healthcare manager winter 2011
DESCRIPTION
Healthcare Manager magazine issue 12, winter 2011 from Managers in Partnership (MiP).TRANSCRIPT
healthcaremanagerissue 12
winter 2011
STATE OF MINDSOPHIE CORLETT ON A BETTER DEAL FOR MENTAL HEALTH
helping you make healthcare happen
plusNHS PRODUCTIVITY:DELIVERING MORE FOR LESS
ALL WORKED OUT:BETTER WAYS TO BEAT STRESS
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healthcare manager | issue 12 | winter 2011 1
inside
healthcaremanagerissue 12
winter 2011
published by
Managers in Partnershipwww.miphealth.org.uk8 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.
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 HowesExecutive editor
heads up:2What you might have missed & what to look out forLeading edge: Jon Restellinperson: Dr Cathy Rooney, Scottish National Blood Transfusion Serviceinpublic: Jubilee Gardens Health Centre and Library
letters & comment:8Paul Scourfield: the Bill falls short on public health
features:10Staff engagement: engaging staff is the key to better outcomes for patients.Interview: Sophie Corlett, Director of external relations, MindProductivity: how does the NHS really compare? Stress: stop it before it starts
regulars:20Legal eye: using freedom of information lawsCareers: the power of the mentorMiP at Work: Link member Jeremy Baskett
backlash:24
2 healthcare manager | issue 12 | winter 2011
heads upHEADS UP
what you might have missed and what to look out for
healthcare managerissue 12 | winter 2011
ISSN 1759-9784published by MiP
All copy © 2011 MiP or the author. Opinions stated are not necessarily those of healthcare manager or MiP.
Executive EditorMarisa [email protected]
Associate EditorCraig [email protected]
Art DirectorJames Sparling
Design and Production [email protected]
ContributorsJeremy Dawson, Marisa Howes, Jim Keegan, Liz McCarten, Helen Mooney, Alison Moore, Derek Mowbray, Noel Plumridge, Jon Restell, Craig Ryan, Paul Scourfield, Jo Seery.
Print Warners Print, Bourne, Lincs
Advertising Enquiries020 8532 9224 [email protected]
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.
EnvironmentClimate Week 12-18 March 2012
Climate Week is a national campaign to inspire a new wave of action on climate change, featuring thou-sands of events and activi-ties, planned by organisa-tions 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 McCart-ney, 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, pri-mary care trusts, ambulance services, as well as some of the Royal Colleges and Socie-ties. The winner of the award for the ‘Best Initiative by a
Public or Uniformed Sector’ was the University Hospital of South Manchester, who man-aged 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 green-house gases, the NHS is cru-cial to cutting emissions both from its own estates, and by highlighting the detrimental effects of carbon-intensive lifestyles on health and com-munity well being.
To find out more about getting involved in Climate Week go to www.climatew-eek.com, email [email protected] or telephone on 020 3397 2601.
Patient voiceWatchdog seeks chairThe search has begun for a chair to lead HealthWatch England, the proposed ‘con-sumer champion’ which will represent the views of pa-tients and the public within the government’s new NHS structure.
Patrick Vernon, Chair of the
HealthWatch advisory group said: ‘HealthWatch England’s chair will have a pivotal role in providing leadership and estab-lishing 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 serv-ices 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 recom-mend’ that the Care Quality Commission investigates pub-lic concerns about health and social care services in Eng-land.
Subject to parliament passing the Health and Social Care Bill, the new chair is expected to take up the post in April 2012.
For further details, visit the CQC website at: www.cqc.gov.uk.
