Healthcare Manager autumn 2013 - issue 19

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healthcare manager | issue 19 | autumn 2013 1

inside

healthcaremanagerissue 19

autumn 2013

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 the autumn issue of healthcare manager, the magazine from MiP, the specialist trade union for health and social care managers.In this issue we focus on what’s

happening outside the hospital envi-ronment. Thanks go to Rob Webster, chief executive at Leeds Community Healthcare, for telling us to look at community services to find exciting innovations and real transformation of services: Noel Plumridge finds plenty of change taking place and some real challenges for providers and commissioners alike. We also take at look at the latest innovations in telehealth and hear about the NHS sport challenge.Our interviewee is Stephen Dorrell,

the influential chair of the health se-lect committee, who gives his views on management in general and com-missioning in particular. We also have our regular features – including Michael West giving his tips on do-ing successful appraisals.To support breast cancer aware-

ness month, we asked Breakthrough Breast Cancer to tell us what man-agers can do to help with the early diagnosis and prevention of breast cancer.Enjoy the magazine – and do get in

touch if you have any news, views or comments.

Marisa HowesExecutive editor

heads up:2What you might have missed & what to look out forLeading edge: Jon Restellinperson: Karen Dunwoodie, patient experience lead, Airedale NHS Foundation Trustinpublic: Murray Royal Hospital, Perth

comment:9Dr Caitlin Palframan: turning good intentions into the better care for breast cancer patients

features:10Telehealth: are we ready for takeoff?Interview: Stephen Dorrell – let’s hear less about structures and a lot more about care. Community Care: how community services are leading the way in reshaping the NHSNHS Sport: healthier staff leads to better care

regulars:20Legal Eye: take care with settlement agreements Tipster: appraisals don’t have to be painfulMiP at Work: supporting a learning culture at work

backlash:24

www.miphealth.org.uk

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2 healthcare manager | issue 19 | autumn 2013

heads upHEADS UP

what you might have missed and what to look out for

healthcare managerissue 19 | autumn 2013

ISSN 1759-9784published by MiP

All copy © 2013 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]

ContributorsMike Farrar, Marisa Howes, Helen Mooney, Alison Moore, Caitlin Palframan, Noel Plumridge, Jon Restell, Craig Ryan, Jenny Sims, Neil Todd, Michael West.

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.

Once again we have brought together a great line-up for the MiP annual conference on 27 November. We’ve got speakers from the key areas of healthcare policy, including politicians Andy Burnham and Stephen Dorrell; healthcare chief executives David Dal-ton, Ann Radmore and Lisa Rodrigues; think tank Profes-sors Chris Ham and Derek Mowbray; and MiP’s own chief executive Jon Restell.

Channel 4 News health corre-spondent Victoria Macdonald will

chair the conference. Discussions will include the implications of the reports from Robert Francis, Bruce Keogh and Don Berwick, management standards and the impact on managers’ health and wellbeing of the pressure to im-prove quality while making huge savings. The programme includes masterclasses and focus groups covering a range of topical issues. It is free to attend for MiP mem-bers and is CPD certified.

To register visit the conference website at www.mip-conference.co.uk

Special offer for MiP membersMiP is pleased to sup-port this conference for those involved in the transformation and de-livery of health and so-cial care services for people with long-term conditions, taking place on 21 January at the QEII Conference Centre in London.

Long term conditions account for 70% of health and social care spending, so improving early inter-vention, clinical provision and rehabilitation is essen-tial to maintaining service levels in the face of grow-

ing demand. This confer-ence brings together over 300 healthcare specialists from across government, and the public and private sectors, to hear the latest thinking on recent policy changes, funding, innova-tive strategies and new models of care to achieve quality outcomes.

MiP members can attend this event at an exclusive rate. Places are allocated by sector and limited in number, so to enquire about your discount, please con-tact the team on 0161 211 3453 or visit the website: long-term-conditions- conference.co.uk

Quality managers delivering quality careMiP national conference 201327 November, Congress Centre, London

mailto:[email protected]



[email protected]

www.miphealth.org.uk/hcm


HEADS UP

Leaders who say one thing but do another soon find they have a trust problem. This

can happen when leaders don’t care what they say, don’t know what to say, or don’t know how to say it. More often than not, how-ever, trust gets lost because leaders don’t know how to turn what they say into practice.

MiP has recently talked to politi-cians throughout the UK. An emerg-ing theme is politicians who have encouraging, affirming things to say about managers but don’t seem to have concrete policies and positions to support their rhetoric. For example, in Scotland health ministers routinely talk about how they value managers, yet they still pursue disproportionate cuts in senior manager posts and, as a recent MiP survey demonstrated, they leave managers feeling that they are treated differently from other staff, especially over pay.

But the mood is changing as the scale of the challenge facing health and social care comes into ever-sharper focus. Quality of care and ef-ficiency dominate thinking with fresh urgency, as people wake up to the reality that management structures

are not the most important issue. Inevitably, there has been political recoil from the pointlessly seismic Lansley restructuring. This now even includes scorn for those simplistic graphics – in the style of Soviet tractor production figures – showing fewer managers and more doctors. (Com-rades, rejoice!)

There is a growing understanding that healthcare needs you! More and more politicians and policymakers are ‘getting’ how important professional managers are in the healthcare team, as Stephen Dorrell, your cover boy for this issue, and a politician who has walked the talk, has consistently argued.

Our job in the next year is to help poli-ticians and employers walk the talk.

First, the voice of managers must

be at the heart of the debate on future direction. Managers bring a unique view of the system, with their overall concern for strategy, structure, pro-cesses, measurement and people.

Second, we must champion the workforce, as its values, attitude and skills are central to success. The evi-dence piles up to show staff engage-ment, building trust and commitment (through leadership, involvement, security, team working, encourage-ment, communication and career opportunities) delivers in spades for patient experience, mortality, staff well-being and financial and opera-tional performance.

Third, we must ensure through the practical business of day-to-day representation that managers are treated as other staff are treated. The trust, engagement, and commitment of managers matters more than ever, because management matters more than ever – and while words are important, it takes more than words to make people feel trusted, respected and engaged.

l never counsel despair on the NHS or publicly funded healthcare. There is always something great managers can do.

leadingedgeJon Restell, chief executive, MiP

“There is a growing understanding that healthcare needs you! More and more politicians and policymakers are ‘getting’ how important professional managers are.”

Flu Fighter’s backThe annual Flu Fighter cam-paign aims to further in-crease uptake of flu vacci-nation among front line NHS staff to protect patients in their care.

Run by NHS Employers with the support of the Department of Health and NHS unions, including MiP, the national seasonal cam-paign has seen vaccination uptake in healthcare workers with direct patient contact continue to in-crease, from 35 per cent in 2010-11 to 46 per cent last winter.

All the information you need on

how to run a successful campaign for 2013-14 is available from the Flu Fighters website (www.nhsem-ployers.org/flu), including the lat-est news about flu, uptake figures and an updated set of tools and resources.

Follow @NHSFlufighter on Twitter for all the latest flu updates and developments across the NHS.


HEADS UP

MiP has secured a promise from health minister Alex Neil to improve the pay of NHS managers in Scotland and to review

existing pay arrangements which the union says are ‘not up to the job’.

In a message to MiP’s event for members in Edinburgh (see page 23), Neil said: ‘This settlement will be better than in recent years but I accept that questions will remain about whether the management pay arrangements introduced by the previ-ous administration continue to be fit for purpose. I would like to be able to review elements of these within our vision for an

integrated workforce.’Neil added that he understood ‘the con-

cerns that now exist following several years of pay restraint’.

MiP chief executive Jon Restell wel-comed Neil’s pledge but said the entire pay system needed to be changed. ‘The current pay system for senior managers in NHS Scotland is not up to the job and it could be challenged by people under equal pay legislation.’

Pay

Minister promises better deal for Scottish managers

NHS Scotland is to spend £1.5m on testing innovative ways to deliver healthcare in remote areas in the face of mounting difficulties with recruiting and retaining professional staff in rural communities.

NHS Highland, which has pioneered such innovations as GP teleconferencing and home-based ‘pods’ linking patients with local clinics, will use the money ‘to explore new approaches to build-ing sustainable health and care services’ for the 20% of the Scottish population who live in rural areas.

Announcing the scheme during a visit to Campbeltown Com-munity Hospital, Scottish public

health minister Michael Matheson (pictured) admitted the NHS had problems recruiting enough staff in rural Scotland. The scheme ‘will play a vital role in helping to develop long term solutions that meet the healthcare needs of rural communities,’ he claimed.

‘I would expect this to have rel-evance not only for other remote areas in Scotland, but that it will inform new models for testing in urban areas as well,’ he added.

Under the model being de-veloped in Campbeltown, the community hospital and three local GP practices will provide ‘24/7 care’ supported by ‘an enhanced Scottish Ambulance Service response’.

Claire Pullar, MiP’s national officer for Scotland, said: ‘We are delighted that the Scottish Govern-ment has recognised with further investment the excellence and innovation that employees of NHS Highland deliver time and again with their telehealth programme. This has led to some fascinating innovations and we look forward to seeing what NHS Highland will deliver next.’ Successes and setbacks with telehealth in the NHS – see page 10.

