Never mind the workers

musical chairs_colourSTPs 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.

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An East End success story

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

Tipster: how to hold better meetings

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.

Read the cutting

Autumn 2015 issue of Healthcare Manager is out

The Autumn 2015 issue of Healthcare Manager is all about valuing the people who work for the NHS. We have Karen Lynas, deputy managing director of the NHS Leadership Academy talking about how to be a great line manager, South Tees chief exec Tricia Hart on how staff add value and Professor Derek Mowbray on putting staff welfare at the top of your to-do list. Plus my Tipster piece on how to avoid wasting people’s time with pointless meetings. We also have our digital health correspondent Jenny Sims looking into the NHS’s efforts to engage disadvantaged people with online  healthcare.

I am associate editor of Healthcare Manager, which is also designed and produced by my company, Lexographic.

Read the online version here or download our free digital edition here.

Summer 2015 issue of Healthcare Manager is out

This issue celebrates the tenth birthday of Managers in Partnership (MiP), the union for NHS managers and publishers of the magazine. We feature exclusive interviews with ten key NHS players on how MiP has supported managers and contributed to the development of the NHS. We also have the Health Foundation’s chief economist Anita Charlesworth on NHS productivity, Daloni Carlise on how to engage NHS staff, and the fantastic Lis Paice on how to give presentations people will stay awake for. There’s also vital information for NHS managers about their pensions (sorry). Healthcare Manager is edited by me, and designed and produced by Lexographic, on behalf of MiP.

Read or download the digital edition here.

Staying out of trouble on social media

My Tipster column on avoiding pitfalls using social media is published in the latest Healthcare Manager. Click here to read or download the cutting.

It’s not essential to have separate “work” and “personal” social media accounts, but if you use personal accounts to talk about work, put a disclaimer in your profile. Your employer could still take action against you if you say something that causes the organisation “reputational damage”, breaches staff or patient confidentiality, or is racist, sexist or otherwise so generally offensive that it brings into question whether you should be in the job at all. Use common sense and, if in doubt, don’t post it.

Up in the air – the election and the NHS

Healthcare Manager 25 cover, Spring 2015.It’s already become a cliché to describe the 2015 general election as the “NHS election”. But clichés are often just things that are true. Polls show the NHS is the most important issue for voters, ahead of the economy, immigration or Europe. The papers are full of NHS stories – at the time of writing, there has been one on the front page of at least one national for eight days. Which party gets the first go at forming a government on 8 May may well depend on who voters mistrust the least on the NHS. [Read the rest…]

Ghosts in the machine

My feature in Healthcare Manager asks if bureaucracy is really a big problem or just a scapegoat for political and other managerial failures.

I used to go to regular meetings at the Treasury, where tea and biscuits were served in regulation “Treasury green” cups. There were always exactly the same number of biscuits as attendees at the meeting. If someone didn’t turn up, the number of custard creams was adjusted accordingly.

Read the cutting here.

False economies

Healthcare Manager issue 21 Spring 2014 Healthcare is expensive. People are living longer and treatments keep getting more sophisticated and costly. In the US, healthcare consumes 18% of national income. In the UK it’s only half that, but it’s rising fast, especially as a proportion of shrinking government spending. In France, Europe’s biggest healthcare spender, it’s gone from 7% of GDP in 1980 to almost 12% today. Healthcare is a drain on the economy. A worthwhile drain, but a drain nonetheless.

But is this the right way to look at it? Why is healthcare seen as a dead cost and not as investment? In fact, why do we see healthcare as something we have to spend money on in order to be productive, and not as production itself?

We don’t say construction costs 6.7% of GDP, we say it contributes 6.7%. The same goes for transport, agriculture, leisure or culture. Perhaps this is because people like their cars, their food, telly and going to the theatre. No one likes going to hospital or being told to eat salad. Perhaps it’s also because — in Europe at least — most healthcare spending comes from the government and is financed by taxes on other economic activity.

But if healthcare is not exactly a product like any other, it’s a product all the same. It’s something people want. And like other economic activities, it creates jobs, pays wages, and supports a long chain of suppliers (everything from paper merchants to computer programmers — hospitals are in the market for almost everything), stimulates investment and encourages workers to acquire new skills. People are organisms, they get sick, and they need treatment. Just as they need somewhere to live, ways to move about and protection against risk. Healthcare is just as much production as building houses, making cars or providing insurance.