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.
healthcare manager | issue 12 | winter 2011 3
HEADS UP
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 pen-sions. You will have seen much media reporting and comment, some of it ac-curate. You will also have received in-formation from your union. The day of action on 30 November will be immi-nent 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 ca-reer 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 Govern-ment’s plans. Union negotiators there-fore have drawn much the same conclu-sions 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
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 em-ployee contributions. By mid-Septem-ber 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 negotia-tions 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 long-term 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 frame-work 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 pen-sion 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 contribu-tions. And this brings us to another rea-son why the government’s move does not meet the objectives of our campaign for pension fairness. The government resolutely refuses to negotiate contribu-tions 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 incred-ible pressure and protest from staff and their unions. That’s why it’s vital every-one does everything they can to keep up that pressure.
leading edge
Jon Restell, chief executive, MiP
“Since April progress in talks has been glacial. Worse, ministers have relentlessly pressed on with plans to cut the value of pension indexation.”
New regulations came into force in September requiring all public bod-ies, 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
demonstrating their compliance’ and to set themselves ‘specific, measurable equality objectives’. The equality duty requires pub-lic bodies to prevent unlawful discrimina-tion, 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 Sys-tem 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 regula-tions, available at: http://tinyurl.com/76cxf4k
Equality
New equality regulations take effect
4 healthcare manager | issue 12 | winter 2011
HEADS UP
MiP 2012subscriptionsMembers who joined MiP after 1 June 2005 pay MiP subscriptions, as set out below. Mem-bers who transferred into MiP from FDA or UNISON when it was launched on 1 June 2005 (founding mem-bers), pay the relevant rate of the partner un-ion from which they transferred.
MiP subscriptions are proposed by MiP’s man-agement board, in consul-tation with MiP’s national committee, and approved
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.
Tax relief on MiP sub-scriptionsAs a healthcare manager, you may be entitled to tax relief on your MiP subscrip-tions in the same way as members of other profes-sional organisations such as the Royal College of Surgeons. For more infor-mation log into the mem-bers’ page of the MiP web-site: www.miphealth.org.uk
Band Annual basic salary SubscriptionPart Time
A up to £25,750 £20.50B £25,751-£38,850 £22.50Full Time
A £38,851-£61,800 £25.20B £61,801-£72,100 £28.40C £72,101-£82,400 £30.55D Over £82,400 £33.10Management trainee £12.80FDA founding members
A £15,500-£33,500 £12.55B £33,501-£47,000 £24.35C £47,001-£70,500 £26.55D £70,501-£88,000 £28.85E Over £88,000 £31.50UNISON founding members
BAND K Over £35,000 £22.50
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 Au-thority 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 suc-cessful passage of the bill.
The authority will also work with com-missioning groups, GPs and the Department of Health to agree how Clini-cal Commissioning Groups (CCGs), which will replace PCTs from 2013, should be set up and run.
NHS chief executive Sir David Nichol-son, 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 com-missioning 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.
‘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.’
NHS reform
Commissioning Board casts long shadow
Professor Mal-colm Grant has been narrowly confirmed as Chair of the new NHS Com-missioning Board after members of the Commons health commit-tee split along party lines over his appoint-ment.
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 Lib-Dem 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 for-ward the plans to establish the Board and its structure and provide strategic leader-ship 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 back-ground. It can sometimes help for the chair to have an outsider’s cool eye. How-ever, 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 prom-ised to donate his £63,000 NHS salary to the university.
Legal academic to head Board
healthcare manager | issue 12 | winter 2011 5
HEADS UP
inperson
‘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 pro-tect and preserve the work of the service both in terms of research out-comes 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 pep-tides (with the University of Aberdeen), cell therapy research (Universities of Ed-inburgh 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 serv-ices 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 scien-tists, clinicians and other staff in the transfusion service would not be adequate-ly managed,’ says Cathy. ‘Without proper management poor deals may be done with third parties and, as a result, the public in-vestment that goes into the SNBTS’ research and development would not see proper reward. The IP generated over years of re-search 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 appropri-ately 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
transplantation has the possibility of re-storing 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 hormone-producing cells) are selectively destroyed in patients with Type 1 diabetes, clini-cians and researchers are actively pursuing islet transplantation as a way to restore beta cell function in these pa-tients. They hope this could lead to an alternative to a complete pancreas trans-plantation or an artificial pancreas for people with severe Type 1 diabetes.
