Make the perfect PCT
New beginnings for end
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18 JUNE 2009
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Our NHS is
too precious
to be left to
the market
The BMA believes the NHS is under threat from continuing market-driven reforms which are moving the
NHS away from its founding principles of being publicly funded, publicly provided and publicly
accountable. We want to see the NHS restored as a public service working co-operatively for patients,
not as a market of commercial businesses competing with each other.
That’s why the BMA is calling for an NHS which:
1. Provides high quality, comprehensive healthcare for all, free at the point of use
2. Is publicly funded through central taxes, publicly provided and publicly accountable
3. Significantly reduces commercial involvement
4. Uses public money for quality healthcare, not profits for shareholders
5. Cares for patients through co-operation, not competition
6. Is led by medical professionals working in partnership with patients and the public
7. Seeks value for money but puts the care of patients before financial targets
8. Is fully committed to training future generations of medical professionals
Have your say
Agree with the BMA’s principles? Visit to lodge your support and/or views
or email [email protected]
Visit and submit examples of how NHS market reforms are affecting you.
‘We need to sit
down with the
unions as quickly
as we can’
Talent Management conference is in
London on 2 July,
The latest issue of Intelligence, HSJ’s
information and technology
supplement, considers how NHS
Evidence will keep clinicians up to date
with the ever-expanding body of
information, and asks why PCT
websites are so often not up to scratch.
With this issue
To die at home has long been the wish
of many people who know their life is
ending, but too often this has not been
fulfilled. Now, at last, things are
beginning to change and end of life
care is becoming a priority. As one
palliative care consultant says: “For
the first time in my practice I can see
the oil tanker changing direction.”
Page 22
In 2003 a heatwave
killed an estimated
52,000 people in
Europe, with more
than 15,000 excess
deaths in France
alone. With another
summer” predicted,
what can PCTs do to
get their heads
around a major
public health
Page 12
‘Common but fairly
inoffensive jargon
includes “stakeholders”
– Bullfighter suggests
“vampire slayers” as
an alternative’
Dave West
Salary band 9
starts on page 27
Director of finance,
information and
procurement, Cumbria
Salary band 8
starts on page 33
Service manager,
Sheffield; Clinical service
manager, Roehampton
Salary band 7
starts on page 42
Assistant directorate
manager, Manchester
Search all current
jobs online at
updated daily
18 June 2009 Health Service Journal 1
Managers have called on unions and employers
to begin negotiating now on the 2011-12 pay
deal. But health secretary Andy Burnham said a
deal would be hard without knowing what the
next spending review will bring.
Page 4
“I’m a regular user of during
work hours and from
home, because I trust
the relevance of
the information.” member since 2006 has an unrivalled ability
to target and personalise information
to doctors, by seniority, speciality and
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It is a unique channel to rapidly
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We work with organisations across the
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Get in touch to see how you can drive
and measure rapid, clinical engagement:
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HSJ_12-06-09_doctorsnetuk_v02.indd 1
15/06/2009 09:54:08
Flu pandemic could kill off a
generation of local managers
The fear in the Department of Health
over swine flu is palpable.
Its leadership is worried that
primary care trusts have become
complacent (news, page 7). The
modest numbers infected so far and
the mildness of the symptoms have
provided false assurance that we
have been spared a major and deadly
The propaganda from ministers
and experts has exacerbated the
problem. The soothing refrain is that
Britain is better prepared than any
other country in the world.
Britain has amassed huge
stockpiles of antiviral drugs, and
PCTs have been drafting plans to
co-ordinate action with hospitals,
councils, strategic health authorities
and businesses.
But the DH fears many of these
plans will fall apart in the face of a
renewed and more virulent
onslaught in the autumn. Last week,
behind closed doors at a hastily
arranged meeting hours before the
World Health Organisation declared
a pandemic, flu czar Ian Dalton
ordered PCTs to test their plans to
Some PCTs will get it right, others
will be lucky. Those who get it
wrong and are unlucky will be
‘The political climate has
rarely been more hostile
to public servants, and
NHS managers are seen
as a legitimate target’
exposed to the full force of public
anger. The exemplary performance
of the best PCTs will be used as a
stick with which to beat the worst.
Local managers should be in no
doubt about what they will endure if
they fail. After five years of
preparation, millions of pounds of
investment, months of warning over
swine flu and endless declarations
that the country is ready, the public
and local and national media will
lynch you.
The political climate has rarely
been more hostile to public servants,
and NHS managers are always seen
as a legitimate target. If you are
deemed to be responsible for
avoidable deaths they will dissect
your pay packet, dissect your
organisation and dissect you. ●
Limits on Monitor should not threaten FTs
The Department of Health
is moving to weaken the
power of foundation trust
regulator Monitor.
As HSJ reveals this week
(news, page 5), the
department is planning to
split the post of executive
chairman, presumably
when incumbent Bill
Moyes finishes his second
term next January.
Mr Moyes has amassed
considerable power and
has aggressively defended
foundation trusts against
what he sees as DH
He is not regarded
warmly in the DH, and the
antipathy between him
and NHS chief executive
David Nicholson is an
open secret.
But whatever the
motivation, splitting the
post to establish a chair
and chief executive is the
right decision. In the age
of good governance it is
anomalous for any major
public sector body, let
alone a regulator, to place
so much power in the
hands of one post.
Splitting it will send the
right message to
foundation trusts about
the centrality of effective
However, it must not
lead to a weakening in the
voice and independence of
foundation trusts. Monitor
took the DH at its word in
professing its belief in
autonomy, and has
provided a competing
centre of gravity in the
NHS which has drawn the
orbit of FTs a little distance
from the DH. Although Mr
Moyes’ tactics have
occasionally been
confrontational, his
organisation has certainly
worked to put a line in the
sand which the DH crosses
at its peril. This autonomy
must be defended. ●
18 June 2009 Health Service Journal 3
Contact the news desk on
020 7728 3757, [email protected]
Home care to
ease hospital
bed demands
A Number 10 document setting
out the government’s plans for
the next 12 months will promise
more care for people in their
own homes.
Next week Downing Street is
expected to publish Building
Britain’s Future, which will list
the government’s forthcoming
strategies and white papers.
It is understood that following a disastrous showing in the
local elections and the installation of a new cabinet, the government feels it must set out its
priorities more clearly.
The intention to offer people
more healthcare in their own
homes fits with the emphasis
from the Department of Health
and the NHS on the need to
reduce the use of hospital beds
– even more pressing given the
impending spending cuts.
HSJ understands this will
include palliative care, cancer
and children’s services.
The document is also expected
to signal the government’s
intention to set out new proposals on maternity later this year,
likely to seek to extend birthing
units, improve post-natal care
and give parents, particularly
fathers, a bigger role in the birth
of their children. Individual
budgets are understood to be
under consideration.
Several of the targets set out
in Maternity Matters to improve
services by the end of this year
are widely expected to be missed,
and the government has been
concerned that maternity services are one “shop window” of
the NHS that it has not
A greater emphasis on prevention will echo health secretary
Andy Burnham’s stated priorities
for the NHS, and there will be
plans to reform social care.
’s Achieving Excellence Care
in NHS Customer
conference is on 23 June,
4 Health Service Journal 18 June 2009
Managers worried by b
cuts call for early pay t
Staffing levels
expected to take the
brunt of predicted
tightened spending
Sally Gainsbury
[email protected]
NHS managers have called for
unions and employers to start
talks now on the NHS pay deal
for 2011-12 in a bid to minimise
job losses.
Staff pay represents more
than 40 per cent of total NHS
spending. There are concerns
that with analysts projecting a
shortfall of up to £25bn by 201314, headcount reductions will be
NHS Confederation chief
executive Steve Barnett told
HSJ: “We need to sit down with
the trade unions as quickly as
we can.
“If we are in a situation where
we could be £20bn short, mature
people are going to have to sit
down and talk about how that
gets managed. There cannot
necessarily be inflation based
[pay] increases each year,” he
Speaking at the NHS Confederation conference last week,
Christchurch Hospitals foundation trust chief executive Tony
Spotswood said the scale of
required savings implied a 15
per cent reduction in the workforce – equivalent to around
180,000 staff or £5bn of the
annual pay bill.
That would equate to more
than half of the public sector
jobs the Chartered Institute of
Personnel and Development this
week warned are likely to go
between 2010-11 and 2014-15,
NHS workforce
in numbers
Total staff employed
l 1998: 1,071,562
l 2008: 1,368,693
l Increase: 28 per cent
Total spending on NHS staff
l 2005-06: £33.9bn (47 per cent
of NHS spending)
l 2006-07: £35.2bn (45 per cent
of NHS spending)
l 2007-08: £36.5bn (42 per cent
of NHS spending)
Total spending on management,
administrative and clerical
posts at PCTs and trusts*
l 2005-06: £5.4bn (7.3 per cent
of NHS spending)
l 2006-07: £5.3bn (6.8 per cent
of NHS spending)
l 2007-08: £5.0bn (5.8 per cent
of NHS spending)
Spending on agency staff*
l 2005-06: £1,182m (1.6 per
cent of NHS spending)
l 2006-07: £798m (1.0 per cent
of NHS spending)
l 2007-08: £883m (1.0 per cent
of NHS spending)
*Excludes foundation trusts
Sources: Department of Health,
NHS Information Centre, York
Centre for Health Economics
triggering strike action and
“guerrilla war” from public sector trade unions.
However, health secretary
Andy Burnham told HSJ it was
still too early to begin detailed
negotiations. “It’s hard to sign a
new pay deal without knowing
what the next spending review
is. We couldn’t sensibly sign a
new deal – but we could do the
preparatory work,” he said.
Managers have told HSJ that
attempts to minimise redundancies through workforce
planning and natural wastage
are hampered by the uncertainty surrounding the pay deal
after 2011.
The rest of the economy could
be moving into recovery by
then, making it difficult to cap
public sector increases in the
face of rising salaries in the private sector.
Workforce Chief turnover ‘stifling’ NHS 6
Foundations Private meetings defended 8
Michael White On spending cuts 10
y budget DH plans to split Monitor top job
y talks
regulation Dividing the role will minimise ‘personality issues’
Helen Crump
[email protected]
Monitor’s top job is to be split in
two under plans being developed
by the Department of Health.
HSJ understands that DH
permanent secretary Sir Hugh
Taylor will oversee the move to
replace the executive chairman
position – currently held by Bill
Moyes – with separate chief
executive and chair roles.
Being executive chair gives
Mr Moyes an unusually powerful role. Most NHS organisations have a chair and chief
executive. The move would also
bring Monitor in line with other
regulators, such as the Care
Quality Commission.
A Whitehall source said there
was “a sense within the NHS
and the Department of Health”
that a clear separation of the
roles was needed.
A government source said
Bill Moyes: separate roles needed
there was a view at the DH that
separating the roles could “take
some of the personality issues
out of Monitor”.
Mr Moyes clashed with the
Department of Health last year,
criticising it for taking a “directive” and “instructive” tone in
letters to foundation trusts, and
sharing his views with trusts
after his own exchange of letters
See leader, page 3
Mental Health Services exposed by payment by results delay
Tariff timescale ticks off trusts
Charlotte Santry
[email protected]
Mental health trusts have
expressed dismay that a national
tariff will not be in place until
2013 at the earliest.
The timescale was revealed in
a letter to managers on Monday.
It follows a pledge in the next
stage review that mental health
“currencies” would be available
by 2010. Service providers had
originally anticipated that the
national tariff would be developed quickly afterwards.
The letter, from Department
of Health director of mental
health policy Kathryn Tyson and
NHS finance director Bob Alexander, says the proposed currencies will be published in 2010-11
for use “if there is local agreement and capacity to do so”.
By 2011-12, all health economies should be using the currencies “in some form” and be
establishing local prices.
But 2013-14 will be “the earliest possible date” for a national
payment by results tariff for
mental health, and only if there
is seen to be a “compelling case
for a national price”.
The timetable has fuelled
concerns that mental health
services will be more “exposed”
to commissioners’ cost cutting
measures if they do not have a
tariff at a time of tightened public spending.
