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Report of Senior Amicus NHS Representatives Course, Perth 4 - 6.2.03




Sharon Riddell
This report is taken from notes made during the course and accurately reflects the course,
to the best of my knowledge.

The main outcome from the course should be the Amicus Plan for the NHS in Scotland for 2003.

Sharon Riddell, the facilitator for the course, opened the course
and provided an overview of the course and its objectives.

The course itself took place in the Queens Hotel, Perth.


Queens Hotel

Partnership in NHS Scotland
Michael Fuller, Regional Officer, Amicus-MSF
This was a presentation on partnership and how it has changed over the past few years. The original model of partnership had terms and conditions negotiations outwith the partnership circle, but now it is included within partnership.

            

It has been agreed that the NHS needs the best staff and the only way to get this is to be an exemplar employer with the best terms and conditions. The previous tripartite model is shown below.

                                    

This model has to be duplicated at NHS Board level. The White Paper issued later this month is likely to state that Scotland will be a Trust free zone by October 2004 and the idea of competitive organisations will disappear completely at the same time as the idea of Trusts is reinvented as Foundation Hospitals in England. There are two requirements for partnership -

1. we need to sort out structures for NHS Board groups and remove the primary care and acute divide.
2. we have got to deliver.
There is political pressure to show that partnership produces better services.
For the union, we need to consider


What achievements has partnership brought?
Audit Scotland are now part of the picture with their involvement in the Staff Governance Audit assessment tool.
The meeting then split into groups to consider improvements achieved by partnership and how they could be consolidated and concerns and how they may be remedied.

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Campaigning and Priorities
This session was a general discussion on what reps need to cope with the size of the agenda. There will be some hard terms and conditions issues coming up this year. If NHS Boards are to be the main structure it will be necessary to ensure that the local partnership forum is working. Will it be necessary to have local HRFs? There are two scenarios facing the union


What does the union need to do to ensure this happens? The first thing is to ensure that proper facilities time is arranged for active reps to allow preparation for meetings, the meetings themselves and feedback from the meetings. The NHS Board then needs to work on the tripartite basis shown in fig.2. At the moment there is no mechanism for working with the Board in the same way that we work with the Trusts, as the Area Partnership Forum feeds into the Clinical Governance Committee which feeds into the Board. A different organisational structure will be needed.

The SPF will have three main areas of activity


The equivalents for the Area Partnership Forums will be
There is a big problem with SEHD wanting something for nothing. Often, no additional resources are ploughed in to make new initiatives work, and this causes problems. Staff Governance will not happen unless penalties such as those for non-compliance with the junior doctors hours are used and resources are identified. If Trusts are having to cut back on surgery because of lack of funds, why should they cut back further to afford staff governance? If Trusts are working in proper partnership, why are we fighting for facilities time? The Staff Governance Audit Tool should be used to help. All the tools for these discussions are in place.

The White Paper, due out later this month, will show how funding will increase from 35.5b to 38b over the next two years. The debate will then be on where to spend the money. It was acknowledged that the tools are good but that the training to use it properly is not there for either managers or reps. Do reps have the wherewithal to make bids for the money. Reps need to know the whole agenda and not just the bits they are involved in whereas managers really only need to be aware of their immediate responsibilities. The lack of this training means that most reps want decisions from the centre rather than directions. Publicly, the situation in Argyll and Clyde showed that SEHD considers balancing the books to be the most important performance criteria with four Chief Executives removed, not because they were not properly implementing staff governance. In actual fact, the problem was only partly about the money. The fact that the four were not working in partnership with each other meant that decisions were not being taken and the healthsystem was foundering.

There is no allocation for staff governance at Trust level because the Trusts don't have the abilities to carry it out. There are also problems at Board level where their priorities are different, and new funding has already been allocated, in many cases to get the Boards out of a financial hole.