Another area of development, in part-nership 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 col-laborations need to be IP managed and
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 ben-efitting 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
Dr Cathy Rooney, External Funding and Licensing Manager, Scottish National Blood Transfusion Service
“Without proper management, poor deals may be done and public
investment in research and development
would not be properly rewarded.”
6 healthcare manager | issue 12 | winter 2011
HEADS UP
Ministers are to change the NHS Con-stitution 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 ‘whistle-blowing’ 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 re-sponsibility to their patients to raise concerns if they see risks to patient safety. And when they do, they should be reas-sured 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 sup-port staff and investigate any claims fully.
Whistleblowers
Staff who speak outwill be protected
Regulation
‘Confused’ Monitor could failMonitor, the foundation trust regula-tor, 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 govern-ment to issue guidance to resolve confu-sion over how Monitor, the CQC and the proposed National Commissioning Board will work together.
Anna Dixon (above), director of policy at the King’s Fund, said: ‘Monitor has been set a formidable task with little prec-edent and supporting analysis, so the risks of failure are considerable. Unless economic regulation is designed and ex-ecuted well, it may end up imposing more costs than the benefits it delivers.
‘As the Health and Social Care Bill pro-ceeds through the House of Lords, we hope that ministers will look again at the lessons to be learned from other regula-tors 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 envis-aged by the government’s reforms oper-ates in the interests of the public and pa-tients, 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
The NHS is making slow progress in im-proving the way it handles complaints, with too many minor disputes being es-calated 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 organisa-tions, receiving 46% of all complaints. The report found that the most common com-plaints 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
15,000 complaints about the NHS in 2010-11. ‘As the stories in the report illustrate, last year relatively minor disputes about unan-swered telephones or mix-ups over appointments ended up with the Ombuds-man because of knee-jerk responses by NHS staff, and poor complaint handling,’ said Abraham.
Ombudsman
NHS ‘patchy and slow’ dealing with complaints
healthcare manager | issue 12 | winter 2011 7
HEADS UP
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 li-brary and a host of community and specialist health services including audiology, maternity, podia-try, and mental health and wellbeing.
It was developed jointly by the PCT and the council, in partnership with Building Better Health, a company spe-cialising in projects under the
government’s Local Improve-ment Finance Trust (LIFT) scheme. It followed a joint needs assessment which high-lighted the need for an increase in the number of general practices and commu-nity health services in the borough.
According to Linda Smith, NHS Ealing’s LIFT commis-sioning manager, who was also the centre’s manager dur-ing 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 stand-ards of healthcare. She says that residents now have access
to multiple integrated re-sources under one roof, which has also helped to reduce un-necessary and time-consuming referrals to hospitals or across the bor-ough 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 com-bining the health centre with
the library helped to save the library from closure. ‘The li-brary 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 al-ready there,’ she says.
Marie Pemberton, stake-holder engagement manager at NHS Ealing agrees. ‘The re-sponse 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 im-proved access to a wider range of services closer to where they live.’
The fact that the health cen-tre also houses a library is a big plus for the local popula-tion. The two spaces merge together seamlessly while still being able to function inde-pendently, 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
inpublicJubilee Gardens Health Centre and Library, Ealing, London.
“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.”
8 healthcare manager | issue 12 | winter 2011
Passing the batonI 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 net-works are developing. More and more of our link mem-bers 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 com-munication with each other, discussing current issues and sharing skills, knowl-edge and experience. And although I am stepping down from the national committee, I will still play an active role in our Scottish network.
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 prideI 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,
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 col-leagues 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 oth-er unions with a real sense of PRIDE.
George Shepherd MiP national officer
lettersLETTERS
to the editor
Letters on any subject are welcome. Please send to editor@healthcare-
manager.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.
