National direction set

The NHS Confederation last week published a letter to the Prime Minister, David Cameron, to urge the Government to provide political will and financial backing to secure the future of hard pressed NHS services.  This was co-signed by 50 leaders in healthcare, including me.

The publication of the letter coincided with a major speech from Mr Cameron (link) and Chief Executive of NHS England, Simon Stevens (link).   

The overarching themes from these speeches was further commitment to implement the Five Year Forward View, making a 7-day NHS a reality, greater focus on healthy lifestyles and prevention and treating mental health with equal importance as physical health.  The Government has pledged to provide the NHS with an additional £8 billion in funding by 2020, but this is in the context of the NHS still needing to find £22 billion in efficiency savings. 

The level of change and challenge facing the NHS will continue to be significant, but we now have a clear sense of direction and purpose at a national level, guided by the Five Year Forward View.  On a more regional level, Greater Manchester is progressing plans for the devolution of health and social care from central government to the city region.  

At a Trust level, Pennine Care continues to be a high performer in terms of both quality and finance.  However, we still need to achieve £47.5 million in efficiency savings over the next five years to contribute to the overall NHS target of £22 billion.  This will be tough at times but we must ensure that the care and safety of our patients and the wellbeing of our staff are at the forefront of any changes we make.  We are now engaging with our staff widely on developing plans for the future and I would encourage all of you to get involved. 

I would encourage you to read these when you can as it will help to give you a sense of direction for the NHS over the next five years.  We will of course provide regular updates about how these changes will impact our frontline staff as it becomes clear. 

Thank you

Michael 

Opposites attract - listening to everyone's point of view

I have been learning more recently about polarity management.  I probably couldn’t do it justice to try and describe the theory here but it’s a simple concept once you understand it - read here or watch this video. 

I wanted to write about it as I think it’s key to managing change in a trust like Pennine Care. So I will talk about it as plain as I can, avoiding the theory bit.

If you think about relationships; can opposites attract?  Can a Marmite lover live and dine harmoniously with a Marmite hater (or other reputable yeast based spreads!)? Can a Manchester United fan live happily ever after with a partner who supports the noisy neighbours from over the way?

When I was thinking about this, whether at work or at home, there is always a need to understand someone else’s point of view, likes and dislikes, beliefs and values.  Essentially that’s the theory behind polarity management; you can’t work or live with someone unless people try to understand each other. Relationships don’t work unless there is some give and take.

Equally where someone states their point of view to the exclusion of hearing another’s, this will tend to push people apart. We have all heard the phrase, ‘poles apart’ where two people just can’t agree on some matter or other.

Putting it into practice 

So what does this mean for Pennine Care and how we manage our strategy and work with our staff in future years? This might sound barn door obvious, but we have to listen to and work with the views of our staff.

If as Chief Executive, I continually communicate the need for change, transformation, redesign and improvement but it’s not unreasonable that some staff may ask "what’s wrong with the work I do now?" Often the argument for change can be received as a criticism by those who value what works now.

In a recent workshop with Executive Director colleagues, we looked at the following polarities, or opposites of a type:

• Change and Continuity
• Competition and Collaboration
• Team and Individual
• Cost and Quality
• Integration and Specialisation

In these areas, we discussed that there are positives and potential negatives or upside and downside cases.  So in the case for changing something, there are potential benefits, but equally some might argue that maintaining what has worked up to date has benefits. And you could put arguments for and against either change or continuity.

People value different things and if you don’t acknowledge that or understand that, you can frustrate, ignore even lose people in what you are trying to do. The polarities of how people view things are important, it is a tension I believe we should view positively and embrace.

The tension works something like this - if you argue for change with someone who values keeping continuity, you are likely to increase their focus on the negative aspects of change.  If you don’t value what works well now, you are likely to focus on the negatives of things staying the same.

“If it ain’t broke don’t fix it” or ‘Don’t throw the baby out with the bath water” are both phrases which reflect the views people sometimes express when discussing change.

Recognising the good 

So why am I blogging about this? The language of the NHS at present is packed full of change at scale, transformation, significant financial efficiencies, redesign, more generic care work is needed and so on. The financial challenges I discussed in my first blog have introduced a driver for change that is being continually pushed and one that’s often underpinned with claims of inefficiency in the NHS and the need to improve care.

