ALTHOUGH HARRIET HARMAN never held a front-rank cabinet job, she is probably one of the most influential politicians of recent decades. “I knew exactly what I was coming into Parliament to do,” she writes of her arrival at Westminster following the 1982 Peckham by-election. “I was there for women… we wanted equality, in work and in politics. We wanted childcare, maternity rights, for domestic violence to be taken seriously and for women to play and equal part in political decision making.” Harman has stuck to her agenda for 35 years, with a measure of success that puts most male politicians in the shade.
STPs ARE THE FLIPSIDE of the Five Year Forward View. The 5YFV’s broad vision for the NHS was breezily optimistic, but STPs are – or will be – all about the grinding detail of realising it. In these 44 hastily cobbled-together “footprints” the stark reality of what £22bn in efficiency savings really means for the NHS will play itself out.
As the King’s Fund recently observed, STPs started out as being all about new care models, integration and public health but “the emphasis from national NHS bodies has shifted over time to focus more heavily on how STPs can bring the NHS into financial balance (quickly).”
Most STPs have now found their way into the public domain one way or another. But it’s as clear as mud what they mean for people working for the NHS. Most of the STPs I’ve read have little to say about the impact on the NHS workforce, and engagement with staff and their trade unions – as with patients and the public – seems to have been minimal at best.
One of our favourite economists at English Economic (yes, one or two are all right) is Oxford University’s Simon Wren-Lewis. Simon has been one of the most trenchant critics of Britain’s Tory government within mainstream economics, and his clear and straightforward arguments generally go unanswered by government supporters. Simon is also one of the few academic economists to make a concerted effort to reach out to non-economists, both through his Mainly Macro blog (which caters for both economists and the rest of us) and his campaign against “media macro” – the distortion and misinformation in the mainstream media which does so much to promote right-wing economic ideas and always seems to favour the interests of the rich and powerful.
One of the most important questions Simon has been tackling recently is why all the extraordinary measures taken in the UK and the Eurozone in recent years have failed to get the economy moving. Put very simply, there are two ways for the authorities to stimulate the economy quickly (in what economists call the “short-run”), so we can see some economic growth and start getting pay rises again. The government can either spend money itself or it can encourage other people to spend money. Either way, someone somewhere has to start putting some money down.
ONE EVENING IN APRIL 2010, Kamran Uzzaman, a 20-year-old patient on Roman Ward, a mental health facility run by East London Foundation Trust (ELFT), slipped into the room occupied by fellow patient Prodib Debnath and killed the 31-year-old expectant father by stamping on his head. At his trial in May 2011, one psychiatrist described Uzzaman as “one of the most mentally unwell patients I’ve ever seen”.
The killing of one mental health patient by another is fantastically rare
– on average it happens once every 17 years in England. But within a year Roman Ward had seen another patient commit suicide with a plastic bag and a third die unexpectedly from natural causes. These three tragic deaths sparked a remarkable improvement drive founded on boosting the engagement and wellbeing of the trust’s staff.
“We really questioned our own roles as leaders,” says the trust’s director
of corporate affairs, Mason Fitzgerald. “I was probably one of the most guilty people. I was sitting in my office thinking I was doing lots of very important things, but I wasn’t really. What’s really important is making sure we understand the issues staff are going through on a daily basis.”
East London in 2010 was no Mid- Staffs. It was meeting its national targets and was rated around the middle of the pack for London mental health trusts. But a closer look uncovered multiple problems on Roman Ward: key posts left vacant, high sickness absence rates and abnormally few incidents, suggesting problems were not being reported through the formal channels.
“There was perhaps a culture that the board were worried about finances and performance targets and not as concerned about quality and safety,” says Fitzgerald. “Of course, we thought we were worried about quality and safety.”
In the last five years, ELFT has become a leading exponent of using staff engagement to improve quality, job satisfaction and patient safety. In 2014, it came top among mental health trusts for staff engagement and was named by the HSJ as one of the ten best places to work in the NHS. Last year, it picked up the HSJ Award for staff engagement, sponsored by MiP and Unison.
“I can see that when staff are well supported and given the chance to develop it leads to better engagement between staff and service users,” says one patient who has worked on developing the trust’s Quality Improvement programme.
The roll-call of initiatives is familiar: a culture of ‘listening and learning’ from staff; reducing the gap between ward and board with executive ‘walkabouts’; continuous improvement through team- work; development schemes for people in all disciplines; coaching and mentoring from inside and outside the trust; and investing in communications technology to encourage open, honest feedback.
But a list of initiatives is one thing, delivering sustained and tangible improvement is another. The 2015 NHS staff survey found that almost half the people working for the NHS don’t feel valued by their organisation and wouldn’t recommend it as a place to work. Effective staff engagement is hard. If it wasn’t, everyone would be doing it.
