Healthcare Manager Spring 2018 by lexographic

issue 37 spring 2018

healthcare manager

BREAKING THE SILENCE It’s time to talk about mental health at work

COUNTY CHAMPION Mary Hutton on Gloucestershire’s health and care transformation plus WHAT’S HAPPENING TO ME? How the menopause can wreck women’s careers

OPENING UP TO MENTAL HEALTH AT WORK M Mshire plus MEDINAGERS Umesh Prabhu on hctors

inside front cover_unison.pdf

12/4/17

10:17

There’s more to life than work

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to secure some of the best deals exclusively for you. Take a look at benefits.unison.org.uk Or call UNISON Direct on 0800 0 857 857 You’ll see how your UNISON membership can benefit your everyday life too.

issue 37 spring 2018

healthcare manager inside

Craig Ryan Editor

heads up:2 Leading edge: Jon Restell – we need to get serious about leadership.

analysis:8 Three letter words: How to sort your STPs from your ICSs and ACOs.

features:10

published by Managers in Partnership

Menopause: Supporting women in the workplace. Interview: Mary Hutton, Gloucestershire’s NHS chief. Out in the open: Why we need to talk about staff mental health. Managing Better Care: Hands-on innovation at Imperial College.

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: Making an Employment Tribunal claim. Tipster: Becoming an inclusive leader. MiP at Work: What you need to know about the NHS pay deal for England.

the sharp end:24 Outsourcing: Why the NHS needs to build better long-term relationships with its suppliers.

It was a humbling experience, while working on this issue, to speak to two brave managers whose mental health was broken, at least in part, by their efforts on behalf of the NHS (see page 15). This really brought it to home to me that, while employers have much to do, mental wellbeing at work is the responsibility of all us – as managers, trade unionists, colleagues and friends – and not something that will come about just through procedures written down in a staff handbook. Yes, we want great workplaces where everyone can thrive. But even with reasonable workloads, supportive employers, understanding colleagues and adequate funding, healthcare will always be emotionally and mentally demanding. Some of us will inevitably fall by the wayside. Recognising and dealing with that is the price we pay for having real, live human beings working in our health and care services. I must apologise to members for this issue reaching you slightly later than normal – mainly due to the work we’ve been doing on the brand new MiP website. With our new site, we’ll be able to bring you lots more coverage of the issues that matter, much more quickly – as well as online access to everything in Healthcare Manager. We’re almost there now, and I can promise you it will be worth the wait.

healthcare manager | issue 37 | spring 2018

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

NHS Funding

May’s long-term cash pledge may need Labour support

a long-term funding regime for both health and social care. May told a meeting of Commons select committee chairs on 27 March that ministers would publish a new funding plan for the NHS ahead of next year’s planned Whitehall spending review. “I want that to be done in conjunction with NHS

healthcare manager

Design and Production Lexographic www.lexographic.co.uk

Cover image

issue 37 | spring 2018 ISSN 1759-9784 published by MiP

Contributors

DANIEL LEAL-OLIVAS/PA WIRE/PA IMAGES

Healthcare experts have given a cautious welcome to prime minister Theresa May’s promise to unveil a “long-term, sustainable funding plan” for the NHS later this year, warning that the funding gap was unlikely to be plugged without tax increases and cross-party agreement on

leaders and provide a multiyear funding settlement consistent with our fiscal rules and balanced approach,” she said. “Ensuring the NHS can cope with demand ahead of the spending review, I would suggest we can’t wait until next Easter,” she added. “I think in this 70th anniversary year of the NHS’s foundation we need an answer on this.” Whitehall sources suggested health secretary Jeremy Hunt was pushing for a ten-year funding settlement, with Chancellor Phillip Hammond considering a £4bn funding boost to mark the NHS’s 70th birthday on 5 July this year. King’s Fund chief executive Chris Ham welcomed the announcement but warned that the NHS funding gap was set to widen to £20bn by the end of this parliament, and that social care services needed an immediate injection of at least £2.5bn

Editor

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

Daloni Carlisle, Anna Charles, Jane Farrell, Matthew Limb, Alison Moore, Jon Restell, Matt Ross, Craig Ryan, Bernie Wentworth. Opinions expressed are those of the contributors and not necessarily those of healthcare manager or MiP.

healthcare manager | issue 37 | spring 2018

to meet current demand. “The prime minister’s announcement is welcome recognition that the NHS can no longer maintain standards of care with the funding it has been given,” he said. “A new health and social care settlement is required to stabilise services and enable them to plan with certainty for a growing and ageing population.” Professor Anita Charlesworth, director of economics and research at the Health Foundation, said meeting the NHS’s long-term funding needs, while hitting targets to reduce government debt, “will almost certainly require a commitment to increase tax”. “A commitment to long-term stable funding for the NHS is a really important development,” she added. “But a 10-year settlement will span a general election and, if it’s to hold, there will need to be cross-party support.”

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Letters

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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

n the NHS, as for all human enterprises, leadership is the thread running through everything. For any system to survive and thrive, someone needs to take a lead and motivate people to follow. With every major issue in health and care, leadership is crucial to changing the way things are done. Given this, outsiders might expect leadership to be one of the highest national priorities in health and care. But they would be wrong. For all their fine words, when the time for action arrives, politicians and policymakers often fail to thread the needle. This failure to invest attention and resources in leadership has been so persistent and damaging that the many achievements of the NHS workforce, particularly in recent years, seem even more remarkable. Politicians and policymakers fail for two reasons. First, they don’t properly value the ‘support’ staff of the NHS, who, despite making up 45% of the total, have been accurately described as the “invisible workforce”. Second, they suffer from a deep-rooted aversion to management, a feature of both left and right in British politics. We pay a high price for those failings. How many young people think of the NHS, one of our largest employers of IT professionals and accountants, as a great place to pursue a non-clinical career? Endless re-organisations and job cuts have robbed services of experienced, specialist managers, and the absence of management from workforce strategy means we won’t attract the next generation of skilled managers. Bluntly, if it doesn’t say Nurse or Doctor, it doesn’t matter.

“Outsiders might expect leadership to be one of the highest national priorities in health and care. But they would be wrong.”

Nowhere can you see this aversion more clearly than with pay. The proposed three-year pay deal for Agenda for Change staff (see p22) finally ends the pay cap and has good features for everyone, including managers. But it unfairly singles out staff at the top of Bands 8D and 9 for smaller pay rises, and denies those in Bands 8 and 9 the investment offered to all other staff in reducing the time it takes to progress through their pay bands. As our national committee identified early in the talks, it’s already hard to attract clinicians to 8A management jobs: the extra responsibility and unpaid hours aren’t worth the candle. And the strategy for very senior managers seems to be little more than a series of transient tactical judgements based on the likely attitude of the Daily Mail. In other words, it’s not a strategy at all. The situation is not without hope. Local employers and staff are much better at valuing and supporting managers than politicians (with the odd honourable exception, like Philip Dunne). There are signs of good intentions from national bodies, with NHS Improvement’s leadership framework, the programmes of the NHS Leadership Academy, and encouraging noises from new NHS Improvement chair Dido Harding about a more nuanced approach to

senior management accountability. But good intentions burn up in the heat of media and political controversy, and single initiatives can never replace the need for a comprehensive workforce strategy for managers. Politicians are the key. Our submission on the draft workforce strategy for England made three key suggestions to help thread the needle: ■■ Support staff are as important as clinical staff in delivering the services patients need, and deserve the same strategic focus. Just as there are safe staffing levels for clinicians, we need indicators for the required level of other staff in relation to clinical and patient activity. ■■ Recognise the complexity of managers as a staff group. There is no single supply line – management is populated in fundamentally different ways. Some manage full-time, while others do it alongside hands-on clinical work; some are managers throughout their careers, while others take on managerial responsibilities after substantial careers in other roles. ■■ Invest attention and resources in management careers and ensure that managers are more representative of the population they serve – this requires a supportive and realistic approach to accountability, and proportionate spending on pay and training. Politicians face a choice about leadership and managers: invest, or continue to ignore. None of our suggestions will happen without their sustained support. The long term funding settlement proposed by the Prime Minister is the opportunity to make that choice.

healthcare manager | issue 37 | spring 2018

HEADS UP

Former MiP chair Zoeta Manning chaired the 2018 Women into Leadership (WiL) Healthcare conference in London on 21 March. WiL Healthcare, which is supported by MiP and NHS Employers, explores the issues that matter to women healthcare leaders and offers practical advice and coaching on how to further develop your career in times of change. This year, MiP national officer Jo Spear gave a presentation on leading and surviving organisational change, and other speakers included Royal College of Nursing president Cecilia Anim, UNISON head of health Sara Gorton and NHS England’s director or organisational change Sheree Axon. For further information, visit the WiL Healthcare website at: healthcare.womenintoleadership.co.uk.