But the more the NHS, leaders and commentators talk predominantly about the need for change, and focus on inefficiency to the exclusion of celebrating the great work that the majority of staff do every day, the more likely staff will be turned off by the prospect of change. Staff will start feel more and more the subject of change, rather than a participant in a dialogue about the future of their service.

And in Pennine Care we need to manage change well and be mindful we don’t throw the baby out with the bath water, or devalue someone’s hard work by talking about how we need to make things better through redesign and efficiency programmes.

I think we do need to change the way we run some services and some change, I anticipate, will be far reaching. However, rather than start with "These services need transforming and we need to save money" I want to start with "What are the really good things we do and how can we use the really good things as a starting point to talk about how we can take services forward?"

It will be challenging as the financial savings are steep. However, we can’t let the financial challenges drive us into making quick decisions on what our plans should be, without talking to staff, our patients and partners first. So we have to include staff and all of our stakeholders in our discussions and engage them in developing the plans to deliver our vision.

I hope this all makes sense. This week I signed off a programme which aims to engage each and every single member of staff in Pennine Care, around 6,000 people, to talk about the future and how together we will move forward. This will begin late summer through to early autumn and will continue throughout the next few years.

Using a range of methods, events, workshops, meetings, social media, intranet forums, we intend to work with our staff to build a shared narrative on future plans. It won’t be easy, there will be lots of different views! We will have to make some difficult decisions. I’m determined though, we will make our plans carefully, in close partnership with our staff and partners. Pennine Care is built by experienced staff who provide great care. We need their views and expertise to inform our future plans.

Comment below or tweet your thoughts to @MichaelMcCourt1

30 minutes on transformation and ideas for change

Ok, I have really been struggling to find the time to blog but I keep hearing how valuable people are finding it so thank you for your comments.  

I have just found thirty minutes and I have set myself a task to tell you as much as I can about our transformation programme in that time *closes door and slides down in  chair so no one can see me!*

Last week I spent nearly four hours with the executive team talking about the next phase of our challenge. We have since launched our vision and strategy but now need to work with our staff, service users, carers and partners to talk about the plans we need to develop and put in place… and let’s not forget we also have to find around £45 million of savings over the next five years.

The vision and the strategy are crucial to a successful future but all the plans in the world are meaningless if we don’t lead a well-run organisation now. I like the concept of high reliability organisations, which I think is derived from the aviation industry.  It also has been adopted and applied by many healthcare organisations.

Simply put, it promotes a culture of safety and learning from adverse events. I already think we do this well, but we can do even better and drive out variation and improve standards even more. Given the challenges we face, and the change we will have to go through, keeping this as a priority is key.

Every leader and all staff in Pennine Care have a responsibility to provide safe patient care and we all have a shared responsibility to not only spot problems but to develop solutions together.

A culture of safety means ensuring we are clinically-led. This can be challenging as clinicians, understandably, are often concerned about the impact on quality due to financial savings. Whilst it is challenging I believe the only solution is to work even more closely together and to share the responsibility to find the best plans to take services forward and reduce costs.

I also am of a view that we have to hold an ambition to improve services, even when facing £45 million savings plans. I don’t think we should just assume, give up or accept the notion that this level of savings will make things worse or reduce services. It will change services, yes, but £231 million (the pot left behind) is still a lot of income and we should work together to design a future that makes the best use of this investment.

I’m not wearing rose-coloured spectacles or being blinkered to the challenge, but if we put patients first then we have to drive to deliver the best possible change for them. We can’t change the financial climate we are in but we are in control of our attitude and approach to the challenges we face.

*Half way through the thirty minutes… tick, tick, tick!*  

We also talked about the vision and strategy. I am really pleased we have put together a vision and a strategy, including a plan on a page of our Service Development Strategy. This sets out our overall ambition rather than our detailed plans.  

Therefore, in the last 12 minutes of my 30 minute blog I’ll share some quick thoughts on what each of the transformation programmes could mean.  The transformation programme has seven steps:

Living well

This means promoting self-care and self-management, health literate and empowered patients. If patients can be less reliant on current care systems we may be able to change the way hospitals work and our community-based services are designed.