Innovation

Cash boost for rural Scottish services

Partnership

CCG signs up to partnership working

MiP has signed a groundbreaking part-nership agreement with East and West Suffolk CCG.

MiP national officer George Shepherd (pic-tured right) who worked with the CCG and other unions to develop the new partnership arrangements, said: ‘This partnership agreement is an important commitment by East and West Suffolk CCG and ourselves to work together to develop fair employ-ment policies and to make this a great place to work.

‘It makes my role a pleasure when you have an employer like this who em-braces true partnership working, and respects our opinion as trade unions, and where the joint working ethos is seen as an asset. Amanda Lyes, HR director, has championed the agree-ment and has adopted a no surprises culture. This is a model approach which other organisations can learn from.’

Further info on the partnership agreement is available on the Social Partnership Forum website: www.socialpartnershipforum.org

Mike Kavanagh, RCN regional officer, Amanda Lyes, HR Director West Suffolk CCG and MiP national officer George Shepherd.


HEADS UP

inperson

Passionate about people, Karen Dunwoodie describes herself as ‘very much a people person’.After working for what was then the National Union of Public Employees, now UNISON, for 15 years she became a mature student at the University of Cardiff, gaining a degree in industrial relations and psychology.

Karen has held various roles in and around the NHS with the chief aim of helping patients and car-ers get the best experience out of the services they use and trying to make sure their feedback is used and valued.

As chief officer for Wakefield Com-munity Health Council for fourteen years before its abolition in 2004, she says her work focused on ways to improve things for patients. ‘It was a fascinating role that covered all aspects of health from acute, to pri-mary care, ophthalmology, dentists, and mental health,’ she explains.

After a short time as complaints manager at Leeds Teaching Hospitals NHS Trust, Karen moved into her current role as patient experience lead at Airedale NHS Foundation Trust, where she has worked for the last four years. When she started, the trust had not previously employed someone specifically charged with leading on public engagement – instead the job was attached to that of the deputy director of nursing.

‘My job at the start was to strategi-cally look across the organisation to see what needed to be done to engage patients and what was already being done,’ she says. ‘It was like a giant jigsaw puzzle. There was a lot hap-pening but my job was to bring it all together and it was about making people aware across the organisation about what was happening.’

Karen was charged with develop-ing a strategy for the trust on patient and public engagement, which included establishing a steering group to look at patient experience. ‘The executive team at the trust very much have patients at the heart of what we are doing and I believe that I am really pushing at an open door and that this is their highest priority,’ she says.

Under Karen’s stewardship the trust has also set up a patient and carer panel which meets monthly and give a first-hand perspective on services that are being developed or changed at the trust. ‘The panel decide on the projects they want to take on. Most recently they were involved in looking at end of life care and the Liverpool Care Pathway,’ she says.

Recently, the trust has also set up a youth panel, working with schools and youth groups, in order to make

sure it was getting opinions and experiences of young people on the services that it provides.

The trust, with the help of volun-teers, conducts real-time surveys every day, interviewing patients about their experience just before they are discharged. ‘The results of those surveys are inputted into our system and staff can access them at any time,’ she adds.

So what does she make of the Government’s new friends and fam-ily test? ‘It’s been a massive piece of work and I think staff were expecting that they would get lots of negative feedback but it has actually given people who have had a positive experience the chance to comment where they wouldn’t ordinarily,’ she says. ‘I think it is has served to improve staff morale and it has been a good thing.’

Helen Mooney

Karen Dunwoodie, patient experience lead, Airedale NHS Foundation Trust

“The executive team have

patients at the heart of what we

are doing. I am really pushing at

an open door.”

Karen Dunwoodie, left, with Isobel Scarborough, chair of the patient and carer panel, launch a patient experience initiative at Airdale NHS Trust.


HEADS UP

The NHS confederation has called for urgent measures to avert a ‘winter meltdown’ in NHS emer-gency services after a survey of senior managers found less than half expected to meet government targets for A&E waiting times this winter.

The Confed said ‘myths and misinformation’ about the state of A&E services were preventing managers from dealing with the problem. The survey revealed that the troubled roll-out of the NHS 111 service earlier this year was not a major factor: instead nearly half of respondents said the rising number of frail elderly people with multiple conditions was the main source of pressure on A&E departments.

More than a quarter identified problems with discharging patients and setting up alternative care ar-rangements as the biggest problem they face.

Outgoing NHS Confed chief ex-ecutive Mike Farrar, said the public

had ‘so little confidence’ in alterna-tive services, they saw A&E as their only option. ‘It’s a vicious spiral,’ he warned.

‘But as if the genuine rise in seriously ill, frail A&E attendees wasn’t putting enough strain on the system, the NHS is also struggling from ill-informed speculation about what is causing the pressures and what services they can rely on to meet their needs.’

Farrar warned the problem was complex and there clearly wasn’t a single solution. ‘There needs to be cultural change in order to intro-duce seven day a week working in the NHS and social care, and a great-er shift of our resources to enhance community services, so patients are treated closer to or in their homes rather than automatically default to A&E when they are ill.’The report, Emergency care: an accident waiting to happen? is available from the NHS Confederation website at: www.nhsconfed.org.

The government has announced a £1bn fund for investment in new technology to im-prove patient care and ease pressure on A&E departments, as a first step towards a ‘paper-less’ NHS by 2018.

Ministers say a paper-less NHS would see fewer unnecessary tests and hospital admissions, re-duce mistakes with medi-cation and speed up dis-charge procedures.

The government says the initiative will form part of its long-term solution to the rising pressure on cas-ualty departments by cut-ting down on bureaucracy and freeing up doctors, nurses and care profes-sionals to spend more time caring for patients. Much of the cash will be spent on systems allowing hospitals, GP surgeries and other organisations to access patients’ electronic re-cords, and enabling pa-tients to book GP appoint-ments and order repeat prescriptions online by March 2015.

Health Secretary Jer-emy Hunt admitted past failures had dented public confidence in NHS IT sys-tems. ‘But rather than imposing a clunky one size fits all approach from Whitehall, this fund will empower local clinicians and health services to come together and find innovative solutions for their patients,’ he said.

‘Technology is key to helping our A&E staff meet the massive demand they face as the popula-tion increases and ages.’

David Dalton, Chief Ex-ecutive of Salford Royal Foundation Trust (pictured) said: ‘I’m really pleased that the government is supporting local IT solu-tions to local problems – this is so much better than the previous one-size-fits-all approach. Investing in electronic patient records has the power to transform patient care. It has been key to helping us improve safety and drive up stand-ards of care for patients in Salford.’

The initiative follows the announcement in June of a £3.8bn fund to promote joint working between the NHS and social care ser-vices in 2015-16. Projects seeking funding from the Integration Transformation Fund must include pro-posals for better data sharing between health and social care.

Technology

NHS to go ‘paperless’ by 2018

A&E

Misinformation risks ‘meltdown’ in services

The Stroke Association has re-leased a video aimed at helping surgery staff better understand the needs of stroke victims after a sur-vey revealed many had problems communicating with their GP.

The survey revealed that one in five patients with aphasia – the most common post-stroke commu-nication disorder – had problems making GP appointments and 43% found it hard to communicate with their doctor.

The three minute ‘aphasia etiquette’ video, entitled Ask, Wait, Listen narrated by BBC interroga-tor-in-chief John Humphrys, has been developed from feedback by stroke survivors with aphasia and

uses simple solutions like offering them the opportunity to express “yes”, “no” or “I don’t understand”.

Dr Clare Gerada, chair of the Royal College of GPs said: ‘Patients presenting with aphasia are still quite rare in general practice and so the video is an innovative and simple approach to help GPs im-prove interactions…by reminding us quickly and easily of the vital things to remember.

‘Anything that enhances commu-nication between GPs and practice staff and their patients with aphasia should be encouraged,’ she added.

To view the film and find out more about training and support for patients with aphasia visit www.stroke.org.uk/aphasia.

Stroke CareGPs urged to ‘ask, wait, listen’


HEADS UP

NHS Tayside has invested in a new £75m facility at the Murray Royal Hospital in Perth, which has been set up to provide state-of-the-art mental health treatment facilities for the people of Tayside. The new building, which was opened by Scotland’s First Minister Alex Salmond in July 2012 (pictured right), is the first hospital in Scotland to be delivered under the new non-profit distributing (NPD) scheme – a Scottish alternative to the controversial private finance initiative used in England.

The NPD model puts a cap on pri-vate sector returns, ensures that there are no dividend-bearing shares, and that any surplus is directed back into the public sector. The NPD health programme is set to run until 2017 and the Scottish Government claims it will result in more than £800 mil-lion being spent on new NHS construction projects.

The new hospital has a total of 102 beds providing psychiatric services for adults and elderly patients along with new old-age psychiatry day services. According to NHS Tayside chair Sandy Watson the new hospital will provide mental health facilities that are ‘fit for the 21st century’.

‘This project, which has had so much input from so many people with a real involvement in the hospital, underlines NHS Tayside’s commitment to the care of patients with mental health problems,’ he said.