“Leaders need to ensure trust, fairness and inclusiveness throughout the organisation,” explains Michael West, professor of organisational psychology at Lancaster University, who has worked with ELFT. For leaders personally, this boils down to “listening with fascination to staff, understanding their work challenges, being empathic and taking intelligent action to help them,” he says.
East London FT encourages staff to be “courageously curious”, says trust chair Marie Gabriel. “Our leaders actively empower our staff and patients to be brave and to constructively challenge our decision-making as a board – with no fear of negative consequences.”
That can be near impossible in a failing organisation. “Operationally,
you have to be pretty decent,” agrees Fitzgerald. “It’s really hard for leaders to get out and engage with staff if your finances are out of order, if you’re missing your national targets, if you’ve got commissioners and regulators breathing down your neck.” He advises struggling organisations to “pick two or three really important things and focus on them. I always despair when I see an action plan that’s 20 or 30 pages long, looking at every indicator.”
Fitzgerald says East London learned a lot from working with the Oxleas mental health trust across the Thames in Dartford. “They’re the benchmark. What’s quite remarkable is their consistency [in staff engagement scores] across different parts of the organisation and different demographics – we still have quite a lot of variation.”
One area of “variation” is discrimination. “ELFT have made great progress, but a stronger focus on workplace trust, fairness and justice – dealing particularly with high levels of reported discrimination against BME staff – is needed,” says West.
“It’s something we’re still trying to understand,” adds Fitzgerald. Tackling violence and aggression towards staff has reduced discrimination from patients. “But with discrimination from managers and colleagues, we’ve not made so much progress,” he admits. He refers to a young black nurse who recently reported being racially abused by a patient. “He didn’t feel that his team and management supported him as we should’ve done. So he felt discriminated against by the organisation as well,” Fitzgerald explains.
Unison’s Margaret Brown, ELFT staff side chair, agrees the trust’s good intentions aren’t always matched by practice on the ground. “I’ve experienced managers and service directors who are empathic, supportive and engage staff in service review and development. But there are others with a didactic, autocratic, top-down approach.”
Nevertheless, Fitzgerald sees the strong tradition of partnership working with unions at the trust as a big asset. “We have our arguments but it’s fantastic the work that’s done in that working environment,” he says.
When 100 staff were threatened by redundancy last year, managers worked with unions to redeploy almost all of them. “To have done all that and still have these [staff engagement] scores is a testament to staff side and how they support their members, and how they tell us when we’re going wrong,” says Fitzgerald.
Problems with a recent review of psychology services were down to the board ignoring union concerns, for what “seemed like good reasons at the time,” he says. “But it made the overall outcomes worse for everyone. The vast majority of the time, if they come to talk to us, we listen.”
There are few tougher briefs than running mental health services in East London, with its complex patchwork of ethnic communities, widespread deprivation, mobile population and fierce competition for resources. But ELFT
is one of the NHS’s everyday success stories, a vital but unglamorous service which has been turned around by the efforts of its staff and management – not just because it got a kicking from the CQC.
There are also lessons for how the NHS can learn from its failures. After the tragedies in 2010 and 2011, there was no clear-out of the board and no witch-hunt looking for people to blame – just hard, painstaking work to make the trust a better place to work and to care for patients.
“It came from our feeling that we had failed those staff and those families,” says Fitzgerald. “In the end you have to do it because you think you need to.”
Photo: © 2016 East London Foundation Trust
GEORGE OSBORNE HAS turned his budgets into a kind of game show, where he flings statistics and targets around and we have to work out which ones are true, which are guesswork and which are just downright porkies. Every few months, he comes back with another set of teasers. It’s a sort of political Would I Lie to You?, except Osborne’s jokes aren’t as funny as Rob Brydon’s.
For all his showmanship and political craft, Osborne can’t escape the reality that six years of austerity have delivered neither prosperity nor any reduction in government debt. Osborne still claims it will happen – some time way off in the future – but he says that every year.
Austerity has done itself in. Like the abstract “free market” Osborne has so much faith in, austerity is an idea that devours itself. It has delivered so little growth it has failed to meet its sole objective: reducing government debt by eliminating the deficit. Even Osborne doesn’t believe in it any more, which is why he effectively abandoned austerity yesterday and rushed to borrow another £38.4bn over the next three years – before savagely cutting back again in 2019. The problem is that he doesn’t have a clue what else to do.