Chief Executives are the accountable officers within the NHS for delivering the service and have a legal duty to live within budget and comply within clinical governance. Some terms and conditions are produced as statutory obligations -


PIN Guidelines are not statutory whilst Junior Doctors Hours reduction is, thus explaining the difference in their implementation. Within Scotland, the NHS is the biggest political consumer of resources. Living within budget and waiting times are the two targets which must be delivered.

How do we ensure Staff Governance has the same profile and importance as Corporate Governance and Clinical Governance? There needs to be training for both reps and middle managers. Reps need to be developed and there was a question as to whether full-time reps were the way forward. We also need to be sitting at the top table when the decisions are being made. If they don't want to negotiate, how can they be forced to bargain? The SAAT is there to be used, but there are likely to be hard decisions to be made about workload. The discussions proceeded on how to equip reps for this agenda and how to boost the profile of both Staff Governance and the Staff Survey. What support was needed from Amicus was also identified.

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Agenda For Change (i)
      

As might be expected, there was considerable discussion on the recently published documents. The job evaluation handbook identifies what knowledge and skills are required for the job and does not include anything which is only desirable. An interesting note was that job description "catch-all" clauses such as "Any other duties required by Principal Pharmacist." must be taken out. The job description must detail exactly what you do. It was announced that a full postal ballot of members was to be carried out, rather than a workplace ballot. It is therefore vital that an up to date home address is available for ALL members. Any non-members wishing to vote in the ballot must have joined by the end of March. If it all goes ahead, there will be a very difficult job around implementation. If the Human Resources Forum is running by that time, we will be in a better position to make this a winner.

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Joint Futures
Ian Reid, Chief Executive, Greater Glasgow Primary Care Trust

A ministerial group produced the document "Community Care: A Joint Future" in 2001. It recommended sharing of information, joint resourcing and joint management. It was intended to focus care on the patient, rather than the provider. The "Bottom Line" circular stated that by April 2003 there should be -


A partnership group comprising local authorities, NHS, COSLA, Scottish Executive, the voluntary sector and the trade unions was set up in 2002 under the auspices of the Integrated Human Resources Working Group (Bates Report) to consider a joint solution. There was consultation and a commitment to the idea. The group had to consider the role of the elected local democracy (Councillors), recognise the differences as well as the similarities, achieve improvement without major structural upheaval and be aware it was not about staff transfer. The critical requirements for implementation were identified as


Of the 38 recommendations made by the group, 37 were accepted by the Scottish Executive. These are broken down into short and medium term

Short term Medium term Further structural and policy developments
There is now a joint ministerial group involving health and local government; a Joint Futures Advisory and Implementation Group; 32 local partnerships and also legislation.

Glasgow City has a Joint Community Care Committee and an Integration Steering Group with various working groups - Finance; Human Resources; Information; and Performance Management and Accountability. There are also city wide Localities Planning and Implementation Groups working on joint services for older people, those with learning disabilities, addictions and the homeless.

There is an HR group looking at integration and charged with addressing local HR issues linking to the national agenda and managing an organisational team development programme.It is intended to support the joint staff forum and manage joint training activity.

A Joint Staff Forum has been set up to


There are, however, some continuing HR challenges
The Bates Report stated, "We have in Scotland a talented, committed and enterprising workforce across the NHS, local government, voluntary organisations and the independent sector. That workforce is eager to take the joint future agenda forward but rightly look to their respective leaders and representatives to resolve some of the very real dfficulties that get in the way of change. A sense of realism is therefore needed about the pace of change and some of the challenges. Change will not happen without leadership, involvement of the workforce, good communication and models of behaviour that demonstrate by example why we need to move from silos and old demarcation lines to a modern user-focused culture that is fit for purpose." There are a lot of demarcation issues based on state registration requirements. The idea was that there would be one person acting as Care Manager who then brokers the support required for the patient. Current thinking is moving away from this model towards a Care Manager who would refer into nurses and social work. The only alternative is opening up the registration route e.g. cross registration. The problem is that this is a reserved power, so that even if the Scottish Executive wants it, they cannot introduce it unless it is introduced on a UK-wide basis by Westminster. There are problems with accountability. The public have conceptions of accountability, and moving to this system does blur accountabilities. This has to be considered and is slowing implementation.

