Category Archives: NHS Management

All the Tory contenders to be prime minister should categorially rule out the NHS being part of any future US/UK trade deal, Unite, Britain and Ireland’s largest union, said today (Wednesday 5 June).
Unite, which has 100,000 members in the health service, said the new prime minister ‘should not offer up the NHS as a sacrificial lamb to US president Donald Trump’.
Unite national officer for health Colenzo Jarrett-Thorpe said: “The Tory prime ministerial contenders need to put the national interest – in this case, the safeguarding the NHS from US privateers – before the personal ambition of getting their hands on the keys to 10 Downing Street.” 
Concern about what a US/UK trade deal could mean for the NHS has heightened this week following remarks by Donald Trump and his ambassador in London, Woody Johnson about the NHS being included in a future US trade deal
Colenzo Jarrett-Thorpe added: “The NHS is the UK’s greatest achievement – but for Trump and his ilk, who despise the very idea of universal healthcare free at the point of delivery, all they can see is the money to be made from the sick, frail and vulnerable. 
“This was made obvious by the US ambassador’s very frank comments about his country’s intentions towards the NHS in any future US/UK trade deal, a point that was again made by Trump himself. The president’s comments today are not reassuring in any way. Unless the government categorically says that the NHS is not for sale, then patients and staff will face increasing uncertainty and worry.
“The Tory leadership hopefuls need to state categorially to the British public that the NHS is not up for sale to profit hungry US private healthcare companies as part of a future trade deal.
‘Leading Tories and their cheerleaders in the media may think that the US offers a blueprint for how a post-Brexit Britain should be – however, it should not be forgotten that millions of Americans don’t have any health insurance which does not inspire confidence.
“We strongly believe that the NHS should not be offered up as a free trade sacrificial lamb to the mercurial whims of Donald Trump – our sick, frail and vulnerable deserve so much better.”

 

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Security staff at Southampton General Hospital being attacked in the A&E department is key to an industrial dispute over pay and sickness pay.

Unite, Britain and Ireland’s largest union, said its 21 security staff members were being attacked on a regular basis by members of the public either under the influence of drink or drugs, or with mental health problems.

Unite is currently holding a ballot for strike action or industrial action short of a strike of its members, employed by Mitie Security Ltd, at Southampton General Hospital over pay and conditions. The ballot closes on Wednesday 15 March.

Unite said that Mitie Security was refusing to provide adequate personal protection equipment (PPE), such as stab vests and  safety restraints, even though knife-related incidents are increasing.

Unite lead officer for health in the south east Scott Kemp said: “With cuts to the police force and mental health services, there is a tendency for those suffering from various conditions to be dropped off at the hospital and left to the security guards. 

“The statistics are not easily available as to the number of our members who have been injured. There has been a lack of proper investigation into the incidents over a considerable period.

“The guards report incidents that have occurred on every shift, but the bosses at the University Hospital Southampton NHS Foundation Trust and Mitie Security will only investigate when someone is injured.

“Our members are very concerned over incidents occurring right across the Tremona Road site when there has been little or no support from the police who are under pressure because of government cuts.

“Our argument is that we should not have to wait for someone to get injured before a full investigation is instigated.

“That is why the sick pay arrangements are really important. At present, if the security staff are injured at work, and if the resulting investigation finds in their favour, they get two weeks’ full pay and then two weeks’ half-pay. After that, it is the statutory minimum.

“We have members getting beaten up and then having to return to work after two weeks, when they are clearly not fit to, as to drop down to half-pay would mean missing mortgage or rent  payments and significant financial hardship.

“What we want is enhanced sickness payments for those off work due to being injured protecting patients and hospital staff; proper and transparent investigations into all attacks; and our members having the necessary personal protection equipment.

“Our members are seeking six months’ full-pay, followed by six months’ half-pay for all sickness absences. We don’t think those are unreasonable requests, given the level of violence in today’s society generally.”

Unite said that the demand for an increase in pay from the current £8.64 an hour reflected the stress of the job. The security staff are seeking £10.50 for security officers and £12.16 for supervisors, with additional payments of 50p per hour on night rates; £1 an hour on Saturday and double time on Sunday.

Scott Kemp added: “Our members are at the forefront of providing security and a safe environment for staff, patients and visitors – that’s why Mitie’s management needs to get around the table and negotiate constructively.

“There is now a good window of opportunity for such talks before the ballot for strike action closes on 15 March.”

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The Health & Care Professions Council (HCPC) delivered a snub today (Thursday 14 February) by pushing ahead with an ‘extortionate’ registration fee hike, despite receiving a 38,000-signature petition protesting at the 18 per cent increase.
Unite, Britain and Ireland’s largest union, led the protests at the increase from £90 to £106 a year – on Monday (11 February) the union handed in the petition to HCPC chief executive Marc Seale calling for the rise to be scrapped.

Unite lead professional officer for regulation Jane Beach said: “Today the views of the 38,000 mainly health professionals who signed the petition have been ignored which is very disappointing, given the cogent arguments we put forward that NHS pay has stagnated in real terms while the cost of living has raced ahead.