#NHSManagersGreat 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_stringer1http://tinyurl.com/85qkzzy
#HealthBillHarry Cayton, CHRE: “There is no patient representation on the National Commissioning
Board. Where are the incen-tives to change?”@TheKingsFund
Are we to have competition or stalinism? or both at once? http://fb.me/ZdI31eWg@socialisthealth
#BreastScreening“Screening is not prevention. We’re not going to screen our way to a cure.” The Limits
of Breast Cancer Screening: http://nyti.ms/vtI44p@kremersonian
#MonitorNew NHS regulator ‘risks failure’ http://ow.ly/7l2e8 @Health UBM#PCTs
Recently an influential male GP told me,you can forget all that equality stuff,we will decide who we employ @mitya2
GPs cost too much, think they can do too much and will never commission without reinventing PCTs @RoyLilley
#ElderlyCareMost hospitals care for elderly well. Gov doing usual thing & extrapolating black propa-ganda 2 reflect #NHS badly overall @dianehain
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
#EmergenciesIn the new @NHS how & who would coordinate a major trauma response involving
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
#DowntonAbbeyLavinia had the lowest public vote, so now Lady Cora and Carson will have a sneeze-off as the elimination goes to Deadlock. @PeteDeveson
Tweet BoxA selection of tweets on issues covered in healthcare manager
healthcare manager | issue 12 | winter 2011 9
COMMENT
comment
Paul Scourfield Chief executive, Faculty of 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. .
Health bill falls short on public health
“Fortunately, no public health specialist
has yet made such a serious error of
judgement that an unnecessary crisis has
occurred.”
Views expressed are those of the author and not necessarily those of healthcare manager or MiP.
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10 healthcare manager | issue 12 | winter 2011
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 organisa-tional performance; some of our re-search in the past decade has shown links between HR practices in NHS trusts and outcomes such as hospital patient mortality. Since the NHS na-tional staff survey began in 2003, we have collected data annually about em-ployee perceptions of their organisa-tions, their experiences at work, atti-tudes and well-being. This and other routine data collection has allowed us to show the extent to which NHS staff experience might affect trust perform-ance. In particular, team working, line management and staff engagement are
key predictors of outcomes.One key outcome we studied was
patient satisfaction. A consistent find-ing 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 cir-cumstances 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’ percep-tions 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
Engaging staff is the key to better outcomes for patients, especially at a time of upheaval in the NHS, says Jeremy Dawson.
discrimination, patients were more likely to report respectful and helpful encounters with clinicians.
The converse of this is that when staff report aggressive behaviour (ver-bal or physical) from patients or their relatives, there is lower patient satisfac-tion. 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 ex-cessive 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 re-lated to lower patient mortality in acute trusts, as well as higher patient satisfac-tion. The percentage of staff receiving appraisals, and particularly helpful ap-praisals, is related to patient mortality rates. Appraisals are a powerful means of ensuring that staff have clear objec-tives, that they are developing their skills and that they feel valued, respected and supported by their managers. The ex-tent 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
Staff ENgagEmENt
healthcare manager | issue 12 | winter 2011 11
regularly to review their performance, and whose members work interde-pendently. When staff work in a well-structured 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 lev-els 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 clear-ly linked to other aspects of staff expe-rience. Unsurprisingly, staff are more likely to leave or be absent after experi-encing 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 ab-senteeism 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 infec-tion rates in acute trusts. Where a large percentage of staff feel they can con-tribute towards improvements at work, infection rates are decreasing, reinforc-ing 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 vigi-lance plays a role too: where staff re-port 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
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 com-municating with staff. Rather, it is ena-bling staff to have meaningful and re-warding jobs, fostering identification with and commitment to their work and the wider organisation, and giving staff opportunities to be involved in deci-sions which affect them. This in turn is helped by effective management prac-tices, 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 per-formance and didn’t leave them feeling valued – engagement was actually low-er than among staff who had no ap-praisal at all. Similarly, staff working in teams that were not well-structured (as defined above) were more likely to ex-perience 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 param-eters – particularly objectives – is a key part of ensuring staff are engaged and outcomes are improved.
