issue 12 winter 2011
healthcare manager
STATE OF MIND
SOPHIE CORLETT ON A BETTER DEAL FOR MENTAL HEALTH plus
NHS PRODUCTIVITY: DELIVERING MORE FOR LESS ALL WORKED OUT: BETTER WAYS TO BEAT STRESS
helping you make healthcare happen
Working together for you The Open University and Managers in Partnership have joined forces to encourage greater participation in health sector education and training. Between us, we offer a wide range of modules and qualifications to make a difference to your life, your career and the people in your teams. Whether you are an Administrator or CEO, Clinical Nurse Manager or Business Manager, there are a range of modules and qualifications that will help develop skills in areas of practice from policy interpretation to research. Our flexible work-based learning fits with busy work and home commitments. Modules are vocationally relevant based on cutting-edge research and learning materials, to ensure that what you learn today, you can apply tomorrow – making an immediate and effective impact to improving levels of care. Did you know? • UNISON/MiP members receive a 10% discount on many of our courses • Learning materials reflect the day-to-day practical issues involved in running a hospital ward or clinic.
Postgraduate options designed with you in mind Postgraduate Certificate in Advancing Healthcare Practice (C92) Postgraduate Diploma in Advancing Healthcare Practice (E46) MSc in Advancing Healthcare Practice (F52) MBA (AMBA accredited) (F61) Professional Certificate in Management (C31) Certificate in Professional Practice in Delivering Public Services (K02) Postgraduate Certificate in Clinical Leadership (K04) Postgraduate Certificate in Professional Practice (Children and Families) (K14) Postgraduate Diploma in Advancing Professional Practice (Children and Families) (E70)
Advance your career www.openuniversity.co.uk/mip
0845 300 8846 Quote: GAMAEG
INSPIRING LEARNING
The Open University is incorporated by Royal Charter (RC 000391), an exempt charity in England and Wales and a charity registered in Scotland (SC 038302).
issue 12 winter 2011
healthcare manager inside
heads up:2 What you might have missed & what to look out for Leading edge: Jon Restell inperson: Dr Cathy Rooney, Scottish National Blood Transfusion Service inpublic: Jubilee Gardens Health Centre and Library
letters & comment:8 Paul Scourfield: the Bill falls short on public health
features:10 published by
Managers in Partnership www.miphealth.org.uk 8 Leake Street, London SE1 7NN | 0845 601 1144 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.
Staff engagement: engaging staff is the key to better outcomes for patients. Interview: Sophie Corlett, Director of external relations, Mind Productivity: how does the NHS really compare? Stress: stop it before it starts
regulars:20 Legal eye: using freedom of information laws Careers: the power of the mentor MiP at Work: Link member Jeremy Baskett
backlash:24
healthcare manager | issue 12 | winter 2011
Welcome to issue 12 of healthcare manager, the magazine from MiP, the trade union organisation specifically for managers working in health and social care. What with restructuring and management cuts and restructuring of the restructuring, we’ve certainly been kept on our toes in healthcare. In this issue we look at the impact of those changes. Noel Plumridge delves behind the rhetoric to see if NHS productivity is really as bad as they say. Jeremy Dawson reports on research showing the positive impact of staff engagement on productivity and heath outcomes. The upheaval in the NHS is taking its toll on managers, and Derek Mowbray gives his advice for dealing with stress. In our interview, Sophie Corlett, from Mind, sets out her concerns and argues for mental health to get parity with other health issues, and for people to realise it is as important as physical health. And of course we are still campaigning to get pension fairness for NHS staff. Jon Restell reports on progress there. So I hope you enjoy this issue. For MiP members receiving this by post, we enclose a calendar mousemat, with best wishes for the coming year from all at MiP. Marisa Howes Executive editor
1
HEADS UP
heads up what you might have missed and what to look out for
Staff from University Hospital of South Manchester part run cycle to work and car-share schemes, as well as being the first UK hospital to install a Biomass Boiler.
Environment
Climate Week 12-18 March 2012
Climate Week is a national campaign to inspire a new wave of action on climate change, featuring thousands of events and activities, planned by organisations from every part of society including the NHS. Showcasing real, practical ways to combat climate change, the campaign aims to renew our ambition to create a more sustainable,
low-carbon future. Climate Week is backed by every part of society – from the Prime Minister to Paul McCartney, the NHS to the National Trust, the TUC to the CBI, Girlguiding UK to the National Association of Head Teachers. During the first Climate Week in 2011 over 80 events were organised up and down the country by NHS hospitals, primary care trusts, ambulance services, as well as some of the Royal Colleges and Societies. The winner of the award for the ‘Best Initiative by a
Public or Uniformed Sector’ was the University Hospital of South Manchester, who managed to cut CO2 emissions by 26% in 2010 saving £120,000 from its energy budget which could then be invested back into patient care. As a huge emitter of greenhouse gases, the NHS is crucial to cutting emissions both from its own estates, and by highlighting the detrimental effects of carbon-intensive lifestyles on health and community well being. To find out more about getting involved in Climate Week go to www.climateweek.com, email info@climateweek.com or telephone on 020 3397 2601.
Patient voice
Watchdog seeks chair The search has begun for a chair to lead HealthWatch England, the proposed ‘consumer champion’ which will represent the views of patients and the public within the government’s new NHS structure. Patrick Vernon, Chair of the
healthcare manager
Executive Editor
Contributors
issue 12 | winter 2011
Marisa Howes m.howes@miphealth.org.uk
ISSN 1759-9784 published by MiP
Associate Editor
Jeremy Dawson, Marisa Howes, Jim Keegan, Liz McCarten, Helen Mooney, Alison Moore, Derek Mowbray, Noel Plumridge, Jon Restell, Craig Ryan, Paul Scourfield, Jo Seery.
All copy © 2011 MiP or the author. Opinions stated are not necessarily those of healthcare manager or MiP.
Craig Ryan editor@healthcare-manager.co.uk
Art Director
Lexographic production@healthcare-manager.co.uk
2
For further details, visit the CQC website at: www.cqc.gov.uk.
healthcare manager is sent to all MiP members. All weblinks mentioned are at www.miphealth.org.uk/hcm healthcare manager is printed on uncoated paper with vegetable-based inks. The paper is FSC approved and the cover wrap is biodegradable.
Print Warners Print, Bourne, Lincs
James Sparling
Design and Production
HealthWatch advisory group said: ‘HealthWatch England’s chair will have a pivotal role in providing leadership and establishing it as the new consumer champion for health and social care in England. ‘The chair will voice the views of people who use health and social care services to those responsible for services locally and nationally and be able to use those views to influence national policy.’ HealthWatch England will work with local HealthWatch bodies and advise the NHS Commissioning Board, English local authorities, Monitor and the Secretary of State. It will also have the ‘power to recommend’ that the Care Quality Commission investigates public concerns about health and social care services in England. Subject to parliament passing the Health and Social Care Bill, the new chair is expected to take up the post in April 2012.
Advertising Enquiries 020 8532 9224 adverts@healthcare-manager.co.uk
healthcare manager | issue 12 | winter 2011
HEADS UP
leading edge Jon Restell, chief executive, MiP By the time you read this piece, your employer will have written to you about what the Government describes as its ‘enhanced offer’ on public service pensions. You will have seen much media reporting and comment, some of it accurate. You will also have received information from your union. The day of action on 30 November will be imminent or have been and gone. You will rightly be thinking about what all this means for MiP’s campaign for pension fairness. Does it change anything? I am representing MiP members in the NHS pension scheme negotiations. It’s important we have a seat at the table, because managers have particular career patterns that might otherwise be ignored. But, at the end of the day, all health workers – indeed all public sector employees – share the same concerns, interests and anger over the Government’s plans. Union negotiators therefore have drawn much the same conclusions about the ‘enhanced offer’. We welcome the Government’s move. It is a substantial and important step in the right direction. Why it took so long is a question only ministers can answer. Moderate unions have been ever willing to talk. But we expect to change terms and conditions of central importance to our members by negotiation and agreement. Since
“Since April progress in talks has been glacial. Worse, ministers have relentlessly pressed on with plans to cut the value of pension indexation.” April progress in talks has been glacial. Worse, ministers have relentlessly pressed on with plans to cut the value of pension indexation and hike up employee contributions. By mid-September the situation left us with little choice but to ballot for industrial action. Now, at least, we can say that we have something approaching proper negotiations for a new pension scheme from 2015. The Government’s move concerns three key issues about which we have been pressing ministers. First, the amount of money available for the new pension scheme. Secondly, the lack of any transitional protection for existing scheme members. Thirdly, the absence of confidence among our members in any government’s ability to honour longterm agreements. The Government has moved on all three fronts and, indeed, has accepted the idea of protecting
some existing members (those closest to retirement) for the first time. But the Government hasn’t made an offer. It has adjusted the notional framework in which scheme level discussions can take place. Much work is needed before we can see what the three shifts mean for our members in the NHS pension scheme. Many important details are unclear, and pensions is definitely a game of devil and detail. Furthermore, the gap remains vast between what the government is offering and what we have now. Even the protection for staff within 10 years of their normal pension age will not protect them from worse indexation value or the hike in contributions. And this brings us to another reason why the government’s move does not meet the objectives of our campaign for pension fairness. The government resolutely refuses to negotiate contributions or indexation of benefits. We are committed to negotiations. A series of meetings are in the diary right up until Christmas. But we need to be clear that the Government’s offer has not gone far enough. We also need to be clear that the Government’s move has been brought about by the incredible pressure and protest from staff and their unions. That’s why it’s vital everyone does everything they can to keep up that pressure.