National bodies

MiP has demanded “full engagement” from management at NHS England and NHS Improvement, after the two organisations unveiled plans for closer working relationships, including joint national activities and the integration of regional teams – without prior consultation with trade unions. In a joint announcement to staff on 27 March, NHS England chief executive Simon Stevens (pictured left) and Ian Dalton (pictured right), chief executive of NHS Improvement, ruled out a merger between the two bodies, but said the existing pilot of closer working arrangements in the South of England would be extended across the country. “The public see the National Health Service as a single organisation so, as we work to improve care for patients, it’s right that the national leadership of the NHS work more closely. Together we are more

PA ARCHIVE/PRESS ASSOCIATION IMAGES

Unions demand consultation over “closer working” threat to jobs

than the sum of our parts,” said Stevens. Jo Spear, MiP national officer and interim chair of the staff side for NHS England, said the only consultation was a briefing at which union officials were given the same slide deck and documents shared with staff later in the day. “I told the employers that we are very concerned and disappointed about the lack of notice or engagement with staff side about the announcement,” she added. “This in the context of continual requests from staff side for more clarity about the South trial and

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about when or if it might be rolled out.” Spear said the two organisations’ plans were “at a high level stage of discussion” but “both boards are clear that their proposals do not amount to a merger or a take over by one organisation or the other”. Under the plans, the two national bodies plan to “integrate and align” national programmes and activities, with “one team where possible”, and merge their regional teams under a single director working for both organisations. They will also take steps to “use collective resources more effectively” and

“remove unnecessary duplication”, the two organisations say. The impact on members’ jobs remains unclear at the time of going to press. “MiP – and the other unions – expect full engagement in the further development of the proposals in yesterday’s announcement and in the consultation process,” said Spear. “This is essential to ensure the protection of our members’ employment rights, job security and terms and conditions.” She added: “This is a very unsettling situation for everyone in both organisations, not helped by the manner of the announcements and the failure to engage us beforehand. Working together and sticking together we should be able to improve matters and represent your interests effectively with the employer.” If you work for NHS England or NHS Improvement and are concerned about what closer working plans will mean for your job, contact Jo Spear: jo.spear@miphealth.org.uk.

HEADS UP

Workforce strategy

Don’t ignore support staff, says MiP MiP has welcomed the draft NHS workforce strategy, published by Health Education England (HEE) in December, but called for more investment and attention for the “wider NHS workforce” – including managers and support staff – and warned that staff shortages cannot be tackled without more investment in the NHS. The draft workforce strategy for England, Facing The Facts, Shaping The Future, is the first attempt to devise a coherent plan for the NHS workforce for 25 years. It sets out six “principles” to support better workforce planning: boosting the supply of skilled staff, investment in training and education, improving career pathways, widening participation, modernising employment practices and “joining up” service, financial and workforce planning. In its submission to HEE’s consultation, MiP called for the adoption of indicators for required levels of support staff, similar to those already in place for clinical staff. “Just as there are staffing level indicators for clinical staff in relation to patient activity, there could also be ones which map out the required level of staff working in the wider workforce in relation to clinical staff and patient activity,” said MiP’s submission. “The development of such ratios could in itself demonstrate the value placed on this group of staff and guide employers on what is the bottom-line.” The union criticises the continuing under-investment in training for support staff, who make up 40% of the NHS workforce but receive only 5% of the training budget. The submission stated: “Investment is key for this group, which includes many with the lowest level of pay and status, in order for them to be both effective in their ‘day jobs’ and have worthwhile and progressive careers. “The strategy needs to give a loud and clear message that making the time to train and learn is as important as “doing the day job” in order to secure the longterm future of the workforce,” MiP added.

“The strategy needs to give a loud and clear message that making the time to train and learn is as important as ‘doing the day job’ in order to secure the long-term future of the workforce.” MiP says the workforce strategy must ensure that all NHS staff feel valued. “There are some staff groups which feel that they are valued less than others,” said the submission, adding that managers are “a case in point as they have the responsibility to take actions to manifest valuing staff at the same time as being a group of staff which is valued less, especially by those outside the health and social care system.” MiP also argues that ensuring an adequate future supply of skilled staff is about

“more than getting the size and nature of the supply lines right” and must include best employment practice and adequate investment in NHS services. “The impact of best employment practice includes: encouraging staff to remain in and want to pursue careers in the workforce; increasing productivity as staff perform better; and promoting the NHS and care system as an attractive place to work,” said the document. MiP endorses HEE’s view in the draft strategy that current staff shortages are the result of “a historic disconnect” between service planning, financial planning and workforce planning. “However, the most significant determinant on the size of the workforce has always been how much money is invested in the NHS,” the union said. Consultations on the draft workforce strategy have now closed, and the final strategy is expected to be published in July. Read MiP’s submission in full on the MiP website: miphealth.org.uk.

healthcare manager | issue 37 | spring 2018

HEADS UP

Pay

Scottish staff promised 3% rise, but top managers could miss out

“This agreement is an important first step to securing a Scottish deal for Scottish NHS workers, and we’re determined that it will deliver for our staff and roll back the pain of austerity.” TOM WATERSON Chair UNISON Scotland Most NHS staff in Scotland are set to receive a 3% pay rise this year, under proposals tabled by the Scottish Government in response to the threeyear pay deal agreed in March by unions and NHS Employers in England. But some senior MiP members could miss out after the Scottish Government suggested the full 3% pay rise would be restricted to staff earning less than £80,000 a year. MiP chief executive Jon Restell said the union would press the Scottish Government to clarify the pay position for senior managers as soon as possible. 6

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“It would be very disappointing if the Scottish Government chooses to follow the Westminster government by unfairly singling out some senior staff for lower pay rises,” he said. The 3% deal is an interim offer for 2018, while further talks are held with unions on implementing a Scottish version of the complicated restructuring of the Agenda for Change pay system agreed for staff in England. Tom Waterson, chair of UNISON’s Scotland committee, said: “UNISON Scotland accepts the offer of 3% and demands that it‘s implemented without further delay. This agreement is an important first step to securing a Scottish deal for Scottish NHS workers, and we’re determined that it will deliver for our staff and roll back the pain of austerity.” He warned UNISON would not accept suggestions from some Holyrood sources that the 3% rise could be held back until the pay deal in England has been formally implemented, which is not expected to be before July. “That is not acceptable… the government has promised 3% and UNISON won’t allow anyone to delay the implementation of that rise,” he said. Under the ‘Barnett formula’ – the Treasury rules which link the budgets of devolved governments to spending levels in England – Scotland is set to receive an additional £370m as a result of the pay deal in England, while the Welsh Government will see its budget rise by £210m. Devolved governments are free to spend the money as they wish, but ministers in both Edinburgh and Cardiff have promised the full sum will be spent on NHS pay. Meanwhile in Wales, talks between unions and the Welsh Government are continuing in a bid to resolve an existing dispute over the reinstatement of terms for unsocial hours, mileage and preceptorship payments, and no pay offer for 2018 had been made at the time of going to press. “NHS Wales workers are keen to know

“Talks around what the England Pay deal means for Wales will take place shortly. We will not enter into pay talks without an agreement over the reinstatement of your terms and conditions.”” DONNA HUTTON Head of Health UNISON Wales

how the headline-grabbing NHS England deal will affect the Welsh workforce,” said Donna Hutton, head of health for UNISON Cymru-Wales. “Talks around what the England pay deal means for Wales will take place shortly… To be clear, we will not enter into pay talks without an agreement over the reinstatement of your terms and conditions.” She promised UNISON members in Wales would have “the final say” on the outcome of the talks. Read more about the proposed NHS pay deal in England on page 22.

HEADS UP

Speaking up for NHS managers – your chance to join the FDA’s Executive committee Following the recent elections, three MiP members have been elected to the FDA Executive Committee: Richard Carthew, Simon Brake and Diane Lester. One MiP seat remains unfilled, and the FDA is now running a by-election to fill this vacancy. MiP is a partnership between UNISON and the FDA, and MiP members belong to both unions and are

entitled to participate in their structures. By becoming a member of the FDA’s Executive Committee (EC) you can speak up for NHS managers and contribute to the running of the UK’s senior public servants’ union. Becoming a member of the EC is incredibly rewarding, as you can network with members from across the civil service and public service and develop your skills, knowledge and experience. New members of the committee are well supported by the MiP and FDA staff, and by fellow committee members. Organisations that have a diverse

leadership are more successful. All members have valuable skills, knowledge and experience, and we particularly encourage members from currently under-represented groups (e.g. women, BME members, members with a disability and younger members) to seek election to the EC. But don’t hang about – nominations for the election close at 5pm on 4 May 2018.

For more information or a nomination form contact Amy Leversidge, FDA assistant general secretary: amy@fda.org.uk or 020 7401 5555.

Efficiency

Management consultants make trusts less efficient, study finds External management consultants do not save the NHS money and could make healthcare services less efficient, according to new research by academics at three universities. A study of 120 English hospital trusts over four years by researchers at the universities of Bristol, Warwick and Seville revealed that trusts spent an average of £1.2m a year on management consultants. Although a minority of trusts experienced some improvements in efficiency, the study found that higher spending on consultants was generally associated with increased inefficiency, as measured by patient outcomes and financial performance. Andrew Sturdy, Chair in Organisation and Management at Bristol University, and one of

the authors of the report, said analysis of the data over time “pointed to the fact that it is spending on management consultants that makes hospital trusts more inefficient, rather than the other way around”.