NHS Confederation Mental
Health Network director Steve
Shrubb said: “This will disappoint a number of people.
“We’re in a recession. Commissioners have a tariff with
their acute customers and not
with mental health providers,
so that exposes mental health.
“When we consider what a
large proportion of the NHS
spend is on mental health, it
seems not unreasonable to
expect it should receive a higher
The tariff involves grouping
patients into clusters based on
their symptoms and needs, with
commissioners paying for the
number of people in each cluster.
Cumbria Partnership foundation trust chief executive
Stephen Dalton said he welcomed the phased approach.
But he warned treatment
costs varied widely across the
country. The economic climate
meant there would be no “safety
net” for trusts that lost out
under the tariff, he said.
18 June 2009 Health Service Journal 5
Unite national officer Karen
Reay said her union’s members
were angered by the suggestion
that the first port of call for cuts
should be staff and pay. She
pointed to the £300m a year the
NHS spends on management
consultants and claimed the
operation of the internal market
cost another £20bn.
She said her union would not
accept a 2011-12 settlement
below the going rate in the rest
of the economy and warned
“staff will vote with their feet” if
that was the deal.
HSJ understands other unions
may be more open to a pay deal
that balances a low pay increase
with guarantees over staffing
levels, the NHS pension and
career flexibilities.
Unison national officer Mike
Jackson told HSJ the union
would be happy to discuss
another three year deal now
“without prejudice”, but members would be looking for guarantees over inflation. “Just as
NHS trusts want pay certainty,
so do our members,” he said.
NHS Employers director of
pay, pensions and employment
Gill Bellord said it was “very
much open” to having early conversations with unions, but confirmed these were not taking
place at present.
But she added that with
30,000 people retiring from the
NHS each year, job cuts were
“not inevitable”.
Fresh attention is also likely
to be paid to trust spending on
agency staff.
Department of Health figures
show that during the cutbacks
of 2006-07, when the NHS was
pulling itself out of deficit,
agency staff spending dropped
by a third to £798m, or 1 per
cent of total NHS spending. The
following year the cash amount
grew by 11 per cent.
with NHS chief executive David
Nicholson had revealed disagreements between them (news,
page 4, 22 February 2008).
Managers welcomed the plan
to split Monitor’s top job.
An NHS chief executive said:
“It’s an open secret that Mr
Moyes isn’t everyone’s favourite
person at the DH, so my question would be is this truly about
the role or about the person?
“Monitor and the private sector good governance codes all
recommend separation of the
chair and chief executive so it’s
a bit ironic that the body that
governs foundation trusts has
never done this.”
A DH spokeswoman said:
“The current appointment of
the [executive] chair of Monitor
ends on 31 January 2010. No
decisions have been taken
beyond that point.”
Monitor declined to comment.
Half measures
Only half of trusts have said they
met all standards assessed in the
annual health check during the
financial year 2008-09. The Care
Quality Commission has said
compliance with the core standards
will be a key indicator of whether a
trust meets the new registration
requirements. The regulator will
be checking the accuracy of trusts’
self declarations.
For more details visit
Scots on board
Members of the public will be
directly elected to the boards of
NHS Fife and NHS Dumfries and
Galloway from next year, Scottish
health secretary Nicola Sturgeon
has announced. The elections,
which are a pilot, will be held for
the first time this spring. The
system uses postal ballots and will
run for at least two years before an
Outram for MEE
Leeds primary care trust chief
executive Christine Outram has
been appointed managing director
of the workforce training and
planning body Medical Education
England. Ms Outram is expected to
take up the new role later this
month. The PCT’s finance director
Kevin Howells will become acting
chief executive. Director of
commissioning Matt Walsh has also
resigned to take up the post of
medical director at Calderdale PCT.
The government will introduce a
new independent regulator for
pharmacy professionals and
premises next year. The General
Pharmaceutical Council will
replace the Royal Pharmaceutical
Society of Great Britain as
regulator for pharmacists and
pharmacy technicians.
UCL’s new partner
The UCL Partners academic health
science centre has appointed David
Fish as managing director.
Professor Fish is currently medical
director for specialist hospitals for
University College London
Hospitals foundation trust, and has
been a professor of epilepsy and
clinical neurophysiology at UCL
since 2000.
6 Health Service Journal 18 June 2009
‘Startling’ senior executive
turnover stifles innovation
Charlotte Santry
[email protected]
The “startlingly” high turnover
of NHS chief executives and
finance directors is discouraging trusts from making the bold
decisions needed during an economic downturn, recruitment
experts have found.
Up to half of senior executives
are likely to spend less than two
years in the same post, according
to a survey by recruitment consultancy Hoggett Bowers.
This compares with the seven
years that the average private
health sector chief executive
officer stays in the job, notes the
report, NHS Chief Executives,
Bold and Old.
High profile departures are
exacerbating the risk averse
“heads down” culture, which
will “stifle initiative and innovation”, it says.
“The NHS needs to do more
to explicitly encourage and demonstrate support for the unconventional, that is, for the bold
CEOs who have the capability,
drive and tenacity to initiate and
inspire innovation.”
A quarter of respondents to
the survey, which covered 57 per
cent of NHS organisations over
four years, were promoted to
roles in larger, more complex
NHS organisations or the
Department of Health.
Almost 30 per cent left their
jobs due to mergers or reorganisations, just under 10 per cent
haldane’s view
left to join other sectors and 10
per cent moved into more junior
NHS roles.
Only 5 per cent retired at their
full pensionable age and around
a quarter had a leaving package
such as a compromise agreement, early retirement or ill
health retirement.
Hoggett Bowers head of
healthcare practice and report
author Annette Sergeant called
turnover levels “startling”.
Primary care trust mergers
had influenced the figures but
analysis carried out over the past
12 months showed the results
were still relevant, she said.
Interviews with chairs, nonexecutive directors and chief
executives revealed many senior
staff who signed compromise
agreements left due to difficult
relationships with their chair or
other senior figures, a failure to
judge “local politics” or recog-
nise key influencers or achieving change too slowly.
Long lasting chief executives
tended to be politically astute
and were able to quickly assess
an organisation’s climate and
Frank McKenna, director of
NHS and healthcare at HR consultants Harvey Nash, said trusts
were increasingly looking for
bold, transformational leaders.
He said: “The challenge the
NHS has is driving up quality
while driving improved costs.
The only way that is going to be
possible is to radically transform
and innovate in a way we have
not seen before.”
But some challenged trusts
were more interested in chief
executives who would ensure
targets were met, he said.
Pharma regulation
workforce Short term leaders shy from making bold decisions
’s Talent Management
is on 2 July,
integrated care
Competition probe into merger
Sally Gainsbury
[email protected]
A Department of Health integrated care pilot scheme is to be
investigated by the co-operation
and competion panel to see if it
breaches merger, choice and
competition rules.
Under the pilot scheme, City
Hospitals Sunderland foundation trust plans to merge with a
local GP practice.
The merger would represent a
case of “vertical integration”,
which the DH has been wary of
due to concerns acute trusts
could use control of a GP practice to drive up the number of
acute referrals.
DH competition rules, published in 2007, state that primary care trusts must seek permission from the department
before contracting for “list based
primary care services” through a
hospital provider.
The panel’s investigation will
use the Sunderland case to test
assumptions and concerns about
vertical integration.
In a statement, the panel said
it would “assess the extent to
which the integrated care
scheme may limit patient choice
in relation to the type of NHSfunded healthcare services provided by each [provider]”.
It will also assess any benefits
the model brings patients and
The panel is inviting submissions from interested parties.
The closing date is 26 June.
panel will complete the investigation is early August, with
the possibility of it continuing
until the end of November
should the issues be deemed to
be complex.
swine flu Confederation says PCTs are confident about plans
Flu czar cracks the whip
Helen Crump
[email protected]
Primary care trusts have been
ordered to “test to destruction”
their plans to deal with swine
flu amid concerns that some
may be complacent about their
The Department of Health
has cranked up its message to
the service, with health secretary Andy Burnham and NHS
chief executive David Nicholson
both stressing the need to be
ready as the number of cases in
the UK and elsewhere in the
world rose last week.
Mr Nicholson said a significant outbreak was likely this
year and the NHS “getting its
act together” was vital.
National director for flu resilience Ian Dalton called PCTs to
a private meeting about their
swine flu plans, hours before the
Flu preparations
All PCTs should have:
l Pandemic influenza co-ordinator
in place
l Strategy for co-ordination with
local authority, acute trust and
l Strategy to communicate with
public and local business
l Contingency plan for
distributing vaccinations
l Plan to mobilise general
practice and other primary care
World Health Organisation
declared a pandemic.
The flu czar warned PCT managers they should be “testing
their plans to destruction”. HSJ
understands there are concerns
that plans could “fall apart”.
One source at the meeting
told HSJ: “The subliminal message was ‘we’re not convinced
everyone is taking it seriously’.
“If some places cope and others
are found wanting, be clear
you’ll be held to account for it.”
Human resources issues, such
as whether PCTs had planned
for staff shortages, whether staff
knew what to do if not enough
drugs were available, and GP
provision were of particular concern, the source said.
NHS Confederation PCT Network director David Stout said
PCTs were “reasonably confident” about their plans.
“I’m not picking up a real
major concern [from PCTs] but
as the prospect of fairly serious
demand grows people are going
to have to look again.”
He said the confederation’s
own polling of PCTs and hospitals had found them to be largely
confident plans were robust.
See leader, page 3; news analysis,
page 12; opinion, page 15.
Alder Hey
park takes
Lewis Tipper, a patient
at Alder Hey hospital,
and his mum Sarah
examine plans for a
children’s park and a
new hospital on the
Merseyside site.
Options under
review are a £288m
children’s health park
scheme or a £326m
new hospital. The
consultation is open
until 26 July.
hospital infection
Trusts to get
own targets to
cut MRSA
Charlotte Santry
[email protected]
Trusts will be expected to reduce
MRSA rates to levels set nationally based on their performance
and number of bed days.
The Department of Health is
considering setting each NHS
organisation an “attainable minimum” goal to reduce the level
of MRSA infections, as revealed
in HSJ last week.
An impact analysis of the policy says while the national target to halve MRSA between
2003-04 and 2007-08 was hit,
there remains “substantial variation in local performance”.
Under the proposals, each
organisation would be given a
permitted rate of MRSA infections, based on bed days for
acute trusts and population
rates for primary care trusts.
Organisations would be told
to bring their rates in line with
the median or best performing
Those achieving this already
would need to reduce MRSA
cases by 10 per cent each year,
apart from the top 10 per cent of
improvement targets could be
set locally.
Cases will only be attributed
to hospitals if they appear 48
hours after the patient’s admission.
The plans will save the NHS
up to £57.5m in avoided deaths,
according to the analysis.
Responses to the consultation
must be submitted by 24 July.
See Andy Burnham story, page 9
primary care
Britnell move ‘will not hit commissioning’
Helen Crump
[email protected]
would be overseeing work on
commissioning, he added.
Primary care trust managers
warned the post must be filled
quickly amid fears the commissioning drive could lose focus.
One source said: “We need
someone as strong as Mark to
balance the David Flory view of
the world, which is not necessarily quite so sympathetic.”
NHS Confederation PCT Network director David Stout said:
“It’s not a time to Elose
tion… given the looming financial crisis.”
The Department of Health is
downplaying Mark Britnell’s
departure for the private sector,
insisting the world class commissioning programme will not
founder without him.
HSJ exclusively revealed
online that Mr Britnell is to
leave his DH job as director general of commissioning and system management for a leading
role in consultancy firm KPMG’s
European health practice.
HSJ understands Mr Britnell
has asked the Cabinet Office for
permission to take a job outside
the civil service and has stood
aside as the process takes place.
A DH source said there was
“no indication” of when Mr Britnell’s post would be filled, or
whether the successful candidate would be of a similar level
to Mr Britnell and carry out a
similar role.
He said: “Mark Britnell is just
an individual – the agenda
hasn’t changed.” NHS chief
executive David Nicholson
Mr Britnell launched world
class commissioning and established the co-operation and
competition panel to ensure fair
access to the health market.