Construction began in June 2010, with designs created through detailed dialogue with service users, carers, clinical and non-clinical staff, together with a wide range of technical experts. Watson said that the role of art and nature in healing was taken into account in the design with a detailed art strategy drawn up in con-sultation with stakeholders.

There had been a mental health hospi-tal on the Murray Royal site since 1827. The first buildings were constructed thanks to an 1814 legacy from James Murray – a labourer who inherited a for-tune from his merchant brother – for the construction of an asylum for Perth and its neighbourhood. Since then, a number of buildings have been added to meet the increased need.

The new hospital main hub building contains the main reception, café, outpa-tients department and administrative services. There are three general adult psychiatry wards and three wards for psy-chiatry in old age, providing a total of 102 beds. All patients in the new Murray Royal Hospital have a single room with en-suite facilities.

Around £5m was also earmarked for landscaping the extensive grounds, which

are also open for public use in a bid to keep the new hospital at the heart of the local community.

The hospital’s new Birnam Day Centre provides facilities for former service users and the site also houses the Strathmore Dementia Service, one of three national demonstrator sites for dementia care in Scotland.

The new Murray Royal Hospital is part of a wider £95m project to modernise mental health facilities across Tayside, which also includes the new Susan Carn-egie Centre at Stracathro Hospital together with Rohallion, a new secure unit on the Murray Royal site which is jointly funded by Tayside, Grampian, Highland, Orkney and Shetland NHS Boards.

Helen Mooney

inpublicMurray Royal Hospital, Perth, NHS Tayside

“The role of art and nature in healing was taken into account...

with a detailed art strategy drawn up in

consultation with stakeholders.”


HEADS UP

MiP is wholeheartedly backing Unison’s application for judicial review of the latest attack on employment relations by the government. Changes to the em-ployment tribunal system introduced in August will have a major, detrimental impact on employment relations and the way we resolve disputes.

Claimants will now have to pay up-front fees for submitting a tribunal claim. Fee levels vary according to the type of case, but start at £160 plus £230 for a hearing, and range up to £250 plus a hearing fee of £950. For example, the fees for taking a discrimination claim would total £1,200.

MiP will pay these fees for our members where we lodge a claim, but it will signifi-cantly impact on the way we work and how we resolve disputes with employers. For instance, MiP will sometimes lodge a tribunal claim as a safeguard in case we fail to reach a settlement on a legitimate claim

with an employer. High fees make it much more difficult to do this.

There will also be closer scrutiny of how the facts are set out in claims and they could be rejected on technicalities without being referred back for clarification. Our solicitors will seek to ensure the tribunal claims are correctly set out, but with more stress on getting the details right first time, we are unlikely to be able to lodge a claim successfully at the last minute. The changes also mean claims will be heard by a single judge, not by a tripartite panel as happens now.

Two further procedural changes are expected in Spring 2014 when the gov-ernment intends to introduce the Early Conciliation Scheme. This will force claimants to submit a form to ACAS before they have the right to take an employment tribunal claim, and introduce financial pen-alties for employers (although those will be

paid to government, not to the claimant).‘The government has slipped these

changes in during the summer to minimise publicity,’ said MiP chief executive Jon Res-tell. ‘They undermine the tripartite nature of employment dispute resolution. We will ensure our members’ claims are properly dealt with and cover the fees, but the addi-tional red tape means we will be prevented from submitting claims at the last minute and we will have to ask our members for much more detailed information.

‘Getting the facts straight in employment claims can be a tricky business and people should not be penalised for not getting it absolutely correct first time. There was already provision in the system to prevent vexatious claims. This is nothing more than a cynical exercise to make money out of the misery of working people.’

Tribunals

Government undermines employment tribunals

The whole healthcare team needs to be involved and engaged in order to improve care and the patient experi-ence, MiP vice chair Sam Crane told the TUC Congress when it met in Bournemouth in September.

Speaking in a debate on the future of the NHS, she said: ‘We cannot underestimate the importance of being a learn-ing organisation – as flagged by Don Berwick in his report – and investing in training for the whole team – clinical,

managerial and support staff – so that all staff feel empow-ered to make suggestions for improvements and feel safe to raise concerns about issues before they become problems.’

Crane warned policy mak-ers to stop messing with NHS structures. ‘We know that we have to develop our staff and our services to make sure we meet the healthcare needs of our communities. But staff need stability and boring continuity instead of con-tinual change to enable this to

happen. So ministers and potential ministers please take note – give us a break from constant re-disorgani-sation. And please stop knocking our great NHS and those who keep the show on the road 24/7.’

She finished by call-ing for policy makers to work with the unions to achieve effective change: ‘Let’s move away from the blame culture in the NHS. Give staff the training and support they

need without the threat of criminal sanctions hanging over them. Stop looking for scapegoats and work with us to keep our NHS great.’

TUC

MiP calls for stability and engagement in the NHS


COMMENT

comment

Dr Caitlin Palframan head of policy at Breakthrough Breast Cancer

In June 2013, NICE published its updated guidelines on familial breast cancer. Three per cent of the population has a family history of breast cancer, but their increased risk means they account for one in five diagnoses of the disease in the UK.

NICE made recommendations to improve the standard of care across the entire patient pathway, which Breakthrough Breast Cancer welcomed as a ‘game-changer’ with the potential to revolutionise the way we prevent breast cancer in the UK, and to reduce the burden of the disease on the NHS. The challenge is taking this potential, and putting it into practice.

Two recommendations in particular have the most potential impact on pa-tients at risk of, or living with, familial breast cancer. The first is to offer, for the first time, chemoprevention (risk-reducing drugs) to women with a family history of the disease. This represents a valuable new option for women in man-aging their risk, with massive potential to reduce breast cancer incidence, but its success depends entirely on proper implementation across the NHS.

Secondly, but of equal importance, was the recommendation to offer genetic testing more widely, allowing people who were previously not eligible for testing to better understand and manage their personal risk. Knowing

your risk of developing breast cancer opens the door to personalised care, but there are infrastructure issues that must be addressed to ensure this step is a success.

This is where healthcare managers come in. Implementation of these new guidelines is likely to be challenging, as without a plan to make frontline staff aware of the guidelines, and to give them the confidence to put them into practice, they will be of little benefit to patients.

Communication will be central, and begins with primary care: GPs will be involved in the prescription of chemo-prevention, so their understanding and cooperation will be necessary to real-ise the full potential of this innovation. There is still confusion among profes-sionals and commissioners about who is actually responsible for prescribing chemoprevention, and setting the pa-tient pathways for its use. Healthcare managers must step in, take ownership of the issue, and ensure that patients benefit from the promise of these new guidelines.

There is little question that wider ge-netic testing will also prove challenging for the NHS. After years of unacceptably long waits (sometimes two years) for test results, waiting times for NHS ge-netics services are now acceptable. But implementing these guidelines will no doubt place NHS genetics laboratories under more pressure, and will require them to turn around more tests. Simi-

larly, genetic counselling services will also need to provide enhanced support to more people presenting with a family history of breast cancer.

The potential benefits for patients, and for the NHS as a whole, are huge. Breast cancer remains the most com-monly diagnosed form of cancer in the UK, with 50,000 women and 400 men facing a diagnosis each year. And as the public become more aware of the role genetics and family history play in an individual’s risk of developing the dis-ease – assisted by high-profile stories such as Hollywood star Angelina Jolie’s – commitment will be needed from NHS frontline staff, with the support of chari-ties, patient groups and healthcare man-agers, to ensure the NHS is able to meet increased need without compromising the quality of services.

NICE guidelines represent best prac-tice, but they are not mandatory and their impact is limited if they are not universally implemented. Breakthrough Breast Can-cer works closely with the NICE Guide-line Development Group, and is one of the patient representatives advising NHS England on commissioning genetic ser-vices. As a result, we are well placed to support healthcare managers in working towards translating these gold-standard guidelines into gold-standard care.

Go Pink! October is Breast Cancer Awareness Month. For further details visit: www.breakthrough.org.uk

NHS must turn gold-standard intentions into gold-standard care


The age of telehealth and telecare may have dawned, but not everyone has woken up to it. Organisations who are willing and able to embrace it are beginning to reap the benefits including ‘doing more for less’, saving time, money and lives, improving outcomes and the quality of health and care services.

Health and social care managers in hospitals and the community need to keep abreast of developments in both fields if they are to cope with staffing and skill shortages, funding cuts and increasing demand for services.

Despite considerable barriers to up-take, successful innovative schemes can be found across the UK, particu-larly in managing chronic conditions and caring for older and vulnerable people, as a recent King’s Fund confer-ence on telehealth (TH) and telecare (TC), held in July 2013, demonstrated.

Politicians, health policy analysts, and the technology industry agree that shar-ing knowledge and best practice is es-sential for TH and TC to take off. And Scotland has proved pretty good at it, which is why Professor George Crooks, medical director of NHS24 and director of the Scottish Centre for Telehealth and Telecare, is well placed to advise that ‘the key to success is collaboration.’