The implications for patient care, pro-ductivity 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 organisa-tional 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 main-taining 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.
Staff ENgagEmENt
“Staff engagement is not a quick fix and involves far more than just communicating with staff.”
12 healthcare manager | issue 12 | winter 2011
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 im-proved 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.
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.
Mental health is much more under-stood 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 experi-ences 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 con-cerned 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, fund-ing 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 pres-sure 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 pub-
INTERVIEW
Alistair Campbell, ex-President of Mind Melvyn Bragg, current president Stephen Fry and Heart FM DJ Matt Wilkinson launching Mind Week in 2009.
healthcare manager | issue 12 | winter 2011 13
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 in-volved 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 un-derstood and that it is quite compli-cated 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 commission-ing 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 com-mission it, she warns. ‘Mental health users tend to need services for a rela-tively 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 peo-ple have not found the solution.’ And some mental health patients will need
some very complex services – including some non-healthcare ones such as debt advice, she says.
While the policy of ‘any qualified pro-vider’ 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 com-plicate 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 plan-ning 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
INTERVIEW
“Mind is looking for mental health to get parity with other health issues.”
14 healthcare manager | issue 12 | winter 2011
public and patients. Health and wellbe-ing boards will, of course, have an im-portant 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 in-volved 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 ex-pertise 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 integra-tion 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 psy-chological liaison that speeds up peo-ple’s recovery and reduces the likeli-hood of reoccurrence. The irony is that it does not reduce the costs for the commissioner, it increases them.’
Mind is talking to the NHS Confed-eration, 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 health-care, but ultimately many decisions will be made locally and here the right guidance will be vital.
whether they are going to eat,’ she warns.
Of particular concern are the capac-ity 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 pres-sure to look for work.
‘We are concerned that the systems for assessing people for disability-based benefits are not being done ac-curately. We know that a lot of deci-sions 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 employ-ers say they would not employ some-one 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 com-munity-based interventions. This can avoid care which is expensive and dis-ruptive to people’s lives, but she warns that it is not a panacea and won’t al-ways head off the need for more inten-sive care later on. And like many men-tal health interventions, the department which pays for it may not be the one which realises the savings .
INTERVIEW
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 productivity and welfare payments. It also has a tremendous impact on individuals and their families.
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
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?’
Crossed lines?
The Government’s 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.”
healthcare manager | issue 12 | winter 2011 15
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 dec-ade to justify such a high level of in-vestment. And now, under the so-called QIPP (quality, innovation, pro-ductivity and prevention) initiative, pro-ductivity 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 improve-ment, and politicians are not averse to making capital out of perceived mana-gerial or system weaknesses. The busi-ness of the NHS in England appears, once again, to have become reorgani-sation. Yet international comparisons suggest the NHS may already be amongst the most efficient health pro-viders in the developed world.
Systemic weaknesses have been highlighted most recently by the Public Accounts Committee (PAC). The PAC
scrutinises public expenditure on be-half of parliament, using value-for-mon-ey criteria based on the principles of economy, effectiveness and efficiency. In March 2011, its report on NHS hos-pital productivity in England reported that ‘in 2002 the Department [of Health] promised that, in exchange for in-creased funding, it would deliver annual productivity improvements. The De-partment 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 Eco-nomics 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
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.
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: Liberat-ing the NHS, published in July 2010, which suggested:
‘Compared to other countries… the NHS has achieved relatively poor out-comes in some areas. For example, rates of mortality amenable to health-care, rates of mortality from some res-piratory diseases and some cancers, and some measures of stroke have been amongst the worst in the devel-oped world.’
These allegations were quickly chal-lenged. The British Medical Associa-tion, noting wide variations between international comparisons of health
PRODUCTIVITY
“...this produces a suitably large, headline-grabbing figure, usually expressed in billions of
pounds and easily interpreted as ‘the price
of NHS inefficiency’.”