The study data did not point to a conclusive reason for why management consultants make NHS services less efficient. Possible explanations cited by the researchers include the “highly disruptive”

nature of management consultancy projects, “artificial demand” generated by sophisticated selling techniques, and consultants being used to “justify or force through existing decisions” without considering alternative sources of expertise. Sturdy suggested further research was required to identify how and when management consultants should be used in the NHS. “In the meantime, given the financial pressures facing the NHS, trusts should seriously rethink their use of external management consultants that do not deliver value for money – and, in fact, do quite the opposite.” “The impact of management consultants on public service” is published in the journal Politics and Policy and is available online at: bit.ly/ consultants-study.

healthcare manager | issue 37 | spring 2018

ACCOUNTABLE CARE

Analysis With ACSs blending into ICSs, and ACOs in hot water, Anna Charles looks at what’s cooking for the NHS in England.

Making sense of the alphabet soup There has been a recent proliferation of three-letter acronyms in the NHS. We have been introduced to accountable care organisations (ACOs), sustainability and transformation partnerships (STPs) and accountable care systems (ACSs). The latter have since been rebranded as integrated care systems (ICSs). Behind the confusing acronyms lie important objectives for the health and care system, with significant implications for its future. At the King’s Fund, we have been working to make sense of these developments – and exploring their implications for health and care managers. Why is change needed? Constraints on funding combined with rising demand from a growing and ageing population have put the NHS under enormous pressure. The NHS will have to work differently, breaking down barriers between services to integrate care around people’s needs and placing greater emphasis on population health.

The NHS Five Year Forward View set out a road map for achieving these objectives and is now being pursued through STPs, integrated care systems and new care models. This represents a different way of working for the 8

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NHS, with the emphasis on places, populations and systems rather than organisations.

What do the different terms mean? A variety of terms are used to describe different ways of integrating care and they are often used interchangeably, leading to confusion.

Integrated care systems (ICSs) have evolved from STPs. They bring together NHS providers, NHS commissioners and local authorities to work in partnership to improve health and care in their area, take the lead in planning and commissioning for their populations, and provide system leadership. Across England, providers are forming integrated care partnerships – local alliances which aim to join up the delivery of care. They may include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved in some cases. Some of the new models of care implemented through the vanguards programme, including the multispecialty provider (MSP) and primary and acute care system (PACS) vanguards, are examples of integrated care partnerships. Early evidence reported by NHS England shows that some have moderated demand for hospital care. Accountable care organisations

(ACOs) are a more formal version of integrated care partnerships: commissioners award a long-term contract to a single organisation to provide a range of health and care services to a defined population following a competitive procurement. This organisation may subcontract with other providers to deliver the contract. ACOs do not yet exist in practice. NHS England is developing a new contract for commissioners wishing to go down this route, and the Department of Health and Social Care has consulted on changes to regulations to facilitate this. Current indications are that only Dudley and the City of Manchester are planning to use the contract. Nevertheless, these developments have been met with a wave of concern and prompted two separate legal challenges. NHS England has now delayed introducing the contract and agreed to consult on how it should be used.

Why are ACOs so controversial? Two key factors are behind the controversy over ACOs. The first is that the language of accountable care originates in the United States, raising concerns that ACOs signal a move to an ‘American-style health system’. These fears are largely unfounded. It is only the idea of holding providers to account for improving outcomes for a defined

ACCOUNTABLE CARE

What does this mean for local leaders? As part of these developments, CCGs are working more closely with each other and with local authorities to develop joint or integrated commissioning, and with providers to plan care for their populations. Looking to the future, commissioning is likely to become more strategic, focusing on the planning and funding of new models of integrated care rather than annual contracting rounds. It is also likely to involve longer-term, outcome-based contracts in place of the current system of Payment by Results, which was designed to support choice and competition.

population that has been adopted from the US. The principles of a universal and comprehensive health system funded through taxation and available on the basis of need would not be affected.

The second factor is that NHS England’s proposed contract would involve using competitive procurement, raising concerns that private companies would be able to compete to deliver NHS care. In practice, this is unlikely to happen, as a successful bidder would need to demonstrate that they have the capability and experience to deliver a wide range of NHS services, and that other local providers – including GPs – are willing to work with them. However, these arguments offer little reassurance to those who doubt the capability of commissioners to manage procurements of this nature, or the motivations of some providers. In our view, it is unclear why the contract is even needed, when many areas have developed new models of integrated care without it – making use of existing flexibilities to pool budgets and join up services. A further question is whether the competitive procurement process required by law to award an ACO contract will risk undermining the collaboration between commissioners and providers that has characterised many successful integrated care partnerships.

The national bodies need to spell out the expected benefits of the contract and respond to these concerns if they wish to pursue its introduction. The vacuum created by the lack of clarity so far has fuelled suspicion and risks toxifying the wider transformation and integration agenda.

What’s happening in integrated care systems?

Ten STP areas have been selected to lead the development of integrated care systems. They have been working to put in place the structures needed for an ICS to work – making agreements to share funding and responsibility for performance, forming boards, appointing leaders to oversee the system, and renegotiating their relationships with the regulators. The updated planning guidance for 2018-19 from the national bodies makes clear that ICSs will become increasingly important in planning services and managing resources. Areas operating in this way will prepare a single system operating plan and may take responsibility for a system control total – an annual financial target set by NHS Improvement for the whole system – in 2018-19. Other systems will soon be joining the programme if they can demonstrate their readiness to do so.

Providers will need to adjust to an environment where collaboration, not competition, is the order of the day. Organisations will be asked to give up some of their own sovereignty and act in the interests of the wider system and populations they serve. Our work on system leadership points to the importance of local leaders investing time and effort in building trust and collaborative relationships. This can only be done at a local level, takes time and requires sustained commitment. A major risk to these developments is that leaders may not be able to find time to develop new ways of working while also tackling huge operational pressures. Even for the most experienced leaders, leading the development of integrated care systems alongside their day jobs is a significant ask and will not be sustainable in the long term. ICSs are not a panacea, and national and local leaders need to be realistic about how long they will take to deliver results. ICSs will not address the significant operational and funding pressures facing the health and care system in the short term. However, the King’s Fund believes that they offer the best hope for creating a health and care service that meets the needs of the population now and in the future, and their development should be supported.

Anna Charles is senior policy adviser at the King’s Fund. healthcare manager | issue 37 | spring 2018

MENOPAUSE

Daloni Carlisle speaks to one senior NHS manager whose career was wrecked by menopausal symptoms – and finds out what employers, colleagues and MiP can do to support women going through the so-called ‘change of life’.

t took Sarah Cooke a while to work out what the problem was. Same old stress at work, same high workload typical for NHS senior managers. But where she had always coped – thrived, even – now she was struggling. Three years on and with her NHS career at an abrupt and unsupported end, Sarah can finally acknowledge what was at the root of her disintegration: the menopause. If it had been possible to discuss the menopause at her workplace, things might have been different. If she had had support during the two years she went through the symptoms of menopause, she might not have forfeited her job and pension rights, and taken a £20,000 a year salary drop to join a new employer. And the NHS might not have lost a talented and committed senior manager. Something has to change. “I really did not understand what was happening to me,” says Sarah. “My memory was gone, my concentration was gone and I had hideous sleep patterns. My head felt like a fuzz in the mornings and I was having hot flushes.” Some male colleagues seemed to think this was hilarious, she adds. “At first I thought it was stress and I just wasn’t coping so I downgraded to a less senior job,” she recalls. “But that didn’t help. I felt a lot of self-doubt as I 10

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“This is not a women’s issue. If you’re a male manager, you’re going to have to deal with it. If you’re a woman, you’re going to have to go through it. Women should not have to suffer in silence.”

tried to work out what was happening to me and why I couldn’t function. I felt a failure.” A supportive GP referred her to a gynaecologist who diagnosed her as perimenopausal – in other words, actively going through the changes that lead to the menopause when periods stop. But rather than put her work problems down to this, Sarah was determined to believe she was suffering from stress and kept changing jobs in a bid to find a solution. Rather than take time off, as recommended by her GP and consultant, she battled on. To cut a long story short, Sarah eventually involved MiP, but by then it was too late. Occupational health proved unhelpful and when she was threatened with redundancy when she eventually went off sick, Sarah left the NHS for a

lower paid, less senior job. Sarah details the shortcomings in her case. “There was no one-to-one support and no risk assessment was carried out. There was no proper work plan agreed. And I didn’t involve the union soon enough.” She adds: “The combination of menopause and stress at work is a lethal one for your mental health and it’s a combination that carries a lot of stigma. We need more awareness of the symptoms of menopause and how this can affect women at work, and we need more support for women and more empathy.” There’s a strong chance that quite a lot of readers will have switched off by now. Who wants to read about the menopause? I mean, it’s just embarrassing, isn’t it? Actually no, say MiP national officers Jo Spear and Claire Pullar. It’s a natural part of women’s lives but one that can affect them significantly at work. We need to talk about it more – and without the giggling in the corner, thank you very much. The TUC and UNISON both recognise that the menopause is an occupational health issue. The TUC’s briefing on the issue says: “Employers have been slow to recognise that women of menopausal age may need special consideration and for too long it has simply been seen as a private matter. As a result it is very rarely

MENOPAUSE

FIND OUT MORE ABOUT HOW THE MENOPAUSE AFFECTS WOMEN AT WORK ■■ The menopause and work: a guide for