Indeed, much can be learned from collaborative partnerships throughout Scotland, where telecare is now em-bedded in health and social care, due in no small part to the Scottish govern-ment’s funding of innovative projects such as the Telecare Development Pro-gramme which has driven up the adop-tion of telecare by both health and so-cial services. Projects such as Ren-frewshire Community Health Partner-ship’s (CHP) home telecare service for people with dementia have proven cost and other benefits which could be real-ised in mainstream services.

Between April 2007 and March 2012 the CHP delivered telecare packages to 1,045 vulnerable and older people, including 325 diagnosed with dementia. Dementia sufferers were supplied with

Telehealth and telecare projects are beginning to pay dividends, with collaboration and the willingness to take bold decisions proving the keys to success, says Jenny Sims.

equipment such as door monitors, smoke detectors, pill dispensers and GPS tracking for ‘buddy support’. Monitored by a 24-hour call service, activation of sensors and alarms resulted in a response from the Community Service Responder Team

According to an evaluation by the York Health & Economics Consortium (YHEC), over five years the benefits included fewer delayed discharges, reduced hospital admissions, reduced home care placements, and fewer nights of sleepover care, according to a recently published evaluation of the service. This produced estimated net savings of £2.8 million.

For people with dementia, 67% of the savings were from avoided hospital admissions or shorter lengths of stay, with a further 24% from avoided care home admissions.

In addition, the YHEC report points out there are user benefits which can’t be measured in money terms: ‘feelings of reduced anxiety, greater independence, improved security and overall better quality of life’. Carers may also benefit from reduced stress and anxiety but this wasn’t measured in the study.

‘Overall the telecare service is per-forming very well from a qualitative per-spective with satisfied users and carers,

TELEHEALTH & TELECARE

“Many analysts suggest that ‘perverse incentives’

in the way the NHS is funded remain a big

barrier to implementing telehealth schemes.”


excellent staff and good support from many NHS elements and the police,’ concluded the report. ‘Telecare for peo-ple with dementia is cost effective and high quality,’ added Nick Hex, associate director of the YHEC.

The report recommended that all community care assessments and hos-pital discharge plans should include an assessment of the patient’s suitability for telecare. This will help to ensure that patients can benefit when prob-lems are beginning to develop, instead of waiting until their dementia is too advanced and they are unable to learn how to use the equipment.

Many studies, including the Depart-ment of Health’s prestigious Whole System Demonstrator Programme (WSD) have shown that even if patients and staff have reservations about using technology, familiarity with the equip-ment usually wins them round.

A 2012 RCN eHealth survey of nurs-es’ attitudes towards telehealth, found that experience of such systems had grown from 55% to 62% since 2010. Of those with experience of them, 85% welcomed and supported the use of telehealth systems.

‘The survey showed that experience of telehealth gives nurses a positive perception of its benefits’ said David Barrett, a nurse and lecturer in tele-health at the University of Hull, which analysed the results.

Innovative projects involving mobile devices are also proving effective and popular with users. Mobile telehealth is relatively new, but with management of long-term conditions accounting for 70% of primary and secondary budg-ets, it’s becoming a useful manage-ment tool – enabling patients to be ac-tive in managing their conditions.

NHS Lothian and North Somerset Community Partnership (NSCP) have both trialled O2’s Health at Home scheme to monitor patients with COPD and heart failure. Patients are provided with a tablet computer connected to the mobile network, as well as ‘smart’ moni-toring devices including pulse oxime-ters, weight scales and blood pressure monitors.

If a patient’s readings trigger an alert, a clinician is informed. Early findings showed that the average length of hospital stays has decreased by 59% in the small COPD group.

Leeds City Council is also using mobile and GPS devices to give more indpendence to frail patients or older people with dementia or other long-term conditions. Users are given a small handset which can detect falls and allows them to contact a 24/7 alarm-receiving centre should they need to.

But there are dangers in relying on very specific and intensive tehcnologies like O2’s Health at Home. The company announced recently it was withdrawing the service from the end of 2013. While insisting the global prospects remain strong, ‘the uptake of mobile telecare and telehealth in the UK marketplace has been slower than anticpated,’ said an O2 spokesperson.

However, big government funded initiatives such as the Technology Strategy Board, the Dallas programme and 3millionlives, as well as the Academic Health Science Networks and the industry’s Telecare Services are all helping drive TC and TH forward and improve the identification, adoption and spread of innovation in the NHS.

But many analysts suggest that

‘perverse incentives’ in the way the NHS is funded remain a big barrier to implementation. Many organisations fear TH and TC will reduce clinical activity, threatening funding and jobs, although TH and TC can result in clinicians seeing as many – or more – patients, and give them more face-to-face time with the most needy ones.

‘It’s a real issue. We don’t have a sufficient system of fiscal rewards, a new model of rewards is needed,’ warns Professor Stanton Newman, dean of the School of Health Sciences at City University London, and principal investigator on the WSD project.

Many also argue that much of the financial benefit of TH and TC will only be achieved if brave decisions are taken by hospital managers to reduce beds when successful schemes such as the Renfrewshire CHP’s telecare service show they are not needed.

Are you brave enough to do that? With the NHS facing a £30 billion hole in its budget by 2020 – you may have to be. .

Jenny Sims is a freelance writer and editor specialising in healthcare.

Details of the King’s Fund’s Third Annual International Congress on Telehealth and Telecare are available from: www.kingsfund.org.uk. Telecare for People with Dementia, the evaluation report of the Renfrewshire project is available from www.yhac.co.uk

TELEHEALTH & TELECARE


ple forget the majority of patient contact with the NHS is through the private sec-tor – the pharmacist,’ he says.

Dorrell – the first MP to chair a select committee covering their former area of responsibility as a secretary of state – is well placed to take a historical per-spective on the NHS. He was a junior health minister as far back as 1990 and health secretary from 1995 to 1997, so there’s little he hasn’t seen. At one point in our conversation he winces and confesses he has just advocated something that was being talked about when he was a junior minister – the unspoken implication is that not much has advanced in more than 20 years.

But with this long view comes scepticism about the ability of big structural changes to transform the health service. ‘The issue is not how we reorganise management, it’s how we reorganise healthcare,’ he says. ‘I hope we will have rather less talk about structures and rather more about care. If there was a performance management solution we would have stumbled across it by now. We need to focus on the day job.’

But what is that day job? ‘There are two real issues for management of the service and management structure is

Stephen Dorrell, health select committee chair and health secretary in John Major’s government, has seen a few NHS reforms in his time. Now, we need less talk about structures and a lot more about care, he tells Alison Moore.

INTERVIEW: STEPHEN DORRELL

It’s always a bit surprising when a senior politician says there are no significant differences between his party and the opposition on a major policy area. Even more surprising when that area is health – one of the key election battlegrounds and traditionally one of the most politicised policy debates.

But the former health secretary and chair of the health select committee, Stephen Dorrell, believes the strength of passion over the subject does not re-flect real differences. For example, when it comes to the private sector providing NHS-funded healthcare, ‘there is very, very little policy distinction between the three major parties,’ he says.

Both Conservatives and Labour have accepted the purchaser/provider split, first proposed by a Conservative gov-ernment in 1990. Since then Labour has gone on to give trusts much more freedom than the Conservatives origi-nally envisaged.

‘With the exception of Frank Dobson, every health secretary since 1990 has followed the same policy,’ says Dorrell. ‘I’m a straightforward Blairite – the Blair model was the Clarke model.’ He points out that the private sector has always had a role in healthcare – whether it’s GPs, elderly care or pharmacists. ‘Peo-

not one of the two. The issues are the quality of care delivered and the effi-ciency with which resources are used,’ Dorrell says.

‘The easy option is to say that quality is not good enough because of not enough resources. But we all know that there are many examples of services that don’t use resources as well as they could if issues are addressed. Efficien-cy is about reinventing what we do. In the times when money was plentiful it did not happen. Now we have no choice but for it to happen.’

‘Labour were in office at a time where they could devote significant resource growth to health and care,’ he says. When this growth came to an end, the need to deliver the Nicholson savings emerged. Dorrell has been quite clear in past interviews that this, rather than reorganisation, is the major challenge the NHS must cope with. The demand for 4% annual savings, he says, is twice the average productivity gain in the economy.

Dorrell puts tremendous stress on joined-up or integrated care, especially as a means to keep people’s health from deteriorating to the point where they need hospital care. ‘Most people who work in the health and care sector would recognise the argument that we



need to have a more joined up model that lays more emphasis on supporting people in normal life rather than waiting for them to become acutely ill,’ he says. ‘That delivers better care and probably delivers better care for more people because we are using resources more effectively.’

And he raises the question of why the NHS is still operating with organisa-tional barriers inherited from the time of Nye Bevan – with primary care sepa-rate from community healthcare, a so-lution which was seen as ‘sub-optimal

nearly 70 years ago’, he suggests. ‘I don’t personally think that the changed services would look the same every-where. When you look at integrated care in Lambeth and integrated care in Oxfordshire, it will look different.’

And here is another point of agree-ment with Labour: Dorrell favours what he calls the ‘Burnham plan’ with health and wellbeing boards developing com-missioning across health and social care from a single budget. This was, he points out, first mooted by his health select committee.

