental and lasting improvements are being hampered by a very confused organisational landscape at national level in England, where six statutory bodies are sending out conflicting messages and competing over policy territory. They can seem more focused on defining and protecting their roles than on supporting health providers to deliver good services.

I’ve spent 30 years in NHS HR, working for many different trusts and national bodies, and throughout my career there’s been tension around how the centre relates to providers. It’s nothing new, but the problem feels particularly stark today.

There’s little clarity in the division of responsibilities between the Department of Health, NHS Improvement, the Care Quality Commission, NHS England, Public Health England and Health Education England. The result is a lack of coherent strategic management across our health services, which affects how we do our jobs and the cost-effectiveness of the NHS – and could damage patient services.

One example is the ending of bursaries for student nurses. We’ve seen lots of media coverage of the extra costs of qualifying as a nurse. The centre defended the decision but missed the opportunity for a national campaign to boost nurse recruitment, and I’m sure that’s partly because it’s not clear who’s doing what. I believe a campaign similar to those for recruiting

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healthcare manager | issue 35 | autumn 2017

JOHN LEVERS

The confused centre is holding us back W

teachers would have helped avoid the fall in student nurse applications we’ve seen.

We see the same problem with national bodies publishing conflicting guidance, or getting involved in policy fields outside their core roles. In theory, the DH has largely passed provider guidance work to NHS Improvement – but it still puts out lots of material. NHS Improvement publishes guidance on consultant job planning, which you’d expect to come from NHS Employers. And of course everyone has a view on the implications of Brexit.

When the Getting It Right First Time team (GIRFT), which identifies variations in hospital care, recently argued for more consistency in commissioning, NHS England responded that GIRFT has nothing to do with commissioning and that CCGs must be free to make decisions locally.

Many believe the underlying problem is that Andrew Lansley’s reforms have never operated as intended; these statutory bodies were created for a system that doesn’t exist. Lansley wanted to put clinicians in the driving seat as commissioners, believing that patient choice

and competition would improve quality.

But it seems to me that CQC inspections have become the main drivers of quality.

Meanwhile, the DH, which was supposed to leave hands-on management to NHS England, hasn’t in fact relinquished its traditional roles. The result is that national bodies appear introspective and key policies lack a single, clear voice.

Sustainability and Transformation Plans are exposing these weaknesses. STPs require delivery bodies to compromise some individual goals for the greater good.

However, regulators like NHS Improvement and the CQC still hold each provider to account individually. STPs are essentially voluntary partnerships that managers are asked to pursue around their day jobs, and so we’re often disincentivised from co-operating on common goals such as reducing the use of agency staff.

We need more strategic direction across the system, rather than a complex set of national regulators and performance management systems that don’t line up with current policies. For years we’ve tried to manage the impact, but experience shows we now need another solution.

I understand people’s reluctance to embark on a new wave of NHS reforms. But I think we need fresh legislation to bring much greater clarity to organisations’ responsibilities and rebuild performance management around today’s policy goals.

Providing better care for an ageing population is the aspiration of all my colleagues working on the frontline. To achieve that, we all need to work towards and support the same goals – from the centre out. In my opinion, that demands a new, more streamlined system.

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The Sharp End is your chance to tell politicians and civil servants how their policies affect your work and your organisation. To work with a reporter on your own story, email thesharpend@healthcare-manager.co.uk. When requested, anonymity is guaranteed.

Our pledge to you

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Standing up for you

Free to attend for MiP members

MiP Members’ Summit 2017 ACTIVE MANAGERS, ACTIVE UNION Tuesday 31 October 2017 ■ 9.30am-6.00pm

Westminster Central Hall ■ Storey's Gate, London SW1H 9NH Join us at our exciting new look annual event for members from across the UK which will include a full day of policy debate, interactive training and practical workshops.

There will be opportunities to: Discuss your priorities for MiP, whether you work for a provider, commissioner or system body, in our ‘System Change’ regional/country forums.

Attend ‘Management Life’ workshops led by our lay and professional officers and featuring experts on: an equal workplace for everyone; leadership development and planning your career; managing people well; and well-being for you and your staff; partnership working to create change in the workplace.

Network with other members and allies over lunch Debate MiP’s policy on pensions, pay, funding and management standards, in the ‘Influencing the World’ session in the afternoon Learn from NHS leaders about the importance of MiP and its reps for employers and patient care Understand how you can change the workplace by becoming more active in the union Take positive experiences back to your workplace

After the summit, we will walk across to the House of Commons to host a parliamentary reception to lobby MPs on support for health and care managers.

Register at www.mipsummit.co.uk

For further information email register@mipsummit.co.uk or phone Connect on 020 7592 9490