Westminster PCT chief executive Michael Scott said: “We
mustn’t fall into a cult of personality.” But Hull PCT chief Chris
Long said: “He’s going to be a
hard act to replace.”
Mr Britnell was unavailable
for comment.
Read HSJ editor
Richard Vize’s blog at
18 June 2009 Health Service Journal 7
nHS cOnfederatiOn cOnference
I interviewed master of spin
Alastair Campbell at the NHS
Confederation conference in
Liverpool. A daunting task by any
standard, especially as it was at
five minutes’ notice. Oh, and I
could only ask two questions.
I wondered how he expected
the audience to react to his newly
crowned status as mental health
champion, given he’s primarily
known as a bullying spin doctor.
His answer, more or less, was
that he did not care whether
people subscribed to that image of
him, which had been “passed
down” through the media. Funny, I
had a feeling the media, rather
than his own behaviour, would
somehow be to blame.
With more time, I would have
liked to ask what it was like to
work in the upper echelons of
government while battling a
mental health condition.
As it happens, he addressed
some of this in his speech 15
minutes later, expressing genuine
anger at the way MPs who are
sectioned get “chucked out” of
Parliament. “As a signal, that’s
just wrong,” he said.
He also convincingly argued
that the NHS should be a model
employer in supporting staff who
suffer with mental illnesses. The
upcoming Boorman review will
assess whether this is the case,
but the staff survey does not make
for easy reading. Other findings
show NHS staff are almost four
times as likely to be absent from
work with stress as people with
other occupations, as reported in
our sister title Nursing Times.
Campbell’s call for the NHS to
“lead the way” should not be a big
ask given its primary function is to
care for people’s physical and
mental health, but I suspect it has
some way to go – it would be
interesting to hear whether staff
and managers agree.
Charlotte Santry
Watch the interview with Alastair Campbell at
8 Health Service Journal 18 June 2009
fOUndatiOn trUStS calls mount for increased transparency
directors defend need for
board meetings in private
Dave West
[email protected]
Foundation trust directors have
defended their decisions to meet
in private, despite growing pressure on them to be more open.
Following the Mid Staffordshire foundation trust scandal,
the government has said all
boards should meet publicly.
Care Quality Commission chief
appeared to support that view at
the NHS Confederation conference last week.
However, several foundation
trust directors and the Foundation Trust Network insisted their
governance system allowed
them to be more open than other
trusts, for example by giving
additional information and
access to governors. Those with
open meetings could avoid scrutiny by discussing sensitive topics in private sessions.
Chesterfield Royal Hospital
foundation trust chair Richard
Gregory, also chair of Yorkshire
Bank and former managing
director of Yorkshire Television,
told a conference seminar that
public meetings made it difficult
Adrian Masters: FT boards need to
discuss sensitive issues in private
to “discuss issues constructively”. They would also discourage private sector directors from
joining foundations, he said.
“How many FTSE100 nonexecutive directors would want
to have meetings in public or
indulge in the hypocrisy of holding meetings in two parts?” said
Mr Gregory.
Liverpool Women’s foundation trust chair Ken Morris said:
“I do not think there is any
evidence that open meetings are
effective in terms of promoting
confidence and getting people
interested. Arguably it is a soft
position [compared with more
information and involvement
for governors].”
Monitor strategy director
Adrian Masters said it was
sometimes right to meet in private. He told a separate seminar
at the conference: “I think if you
hold board meetings in public,
what you risk is that the really
important conversations do not
happen at the board… then you
do not have a fully effective
board because the really important questions are not being
debated there in an open way.”
However, Ms Bower said the
public was becoming less tolerant of information being kept
private. “If you hold privileged
information that you are not
putting into the public domain
then you are going to have to
have a very good reason why
you are doing that.”
An HSJ straw poll in April
suggested less than a quarter of
foundation boards met in public, contradicting government
it’s ‘make or break’ for the nHS
Rebecca Evans
[email protected]
The NHS is facing a “make or
break” moment in its history,
NHS Confederation chief executive Steve Barnett told delegates
at the conference last week.
“This year’s conference sees
us standing at the threshold of
what’s clearly going to be a most
challenging, even make or
break, period in the history of
the NHS,” he said.
Speaking on the day shadow
health secretary Andrew Lansley
had insisted “real terms growth”
for the NHS would continue
after 2011 under a Conservative
government – at the expense of
other government departments
– Mr Barnett said the confedera-
tion had calculated the health
service could face real terms
funding cuts of up to £20bn in
the three years from 2011.
“A change of government will
not change our predicament,”
he stressed.
“The cold hard fact is that
today we have just under two
years to take radical action if
our NHS is to remain true to its
founding principle of excellent
care free at the point of need.”
He pledged to defend managers in the face of any claims that
the NHS could be run by frontline staff alone.
“The notion that managers
somehow get in the way of
patient care is more than merely
misguided. It is preposterous to
imply that such an enormous
and complex service can operate
effectively without the crucial
role played by managers and
“I intend to address that distortion head on and defend in a
properly balanced way the real
contribution that managers
make – delivering care to
patients – part of the broader
team, not sitting on the bench.”
As finances tighten, local
leadership was vital, he said.
“Local leadership in good times
and in bad times, that is your
calling and it will strengthen the
reputation of NHS managers.”
He called for “disruptive and
courageous innovation” and
called on the Department of
Health “to deliver on devolving
to you”.
POLICY New health secretary outlines plans to place local needs at heart of the NHS
Burnham to overhaul target culture
Health secretary Andy Burnham
has promised to “deep clean the
target regime”.
Mr Burnham also told last
week’s NHS Confederation conference that illness prevention
would be a major policy tenet
under his leadership, but he was
unable to match Conservative
promises to increase NHS funding from 2011.
Mr Burnham said patients
should now be the “pre-eminent
force” driving health policy,
rather than targets.
“It offers the chance to change
the debate about targets fundamentally,” he said.
Existing targets would either
become minimum standards for
services or “removed”, he told
the audience in his first major
speech as health secretary.
“We have got to make sure
that minimum standards are
fairer and more focused on local
context than the targets that
preceded them.”
He gave the example of the
MRSA target, saying it was
important that standards were
Andy Burnham at the conference: targets will become minimum standards
high, but a national target was
“no comfort” to patients in areas
where their local hospital was
not up to standard. “We need a
standard that reassures patients
and better reflects the different
challenges that different core
settings face,” he said.
His announcement came as
HSJ revealed managers are to be
consulted on a “zero tolerance”
objective on MRSA to be in the
next NHS operating framework
(news, page 8, 11 June).
Waiting times targets such as
18 weeks and four hours in accident and emergency are also
expected to become minimum
service standards.
On finance, Mr Burnham has
refused to match the Conservatives’ pledge to give the NHS
“real terms” funding increases
from 2011-12.
He urged people to judge the
Labour government’s commitment to the NHS by its performance over the past 12 years. “Look
at our record. This government
has looked after the NHS and
Lansley pledges bigger budget
Charlotte Santry
[email protected]
Shadow health secretary Andrew
Lansley has confirmed the Conservatives’ commitment to
increasing the NHS budget in
real terms after 2011 while calling on managers to justify the
extra spending.
Speaking at the conference in
Liverpool, he said the NHS owed
Conservative Party leader David
Cameron and shadow chancellor George Osborne productivity
increases in return for the funding pledge.
He said: “David Cameron and
George Osborne have gone out
on a limb. They said we are not
going to cut the NHS budget.
“I think it’s incumbent to
repay them by bringing the
greatest possible efficiency.”
He stated his three priorities
were equity, efficiency and excellence, and repeated his belief in
Andrew Lansley: NHS must repay
increase with better performance
ringfenced public health budgets to address health inequalities.
Stressing the importance of
efficiency, he said: “The responsibility of people in the NHS to
use resources well is probably
greater than anybody else’s. I do
not mean anybody is setting out
to waste money.
“We need good managers – it
is not about how many managers – to… design services that
have much higher levels of efficiency.
“The NHS should be an
example in the public services
and to the private sector as well
in terms of what is possible to
Mr Lansley also criticised the
“command and control” structure that he said had led to leadership becoming confused with
More power needed to rest
with the patients, he said, which
would be promoted by expanding practice based commissioning.
funded it properly,” he said. He
added no one would thank him
if he “used a form of words” to
wriggle around the issue.
Mr Burnham also said prevention would become a fourth
priority alongside quality, productivity and innovation.
“In its first 60 years the NHS
has often picked up the pieces,
in the next 60 years it should be
all about helping people lead
healthy, happy and fulfilling
lives,” he said.
He called prevention a “long
term insurance policy” and
acknowledged it may not reap
immediate financial rewards:
“It may deliver some short term
dividends but the real gain
comes over the long term.”
He called for the health service to “press ahead” with more
investment in preventive services for older people and said
the proposals that will be in the
imminent social care green
paper would “open up new
opportunities to keep people
out of hospitals”.
Mr Burnham also backed a
review of private patient income
limits on foundation trusts.
Service design
Local control
can save NHS,
says Lamb
Liberal Democrat health spokesman Norman Lamb has called
for further devolution and local
accountability in the NHS.
Mr Lamb told delegates in
Liverpool: “There needs to be a
fundamental change from the
situation at the moment where
the only person accountable is
the secretary of state to a situation where there is local democratic accountability for the
“We need to scale back the
Department of Health.”
He said the survival of the
NHS was at risk if it did not
respond to expected cuts in
“If it is to survive and
prosper in the future it has to be
capable of adapting to the challenges that now confront it,” he
18 June 2009 Health Service Journal 9
neil o’connor
HSJ reporters
A health-minded Tory MP of my
acquaintance took me aside the
other day to suggest that a
pandemic recurrence of swine flu
this autumn, the kind which the
newspapers have been panicking
about (again), might do wonders for
Gordon Brown’s image.
“It’s the kind of thing he’s good
at; the government might be seen to
be handling it well,” the MP
conceded. No, I don’t believe it
either, though I follow his train of
thought. By all means write off
Brown, but don’t bet the whole
pension fund on it.
I mention it because it underlines
uncertainty, not just porky flu, but
financial. No need to panic about
that either, just be sensible. As with
flu – which happens every year too
– no one can claim to know what is
going to happen to the economy,
only this year more so.
choice is Tory cuts or Labour
cuts”) they said “look, we all
know both sides will make cuts to
help pay for the recession”.
So by Monday shadow
chancellor George Osborne was
writing: “The real dividing line is
not ‘cut versus investment’, but
honesty versus dishonesty.” Ed
Balls was complaining that
Chancellor Osborne would cut
education spending and training
to fund tax cuts for the rich in the
shape of inheritance tax abolition.
They’re both right and both
wrong. Yes, a Cameron
government would be under
pressure from its own side to
slash spending (not all of it
“wasteful”) and cut taxes. Yes,
Labour is already committed to
curbing recent high spending
increases after 2011, though
Chancellor Balls would have been
Spare a thought for the
Ministry of Defence
Thus our new health secretary,
Handy Andy Burnham, has been
enduring a baptism of fire over our
old friend spending cuts,
triggered by those careless
remarks from his Tory shadow,
Andrew Lansley.
Just in case you missed it. On
Radio 4 Candid Andy Lansley said:
“We have made it clear where our
priorities are. We are going to
increase the resources for the NHS.
We are going to increase resources
for international development aid
[and] schools. But that does mean
over three years, after 2011, a 10
per cent reduction in the
departmental expenditure limits for
other departments.”
I know what you must be
thinking. “Hasn’t old Lansley got
form? Did he blurt out something
about this once before?” Yes, he
did, and I am sure the Cameron elite
is a bit cross with him since Brown
and his sidekick, the ex-future
chancellor Ed Balls, leapt on it.
Lansley went very quiet.
But politics is an opportunity
crime. After Brown-Balls reverted to
their default position, citing key
“dividing lines” between the parties
(on cuts vs investment) the Tories
rallied. Citing the independent
Institute for Fiscal Studies (“the
10 Health Service Journal 18 June 2009
more of an instinctive tax-raiser
than Alistair Darling, who hung on
to the job.