16 healthcare manager | issue 12 | winter 2011
outcomes, observed that this is ‘some-times simply due to concepts of illness and different cultures of diagnosis’. The BMA also published detailed disease-specific analyses of UK outcomes. Meanwhile John Appleby, chief econo-mist at the King’s Fund, was question-ing the government’s use of evidence and highlighting significant improve-ments in NHS performance since 2006.
Outcomes are a central aspect of health service performance, but pro-ductivity measurement involves com-paring outcomes with resources con-sumed, and adjusting for relative levels of service quality. The most recent au-thoritative independent evaluation of NHS productivity was published by The Commonwealth Fund, a US-based pri-vate foundation, in June 2010. Mirror, Mirror on the Wall compares the per-formance of the UK health system with six other countries: Australia, Canada, Germany, the Netherlands, New Zea-land and the United States.
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
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 GDPpercentage of health expenditure ■
spent on administration and insurancepatient time spent on paperwork, ■
disputes related to medical bills or health insurancevisits to A&E for conditions treatable ■
by GPsfailures of medical records or test ■
results to reach doctors’ offices in time for appointmentsduplication of tests by different ■
health professionalshospital readmissions for ■
complications after dischargepractices with high clinical IT ■
functions
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 non-system’ is pertinent. Corrigan, former
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, bu-reaucratic monster of media myth. So why, then, the persistent canard of NHS inefficiency?
A prime reason is the seemingly nev-er-ending flow of reports, from various sources, highlighting scope for im-provement in specific areas of NHS performance. These have been given a new impetus and urgency by the cur-rent ambitious savings targets: indeed, it sometimes seems that ‘productivity’ has become a euphemism for ‘sav-ings’. 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 neces-sary. 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
PRODUCTIVITY
1 United States of America $7,164
4 Norway $5,207
5 Switzerland $4,815
6 Netherlands $4,233
9 Belgium $4,096
10 Germany $3,922
11 Canada $3,867
12 France $3,851
18 Australia $3,365
20 United Kingdom $3,222
22 Greece $3,010
23 Spain $2,941
24 Italy $2,836
25 Japan $2,817
United States of America
Norway
Switzerland
Netherlands
Belgium
Germany
Canada
France
Australia
United Kingdom
Greece
Spain
Italy
Japan
$0 $2,000 $4,000 $6,000 $8,000
$2,817
$2,836
$2,941
$3,010
$3,222
$3,365
$3,851
$3,867
$3,922
$4,096
$4,233
$4,815
$5,207
$7,164
Health Expenditure Per Capita 2008 (PPP; International $)
healthcare manager | issue 12 | winter 2011 17
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. Con-veniently, this offers a suitably large, headline-grabbing figure, usually ex-pressed in billions of pounds and easily interpreted as ‘the price of NHS inef-ficiency’.
Some examples. Late in 2010 a re-port by consultancy EC Harris found an average of 12.5% of the NHS estate to be empty or underutilised, and identi-fied potential revenue savings of £500m per year. The Harris report reso-nated with cross-government concern about the use of public sector land and buildings, inherited from the ‘total place’ during Gordon Brown’s adminis-tration.
Next, between £600 million and £1 billion could potentially be saved, ac-cording 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 – in-cluding length of hospital stay, pre-operative 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, adher-ence to best clinical practice and diag-nostics. It highlighted, for example, a ten-fold geographical variation in high-risk 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
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 in-tense 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 re-ducing variations, consolidating orders and negotiating economies of scale. Once again, the Public Accounts Com-mittee 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 ex-amination gloves easily attracted sub-stantial press coverage.
It all struck a chord with a govern-ment convinced about poor procure-ment 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 miss-ing an artificial and challenging savings target is not synonymous with ineffi-ciency. 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.
PRODUCTIVITY
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18 healthcare manager | issue 12 | winter 2011
Stress is a personal response to an event. It manifests itself in sensa-tions of anxiety and sometimes de-pression. Stress is now the princi-pal cause of sickness absence, and the incidence of stress continues to rise.