Equality
New equality regulations take effect New regulations came into force in September requiring all public bodies, including NHS organisations, to publish information on steps they are taking to comply with the equality duty under the 2010 Equality Act. The regulations require public bodies to publish ‘relevant, proportionate information healthcare manager | issue 12 | winter 2011
demonstrating their compliance’ and to set themselves ‘specific, measurable equality objectives’. The equality duty requires public bodies to prevent unlawful discrimination, advance equality of opportunity and foster good relations between people from different backgrounds and social groups. NHS trade unions and NHS Employers
have developed an Equality Delivery System as a framework to help organisations meet these new requirements. Details of the EDS are available from http://tinyurl. com/3wydr2v. The Equalities Office has produced a quick start guide to complying with the new regulations, available at: http://tinyurl.com/76cxf4k
3
HEADS UP
NHS reform
Commissioning Board casts long shadow The NHS Commissioning Board, which will oversee commissioning in the NHS in England from 2013, began work in shadow form on 31 October, before the passage of the Government’s Health and Social Car Bill has been approved by parliament. The NHS Commissioning Board Authority has been established as a special health authority with the brief to devise ‘an innovative business model for the Board, which puts patients and clinical leadership at its heart’, subject to the successful passage of the bill. The authority will also work with commissioning groups, GPs and the Department of Health to agree how Clinical Commissioning Groups (CCGs), which will replace PCTs from 2013, should be set up and run. NHS chief executive Sir David Nicholson, who will be chief executive of the Commissioning Board, said: ‘Building this new system over the next two years…is a major challenge. But I firmly believe that what we are trying to achieve – a stronger, more innovative and more coherent commissioning system – will be critical to sustaining the NHS in years to come.’ When fully set up, the board’s job will be to make sure CCGs work effectively and to commission services that will only be provided at national and regional level.
MiP 2012 subscriptions Members who joined MiP after 1 June 2005 pay MiP subscriptions, as set out below. Members who transferred into MiP from FDA or UNISON when it was launched on 1 June 2005 (founding members), pay the relevant rate of the partner union from which they transferred. MiP subscriptions are proposed by MiP’s management board, in consultation with MiP’s national committee, and approved 4
Legal academic to head Board Professor Malcolm Grant has been narrowly confirmed as Chair of the new NHS Commissioning Board after members of the Commons health committee split along party lines over his appointment. Grant, currently Provost of University College London, was nominated as chair by health secretary Andrew Lansley, but before taking up the post he had to face a pre-appointment hearing in front of the select committee. Two Conservative members and one LibDem member backed Grant, with all three Labour members voting against, leaving committee chair Stephen Dorrell to cast his
deciding vote in favour of the appointment. New Zealander Grant, a 65-year-old law professor who has admitted he does not use the NHS, secured the part-time £63,000-a-year post despite telling MPs that he found the government’s health bill ‘completely unintelligible’. Health Secretary Andrew Lansley said: ‘Professor Grant’s role will be to take forward the plans to establish the Board and its structure and provide strategic leadership and vision for NHS commissioning.’ Welcoming Professor Grant to his new job, MiP chief exeutive Jon Restell said: ‘MiP wishes Malcolm Grant all power to his elbow in his new job. We are not too worried about his lack of an NHS background. It can sometimes help for the chair to have an outsider’s cool eye. However, Professor Grant has a big role in the proposed new structure of the NHS.’ Grant will retain his £380,000 at UCL for two years, during which time he as promised to donate his £63,000 NHS salary to the university.
‘Speaking after the launch of the board in shadow form, MiP chief executive Jon Restell said: ‘MiP will work closely with the new Commissioning Board on the HR policies for the appointment and transfer
of thousands of people, including many MiP members. The health and social care bill is not yet law. If and when it is, we will do everything we can to help the Commissioning Board succeed.’
by the FDA annual delegate conference. All subscription enquiries should be made to MiP. All subscription rates shown in the table come into effect on 1 January 2012.
Band
Tax relief on MiP subscriptions
C
As a healthcare manager, you may be entitled to tax relief on your MiP subscriptions in the same way as members of other professional organisations such as the Royal College of Surgeons. For more information log into the members’ page of the MiP website: www.miphealth.org.uk
Management trainee
Annual basic salary
Subscription
up to £25,750 £25,751-£38,850
£20.50 £22.50
£38,851-£61,800 £61,801-£72,100 £72,101-£82,400 Over £82,400
£25.20 £28.40 £30.55 £33.10 £12.80
£15,500-£33,500 £33,501-£47,000 £47,001-£70,500 £70,501-£88,000 Over £88,000
£12.55 £24.35 £26.55 £28.85 £31.50
Over £35,000
£22.50
Part Time A B Full Time A B D FDA founding members A B C D E UNISON founding members BAND K
healthcare manager | issue 12 | winter 2011
HEADS UP
inperson Dr Cathy Rooney, External Funding and Licensing Manager, Scottish National Blood Transfusion Service ‘I look after the intellectual property (IP) of the transfusion service,’ Dr Cathy Rooney explains. Cathy is the external funding and licensing manager for the Scottish National Blood Transfusion Service (SNBTS) and it is her job to protect and preserve the work of the service both in terms of research outcomes and its products. Cathy says the service is constantly working on its research into improving patient care in areas that include immune response modification using small peptides (with the University of Aberdeen), cell therapy research (Universities of Edinburgh and Glasgow) and optimal blood usage, for which SNBTS was selected as lead organisation by the European Blood Alliance. The EU Optimal Blood Use project now involves 18 transfusion services across Europe and is in its second year of implementation. ‘If my job didn’t exist the risk is that the intellectual assets being generated by scientists, clinicians and other staff in the transfusion service would not be adequately managed,’ says Cathy. ‘Without proper management poor deals may be done with third parties and, as a result, the public investment that goes into the SNBTS’ research and development would not see proper reward. The IP generated over years of research could be easily squandered.’ She says the job involves managing complex IP deals done in collaboration with universities, the NHS, other blood services and commercial firms, to license proprietary information and IP, and to draft agreements with the service’s legal teams to make sure its work is appropriately protected and managed. In addition to research and development, the SNBTS is moving into implementing new areas of cellular therapy, such as islet transplantation in diabetes patients in collaboration with Lothian Health Board. Early research has shown that islet cell healthcare manager | issue 12 | winter 2011
transplantation has the possibility of restoring pancreatic cell function for people with Type 1 diabetes. Because the beta cells in the islets of Langerhans (the part of the pancreas that contains hormoneproducing cells) are selectively destroyed in patients with Type 1 diabetes, clinicians and researchers are actively pursuing islet transplantation as a way to restore beta cell function in these patients. They hope this could lead to an alternative to a complete pancreas transplantation or an artificial pancreas for people with severe Type 1 diabetes. Another area of development, in partnership with the University of Edinburgh, University of Glasgow, NHSBT and Roslin Cells Ltd is research into the derivation of red blood cells from embryonic stem cells. ‘All our research programmes and collaborations need to be IP managed and
“Without proper management, poor deals may be done and public investment in research and development would not be properly rewarded.”
have legal contracts agreed,’ Cathy says. Every pharmaceutical company carefully manages its IP and the same requirement applies to the NHS. It has to follow through on the money invested in its R&D.’ She believes the field of IP management is an extremely important one. With thousands of NHS patients already benefitting from new technological developments, scientists and clinicians must realise it is important to look into third party patents and ‘examine whether they will create a problem down the line’. ‘It is also my job to do IP research into what other people are doing and to make sure we are able to translate the results of our research into improving patient care – as managers we play a pivotal role in this.’ Helen Mooney 5
HEADS UP
Regulation
Ombudsman
Monitor, the foundation trust regulator, could fail unless ministers clarify its objectives, so the quango can concentrate on protecting patients’ interests, according to a new report from health think tank The King’s Fund. The report Economic Regulation in Health Care also called for the government to issue guidance to resolve confusion over how Monitor, the CQC and the proposed National Commissioning Board will work together.
The NHS is making slow progress in improving the way it handles complaints, with too many minor disputes being escalated because of poor handling by NHS bodies, according to health Ombudsman Ann Abraham (pictured). In her review of complaints handling for 2010-11, Listening and Learning, Abraham also reported that London and the North West regions received the most complaints and that acute hospitals were the most commonly complained-about organisations, receiving 46% of all complaints. The report found that the most common complaints were about poor explanations and failure to acknowledge mistakes. Describing progress as ‘slow and patchy’ Abraham said ‘the NHS is still not dealing adequately with the most straightforward matters’ and that too many minor disputes were escalated to her Office when they should have been resolved earlier. The Ombudsman’s Office received over
‘Confused’ Monitor could fail
NHS ‘patchy and slow’ dealing with complaints
15,000 complaints about the NHS in 201011. ‘As the stories in the report illustrate, last year relatively minor disputes about unanswered telephones or mix-ups over appointments ended up with the Ombudsman because of knee-jerk responses by NHS staff, and poor complaint handling,’ said Abraham.