Even on Darling’s current plans
there will be a slight cut (0.1 per
cent) in real (ie after inflation)
terms and higher taxes.
As HSJ reported last week,
more will follow. But one thing
Brown and Cameron, Osborne and
Darling, Handy Andy and Candid
Andy all agree upon is that
protecting the NHS budget is their
number one priority.
Kevin Barron, Labour’s health
select committee chair, takes that
as a given. He’s right. Times will
be tough. Health department
strategists are engaged in their
fundamental review of budget
priorities: last week’s £500m
cottage hospital scare may be a
And finance directors will be
seeking better patient outcomes
for less resources from NHS staff.
Right wing think tanks will
demand more market solutions –
just as President Obama says the
But cheer up. If you think you
have problems, spare a thought
for the Ministry of Defence.
Michael White is assistant editor
(politics) of The Guardian.
Panel offers advice
on tendering traps
Helen Crump
[email protected]
Co-operation and competition
panel director Andrew Taylor
has revealed some of the basic
mistakes primary care trusts
have made when tendering out
In an NHS Confederation
conference seminar on market
management, Mr Taylor outlined cases such as a PCT that
appointed one of the bidders in
a tender process to the evaluation panel for that tender.
Another bidder who protested
that this was not fair had to
write two letters before the PCT
changed its approach. As a
result, the PCT is now having to
restart the tender.
In a different case, a bidder
rang a PCT on the final day of a
tender process to be told that as
they were the only bidder for the
service, the PCT would have to
find another one. The PCT
entered this second bidder into
the process after the closing date
had already passed.
Mr Taylor said: “There are
very basic things that anyone
should be able to get right in
any kind of procurement process. If you avoid these easy mistakes, you may be a significant
way down the path [towards
successful market management].”
He urged PCTs to go to the
panel for information and advice
in order to avoid pitfalls during
the tendering process.
Private firms ‘must take risks’
Private companies must take on
more risk if they want to gain a
bigger share of the primary and
community care market.
Sarah Crowther, Harrow primary care trust chief executive
and chair of the London PCTs’
commercial board, said the perception within the health service
had been for some time that risk
sharing had been working in
favour of the independent sector.
She said: “Perhaps what
[independent sector providers]
need to think about for the next
period of time is how do you
incentivise PCTs to change some
of their provider relationships,
to have the confidence to work
with you.”
Ms Crowther, speaking at an
NHS Confederation seminar,
said the Department of Health
commercial directorate, which
has been replaced by local commissioning
“hadn’t done the independent
sector any favours” by negotiating costly deals which loaded
risk back onto the NHS.
She said: “The days when it
was all about how do you get the
independent sector involved are
gone. Actually what we’re interested in as commissioners is
who is the right provider to give
Sarah Crowther: incentivise PCTs
us the right deal to provide the
right service.”
But she acknowledged not all
PCTs would be taking the same
approach to competition and
“That may not be perfect, but
it’s the reality. Get over it,” she
She advised independent providers to think about taking on
projects that were not of optimum size in the first instance,
in order to build a track record.
Linked to that, PCTs needed
to get better at building relationships, she added.
And the private sector would
need to tell commissioners how
it was going to help them take
capacity out of the health system.
FUNDING Nicholson says public will expect more for their money
Sally Gainsbury and Dave West
[email protected]
David Nicholson: “If we don’t think about it, the money will dry up”
our staff as well as we could
have done”.
“If we don’t think about it
again until Christmas and we
just carry on to the end of 201011, the money will dry up and we
will have to rush around trying
to solve the problem,” he said.
“It will be winter and there will
be lots of ambulances waiting
outside hospitals. Waiting lists
will bulge; managers and clinicians will be at loggerheads.”
He said clinicians would be
talking about quality, managers
would be talking about cuts, and
politicians would inevitably start
describing the model as unsustainable with the need for “some
kind of massive reorganisation”.
EVEN charging
He dismissed user
as a solution to the problem,
saying the NHS should first
address issues like variations in
performance, poor value proTS
NHS chief executive David
Nicholson has warned that the
NHS must plan for cuts in real
terms, despite protestations
from the government and the
Conservative opposition that
they would continue to give it
real terms increases.
“I’m a manager, not a politician,” Mr Nicholson told the
NHS Confederation annual conference in Liverpool.
“It’s great politicians have
said they will increase [funding]
in real terms. I believe they want
to provide more resources for
the NHS. But if they give us
extra money the taxpayer will
expect more for it. So even if
they give us more money we will
need to do even more with it.”
shadow health secretary Andrew
Lansley’s pledge that a future
Conservative government would
give the NHS “real terms”
spending increases, even if that
meant 10 per cent cuts for other
parts of the public sector.
But Mr Nicholson warned
managers not to put off dealing
with the issue.
To do so, he said, would
lead to a repeat of the deficit
turnaround period of 2004-06,
which he told HSJ was marked
by having to move “so quickly
sometimes we didn’t manage
curement and back offices and
the “huge numbers” of patients
who were treated in hospital
when they did not need to be.
He said if the NHS acted now,
it was in a “good place” to make
changes without the need for
panic or a “big disaster”.
He told the audience that
reforms such as choice and foundation trusts had also been successfully introduced and patient
and public satisfaction was
higher than ever.
“I thank you for your hard
work and efforts,” he said, but
added that the perception of the
efficiency of people working in
the NHS is “only as good as
what we do tomorrow”.
For full coverage from the
conference including David
Nicholson’s two-minute
version of his speech on video, go to
clearly need to start
planning now. I remember
the 1980s and 1990s
when we had nil growth.
We could not even afford
pay awards and I had to
find savings for that.
“That’s reality; it’s part
of the core business of
NHS management.”
Les Howell, chair,
St Helens and
Knowsley trust
“There are too many
policies and they don’t all
join up together. They
sound good as individuals
but the totality is not
obvious to anyone.
“The link between PCTs
and trusts certainly needs
to be reviewed. And
clearly there is a big piece
in the jigsaw to do with IT.
It is not good enough to
keep promising – if it
doesn’t catch up now it
will never catch up.”
David Whitney,
non-executive director,
Chesterfield Royal
Hospital foundation trust
“David is very passionate
and earthy and says it as
it is. He was really trying
to give a focus on the
managerial aspects rather
than the political aspects
of the healthcare system.
“The NHS needs to be
aware of what’s coming –
it is easy after 10 years of
growth to lose sight of
what’s going to happen in
two or three years and we
Pat Holman, chief
executive, Norfolk and
Waveney mental health
partnership trust
“For two years running we
had to take 10 per cent
out of our costs. We are
very experienced and
ready for what is coming.
“Innovation was driven
out with targets. If you
want an organisation that
innovates you have to be
tolerant of failure. If you
fail you have got to not be
To see video interviews of all
the responses to
the speech go to www.
hsj. .uk/confed
In his speech to the NHS
Confederation last week, new
health secretary and former
Confed employee Andy Burnham
made a point of cosying up to NHS
managers, promising he would
always defend their interests.
Unlike most politicians, he
claimed, he understands the
brilliant job that managers do and
that the health service would fall
apart without them. He will miss
no opportunity to tell everyone so.
Media Watch’s count of how many
of his praiseworthy mentions of
managers make it into the press
starts here… None so far (apart
from of course).
But he was happy to make
enemies too, breaking with his
predecessors’ script by making a
firm call for water fluoridation in
more areas.
Why would Mr Burnham wish to
invoke the wrath of the vociferous
‘Vince Cable felt
“too weak” to
insist on equality
and was moved to
a nice room’
and tenacious anti-fluoridation
lobby in his first week in the job?
Turns out he was vice-president of
the British Fluoridation Society,
and therefore presumably used to
standing up to the worldwide
campaign on the other side of the
argument. The Times reported that
he will now be standing down from
that role as a result of its inquiries.
Meanwhile Vince Cable, one of
Britain’s most trusted politicians,
has been undermining Mr
Burnham’s pro-manager PR by
laying into them in the Mail on
Sunday, describing what he learnt
about the NHS while having his
appendix out. Despite the fact that
it was management – “a smart
lady with a clipboard” – that got
him out of his cubicle and into a
nice room (he “felt too weak to
insist on equality”, apparently),
he went on to pin all of public
services’ problems on managers.
This meant, he wrote, “sitting in
big offices, attending meetings,
burnishing their mission
statements and issuing edicts
based on government targets”.
That’ll be the last time he gets a
room with a view.
Rebecca Evans
18 June 2009 Health Service Journal 11
Chief warns managers
to prepare for cuts now
news Analysis
Public health
Heatwave planning gets
PCTs hot under the collar
While public attention has been diverted by swine flu, the
predicted heatwave this summer also poses a danger to life,
particularly to older people. By Alison Moore
Primary care trusts face a
challenge to prepare the health
service for the flu pandemic. But
another public health threat is
If forecasts of a “barbecue
summer” prove to be correct,
PCTs’ heatwave plans will be put
to the test.
The 2003 European heatwave
resulted in more than 15,000
excess deaths in France alone
and the very hot weather in
2006 led to 1,000 extra deaths in
England and Wales in a two
week period.
Unlike cold weather, there is
little time to act when a heatwave
strikes: deaths, principally
among the vulnerable elderly,
start within one or two days.
This means preparedness is
vitally important.
Last month, the Department
of Health updated its heatwave
plan, which sets out what NHS
organisations can do in advance
of hot weather. PCTs in
particular are tasked with
identifying potentially high risk
people (such as the elderly who
live alone) and including
necessary changes to their care
plans such as additional visits by
staff; working with their families
and informal carers to ensure
awareness; and making requests
to local authorities to find out if
their living conditions during a
heatwave would be tolerable.
Although some of these points
are fleshed out in more depth in
this year’s plan, the majority of
them have been in the plan since
2004 – and therefore ought
already to be in place.
12 Health Service Journal 18 June 2009
The need is urgent: the risk to
health is greater from a
heatwave in the early part of the
summer, when people have had
less chance to adapt to higher
Red alert
But are PCTs getting to grips
with the requirements for
preparation? This year, strategic
health authorities have been
tasked with ensuring that local
NHS organisations are planning
NHS London head of
emergency preparedness Andy
Wapling says he is “pretty
confident” the capital is ready.
In the North East, the SHA
has already told other
organisations to review their
heatwave plans and to liaise with
social care partners, although it
has been unable to tell HSJ what
its monitoring of these plans has
But according to their
websites, many PCTs appear to
have heatwave plans that merely
repeat DH guidance, with little
indication of how it will be
applied in their areas and who
will be responsible for different
parts of the plan.
And in some cases the 2008
plan is still to be updated. Even
some PCTs along the south coast
with large elderly populations
have been unable to tell HSJ
about their plans.
Faculty of Public Health
president Alan Maryon-Davis
says: “Theoretically it should all
work very well. In practice it
comes down to how many
people are getting into a
vulnerable state.”
Association of Directors of
Public Health vice chair Chris
Packham says PCTs have been
helped by the pandemic flu plan
– which requires them to
identify a similar group of
vulnerable people.
“We already have lists of
vulnerable people and people
who can contact them,” he says.
“It is quite transferable.”
In London, lists are held by a
number of bodies with the
intention they should be brought
together quickly in the event of a
But public health officials are
less clear about whether care
plans are being adjusted in
advance of a heatwave – one of
the DH document’s demands.
Dr Packham was unable to
say whether it was the case for
his PCT, Nottingham City. In
Birmingham East and North,
head of business planning Dawn
Roberts says staff are told to
ensure care plans are adjusted
for temperature, but this is not
In London, clinicians have the
information available to them to
review care plans in the event of
problems, says Mr Wapling.
NHS Confederation PCT
Network director David Stout
points out that many of those
potentially at risk will not have
care plans and some high risk
people will not necessarily be in
touch with the NHS on a very
regular basis – making it less
likely they will be on any list.