Tonio Borg, the European Commissioner for Health, says he wants “to shift the still widely held perception of health expenditure as primarily a ‘cost’ rather than an investment, and to pass across the message that health contributes to inclusive economic growth.”

In depths of our 21st century great depression, NHS funding was seen as part of the problem, rather than part of the solution. But healthcare spending can be a highly-effective way of stimulating a dormant economy.

Research published in Globalization and Health last year by a team of researchers, including Professor Martin McKee of the London School of Hygiene and Tropical Medicine and University of California economist David Stuckler, calculated the “multiplier effect” for different forms of government spending among 25 EU countries from 1995 to 2010. They found the multiplier for healthcare was 4.32, compared to an average 1.61 for all government spending. This means that for every £1 spent on healthcare by government, GDP grew on average by £4.32 once all the knock-on effects had worked their way through the economic system.

This is a much better return than for defence (where the multiplier was actually negative), housing, industrial support or even “social protection” like unemployment benefits. Only spending on education and environmental projects matched the power of healthcare as an economic stimulus.

Why? Firstly, in advanced economies at least, most of the money is spent at home — healthcare workers generally work where the services are provided. This is why the multiplier for defence spending is usually negative: most of the money gets spent on expensive imported equipment (although our big defence industry means this is less true for the UK than many others). The UK, with relatively large medical equipment and pharmaceutical industries, is well-placed to take advantage of healthcare’s capacity for economic stimulus.

Secondly, healthcare remains relatively labour intensive. Around 55-60% of the NHS’s £110bn budget goes on staff costs (the Department of Health won’t disclose exact figures). Health and social care, particularly for the very young and the very old, is a people business. In one of those paradoxes in which economics abounds, healthcare’s low productivity means it is good at creating jobs. You need to employ a relatively large number of extra people to achieve a given increase in output.

Furthermore, many of these jobs are relatively low paid. Lower paid people tend to spend their wages rather than saving them, and are less likely to spend them on foreign holidays or imported cars.

Of course, money spent on healthcare is money not spent on something else. The government could, as Keynes facetiously suggested in the 1930s, pay people to dig holes and fill them in again. In a slump, this would be better than nothing. But if we’re going to spend money creating jobs, we might as well spend it on something worthwhile, which will bring long-term economic benefits when the recession is over.

Investing in healthcare services, public health programmes and research can increase labour supply, productivity, skill and education levels, and reduce inequality, poverty and the cost of sick pay and welfare benefits. This helps to offset the undoubted tendency for healthcare costs to rise faster than general prices.

This is why the European Commission designated healthcare as “growth-friendly” spending and made investment in public health a cornerstone of its “Europe 2020” ten-year economic growth strategy.

The Commission’s paper, Investing in Health said: “Health is a value in itself. It is also a precondition for economic prosperity. Investing in people’s health as human capital helps improve the health of the population in general and reinforces employability, thus making active employment policies more effective, helping to secure adequate livelihoods and contributing to growth.”

None of this means there’s a blank cheque for healthcare. Much as spiralling house prices do nothing to solve the housing crisis, simple inflation in healthcare costs does nothing to improve health outcomes or bring long-term economic benefits. The US spends almost 50% more on healthcare than anyone else, but with decidedly mediocre results. Costs keep rising, but the returns — better treatments, better survival rates, a healthier population — lag far behind.

The European Commission recognised this in its 2012 survey, The Quality of Public Expenditures in the EU: “The relatively large share of healthcare spending in total government expenditure…requires more efficiency and cost-effectiveness to ensure the sustainability of current health system models. Evidence suggests there is considerable potential for efficiency gains in the healthcare sector.”

Professor Michael Stople of Kiel University, a leading expert on Europe’s healthcare economy, believes Europe’s ageing population and its relatively low level of investment in healthcare research, means healthcare has a major role to play in reviving European economies. “In the aftermath of the financial crisis, the growing size of Europe’s elderly cohorts is boosting the social rate of return on health-related public-good investments at a time when the borrowing costs of many European governments are at record lows.

“With sufficient translation of health improvements into longer, more productive working lives, Europe’s currently depressed economies can thus be supported in returning to sustained long-term growth and in generating the additional tax revenue that will eventually help governments balance their books.”