The team leader posts are vital, as often the performance of the team is down to the personality of the team leader. Career structure is another big issue which needs discussed. The whole thing might work on a secondment basis to allow staff to return to the NHS or Social Work if they desired. Ultimately, it needs to involve staff transfer. However, managers have been told that the process has to slow down until some of the current problems have been resolved.

Until now, involvement of the acute hospitals in Glasgow has been minimal. This is expected to increase with the appointment of Tim Davison, the previous Chief Executive of the Primary Care Trust, as Chief Executive of the North Glasgow Acute Trust.

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The Future - "2020 Vision" People Centred Healthcare
Refocusing Investment: Reinvigorating Reform

Trevor Jones, Chief Executive, NHS Scotland

As he was unable to discuss the forthcoming Health White Paper until it had been published, he presented a summary of the work that had been done for inclusion in the document and details of themes emerging from this work. The presentation had been developed the previous year to consider what the Health White Paper might look like.

NHS Scotland had a 2020 vision of people centred healthcare. He has a foot in two camps - Chief Executive of NHS Scotland and person in charge of the Scottish Executive Health Department - and this can cause difficulties. In his two roles, he has to provide policy advice to ministers and also protect ministers; to represent the NHS and protect the NHS. This conflict of interest can cause problems, and there is a similar dichotomy within the Health Department.

The objectives are straight out of "Our National Health"


There are several challenges within this

Improving Health

Leadership nationally will come from Jack McConnell and Malcolm Chisholm.
Mainstream funding - for too long, Health Improvement has been something done when everything else had been sorted. Now it will be taken more seriously.

Interaction between the Health Department and others e.g. Education ; all talking health improvement.
Phase 1 is a huge agenda, and no other country has attempted anything as big. Therefore, it is necessary to focus on specific areas.

This is not about the production of reports; there are many of them already. The Executive is now saying "do something practical about it". It is the widest possible definition of health improvement, including environment, housing etc..It will take time to get it up and running. Television adverts on diet have started and a major campaign on exercise is due later this month.

Healthcare issues
Ideally, there would be healthcare


How can this be achieved? It needs to be a balance between sustainability and the ideal.

The Broad Vision
People centred, better integrated care, mainly delivered in local communities


The Health Department doesn't have solutions. If competencies rather than qualifications were investigated, health care might look quite different. Some integration of registration bodies might occur. In Social Work there is Local Authority and NHS education. Is there scope for joint training of community nurses and social workers o what areas are common? It was stressed that this is a possible future.

No decision has been taken on whether the NHS University will apply in Scotland. It doesn't fit the Scottish agenda. NHS Education Board is looking at training over the whole NHS.

Care Pathway Approaches
There is a need to reconsider the role and the setup of LHCCs/DGHs. Also to look at each clinical condition to assess what is required at each level. Care will most probably go upwards, but some will move downwards.

IM&T has been woefully underfunded in the past. The Wanless Report stated that it would have expected ten times the amount of money to have been spent than has been.

In Emergency Care there will not be enough doctors in future to run the hospitals we presently have.
At the moment we have the institutional model The patients vision is

How do we plan across organisational boundaries and reduce the boundaries? The status quo is not an option.

A modernisation agenda linking everything together is needed to provide the best possible service within the limitations we have and will have. There is a need to get people involved and to support them. How do the public get involved? We also need to get the 136,000 NHS staff involved.

How does it translate into service change?
new working practices - redesigning the process and minimising hand-offs
new and extended roles - breaking down traditional demarcations and matching skills to work
new technologies - creating the communications and information infrastructure.
NHSScotland Review of Management and Decision Making
This was announced in 'Our National Health', but is now a much wider exercise.
There used to be an opinion that there is either management of institutions or management of the service. This is not true and there needs to be a combination of both. The emphasis should be on the service but we still need to manage the institutions. Since NHS Scotland and the NHS south of the border are going in totally different directions, one of them must be wrong - but which?