UNISON safety reps: unison.org.uk/ onlinecatalogue ■■ Working through the change: health and

safety and the menopause (TUC): tuc.org.uk/workplace/tuc-6316-f0 ■■ NHS menopause guidance:

www.nhs.uk/Livewell/menopause/ Pages/Menopausehome.aspx ■■ Menopause support for women:

www.menopausematters.co.uk

If menopausal symptoms are affecting your work and you’re not getting the support you need, talk to your MiP national officer.

discussed and many managers will have no awareness of the issues involved. This means many women feel that they have to hide their symptoms and will be less likely to ask for the adjustments that may help them.” The menopause affects all women, usually between the ages of 45 and 55 and typically lasting for two to five years while hormones change and periods stop. While every woman’s experience is different, symptoms can include: ■■ Hot flushes ■■ Sleep disturbance ■■ Lack of energy ■■ Anxiety attacks ■■ Frequent urinary tract infections ■■ Heavy periods and clots ■■ Dry skin and vaginal dryness All of these can have an impact on women at work. Just think about offices with no temperature control or long meetings when it’s hard to excuse yourself to visit the toilet. Think about the embarrassment of hot flushes or the anxiety of not knowing when you might bleed through your clothes. That’s why MiP has taken it up as a national issue and will be offering training and advice for local reps. “It’s a natural process and it’s natural to support people who are going through this,” says Pullar. “Yet I come across women who say they want to give up work because of their menopausal

symptoms and because their line manager won’t support them.” Jo Spear says the stigma surrounding the “change in life” means many woman can’t be open about what they’re experiencing. “They go off sick but they’re not open about the real reasons. This triggers performance management and capability reviews,” she explains. Women are regularly penalised for several short periods of absence when these absences should be recorded as part of an ongoing issue. This, says Spear, is totally inappropriate. When a woman is going through menopausal symptoms, reasonable adjustments at work should be possible. Too often, that’s not the case. “As much as we would like to be able to sit down with employers and talk about reasonable adjustments, the first thing they are going to say is that this is not a disability. And it’s not. But there are simple things employers can do to treat people fairly,” Spear adds. UNISON has published a guide for safety reps which sets out employers’ responsibility to take into account the difficulties that women may experience during the menopause. “The Health and Safety at Work Act requires employers to ensure the health, safety and welfare of their employees, and they are required to do risk assessments under the Management Regulations which should

include any specific risks to menopausal women. They also have a duty not to discriminate under the 2010 Equalities Act.” Both Spear and Pullar are heartened by what they hear from MiP reps who, they say, are very interested in finding out more about the menopause and how they can support members. Taking up individual cases and using UNISON’s checklist for employers is important, says Spear. So is simply raising the issue of the menopause and creating a space where it’s possible to talk about it. “This is not a women’s issue,” she says. “If you’re a male manager, you’re going to have to deal with it. If you’re a woman, you’re going to have to go through it. Women should not have to suffer in silence. Talk to your line manager, talk to your health and wellbeing lead, talk to your union rep about what they are doing to support menopausal women.” But what of Sarah? The salary hit has been hard, but she says she is happier now than she has been in a long time. Where once she would have been planning her route to chief executive, now she’s planning retirement and a camper van trip around Europe. “Now I have come through this, I have been able to see what really matters in life,” she says. For Sarah, the “change of life” turned out to be exactly that.

healthcare manager | issue 37 | spring 2018

INTERVIEW: MARY HUTTON

A veteran of 30 years in NHS management, Gloucestershire’s Mary Hutton doubles up as leader of the CCG and the STP. Despite the county’s fierce attachment to local services and lively tradition of dissent, she tells Alison Moore she’s optimistic the public will embrace real change.

ary Hutton admits she’s an optimist – and there can’t be many of those left in the NHS after recent months. As both the lead for Gloucestershire Sustainability and Transformation Partnership (STP) lead and head of the county’s Clinical Commissioning Group, she claims to see positive changes happening and believes they will accelerate. She’s particularly proud of strengthening the county’s services for prevention and self care. These inclide a large social prescribing service run jointly with the local authority, where GPs can refer patients to a range of local, non-clinical services, such as sports, volunteering and social groups. The CCG is also working with the voluntary sector on the commissioning of arts and cultural programmes that benefit the health and wellbeing of local people. “We’re seeing real change and will be publishing evaluation of this work in 2018-19,” she says. Austerity has made funding this kind of work a challenge for all partners, but Gloucestershire has found money for slimming classes, for example. While health promotion initiatives can sometimes take decades to deliver, a few “quick wins” can help build support. In Gloucestershire, there’s a mix of both

healthcare manager | issue 37 | spring 2018

Hutton insists organisations can co-operate and work towards common outcomes while remaining separate and accountable: “It sounds a bit idealistic but I think we have a real vision of things changing dramatically.” long-term and short-term projects. While some schemes should bear fruit within five years, others – such as work with primary-school children and their perceptions of health and self-care – may take much longer to deliver measurable health benefits. Such projects are a sign of early success for the STP which, like many others, is looking to improve outcomes despite challenging finances – in this case, principally a deficit sitting with the main acute provider, Gloucestershire Hospitals Foundation Trust. Gloucestershire is hoping to be in the second wave of moves to an integrated care system, where commissioners and providers will work much

more closely together (see page 8). How this should be achieved – and whether the law needs to change to realise some of the potential benefits – is still a hot topic nationally. Here, Hutton is again optimistic. “We can do 90 per cent of what we need to do without legislation,” she says. Organisations can do more to co-operate and work towards common outcomes while remaining separate and accountable, she insists. “It sounds a bit idealistic but I think we have a real vision of things changing dramatically.” Most of the STP savings will come from streamlining and improving services, she says, rather than reducing them. Proposals for these are likely to lead to public consultation in the future but she points out that the public have been involved in other ways already. “We have a large number of lay champion representatives as well as Healthwatch working with us on our transformation plans, and it’s clear that we would not have achieved the same answers without their involvement,” she says. “For specific schemes, we’ve worked with a reference group and are just increasing the number of people who will work with us on co-production of our plans. We’re at the stage now where we need to explain our messages

ALL PHOTOS: SAM FROST

INTERVIEW: MARY HUTTON

clearly to ensure people want to work with us to develop and then support the future changes we propose.” Hutton sees the future for acute services as quick diagnosis and treatment of conditions, with the patient returning ‘home’ as soon as possible. “We don’t want people admitted because they’re waiting on a diagnosis,” she says. “And things like IV antibiotics should be available in the community.” She talks about the two large acute hospitals in the area – Gloucester and Cheltenham – becoming centres of excellence. Both are likely to get urgent care centres but whether each will offer 24/7 A&E has been the subject of much speculation locally: Cheltenham A&E has been closed overnight for serious cases

for some years. However, Hutton suggests the public are “reasonable” about changes to traditional services. “They are beginning to understand that treatment in a bed is not always the best place for them,” she says. Hutton has worked in the NHS for nearly 30 years, first in a health authority and then in the provider sector. She often had to represent her organisation in discussions with commissioners and that led to her wanting to get more involved in commissioning. “I felt there was a better way of doing commissioning and I had to have a go myself,” Hutton recalls. She feels commissioning has shifted away from just driving good outcomes towards devising

services which will improve people’s health and wellbeing. And commissioning has seen a shift towards clinical leadership – something she welcomes. “I think CCGs have got the right clinical leadership, although I think they need to be larger,” she explains. NHS Gloucestershire, however, may be an exception to this. Serving a population of 620,000, the CCG is already fairly large and has the advantage of being coterminous with the county council and, to a large extent, other NHS organisations in the area such as Gloucestershire Hospitals. Despite including many affluent areas, Gloucestershire has pockets of deprivation – notably the Forest of Dean, but also parts of both Gloucester and healthcare manager | issue 37 | spring 2018

INTERVIEW: MARY HUTTON

Cheltenham. There is fierce public attachment to local services, and not just in the acute sector. Protestors in Stroud saw off an attempt to close the town’s standalone maternity unit more than a decade ago and are vigilant about any perceived threats. Even a proposal by the community services trust to replace two ageing hospitals in the Forest of Dean with a new one has been controversial. Many of the planned changes to services in the next few years will involve developing a different workforce, and she admits there is more to do on workforce planning. “We know the scale of the challenges we are facing. We have active work with partners such as universities in place, and hope to have plans developed by summer 2018,” she says. With GPs, there has been a shift towards more “portfolio” careers, she says, which may include spending some time in an emergency or urgent setting – something which urgent care centres may help to provide. “Within primary care there has to be a real understanding of the kind of roles that people will want in the future,” she adds. The county already has about 30 clinical pharmacists working in GP surgeries and is developing a mental health worker role – some are already in place and taking direct appointments in primary care. Hutton is keen to point out that, so far, none of the STP-driven changes have involved changing terms and conditions for staff and, with staff shortages in many areas, it’s unlikely that people will find themselves out of a job, although some may see their jobs change as new services are developed. Driving forward multiple work streams across all parts of the health sector has been a challenge for many areas’ STPs, with management “bandwidth” often under pressure. In Gloucestershire, Hutton has pushed for collaborative and distributed leadership, with people in different organisations taking the lead on particular projects. “We need to have people owning the change,” she says. “The STP came at a good time.” Distributed leadership may also take 14

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experience of being in a provider as well. I think the focus on population health and wellbeing is going to be the huge driver for the future. It’s really inexcusable for people to be admitted for a [range] of long-term conditions that can be managed at home.”

