Wednesday, 31 December 2014

New Year, New Challenges, New Opportunities

As we approach the end of 2014 and look forward to 2015, I thought I’d write a blog ahead of the New Year.

I hope everyone who celebrates Christmas enjoyed their seasonal festivities.  Whilst Christmas can be a great time for friends and families to get together, it can also be a struggle for those going through a tough time, bringing back difficult memories or adding to a sense of isolation for some.

Pennine Care is a 24/7, 365 days-a-year provider and many of our staff will have worked over Christmas to ensure those who rely on our services received the care they needed.
I want to acknowledge those staff who keep services operating, whilst Christmas and New Year is taken off by many.  The care we provide is critical for so many people and amongst all the festivities it’s easy for some to forget that NHS staff work day and night throughout the season. So a big thank you and much appreciation to Pennine Care staff and the partner staff we work with.

The NHS England Five Year Forward View
Well it’s been a year (just about) since I took up post as Chief Executive. I have thoroughly enjoyed it and I am grateful for the great support I have had from Trust staff, partner organisations and wider leaders in the NHS. It has been incredibly rewarding, at times really tough, but I am still as pleased and as proud to be doing the job one year on.

If anything, I am more proud than ever. Recently NHS England published its Five Year Forward View and guidance on implementation. If you read this you will see a strong endorsement for the strategy we have been pursuing, with partners, for approaching two years now. 

Here is a snapshot from the Health Service Journal (HSJ) describing the guidance:
The guidance, The Forward View into Action, says those sites chosen to be in the “vanguard” must already have a record of “tangible progress” to new ways of working over the past year and positive relationships between commissioners and providers.
The selected areas will receive investment from the transformation fund, announced earlier this month as part of the chancellor’s autumn statement.
A support programme will be co-developed rapidly with the initial sites which aims to “blend the provision of technical expertise with peer learning, and removal of barriers to change”, the document said.

In particular it says areas must have “realistic ambitions for activity diversion initiatives”.
It added: “Unless and until it is clear that demand has reduced, we strongly advise system resilience groups not to switch off additional winter capacity for urgent and emergency care.”
The guidance was published jointly by NHS England, Monitor, the NHS Trust Development Authority, Public Health England, Health Education England and the Care Quality Commission.

The key new requirements and initiatives set out in the document are:
  • clinical commissioning groups must increase their spend on mental health by at least as much as the increase in their allocation;
  • new commissioning for quality and innovation payments for treatment of sepsis and acute kidney injury, which replaces the requirement to report patient safety thermometer and friends and family trust data, will become part of the national contract;
  • a new CQUIN on improving urgent and emergency care;
  • a “revitalised” national quality board to review the current state of quality of care and barriers to delivery of high quality care;
  • a new workforce advisory board, chaired by Health Education England with senior membership from across the system, to develop a health and care workforce with the skills to support the implementation of new models of care;
  • providers and commissioners to agree plans to make further progress towards seven day working; and
  • CCGs and providers to agree plans to improve antibiotics prescribing in secondary and primary care.
Simon Stevens, chief executive of NHS England, said: “Today we are allocating extra cash for towns, cities and villages across England to help the local NHS meet the rising demands and changing needs of the patients we’re all here to serve.
“Frontline nurses, doctors and other staff are working incredibly hard, including over this holiday period, but with a growing population and an aging population it’s clear the health service can’t just keep running to catch up. Instead we need to begin to radically reshape the way we care for patients, which is why there is such widespread support and enthusiasm for the NHS Five Year Forward View.”

What it means for Pennine Care?

I don’t know whether we will go forward to be part of the ‘vanguard’ schemes. It’s not my decision anymore, and that’s a sign of the progress we have made. We have shifted from the old fashioned ‘sovereignty’ of Foundation Trusts and moved to place-based delivery. So we now work alongside partners and build local service delivery through local partnership boards.

The six towns we work in are each at different stages of development, but in my view there is a common sense of direction.  Therefore, if we were to go forward and submit an expression of interest, it would be a decision made by the partnerships with commissioners.

Who is in these partnerships?  Pennine Care, the local authority or social care provider, the Acute Trust, the third sector and importantly a strong relationship with primary care. We also see partnerships growing to include housing and links to employment.

If the partnerships thought we should submit an expression of interest to be a ‘vanguard’ site, I think we would be in a good position to be selected. The criteria say applications should be from those with a track record of already developing these models of care. NHS England describes these models (in our case) as Multiple Specialty Community Providers, which very much reflects the type of partnerships we have been forming over the last one to two years.

Critically, the models for implementation must demonstrate genuine diversion activity – that is, the diversion of patient care into the community and away from acute trusts. I am pleased, impressed and keen to share the diversion work we have been building for two years. Across the Trust we now provide RAID services (Rapid Assessment Interface and Discharge) or mental health liaison services for the acute hospitals. 

In Trafford, we have developed a community enhanced care service for physical health presentations. Both have been developed where commissioners have really backed schemes to deliver diversion.