Stress at work causes massive un-der-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 concen-tration, constitute a growing reservoir of workers suffering from ‘psychologi-cal presenteeism’.
Contributing to this rapidly filling res-ervoir are staff facing particular chal-lenges in the NHS. Many NHS staff experience one of five possible stress-provoking situations:
Staff who have been asked to stay ■
(after going through a period of con-siderable uncertainty)Staff who have been asked to stay ■
but do a different job or move to a different locationStaff who have been asked to stay ■
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 uncer-tainty)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 com-pounded by the political will to change the way it is managed and controlled. Change is a known stressor and, al-though 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.
NHS managers need to move away from managing stress towards preventing it happening in the first place, says Derek Mowbray.
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 per-formance. It is more effective to stop stress from occurring in the first place.
There are only two ways of prevent-ing stress:
Creating healthy organisations and ■
changing managers’ behaviour, based on the principles of psychological wellbeing and performanceStrengthening psychological immunity ■
against adverse events at work, in-cluding 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 organisationHealthy organisations are characterised by:
A ‘buzz’ of high level performance ■
The capacity to respond faster than ■
competitors to internal and external pressures
STRESS
healthcare manager | issue 12 | winter 2011 19
The capacity to renew themselves ■
quicklyDetermining their own destiny ■
Being ‘ambidextrous’ – delivering ■
high performance today and shap-ing itself for the future
In my article The Management Stand-ards for A Healthy Organisation (www.orghealth.co.uk/article-library.html), I set out the standards for achieving a healthy organisation, based on promot-ing wellbeing and performance through commitment, trust and engagement between the workforce and the organi-sation. Evidence shows that commit-ment and trust have a major impact on preventing stress at work. The stand-ards also promote ‘adaptive leadership’ principles, based on shared responsibil-ity 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 moti-vate the workforce, and the rules gov-erning how the organisation should work, based on promoting commit-ment, 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 en-gagement.
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 atten-tive to the first person. This is the es-sence of successful interaction. Disen-gagement occurs when one person breaks their attentiveness to the other. This leads to under-performance.
ResilienceResilience is the ability to cope with stressful situations without experienc-ing stress. It is also the ability to grow and become stronger by overcoming stressful situations without experienc-ing stress.
Strengthening resilience involves forming a positive attitude towards ad-verse events. Attitudes are formed from thinking and feeling, and an assess-ment 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 deter-mine whether or not they can overcome and tolerate it.
Resilience is akin to psychological immunity. Exposure to stressful situa-tions, and overcoming them success-fully, provides stronger immunity to future similar situations. People’s innate immunity may be ‘topped up’ with spe-cific exercises. One resilience pro-gramme is based on a seven-element model, encompassing vision, determi-nation, relationships, problem solving, interaction, organisation and self-confi-dence, each of which, evidence shows, contributes to psychological immunity against stressful events.
Psychological wellbeing and per-formance goes beyond health. Indi-viduals can be very healthy and still suffer stressful consequences from an adverse event. However, a healthy life-style can help to boost physical wellbe-ing, which has a knock-on positive ef-fect 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 – creat-ing and sustaining a healthy organisa-tion and strengthening personal resil-ience against stress.
Adopting management standards that promote a healthy organisation, a manager’s code of conduct and pro-grammes to strengthen resilience, when taken together, provide the infor-mation 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.
STRESS
HEALTHYORGANISATION
MANAGERBEHAVIOUR
HEALTHYLIFESTYLE
PERSONALRESILIENCE
PREVENTINGSTRESS@WORK
20 healthcare manager | issue 12 | winter 2011
LEGAL MATTERS
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
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 RequestAn 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.
legaleye
Jo Seery explains how the Freedom of Information Act can be used to access information.
healthcare manager | issue 12 | winter 2011 21
CAREERS
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 self-resolution.
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 mentorUse 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.
PlanningYou’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 goalsYou 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 mentorApproaches 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 men-tor, 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 commit-ments. 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! .
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.
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
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.