‘Health and wellbeing boards have two opportunities,’ he says. ‘One is managing a single budget and the oth-er is offering greater local accountabil-ity through councillor representation. One of the changes in the 1990 Act which I was uneasy about at the time was the removal of local authority rep-resentation from health authorities. I’m strongly in favour of local authority in-volvement in healthcare.’

The transfer of public health into local government led to upheaval but was justified, he says. But he is more circumspect on other aspects of the 2012 Act and has previously suggested the rhetoric on all sides has been ‘grossly overblown.’ The jury is out on CCGs, he says, but despite his comments about having single com-missioners he supports the local/na-tional split in commissioning exempli-fied by CCGs and NHS England.

‘We can’t have local commissioning doing paediatric heart surgery and you can’t have a national plan for physi-otherapy. There has to be a balance and the balance between NHS England and CCGs will evolve. It’s not black and white, it’s shades of grey.’

Dorrell sees a key role for commis-sioners in upholding quality after the uncomfortable questions raised by the Francis Report on Mid Staffordshire and the Keogh report into mortality rates at 14 trusts.

‘What happened in Mid Staffordshire was a particularly egregious example, but there are departments which NHS insiders would not go into,’ he says. ‘It’s the NHS’s dirty secret. We know

“‘With the exception of Frank Dobson, every

health secretary since 1990 has followed the

same policy. I’m a straightforward Blairite

– the Blair model was the Clarke model.”

© A

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that there are significant quality issues in parts of the system. This double challenge of quality and finance needs to be the key focus.

‘If you have to sign a cheque with the public purse for the commissioning of healthcare you have to ask yourself the question, “Does the care I’m commis-sioning meet efficiency and quality standards?” I agree it’s not simple but because something is not simple is not a reason for not doing it. If it was easy someone would have done it by now.

‘How do we do it? Through the spot-light on outcomes data. It’s about en-gaging the professionals in this process because, when we talk about out-comes data, people say it’s fine in car-diothoracic, it’s more difficult in psy-chiatry. But if you get a group of psy-chiatrists in the pub on a Friday night they will tell you who’s no good. There are ways of measuring quality even in these difficult areas.’

But Dorrell is reluctant to con-demn commissioners who fail to intervene when there are prob-lems at hospitals – such as those at Whipps Cross hospital in east London, highlighted by a recent highly critical CQC report. ‘Quite often it is did they know or ought they to know?’ he says simply.

Openness and transparency will be key going forward. ‘I don’t accept that argument that the NHS model can’t be sustainable,’ he says. ‘But I do think that it can’t be sustained if it runs a secret world where it is not account-able to the people who pay for it. We have no choice but to make the system more transparent. That may require facing some uncomfortable truths, he warns. ‘It is about matching reality to rhetoric - delivering the promise.’

Dorrell has led the health select com-mittee in producing a number of scath-ing reports, and some evidence ses-sions which have been obviously pain-ful for the high-level NHS people in-volved. But he is unwilling to enter into anything which even hints at manager-bashing. ‘One needs to recognise that all management in the public sector raises difficult challenges because the risks are asymmetric. There is a great tendency to blame failure rather than celebrate success. The public sector is nowhere near as good at celebrating success as the private sector is. That’s true of all public sector management but particularly of the healthcare sys-tem.

‘Ministers need to recognise the val-ue and specific difficulty’ of good man-agement in healthcare, he says. He points to the ‘accountable officer’ role

of the new NHS England chief execu-tive – whoever it will be – as important in making them responsible for the whole of the commissioning budget. That, one suspects, might be the focus of grillings from Dorrell’s committee over the next few years.

Responsibility and accountability across the whole system is something Dorrell is clearly keen on. Registered healthcare practitioners obviously have professional obligations about raising concerns, but the concept of manage-rial responsibility is more subtle and elusive. His support for the proposed ‘fit and proper person test’ seems less than fulsome: ‘It’s occasionally just worth considering the counterfactual – what’s the case for an unfit person?’ he says. ‘Sometimes it’s important to separate the surrounding noise from the substance. I’m not in favour of try-ing to invent a series of professional obligations for managers.’

But managers do have a specific obligation when they are spending public money, he says. ‘If they are con-cerned that there is not sufficient infor-mation around quality or it does not represent best value they should not sign the cheque.’ Should they then be protected if they raise such concerns? ‘Yes.’

But it’s a tough life for managers, he admits. ‘Managers are there in order to deliver the promise of high quality and good value. Provided they do that, I think managers are entitled to support,’ he says. .

“I don’t accept that argument that the

NHS model can’t be sustainable...but we

have to make the system more transparent.”


Rob Webster, chief executive of the Leeds Community Healthcare NHS Trust, highlights the needs of a 21st century health system. ‘You can’t be cured of most long term conditions or of being old. The system needs to make a volte-face. Services need to start with people’s lives and aspirations, with inte-grated support to deliver them.’

Webster emphasises that with com-munity services the power balance is different to hospital care and failures in dignity, care, and compassion are most-ly absent. And most NHS care already happens outside hospital: around 300 million GP appointments a year, com-pared with around 20 million A&E visits.

‘We have a massive opportunity in England’, he insists, ‘to harness these resources and drive innovation and im-provement. Other countries would love to have a system of registered list-

Community services, for so long the Cinderella of the NHS, are becoming the cutting edge innovators that will shape the rest of the service, says Noel Plumridge.

COMMUNITY

Although the NHS headlines in recent months have been dominated by troubled acute hospitals – from Stafford to Barrow-in-Furness – and overworked A&E departments, the managerial focus has continued to swing quietly towards non-acute care. Two buzzwords dominate: “integration” and “transformation”.

We want integrated, not fragmented, care. Boundaries and demarcation squabbles between partner organisa-tions so often become the source of delays, system failures, high transaction costs and patient and user frustration. In the English NHS, two decades of mar-ket rhetoric and competition, backed since 2004 by tariffs which encourage hospital admission rather than commu-nity care, have only served to reinforce such dislocation.

And we want transformation. The re-lentless grind of annual savings targets, coupled with a pattern of service trans-fer away from acute hospital settings, render whole system efficiency not just desirable but essential. Managers schooled in the models and mantras of improvement science – the gospel ac-cording to Don Berwick – understand that what is needed is step change rath-er than incremental gain.

based general practice and community services on the scale we have.’

So what sort of step change, and how do we achieve it? Two key questions fol-low. The first concerns the nature of an “integrated” or “transformed” health system: what exactly would success look like? (And, by extension, what would it mean for the status quo: in par-ticular, what are the implications for al-ready-struggling yet much loved general hospitals?) The second is whether com-missioners or providers are best placed to lead the radical changes we need.

Provider-led innovation continues to thrive. Norfolk, for instance, has engi-neered extensive integration between NHS and social care, allowing home care packages that span what tradition-ally has been a major divide. Teams are co-located and co-managed. The com-munity matron, managing long-term conditions, has emerged as an espe-cially useful role, working with individual patients to co-ordinate government-funded services ranging from housing to medication.

Such innovation also extends across traditional NHS boundaries. Crucially, Norfolk’s community matrons have the confidence of GPs, relieving pressure on primary care practices. Meanwhile Nor-folk Community Health & Care NHS

“The practical implication is that 21st century

general hospitals will be radically different, and

much more closely bound to primary and

community care.”


COMMUNITY

Trust has been commissioned to run community paediatric nursing across the county. Investment in community services is seen as the route to reduced hospital admissions. It is now in the pro-cess of establishing community-based services for older people, including older peoples’ centres and medical consult-ants: a radical change in a largely rural county where many older people live far from hospitals.

Michael Scott, chief executive of the Norfolk trust, argues the source of inno-vation has been his own community services linking with like-minded others: GPs, social care staff and the voluntary sector.

He says the myth that community services are a sleepy backwater persists mainly because of the money: ‘We don’t get incentivised. Plus, it’s perpetual re-organisation.’ He hopes foundation trust status will offer much-needed stability.

The Leeds trust, meanwhile, uses a system wide approach built around three guiding principles:

■ risk stratification of all patients – with a bespoke risk stratification tool

in place, and plans to enhance it using social care data.

■ fully integrated health and social care teams supporting patients. This is already in place for district nurses and social workers; the next stage is to include community matrons and intermediate care.

■ supported self care on a massive scale, with commissioned neighbourhood networks supporting older people who may, for instance, get a “social prescription” for company.Rob Webster links Leeds’s success

to a structure of relationships - the Leeds Innovation Health Hub – that involves all local and national health partners in the city with the council, the universities and the private sector.

Other community providers are transforming the traditional services they offer. In West Yorkshire, the Locala Community Partnership, a social enterprise (which describes itself as ‘part of the NHS family’), has trimmed the average length of stay in intermediate care from 24 to 16 days, essentially by offering seven-day therapist input. Locala has also increased the number of community nursing appointments it provides each year from 270,000 to 410,000, while simultaneously reducing the nursing headcount by 8%.

Robert Flack, Locala’s chief execu-tive, attributes these improvements to the power of information. ‘We set out to create a performance culture’, he ex-plains. Significant investment in ‘agile technology’ has been the engine for Locala’s transformed productivity.