“The HCPC has given a massive snub to our members’ legitimate concerns about any fee hike.

“We consulted widely with our members who have to register with the HCPC in order that they can work professionally – and they gave the proposed increase a resounding thumbs down. Now they have been given a financial kick in the teeth by the HCPC.”
Unite argued that the increase from October 2019 would be another financial blow to hard-pressed NHS staff, such as biomedical scientists, paramedics and speech and language therapists, who have seen the fees increase by 40 per cent since 2014.

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Following the Judicial Review in London in July, NHS England quietly launched its promised public consultation on the Integrated Care Provider (ICP) Contracts on 4 August. The consultation closes on 26 October.  If the appeal granted at the other Judicial Review called for by 999 Call for the NHS in Leeds is successful, this ICP contract may yet be unlawful, but it is nonetheless essential that we respond to the feedback.

The ICP consultation document is a daunting read for most of the public. However, Health Campaigns Together (HCT) has provided expert answers to all 12 points in the public feedback document. 

HCT’s aim in providing these answers is to prevent flawed plans being adopted. They are seeking to prevent long-term contracts being signed that will undermine our NHS. This is in order to preserve any hopes of achieving a genuine integration of health and social care as public services, publicly provided free at point of use – and publicly accountable.

 

A reminder on what’s happened so far: There have been two judicial reviews on the Accountable Care Organisations and these Integrated Care Provider (ACO/ICP) contracts. And the courts found in favour of the NHS. But one of the campaign groups, 999 Call for the NHS, has now been granted permission to appeal. 

This is some very good news. But it also means NHS England is consulting on an ACO/ICP contract that may be unlawful. 

NHS England knew full well that an appeal was a possibility. Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the ACO/ICP contract. The consultation says that the Judicial Reviews had ruled in their favour. This consultation runs until 26 Oct.

 

We all know that this ICP consultation needs to be combatted and stopped. But in the meantime, here’s all the information you need to fill in the consultation feedback.

As stated, the judge in the London NHS Judicial Review said that the ACOs (now ICPs) should not be enacted until a lawfully conducted consultation was held, and any eventual ICP contract would have to be lawfully entered into.

Since then, NHS England have moved swiftly and stealthily into gear, and you will find their monstrous ICP ‘consultation’ document at this link.

And here is Health Campaigns Together on the subject at this link.

As you see, the consultation document includes 12 points for feedback and Health Campaigns together has provided suggested responses to these points – very good responses too, I think. You’ll find them at this link.

When you’re ready here is the direct link for public feedback to the document, just copy and paste from the Health Campaigns Together link above.

As stated, there is a move afoot to get the consultation suspended until after the appeal granted to the 999 for the NHS has been concluded, but it’s very important to counter what will definitely be lots of responses from the allies of NHS England. Otherwise they will be able to hail the result as a democratic mandate.

Health Campaigns Together say that it is OK to copy and paste HCT’s responses into the feedback boxes on the questionnaire, although if possible, it would be good if respondents could add a few tweaks of their own.

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National Health Service (Co-Funding and Co-Payment) Bill

2017-19

Type of Bill:

         Private Members’ Bill (Presentation Bill)

Sponsor:

         Mr Christopher Chope

Progress of a Bill

House of Commons

First reading, Second reading, Committee stage, Report stage, Third reading

House of Lords

First reading, Second reading, Committee stage, Report stage, Third reading

Consideration of the Amendments

Royal Assent

This Bill is expected to have its second reading debate on Friday 26 October 2018.

This Bill was presented to Parliament on Tuesday 5 September 2017. This is known as the first reading and there was no debate on the Bill at this stage.

Details of the Bill

National Health Service (Co-Funding and Co-Payment) Bill (HC Bill 37)

A

BILL

TO

Make provision for co-funding and for the extension of co-payment for NHS services in England; and for connected purposes.

Be it enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons, in this present Parliament assembled, and by the authority of the same, as follows:—

1.    Amendment of section 1 of the National Health Service Act 2006

  (1)      The National Health Service Act 2006 is amended as follows.

  (2)     In section 1 (Secretary of State’s duty to promote comprehensive health  service), in subsection (4)—

           (a)   the words “the making and recovery of charges is expressly provided for by or under any enactment, whenever passed” become paragraph
                  (a), and

                 (b)   after paragraph (a), insert or

                 (b)   the charges form part of an agreement in England for co-funding or co-payment.

2.  Other amendments of the National Health Service          Act 2006

  (1)       The National Health Service Act 2006 is amended as follows.

  (2)      After section 12E (Secretary of State’s duty as respects variation in provision of  health services), insert—

                                       ““Co-Funding and Co-Payment

  12F                Co-Funding and Co-Payment: England

  (1)            For the purposes of this Act, co-funding of NHS care shall be permissible in England when NHS-commissioned care is proposed to be partly funded—

                     (a)         by a patient, or

                     (b)      on behalf of a patient

  (2)           Co-payments permitted by virtue of this Act shall, in England, include payments made through co-funding as provided for in subsection (1)

 3             Extent, commencement and short title

  (1)          This Act extends to England and Wales.