Whistleblowers
Anna Dixon (above), director of policy at the King’s Fund, said: ‘Monitor has been set a formidable task with little precedent and supporting analysis, so the risks of failure are considerable. Unless economic regulation is designed and executed well, it may end up imposing more costs than the benefits it delivers. ‘As the Health and Social Care Bill proceeds through the House of Lords, we hope that ministers will look again at the lessons to be learned from other regulators and make the changes needed to enable Monitor to succeed in its new role.’ The report also looks at the need to ensure the new healthcare market envisaged by the government’s reforms operates in the interests of the public and patients, and asks what lessons can be learnt from the experience of economic regulation in other sectors. Further details at: www.kingsfund.org.uk/ publications/economic_regulation.html
6
Staff who speak out will be protected Ministers are to change the NHS Constitution to protect whistleblowers who raise concerns about poor patient care after a number of high profile cases where staff believed they were ignored or victimised after speaking out. Health secretary Andrew Lansley said the changes would make clear that ‘whistleblowing’ is the duty of all NHS workers and would ban ‘gagging clauses’ under which whistleblowers can be ‘paid off’ or dismissed. ‘The first lines of defence against bad practice are the doctors and nurses doing their best to care for patients,’ said Lansley. ‘They need to know that they have a responsibility to their patients to raise concerns if they see risks to patient safety. And when they do, they should be reassured that the government stands full square behind them.’
Dean Royles, director of NHS Employers, welcomed the changes which he claimed would reinforce the responsibilities of staff and employers to report concerns and act on them. ‘Setting out duties and guidance with clarity is clearly helpful in ensuring that concerns are reported. Protecting patients is of paramount importance and employers have worked hard to improve procedures and policies for reporting any concerns about patient care. This guidance will help embed a culture where this becomes part of the organisations’ DNA.’ The Department of Health said the changes will be incorporated into the new NHS Constitution from early 2012. They will include an expectation that staff should raise concerns at the earliest opportunity, and requirement for organisations to support staff and investigate any claims fully. healthcare manager | issue 12 | winter 2011
HEADS UP
“The library is heavily used every day and the internet zone is especially popular, it is fantastic that they didn’t take away services that were already there.” Jubilee Gardens Health Centre and Library, Ealing, London.
inpublic
Ealing’s Jubilee Gardens Health Centre and Library was opened in January 2010 in a bid by NHS Ealing and Ealing council to provide a fresh approach to healthcare facilities in the area without closing services elsewhere. The £4.9m scheme houses two general practices, a library and a host of community and specialist health services including audiology, maternity, podiatry, and mental health and wellbeing. It was developed jointly by the PCT and the council, in partnership with Building Better Health, a company specialising in projects under the
government’s Local Improvement Finance Trust (LIFT) scheme. It followed a joint needs assessment which highlighted the need for an increase in the number of general practices and community health services in the borough. According to Linda Smith, NHS Ealing’s LIFT commissioning manager, who was also the centre’s manager during its construction, the original health centre and library buildings were built in the 1930’s and had become outdated and unable to offer Ealing residents high standards of healthcare. She says that residents now have access
healthcare manager | issue 12 | winter 2011
to multiple integrated resources under one roof, which has also helped to reduce unnecessary and time-consuming referrals to hospitals or across the borough to other community health services. Smith explains that the health centre was built on the site of an old library and that the PCT worked together with the local authority to make sure that the library services were retained in the new building. ‘The library – and Ealing council – are now a tenant of ours in the health centre,’ she says. Smith also thinks that combining the health centre with
the library helped to save the library from closure. ‘The library is heavily used every day and the internet zone is especially popular. I think it is fantastic that they didn’t take away services that were already there,’ she says. Marie Pemberton, stakeholder engagement manager at NHS Ealing agrees. ‘The response to the scheme has been positive. Since opening, the new health centre is now working to near capacity. The modern facilities ensure that the local population has improved access to a wider range of services closer to where they live.’ The fact that the health centre also houses a library is a big plus for the local population. The two spaces merge together seamlessly while still being able to function independently, offering patients the opportunity to combine a doctor’s appointment with a library visit or use the services separately. Building Better Health chief executive Sylvie Pierce says Jubilee Gardens is a ‘perfect example of how the public and private sectors can work in harmony to deliver high quality facilities that are a real asset to the community.’ Jubilee Gardens is being followed by the £5.4million Grand Union Village Primary Care Centre, also in Ealing, where the health centre will also house a pharmacy. Helen Mooney
7
LETTERS
letters
Letters on any subject are welcome. Please send to editor@healthcaremanager.co.uk or to 8 Leake Street, London SE1 7NN. We may edit letters for length. Name and address must be supplied, but you may ask for them not to be published.
to the editor
Passing the baton I am passing on the baton as one of the representatives for Scotland on MiP’s national committee – and also as MiP’s Vice Chair. It has been a great pleasure to serve on the committee from the start, but I feel now is the time to move on, and make way for new blood. I think we can be proud of what we have achieved in such a short time since the creation of MiP. We have a seat at the negotiating table for key issues such as the NHS pension scheme, our views are sought on matters such as senior
managers’ pay, and we are major players in partnership discussions on issues such as management cuts and restructuring. And we can be proud of the way our member networks are developing. More and more of our link members have a seat at the table in partnership discussions at local level. And our networks of members are growing steadily. Here in Scotland we meet regularly, as well as keeping in email communication with each other, discussing current issues and sharing skills, knowledge and experience. And although I am stepping down from the national committee, I will still play an active role in our Scottish network.
Tweet Box
A selection of tweets on issues covered in healthcare manager #NHSManagers Great piece this week in @HSJ on the imp of middle managers. Time for a HSJ100 for the people who have the toughest job in nhs? @joe_stringer1 http://tinyurl.com/85qkzzy #HealthBill Harry Cayton, CHRE: “There is no patient representation on the National Commissioning
8
I wish my successor and the committee all the best for the future – the coming year will be challenging, but I think also exciting. Dr Rosie Ilett Deputy Director Glasgow Centre for Population Health
Genuine pride I had great pleasure in participating as a delegate at the TUC LGBT conference this summer. It reminded me of the great transformation in legal rights that the LGBT community has seen in recent years, including equal age of consent,
of Breast Cancer Screening: http://nyti.ms/vtI44p @kremersonian
the right to adopt, civil partnerships, equality act, Section 28 and the lifting of the exclusion of lesbians and gays from the military. But with cuts in public spending, including police funding, we need to remain vigilant to maintain and improve those achievements in the face of continuing homophobia. Finally we joined colleagues to carry the FDA banner, along with many other union banners, at the front of the Pride London parade. I felt such honour as a gay trade unionist to be marching with so many other unions with a real sense of PRIDE.
#ElderlyCare Most hospitals care for elderly well. Gov doing usual thing & extrapolating black propaganda 2 reflect #NHS badly overall @dianehain
Board. Where are the incentives to change?” @TheKingsFund
#Monitor New NHS regulator ‘risks failure’ http://ow.ly/7l2e8 @Health UBM#PCTs
Are we to have competition or stalinism? or both at once? http://fb.me/ZdI31eWg @socialisthealth
Recently an influential male GP told me,you can forget all that equality stuff,we will decide who we employ @mitya2
Many elderly end up in hospital due to social care failings, YET the NHS take the flak for those funding, staffing & private sector mess ups @NHSspy
#BreastScreening “Screening is not prevention. We’re not going to screen our way to a cure.” The Limits
GPs cost too much, think they can do too much and will never commission without reinventing PCTs @RoyLilley
#Emergencies In the new @NHS how & who would coordinate a major trauma response involving
George Shepherd MiP national officer
hospitals, ambulance, paramedics,first-responders, air-amb etc? @clarercgp When you knock the NHS because your hernia wasn’t repaired within 6 months, or the GP didn’t ‘cure your ME’ - look at scenes on the M5 now. @welsh_gas_doc
#DowntonAbbey Lavinia had the lowest public vote, so now Lady Cora and Carson will have a sneeze-off as the elimination goes to Deadlock. @PeteDeveson
healthcare manager | issue 12 | winter 2011
COMMENT
comment
“Fortunately, no public health specialist has yet made such a serious error of judgement that an unnecessary crisis has occurred.”