Not financial information, not service line reporting, but solid performance data. Locala faces the same efficiency pressures as the rest of the NHS, yet it is the philosophy of quality improvement rather than a quest for savings that un-derpins its innovation. And technical innovation isn’t limited to activity data. Central to Locala’s new way of working is using the power of video technology to simplify care for anyone with internet access. If you have a camera on your

computer or tablet, you needn’t come to hospital, or get visited, so often – and that’s better for everyone.

Flack insists that modern care of the elderly, seen through the eyes of the Kirklees community, is about getting services into a person’s life, not getting that person into hospital.

But what does that mean for the hos-pital? Squeezed between an ever-tighter tariff regime and medical advances – in equipment, in pharmaceuticals, in sup-port – that allow care closer to home, smaller general hospitals are failing. Some, like Hinchingbrooke in Cam-bridgeshire, have been sized up by commercial providers. Elsewhere, par-ticularly around the periphery of big cit-ies, there are whispers that we have too many hospitals, and some closures are inevitable.

The type of transformation being pio-neered in Leeds, Norfolk, West Yorkshire and elsewhere is umbilically linked to the politically challenging question: what is the future of the general hospital? No sane MP wants a local hospital to close. Lewisham, in south-east London, is only the latest “downsizing” proposal to pro-voke public demonstrations. “Save our hospital” remains an emotive cry.

If the managerial answer is fewer hos-pitals, the practical implication is that 21st century general hospitals will be radically different, and much more closely bound to primary and commu-nity care. The remorseless logic for care of the frail elderly, people with long term conditions and end-of-life care, is a sys-tem of “inreach” into the hospital, when necessary, from an integrated commu-nity service. “Payment by results”, ob-sessed by cold surgery and hospital throughput, is being called into question but, less prominently, so too is the “ownership” of general hospitals. Soon competitive tendering, with CCGs pur-suing lead providers for services, may result in the de facto control of smaller hospitals by integrated community pro-viders.

The frail elderly are increasingly being recognised as a group with specific needs. Pressures in hospital A&E de-partments during 2013 have also high-

Michael Scott, chief executive of the Norfolk Community Health and Care Trust.


COMMUNITY

lighted how significant frail elderly peo-ple now are to hospital workloads. Long-established demographic trends – more people living longer – and cut-backs in social care now position casu-alty departments, and the ambulances that serve them, as the NHS safety net for older people.

People with long-term illnesses also have specific needs that cut across conventional care boundaries. This ap-plies equally to potentially life-limiting conditions, such as respiratory illness or heart failure, where the locus of care has for years been moving away from hospi-tal, and to musculoskeletal conditions like arthritis and lower back pain which generate so much of a GP’s workload. The value of specialists – in diabetes nursing, for instance, or in extended scope physiotherapy – has long been recognised. But increasingly the focus is on creating a capable and coherent ser-vice for the chronically ill, rather than shoe-horning them into generic health provision.

So might future transition to genuinely integrated services be led not by visionary providers but by commissioner demands? Many eyes are closely following developments in Cambridgeshire, where the Cambridgeshire and Peterborough CCG – one of the largest in England – is seeking a patient-centred service for older people.

According to the CCG, the preferred approach is to move away from pay-ment by results and block contracts and use a ‘year of care’ budget for old-er people. The commissioners’ timeta-ble envisages a contract starting in July 2014, running probably for five years with potential for a further two years. The financial value, says the CCG, is around £150m per year.

Cue a month of outrage about “£1bn privatisation plans”. Yet consider the CCG’s success criteria: ‘care organised around the patient’, ‘services which are sensitive to local health and service need’, ‘a move beyond traditional or-ganisational and professional bounda-ries, so front-line staff can work effec-

tively and flexibly together to deliver seamless care’, and reductions in avoidable emergency admissions, re-admissions and extended stays in acute hospitals – all within ‘an organi-sational solution… which can demon-strate strong leadership, sound govern-ance, resilience…’

The intended service for older people in Cambridgeshire, pursued by commis-sioners, doesn’t appear so very different to that already emerging via provider leadership in other parts of the country.

Some sceptics suggest squeals of anguish over privatisation only seem to arise when hospital doctor jobs are involved. But there is a deeper doubt: not about Cambridgeshire’s intent, but about imposing such change through tendering. One chief executive of a so-cial enterprise, which successfully manages integrated community ser-vices in southern England, likens the frequent retendering of community ser-vices to ‘modern slavery’.

‘There’s a battle’, she says, ‘and the winner takes the staff and enslaves them to their regime. Then there is an-other battle and a different winner takes the staff and enslaves them to their re-gime.’

The inevitable outcome, argues the chief executive, who asked to remain anonymous, is caution: ‘Staff engage-

ment has a massive impact on quality of service, commitment and continuity of care. What happens if staff are passed from pillar to post? The answer is they don’t know whom they work for; they have loyalty only to their local team, and transformational change, corporate values and improvement be-come almost impossible. You create a siege mentality where keeping your head down is the best chance of sur-vival.’

But the vision remains strong. Rob Webster spells it out: ‘For me, the real thing we need to do is apply the same approach to older people that was seen in mental health services in the past. In a decade or so, I would want people to be shaking their heads and wondering “did we really keep all of these older people in hospital?”, be-cause supported self care, and com-munity provision is the default. With brilliant hospital services free to be able to cope with the short term needs of the acutely ill.’

Community services are driving NHS transformation: of that there is no doubt. Not just internally, but across health and social care. Whether this process will in future be led by innova-tive providers or by demanding com-missioners may be played out in the months ahead. .


The recent report Going for gold: Inspiring results for workforce health, wellbeing and performance highlights the success of the NHS Sport and Physical Activity Chal-lenge. Our analysis shows clearly that there are significant benefits to individuals, to organisations and to patients from taking effec-tive, supportive action to promote the health and wellbeing of staff through sport and physical activity.

In 2009, the final report of the inde-pendent NHS Health & Wellbeing Re-view, led by Dr Steve Boorman, made clear the potential gains for the NHS from improving staff health and wellbeing.

Equally there is clear evidence that physical activity has benefits for both physical and mental wellbeing. It was recognised, from the Boorman Review, that too few staff were meeting physi-cal activity recommendations, and that increasing activity was likely to have a range of benefits for individuals and for the NHS as a whole through the better health of its workforce. These include improved retention and recruitment, reduced sickness and absence and its attendant costs, more effective working and better quality care for patients.

Building on this, in 2010, NHS chief

executive Sir David Nicholson chal-lenged NHS managers to improve staff health and wellbeing, using the inspira-tion of the London Olympic and Para-lympic Games as an opportunity to get NHS employees actively engaged in sport or physical activity as part of, or associated with, their NHS employment, by the time the Games arrived in 2012. Since then, many organisations have been working to get NHS employees actively engaged in sport or physical activity. Across the country, many thou-sands of NHS staff have been walking, cycling, running and dancing their way to better wellbeing, and many NHS bod-ies have been reporting reductions in staff sickness and improvements in mo-rale and team working – all fundamental ways for the NHS to improve its perfor-mance both as an employer and as a provider of vital services.

The Challenge consists of a range of sport and physical activity pro-grammes designed to maintain and promote a healthy lifestyle and encour-age staff to get more physically active. The focus is on NHS people challeng-ing each other and themselves to in-crease their involvement in fun and physical activity and improving their health and wellbeing. This means staff

The success of the NHS Sport and Physical Activity Challenge shows helping staff to become healthier and more active improves efficiency and leads to better patient care, says Mike Farrar.

can be better role models for patients and results in better patient care.

The Challenge has two main ele-ments – national activity and local re-sponses. At a national level, key activi-ties included:

■ raising the profile of the programme and creating a ‘national NHS movement’

■ creating and maintaining momentum through a website and regular updates

■ creating and promoting a number of national partnerships

■ recognising success through an accreditation scheme

■ using the website and updates to promote good ideas and provide further encouragement and support

The national programme was supported by the London Organising Committee of the Olympic Games (LOCOG) and Jona-than Edwards, the former British triple jumper gold medallist, sits on the steer-ing group. The programme provides sup-port and information about how to set up sports and physical activities within the NHS, providing easy, cost-effective and fun ways to improve staff health and wellbeing. All NHS bodies were encour-aged to set up their own local pro-grammes.

SPORT IN THE NHS


NHS organisations have found a number of benefits from participating in the Challenge and increasing levels of physical activity among staff, many of whom reported they were not previously meeting the recommended levels of activity. Many programmes aim to be-come sustainable by encouraging staff to try a programme and then continue it. For instance, Great Ormond Street Hos-pital’s staff evaluation found that:

■ 77% of respondents did not previously meet the recommended minimum of five to eight half-hour sessions of exercise a week

■ 70% have taken up more exercise as a result of taking part in the challenge

■ 83% have felt benefits to their health and wellbeing as a result of these activities, including more energy, weight loss, reduced stress, a sense of wellbeing and more social interaction.

Many NHS bodies embraced the Challenge and can demonstrate significant numbers of staff get-ting involved and giving very positive feedback about the nature of the Chal-lenge. This is key to enabling NHS bod-ies to meet national priorities, including supporting better health and wellbeing among staff with its concomitant ben-efits for morale, team working and re-duced sickness rates, and a better pa-tient experience.