The Chancellor has only himself to blame. He set the fanciful targets, he made the silly rules. Osborne has now broken two of his three “golden rules” within three months of setting them. Far from reducing the government’s pile of debt every year as promised, Osborne admitted yesterday it will actually rise this year. The slowing economy and stagnating wages had already done for his cap on welfare spending. And not even Osborne can really believe in the ferrago of coincidence and convenience which would be necessary for him meet his third rule, eliminating the deficit by 2020. The independent Institute of Fiscal Studies puts his chances of success at no better than fifty-fifty. Many other commentators put them a lot lower lower than that.
I wouldn’t mind, but these are the iron rules which Osborne, in his rush to embarrass Labour, said the government must live by – at least in “normal” times. Yet he has thrown them over at the first time of asking. He can’t have it both ways. Either the British economy is doing well, as he claims, and he must live by his rules. Or it isn’t, in which case he only has to look in the mirror to see the one who should be embarrassed.
The OBR twisted the knife in Osborne’s back, sharply downgrading its forecasts for economic growth into the forseeable future. Worse, the OBR has now discovered that the £27bn in extra tax receipts it “found” down the back of the Treasury sofa last November – which Osborne used to fund his U-turn on working tax credits – has turned into a £56bn black hole. “The sofa has swallowed roughly two pounds this time for every one that it yielded last time,” said OBR director Robert Chote – presumably trying very hard not to giggle.
Osborne tried to blame the sharp deterioration in his financial position on a “dangerous cocktail” of global economic threats. That won’t wash. Osborne’s own Budget Red Book shows that the expected global slowdown accounts for well under half the reduction in expected UK growth – most of which comes from a big downgrading of forecasts for the UK’s productivity performance – overdue recognition from the OBR of one our most persistent and serious economic problems.
Osborne’s eye-catching announcements – the sugar tax, forcing all schools to become “academies” under Whitehall control and incoherent plans for further devolution to local councils – were diversionary tactics. In reality, this was a desperately thin budget. There were some modest tax cuts, mostly benefiting the well-off and corporations, more cuts to support for the disabled, some sensible measures to encourage savings, plus some further unspecified cuts to Whitehall spending, left hanging in the air like a bad smell until just before the next election. In short, a pretty typical Tory budget for “normal” times. This was a budget for the economy George Osborne would like to be running, rather than the one he’s spent six years ruining.
On our big economic problems – dismal productivity, low wages, the housing crisis – he offered almost nothing. In six years Osborne has failed to come up with a single meaningful initiative to improve productivity, which almost everyone recognises as the root cause of many of Britian’s economic woes. One housing group even welcomed Osborne’s inaction on housing – on the grounds that everything he’s tried before has made matters worse.
Osborne can’t do anything about these problems because they require active government, and doing things like strengthening trade unions and building more social housing, which are ideological anathema to the Tory MPs and activists he needs to appease to get his feet into David Cameron’s shoes. So, with austerity now a busted flush and constrained by the need not ruffle feathers before June’s EU referendum, Osborne was left with nothing much. That’s why he had to mount a smash and grab raid on other departments’ to-do lists to find something to put in his red box.
Economically, this was a budget from a Chancellor at the end of the road, a Chancellor who has missed every significant target he has set himself, a Chancellor who really wants to be doing something else. In ten months, Osborne has gone from hero to almost zero in the Tory party (how he must now regret turning down David Cameron’s offer of a different job after the 2015 election). But it’s Osborne’s constant complusion to put politics ahead of economics which has put him there.
Photo: Jessica Taylor/UK Parliament/Creative Commons 2.0 (cropped).
Sandbrook draws some political conclusions as wonky as one of Doctor Who’s early sets. If Britain’s cultural success vindicates Thatcherite individualism, why did most of the figures he celebrates emerge in precisely the kind of “collectivist” society that Thatcher despised?
I have two (rather belated) pieces on English Economic in response to George Osborne’s Autumn Statement and Spending Review on 25 November. The first argues that the spending review was a deal done from a position of weakness and reflects Osborne’s economic failure. His financial statements are turning into twice-yearly Groundhog Days, in which the same failed solutions chase the same unsolved problems.
The second is a ranty thing about economic forecasting, which has, as the Financial Times itself put it, “an astonishing record of complete failure”. Why should we take the Autumn Statement seriously, when the whole thing is based on projections by people with an impressive track record in being wrong? When you look at the facts, economic forecasting deserves to be treated no more seriously than astrology or football punditry.
Labour needs to win back poor voters who think it won’t do enough, and prosperous voters who fear it will do too much and wreck things. The next leader’s biggest battle will be to convince voters that Labour hasn’t just run out of road.
The single thing that must come out of any meeting is agreement on what happens next — even if it’s just another meeting! Everyone should have something to do as a result of the discussion; otherwise, you need to ask yourself why they were there in the first place.
Published in Healthcare Manager, Autumn 2015.