Paul Scourfield
Chief executive, Faculty of Public Health
Health bill falls short on public health As the Government’s Health and Social Care Bill is debated in the House of Lords, the Faculty of Public Health (FPH), the standard setting body for public health specialists in the UK, is lobbying for four key amendments. Firstly, the FPH wants to see new rules requiring all public health specialists to be registered by law to protect the public. The public needs to be able to trust the people who make life-or-death decisions about their health. That could be a decision about whether to immunise children, or how to deal with a disaster such as flooding or an outbreak of swine flu. Fortunately, no public health specialist has yet made such a serious error of judgement that an unnecessary crisis has occurred. But we should not wait until such a crisis occurs before holding all specialists to account. As part of this new regulation, the Bill needs to include a definition of a public health
expert or consultant. In effect, this would be an extension of the existing regulations for public health doctors and dentists. Secondly, the NHS commissioning boards need at least one member who is a public health specialist, to ensure the public’s health is protected. The NHS National Commissioning Board will be nationally accountable for the outcomes achieved by the NHS. It is vital that national decisions about NHS services have input from public health specialists who understand about commissioning for whole populations. Otherwise, there is a risk that the health of entire communities will be put at risk, particularly those people who are hard to reach. Thirdly, directors of public health need direct access to senior leaders. Under the Bill, Directors of Public Health (DPH) will be employed by local authorities. DPHs will need direct access to senior
local leaders in both local government and the NHS in order to drive through public health gains for their community. That is why FPH believes DPHs must be appointed as chief officers at a corporate or strategic director level, such as that of the director of adult social services. The DPH also needs to be able to influence commissioning decisions made by GPs to make sure local people get the right services. Finally, the Bill needs to make it clear that local authorities are responsible for dealing with public health outbreaks or emergencies. It is not explicit in the Bill that local authorities should be responsible for ensuring that outbreaks and emergencies are properly managed. Public Health England, the NHS and local authorities should have a duty to co-operate. We need clarity on this to avoid putting the public at risk of serious harm.
.
Update your details MiP members should have received new membership cards and a request to check and update their details. We need an up to date membership record so we can keep you informed and identify your employer, job title and workplace. And as things are moving apace in the pensions campaign, we use email to keep you up to date. If you don’t receive emails from us, you probably need
healthcare manager | issue 12 | winter 2011
to update your record. So please take a few moments to check your record and make any necessary changes. You can do this online by logging into the members’ area of the MiP website at www.miphealth.org.uk/MembersArea/ mip_myMIP.aspx and following the prompts to update your details. If you haven’t received a new card, please Views expressed are those of the author and not contact us on info@miphealth.org.uk.
necessarily those of healthcare manager or MiP.
9
staff Engagement
Engaging staff is the key to better outcomes for patients, especially at a time of upheaval in the NHS, says Jeremy Dawson.
Periods of organisational change are always a time of concern for employees. With the current NHS upheaval, exacerbated by uncertainty about how and when changes will actually materialise, the potential effect on staff is huge. While this should concern employers in itself, a broader question is how the experiences of staff translate into patient outcomes and other measures of organisational effectiveness. Research we have conducted suggests such effects can be real and substantial. Copious research from other sectors has demonstrated links between staff management, attitudes and organisational performance; some of our research in the past decade has shown links between HR practices in NHS trusts and outcomes such as hospital patient mortality. Since the NHS national staff survey began in 2003, we have collected data annually about employee perceptions of their organisations, their experiences at work, attitudes and well-being. This and other routine data collection has allowed us to show the extent to which NHS staff experience might affect trust performance. In particular, team working, line management and staff engagement are 10
key predictors of outcomes. One key outcome we studied was patient satisfaction. A consistent finding was that the best outcomes and most positive patient ratings occur in NHS trusts where care is provided by teams that have clear objectives; and where individual staff members have clear goals for their jobs. In such circumstances communication between patients and staff is good and patients feel involved in decisions about their care. Leadership by managers helps to ensure clarity of purpose: when staff see their leaders in a positive light this is strongly related to patients’ perceptions of the quality of care they receive. There is a clear ‘spiral of positivity’ in the best performing NHS trusts. The extent to which staff are satisfied in their jobs and would recommend their trust – as a place to receive treatment and as a workplace – is strongly related to patient satisfaction. Top performing trusts have climates of trust and respect. One manifestation of this is the link between discrimination against staff and patient satisfaction: the greater the proportion of staff from a black or minority ethnic background who experienced discrimination at work, the lower the levels of patient satisfaction. Where there is less
discrimination, patients were more likely to report respectful and helpful encounters with clinicians. The converse of this is that when staff report aggressive behaviour (verbal or physical) from patients or their relatives, there is lower patient satisfaction. A ‘spiral of negativity’ can emerge when staff are not treated supportively and with respect, by managers or by the public, and patients pick up on excessive work pressure on staff. Consistent with previous research, we also found that the sophistication and extensiveness of HR practices (as measured by staff themselves) was related to lower patient mortality in acute trusts, as well as higher patient satisfaction. The percentage of staff receiving appraisals, and particularly helpful appraisals, is related to patient mortality rates. Appraisals are a powerful means of ensuring that staff have clear objectives, that they are developing their skills and that they feel valued, respected and supported by their managers. The extent of job-relevant training, learning and development, and quality of support from line managers, are also factors linked with lower mortality levels. The strongest HR predictor of patient mortality, however, is the percentage of staff working in well-structured teams: teams that have clear objectives, meet healthcare manager | issue 12 | winter 2011
staff Engagement
regularly to review their performance, and whose members work interdependently. When staff work in a wellstructured team environment they are also more likely to be an advocate for their trust, to have better overall health and well-being and to report lower levels of work-related stress. Trusts with more well-structured team working also have lower levels of staff absenteeism and turnover, thus making big financial savings too (absenteeism alone costs the NHS £1.75 billion per year). Absence and turnover are also clearly linked to other aspects of staff experience. Unsurprisingly, staff are more likely to leave or be absent after experiencing harassment, bullying or abuse from their colleagues or managers, when they witness errors that could harm patients or staff, or when they do not see effective action taken following such events. They are less likely to leave if they can work flexibly, and absenteeism is lower in trusts where staff feel satisfied with the quality of care they are able to deliver. There was also evidence that some of these factors are linked with infection rates in acute trusts. Where a large percentage of staff feel they can contribute towards improvements at work, infection rates are decreasing, reinforcing the value of staff involvement in service improvements, and of creating cultures of engagement and innovation. Infection rates are also lower in trusts that invest in staff training. Staff vigilance plays a role too: where staff report errors, improvements in the quality of patient care result. The factors mentioned above – including well-structured team working, helpful appraisals, training, supportive, trusting and safe working environments, and a lack of discrimination – add up to a positive work climate. How can such climates be developed and maintained in the NHS? A key route is staff engagement. In trusts where staff engagement is high, patient satisfaction, patient mortality rates and healthcare manager | issue 12 | winter 2011
“Staff engagement is not a quick fix and involves far more than just communicating with staff.”
trust financial performance are better, and absenteeism, turnover and infection rates are lower. Outcomes are better for the organisation, for patients and for the staff themselves. Staff engagement is not a quick fix and involves far more than just communicating with staff. Rather, it is enabling staff to have meaningful and rewarding jobs, fostering identification with and commitment to their work and the wider organisation, and giving staff opportunities to be involved in decisions which affect them. This in turn is helped by effective management practices, provided they are truly effective and not just box-ticking exercises. Our analysis showed that appraisals that didn’t set clear objectives didn’t help the appraisee to improve their performance and didn’t leave them feeling valued – engagement was actually lower than among staff who had no appraisal at all. Similarly, staff working in teams that were not well-structured (as defined above) were more likely to experience harassment or violence, suffer from stress, witness errors, and have
lower engagement and job satisfaction than staff not working in teams. The definition of correct job or team parameters – particularly objectives – is a key part of ensuring staff are engaged and outcomes are improved. The implications for patient care, productivity and staff well-being are clear. Creating environments where staff can perform at their best leads to patient satisfaction and lives saved. This is not an optional extra, something that can be put to one side while wider organisational changes are the focus. On the contrary, providing outstanding support and guidance, via good HR practices, managerial support and effective team working, is an important way of maintaining outcomes in the face of external pressures and uncertainty
.
Jeremy Dawson is senior lecturer in health management at Sheffield University and co-author with Michael West of NHS Staff Management and Health Service Quality.
11
INTERVIEW
Sophie Corlett of leading mental health charity Mind talks to Healthcare Manager’s Alison Moore about prospects for mental health services in the new model NHS.
While many healthcare organisations and charities occupy offices in the centre of London, Mind is based in the slightly grimy surroundings of Stratford in East London, not far from the building sites of the Olympic park. It’s perhaps an appropriate setting for a charity which deals with the tough end of the market – people with a range of mental health problems, some of which are long-term, hard to resolve
and don‘t gain the public‘s sympathy that other conditions do. But the regeneration of the area is perhaps a metaphor for what Mind would like to see happen to mental health services. Director of external relations Sophie Corlett has no doubt things have improved over the last few years – but also that there is much more to do. ‘We are in a really different place to where we were five or ten years ago.
Alistair Campbell, ex-President of Mind Melvyn Bragg, current president Stephen Fry and Heart FM DJ Matt Wilkinson launching Mind Week in 2009.