The setting up of a national movement – the Challenge – has given NHS bodies impetus to take action: although some Trusts were able to build on their existing health and wellbeing activities, for many the Challenge provided the impetus to take the first steps in creating an organi-sation-wide programme aimed at getting staff more active using sport and other forms of physical activity.

Organisations have also obtained

value for the NHS by using the Chal-lenge to forge new partnerships within the NHS and with external bodies in the public, private and not-for-profit sectors. For instance, NHS Somerset formed partnerships with 152 local sports and physical activity related businesses which provided the NHS staff taking part with discounts, special offers and special events.

We are now working to grow a ‘na-tional’ NHS movement for staff sport and physical activity, create more mass participation events and develop a sus-tainable business model to secure long-term investment. We have recently launched an NHS Health and Sport con-sultancy service to support NHS organi-sations in improving staff health and wellbeing.

NHS staff are in an almost unique position in being able to demonstrate the benefits of taking the NHS’s own advice – that being active is one of the best ways of improving and maintain-ing physical and mental wellbeing – as well as being fun and a great way to build networks and support. .

Mike Farrar is the outgoing chief executive of the NHS Confederation and national NHS Champion for Sport and Health.

Download the full report from: www.nhsconfed.org..For more information contact Sue Henry, [email protected]

SPORT IN THE NHS

■■ 220 organisations are taking part (excluding organisations outside the NHS who participated in locally run NHS programmes)

■■ at least 17% of NHS staff have taken part (excluding staff participating in mass participation events such as the NHS Fun triathlon)

■■ 68 NHS organisations have been awarded an accreditation certificate

KEY OUTCOMES

from the NHS Sport

and Physical Activity

Challenge

Leeds Community Health’s cycle challenge involves cycling 874 miles – the distance from Land’s End to John O’Groats – over four weeks.


There’s more to settlement agreements than just a change of name, says Neil Todd.

LEGAL MATTERS

A legally binding contract to end an employment relationship on agreed terms is now known as a ‘settlement’ – rather than a ‘com-promise’ – agreement.

So what’s in a word? As legal docu-ments, the two are very similar. Both are entered into voluntarily. Both are legally binding contracts. Both waive an individual’s rights to make a claim on issues covered by the agreement to an employment tribunal or court.

But the difference is more than se-mantics. Indeed, it could hardly be more fundamental.

Settlement agreements have been introduced by the government because employers wanted greater scope to initi-ate termination discussions without risk-ing a claim for unfair dismissal.

Previously, it was only when there was an existing employment dispute that an employer and employee could enter into discussions about settling that dispute on a “without prejudice” basis. This meant, in turn, that only statements made in a without prejudice discussion, which were made in a genuine attempt to resolve an existing dispute, were pre-vented from being put before a court or tribunal as evidence.

However, section 111 of the Employment Rights Act has now been amended so that “pre-termination negotiations” – to discuss a potential settlement agreement – cannot normally be referred to as evidence in an unfair dismissal claim in any circumstances. This will protect employers who offer a settlement termination payment even when there has been no previous dispute between the employer and employee.

This allows employers to ‘pop’ the termination question secure in the knowledge that the discussions are, in effect, secret and cannot be used against them later.

There are some exceptions to the application of section 111A. Claims that relate to an automatically unfair reason for dismissal such as whistleblowing, union membership or asserting a statu-tory right are not covered by the confi-dentiality provisions. Neither are claims made on grounds other than unfair dismissal – such as claims of discrimi-

nation, harassment or victimisation and claims related to breach of contract or wrongful dismissal (a dismissal which is in breach of contract).

The only other exceptions to the ap-plication of 111A are if anything was said or done at the meeting which was improper or connected with improper behaviour. In these circumstances an employee will be able to rely upon what was said or done in the meeting in a tribunal or court.

One example of this would be an em-ployee not being given enough time to consider an offer and an employer say-ing – before any form of disciplinary pro-cess has begun – that if the employee rejects a settlement proposal, he or she

will be dismissed anyway. The ACAS guide to settlement agree-

ments makes clear that, for a settlement agreement to be legally binding, the em-ployee must have received advice from a relevant independent adviser, such as a lawyer or a trade union representative. It also recommends that employees should be given a minimum of 10 cal-endar days to consider the proposed conditions of the agreement.

The problem, however, is that there is no guidance on what the offer should contain. Employees who lack confi-dence may be pressurised – simply by negative feedback on their work – to leave on derisory terms.

Employees and their representatives should remember that they have every right to refuse a settlement agreement. They can tell the employer to use a performance management, disciplinary or grievance process instead, where the employer will have to follow a fair pro-cess or risk a claim of unfair dismissal. However, once an employee signs a settlement agreement, it will be impos-sible to do anything about it unless it falls into one of the exceptions outlined above, such as a claim relating to an automatically unfair reason for dismissal or the employer being shown to have behaved ‘improperly’.

On this basis it looks like impropriety may well become a new battleground in employment law. .

Neil Todd 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

“Employers can ‘pop’ the termination question secure in the knowledge that the discussions cannot be used against them later.”


TIPSTER

Appraisals to look forward toMichael West, professor of organisational psychology at Lancaster University shares his tips for making appraisals something to relish rather than dread.

■ APPRAISAL IS A CONVERSATIONPeople should leave the conversation believing they can do their job better and feeling valued, respected and sup-ported by you and the organisation. A helpful, focused, forward-looking and, above all, appreciative conversation will ensure you both come to relish the opportunities appraisal gives.

2 YOUR ROLEThe appraiser’s role is to listen, encourage, explore and probe, to find ways of helping, and to enable growth, development, innovation and proactivity. Empathise with difficulties and work out how to support the person in their job more effectively. Take every opportunity to celebrate and appreciate their contributions.

3■ PREPARATIONIt’s vital that you both prepare by thinking through the questions below and drafting clear objectives for the next year, focusing on improving quality and performance.

4■ REVIEWING PROGRESSThe best starting point is to discuss progress against last year’s objectives. Set the tone by celebrating the person’s achievements. Adopt an ‘Appreciative Inquiry’ orientation throughout in order to be motivating and effective. Probe for what helped them to succeed and what can be learned from that. Ask about what impeded progress and what you can both do to remove such obstacles. Performance and behaviour problems should have been addressed throughout the year and should not be introduced for the first time in the appraisal.

5■ SETTING OBJECTIVESThis is the most powerfully motivating element of the appraisal conversation. Look at the proposals the appraisee has brought. Objectives should focus on effectively implementing innovations or improving quality and performance. They should be limited in number (five or six maximum), specific and challenging. Specific objectives are far more motivating and helpful than ‘do your best’ vague goals. Research shows that performance tends to improve when goals are more challenging, except when they are clearly unattainable.

6■ RECOGNISE PROGRESSSetting challenging objectives means you should not expect people to achieve all their objectives. They will simply resist setting challenging objectives next time round. Celebrate and recognise progress towards goals not just attaining them.

7■ SUPPORTING PROGRESSDiscuss the support the appraisee needs to successfully progress towards their objectives in the coming year. With lashings of celebration and appreciation, it’s easier to ask, ‘What didn’t go so well? Why? What can we learn or change as a consequence?’ Ask about your role, what you can do to help and anything you do that hinders them. How can you best reinforce helpful behaviours and reduce or avoid unhelpful ones? Take time to explore the answers openly and in depth so you can learn to support the appraisee’s work more effectively.

8■ TRAINING AND DEVELOPMENTDiscuss how you can together make this a year of really exciting learning and growth for the appraisee. Make sure you are talking about high-quality learn-ing opportunities rather than just going through the motions.

9■ LOOKING AHEADAsk the appraisee about their growth or career aspirations for the next five years. ‘What do we need to be planning or implementing to make that happen? What other issues would you like to talk about?’ Give plenty of time to these questions rather than just treating them as a polite way to wrap up the meeting. You both need to summarise the actions you will take, with clear timescales and allocated responsibility.

■ SAY THANK YOUFinish by acknowledging the appraisee’s substantial contributions and how valuable they are to the team and the organisation as a whole. Pick up on the special qualities they bring to the team. Make sure you emphasise how important their contribution is to you personally as a team leader. And remember to emphasise how their contribution makes a difference to patients and the public, as well as to their colleagues.

More information can be found on Michael West’s blog www.nhsemployers.org/PlanningYourWorkforce/Organisational-Development/ProfessorMWDoODblog/Pages/ClearobjectivesinNHS.aspx


MIP AT WORK

If we didn’t know it already, the three big reports on patient safety triggered by the failings at Mid Staffordshire – from Robert Fran-cis, Bruce Keogh and Don Ber-wick – all highlighted the need for healthcare organisations to be learning organisations. These and other evidence clearly show that a strong learning culture which supports broad skills development can improve health outcomes for patients. It also helps employees in their personal development, career progression and job satisfaction.

In August, the NHS Social Partnership Forum launched the Learning for Life campaign to support a culture of learning. We have

produced an online toolkit, available on the Social Partnership Forum website, which gives organisations the information, advice and tools to help them develop high quality local learning programmes.