Living well may mean more care coordination, risk stratification, expert patient programmes and different team make up and skill mix and different provider models to deliver care.

Easy access

Better co-ordinated access is something many patients ask for. In Oldham we are working with Age UK to appoint four ‘Promoting Independence in People (PIP)’ workers, who will help patients to navigate through the system to become empowered in managing their own health and care needs.

This has meant changing our multi-disciplinary teams and having different non-professional workers join from the voluntary sector. It is just one example of how we are doing things differently and better.

Whole person care

I have a view that parity of esteem in mental health means better physical care for people with mental illness, as well as better psychological care for people with physical health conditions. This aspect of a person’s care is still barely featured in models of care.

Cognitive Behavioural Therapy (CBT) or psychoeducation should be a standard aspect of our care pathway for long term conditions and means making sure our staff are more broadly trained.

It also means we need to bring our mental health and community teams closer together, providing integrated care to each patient.

Places that work

Our care should be provided in the homes of people we care for or as close to their homes and families as possible. This means we need to organise services around our local communities and neighbourhoods, not around professional groups or disciplines.

It doesn’t mean losing professional identity, we need strong clinical voices, but delivering locally with primary care, social care and community resources.

Better use of technology

I could write on this alone but I’d rather ask a question - how much does technology play a part in the care you deliver in your team? And do you use the latest technology in your team?

I know the Trust has a responsibility to put this in place and we are doing this with the PARIS clinical system, but do you drive it forward in your teams? How modern are you in your thinking on different ways to deliver care?

I would put forward that rather than digital by design, nurses and health care professionals should be working digitally by prescription. The application of technology should be a common feature of assessing someone’s needs, as you would for wound care or medicine.

Fewer buildings

Buildings are expensive and I’d rather work differently and invest in staff than bricks and mortar. The problem is buildings are also a hard habit to give up, but we have to reduce the cost of office space.

Where we have buildings we should open them up to communities and interested groups when we aren’t using them. We often leave an expensive building empty in the evenings and at weekends, when community groups would love to have some space to meet in.

Different ways to deliver care

We have to think broadly what this could mean? Different ways of delivering different aspects of what we do, set up a social enterprise maybe? We have discussed this as one example. Some commissioners have a view that some of our services are uneconomic, I also think we could do some things better at a reduced cost. We have to find ways to deliver better value in some areas.

Bed-based care is a significant cost and some trusts are reducing their bed base. I think we have avoided going any further than our historical changes, for good reasons, but we should still have the conversation and look again.

I could go on and on considering what transformation planning might mean but I have run out of time!  What I will say in closing is that it is critical that we involve patients, carers, staff and stakeholders in developing plans to respond to our challenges, and that we must not lose sight of being a great place to work.  Pennine Care must still engage, recognise and reward our staff for the hard work, dedication and commitment they give every day.

We owe our staff both of those points to support them through the challenges we will face together.

Tweet your thoughts to @MichaelMcCourt1 or comment below. 

The bottom line

Welcome to my first blog post!

I have had positive feedback on my efforts to be as open and transparent as possible, so thank you. Both Twitter and Trust communications have been well received so far and the idea of this blog is to provide further thoughts on Trust strategy, challenges and the wider health and social care system.

It’s intended to contribute to the reader’s thoughts and views, I hope, and promote discussion and debate.  It is primarily for Trust staff, but stakeholders and interested others are also very welcome.

So, where to start?
In April we will launch the Trust’s vision and strategy. I will soon blog about that specifically. However, I’d like to take a few steps back for this first blog and talk about money.

Surely I should be talking about patient care, quality and values? Well yes, it is the reason I joined the NHS as a student nurse in 1984 and why I get up each day for work, to deliver the best care possible.  But I don’t think we can get on to that without discussing the financial context in which we work.

As a student nurse, even as a staff nurse and a ward manager, I didn’t understand where the money came from to run services. It didn’t cross my mind to think who paid my wages. We are now in different times.