Both of these schemes have been evaluated; RAID independently by the University of Chester and the evaluation of the Trafford service has been jointly signed-off by Trafford Clinical Commissioning Group and Pennine Care. 

Both demonstrate significant diversion activity and we intend to share these service models across Greater Manchester and wider. I believe they should form a key foundation for models of care outside of hospital.

I will talk more on service models in future blogs. One key theme amongst all of the above is change; significant change and change at scale. I am pleased to say Pennine Care staff have embraced this challenge and we are making great strides forward to deliver community based redesign of services.

Financial pressures

During the Party Political Conference season, and through lobbying of the political parties and the Department of Health by the NHS Confederation, NHS Providers and many of the Colleges, the financial pressures on the NHS were finally debated. Plus there is additional money being made available.

I personally don’t think additional money will substantially change the £45 million efficiency target Pennine Care has. We still face significant redesign challenges and any money should only pump prime change. We will never be able to shore up the current system; it’s unaffordable and pretty much everyone now agrees that.

However, we have yet to see the money challenge and the NHS Five Year Forward View put together as one clear plan. I think this is work we need to lead locally, as there will never be a top down magic bullet for this challenge. We have to manage redesign plus savings. It’s not ‘do more with less’, as some have said. It is ‘create different with less’ and optimise resources through better partnership working.

In summary the NHS still faces a significant financial challenge and we mustn’t let the forthcoming election cloud our thinking or slow our decision making. Plans and savings still need taking forward.

In the early part of 2015, Pennine Care  will commence large scale engagement with our staff, to discuss, consult and plan together on future challenges. Please do connect with this discussion; it will be our largest ever planned engagement.

I understand that It can be difficult to engage positively with plans for change when these changes lead to worries about job security.
So I thought I would end this blog, where I started my first one a year ago, talking about money, challenges of change and job security, and the risks of redundancies.

When I have been out on service visits over the last few years, questions on job security have been high on the agenda of staff. This is entirely understandable. More than a few years ago, I was always very upbeat as we very rarely made anyone redundant. In the years since then, the levels of savings required has risen and the impact of year on year savings has moved us towards far more redesign and significant changes to services and the jobs our staff do.

Pennine Care’s staff , Staff Side representatives and organisations have worked closely together to deliver these savings year on year. Last year was no exception; we delivered over £7 million of savings (Cost Improvement Plans or CIPs, as they are known in the NHS). Going forward we face more than £8 million of CIPs every year for five years. Who knows, additional investment may soften this - I hope so -  but either way we face a substantial challenge.

£8 million, on average, is the equivalent to around 220 job posts. That means, in theory if we only made the savings through pay, we have to lose 1,000 jobs over 5 years. With redesign you may also need to reduce further to introduce new roles.

In terms of job security, it may make stark reading, but I think we need to take a measured look at this and I hope that by doing so, I can give staff some reassurance.

Firstly, whilst we do have to make these savings, we are committed and determined, along with our Staff Side partners, to keep staff in jobs and avoid redundancies wherever possible.
Each year, we actually lose around 8% of staff a year through turnover (such as
retirement and moving to different jobs), which equates to just under 500 staff. It’s an over simplification but if we didn’t recruit to the posts where people leave we could still recruit 280 staff and achieve the CIP.

So yes, there is a risk we will have to make redundancies due to savings, but as you can see, that risk is very much lessened by natural turnover each year.

The CIPs and the need to change the way we deliver services does mean far reaching change - to achieve £8 million of CIPs will mean formally going through cases for change, consulting on changes to people’s posts, redeployment and yes, at times, redundancy. But against a backdrop of 500 staff going every year, it does make the challenge somewhat more achievable without large scale redundancy.

As I was writing this I thought I would revisit the redundancy figures for 2014/15. We had to make over £7 million of CIPs this year. How many compulsory redundancies did we make?

I agree that’s seven too many, but it’s not 200. We also made 17 redundancies through voluntary agreements. That’s 24 in total, still a much lower figure than you might imagine when first considering the several million pounds worth of CIPs we have to make.

If staff ask me a question on job security on my next service visit, I will say it isn’t like it was. The need for change is ever pressing and the impact on roles from redesign will be there for some time to come. However, there is still a good deal of job security and far more in Pennine Care (where we have stable, well-managed finances) than in some other public sectors and other parts of the NHS.

I hope this gives some assurance to the Trust’s staff and I can give my personal reassurance that we remain determined to keep as many people in work as we possibly can during 2015.

I would hope with relative job security you will engage in the conversations we are planning in the New Year to discuss the challenges ahead. The more engagement we have with staff and the more people contribute their ideas, the more we can lower the risk of redundancies together. That’s because, in my view, we will make the best plans based on the views and thoughts of staff who work in services every day.

I really do hope that gives some reassurance as we move into 2015.

Finally, I would like to thank each and every one of our staff in Pennine Care for all their hard work, commitment and dedication to delivering the best possible patient care in the communities we serve, and wish them all the very best for 2015 - Happy New Year.