And there is scepticism that
‘Many PCTs appear
to have plans that
merely repeat DH
guidance without
saying how it
will be applied in
their areas’
‘No matter how many times Andrew
Lansley repeats his pledge on real
terms growth in spending under the
Tories, the NHS is not convinced’
Richard Vize
French lessons: the 2003 heatwave
many homes are being assessed
by local authorities to ensure
they will be suitable in a
heatwave: the plan says health
workers should refer some high
risk people for assessment under
the housing, health and safety
rating system. This could lead to
funding for improvements to the
home that could prevent heat
related problems.
Mr Wapling says it is a useful
mechanism but is unlikely to be
happening on a large scale.
Acute danger
Community hospitals and acute
trusts also need to ensure
temperatures are kept low: this
can be challenging for some
where the buildings do not lend
themselves to creating a cool
The 2003 European heatwave was described as having the highest death
toll from a natural hazard in the region for 50 years: the Earth Policy
Institute calculates that 52,000 people died as a result.
The effect on France was particularly dramatic with around 15,000
deaths and a resulting political storm. In England, the excess deaths were
around 2,000. But the high death toll did prompt research into the
factors affecting mortality and morbidity from heat:
l In France, a significant number of people who died were already in
hospital or nursing homes; the ability of hospitals to provide cool areas
may be important
l Many who died were elderly, living alone but not in regular contact
with health services. The over-95s and women were at higher risk
l The heatwave saw extreme temperatures during the day – seven days
of over 40C in some areas – but also unusually high night time
temperatures and duration of heat. Air pollution – ozone – was also likely
to have been a factor in the number of deaths
l The effects of the heatwave were probably exacerbated by it coming at
a time when many French people took holiday, so public services could
have been less able to cope. While this August shutdown does not occur
to the same extent in the UK, staff holidays could still affect capacity
l Some groups who could be
expected to suffer during a
heatwave were much less
affected, such as children and
young babies
l The number of deaths in
cities was high, possibly
because cities can become
much hotter than surrounding
rural areas. But social isolation
in cities could also be more
Hot topic: 52,000 people died from
the 2003 European heatwave
In Birmingham, cool areas
rather than rooms have had to
be created. Professor MaryonDavis warns that a severe
heatwave could lead to elective
surgery being cancelled. Mr
Wapling says mental health
patients in the community could
be brought into hospital in the
event of a heatwave.
Nursing and residential
homes are likely to be important
partners in preparation but
Frank Ursell, chief executive of
the Registered Nursing Homes
Association, is unconvinced that
PCTs are being proactive. He
says preparedness may actually
have declined over the past
couple of years. He will be
contacting his members and
drawing their attention to the
DH guidance, but points out
that many homes do not belong
to any association.
No one doubts that a severe
heatwave will stretch the NHS’s
resources, just as winter flu does.
PCTs will face an enormous task,
potentially having a large
number of high risk people to
monitor, in some cases needing
to make contact with them daily.
This is likely to coincide with
a time when many staff will have
booked annual leave. Weekends
will be a critical period when
fewer staff will be on duty and
GPs in particular may not be
And getting staff, local
authorities, nursing homes and
voluntary bodies to realise how
quickly they need to react once
temperatures rise may be the
final hurdle. l
18 June 2009 Health Service Journal 13
alamy, reuters
Climate control: hospitals and care
homes must ensure there are places
for older people to cool down
during this summer’s heatwave
Writing this, I know there will be
catcalls from many quarters
because as a chief executive of a
large acute organisation I will be
regarded as self interested, self
serving or at worst
unreconstructed, but here goes.
In the first year of the second
greatest recession in a century,
why do we continue to consider
setting up new organisations to
deliver community services,
further crowding the space
between hospital and
community doctors?
Last year’s operating
framework encouraged vertical
integration, provided it was in
the best interests of patients and
the taxpayer. This year, as the
government struggles to cope
with meltdown in the financial
sector and global recession, the
mantra is quality, innovation
and productivity. If we are to
save something like
£15bn-£20bn from 2011 on, one
thing we really must do is
systematically address this hoary
old chestnut.
I know some people will say
the last thing we should be
doing at the moment is
restructuring but that is exactly
what the large corporations are
doing in the face of tough
economic conditions.
So here is my “manifesto”
for implementing vertical
integration swiftly.
● The patient experience will be
better because there will be
greater capability to provide
more single points of access and
assessment. Incentives to
improve co-ordination and
communication between GPs
and hospital doctors would be
stronger so fewer patients would
need to attend multiple venues
for diagnostic tests,
consultations and treatment.
Better targeted use of specialist
intervention, skilled
practitioners and new
14 Health Service Journal 18 June 2009
technologies would mean that
innovative schemes for treating
patients at home or in
communities would be more
likely to come to fruition. This is
a once in a lifetime opportunity
to integrate the activities of
generalists and specialists in
primary and secondary care
around the patient rather than
organisational need.
● Delivery of Darzi models of
care will be swifter and easier
because integrated urgent and
emergency care services will
ensure patients move along the
right pathway first time, every
time. Use of nurse practitioners
and integrating GP out of hours
and hospital services will save
costs and the door will be open
for delivering day surgery and
diagnostic, outpatient and
rehabilitation services in
community based settings,
reducing costs from unnecessary
hospitalisation and inefficient
outpatient departments. There
will be greater momentum
towards integrating community
and hospital based specialty
teams in dermatology,
respiratory medicine, cardiology,
rheumatology and diabetes
services in community based
facilities with no organisational
boundaries to get in the way.
● Systems and performance will
improve because of improved
capability to eradicate delays in
requesting tests and results
reporting. Integrated
governance systems will be
easier to introduce without
organisational boundaries. A
single focus will also create the
environment for more effective
delivery of patient care pathways
and protocols, and integrating
business practices and systems
will lead to better capacity
planning and stronger
performance management.
● Waste will be reduced and
significant amounts of money
will be saved because demand
will be reduced in secondary
care. There will also be less
fragmentation of service
provision and duplication of
activities. Integrating
community and hospital based
staff will be easier to do,
Swine flu Take the
lead on planning 15
Readers’ letters 16
The recession
is a once in a
to integrate
allowing for swifter development
of workforce plans that enable
more effective use of generic
skills, rotation between different
parts of the service and
economies of scale. A single
focus across the patient pathway
will ensure that productivity
improvements and reducing
costs will be easier to introduce
and have greater scope to
deliver. Management costs and
bureaucracy will be reduced.
Performance on integrating
services in the UK has been
miserable. The new integrated
care pilots are pointing the way
but are too small scale and often
lack ambition. In County Durham
and Darlington we have one of
the larger pilots. We are ceding
control to those at the front line
to deliver better, more cost
effective services. Strong local
commissioning is giving us a
sense of direction by wielding the
power inherent in the world class
commissioning framework and
using our combined spending
power to deliver financial returns.
We need to move forward
quickly, adopting large scale
models that make most sense in
each health economy. We should
not baulk at the idea of mergers;
I don’t think the co-operation
and competition panel would be
too concerned if large scale
change led to better patient care
and more cost effective services.
Whatever we do though, we
should avoid setting up new
organisations just to manage
community services. How can
this possibly represent value for
money when there are already
enough organisations on the
pitch to deliver cost-effective
vertically integrated services?
You can believe I am taking
advantage of the economic
storm to peddle a predictable
argument for radical action. I am
prepared for my “manifesto” to
be regarded like a bag of
bananas left too long in the sun.
I leave you with the words of
Machiavelli: “Nothing is more
difficult than to initiate a new
order of things.” ●
Stephen Eames is chief executive of
County Durham and Darlington
foundation trust.
Philip dasilva
on pandemic
It’s still not too late to get ready
In the uncertain wait to see what
pattern the swine flu virus will
take, the UK has a small window
of opportunity to prepare. Plans
must be integrated and ready for
swift, flexible implementation
depending on the numbers and
location of confirmed cases.
It is perhaps unusual to focus
so much energy on flu as we
blow the dust off heatwave plans
and enjoy the summer months.
However, as the World Health
Organisation last week declared
the first pandemic for 40 years
and with more confirmed cases
being identified daily by the
Health Protection Agency, we
need to prepare now for what
may be a tough winter.
It is therefore right for all
NHS organisations to refresh
their flu plans and gain
assurance they are fully
integrated into core business.
Although the H1N1 virus that
has been spreading is relatively
mild, with few hospitalisations,
the pandemic declaration must
make this become a top priority
for all boards: it is a key
governance issue, not just a
public health responsibility.
This may require fine-tuning
structures and, where necessary,
enhancing support through, say,
public health teams, to ensure
the wider “winter planning”
process is fully integrated. It is
unacceptable for organisations
to keep pandemic flu planning
with public health departments
while they prepare winter plans
for the customary seasonal
increase in activity. It is
important that all NHS boards
are assured now that their local
plan is robust, integrated and
can be implemented successfully.
The good news is that we are
approaching this challenge from
a strong platform. Many people
have been working tirelessly on
preparing pandemic plans for
several years, albeit built on the
science and knowledge of the
moment. The Department of
Health has acted with clear
leadership through the national
director for pandemic influenza
preparedness and this is now
complemented with the
secondment of a strategic health
authority chief executive to
support the implementation of
pandemic plans across the NHS.
The SHAs have responded
and are working with their
constituent organisations,
including the Health Protection
Agency, to co-ordinate a review
of plans and encouraging
frontline organisations to work
collegiately with local
‘All NHS boards are
required to assure
themselves they
have a plan and
clear process to
stakeholders to prepare to
implement plans as required.
The lead for this
implementation at a local level
must come from the primary
care trusts, in harmony with
their NHS partners and wider
stakeholders. PCTs should
assure themselves that the local
health and social care economy
is well prepared to respond to
the imminent increase in
confirmed cases.
Win confidence
The NHS has worked through
two previous pandemics, the
Asian flu pandemic of 1957 –
which coincidentally was when
the number of beds in the NHS
was at its peak – and 1968; but
we are now planning for a
pandemic with fewer NHS beds.
While this subject is too often a
political football, it does reflect
the significant advances in
technology and improvements in
the efficiency of care and
patterns of treatment, while also
revealing that the NHS is
operating more efficiently.
But this requires plans to be
robust and to use all available
modes of intervention and
flexible use of resources, avoiding
all unnecessary hospitalisation of
cases. It is also vital that as
organisations move from
planning to implementation, they
retain the confidence of the
public and the good reputation of
the NHS through clear and
timely communication.
This, together with advances
in medicine, particularly in
vaccines and the advent of
antivirals, offers us a real chance
to plan to control the impact of
any pandemic and minimise the
morbidity and mortality of
disease. But we will only achieve
this if all NHS staff appreciate
the important role they play.
There is a social responsibility
and professional duty on all staff
to ensure they understand the
actions required to contain and
control the spread of the virus.
This includes conveying good
hygiene messages and
intervening to minimise the
effects of any pandemic. This
will only be achieved if all staff,
especially frontline clinicians,
feel supported, and this is
particularly important for the
primary care teams, which will
inevitably be facing the biggest
challenge of all.
This governance issue
requires all NHS boards to act
now and assure themselves they
not only have a tested plan, but
that there is a clear process to
implementation. All NHS staff
must respond to the threat of a
pandemic and make themselves
aware of their organisation’s
plan and how to respond when it
comes to implementation.
Do not rely on the emergency
planning officer or flu lead to do
it – they may not be there. l
Philip DaSilva is lead director of
flu resilience preparedness, NHS
East Midlands.
18 June 2009 Health Service Journal 15
Last week the WHO declared a flu pandemic. Preparedness must now become a top
priority for boards rather than treating it as part of the annual winter planning routine
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16 Health Service Journal 18 June 2009
‘Should the NHS
emulate Disney?
Can we learn from
the giants?’
Ann Axford
[email protected]
Health Service Journal
Greater London House
Hampstead Road
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0844 848 8858
Race to the front
All for one
Oh dear, oh dear. You quote a
Monitor spokesman as saying
that “Monitor did not expect to
be involved in issues for which
the Equality and Human Rights
Commission had a remit unless
persistent failures indicated
fundamental governance failings
and authorisation breaches”
(news, page 9, 11 June).