  (2)          This Act shall come into force at the end of the period of two months after the day on which it receives Royal Assent.

  (3)          This Act may be cited as the National Health Service (Co-Funding and Co-Payment) 2018.

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What can it be like to lose the life of a loved one to an institution?

Clinical care is currently running the risk of burying its head in the sand of less than adequate regulators, and being dehumanised in a swathe of bureaucracy.

It struck me recently that the 6Cs of nursing, which arose from NHS England’s “Compassion in practice”, can be, to some extent, applied to patients as well as clinicians.

 

[graphic source]

The 6Cs are: care, compassion, competence, communication, courage, and commitment.

One of my issues is that, while the 6Cs are elegantly branded and themselves slickly marketed, they can, at worst, trivialise what are important issues for the entire health and social service. The issues are inherently more complex than might first appear.

I’m not one of the brigade who believes that everything in healthcare can be measured. One of the problems I have with the adage, ‘If you value it, measure it’, is that you can do inadvertent damage by measuring the wrong ‘key performance indicators’, or skew the discussion unfairly in a particular way.

Arguably, the 6Cs are the sorts of things which ‘you recognise when you see it’, and the same sort of thing can be said for some long term conditions such as dementia and frailty. But merely eyeballing the issues may be necessary but not sufficient. What is the right level of a competence? What would you rate as ‘good enough’ in the standard of clinical care you’d expect from a Specialist Registrar, such as #BawaGarba?

As it happens, I have been thinking a lot about how ‘courage’ applies to healthcare, not least because I have just written a book, jointly and equally with Rebecca Myers. We both had complementary but not identical views about courage in healthcare, from the perspectives of being a service user/patient, leader, manager or clinician.

As it happens, I am still not entirely sure of what the exact definition of courage is. What I do know is that the #BawaGarba case rumbled on, such that the GMC felt it appropriate to bend over backwards in removing a senior junior Doctor from the register of medical professionals. That was courageous, as it was a pretty ubiquitously unpopular decision in the light of organisational learning and ‘just culture’. One can only also imagine the huge courage needed to the parents of the child, or #BawaGarba herself in the face of a media and regulatory lynching.

When writing this book, I myself had substantial health problems. During last year, during the stress of my personal independence payment being refused despite being clearly physically disabled with mobility problems. I had a haemorrhage in my eye.

This meant my visual acuity went from cloudy, to ‘counting fingers’ to only seeing light, over a period of months.

I had an eye operation on January 25th 2018, but unfortunately I soon afterwards had a post-operative bleed, which meant my vision rapidly worsened. I then had a ‘repeat’ operation, called a vitrectomy, which cleared up my vision, meaning I can type this piece on my laptop computer with the affected eye without any difficulty.

Whenever I would hear people who are blind on LBC talking about their disability, I’d think, ‘That could be me’. In fact, despite being on the medical register currently, I had never viewed the patient experience through that prism. But it is very educational, if you believe me like me that the NHS should be comprehensive, universally available and free at the point of need or use.

Because I could not see, I actually fell over on a book in February 2018, which meant I had been rushed into hospital in the back of an ambulance inhaling Entonox like a pregnant mother in labour pains. I had dislocated my shoulder, and was in agony. At 2 am, the Specialist Registrar could not reduce the dislocated humerus bone back into joint, and at 9 am I was in theatre, under a general anaesthetic (which I had never had before).

At roughly the same time, my mum was admitted to hospital, living with dementia, but experiencing a horrific delirium. This is an emotional experience which will have a lasting effect for me forever.

All of these ‘patient experiences’ were deeply emotional. They’re not the sort of experiences which would be box office in a conference, such as promoting the joys of self management, or saying how wonderful the ‘dementia friendly communities’ kite mark is.

But nearly going blind mattered to me. Being in agony due to my shoulder (still healing) made me realise my own vulnerability. And when I used to go into hospital to see mum asleep (hypoactive delirium), I would wonder when or if she would ever wake up; she did, and massively improved when discharged out of hospital.

About 11 years ago, I suffered a cardiac arrest, and then spent six weeks in a coma due to meningitis. Actually, it brought my alcohol dependence syndrome to an end, but those were definitely the worst days of my life (and had a worse effect on others.) The thing is, I had no ‘feeling’ for what it was like to have any of these conditions as a junior doctor or medical student.

Whilst I do not subscribe to the idea that you have to be living with a condition to practise in it clinically, I think there are advantages of having sympathy, even if not complete empathy, with a patient’s experience as a doctor. Kay Redfield Jamieson, professor of psychiatry at John Hopkins, has openly written and spoken about her experiences with bipolar affective disorder.

So when I read terms such as ‘affected by dementia’, I find it quite trite to be honest. It’s really marketing. I could be ‘affected by dementia’ in the same way I am affected by herpes labialise, a cold sore, on the top of my lip, or ‘affected by a verruca on my big toe’.

Being both a clinician and a patient/service user is a highly emotional experience, and one thing I learnt from doing this book, essentially which I learned from Rebecca, is that courage is not solely a personal trait, as a lot depends on your vulnerability and strength within the rest of the system.