12
Mental health is much more understood and recognised within society and within mainstream mental health services,’ she says. In 2002, when she joined Mind, it was hard to get celebrities involved with the organisation, but things have changed since. Media darling Stephen Fry is now president of Mind, taking over from Lord Melvyn Bragg, and both have spoken about their own experiences of mental health problems. This trend of both celebrities and ordinary people being more willing to talk about their mental health is another sign of change, she points out. But the organisation remains concerned about the stigma which can still be attached to mental health service users. ‘In the general public perception mental health is not always seen as a worthwhile recipient of attention, funding and compassion,’ she says. And almost inevitably that feeds through into decisions made by healthcare commissioners, especially in harsh economic times. ‘We have a concern that public pressure on commissioning processes will be for the more popular areas of healthcare,’ she says. ‘People find it difficult to take money out of acute healthcare to fund an evidence-based intervention in mental health... the pubhealthcare manager | issue 12 | winter 2011
INTERVIEW
lic does not understand it and we come across evidence that clinicians don’t understand it. That makes it difficult for people to invest in it.’ With all decisions now taking place in the context of tight spending control and even cuts, mental health ‘is taking a big hit,’ she says. Mind is not immune to this: it has seen some local groups close, the decommissioning of some services and some areas facing cuts in funding putting restrictions on the number of users. With the upheaval set to follow the Health and Social Care Bill, Corlett points out that people who are involved in commissioning – largely GPs – need to recognise that there are problems with mental health and how it will survive within the new structure. ‘Most people are aware that there is a problem but have not come up with a solution. They have recognised that mental health is underfunded, not understood and that it is quite complicated to commission and deliver good provision.’ One of the dangers she sees is that the changes could move mental health backwards so the same ground has to be gone over again. For example, PCTs have slowly built up some commissioning expertise in mental health but it is far from clear what will happen to it as PCTs are dismantled and replaced by clinical commissioning groups (CCGs). GPs may feel they don’t know enough about mental health to commission it, she warns. ‘Mental health users tend to need services for a relatively long time but do not have the linear progression that is common in more physical illnesses. ‘People may be more or less capable of finding their routes through. You might go from being involved in a gardening project locally to inpatient care, talking treatment drugs, in your own home and then in supported housing. All of these things might come and go. The level of complexity is being recognised but people have not found the solution.’ And some mental health patients will need healthcare manager | issue 12 | winter 2011
“Mind is looking for mental health to get parity with other health issues.”
some very complex services – including some non-healthcare ones such as debt advice, she says. While the policy of ‘any qualified provider’ could have positive sides – such as improving access to different styles of talking theory and more culturally appropriate services for some groups – ‘there‘s a concern that it could lead to greater fragmentation that would complicate pathways to an unmanageable extent. Once that begins to be even more fragmented how will anyone find their way around?’ she asks. GPs may not be able to offer their patients much help with this task. With integration very much on the agenda since the government’s future forum report, Corlett says
there is a question about ‘how that plays out in commissioning and how that plays out in practice…when Jane Smith goes into a service but recovers so that she needs something more, is she going to have a broker who understands that – will GPs have the time? Who helps Jane Smith so she does not fall into the cracks? The real prize would be if we could integrate across health and social care.’ She is also passionate about service users needing to be involved in planning care. At a population level this means public and user involvement in planning services – something which Mind obviously has concerns about in the future. Commissioning groups will be made up of clinicians with limited lay input and no requirement to involve 13
INTERVIEW
Crossed lines?
Mental health issues are estimated to cost the country more than £100bn a year, when the direct costs of care are added to such things as lost The productivity and welfare payments. It also has a Government’s tremendous impact on individuals and their families.
Mental Health strategy The Government’s cross-departmental strategy
on mental health outcomes, launched in Febraury, involves all government departments working towards a series of outcomes with the emphasis on empowerment, localism and early intervention. It also involves a new national measure of wellbeing. Mind welcomes the new strategy but Corlett now wants to move to implementation and has been
public and patients. Health and wellbeing boards will, of course, have an important part to play. ‘If you have a choice about what treatment you have, the likelihood of benefiting from your talking therapy increases,’ she says. ‘Being more involved in your own healthcare is part of the recovery. A lot of mental health care is very disempowering. We would like to see some requirement…to get expertise from people with experience of receiving that healthcare. If you don’t have a really good voice for mental health when making decisions then bad decisions will be made.’ She is disappointed that the bill does not deal robustly with some of these issues. ‘It has the principles of integration and patient and public involvement but misses out on the full delivery of these.’ Investing in mental health has an impact on physical health as well. ‘There is really good evidence for psychological liaison that speeds up people’s recovery and reduces the likelihood of reoccurrence. The irony is that it does not reduce the costs for the commissioner, it increases them.’ Mind is talking to the NHS Confederation, the Royal College of General Practitioners and the Royal College of Psychiatrists, about producing joint guidelines on commissioning. Corlett says that all the levers need to be pulled to help improve mental healthcare, but ultimately many decisions will be made locally and here the right guidance will be vital. 14
talking to the Department of Health about this. A lot of decisions will be taken outside central government by CCGs, health and wellbeing boards and by individual GPs making referral decisions. ‘I think their aspirations are good and the people we have worked with at the DH are clearly committed to it. But the proof of the mental health strategy will be the extent to which that’s carried through into all the changes that are being made,’ she says. ‘How many managers have read the cancer strategy and how many have read the mental health strategy?’
‘It’s hard. The people that we try to influence are immensely busy trying to do a lot of other things and deal with all these changes. A lot are not convinced it is going to work. The psychiatrists are not convinced, many GPs are very reluctant. Everyone who is building the system is very busy trying to work out how it will work. ’ Mind is looking for mental health to get parity with other health issues, for people to understand that it is as important as physical health and needs to be funded appropriately. But mental health services are often only a part of the picture, and changes in other areas will have an impact on people with mental health problems. For example, support from social care may be important but the increase in eligibility requirements in many council areas can make it harder for people to access these services. ‘The things that people are raising much more with us than healthcare is benefits. People are concerned about
“We have seen an increase in people feeling society is against them. There had been a trend of stigma decreasing but some of the rhetoric around welfare has been distinctly unhelpful.”
whether they are going to eat,’ she warns. Of particular concern are the capacity tests for people on disability-based benefits. If people are not judged to be sufficiently disabled, they will be moved to other benefits which may reduce their income and they may face pressure to look for work. ‘We are concerned that the systems for assessing people for disabilitybased benefits are not being done accurately. We know that a lot of decisions are overturned on appeal but you have to have the wherewithal to appeal and people find it very stressful,’ she says. ‘We have seen an increase in people feeling society is against them. There had been a trend of stigma decreasing but some of the rhetoric around welfare has been distinctly unhelpful. ‘Most people we talk to say they want to work. But six out of 10 employers say they would not employ someone with a mental health problem.’ Early intervention to prevent mental health problems worsening may seem the answer to many of the problems, and the last few years have seen a shift from inpatient beds towards early community-based interventions. This can avoid care which is expensive and disruptive to people’s lives, but she warns that it is not a panacea and won’t always head off the need for more intensive care later on. And like many mental health interventions, the department which pays for it may not be the one which realises the savings
.
healthcare manager | issue 12 | winter 2011
PRODUCTIVITY
Beware of arbitrary efficiency targets and inflated claims about waste. When it comes to productivity, the NHS more than holds its own, says Noel Plumridge.
Is NHS productivity rising or falling? How does it compare with the productivity of other countries’ health systems? In short, what value do UK taxpayers get for their investment? Spending on the NHS in England has risen from some £60 billion at the turn of the century to over £100 billion. Some critics suggest the standard of health care provision, while better, has not improved enough in the last decade to justify such a high level of investment. And now, under the socalled QIPP (quality, innovation, productivity and prevention) initiative, productivity gains to offset perhaps £20 billion of anticipated extra NHS costs, without harming quality or safety, are being sought. These are heroic levels of savings. There is always room for improvement, and politicians are not averse to making capital out of perceived managerial or system weaknesses. The business of the NHS in England appears, once again, to have become reorganisation. Yet international comparisons suggest the NHS may already be amongst the most efficient health providers in the developed world. Systemic weaknesses have been highlighted most recently by the Public Accounts Committee (PAC). The PAC healthcare manager | issue 12 | winter 2011
scrutinises public expenditure on behalf of parliament, using value-for-money criteria based on the principles of economy, effectiveness and efficiency. In March 2011, its report on NHS hospital productivity in England reported that ‘in 2002 the Department [of Health] promised that, in exchange for increased funding, it would deliver annual productivity improvements. The Department failed and we have had ten years of almost continuous decline.’ The committee’s conclusion was based on Office of National Statistics (ONS) estimates that total NHS productivity fell, after 2000, by an average of 0.2% per year, and by 1.4% in hospitals. The PAC brushed aside challenges to the ONS’s method of measuring productivity and its alleged failure to reflect gains in quality. It also suggested productivity gains had been given a lower priority than meeting national performance targets. In 2009, the Centre for Health Economics had arrived at broadly the same conclusion, although they suggested that ‘since 2004-05 there have been productivity gains with output growth exceeding input growth’. This apparent improvement was linked to controls on recruitment, especially in NHS use of
“...this produces a suitably large, headlinegrabbing figure, usually expressed in billions of pounds and easily interpreted as ‘the price of NHS inefficiency’.”