Nowadays I think we all have to have an awareness of the costs of care and the restraints on funding. It has to be an integral part of our plans alongside developing the best care possible. It isn’t easy to do but we must.

There are misconceptions that the NHS budget has been spared from financial efficiencies but in reality it hasn’t.  In percentage terms we might not have had the scale of financial challenges Councils are facing, but we still have to make considerable financial efficiencies year on year.

In 2010, Sir David Nicholson set the Nicholson Challenge against a backdrop of the UK economy in upheaval. He tasked NHS leaders with finding £20 billion of savings, whilst improving quality.

Yesterday the new Chief Executive for NHS England, Simon Stevens, took his new start as a moment to speak frankly.  He said the NHS is facing its biggest sustained budget crunch in years and that success in the coming years will require "a team effort – involving the biggest team in the biggest effort the NHS has ever seen..."  which we are all a part of.

What does it mean for Pennine Care?

I’ll try to explain Pennine Care’s funding challenge as simply as possible (it’s the only way I can understand it!).

Each year we negotiate our contracts with commissioners which include quality and performance requirements, and the price they will pay for services. The price paid is the amount of money we have to run the Trust in that year, to pay wages, pay employers pension contributions and national insurance contributions, rent costs, heat buildings, transport, medicines etc...

The amount we receive this year is less than last year. This is due to a reduction of 1.5% on the prices paid by commissioners across the NHS. The commissioners are required to do this by the government (as part of the overall drive for savings in the NHS). So immediately we have less money than we had last year. We have less money to spend, but the costs are actually going up.  The cost of the 1% wage rise (admittedly only for some following the pay award) isn’t a part of our contract settlement, the Trust has to find money to cover these costs, and each year other costs increase as well. Utilities always go up, cost of medicines always go up and there are many other cost increases -  all have to be met from within that contract value, which is already 1.5% less than the year before.

Then the financial rules we are governed by (from Monitor our regulator) mean that we must generate a surplus, which means putting funds aside to pay for keeping our buildings and equipment in good order, and also to pay for large projects such as capital investment in improving wards or in our new IT systems. A small surplus also gives our commissioners, patients and staff confidence that we are strong enough financially to continue operating even if something unexpected came along. (Remember Woolworths?)

So we have to do better than just break even and the surplus we have to generate is around £2 million.

So in summary, we know the cost of providing our services is around £273 million based on the current financial year but we sign a series of contracts for 1.5% less than this because of a reduction imposed nationally, then from that reduced amount we have to pay increased costs and still generate a surplus. This leaves us short of money and the figure that amounts to is about £8 million, which has to be found through making savings across the Trust.

Is anybody still reading this? Stay with me!

So what does £8m savings mean?

Pennine Care has been successful at meeting savings targets year on year, with minimal job losses.  But it is getting more difficult to find the money.  The £8 million we need to find this year represents the equivalent cost of 218 jobs at band 6.  And that’s why I wanted to start the blog with a post on money, to explain where proposals for redesign and cases for change come from.

When members of Pennine Care's Trust Board spend time with services, there is one consistent theme staff raise, job security. I understand that and I want staff to feel as certain and secure as possible. There is inevitably change required when finding large sums of money to save, but I want to assure our staff we are working really hard to retain staff and keep redundancies to an absolute minimum. 

And that is the reason why we need to be open and transparent.  Nobody wants to be faced with the financial challenge, but it’s a reality we all must face together.  We try incredibly hard to not disrupt patient care and support staff through the changes.  We also ensure we involve staff and patients in the decisions we make.

But making financial savings is now an integral part of the world in which we work, and so unlike when I was a student nurse, we all have to be aware of it.

I’d like to acknowledge and thank staff for continuing to work so hard, so positively and delivering excellent care, despite the financial challenges we face. I continue to be impressed and proud of the enthusiasm, commitment and professional behaviour of staff.

As Chief Executive I don’t underestimate how challenging it is working in the NHS in the current economic climate. Despite these challenges I want the Trust to be a great place to work, a rewarding employer and a supportive organisation. I know that where we achieve that we get the best care.

Next blog I’ll discuss how the financial challenges are creating positive opportunities to improve patient care.

Michael

Twitter: @MichaelMcCourt1