Take, for example, the courage Dr Chris Day must have had in challenging whistleblowing protection for patient safety, essentially himself as a whistleblower, putting him at total odds with the medical profession, who as usual protected themselves but not Day. The corpses of careers of people within health and social care are, unfortunately, widespread, and, if ‘lessons have been learned’, things can only get better?

Courage, like the other 6Cs, may trip off the tongue, but certainly does merit scrutiny. Whilst it can be very positive, giving you the strength to face an operation, it is telling you might need to have extraordinary amounts of it waiting for example on a hospital trolley in a corridor with chest pain.

 

@dr_shibley

 

 

 

 

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By  Ian Kirkpatrick, Andrew Sturdy and Gianluca Veronesi

Few topics have provoked as much debate and controversy in many western societies as the growth in public spending on management consultants. In the UK’s public healthcare sector, the National Health Service (NHS), this spending more than doubled from £313 million in 2010 to £640 million in 2014. Understandably, it is under constant scrutiny and there are considerable pressures to cut the use of management consultants, but spending remains high.

Management consultants provide advice on strategy, organisation, financial planning and assist with the implementation of new information technology. Frequently, they promise significant improvements in efficiency. According to the main industry body in the UK, the Management Consultancies Association (MCA), for every £1 spent on consulting fees, clients can expect £6 in return. However, as shown in a study we conducted recently, published in Policy & Politics, the use of management consultancy in English NHS hospital trusts is more likely to result in inefficiency.

A key question centres on why public sector (or indeed any) organisations use management consultants. On the one hand, it is clear that the growing size and complexity of the NHS has generated a demand for expert advice and support which cannot always be provided in-house. However, critics argue that management consulting firms have fuelled unnecessary demand through sophisticated selling techniques and backstage deal-making with politicians (the so-called ‘revolving door’). A recent example is the development of ‘Sustainability and Transformation Partnerships’ in the NHS which are said to have ‘created an industry for management consultants’.

To date, it has been hard to evaluate these competing claims about the value of management consultants. According to David Oliver, most NHS organisations have been either unable or, for political reasons, unwilling to engage in formal evaluation, resulting in an absence of ‘rigorous, peer reviewable, transparent data’. In this regard, our own study breaks new ground.

To estimate consulting use, we collected data on ‘consulting services’ expenditure from the Annual Reports of acute care hospital trusts in England for four years (2009/10 to 2012/13). In 2013, the 120 hospital trusts included in the sample had a cumulative cost of hiring management consultants of nearly £600 million. This meant an average annual expenditure on consultants of around £1.2 million per trust (although this varied from zero to £5.6 million).

Using pooled time series regression analysis, we looked at the relationship between this spending and the efficiency of each hospital trust over time. The results of this analysis were undoubtedly revealing. While in some cases spending on management consultants did improve efficiency, overall consulting use generated inefficiency, thus making the financial situation of clients worse. In monetary terms, these losses were not great – on average £10,600 for each hospital trust per annum. However, this is in addition to the £1.2 million fees already paid annually to management consultants on average by each trust for little or no gain.

To conclude, these findings suggest that while efficiency gains are possible through using management consultancy, they are the exception rather than the norm, as one would legitimately expect. Overall, the NHS is not obtaining value for money from management consultants and so, in future, managers and policymakers should be more careful about when and how they commission these services. More thought could also be given to alternative sources of advice and support, from within the NHS, or simply using the money saved on consulting fees to recruit more clinical staff.

Of course, when drawing this conclusion, it is necessary to strike a note of caution. From the available data, it is not possible to explain exactly why management consultants are having such a negative impact on efficiency. Part of the problem may be their lack of in-depth understanding of healthcare organisations or disruption caused by having too many consulting projects. However, some responsibility for inefficiency should also sit with politicians and NHS managers who make poor procurement decisions and then fail to implement the advice (even the good advice) they receive. These caveats suggest that more research will be needed in future. Nevertheless, our study is a useful first step in strengthening the evidence base and challenging the myth that management consultants generate efficiency in the NHS.

This article was originally published on Policy and Politics and is republished with permission

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Mad Management: Leaders (not) learning the lessons of history, especially in the Public Sector 

“Good morning, good morning!” the general said, when we met him last week on the way to the line.

Now the soldiers he smiled at are most of ’em dead, And we’re cursing his staff for incompetent swine. 

“He’s a cheery old card”, grunted Harry to Jack as they slogged up to Arras with rifle and pack . . .

But he did for them both by his plan of attack.

This was Siegfried Sassoon’s bitter poem about the World War I battle(s) of Arras. By this time 700,000 British men had died: equivalent to wiping out Sheffield and Hathersage. It is the Arras 101st anniversary this month. In fact, the plan was so bad that Sassoon amended the last line to read “But he murdered them both…”

Rightly, we need to remember and honour all those who died; but we also need to understand why they died in such numbers at Arras and how this ultimately led to the defeat of the British at the second battle of the Somme a year later – and to learn some lessons. The Lloyd George government had been steadily draining the fighting men from the front, leaving exhausted veterans of the first battle of the Somme to carry the burden instead of being reinforced. By the end of 1917 the fighting force had decreased by 7 per cent. The infantry alone was 80,000 short, and was projected to be close to half a million short by October 1918. Then came the second battle of the Somme, 100 years ago this year.