“I think we have identified areas where we can make the money work better for everyone. I am still quite driven by the idea that we should get value for money for the public purse.”

some of the pressure off Hutton herself, as the key person for both the STP and CCG. The CCG releases her for two days a week to take on the STP role, while her deputy fills in for that time. However, her timetable is still hectic – my options for meeting her included the end of the day at a railway station, or mid-morning in a service station on the M5. But she’s adamant that it’s worth it – and the different organisations within the STP are working well together. Hutton insists that, with less money around for everyone, each organisation has to be as efficient as possible. “I think we have identified areas where, if we work together, we can make the money work better for everyone. I am still quite driven by the idea that we should get value for money for the public purse,” she adds. Even with so much on her plate, Hutton has no plans to move on just yet. “I’ve been at Gloucestershire for about seven years. It’s a long time, but [organisational change] takes a long time,” she says. “I’ve really enjoyed being a commissioner, though I have had that

Looking back, Hutton does feel she should have invested more in personal development in her early years. “I feel I’ve never really sat down and planned my career development. I’ve been offered opportunities and some really strong leaders have invested in my future,” she adds. “For me, going through the King’s Fund’s Top Leader programme really allowed me to test my values and personal resilience, [learn] how to apply integrity and move to a more senior role, confident that I would not compromise my own values,” she explains. And, like many women, her mid-career involved juggling family responsibilities and work. She spent ten years in an acute trust – albeit in different roles – which she says might not have been the best option for career planning, but did suit her other responsibilities. “I do have one project I look back on with regret,” she recalls. “We had an organisation that needed to be changed and we didn’t invest enough in the planning phase, including finance and information. The project was not taken forward and I’ve now observed three different organisations grappling with the same problem over a ten-year period.” Her advice to people starting a career in NHS management now is to understand their own values and stand by them, regardless of the challenge – something she feels is particularly relevant for finance manager, who can come under pressure to accept predictions and budgets they know are unlikely to be realised. Hutton was in that position once. “I have been asked to accept a plan that was undeliverable and I was not going to do that.” The position was resolved with a compromise acceptable to all – but it’s no surprise that Hutton stood firmly by her principles.

STAFF MENTAL HEALTH

Last year’s Stevenson-Farmer report set out an ambitious agenda for improving mental health and wellbeing in the NHS. Craig Ryan explores the deep culture changes needed to make sure all NHS staff can thrive at work.

fter another punishing week and a “frantic” 24-hour period on call at the weekend, Paul, a manager for an NHS trust in the South West, found himself unable to get out of bed. He’d been experiencing stress and feelings of anxiety for months, but knew this was different. “I just couldn’t move. My head felt like lead, I couldn’t even contemplate the things I had to do to get into work,” he recalls.

Paul was signed off sick for a few weeks, and was eventually offered early retirement following a capability review. “My line manager was sympathetic, but couldn’t really offer much else. I was in my late fifties, so it felt like the only option,” he says. Paul was just one of the estimated 300,000 people who lose their jobs every year in the UK because of mental health problems. According to Thriving at Work, last year’s independent review by Lord Dennis Stevenson and Mind chief

executive Paul Farmer, the scale of the mental health challenge in Britain’s workplaces “is greater than we thought”. And the NHS is no exception. The 2017 NHS Staff Survey found that 37% of staff regularly feel stressed at work, a figure that has remained constant despite a plethora of national and local initiatives in recent years. Behind every job lost is a personal tragedy, but also a considerable financial cost to the NHS. Research for the Stevenson-Farmer report put the cost healthcare manager | issue 37 | spring 2018

of mental health problems in the NHS at around £2,100 a year per employee – higher than for any other sector except finance. And it’s not just so-called ‘frontline’ workers who are affected. In NHS England, designated by the government as an ‘early adopter’ of the report’s recommendations (see box), ‘stress, anxiety and depression’ accounts for 35% of all sickness absence – more than three times as much as ‘colds, coughs and flu’. More than 80% of calls to NHS England’s Employee Assistance Programme concern work-related stress, and almost a third involve a mental health condition. MiP national officer Jo Spear says she is supporting an increasing number of members suffering from mental health problems, particularly senior managers in provider organisations. “There’s something about that tier of management that seems to make them vulnerable to not just stress at work, but actual diagnosable mental health problems,” she explains. “I think it’s because of the proximity to patients and exposure to risks and governance pressures. With commissioners, we tend to get a lot of bullying and harassment, but fewer diagnosable mental health conditions.” Spear believes most NHS employers simply aren’t “geared up” to deal with mental illness when it affects staff in the workplace. “The policies are too onedimensional and they have a very anodyne way of dealing with it. Someone is ill, they go off sick and you need to performance manage them back to work. That just doesn’t fit the bill for mental health in the same way it does for physical illnesses.” Working together The Stevenson-Farmer review cites long working hours, regular inspections, lack of interaction with colleagues, lack of control over work, and cuts to budgets and staffing as causes of poor mental health among public sector workers. Faye McGuinness, head of workplace wellbeing at Mind, who is working with NHS England on implementing the review, says: “The onus should be on employers to support their staff through 16

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ANDERSON PHOTOGRAPHY.CO.UK

STAFF MENTAL HEALTH

“The onus should be on employers to support their staff through difficult times, so that they can come into work at their best.” – Faye McGuiness, MIND difficult times, so that they can come into work at their best, and in turn get the best outcomes for their patients… which is why implementing the recommendations of Thriving at Work is so important.” Senior managers in the ambulance service are already working with UNISON and Mind to tackle the very high incidence of mental illness among ambulance staff, which research found could be explained by the way staff were managed – particularly the handling of organisational change. In 2015, helped by a grant from the Cabinet Office, Mind set up the ‘Blue Light’ programme to provide direct support to emergency service workers with mental health problems, while working with employers to tackle the root causes in the workplace. Alan Lofthouse, UNISON’s national officer for ambulance staff, explains: “These days, your average paramedic is making really big decisions, yet their work life is still quite prescribed, with long shifts, being told where to go, and that constant requirement to keep doing

more and keep people out of hospital.” Add in the high likelihood of being assaulted, the prevalence of bullying, and a poor record on race equality, “and everywhere you looked you had these red flags that something was wrong with the ambulance service,” he says. “It would be easy for us to criticise management and just say ‘you should be doing something different’,” Lofthouse adds. “But culture-wise, people do what they observe, and historically ambulance services have been managed through grip and command – and through fear a lot of the time… The current managers have developed in that culture, but now we’re asking them to be agents of change and not simply mirror what they did before.” A healthy workplace? In England, action at national level has focused on implementing NHS England’s Healthy Workforce framework, which is being updated to incorporate the standards laid down in the report. “We’ve met with… NHS England to discuss the framework and have provided feedback, including the need for them to ensure that they have clear indicators to measure progress against what’s set out in the framework,” says McGuinness. Despite endorsing the StevensonFarmer report as an employer, the government stopped short of making the new standards compulsory for all NHS organisations – trusts and CCGs will merely be “encouraged” to meet them. “Making implementation mandatory might not be the right approach,” says McGuinness. “We’d hope that the financial argument for putting in place wellbeing initiatives is sufficiently strong that organisations get on board without any coercion.” She cites research by Deloitte which found that workplace interventions – such as Employee Assistance Programmes, which offer 24-hour confidential support, and NHS First Aider schemes – show a return of between £1.50 and £9 for every pound invested. “Even those with small budgets appreciate there are lots of small, free initiatives that make a difference – such as buddy

STAFF MENTAL HEALTH

systems, regular catch-ups with managers, flexible working hours, and options to work in different places,” she says. One of the persistent themes in the Stevenson-Farmer report is the need for employers to abandon the traditional ‘performance management’ approach, where mental health problems – if discussed at all – are tackled as issues of individual capability. “You’ve got people working very long hours under extreme financial constraints and they’re expected to behave as if the job is a vocation,” says Spear. “And then when they look like they’re going under, the finger of capability is pointed rather than support.” Spear is particularly critical of the use of ‘Bradford scores’, where formal procedures are automatically triggered after a number of incidents of sickness (typically three) within a year. “If you have a mental illness, rather than something people can see like a back injury, the assumption is that you’re just not coping and they start performance managing you, giving you performance standards to meet. “What they should be doing is giving basic consideration to whether you’re not coping because you have a workload which no normal person could cope with, and you need to talk to someone other than your line manager,” she adds. Paul agrees that sickness absence procedures often make things worse, hiding the real problems and piling more pressure on already over-worked staff. “They make it all about you, not about the job, or looking at what made you ill in the first place. And that just makes you feel less capable and less supported – sort of hopeless. I can’t see how that’s supposed to help anyone.” Lofthouse expresses sympathy with line managers who are often under pressure to reduce sickness absence and meet response time targets. “Our message is that if they treat staff well and look after them, that will have an impact on those things – but do they really understand that, and does the organisation at board level say that as a clear message?” he adds. This need for leaders to take responsibility is behind one of the

StevensonFarmer: key recommendations for the NHS ■■ Chief executives of NHS organisations to have performance objectives relating to employee mental health ■■ Regulatory bodies (e.g. CQC) to include the employer’s approach to staff mental health in their assessments ■■ Routine monitoring of employee mental health ■■ Enhanced mental health training for staff at all grades, especially for line managers ■■ Employers to identify staff at higher risk of stress or trauma and develop a national framework of support ■■ Tailored in-house mental health support for larger organisations, with signposting to clinical support ■■ Measures to encourage open conversations about mental health and the support available to staff Read the Stevenson-Farmer report, Thriving at Work, at: bit.ly/stevenson-farmer.