locum and agency staff, coupled with higher hospital throughput. Inevitably, the PAC report received widespread media attention. So had criticisms in the government’s white paper, Equity and Excellence: Liberating the NHS, published in July 2010, which suggested: ‘Compared to other countries… the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world.’ These allegations were quickly challenged. The British Medical Association, noting wide variations between international comparisons of health 15
PRODUCTIVITY Health Expenditure Per Capita 2008 (PPP; International $) United States of America
$7,164
Norway
$5,207
Switzerland
$4,815
Netherlands
$4,233
Belgium
$4,096
Germany
$3,922
Canada
$3,867
France
$3,851
Australia
$3,365
United Kingdom
$3,222
Greece
$3,010
Spain
$2,941
Italy
$2,836
Japan
$2,817 $0
$2,000
$4,000
$6,000
$8,000
outcomes, observed that this is ‘sometimes simply due to concepts of illness and different cultures of diagnosis’. The BMA also published detailed diseasespecific analyses of UK outcomes. Meanwhile John Appleby, chief economist at the King’s Fund, was questioning the government’s use of evidence and highlighting significant improvements in NHS performance since 2006. Outcomes are a central aspect of health service performance, but productivity measurement involves comparing outcomes with resources consumed, and adjusting for relative levels of service quality. The most recent authoritative independent evaluation of NHS productivity was published by The Commonwealth Fund, a US-based private foundation, in June 2010. Mirror, Mirror on the Wall compares the performance of the UK health system with six other countries: Australia, Canada, Germany, the Netherlands, New Zealand and the United States.
evaluated, the UK spends the second least per capita at $2,992 (2007). The US spends $7,290 per head. In reaching its conclusion on relative efficiency, Mirror, Mirror on the Wall used eight measures: ■■ total health spending as a proportion of GDP ■■ percentage of health expenditure spent on administration and insurance ■■ patient time spent on paperwork, disputes related to medical bills or health insurance ■■ visits to A&E for conditions treatable by GPs ■■ failures of medical records or test results to reach doctors’ offices in time for appointments ■■ duplication of tests by different health professionals ■■ hospital readmissions for complications after discharge ■■ practices with high clinical IT functions
The NHS emerges from the Commonwealth Fund study rather well. Overall, the UK is ranked second behind the Netherlands. It was considered the most efficient system, second behind the Netherlands in terms of access and equity, and third on quality after New Zealand and the Netherlands. Only on ‘long, healthy, productive lives’ does the UK score poorly. Moreover, of the seven nations
Taken together, these imply a rather broader understanding of efficiency than those preoccupying NHS managers addressing the ‘Nicholson Challenge’. It’s not unqualified praise. Paul Corrigan’s warning that ‘one of the aims… is to shame the US as the world’s richest country into doing something about its chaotic nonsystem’ is pertinent. Corrigan, former
16
health adviser to Tony Blair, observes that people feel good about the Commonwealth Fund results because of the inevitable comparison with the US. It’s also notable that low UK performance on ‘long, healthy, productive lives’ seems to corroborate the poor outcomes suggested by the government’s white paper – though the Commonwealth Fund’s mortality data stretches back to 2003. Yet overall, the Commonwealth Fund report offers some real assurance that the NHS is not quite the hopeless, bureaucratic monster of media myth. So why, then, the persistent canard of NHS inefficiency? A prime reason is the seemingly never-ending flow of reports, from various sources, highlighting scope for improvement in specific areas of NHS performance. These have been given a new impetus and urgency by the current ambitious savings targets: indeed, it sometimes seems that ‘productivity’ has become a euphemism for ‘savings’. The focus has inevitably become, in the words of the King’s Fund’s 2010 report Improving NHS productivity, doing ‘more with the same, not more of the same’. That report explored the feasibility of achieving a 6% annual productivity target – as implied by DH projections – and the robustness of the projected funding shortfall said to make it necessary. It concluded that up to £6.5 billion of assumed cost pressures – including provision for pay inflation – may not materialise. But the report’s principal focus was on helping NHS managers achieve savings. Emphasising the need to obtain more value from the same resources, the King’s Fund highlighted likely areas for improvement, including support services and ‘back office’ functions, managing sickness absence, managing skill mix, reducing variations in clinical practice, avoiding unnecessary hospital admissions, and reducing spending on low-value interventions. It’s a familiar litany. There has been healthcare manager | issue 12 | winter 2011
no shortage of advice recently on the potential for savings in these areas. Moreover, the multiplicity of broadly comparable organisations in the NHS allows for a handy technique for putting a figure on those savings: simply work out how much would be saved if all ‘high-cost’ organisations reduced spending to the ‘average’ level. Conveniently, this offers a suitably large, headline-grabbing figure, usually expressed in billions of pounds and easily interpreted as ‘the price of NHS inefficiency’. Some examples. Late in 2010 a report by consultancy EC Harris found an average of 12.5% of the NHS estate to be empty or underutilised, and identified potential revenue savings of £500m per year. The Harris report resonated with cross-government concern about the use of public sector land and buildings, inherited from the ‘total place’ during Gordon Brown’s administration. Next, between £600 million and £1 billion could potentially be saved, according to research by the Foundation Trust Network published in November 2010, by sharing back offices services. The FTN calculation envisaged all NHS organisations currently spending more than the average hypothetically reducing their expenditure to the average level. Variations in medical practice – including length of hospital stay, preoperative admission, and day surgery as a proportion of total surgery for a procedure – continue to attract their share of attention. The first NHS Atlas of Variation in Healthcare, published in November 2010, documented marked differences in clinical thresholds, adherence to best clinical practice and diagnostics. It highlighted, for example, a ten-fold geographical variation in highrisk transient ischaemic attack cases treated within 24 hours, and a four-fold variation in access to hip replacement surgery. In April 2011 the King’s Fund’s Variations in Health Care found marked variations in surgical procedures, citing, for example, a healthcare manager | issue 12 | winter 2011
Jess Hurd /reportdigital.co.uk
PRODUCTIVITY
range of 30% to 90% in the day case procedure rate for varicose veins. How, it asks, can such disparity be justified? And for once mental health has not been ignored. The King’s Fund and the Centre for Mental Health’s December 2010 report, Mental Health and the Productivity Challenge, calculated that ‘if trusts with high levels of bed days reduced their use of inpatient beds to the average, this would generate an annual saving of £215m nationally’. Most recently, the procurement of clinical supplies has come under intense scrutiny. Back in February 2011, the National Audit Office concluded that a more collaborative approach to purchasing could save NHS hospitals £500 million a year, essentially by reducing variations, consolidating orders and negotiating economies of scale. Once again, the Public Accounts Committee joined the chorus, reporting in May 2011 that ‘the fragmented system of procurement has produced a great deal of waste’. The fact that trusts buy 652 different types of surgical and examination gloves easily attracted substantial press coverage. It all struck a chord with a government convinced about poor procurement practice in the public sector and embarrassed by massive IT investment in the NHS failing to deliver. The deci-
sion of auditors to qualify the 2010-11 “value for money conclusions” of the accounts of 24% of trusts did little to reassure the sceptics. The steady flow of such reports, highlighting scope for improvement within the NHS, fuels an impression of inefficiency. That impression will be reinforced as, faced with demanding savings targets, some NHS organisations fail to deliver and are classified as ‘overspenders’. Such perceptions are deep-rooted. Even among NHS staff, the news that the NHS had a substantial surplus last year, and will almost certainly end 2010-11 in the black, usually elicits disbelief. So it’s worth remembering that missing an artificial and challenging savings target is not synonymous with inefficiency. Yes, there will always be scope for improvement. There will always be outliers. But running healthcare is a complex business, and there are good international indicators suggesting the NHS approach, for all its shortcomings, is more productive than most.
.
Noel Plumridge is a freelance writer on healthcare management and finance and a former NHS finance manager. 17
STRESS
NHS managers need to move away from managing stress towards preventing it happening in the first place, says Derek Mowbray.
Stress is a personal response to an event. It manifests itself in sensations of anxiety and sometimes depression. Stress is now the principal cause of sickness absence, and the incidence of stress continues to rise. Stress at work causes massive under-performance. As soon as someone experiences the anxiety associated with an adverse event, they think about the cause of the anxiety and not their work. People who come to work, and under-perform due to lack of concentration, constitute a growing reservoir of workers suffering from ‘psychological presenteeism’. Contributing to this rapidly filling reservoir are staff facing particular challenges in the NHS. Many NHS staff experience one of five possible stressprovoking situations: ■■ Staff who have been asked to stay (after going through a period of considerable uncertainty) ■■ Staff who have been asked to stay but do a different job or move to a different location ■■ Staff who have been asked to stay 18
but expect to go in the future (they are faced with ‘certain uncertainty’) ■■ Staff who have been asked to stay but are uncertain about their future (they are faced with uncertain uncertainty) ■■ Staff who have been asked to go (they have suffered shock, but at least know where they stand) Even staff who see redundancy as an opportunity to do what they really want are now finding it harder to grasp those opportunities as the pool of available jobs shrinks. The situation in the NHS is compounded by the political will to change the way it is managed and controlled. Change is a known stressor and, although a necessity for survival, is often managed poorly. Unless the approach to managing stress at work is revised, the impact of stress on NHS performance will only become significantly worse, and the NHS may be in danger of being engulfed by the ripple effect of stress.