Guess what? From March to August that year 544,000 troops were somehow found and sent to France! The war ended in November. By this time 700,000 British men had died: the equivalent of wiping out the populations of Sheffield and Hathersage. Many, many of the deaths were unnecessary, caused by the outdated “plan of attack” and staff incompetence, and by government interference.

Does not this sound like a forerunner of our infamous Austerity policy? Admittedly the horrific scale and utter tragedy of the war bears no comparison, but the dynamics have some real parallels with today, especially in the withholding of resources (Treasury finance) and treatment of much of our workforce in the private sector, and the NHS and Social Care. Note, I am talking of the employees, not the customers or patients. First of all, the Treasury has systematically starved the public services of funding, for no other reason than the Chancellor could. This policy clearly displayed the contempt Osborne holds for the British people, as does Cameron. It is the act of a bully, as befits a Bullingdon alumnus.

We know what the impact has been for Sheffield. David Blunkett, now chair of the Partnership Board said in the Sheffield Telegraph last year that “austerity has dealt a terrible blow to our area”. Too right, and austerity continues to deal terrible blows to the one institution that we are most proud of, the NHS, achieving above average outcomes, with below average funding and below average staff numbers.

It was estimated to require £30 billion by 2020 to meet predicted demand, leaving it £2.45 billion in the red, while record numbers of nurses are leaving and GP practices closing down. There is no valid reason for this. It can only be that government wants it to fail, then, a bit like that doyen of the business world, Sir Philip Green, Jeremy Hunt can sell it for a pound to a USA health company. In the meantime, just like the workers in the gig economy or on zero hours, those in the NHS are increasingly insecure, underpaid and demoralised. And, we are talking about 1.3 million dedicated people.

This is our Somme, with Jeremy Hunt way, way behind the lines plotting the strategy, and, as Siegfried Sassoon wrote: “He did for them (all) with his plan of attack”.

How do the private and educational sectors meet the challenge David Blunkett has laid down, i.e. to regenerate and grow Sheffield? Well, I believe there is a step before we can work together as he urges us to do, and that is first to put our own houses in order. Do we pay our providers and suppliers on time? Have we minimised waste in our production and delivery systems, or are workers constantly having to rework and correct, just the way the government has done on almost every new plan it devised, from IT failures in the NHS, Defence and Welfare to Universal Credit to privatising probation services.

The May Council elections will be an opportunity to remind them. If not then, then do not expect any rise in productivity or increase in cooperation. Herzberg pointed out 60 years ago in his famous study on motivation: if people don’t feel they are paid enough, or are supervised badly or feel insecure then they will underperform. This means that unless these basic conditions, called Hygiene Factors, are fulfilled, you can forget about trying to apply Motivation Factors for productivity.

The second challenge is: To pay our staff enough, and give them some sense of security and belonging. For far too long too many firms have been disloyal to their staff, for example, Sports Direct and the banks. This is an opportunity to change that. I suggest that our universities blaze the trail with no more zero hours contracts.

First published on the JCAshby blog

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Trusts around the country are setting up wholly owned companies to deliver services so they can take advantage of taxation changes this allows.

This great VAT saga shows the NHS at its very worst.    Bullied from above, local managers believe the hype from consultants.  They can’t write a proper business case but still launch a project in secret, refuse to consult with staff, totally mislead the staff and public about the real intentions, refuse to give information claiming everything is commercially confidential and plough on regardless – all with the active collusion of a Regulator that is supposed to stop such poor behaviours.  Those involved continue to refuse even to respond to FoI requests.  Questions in both Commons and Lords get stock answers saying this has nothing to do with Ministers – it’s local decision making – nothing to see here.

Unison has been active in opposing the outbreak of wholly owned companies for 18 months.  On the face of it this represents money for nothing – the same staff doing the same job in the same way with the same managers but with “savings” in £millions from tax changes.  No increase in productivity, no innovation, no efficiencies at all – just a tax scam.  The staff loose out by moving out of the NHS and become collateral damage, but this does not matter as they are not nurses or doctors – that may come later.

Tactically the Trusts also get to break out of the national pay and conditions and can pay new staff and even promoted old staff on worse terms and conditions.  This alone should set red lights glowing somewhere.

Oh,  and two fingers up to any local plan about working together, collaboration and that guff – this is every Trust for itself – they even all claim that they will be selling services to each other.

And big issues like the consequences of transferring ownership and control over public assets to a private company (even one which for now is wholly owned) have simply been ignored or lied about.

Facts as opposed to the lies, are slowly emerging.  To take one well documented example. Late in 2016 a Trust did preliminary work with outside consultants on going down the wholly owned companies route.  In December 2016 in secret the Board agreed to go ahead using a particular model solution pitched to them by the consultants.  They did not look at the overall strategy involved and failed to look at other options.  This offer was too good to be true and others had done it; so why not?  The “Business Case” to the Board was laughable being a few pages of platitudes and 63 pages of tax advice.