Stevenson-Farmer report’s most striking recommendations: that NHS chief executives should have staff mental wellbeing enshrined in their performance objectives. “It’s important that… NHS chief executives lead by example, and consider how they can be held accountable for the wellbeing of their staff,” says McGuinness. “Having performance objectives relating to employee mental health is one way they can do this… Showing staff that employee mental health is a key priority, and one that they are willing to be measured against, is a step towards creating a positive culture where staff feel able to talk about their mental health problems.” This would certainly be an unprecedented step, with big potential to drive meaningful change. But how it will be implemented across the NHS remains to be seen. “We don’t yet have any examples of this being done before,” McGuinness admits. Culture of silence Claire, a service lead for a community health trust in the South East, recently

returned to work after several months off with a mental health condition. She says the biggest problem in the NHS is that people simply feel unable to talk about problems at work that might lead to mental health conditions. “Everyone pretends they’re at this level of ‘just about coping’,” she says. “No one talks about being not able to cope until it’s too late. There’s a sort of tipping point. The support you get when you’ve been diagnosed with [a mental health condition] should be there long before things get to that point.” The Stevenson-Farmer report takes particular aim at this ‘culture of silence’, where employees keep quiet about mental illness for fear of being stigmatised, demoted or even losing their jobs. Instead, says McGuinness, employers need “to create a culture where staff feel able to talk openly about stress and mental health, and know that if they do, they’ll be be met with support and understanding rather than stigma and discrimination.” Claire cites supportive colleagues, a sympathetic line manager and a recentlyestablished staff support network as factors which enabled her to resume her career, more or less where she left off. “I was lucky,” she explains. “I work in mental health, so I had a good understanding of my own condition and could navigate the system. Having a supportive manager is really important – someone who’s prepared to stick her neck out and challenge [the employer] if needs be. But most people don’t have that.” She warns the persistent stigma over mental illness still prevents most people from getting help. “The staff network helped me a lot, but it’s mostly the same people – therapists and a few managers – talking to each other. Most people don’t come because they think everyone will know they’ve got problems, and they don’t want their manager finding out. “We want people to know that it’s okay to talk about this, whether they’ve already got an illness or not. When that happens, we might be getting somewhere.”

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

healthcare manager | issue 37 | spring 2018

MANAGING BETTER CARE: IMPERIAL COLLEGE

Severe delays in treating hand injuries at Imperial College were frustrating for both patients and staff, and undermining care standards at the trust. Matthew Limb looks at how a team of managers, clinicians and QI specialists turned the service around.

ot long ago, the experience for many patients suffering hand or wrist injuries in north-west London was “chaotic”, staff say. Injury assessment, surgery and rehabilitation were all subject to substantial delays, raising the risk of complications and poor outcomes. The trust even faced legal claims from patients who needed corrective surgery after delays to wrist injury treatment. Interventions were coming “too late in many cases,” says consultant trauma and orthopaedic surgeon Raymond Anakwe, who works at St Mary’s Hospital, Paddington. “Fractures start to heal after two weeks, so you really need to see patients within that period.” In 2016, managers, clinicians and therapists got together with quality improvement (QI) specialists to tackle the problem. The project was funded by the trust and a £75,000 grant from the National Institute for Health Research’s Collaboration for Leadership in Applied Health Research and Care programme (CLAHRC) covering north-west London. Wendy Carnegie, a CLAHRC improvement science manager employed by nearby Chelsea and Westminster Hospital, had the ideal background for it. “Before, I was a matron of operating theatres at Chelsea and Westminster and I’ve had experience myself of having hand and wrist surgery, and then hand therapy,” she explains. “I was also used to coordinating emergency surgery and very aware of all the opposing needs and that all kind of thing.”

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trust’s own QI team and clinicians, offering support, guidance and help with implementing well-researched QI methods.

“Previously everyone was referred for a face to face consultation. This could be an inefficient ordeal for both patients and staff, with clinics regularly rammed with 60 people and not enough chairs.” — Wendy Carnegie A clinical audit of 2016 data showed that 31% of patients waited over 15 days for surgery following a fracture, and another 28% waited between eight and 14 days. The most common reason for the delays was the long wait for the first clinical review at the fracture clinic. The QI initiative set out to deliver more timely treatment, more efficient use of resources and increased patient and staff confidence in the hand and wrist service. Carnegie worked alongside the

Virtual clinic The team met with stakeholders to agree on what was causing the problems and the objectives of the project. “My position wasn’t to offer solutions, it was to ask well-placed questions to get them to think about their local solutions,” Carnegie explains. In October 2016, work began on developing a new pathway. This meant creating a bespoke referral and “virtual review” software system to reduce the time between presentation and clinical review. The aim was to accelerate triage of patients to one of three destinations - fracture clinic, hand therapy or direct discharge. Patients were referred immediately via the new online system for review by specialist surgeons and therapists from January 2017. The system enabled Dr Anakwe’s team to review case details “live” while patients were notified of the process by text or email, usually before they left A&E or urgent care. “We’re able to remotely look at the history that’s been given by the referring clinician, look at the X-rays and imaging sent with it into our system,” Dr Anakwe explains. “We then prioritise and decide who needs to be seen face-to-face and when they need to be seen. It enables us to manage the workload more efficiently.” Patients who need an operation or to see a consultant are booked in via the system for a consultant appointment.

MANAGING BETTER CARE: IMPERIAL COLLEGE

They receive notification immediately. When the clinical decision is hand therapy – help with rehabilitation, managing pain and re-establishing full function of the hand – the referral and consultant’s diagnosis is copied straightaway to the therapy team, who then contact patients to book an appointment and send injuryspecific information for them to read. Patients who can be safely discharged – such as those with a sprain or soft tissue injury – are sent information and guidance for self-management, links to a patient website and details of education sessions they can attend. At first, both managers and clinicians were worried that discharged patients could feel “fobbed off” by this approach. “When you’re discharged, you’re

Raymond Anakwe, consultant trauma and orthopaedic surgeon

potentially vulnerable,” Carnegie says. “Obviously, patients can walk back into an A&E or urgent care centre but that’s not our hope because we’re trying to manage people effectively.” So it was important to find out how patients felt about using the system and make changes if necessary. Patient and staff feedback was captured online and by verbal surveys and focus groups. As a result, discharged patients now receive a phone call within a week from a hand therapist who can answer their questions, deal with any problems and make sure they don’t feel “neglected” by the system. “We’ve been monitoring this to make sure we are not dismissing patients and making them unhappy, and we’ve got lots of data showing we’re not doing that,” Anakwe explains. Following the 18-month project, all patients now have their first virtual review within 48 hours. “Previously, in the traditional model, 100% of people were referred to the hand clinic for a face to face consultation,” Carnegie says. This could be an inefficient ordeal for both patients and staff, she recalls, with Monday-morning clinics regularly “rammed with 60 people and not enough chairs”. That has changed. Analysis shows that out of 2,449 patients referred into the virtual clinic in 2017, only 60% were

triaged to hand clinic, while 18% were referred for hand therapy and 22% discharged from the service. Managers and clinical staff are delighted with the results. “Before, it was much more chaotic, we didn’t have a very good handle on it,” Anakwe says. “There’s a large cohort of patients we can tell straight away don’t need an operation. We’ve got highly skilled hand therapists, with a background in physiotherapy or occupational therapy, capable of treating a lot of these patients. And with the right information and education, a lot of patients are able to self care.” There are still some glitches to be ironed out. Of the patients discharged, 17% “re-entered” the pathway for treatment in the fracture clinic or by hand therapy. The team says the reasons for this are being investigated. The trust says improvements were observed despite a threefold increase in referrals – from an average 17 patients per week in January 2017 to 57 patients in December 2017. Feedback from patients has shown increased satisfaction with the service, particularly with the reduction in unnecessary hospital visits. Carnegie says she and colleagues from CLAHRC valued the experience of working on the project and felt very much “part of the team” at Imperial, while Anakwe enthuses about the “amazing” support from CLAHRC. “It’s been really important because there’s a temptation to press ahead and do what you want to do, see the good in it and not necessarily hold yourself to account,” he explains. “But they’ve been really good at making us go through the process, use some validated quality improvement techniques and report on what we’re doing as we go.” The “proof of the pudding”, Anakwe says, is that the trust has decided to continue supporting the project now the CLAHRC funding has run its course.