Preventing stress There is a growing realisation in many sectors that simply managing stress is no longer an acceptable approach to reducing the impact of stress on performance. It is more effective to stop stress from occurring in the first place. There are only two ways of preventing stress: ■■ Creating healthy organisations and changing managers’ behaviour, based on the principles of psychological wellbeing and performance ■■ Strengthening psychological immunity against adverse events at work, including promoting healthy lifestyles, known as ‘personal resilience’. Both methods need to be applied to produce the required impact on stress at work. Creating a healthy organisation Healthy organisations are characterised by: ■■ A ‘buzz’ of high level performance ■■ The capacity to respond faster than competitors to internal and external pressures healthcare manager | issue 12 | winter 2011
STRESS
The capacity to renew themselves quickly ■■ Determining their own destiny ■■ Being ‘ambidextrous’ – delivering high performance today and shaping itself for the future ■■
In my article The Management Standards for A Healthy Organisation (www. orghealth.co.uk/article-library.html), I set out the standards for achieving a healthy organisation, based on promoting wellbeing and performance through commitment, trust and engagement between the workforce and the organisation. Evidence shows that commitment and trust have a major impact on preventing stress at work. The standards also promote ‘adaptive leadership’ principles, based on shared responsibility for the success of the organisation between every manager and employee. Implementing these standards is placed firmly within the manager’s domain. The standards include the need to define purpose in terms of the outcome expected from the organisation, the core values that act as drivers to motivate the workforce, and the rules governing how the organisation should work, based on promoting commitment, trust and engagement between the workforce and the organisation. Manager behaviour is known to be massively influential in preventing, as well as causing, stress at work. In the Managers’ Code of Conduct (www. mas.org.uk/codes_of_management), I set out the management behaviour that promotes commitment, trust and engagement. Behaviour is influenced by thinking, and managers should think in ways that persuade others to do things they might otherwise not, without causing any stress. The most important attribute and behaviour for managers is attentiveness. If one person is attentive to another, and they feel the attentiveness, they are more likely to reciprocate and be attentive to the first person. This is the essence of successful interaction. Disengagement occurs when one person breaks their attentiveness to the other. This leads to under-performance. healthcare manager | issue 12 | winter 2011
MANAGER BEHAVIOUR
HEALTHY ORGANISATION
PREVENTING STRESS@WORK
PERSONAL RESILIENCE
Resilience Resilience is the ability to cope with stressful situations without experiencing stress. It is also the ability to grow and become stronger by overcoming stressful situations without experiencing stress. Strengthening resilience involves forming a positive attitude towards adverse events. Attitudes are formed from thinking and feeling, and an assessment of what the adverse event means to the individual. The outcome depends on the individual’s ability to evaluate the meaning of the event and determine whether or not they can overcome and tolerate it. Resilience is akin to psychological immunity. Exposure to stressful situations, and overcoming them successfully, provides stronger immunity to future similar situations. People’s innate immunity may be ‘topped up’ with specific exercises. One resilience programme is based on a seven-element model, encompassing vision, determination, relationships, problem solving, interaction, organisation and self-confidence, each of which, evidence shows, contributes to psychological immunity against stressful events.
HEALTHY LIFESTYLE
Psychological wellbeing and performance goes beyond health. Individuals can be very healthy and still suffer stressful consequences from an adverse event. However, a healthy lifestyle can help to boost physical wellbeing, which has a knock-on positive effect on psychological wellbeing. Stress is on the increase. Existing strategies for reducing stress mostly focus on managing it. A more effective approach is to prevent the risk of stress arising in the first place. There are only two ways of preventing stress – creating and sustaining a healthy organisation and strengthening personal resilience against stress. Adopting management standards that promote a healthy organisation, a manager’s code of conduct and programmes to strengthen resilience, when taken together, provide the information and direction for managers and staff to prevent stress from occurring in the first place
.
Professor Derek Mowbray is director of OrganisationHealth. See page 21 for more on what MiP is doing about stress at work. 19
LEGAL MATTERS
legaleye Jo Seery explains how the Freedom of Information Act can be used to access information. While employment legislation gives union reps the right to obtain information from employers for collective bargaining purposes, the Freedom of Information Act 2000 (FOI) and Data Protection Act 1998 (DPA) provide a way to access information for other purposes. The FOI owes its origins to the European Union principle of transparency – that a higher quality of democracy is achieved by open government and the accountability of public bodies. It sets out a right of access to information held by public authorities such as: ■■ central government ■■ local authorities ■■ health services ■■ police and armed Forces ■■ schools ■■ other public bodies You have the right to request any information held by a public authority, regardless of how long it has been held. However, some information is exempt from the authority’s obligation to disclose it. Anyone can make a request, regardless of age, nationality or location. It must be made in writing (this includes email), must state clearly what information is required and must state the name of the applicant and an address for correspondence. After receiving a request, the public authority should confirm or deny, normally within 20 working days, whether or not they hold the information, and either provide it or explain why it has not been provided. It should provide the information in the 20
form in which it was requested unless it is unreasonable to do so. The authority also has a duty to advise and assist people making requests. The Information Commissioner (ICO) exists to uphold rights to information, to promote openness by public bodies and protect data privacy for individuals. For example, in March 2008 the ICO issued a decision notice on Hounslow Primary Care Trust after it failed to disclose information within 20 working days, and for not providing a refusal notice citing the exemptions it later relied on to withhold some information. The ICO was particularly critical of the PCT’s piecemeal approach to disclosure and recommended a review of its records management system. Refusal of a Request An information request can only be refused if it falls under one of the 23 exemptions set out in the Act (Part 1 Section 17). Some requests are subject to a public interest test, such as information about investigations and proceedings conducted by public bodies, and court records. Others are subject to a ‘prejudice’ test, to determine whether disclosure would prejudice certain activities or interests listed in the exemption, such as national security, an organisation’s commercial interests, or whether it would breach the privacy of individual employees of a public body. Requests can also be refused if the information can be accessed by other means, even if payment is required, such as via the Data Protection Act, or if the request is “vexatious” or the
applicant makes repeated requests. If the information is routinely published as part of a ‘publication scheme’, the public authority can simply direct the applicant there. Refusals must be in writing, must explain why a request is being refused and must also advise the applicant of the public authority’s internal review procedure. If the applicant is not satisfied by the outcome of that review then a complaint can be taken to the ICO. The Commissioner has the power to issue an enforcement notice stating the steps the authority should take to comply with the Act. The Campaign for Freedom of Information produces a users’ guide on making freedom of information requests, including a model letter, which is available on their website at: www.cfoi.org.uk/ The Data Protection Act The DPA applies to almost anyone who processes or stores personal data, as well as the people on whom the information is held. In healthcare, this means the DPA applies to anyone who processes personal data and covers the NHS as well as private practitioners. It applies to information held on both service users and workers.
.
Jo Seery Thompsons Solicitors Legaleye is not intended to provide legal advice on individual cases, and MiP members in need of personal advice should immediately contact their MiP rep.
healthcare manager | issue 12 | winter 2011
CAREERS
Do you need a mentor? A mentor can unlock your career potential, but such a valuable relationship requires a little thought and planning, says Liz McCarten. If you are completely clear about your career path or the one you want to enter, already have a good relationship with a senior person in your field and feel you have access to the advice and support you need, you probably don’t need a mentor. But that’s because you already have one in all but name. If you are not lucky enough to be in that position, look for a mentor who is likely to be an expert in their field, and who can offer advice and guidance as well as encouraging self-discovery and selfresolution. A good mentor will share experience and information. Mentoring can be good for your confidence and allows you to explore issues and topics behind the scenes, as well as helping you gain inside knowledge. Finding a mentor Use your own professional networks (including sites like LinkedIn) or search the internet for one of the many NHS schemes available. While it is ideal to meet your mentor in person for the first session, that telephone mentoring may offer a greater pool of expertise.
Planning You’re gaining access to a great resource through your mentor, so you owe it to them and yourself to be focused about what you want from them and what you need for yourself. Be clear what you want from the relationship before your first meeting. Are you looking for a new role or wanting to seek new skills? Be ready to answer some probing questions. Before you meet think about things like: ** What do you want from the relationship? ** How will you know when you have succeeded? ** How long will the relationship last? ** What form will the sessions take? ** What approach would work best for both of you – formal or informal? ** Are there any restrictions on topics? ** How will you maintain contact between scheduled sessions? Setting goals You will need to work with your mentor to set realistic, achievable goals – there’s nothing more off-putting than a mentee who never does their homework!
Working with a mentor Approaches will vary, depending on your mentor’s work and the approach you have agreed. Remember to be professional and polite with your mentor; although you may have less formal and more personal conversations with them than is usual in the workplace, they may also be someone who, by virtue of their position, is influential in your future career. That said, don’t be intimidated. They’re working with you to help you progress and that means you need to trust them and deal with things you might never raise in a formal setting. Saying goodbye You may stay in contact with your mentor, however, it is important to set a time limit on the more formal mentoring relationship. You chose your mentor because they are busy and successful and they agreed to help because they understand the value of doing so. They need to get on with their other commitments. You need to take what you have learned and implement it independently. Good luck – and don’t forget to become a mentor when your turn comes!
.
Stress busters MiP has seen a significant increase in stress-related cases recently. Management cost reductions throughout the UK, and clustering of PCTs and SHAs in England, means members are often expected to cover the work of two or more people. Where members’ capability is questioned, or their health is suffering, MiP will act to protect their health and wellbeing and ensure employers fulfil their statutory
healthcare manager | issue 12 | winter 2011
and contractual duties. MiP may request risk assessments which often show that members are being over-worked. In serious cases, or where capacity problems are widespread in a trust, we will call in the Health and Safety Executive. Employers are liable for any foreseeable personal injury resulting from sustained overwork and awards for damages can be significant. MiP operates a personal injury stress
protocol for members in conjunction with Thompsons Solicitors. If you find yourself in this position, keep a log of what is required of you. Raise the issue with your manager at regular one-to-ones and have your concerns recorded. If your health is suffering, consult occupational health and your GP. Contact MiP for advice and support.