The Trust worked on in secret, despite being under a very clear duty to engage with the staff on a decision which affected hundreds of them.  Eventually, late in 2017, they had to come clean and start TUPE consultations, but they consistently refused in every forum to consult or engage with staff on what was being proposed – they would only talk about the consequences.  They knew their whole case was entirely bogus.

In public the Trust simply avoided telling the truth.  They maintained throughout that what they were doing had to do with somehow professionalising the facilities management services.  Strangely the Trust had never reported its concerns with these services before they were sold the VAT dodge.  They never engaged with staff to see how they could improve services at all.

The Trusts maintained the fiction that this was nothing to do with tax as they had been instructed to do.  They gave a presentation to staff which had a dozen slides but none of them even mentioned VAT or tax. They signed a secrecy agreement with the consultants they used.  But because information was coming out of other Trusts doing the same thing, but slightly more honestly, they were caught out anyway.

After enormous pressure from Unison the Trust finally revealed at least some of its documents but only after it was already implementing its decision.  What the documents showed was what everyone already knew – the savings almost all came from changes in taxation.  Savings from other sources such as reducing pension rights or bringing in a two tier workforce were tiny in comparison.  This was and is all about tax. All about a Trust in severe financial straights doing anything to make savings.  Doing what it was told.  It was more afraid of external intervention for not trying hard enough than it was afraid of the outrage from its own staff.

Utterly dishonest from start to finish.  But with active collusion from NHS Improvement – the Regulator which knew exactly what they were doing and why, even if they now refuse to release the information and ignore FoI requests.  We know from parliamentary answers that NHSI signed off the deal.  We also know the relevant CCG opposed it and appealed to the Trust not to go ahead – yet again the lie is that everyone was in agreement.

A disgrace from start to finish.  Staff disillusioned, staff relations soured for years to come, further fragmentation of the NHS and a wholly uncertain cloud over the future ownership and control of vital NHS assets.  And NO SAVINGS.  Anything saved in one place is lost to the exchequer in another – its our money and we get no benefit at all.

No Board that agrees to this kind of subterfuge and secrecy is fit to stay in place.  But they will.

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This is blog is not a rant—well not too much of a rant. It is an expression of serious frustration about the way the NHS is run and about the willingness of some senior NHS managers to become complicit in something near to dishonesty.

Everyone at the frontline knows the NHS is running on empty. The more perceptive know that more money for the NHS alone will not improve services for patients. But—and this is perhaps the unpopular “but”—NHS senior managers ought to accept their share of the responsibility for the present crisis because they have colluded in pretending the NHS can deliver the impossible. Does anyone believe that NHS managers have “spoken truth unto power” about limits of NHS productivity?

The importance of public servants confronting ministers with uncomfortable truths has a long tradition. Long before Sir Ivan Rogers used the phrase, a 2015 FCO blog said:

“The UK Civil Service doesn’t have an official motto—but if it did, it would almost certainly be: “speak truth unto power.” It’s a maxim that’s in the blood of good civil servants, even if they know that it won’t make their lives any easier. The best politicians learn to cherish civil service advice which points out the flaws in their arguments. The worst surround themselves with sycophants who create a micro-climate which wraps a warm embrace around their worst tendencies.”

But, who speaks truth unto power in the NHS? When do NHS managers draw lines in the sand about what is realistically achievable in response to NHS England or NHS Improvement? Rarely, and often only at the (premature) end of a career.

The STPs are the latest set of “plans” where NHS mangers have been asked to promise to deliver the impossible. In response the NHS is signing up plans which are more fiction than reality. Privately, NHS senior managers know that STPs are totally undeliverable for a series of interlocking reasons.

First, they know that the NHS does not have effective change management procedures. Every small change has to be negotiated and agreed in detail with all stakeholders before it can get the green light. Thus every CCG, every truculent local authority, and every NHS Trust holds a veto to stop change happening. That stops controversial plans happening for years.

Secondly, politicians can block change. Time after time, local managers are overruled by senior NHS staff to avoid political embarrassment.

Thirdly, even if changes could be agreed locally, the capital needed to deliver effective changes is not available. Managing change is expensive, new buildings cost money and must be built before old ones are sold, and a measure of double running is inevitable. Capital money to fund STPs is spent plugging existing deficits. The iron rule of public service—you can only spend the same money once—seems to have been lost.

So why is the NHS repeating a failed planning process? Because it is told to. Scratch the surface, and many will reluctantly admit that the management culture of the NHS is close to dishonest. NHS England or NHS Improvement tell commissioners and providers what the plans are required to deliver. Once the targets are set, it is not acceptable to say that a plan to create financial balance or deliver 95% A & E performance “cannot be done.” It is equally unacceptable to say “It cannot be done without substantial capital investment, money for double running, and political will to deliver a series of unpopular changes.” NHS officials come under intense pressure to produce plans that confidently predict the undeliverable and most bow to that pressure.