The other team members working on the project were: Joelle Chalmer, Fats Ogunlayi, Andrew Harrison, Sharika Ali, Pooja Panchasara, Alan Poots, and Mable Nakubulwa. For further information, visit clahrc-northwestlondon.nihr.ac.uk or email w.carnegie@imperial.ac.uk healthcare manager | issue 37 | spring 2018

EMPLOYMENT TRIBUNALS

legaleye Bernie Wentworth explains what you need to know about about putting in a claim to an Employment Tribunal. The Employment Tribunal is designed to provide a remedy for workers who have received unlawful treatment in their place of work. With any tribunal claim – whether it concerns discrimination, unfair dismissal, unfair deductions from pay, or a dispute over redundancy payments – there are strict time limits and procedures which you need to stick to for your case to proceed. Time limits The time limit for lodging a claim with the Employment Tribunal is three months, less one day, from the act or incident that you are looking to bring a case about. This time limit is strictly applied. If you are planning to fight an unfair dismissal case, it is very important to accurately work out your effective date of termination (EDT), as this is the date from which the time limit will apply. If your employer dismisses you with notice then the EDT is the date that your notice comes to an end. If you were dismissed without notice then the EDT is the date on which you were told you had been dismissed. If you have any doubt about when your employment terminated then you should use the earliest possible date to calculate the time limit. If you are pursuing another type of claim, such as unlawful discrimination, your case may involve a series of linked acts or incidents of discrimination that occurred over a period of time. If this is the case, then a claim must be brought within three months less one day of the last act in the series of acts. With discrimination cases, the three month time limit may be extended in 20

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exceptional circumstances if the tribunal believes that it is just and equitable to do so. These extensions are very rare, however, and decided on a case-bycase basis. For equal pay claims, tribunal applications must be lodged within six months less one day of the termination of any contract of employment or the day of any transfer of employment.

EARLY CONCILIATION EXPLAINED ■■

Early conciliation is a free service from ACAS, which attempts to resolve disputes between employers and employees through discussion. Although you must register an early conciliation request with ACAS before submitting a claim to the Employment Tribunal, there is no obligation to take part in conciliation if you don’t want to.

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ACAS conciliators will not contact your employer unless you have agreed to conciliation. If you decide not to take part, an early conciliation certificate will be issued within four weeks, allowing you to go ahead with your tribunal claim.

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Your MiP national officer or rep can represent during early conciliation talks, or accompany you to meetings.

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Many cases are settled quickly via phone calls, without the need for meetings.

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Unlike public tribunal hearings, early conciliation negotiations are completely confidential and details are not disclosed to anyone outside the process.

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Early conciliation talks are limited to one month, but can be extended by a further two weeks if both parties agree. If no agreement is reached, an early conciliation certificate will be issued and claims can be taken to an Employment Tribunal.

For further information read the ACAS guide at: bit.ly/early-conciliation

Early conciliation With a few rare exceptions, a claim to the Employment Tribunal cannot be lodged unless you have submitted a request for ‘early conciliation’ (see box). Early conciliation requires contact to have been made with ACAS (the government’s Advisory, Conciliation and Arbitration Service) before an employment tribunal claim is lodged. You can do this over the phone or by completing a form online. Early conciliation usually lasts for four weeks, after which an early conciliation certificate is issued. The early conciliation certificate number must be inserted in the Employment Tribunal claim form, otherwise the form will be rejected and the claim may go out of time. If you think you may have a case to take to the employment tribunal, contact your MiP national officer immediately – they will advise you on the merits of your case and the next steps to take.

Bernie Wentworth is employment law adviser with Thompsons Solicitors. For more information on your employment rights and how Thompsons can help, 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

How to be an inclusive leader With the need to create a more inclusive culture high on the NHS agenda, Jane Farrell offers ten tips on how leaders can champion diversity in the workplace. 1. BE POSITIVE

7. WEAVE INCLUSIVITY INTO EVERYTHING YOU DO

Equality, diversity and inclusion is one of the most exciting areas of work to be involved in. Yet discussions about it can too easily be negative. Inclusive leaders know this, and approach the challenge with creativity and positivity. They find the good practice, then develop a costed plan that fits with their strategic plan and values – one that will deliver measurable results.

No strategic plan will succeed unless you’ve thought through how it will promote equality, diversity and inclusion. Likewise, a bid shouldn’t be taken seriously unless the provider shows how they will address these issues in, for example, how much they pay their lowest-paid staff, how they deliver services to diverse groups, and the job opportunities they offer to young people from different backgrounds. Daily micro-behaviours also matter. Who do you say good morning to? Who do you praise and encourage? People notice.

2. BUILD YOUR OWN NARRATIVE People recognise when we really believe in what we’re saying and when we’re only saying it because we’ve been told to. Think through why you’re passionate about inclusion, personally and professionally. Demonstrate that it’s impossible for you to be excellent at your job without understanding how advantage and disadvantage can play out – in relation to your staff and service users. This will help others think about how they can be more inclusive in their work, day in, day out.

8. RECOGNISE YOUR AGENTS FOR CHANGE

5. FOCUS YOUR EFFORTS

Everyone needs to know their legal responsibilities under the Equality Act. Yes, inclusive leaders make sure everyone has the information they need, but they also ensure their staff can see how the legislation is directly relevant to their everyday work. If your staff don’t think through indirect discrimination, for example, they may inadvertently set job criteria that block or exclude certain groups of people.

Give priority to three areas: performance management, recruitment and service delivery. Inclusive line managers know how to work effectively with different groups of people and have those difficult conversations when needed, not before. Inclusive hiring managers know the potential impact of unconscious bias on recruitment processes, and precisely how to counteract it. And the most inclusive leaders are always thinking about how well they deliver services to different groups, whether that difference relates to age, gender, ethnicity, socio-economic status, and so on.

4. GET YOUR HANDS ON THE DATA

6. RESPOND RIGHT IF YOU GET IT WRONG

The best-performing organisations know which staff groups are more likely to be disengaged, subject to disciplinary action or show high rates of staff turnover; and which patient groups are unhappy about their care. Inclusive leaders understand the hidden cultural codes in their workplaces, and the patterns of who gets what, and why. Then they take action to tackle the inequalities they produce.

When we get it wrong in other areas of life, we acknowledge it, learn from it and change what we say and do next. Being an inclusive leader is exactly the same. Be a role-model: show you’re working on getting it right and that you take this responsibility seriously. Recognise that on occasion you’ll need to say, “I got that wrong, I’m sorry, I’m going to do X to make sure that doesn’t happen again.” And move on.

3. GET THE BASICS RIGHT

Make sure you identify and reward the people whose brilliant work on equality, diversity and inclusivity is making your organisation a better place to work. Thinking through how to reward them for their efforts is fun, too. Get creative.

9. SHOUT ABOUT THE GOOD PRACTICE All too often, people don’t know about this fantastic work their colleagues are doing on equality and diversity. Try giving someone the responsibility to search out and write up case studies showing the progress you are making. Then distribute them for everyone to see.

10. BE CONFIDENT AND COMPETENT Inclusive leaders make a positive difference when they really feel confident and competent about equality and diversity. But it takes work to build this confidence in ourselves and others. We need to feel ahead of the curve, to know what other organisations are doing, to have difficult conversations when needed, and to create a culture where everyone knows being inclusive isn’t an option – it’s required. Jane Farrell is Chief Executive of the EW Group, a leading diversity and inclusion consultancy. Contact Jane on Twitter: @JaneFarrellEW. healthcare manager | issue 37 | spring 2018

MIP AT WORK

AGENDA FOR CHANGE PAY

Two cheers for long-awaited NHS pay deal The NHS pay deal, agreed by unions in March, brought a welcome end to seven years of pay misery for NHS staff – but came with a sting in the tail for some MiP members. MiP has welcomed the end of the seven-year cap on NHS pay, following the pay deal agreed between unions and employers in March, but has criticised as “unfair and divisive” proposals to withhold the full benefit from some senior managers. Under the deal, which will be funded with an estimated £4.2bn in extra cash from the Treasury, most NHS staff will receive pay rises totalling at least 6.5% over the next three years, plus a lump sum of up to £800. Some will receive much more as part of a restructuring of the Agenda of Change pay bands. Although MiP estimates that no member will be worse off than they would have been under the government’s existing pay policy, pay rises for some senior members at the top of their pay bands will be be capped, at 5.4% for managers in Band 8D and 4.5% for those in Band 9. Improvements to the rate at which staff progress through the pay bands have also been withheld from staff in Bands 8 and 9. MiP chief executive Jon Restell, who took part in the pay talks alongside representatives from 13 other NHS unions, said: “This offer finally ends the damaging 1% cap on pay rises and gives higher salaries to all NHS staff on Agenda for Change, including most MiP members. We also strongly welcome the moves towards ending poverty pay in the NHS and the decent pay rises that many hard-working but low-paid NHS staff will at last receive.” Restell blamed political interference for the decision to withhold the full benefits of the deal from senior staff. “Many MiP members will feel that the Government still doesn’t properly value the skilled and experienced managers 22

healthcare manager | issue 37 | spring 2018

THE NHS PAY DEAL Key proposals for MiP members ■■

An increase over three years of 6.5% for staff at the top of Bands 8A, 8B and 8C, 5.4% for staff at the top of Band 8D, and 4.5% for staff at the top of Band 9, with a one-off lump sum payment of 1.1% of salary (up to a maximum of £800) on 1 April 2019

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Increases of between 9.4% and 22.4% for staff below the top of their pay bands

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For most MiP members, a minimum 3% increase from 1 April this year, with a further 1.7% in 2019 and 2020 (rises for Bands 8D and 9 will be slightly lower).