Stress busters
22 healthcare manager | issue 12 | winter 2011
MIP AT WORK
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 Commission-ing Group (CCG). With the collapsing of
the PCT trust boards, our Care Trust has become part of the Humberside Cluster which also in-cludes Hull, East Riding, and North Lincolnshire. We have been downsiz-ing…with staff in the provider services moving into two new social enter-prises, one for community health services (Care Plus) and a stand-alone mental health social enterprise (Navigo).
Staff from the com-missioning services have been through two rounds of voluntary redundancy and we have lost over a third of the staff. We are working towards creat-ing a social enterprise for social care commission-ing which will include the social worker team.
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
Linking up in Lincolnshire
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 pro-viding 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 recruit-ment 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 cer-tainly helped prepare me for chairing the Cluster partnership! I like to think in the six months we have been in exist-ence 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
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.
healthcare manager | issue 12 | winter 2011 23
MiP AT WORK
One thing is for certain in such times – you need support.
MiP is the UK’s only trade union organisation that solely representshealthcare managers.
We provide an influential voice, personal support and employmentadvice, management skills and access to leadership networks.
Our experienced team of employment professionals is on hand tooffer one-to-one confidential advice, negotiation and representationand fast access to legal resources.
Join MiP today. Visit www.miphealth.org.uk/joinus
These areuncertain times.
Reduce the uncertainty.Join MiP.
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the fast moving agenda, has been very rewarding.
What’s it like doing negotiating? Many negotiations are very challeng-ing but they can also be very reward-ing, when you see the points you have raised as a Link member and chair be-ing incorporated in the policies and in the forward plans.
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 relation-ships 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 improv-ing my organisation skills, networking, to negotiation and even project man-agement skills.
Has being staff side chair affected your relationship with your chief exec-utive, 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 [email protected].
To see if there is a link member in your organisation, see the MiP website: www.miphealth.org.uk/Aboutus/locallinkmembers.aspx
24 healthcare manager | issue 12 | winter 2011
backlash
Squaring the Circle
Private 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 mira-cle’ to turn around the trust’s £40bn deficit, meet QIPP targets and still turn a profit. City analysts decribe Circle ‘as investment for risk lov-ers’ 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 hos-pitals. 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.
Noughts and Crosses
Circle has made much of its ‘John Lewis’ style partnership ar-
rangements for staff, but its ownership structure is a bit more exotic than that of Britain’s best-loved depart-ment store. The partnership only owns 49.9% of the busi-ness, 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 prop-erty portfolio is held ‘off bal-ance sheet’ (and off-shore) in a ‘special purpose vehicle’ company, which offers Cir-cle’s healthcare operations 25-year leases subject to ‘upward only’ rent reviews. Does this sound familiar? It should do, it’s the same ‘op-co-propco’ business model followed so successfully by care home provider South-ern Cross. Fingers Crossed then.
Open secret
The Department of Health was ordered on 11 November to release
its strategic risk register fol-lowing 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
excuse for keeping the docu-ment secret for almost a year? Releasing it could have ‘jeopardised the success of the policy’, claimed the De-partment’s lawyers. Which is of course exactly why we should see it. Messing around
Praise indeed for Profes-sor Malcolm Grant, provost of University
College London and the new Chair of the (soon to be, probably) National Commis-sioning 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 col-lapse in the face of political pressure like some.’ Qualities that may not be appreciated by his boss, health secretary Andrew Lansley. In an ami-ably shambolic appearance before the Commons health committee in October, Grant
wasted no time in speak-ing his mind, describing Lansley’s NHS reforms as ‘completely unintelligible’, ‘messy’, and saying it was ‘not clear’ how they could be implemented.
Top of the class
Yet 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 min-ister’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 gain-ing access to specialist clini-cians. Finally, the Common-wealth 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 posi-tive health care experiences than sick adults in other countries,’ said the US-based foundation. Us and the Swiss, who’d have thought it?
by Celticus
Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@
healthcare-manager.co.uk.
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