The plans get signed off and the “system” confidently tells ministers that all will be well, all will be well, and all manner of things will be well. But, of course, now we know that all will not be well without substantial new investment in health and social care or if standards are substantially lowered. But, no one in the NHS is allowed to say that.

The NHS in England is in the mess it is today because of systemic overpromising and underfunding. That is primarily the fault of politicians. But, NHS management culture must bear its part of the blame. NHS managers, with some honourable exceptions, have colluded with politicians to tell them what they wanted to hear, and then demanded those under them produce plans to make good on those promises. Is it time to change the NHS culture by having courage to say what can and cannot be achieved with current resources?

This was first published by the British Medical Journal

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The Department of Health (DH) is to create a new property company to replace the two that currently exist1 nearly four years after the intention was first announced. The move is understood to be one of the recommendations of Sir Robert Naylor’s forthcoming report on the NHS estate.

The current position came into being as an afterthought to the now much derided Health and Social Care Act 2012 “reforms”, with a new DH owned company, Propco, solving the problem of who took over billions of pounds of property (such as primary care centres, clinics, community hospitals and offices) after Primary Care Trusts (PCTs) were abolished.

When Propco was set up there were concerns and issues and the suspicion that this was just a vehicle for privatisation or an asset sell off. Many of the properties were occupied wholly or in part by non-NHS bodies. Social enterprises (largely formed by former NHS community services staff) raised concerns that the change would add further complexity to the management of the estate, stalling the ongoing rationalization of existing property assets. They noted that new leases would have to be prepared with additional expense and management arrangements would become more complicated having overall a destabilising effect on local health economies.

Propco became NHS Property Services and its recent decision to move to market rents has caused a lot of problems. In July last year it was reported that commissioners remain locked in protracted negotiations around how much they will pay for buildings rented off NHS Property Services because of data problems. A senior Clinical Commissioning Group (CCG) finance officer told HSJ the principle of the move was understandable, but raised concerns that the implementation was being “botched”. NHS England director of financial control Steve Wilson informed CCG finance directors in a letter dated 15 June that there had been “a number of data quality issues” with NHS Property Service’s data highlighting earlier concerns that the setup of Propco had been compromised2.

For me locally there are problems with Health Centres facing extra charges and a community based organisation, born out of the Local Authority and NHS working together, suddenly being asked to pay huge increases in rents and charges; which I have taken up on their behalf.

But my wider concern is about the aims and objectives of the new property services company. Is this incarnation an attempt to be supportive of the NHS and its Sustainability and Transformation Plans (STPs)? These STPs are the great hope for our NHS, implementing the Five Year Forward View. Or is this new company just a route to a sell off more of the extensive NHS estate; or is it an income generator getting in the rents and charges. And why not bring in all NHS properties and include management of the many large PFIs (maybe better expertise could renegotiate better deals)?

This confusion about aims and objectives was highlighted when the original Propco was set up. In its March 2014 Report, Investigation into NHS Property Services, the National Audit Office pointed out that the objective “to hold property for use by community and primary care services AND deliver value for money” (emphasis added) was not clear.

This is important because just about every STP has pointed to estates as one of 3 or 4 key enablers of change. So does Newpropco have the role of facilitating these STP changes, or is it about maximizing income or receipts? Are decisions to be made locally, or by Newpropco, or through joint working? How will Newpropco staff be expected to work with localities – at present there is little or no local presence or knowledge.

So far the objectives of Newpropco have not been published but a DH spokesperson has said “The ability to invest in the highest standards of patient care, delivered in the right buildings and facilities, is a priority for this government. The creation of a new NHS property organisation will help to identify unused property to generate funding for reinvestment in the NHS whilst driving down estate running costs and creating opportunities to deliver new homes across the country.” Very laudable but not very specific on how potentially competing aims are balanced.

To add confusion last October, Simon Stevens the Chief Executive of NHS England told HSJ that NHS England was exploring the possibility of NHS organisations keeping their land sale receipts to invest in new services, rather than surrender them to central government.

This tension between running a property company and managing properties on behalf of the best interests of the operation of the care system is probably not resolvable.

I await with interest what Ministers will say about the setup of Newpropco and the Naylor Report when we see it. We must all hope this venture goes a lot more smoothly and with a much clearer strategy than the last attempt. It would also help if it operated in a more open and transparent manner like the NHS is supposed to be and not behaving like a commercial company in disguise.

1 NHS Property Services (Propco) was set up in 2012 to take over the ownership and management of property previously owned by organisations, such as primary care trusts, which were abolished by Health and Social Care Act reforms. It runs 3,500 properties, including offices, primary care and community health facilities. Community Health Partnerships (CHP) was established in 2001 to manage the DH’s interests in local improvement finance trust companies. LIFT is a scheme for public-private community property developments.

2 This is acknowledged now as many tenants have no proper leases or even agreements of any kind to cover rent and charges. Information was never properly collected on start up.