The emphasis of the campaign is on support staff, but a good learning pro-gramme will address the development needs of all staff, including managers. In fact, line managers have a key role to play in developing and sustaining an effective learning programme in their organisation. Good quality appraisals, personal development plans and skills development are essential components of effective team working, which in turn has a positive impact on patient experience and the quality of health

outcomes. If you need more facts and figures to show the value of workplace learning, check out the toolkit.

MiP and other health unions have worked in partnership with the new NHS Property Services organisation to produce a union learning agreement, which was launched in September. Simon Holden, Chief Executive of NHS Property Services, said: ‘Having worked at every level in the NHS, I recognise the huge part that training and development has played in my career. We are committed to being an employer of choice and empowering our staff to achieve their potential. Over the coming months we will be introducing a new performance management process and a variety of training, ranging from powerful appraisals to improving core skills.’

‘All four of our union partners are well placed to promote the benefits of the union learning agreement and their extensive practical experience will enable us to deliver, in partnership, the life-enhancing benefits of training to all our staff.’

MiP hopes that managers will become involved, either as union learning representatives or by giving active support to staff to encourage them to become learning representatives.

Managers can also help themselves by helping others. Workplace learning champions, like learning representa-tives, provide support and guidance to learners. The role benefits the champions as well as the learners:

NATIONAL

Supporting a learning cultureMarisa Howes reports on MiP’s initiatives to support skills development for members and to promote workplace learning for the whole healthcare team.


“Line managers have a key role to play in

developing and sustaining an effective learning programme.”

MIP AT WORK

they receive training to support them in their role and get the satisfaction of contributing to the workforce devel-opment in their organisation.

Two linked initiatives are the ‘digital champions’, who encourage and support people to get the most out of the internet and digital technology, and maths champions, who support people to develop their maths skills.

MiP is also supporting a pilot project to develop an NHS online mentoring scheme and several MiP members have signed up to be mentors. The project targets young people aged 16 to17 living in deprived areas. It aims to raise awareness of the range of careers available in the NHS. Mentors use their personal experience and knowledge to raise the aspirations and motivation levels of mentees through online discussions. They also receive web-based training and can attend other professional development webinars free of charge.

In Scotland, MiP has launched an online training programme in

partnership with Glasgow’s Stow College and the TUC. They have developed an online course on the NHS pension scheme and participants can also access other Union Learn courses. (See Healthcare Manager issue 18 for details.)

As well as working in partnership with employers and other unions to support training and development for the healthcare team, MiP also provides its own masterclasses specifically for managers, helping to develop communications and leadership skills. These are advertised on our website. The next masterclass takes place in Birmingham on 16 October and is facilitated by Big Difference Company, the community organisation working to promote better healthcare. The programme, ‘Learning through good practice’, explores themes that came out strongly in the Francis report – the need to develop effective patient and staff engagement and the need for effective team working – and considers how you can develop personal resilience to manage your workload.

Let us know of any other ways we can support your skills development, including topics for future masterclasses. .

For more information about:The Learning for Life campaign see the SPF web-site at www.socialpartnershipforum.org Learning champions and learning agreements contact Sean Ruddy on [email protected] masterclasses: see the MiP website miphealth.org.uk or contact Sean Ruddy.

SCOTLAND

MiP members build resilience at leadership event

MiP hosted another successful event for Scottish members in Edinburgh in September. There was a great buzz, with over 40 members networking and discussing a range of topics and highlighting the issues they want MiP to take forward.

Workshops covered workplace cul-ture, TUPE, pensions and an update from Europe. MiP chief executive Jon Restell (pictured) led a discussion on personal resilience. Deborah O’Dea and Mark Smithers, of Problem Reso-lution, gave a presentation on media-tion and how it can be used to address complex workplace problems arising from relationship difficulties rather than employment rights. In these circum-stances, the use of mediation rather than traditional grievance procedures can provide a much more successful resolution, which can be accepted by all parties concerned. .If you are based in Scotland and would like one of these workshops to be presented locally contact MiP’s national officer for Scotland, Claire Pullar on [email protected].


backlash

Toil and trouble

Celticus hears dark rumours about something nasty

being cooked up for GPs in Richmond House. Jeremy Hunt’s September attack on the 2004 GP contract – negotiated by that well known soft-touch Dr John Reid – looked like a softening-up exercise for his new contract. Those in the know say Hunt’s plans are heavily ‘market orientated’. Unencumbered by evidence, the SoS said the 2004 contract caused the A&E crisis because it ‘undermined the personal link’ between GPs and patients. Given their commitments to CCGs, LMCs and HWBs, and forming Umbrella Provider Companies to bid for Local Enhanced Services – not to mention preparing to take their practices to market – it’s a wonder GPs have time to see patients at all.

Give and ye shall receive

More than 200 NHS contracts, worth some £2.5bn,

have been contracted out since April alone, according to research by the NHS Support Federation, with Nuneaton’s George Eliot Hospital the latest up for grabs (incidentally, George Eliot is due to be ‘outsourced’ in April 2015 and serves three Tory marginals – where are you Dr Richard Taylor?).

The vast majority of these contracts (84%) have gone to private sector firms, so NHS bidders and charities must be doing something wrong. Perhaps they could learn from the owners of successful bidders like HCA, Care UK and Circle Health, and make a timely donation to the Conservative Party. That’s probably illegal now, but surely ministers can slip a quick clause into the Lobbying and Campaigning Bill to level the playing field?

False economies

Feathers were ruffled in the private healthcare sector by a caustic

report from the Competition Commission, slipped out in August. The commission says prices in Britain’s private hospitals are too high and quality isn’t consistently monitored. It accuses providers of manipulating markets, a lack of transparency and restrictive practices – such as making ‘loyalty payments’ to doctors (kickbacks to you and me). BUPA and AXA also come under fire for not using their purchasing clout to get a better deal for patients. High costs, dominant providers and restrictive practices? It’s just what critics used to say about the NHS. John Reid liked to quip that he was introducing private providers into the NHS to bring them up to NHS standards. Perhaps he wasn’t joking after all.

Dollar bills

One of the hospital providers criticised was Hospital

Corporation of America (HCA), which owns the Gamma Knife facility at London’s Barts Hospital, and was recently awarded a contract to treat NHS brain tumour patients. HCA is no stranger to financial misdemeanours: in the early 2000s it was forced to pay more than $880m to the US government after pleading guilty to 14 felonies including fraudulent billing to Medicare and paying illegal kickbacks to doctors. Civil law suits cost the firm around $2bn. But HCA bosses were back in court in 2005, when 11 senior executives were sued for insider trading and false accounting. HCA eventually settled out of court for $20m.

The other side

Dr Kate Grainger is a 31-year-old registrar for elderly medicine

working in Yorkshire, who is terminally ill with a rare and aggressive form of sarcoma. In her superb blog, she reflects on current NHS issues and her experiences as she approaches the end of her life. Kate’s posts are often moving, always insightful, and offer a (as far as I know) unique perspective on today’s NHS. She has also written two books, The Other Side and The Bright Side, with all proceeds going to Yorkshire Cancer Centre Appeal in Leeds.

You can follow Kate on Twitter (@DrKateGranger) and read her blog at www.drkategranger.wordpress.com.

by Celticus

Send your cuttings, anecdotes and overheard indiscretions (delicately handled) to Celticus at backlash@

healthcare-manager.co.uk.

HUNT PICKS FIGHT WITH GPs

Can I go to A&E now?



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.

The Added vALUe OF

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FREEFOR MiP

MEMBERSQuality managersdelivering quality careWednesday 27 NovemberCongress Centre, London WC1B 3LS

MiP national conference 2013

places are limited: for more information and to register online go to

helping you make healthcare happen

mip-conference.co.uk or telephone 020 7592 9490

keynote speakers include

This year’s MiP conference focuses on quality managers delivering quality care. The Francis Inquiry gave the NHS notice to improve quality and safety in healthcare and the importance of patient and staff involvement. The Keogh and Berwick reports reinforced this message. What is the managers’ role in achieving cultural change? How does the pressure to improve quality and make huge savings impact on managers’ health and wellbeing?

Other speakers include:

• JonRestell, Chief Executive, MiP• DavidDalton, Chief Executive, Salford Royal NHS • AnnieIngram, Director of workforce, NHS

Grampian• ProfDerekMowbray, Director, Management

Advisory Service• ProfElisabethPaice, Chair, NW London

Integrated Care Management Board

• ChrisHam, Chief Executive, King’s Fund • AnnRadmore, Chief Executive, London

Ambulance Service • DrPeterLees, Medical Director, Faculty of

Medical Leaders and Management • LisaRodriguesCBE, Chief Executive, Sussex

Partnership NHS Trust• GillBellord, Director of Employment Relations,

NHS Employers

RtHonAndyBurnhamMPShadow Secretary of State for Health

RtHonStephenDorrellMPChair, Health Select Committee

DameJulieMellorDBEHealth Service Ombudsman

ZoetaManningChair, MiP National Committee

conference chair

VictoriaMacdonaldHealth CorrespondentChannel 4 News

Conferencechair

Documents

Healthcare Manager autumn 2013 - issue 19