Monitor appears to have not
read HSJ’s reports over many
years that have repeatedly
highlighted persistent and
systematic failings across much
of the sector on race equality.
Those failings include an
inability in some cases to even
meet minimal legal compliance,
never mind the “best practice”
Monitor expects on other issues.
It is not good enough for
Monitor to imply that as long as
trusts are doing the legal
minimum, that is good enough
for them.
I was pleased to read the special
report on long term conditions
and self care (pages 27-31, 4
As chair of a mental health
and learning disability trust, I
am aware of the connectivity to
the services we provide.
The large majority of our
service users are people with a
long term condition and much of
the care is self directed. Increasing
emphasis on personalisation has
been the norm for years.
People with a mental
condition or a learning disability
need to be seen outside of those
“boxes” imposed by traditional
commissioning and, sometimes,
provision of care.
It is time to move away from a
position of seemingly automatic
separation of mental health from
physical health to one which
seeks to address all the needs of
individuals, share learning
across the sectors and thereby
reduce health inequalities.
Roger Kline, employment rights
Critical evidence
Improved quality and outcomes
while giving patients more
control will require clinicians
and managers to address a core
issue: does the NHS always
provide people with the right
care at the right time and place?
The answer is no. Supporting
clinicians with evidence based
tools can make their decisions
more robust. This in turn will
support care planning and
resource use, providing evidence
to tackle bottlenecks. It will also
support commissioning by
providing data about how
existing resources are used and
therefore how services might be
better delivered or designed.
Putting the patient at the
centre of care can deliver
significant savings. Reducing cost
does not mean reducing care.
Neil Spragg, vice president,
A tender subject
The competitive tendering
process to choose an established
‘Monitor has not
appears not to
have read HSJ’s
reports on failings
on race equality’
partner for Bedfordshire and
Luton Mental Health and Social
Care Partnership trust was not
“an act of governance Harakiri”
by the trust board (leader, page
3, 28 May).
The board decided on this
process as an innovative way of
ensuring that the trust could
meet the deadline for achieving
foundation trust status. The
board asked the strategic health
authority to work in partnership
with it to ensure the transition
was speedy, fair and transparent.
At the start of the process, it
was announced that the trust’s
chair and non-executive
directors would stand down
once a partner had been chosen
and the handover process had
completed. It was never a
situation where another
organisation was being asked to
take over a poor performing or
unsustainable trust.
It is important that these
issues are clarified to help
maintain the morale of staff and
the confidence of service users
during the transition process.
Alison Davies, chair, Bedfordshire
and Luton Mental Health and
Social Care Partnership trust, and
Stephen Dunn, director of strategy,
NHS East of England
Joyce Catterick, chair, South West
Yorkshire Partnership foundation
Critical evidence
Your report fails to mention a
vital component in the
negotiating process – the
independent pay review body
(“Start NHS pay talks now, Steve
Barnett urges”, HSJ online, 10
In his enthusiasm for “a quick
fix”, Mr Barnett ignores the
statutory role that the PRB plays
in gathering evidence from all
sides and coming to a
considered view. People may
forget that last year the PRB
recommended a 2.75 per cent
pay award for 2008-09 – but
blatant ministerial pressure
undermined its independence.
Unite has always abided by
what the PRB has recommended,
whether we have liked the
settlement or not. We suggest Mr
Barnett shows a similar respect
for the PRB – and not try to
elbow it onto the sidelines.
Karen Reay, national officer for
health, Unite
Can you see why
someone was
appointed to a job
instead of you?
1993 this was a great help to me. I
came to understand why Alan
Langlands was appointed and to
agree he was the stronger
candidate. His distinguished
record as chief executive also
helped me in the years that
If the person appointed does
not seem the better candidate that
will be hard. I am glad I did not
have to deal with that burden.
I also learned another lesson. If
you are not successful do not go
for the job closest to the one you
wanted. Step back and think
again. It may be better to do
something different. In 1993 I
applied for, and was appointed, as
director of human resources with
the additional responsibility of
deputising for Mr Langlands.
Although I did this job to the best
of my ability in my three years at
national level and learned much, it
was not the right job for me.
My three point plan has always
worked for me.
Ken Jarrold is a director at
Dearden Consulting.
Idle talk
saves lives
Explore how debate helps shape health
systems, says Elizabeth Benomran
The Health Debate
In this accessible text David Hunter
explores some central contemporary
debates about health systems and
the influences of such discussion on
their evolution.
The book focuses on several
themes which explore the funding
and organisation of healthcare
systems, examining in chapters one
and three the elements contributing
to private and public arrangements
and reform initiatives.
Chapter four presents an in-depth
exploration of health as a marketstyle consumer good, discussing the
implications of choice and
competition. Other main themes
consider how health systems
prioritise or ration healthcare, the
The Health Debate, David J
balance between “health” and
Hunter, Policy Press 2008
“healthcare” and the surrounding
This informative and insightful text covers the challenges facing
health systems and presents a rationale of meeting such challenges.
Hunter discusses all the interrelated factors, from politics and
government agenda to NHS management and models of health.
The Health Debate is part of a series of books published by Policy
Press under the umbrella “Policy and politics in the 21st century”,
which centre on contemporary policy issues ranging from education
to pensions.
This book is ideal for anyone with an interest in health policy,
health systems development and the wider health agenda. The text
is easy to read and well structured throughout, ensuring that it is a
useful resource for all students of health, health professionals, policy
makers and strategy developers. ●
Elizabeth Benomran is a specialist in public health commissioning and
health improvement at Stockton PCT.
Are you up to speed with the latest management
thinking? If you would like to review management
journals or books for HSJ, email your suggestions to
[email protected]
A lesson we all have to learn is to
cope with the disappointment of
not getting a job we had wanted.
I can still remember how I felt
in December 1993 when the
permanent secretary rang me at
home to tell me that I had not
been appointed as the chief
executive of the NHS in England.
I was honoured to be shortlisted
and realised there was a strong
field but even so I was very
disappointed. It was a job I had
wanted to do ever since it was
created in 1983 following the
Griffiths report. It took me a long
time to come to terms with it.
From this and other experiences
I have learned to recover faster
and more fully from
disappointments. I follow a three
point plan.
First I remind myself the
decision about who to appoint is
the panel’s not mine. It is my
responsibility to decide whether
to apply. It is theirs to decide who
to appoint and no agonising on my
part will alter that.
Second I make sure I have as
few regrets as possible about
preparation and performance. As a
panel member I have been amazed
by the lack of effective
preparation of even some very
experienced candidates.
Interview preparation is hard
work but very straightforward. I
have learned to think of the
interview as a one person show, to
realise I will be the sole attraction
on the stage for 45 minutes to an
hour and not even the greatest
actors would face such an ordeal
without a script.
It is possible to work out most
of the questions you will be asked
and to prepare answers in bullet
point form. It is good to rehearse
the three reasons for applying for
the job, the four reasons you can
do the job, the relevance of your
previous experience, the main
issues you think you will be
tackling and your priorities in the
first six months.
If you do not get the job it is a
great comfort to have as few
regrets as possible and to know
that you did your best.
The third part of the plan may
not be available to you. However,
it is important to use it if it is.
Think about the successful
candidate and be as objective as
you can. Can you see why they
were appointed instead of you? In
18 June 2009 Health Service Journal 17
Group bullying The
‘mob’ effect 18
Primary care Lean
at work for PCTs 20
Mob rule and the
enemies within
The trend of staff picking on a colleague en masse is a tough
one for the victim to cope with mentally – and tougher still
for them to resolve. Graham Clews looks at what they can do
In the US and in Europe outside
of the UK, mobbing is a wellrecognised and established
pattern of workplace bullying. It
has been described as “an
impassioned, collective
campaign by co-workers to
exclude, punish and humiliate a
targeted worker”, with the aim of
pushing the victim out of their
Although less recognised
in the UK, the problem is on
the rise, and the NHS
managers’ union Managers in
Partnership has now produced
guidance for employers and
employees, following their
handling of a number of
mobbing cases.
Its effects can be horrendous,
with victims often reporting
suicidal feelings, with their
mental health taking years to
Staff who are mobbed often
suffer a massive loss in selfesteem and confidence, and
personal relationships outside
the workplace can be harmed.
Critical incident
Mobbing often follows an
established pattern beginning
with a period of social isolation
by colleagues. A whispering
campaign can be orchestrated at
the same time, before the staff
member is subjected to petty
harassment until they are
18 Health Service Journal 18 June 2009
provoked into a critical incident
where a formal complaint is
The victim will often end up
leaving their employer, either
through a settlement,
secondment, resignation or
dismissal, leaving the employer
to bear the costs of recruiting a
Victims may also institute
legal claims against their
employer, and if the
organisation fails to address the
problem it can develop a bad
reputation, making it difficult to
recruit and retain high quality
Behaving badly
Claire Pullar, MiP’s national
officer for Scotland and
Northern Ireland, drew up
the mobbing guidance and says
the UK is one of the few
countries not to recognise the
“It is a step on from bullying,”
she says. “Bullying is recognised
and help is there, but with
mobbing the point of reference
is altered if the majority of
people are giving the same
message. Sometimes the only
people who the victim can turn
to are people at home.”
Ms Pullar says it can be very
difficult to challenge a group of
colleagues behaving badly. Her
advice is to get evidence and
take advice from a union officer
before doing anything. The
union may then speak
confidentially to the target’s
manager, or encourage even
more senior managers to
MiP has produced advice on
how to prevent mobbing and
what to do if you think you are a
How to prevent mobbing:
● Good induction for new
● Clear rules for staff behaviour,
particularly with new colleagues
● Strong staff governance and
clear policies to promote dignity
and respect
In the next few weeks we will be publishing articles on improving stroke care, community
geriatricians, and equality and diversity. If you would like to highlight your organisation’s
ideas and examples of best practice both in HSJ and at the online Resource Centre, email
[email protected]
‘The point of
reference is
altered if the
majority of people
are giving the
same message’
● Management intervention at
the first sign of mobbing, or any
other form of bullying
If you are the target:
● Contact an MiP officer and
describe the behaviour you are
● Keep a note of the date, events
and actions you are subjected to.
● Check your employer’s
relevant policies and procedures.
● Be clear about the outcome
you want from an intervention, ie
exit, formal grievance or
mediation. ●
Managers in Partnership
Agenda for Change Terms and
Conditions handbook, section 32
TUC guidance on bullying at work
University of Waterloo, Ontario,
information about workplace
mobbing in academia
Alan Harrison (not his real name)
was working as a manager at a PCT
service provider when a number of
staff under his control took
exception to his focus on their job
performance issues.
One member of staff in
particular, whom Mr Harrison
believes displayed psychopathic
tendencies, corralled a number of
their colleagues to level spurious
grievances against him.
Mr Harrison was spied on in his
own home, his mental health began
to suffer, and he was eventually
suspended from work.
One of the perils of mobbing is
that it is easier for senior
management to blame the victim,
because they find it easier to
disbelieve them than the large
number of staff involved in the
Consequently, Mr Harrison
suffered both downwards, from
senior management, and upwards,
It was only the intervention of
determined work by MiP, and a
coincidental change in very senior
staff at his PCT, that brought a fresh
pair of eyes to the situation, and an
independent inquiry was set up,
which exonerated Mr Harrison of all
the complaints made against him.
“Mobbing gives rise to modernday witch trials,” says Mr Harrison.
“In my case it was only a good
union rep that had the sense to see
what was going on that saved me.”
18 June 2009 Health Service Journal 19
CASE STUDY: Two way mobbing
resource centre
Taking the waste out of
primary care processes
Training in lean techniques which have brought greater efficiency to secondary
care settings is increasingly available to PCT staff, says Jennifer Taylor
Having enjoyed success in
secondary care through
initiatives such as the NHS
Institute for Innovation and
Improvement’s Productive
Ward, lean techniques are now
making their way into primary
care. Lean is about eliminating
waste by taking out the steps
in a process that do not add
“You can use lean for any
area,” says Tina Kenny, a GP in
Milton Keynes and professional
executive committee chair and
medical director of Milton
Keynes primary care trust, which
ran a pilot of lean in five general
The first step was for
practices to decide what change
they wanted to make.