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The publicly funded, free at the point of use NHS has been described as the UK’s ‘national religion’. Its significance in our national consciousness underlined by its prominence in the opening ceremony of the 2012 London Olympics. Even Mrs Thatcher – whose government enthusiastically privatised many public enterprises such as telephones and utilities – maintained a rhetorical commitment to its ideals. Ongoing sensitivities surrounding the financing and management of the NHS are nicely illustrated by the current debates surrounding the Labour Party leadership contest, with ‘privatising the NHS’ used as a stick which to beat Owen Smith.

In spite of this rhetorical appeal to public-sector purity, a form of marketization was introduced into the NHS as long ago as the 1990s and continues to affect the NHS today, having been maintained and extended by the Labour governments of Blair and Brown. Usually called a ‘quasi market’ because patients do not have to pay when they use health services, NHS agencies are instead allocated money by the government which they spend on behalf of their local populations. Since the latest re-organisation of the NHS under the Health and Social Care Act 2012 (HSCA 2012), these ‘commissioners’ or ‘purchasers’ are known as ‘clinical commissioning groups’ (CCGs), and are led by local general practitioners (GPs), with the help of professional managers.

Although the NHS is still funded out of taxes and is still free at the point of use, hospitals and other providers of healthcare are constituted as semi-independent entities. These are known, confusingly, as ‘trusts’, even though they have nothing to do with the legal definition of a trust, and, although wholly state owned, they are expected to compete with each other for patients. The quasi market is structured so that the amount of money each trust earns should depend on the number of patients it treats. The idea is that market forces (i.e. competition) will encourage improvements in quality of care and improve value for money.

Yet this competition between state-owned providers does not tell the whole story of NHS competition. Alongside NHS trusts, successive governments (including New Labour) have encouraged non-state organisations to enter the quasi market and offer care to NHS funded patients. This includes for- profit firms, and also various forms of third sector organisations, such as social enterprises and charities. This is the ‘privatisation’ against which many are currently campaigning, taking the view that the HSCA 2012 has made a fundamental change to the NHS by attempting to enshrine the need for competition in law, and widening the opportunities for for-profit companies.

And so over the past two-and-a-half decades, the structures of the NHS and the rules governing its operation have undoubtedly shifted in the direction of greater marketisation. At the same time, there has been ongoing debate about the extent to which this marketisation has also permeated the mind-sets of NHS managers and healthcare professionals. One view is that there is a lack of fit between the enduring underlying values of the NHS, such as the focus on individual patients and seeing the NHS as a common enterprise (as celebrated in the Olympic opening ceremony), which encourage collaborative approaches, and the formal rules of commissioning which push for greater marketisation of relationships in the health system. Other researchers have found that the longstanding ‘clan’ culture in the NHS, bonded by loyalty and tradition, has been overtaken by a ‘rational’ culture bonded by competition and emphasis on winning market share.

Marketisation and management culture in the NHS

To find out if NHS culture is changing, our recent research investigated the views of managers about competition in the NHS after the enactment of the HSCA 2012 to examine the extent to which marketisation has become an internalised feature of NHS commissioning practices, and explore how far this is actually changing the NHS in any fundamental way. We investigated the views on competition of senior managers in both providing and commissioning organisations in four local health economies in England; focusing on managers is key to detecting any ‘real’ shifts in the NHS culture, because they hold the power of either translating structural changes into changes in behaviour or hampering such changes.

We found evidence that marketisation has become embedded in the thinking of some NHS managers, however, rather than a wholesale shift in attitudes, this seems to reflect creative incorporation of some market principles into everyday commissioning work – and such work still mostly seems to favour collaborative rather than competitive approaches.

Commissioners and providers (including non-state providers) found the rules introduced by the HSCA 2012 confusing, hard to follow and potentially contradictory. Instead of a shared understanding of the rules, there was a shared sense of confusion, leading to divergent interpretations and organisational responses. A lack of clear policy direction and changing policy emphasis were also noted as the government made a series of policy announcements which appeared to change the direction of competition policy in the NHS without actually repealing the legislation promoting competition.

There also existed a whole spectrum of underlying opinions about the place of competition in the NHS. Although most interviewees preferred collaboration as a main method of solving local service delivery problems, especially in cases of complex service transformations, this was not the only attitude encountered. Some pointed out the benefits of competition when used in a non-prescriptive, creative way. This suggests that, notwithstanding the strong commitment to a ‘public’ NHS amongst NHS patients and staff, some NHS managers have internalised the idea of a more pluralistic NHS. In the face of contradictory and ambiguous rules, participants were preoccupied first of all with preserving their own organisation’s interests and identities.

Overall, this suggests that, whilst in general NHS managers remain committed to co-operation and collaboration, two and a half decades of marketisation have introduced pockets of pro-competitive thinking. The outstanding question is how the changes which are starting to occur in NHS managers’ attitudes will affect our NHS; will the common NHS identity expressed by Danny Boyle at London 2012, which has successfully supported the delivery of care to all citizens regardless of ability to pay, withstand this shift in attitudes?

Note: this paper draws from research published in Public Administration and co-authored with Dorota Osipovic (lead author), Elizabeth Shepherd, Lorraine Williams, Marie Sanderson, Anna Coleman, Neil Perkins and Katherine Checkland.

It was first published on the British Politics and Policy blog

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