21
MiP AT WORK
Linking up in Lincolnshire MiP’s growing network of link members are flying the flag for MiP, raising our profile in the workplace and speaking up for our members. Here we talk to Jeremy Baskett, MiP link member in North East Lincolnshire Care Trust Plus. the PCT trust boards, our Care Trust has become part of the Humberside Cluster which also includes Hull, East Riding, and North Lincolnshire. We have been downsizing…with staff in the provider services moving into two new social enterprises, one for community health services (Care Plus) and a stand-alone mental health social enterprise (Navigo). Staff from the commissioning services have been through two rounds of voluntary redundancy and we have lost over a third of the staff. We are working towards creating a social enterprise for social care commissioning which will include the social worker team. What is your day job? I am assistant director of community engagement, where we have moved to embed public involvement throughout the decision making of our organisation through a community membership scheme. We also work closely with the local authority and third sector. How has the restructuring affected your organisation? We have been through major turmoil, being a pathfinder Clinical Commissioning Group (CCG). With the collapsing of 22
Why and how did you become a link member? I was one of the first members to join MiP and two years ago, with all the changes taking place and staff being dissipated to different organisations, I realised a link representative for MiP was badly needed to support members in taking the changing health and social care agenda forward. I soon became the staff side lead in the Care Trust Plus by default as many active members in other unions were leaving to join other organisations in
the provider arena or taking VR. Six months ago I was elected as staff side chair of the Humberside partnership group where trade union representatives meet with the cluster directors. What support do you get from MiP? MIP has been a great support in providing training for me to tackle my role as Cluster staff side chair with a very complex and demanding agenda. MiP is always supportive of the recruitment drives we undertake across the Humberside Cluster, and the regional officers, Jane and George, are very helpful in providing advice and support in dealing with members’ issues and questions. What’s it like being in a leadership role for MiP? I chair the meetings of the Humberside Partnership on an alternate basis with the Cluster Director of HR. I had a number of years where I was a District Councillor and, for four years when we controlled a hung council, I was on one of the major committees and this certainly helped prepare me for chairing the Cluster partnership! I like to think in the six months we have been in existence we have already managed a very big agenda and I have ensured that we have worked in a constructive way with the senior directors in developing an agreed way forward. Overall being an MIP Link member has been challenging but the insight it has brought, and the opportunity to ensure our members have an input in healthcare manager | issue 12 | winter 2011
16332 MIP ad 213(h) x 110(w):Layout 1
the fast moving agenda, has been very rewarding. What’s it like doing negotiating? Many negotiations are very challenging but they can also be very rewarding, when you see the points you have raised as a Link member and chair being incorporated in the policies and in the forward plans.
31/8/10
13:11 Page 1 MiP AT WORK
These are uncertain times.
Would you say that the skills you use in your ‘day job’ come in useful in your MiP role? Certainly my job requires very good interpersonal and negotiating skills. Has being link member enhanced the skills you use in your day job? Most certainly – in developing relationships throughout the cluster, in being able to support members and staff through the complex environment and ensuring members have a say in their futures. And have you developed new skills through your trade union activity? Yes – many and varied – from improving my organisation skills, networking, to negotiation and even project management skills. Has being staff side chair affected your relationship with your chief executive, your manager and other senior colleagues? Actually, it has improved relationships by developing a much more open and constructive approach between us all and more willingness to discuss ideas at an earlier stage to ensure members’ views are considered. Any advice for members who are thinking about getting active in MiP? It is very rewarding and can really enhance working relationships in the work environment.
.
For more information about becoming a link member contact Martin Furlong at m.furlong@miphealth.org.uk. To see if there is a link member in your organisation, see the MiP website: www. miphealth.org.uk/Aboutus/locallinkmembers.aspx
healthcare manager | issue 12 | winter 2011
Reduce the uncertainty. Join MiP. One thing is for certain in such times – you need support. MiP is the UK’s only trade union organisation that solely represents healthcare managers. We provide an influential voice, personal support and employment advice, management skills and access to leadership networks. Our experienced team of employment professionals is on hand to offer one-to-one confidential advice, negotiation and representation and fast access to legal resources.
Join MiP today. Visit www.miphealth.org.uk/joinus
helping you make healthcare happen
23
backlash
Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@ healthcare-manager.co.uk.
by Celticus
Noughts and Crosses
wasted no time in speaking his mind, describing Lansley’s NHS reforms as ‘completely unintelligible’, ‘messy’, and saying it was ‘not clear’ how they could be implemented.
C
Squaring the Circle
P
rivate health provider Circle finally got the green light to take over the running of the NHS’s 300-bed Hinchingbrooke Hospital in Cambridgeshire. Insiders say Circle will need to perform a ‘clinical miracle’ to turn around the trust’s £40bn deficit, meet QIPP targets and still turn a profit. City analysts decribe Circle ‘as investment for risk lovers’ and even the firm’s own share prospectus admits expanding its NHS services ‘could affect its ability to provide a consistent level of service to patients’. Circle has only one healthcare professional on its 12-strong board and has so far failed to make any profit at all from its chic 30-bed private hospitals. But Circle’s optimistic boss, former Goldman Sachs executive Ali Parsa (pictured above) says it can reinvent healthcare the same way ‘we re-engineered financial services in the 80s’. We have been warned.
24
ircle has made much of its ‘John Lewis’ style partnership arrangements for staff, but its ownership structure is a bit more exotic than that of Britain’s best-loved department store. The partnership only owns 49.9% of the business, with the controlling share in the hands of Circle Holdings plc, an ‘investment vehicle’ registered in the tax-sheltering British Virgin Islands. There’s more. The company’s substantial property portfolio is held ‘off balance sheet’ (and off-shore) in a ‘special purpose vehicle’ company, which offers Circle’s healthcare operations 25-year leases subject to ‘upward only’ rent reviews. Does this sound familiar? It should do, it’s the same ‘opco-propco’ business model followed so successfully by care home provider Southern Cross. Fingers Crossed then.
Open secret
T
he Department of Health was ordered on 11 November to release its strategic risk register following requests from the Evening Standard and former Labour health spokesman John Healey (pictured). It’s expected to spell out the risk of his reforms for patient safety, NHS finances and the provision of services across England. The department’s
Top of the class
Y excuse for keeping the document secret for almost a year? Releasing it could have ‘jeopardised the success of the policy’, claimed the Department’s lawyers. Which is of course exactly why we should see it.
Messing around
P
raise indeed for Professor Malcolm Grant, provost of University College London and the new Chair of the (soon to be, probably) National Commissioning Board. In a gushing tribute on the UCL website, Dr Richard Horton, editor of doctors’ mag The Lancet, says Prof Grant has ‘a remarkably agile mind, able to speak not only intelligently but with great insight’. Dr Horton goes on: ‘What holds particular promise is his independence of mind – he will not collapse in the face of political pressure like some.’ Qualities that may not be appreciated by his boss, health secretary Andrew Lansley. In an amiably shambolic appearance before the Commons health committee in October, Grant
et more evidence, if it were needed, that the NHS ain’t broke (see Noel Plumridge on p15 for even more). First, a study in the British Journal of Cancer contradicted the prime minister’s ill-informed criticism of NHS cancer care, finding that mortality rates have dropped more in England than anywhere else in the last 30 years. Then, the OECD produced figures showing that the NHS is the most equal health service in the world when it comes to gaining access to specialist clinicians. Finally, the Commonwealth Fund produced yet another report with findings that NHS patients have the fastest access to GPs, the best co-ordinated care and suffer the fewest medical errors of the eleven western countries surveyed, ahead of the USA, France, Germany and even Australia. ‘UK and Swiss patients reported more positive health care experiences than sick adults in other countries,’ said the US-based foundation. Us and the Swiss, who’d have thought it?
healthcare manager | issue 12 | winter 2011
e
insuranc
holidays
The Added vA LUe OF MeMBerShIP
s
mortgage
savings
motoring
finance
Members of MiP have access to a range of benefits provided by our partner organisation through UNISONplus. More often than not, these benefits will be on an exclusive basis with leading companies. But it isn’t only excellent terms and value for money we look for in a potential Partner. The products or services they offer have to be among the ‘best in class’. They must share our values and deliver a high quality service, including straightforward call-handling and easy-to-navigate websites. On the UNISON website you’ll find full details of all the criteria we look for, before we award companies with our official Partner accreditation. All you have to look for when you are looking for a name you can trust is the UNISONplus logo. For more information visit www.unison.org.uk and click on the UNISONplus logo or call MiPLink tel 0845 601 1144. You could save the cost of your subscription many times over and guarantee yourself the value for money that you and your family deserve.
Pay more work longer for a smaller pension? NHS staff are faced with a triple squeeze on their pensions. MiP and the other public service unions are ready and willing to have meaningful discussions about the future of NHS pensions to achieve pension fairness. Help us send a clear message to persuade ministers to enter constructive talks. Visit the MiP website to see how you can get involved and to join MiP.
Have your say
speaking up for pension fairness
www.miphealth.org.uk