An outside consultant was
brought in, whose lean
methodology skills were
essential, says Dr Kenny,
because that enabled staff to
focus their efforts on cracking
the problem rather than
cracking the method.
The biggest successes were
seen in a practice that used lean
techniques to improve access to
their appointments system.
The Lean Healthcare
Academy offers open courses at
its three regional centres in
Stoke, Doncaster and Airedale.
The academy also offers
e-learning modules, and can
provide training to PCTs
through a virtual classroom
setting, which includes a half
day video conference with a lean
Full picture
Training staff is important, says
academy regional manager/
senior lean facilitator Abdul
“By not training people you are
not giving them the full picture of
what you are trying to achieve.”
The academy is developing
new projects with NHS
Doncaster to look at using lean
Reducing waits using lean techniques – Bolton PCT case study
Bolton primary care trust provider
services has used lean techniques
to improve access.
“Our commissioners had set a
six week referral to treatment target
for all community based services by
December 2007, because we were
an early adopter site,” says
Elizabeth Bradbury, associate
director for quality improvement
and clinical systems improvement
consultant at the PCT.
In April 2007, 10 services were
identified as the most likely to miss
the target.
Before any improvement work
was started, the NHS Institute’s
sustainability tool (for more
information see the weblink at the
end of the main article) was used to
20 Health Service Journal 18 June 2009
assess the teams’ ability to
implement change and sustain it.
Ms Bradbury says: “If there was
an area that they were weak in, we
would work on that, so that they
were in a better sustainability
position from the outset.”
Over eight months, each service
followed a standard process of lean
improvement work. A team leader
was identified to co-ordinate and
plan, and a clinical lead chosen.
Surveys and focus groups were
used to find out what patients and
professionals wanted. Data was
collected on demand and capacity
weekly, daily and sometimes hourly
and process mapping was used to
see which steps added value to
patients and which did not.
A “dream state” was identified,
as if teams had a blank sheet to
redesign the service end to end.
Realistic action plans were then
devised, which included
improvements a team could make
on its own, plus things that might
take longer and need support.
Facilitators introduced tools and
techniques as required and helped
teams measure improvement.
Progress was reported daily to the
team, weekly to management and
monthly to the board.
The PCT met the December 2007
early adopter 18 week target.
Waiting times were cut from 20
weeks maximum to six weeks or
less, with an average of four weeks
by May 2008.
Number of weeks
knocked off
podiatry referral to
treatment time by
Bolton PCT
provider services
within two years
Weeks cut from
continence referral
to treatment in
Bolton PCT
provider services
PCTs working with
NHS Institute to
develop lean for
community field
based services
ToP TiPs FoR lean
● Demonstrate improvements in
one area before using lean on a
● Ask patients and professionals
what they want from a service.
● Measure and communicate
● Get training for staff on how to
use lean
● Use a consultant who is an
expert on lean methodology
● Avoid lean jargon and talk about
quality improvement instead
HSJ’s conference
on 23 June in London covers the essential
aspects of achieving a robust brand and a strong reputation for
your organisation
More Best PrActice onLine
Resource Centre is online too. Log on to for practical
advice from readers, and tell us about your own work as well
lean ouTcoMes aT BolTon PcT PRoVideR seRVices (see case sTudy)
Shows improved performance on waiting times in aggregate for children’s,
adults’ and older people’s services
Older People
Waiting time (weeks)
in nHs custoMer cAre
For more on the Milton Keynes
project, contact Tina Kenny
[email protected]
Details of training available at the
Lean Healthcare Academy
NHS Institute for Innovation and
Improvement sustainability tool
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
07 07 07 07 07 07 08 08 08 08 08 08 08 08 08 08 08 08 09
Referral to treatment time reduced from 20 to four weeks in continence services
Six week target
Waiting time (weeks)
Apr May Jun
07 07 07
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
07 07 07 07 07 07 08 08 08 08 08 08 08 08 08 08 08 08 09
Referral to treatment time reduced from 12 to four weeks in podiatry
Six week target
Apr May Jun
07 07 07
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
07 07 07 07 07 07 08 08 08 08 08 08 08 08 08 08 08 08 09
Source: Bolton PCT Provider Services
18 June 2009 Health Service Journal 21
Find ouT MoRe
Apr May Jun
07 07 07
Waiting time (weeks)
techniques in practice based
commissioning and general
And for field based
community services – which
involves district nurses, health
visitors, physiotherapists and
speech and language therapists
– the NHS Institute is working
with 13 PCTs across the country
to develop a lean based product.
It is set to be launched in
October, with additional
modules available in early 2010.
The tool will deal with
scenarios relevant to these staff,
such as scheduling a week, the
perfect visit and agreeing a care
plan with a patient.
Engaging frontline teams is
crucial to the process, says Sean
Manning, programme lead for
productive community services
at the NHS Institute. But he
adds that it needs resourcing
and leadership. “You have to
have the organisational will and
commitment behind this.” ●
end of life care
Most people say they would prefer to die at home but many do not
as end of life care has traditionally been neglected. But it looks as if
things are finally starting to change, says Daloni Carlisle
of the end
Stephen Collins
f this were a hard hitting news story, it
would appear under a banner headline
about people dying in hospital in pain
when they would rather be at home
surrounded by loved ones.
It might quote Commons public accounts
committee chair Edward Leigh, talking
about last month’s committee report into
end of life care and saying: “That health and
social care providers have traditionally given
a low priority to end of life care is shown by
the lack of training in basic end of life care
among frontline staff. It is appalling that
people dying in hospital are not always
being given the end of life care they deserve,
including effective pain management and
dignity and respect.”
But this is not a news story and, once
you scratch beneath the surface, a slightly
more complex picture emerges. While
no one is saying that end of life care is
perfect or denying that people need more
choice about where to die and better care
when they do, senior clinicians working in
end of life care contacted by HSJ
immediately after the committee report’s
publication were clear that things are
changing for the better and this has been
driven by the Department of Health’s 2008
end of life care strategy.
Take this from Deborah Murphy, who is
national lead nurse for the Liverpool care
pathway and associate director of the Marie
Curie Palliative Care Institute in Liverpool.
“In my lifetime, I have never known a better
time for absolutely transforming care of
people at the end of life.”
Or this from Edwin Pugh, who leads the
clinical pathway group in NHS North East
and is also a consultant in palliative care
medicine at North Tees and Hartlepool
foundation trust: “For the first time in my
practice I can see the oil tanker changing
direction and speeding up. The challenge is
to keep it going irrespective of the politics of
the next few years.”
The general consensus is that end of life
care is becoming a priority; that strategic
22 Health Service Journal 18 June 2009
health authorities are breathing down the
necks of their primary care trusts to get
moving on this and start commissioning
new services; that PCTs are engaged and for
the most part willing to spend new money
allocated to them; and that acute trusts have
started to address the quality of care they
offer to patients, for example with pain
management strategies.
Key points
Home truths
per cent of people dying at home, but if you
add in care homes, which many people
regard as their home, what happens to the
In some areas they go up to over 30 per
cent of deaths.
While some diseases are fairly
predictable, such as cancer, and allow
forward planning, others are not, he adds.
“In my patch, 75 per cent of people with
respiratory problems die in hospital. We
have to be aware that some of them may
have been admitted appropriately for acute
management but there are
No one is downplaying how far there is still
to go. As Professor Pugh says: “We are one
year into what is a five to 10 year strategy.”
He is keen to get behind some of the
figures, which suggest most people would
prefer to die at home (see box, right).
“The reality is that most people do die in
hospital, a proportion of which, if there was
appropriate support in the community,
would die elsewhere,” he says.
For a start, says Professor Pugh, the
definition of “home” needs to be clear.
“The literature would say that you get 20
l End of life care is beginning to change for the
better, but there is still a long way to go.
l Since people will still die in hospital, high
quality end of life care must become a generic
rather than specialist skill.
l A public dialogue is needed to challenge the
taboo around death and dying for the benefit of
those near the end of their lives.
View from a primary care trust
Norfolk PCT has worked closely with Norfolk
county council to improve end of life care since
2005. Most recently, they jointly commissioned
and delivered the Marie Curie Delivering Choice
toolkit, looking at what was available now and
what should be developed (see page 24).
Some of the results have been very surprising,
says assistant director of out of hospital care
Wendy Hardicker. For example, it has highlighted
a group of people who do not want to die at
home: people aged 40-50 who are single or are
single parents.
“There is nobody at home to care for them,”
she says. “The question is where do they want to
die and how can we provide it? A nursing or care
home alongside elderly people is not going to be
right, nor is the acute hospital. It is going to take
some thinking about.”
It is not a huge group – 48 out of the 8,000
hospital deaths in Norfolk fell into this category
in 2007 – but it is illustrative of how the end of
life care strategy is helping commissioners to
think differently.
“We are starting to think about the provision
of end of life care across the whole continuum
now,” says Ms Hardicker. “Yes, we want to reduce
the number of people dying in hospital, but we
need to get away from the idea that this is at home.
We also want to look at bereavement services.”
The PCT is now looking at how to support high
quality end of life care in care homes. This means
looking not just at clinical care but at the
bureaucracy that surrounds funding for care in
the last six weeks of life.
“We cannot have people saying they cannot
afford to die at home,” says Ms Hardicker.
The PCT also wants to explore how new
technologies can help, such as providing a
webcam so a patient at home can talk to a
Macmillan nurse or palliative care consultant.
End of life care facts
l Half a million people die in England each year,
of which 27 per cent are cancer patients
l 60 per cent of people die in hospital
l Most people, when asked, would prefer to die
at home
l Primary care trusts estimate they spent
£245m on specialist palliative care in 2006-07
l The cost of providing health and social care to
cancer patients in the 12 months before their
death is estimated at £1.8bn
l In July 2008, the DH published its end of life
care strategy, which commits additional funding
of £286m over two years and aims to increase
the availability of services in the community and
develop the skills of health and social care staff
22 undoubtedly a good number who
could be supported better.”
The challenge, he says, is to provide 24
hour support outside hospital.
“Not telephone support, but practical
nursing and pharmacy support, so that if it
is 2am on a Sunday, someone can come out.
When we analysed this in the North East,
we found that providing out of hours
support was the biggest thing that would
enable us to support patient preferences.”
It is beginning to happen in some areas.
West Cumbria has achieved home death
rates of 40 per cent by developing a hospice
at home scheme, for example.
Generic not specialist
Providing these services is one thing;
getting people out of hospital to use them is
another. Ms Murphy outlines some of the
“Suppose you have a patient diagnosed as
being hours or days away from death. You
need a discussion with carers and relatives
about how quickly you can put services in
place to get them home and what level of
risk is involved in that. They could die in the
ambulance. They may be readmitted to
hospital. Is there an ambulance to take
them? Can the GP do a visit?”
The public accounts committee highlights
a tool called the rapid discharge process,
which Ms Murphy’s team has used 25 times
in the past 11 months. Of these, 80 per cent
died at home within 48 hours; the others
improved and remained at home. No one
was readmitted.
“When it works well, it has the potential
to get a patient from hospital to home
within four hours of the decision being
made,” says Ms Murphy.
Given that people will still die in hospital,
the other challenge is to take high quality
end of life care out of the specialist arena.
“We need specialists but this [end of life
care] has to be a generic skill,” says
Professor Pugh. “In my hospital last year,
9.6 per cent of bed days were taken up by
people admitted to die. It is in every medical
specialty. You cannot expect one specialist to
get round all those patients. It has to be a
generic skill supported by specialists and
this is a big issue where we need training.”
Here he is in agreement with the public
accounts committee report, which
highlighted a need to improve health and
social care staff ’s skills. It wants PCTs and
local authorities to commission hospices
and voluntary groups to provide education
for community and care home staff.
The Care Quality Commission should
provide assurance about the skills level of
staff in health and social care organisations,
as part of the new registration, inspection
and monitoring regime, it says.