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Removal of overlaps between pay bands to ensure proper pay rises on promotion and reduce the risk of equal pay challenges

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An increase of 6.5% over three years to the minimum and maximum of all high cost area supplements (HCASs)

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Higher starting salaries for new entrants to the pay bands

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Progression through the pay band to be linked to appraisals for new entrants to the band, or people who haven’t reached the top of their pay band by April 2021

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No change to any other terms and conditions, including annual leave

For further information, please visit the unions’ new pay website at nhspay.org

who work hard to run NHS services under the most trying circumstances,” he warned. “It’s unfair and divisive that political demands for a cap on senior pay rises mean they won’t be getting the same recognition as other NHS staff. Restell added: “We welcome the government’s promise to fund the pay deal over and above existing budgets, but we believe that they have missed the opportunity to invest in NHS leadership and management, at a time when senior staff

are taking on bigger workloads and more responsibilities than ever before,” MiP members will have their say about the new pay deal during an extended consultation period, which lasts until the end of May, with the results announced in early June.

MiP wants to hear your views and questions on the NHS pay deal. Get in touch with us at: info@ miphealth.org.uk. You can read about NHS pay developments in Scotland and Wales on page 6.

MIP AT WORK

CASEWORK

Don’t miss out on redundancy pay – it’s your right! No one should lose their redundancy money just for taking a temp job, but HR departments don’t always see it that way. One senior NHS manager tells Craig Ryan about how expert support from MiP finally secured the settlement he was entitled to. In today’s ever-changing and fragmented NHS, redundancies are sadly commonplace. But it can be fiendishly difficult to work out what you’re entitled to, and even harder to make sure you get it. This is where expert individual representation from MiP really counts. Your team of MiP national officers know the system inside out and will do everything they can to make sure you get the best possible outcome. After working at an NHS trust for around two years, Mark learned that his senior management post was being “deleted” as part of a reorganisation by his new line manager. His application for one of the new senior posts was unsuccessful so, with support from MiP national officer Jo Spear, he agreed redundancy terms with the trust. “With that done, I could have walked out on the spot and taken the redundancy cheque, but I decided to carry on for a short period to provide a satisfactory transition for the trust,” Mark explains. “I applied for posts in other organisations, but unfortunately I wasn’t successful in any of those either.” Mark then left the trust and began working with another NHS organisation on a “bank” basis – with no contractually guaranteed hours of work or job security. Nevertheless, his former employer suggested that this was “suitable alternative employment”, so he was not entitled to redundancy pay. The question of what is and what isn’t suitable alternative employment is a tricky but crucial one: put simply, you lose your entitlement to redundancy pay if your employer, or another NHS organisation, has offered you an alternative job – provided it’s something you’re qualified to do and offers broadly similar pay and conditions.

“My primary concern was to make sure that I received statutory redundancy pay, but I was also slightly concerned about inadvertently establishing a precedent that employment on the bank could be considered as suitable alternative employment,” Mark explains. What should have been a fairly straightforward case turned out to be anything but. MiP assigned associate national officer Jim Keegan, a veteran of NHS redundancy disputes, to work alongside Jo on Mark’s case. “This did require quite a bit of stickability by the union,” Mark recalls. “We went through a very elongated process, with the union politely asking my ex-employer whether they were going to pay me any redundancy, followed by long periods of radio silence, then various attempts to chase them up.” Jim and Jo decided to get a legal opinion on Mark’s case from MiP’s solicitors. “Thompsons said there was no way my bank contract could count as a suitable alternative to the post I had before,” Mark explains. “Even then, it just kept going round and round,” he continues. “It was always

being looked at by their solicitors or NHS Improvement, or considered by the chief executive. It’s one of those cases where you never quite know if it’s slow-paced working or just an attempt to play for time in the hope that we might give up.” MiP didn’t give up, and Mark finally received his redundancy settlement in full over a year after leaving the trust. “Jim and Jo provided me with on-thespot advice, often at very short notice, throughout the process,” says Mark. “I even remember Jim stopping on his way to a football match to give me telephone advice on something urgent that had cropped up that afternoon. MiP was particularly concerned that the trust left it to a single member of the HR team to decide whether David’s bank contract amounted to suitable alternative employment. “They clearly did not have a complete understanding of the rules under Agenda for Change and yet they were unable or unwilling to discuss it with us,” Jo explains. “Far from being commended for his honesty in declaring the bank work, Mark was unfairly denied his contractual rights,” she adds. “Thankfully we did manage to resolve the matter without resorting to litigation.” Mark, who has now secured a 21month contract with his new employer, explains how he came to rely on the support from MiP. “What really counts, especially in a pressurised situation, is the knowledge that there’s someone on your side, someone who’s a regular source of advice and assurance, and who has the determination and preparedness to see it through until the case is resolved,” he says.

If you have any concerns about your redundancy entitlement, contact your MiP national officer for advice. healthcare manager | issue 37 | spring 2018

THE SHARP END: OUTSOURCING

The Carillion collapse shows the perils of driving suppliers to the brink, one support services manager argues. We need to build better long-term relationships to get the most out of our outsourced services.

It’s time to rethink how we do outsourcing

JOHN LEVERS

’m the general manager for an outsourced ‘soft services’ operation in a large hospital, providing services including portering, cleaning and catering. We’re an outsourcing company – but don’t confuse us with PFI. In PFI hospitals, providers own the ‘hard services’ – buildings and equipment – and their interests can differ sharply from the hospital’s; in that sector, I’ve seen examples of profiteering. But in outsourcing, it’s in everybody’s interests to run things as efficiently as possible – then we and the trust can share the savings. My staff and I feel that we’re part of the NHS’s frontline services. When there’s a major incident – such as a serious road traffic accident – we work extra shifts without getting client approval for the spending; we rarely get that money back. And we can end up plugging gaps in services: for example, the trust won’t fund meals for people who’ve been waiting in A&E for more than four hours – but we feed them anyway. In general, though, we run on a very slender profit margin, and we can only do work set out in the contract – under which we’re measured on outcomes, such as the wards’ cleanliness and how quickly we move patients around the hospital. We often spot ways to save money whilst delivering those outcomes. For example, we could deploy fewer porters in departments and more in the central pool. Porters would then spend less time waiting around when their department is quiet, and we could return the money saved to the trust’s estates and facilities department. But the departments like to have their own porters, and the client isn’t willing to persuade departmental staff to get behind changes. The client also runs separate metrics, measuring work done rather than outcomes – like how long we spend cleaning, rather than how clean the wards are.

healthcare manager | issue 37 | spring 2018

This deters us from investing in efficiency, because if we achieve the same result more quickly we get a worse score on these metrics; so does the client’s reluctance to share the proceeds of efficiency reforms. If they were willing to focus on outcomes, to share the rewards of efficiency reforms and to push departmental staff to accept changes, then we could save a lot more money for the trust. We’re already pretty efficient, though. Personally, I’m quite left-wing; but having worked for in-house operations, PFI providers and outsourced services, I’ve concluded that outsourcing can work well for soft services. We can make decisions quickly; we’re held to account against performance targets; we can call on our company’s expertise and systems; and we’re good at working with other businesses involved with the hospital. We also work closely with health unions, and recognise them as key partners. Union representation ensures that we keep our staff in mind when restructuring services. And as long as we are clear and open with the unions, we find that they and their members work with us to support change in the business. People worry about outsourcing staff to organisations like ours. But in reality, much NHS labour is already outsourced – simply because trusts are so depend-

ent on locums. Agency people get paid much more than permanent staff, they don’t have to take on as much responsibility, and they can move hospitals when they like. As a result, many people prefer temporary jobs; and that leaves big gaps in trust staffing, creating competition between hospitals that drives locum rates higher still. These people are paid five times as much as my staff – and until the government addresses this problem, it will struggle to contain NHS costs. Meanwhile, trusts are trying to save money by squeezing outsourcing providers – and given our tight profit margins and the risks involved, contracts can quickly become uneconomic. As things stand, providers don’t expect to turn a profit for two years; and it only takes a few things to go wrong to push us into the red. We see the results in businesses like Carillion, where the public sector gets such a ‘good deal’ that the provider collapses and trusts have to pick up the pieces. An endless focus on price serves nobody. If providers can’t survive on the basic contract, they have to charge for additional labour or services – which encourages sharp practices. And if we’re to meet patients’ needs and invest in efficiency, we need to have a grown-up conversation with trusts: one that emphasises quality as well as cost, and recognises the need to reform operations. We see ourselves as part of the NHS, working for patients alongside NHS colleagues. But we can only make outsourcing work well if trusts – and the government – are ready to recognise the true costs of delivering services.

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

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Thompsons Solicitors has been standing up for the injured and mistreated since Harry Thompson founded the firm in 1921. We have fought for millions of people, won countless landmark cases and secured key legal reforms.

We have more experience of winning personal injury and employment claims than any other firm â&#x20AC;&#x201C; and we use that experience solely for the injured and mistreated. Thompsons pledge that we will: work solely for the injured or mistreated refuse to represent insurance companies and employers invest our specialist expertise in each and every case fight for the maximum compensation in the shortest possible time.

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Managers are an essential part of the team delivering high quality, efficient healthcare. MiP is the specialist trade union for healthcare managers, providing expert employment advice and speaking up on behalf of the UKâ&#x20AC;&#x2122;s healthcare managers. Join MiP online at miphealth.org.uk/joinus

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