The other big challenge is
commissioning. The report is blunt:
“Primary care trusts have limited
understanding of the local demand for and
the cost effectiveness of their commissioning
of end of life care services,” it says.
Mark Roland, clinical director for end of
life care at NHS South Central and end of
‘PCTs have limited
understanding of the
local demand for end
of life care services’
life lead for Hampshire PCT (the biggest
PCT in the country), could not agree more.
“Commissioners in PCTs tend to be junior
people with a high turnover,” he says. “In
only one of the nine PCTs here in this
SHA are the commissioners the same as
they were two years ago when we started
developing our strategy.”
Vested interests
Now, these fairly junior managers are up
against a tough job, he says.
“It is a steep learning curve even
beginning to understand what end of life
care is. Where does it start, how does it
relate to long term conditions, how does it
relate to palliative care and hospices? There
are plenty of clinicians in the field who are
prepared to give conflicting answers. There
are lots of vested interests and
commissioners are in the middle of this.”
Stockport PCT director of commissioning
Nicola Baker, who is also NHS Alliance lead
on end of life care, says Dr Roland paints a
familiar picture – although one that is
changing rapidly. “It is becoming a much
bigger priority,” she says. “We are clearly
getting a view that people do not want to die
in hospital. They want choice.”
Improving commissioning skills is no
easy task. NHS South Central ran a summit
in January 2008 with 120 clinicians and
commissioners from nine PCTs. The result
was a commissioning resource booklet.
“It was fantastic,” says Dr Roland. “But
only one of the commissioners is still in post
and each new commissioner has to try to get
up to speed.”
The SHA’s next move is to employ an end
of life care programme director.
The Liverpool care pathway
The Liverpool care pathway was developed in
the 1990s to provide clinicians with a tool that
would help them plan a care package for people
who were diagnosed as close to death in
It has now been taken up nationally and the
Marie Curie Palliative Care Institute in Liverpool
will produce the second national audit of end of
life care later this year.
Eighty per cent of eligible hospitals are
involved and the results will capture evidence
about quality of care, for example whether
patients had access to the right medicines
available at the right time, and allow trusts to
benchmark their performance.
The national audit will be followed by a new
version of the care pathway that will include a
balanced score card that could be used to develop
key performance indicators for end of life care.
Ms Murphy, who leads on the work, hopes the
Care Quality Commission will consider building
these into its new registration processes.
Dr Roland is now working with PCTs
to deliver results for the extra £286m
funding that came with the government’s
2008 end of life care strategy. Some have
made significant investment already, he
says, but a few are faltering as the financial
screws turn in the NHS. He wants a
reduction in the number of hospital deaths
of 3-6 per cent in the first year and reckons
the central allocation to PCTs is about one
third of what is needed to make alternative
“It is going to take a small investment to
make a small change,” he says. “We hope we
will be able to show that in a population of
250,000, by supporting two people a week
to die at home according to their expressed
preferences, will save £135,000 a year.”
Underpinning this is a massive cultural
shift, outlined by Professor Pugh.
“I went to see a patient at home recently.
She had a lovely bunch of flowers on the
table and I complimented her on them. She
said they were from a friend who had
stopped visiting. She would rather have seen
the friend.
“If any of this is to work we have to start
to challenge the taboo around death and
dying. The real issue is how the public feel
about them and how we incorporate things
like dignity and spirituality into the care we
provide.” l
Marie Curie Delivering Choice programme
The Marie Curie end of care life programme
Marie Curie Cancer Care developed
its end of life programme, Delivering
Choice, in 2004. It has been
evaluated by the King’s Fund and
endorsed by the Department of
Health as the kind of approach that
can be effective in reducing the
number of deaths in hospital.
The programme helps providers
and commissioners develop
24 Health Service Journal 18 June 2009
services that enable people at the
end of their life to die in their place
of choice, most commonly at home.
There are seven official sites across
the UK and more are now using the
model independently.
Lincolnshire was one of the first
on board. It started by creating a
partnership of health, social care
and voluntary organisations that
analysed the barriers to choice and
developed solutions.
New services included discharge
community link nurses, who liaise
between hospital and community
services, a rapid response team to
provide out of hours cover, and a
countywide palliative care
co-ordination centre that books
packages of care.
By 2008, the programme had
increased the proportion of home
deaths from 19 per cent to 42 per
cent for those who accessed the
The evaluation was not able to
show significant savings in acute
care costs, but there was no extra
cost in providing the community
improving patient access
2008 winner: london nhs diagnostic service with croydon federation
“Before putting ourselves
forward for the HSJ Awards, we
spent time as a team
considering to what extent the
Diagnostics in the Community
project had moved existing
services forward for our
patients,” says family practitioner
Agnelo Fernandes.
“In the end what prompted us
to enter were the barriers that
we felt we had been able to
break down as a result of our
collaborative approach to
delivering a faster service closer
to home.”
It was a decision the judging
panel welcomed. They praised
the service not only for the
choice and benefits it offered
patients but also for the scale of
innovation behind the redesign,
the rapid implementation and
the strength of the evaluation
and quality assurance. Added to
this came significant
acknowledgement of the GP
leadership and partnership
features driving the work.
Getting ready for the
presentation to the judges was
also a team affair. Rather than a
number of speakers each talking
about their contribution to the
process, the decision was made
for just Dr Fernandes to make a
presentation, while others made
themselves available for
“One piece of advice we
would definitely offer about this
stage in the process is to keep it
straightforward and honest,”
says Dr Fernandes.
“Don’t make the mistake of
pushing the hard sell. It would
be wrong thinking this is
Dragons’ Den or The Apprentice.
Better to talk openly about what
worked and what didn’t, what
you learned as you made
progress and how you might do
things differently next time
around.” l
What judges want
l Improving patient access to
diagnosis, treatment and care
l Implementing choice at the
point of referral
l Enhancing the patient
l Improvement in clinical
l Increasing public confidence
l Tackling health inequalities by
improving access for hard to reach
building a world class workforce
2008 winner: nhs north west
with the project deadline,” says
NHS North West project
director of its directive medical
workforce development team
Deborah Kendall.
“We had reached the point of
working on our final report for
the year and were able to use
that as a basis for theEVonline
It was not to be the only
The NHS North West entry
focused on work five years in the
planning to achieve 100 per cent
compliance with the European
working time directive by
August 2008. This ambition was
realised across the region, a full
12 months ahead of the rest of
the UK.
“The timing for submitting
the awards entry fell quite nicely
factor in their favour. The
close knit team had been
working together to a clear
project plan for the past year,
had developed strong internal
communications mechanisms
and were used to talking about
the work to stakeholder and
external audiences.
“Three of us went down to
London and put our
presentation skills training to
good effect,” says Dr Kendall.
“I think we demonstrated clear
outcomes supported by good
illustrative overheads that we
talked around rather than about
with enthusiasm and energy.”
“We were also able to bring in
a good mix of reviews, not just
from participating organisations
in the North West but also from
Lord Darzi, who had mentioned
our project as an example of best
practice.” l
What judges want
l Developing new strategic
approaches to workforce planning
l Demonstrating adaptability and
innovation within workforce
planning l Implementing a sustainable
recruitment strategy
l Establishing effective
succession planning techniques to
ensure workforce continuity
l Embedding equality and
diversity in workforce planning
l Developing, promoting and
demonstrating effective leadership
l Successfully embedding the
knowledge and skills framework l Developing a multidisciplinary
workforce through training and
enhanced skill mix
Sponsored by
For more information
on how to enter visit
18 June 2009 Health Service Journal 25
hsj awards 09
16th September 2009
Endorsed by:
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5 reasons to attend:
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Register now quoting HSJFP:
To register:
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Primary Care –
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NHS Foundation Trust
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Primary Care Strategic
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NHS Sustainable
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[email protected]
It should be the best week of the
year, what with Sir Seymour still
away at his annual shoulder rub
with the hoi polloi at the Chelsea
Flower Show and the whole of the
SHA away for a snuffle in the
trough at Liverpool.
A time to catch up on reading?
A time to clear emails, to do lunch,
to walk the talk and press the
flesh? Not on your Nellie, not with
vice chair Bunty Fotherington at
the helm.
What exactly she expects me to
be saying in our dawn, midday and
dusk briefing sessions I’m not
Hard knight
NHS and Department of Health
bosses checking into their NHS
Confederation conference
accommodation should have taken
note of its name – the Hard Day’s
Night Hotel.
It was a hard night indeed for one
primary care trust chief forced to
spend the evening with a furious
knight of the realm ranting that he
had been thrown off his GP’s list for
moving one road outside of practice
boundaries. Clearly, when it comes to
family doctors, even a knighthood
does not guarantee decent service.
● Heston Blumenthal is the latest
celebrity chef to revamp hospital
menus, and is working on more
“exciting” meals for older people.
But will the average granny be
chomping at the bit to try snail
porridge and bacon and egg ice
cream, favourites at his world famous
restaurant the Fat Duck?
Surely it is a clever ploy to
provoke a Jamie Oliver style backlash
A junior manager reckons NHS South Central chief executive Jim Easton
is “absolutely identical” to Hollywood actor Vince Vaughn, star of
countless New York rom-coms and Dodgeball: a true underdog story.
But Mr Easton’s bizarre ravings about the SHA assurance process
suggest he is determined to remove any underdog image and would no
doubt view being pelted with painful objects by NHS chief executive
David Nicholson as a “fantastic opportunity” and “powerful challenge”.
against “posh grub”, with patients
demanding a return to cold potatoes
and watery soup.
● Travel to the NHS Confederation
conference from London was derailed
by signalling faults.
As the massed ranks of NHS
management squeezed on to trains at
Milton Keynes going anywhere apart
from their destination – Liverpool –
NHS Employers deputy director
Alastair Henderson squeezed through
carriages staring at anyone female.
He was searching for conference
chair Sarah Montague; being a radio
presenter he had no idea what she
looked liked. He eventually tracked
her down over an hour later.
“I’ve been walking up and down
accosting various people. Almost got
thrown off two or three times,” he
explained to a bemused Ms Montague.
● It seems the DH's efforts to
promote regional strategies are lost
on NHS managers. Journalists in the
press room at Confed overheard the
following frantic message through an
official’s earpiece: “The
SHA meeting’s EMPTY.
Can you get some people
from next door to come
along? There's plenty of food…”
“Eugh, that’s
disgusting! It’s
Older people
geriatricians can
make a massive
difference to posthospital recoveries,
so why are they so
thin on the ground?
Stroke audit
As well as a stroke
unit it is essential to
have enough staff
trained in response
techniques and
partnerships for
long term care
Plans for the future
With the recession
an obstacle in the
road to realising
Darzi’s vision, HSJ
asks where the
next stage review is
heading next
‘Her 15 minute
soliloquy included
remorse at the
end of the doctors’
white coat’
exactly sure, but feedback from
the presentation of NVQs to the
domestic supervisors was clearly
not what she had in mind.
The lack of progress on the
redecoration of the entire
outpatients department between
breakfast and lunch on Tuesday
morning seemed to hit her hard,
although not quite as hard as
Wednesday’s no show of the
replacement MRI scanner that
she’d suggested on Tuesday night.
The tour of the midwifery-led
birthing unit did not help either.
The insightful questions about
where the doctors were, why the
nurses weren’t wearing hats, why
the patients weren’t in their beds
and the political correctness gone
mad of paternity leave
demonstrating a shrewd reading
of her audience.
But even that paled compared
with her 15 minute soliloquy at
the League of Friends AGM that
managed to combine remorse at
the decline of the doctor’s white
coat and how few of them wear a
smart tie these days, joy at the
advent of swine flu, and total
ambivalence to a £1m donation to
the cancer unit.
Note to self: never let Bunty out
Second note to self: come back
Sir Seymour, all is forgiven.
18 June 2009 Health Service Journal
Advance warning,
at your fingertips
Predicts capacity shortfalls, RTT waiting lists, care
pathways and the percentage treated, week by
week up to three months ahead.
New thinking from The Checklist Partnership 0870 241 6494
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