A lot of detailed thinking needs to be done on the position of the small District General Hospitals (DGHs). The Temple Report stated that if hospitals were to be run in the future in the same way as they are run today, it will be impossible to staff 6 hospitals. Some radical thinking on relationships between local community services, DGHs and specialist centres. Clinical specialists in the small DGHs are on call 24/7 and if there is no orthopaedic surgeon, the A&E service is under threat and by extension, the hospital is under threat.

Traditionally, things are centralised on to the hospital site, but radical thinking on the use of the hospital sites and thinking differently on emergency services and how to run hospitals is required.Not every specialist is required out of hours, and one option is to change out of hours to being 10pm to 8am with shifts covering the rest of the time.An option would be to stabilise the patient with a generalist team which includes GPs and nurses and then wait until the specialist teams are available. Patients who can't wait could be transferred to a specialist centre. This might improve the amount of elective surgery the DGH could do during the day. This is a better idea for a rural DGH but a lot of work needs to be done to see if it could work.

Are there not too many Health Boards for this sort of thinking? There is no intention to set a radically new structure. The clinical agenda gets lost in the discussions on the new letterheads, logos and HQ site. The current policy is centred on the NHS Board, and it would be a great surprise if this was changed as they have only been in existence for a short time. However, closer working is required. The structure today cannot fully work in the way desired in "Our National Health" - some sort of regional planning structure is required.

Stress and workload were identified as the main problems in the staff survey, and cause considerable disruption to the patients journey. All the key staff need to be involved in discussions on how to redesign and reallocate services. The question is how the NHS supports staff trying to change things.

There is a problem with partnership being patchy throughout the service. There are few links with contracted services because there are no structures or mechanisms to allow them. The Health Board are one step removed from Trusts, so an Employee Director was put on the Board. However, SEHD are one step removed from the Boards, so would it be a good idea to have an employee director there giving perspective?

In the NHSScotland Review of Management and Decision Making, there are four areas being considered


There were originally 7 groups, but this was reduced due to mergers caused by overlap of workload. The project board is due to report early in the summer, however, the work done to date has been used to inform the White Paper.

Primary Care and Social Work (inc. joint futures and LHCCs groups)


It is believed a single organisation, accountable to Local Authorities and the NHS Board, should be set up, although there is some anxiety around this on both sides - reduced NHS links vs. take-over by NHS.There is no disagreement with the principles, just how to achieve it. There is an assumption that LHCCs are all alike as organisations and they are not. They are different in size, services etc. and it is also a voluntary organisation.

Support services


The group is looking at standards over the whole public sector rather than just the NHS. SEHD is carrying out a feasibility study on what services should be provided above Board level e.g. finance - payroll and invoice processing - and HR.In England, there is now one system for the whole of London with one supplier and another for Birmingham and the West Midlands with another supplier. Unless we act quickly, the Scottish position will not be an attractive market for the big multinational players. All of the rest needs to be based on economic evaluations.

Leadership and Development


Accountability
Co-terminosity of NHS Boards and local authorities is really a West of Scotland problem and is currently off the agenda, although it seemed to be a high priority at the start.

The White Paper will be published at the end of February and will reinforce current policy. It will be presented to the Scottish Parliament and then launched at a meeting of around 250 NHS and local authority delegates. The documents and presentation will go out to each NHS organisation. There has been no decision on whether there will be a roadshow as was the case when "Our National Health" was launched. It is unlikely that any of the content will require legislation. Each NHS Board will be asked to review their structures in the light of the paper and decide how to proceed; SEHD will not be prescriptive.

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Staff Governance Standard
Jonathan Best, Chief Executive, Yorkhill Hospital NHS Trust

The Staff Governance Standard is a result of partnership and would not have been produced without it. The plan for managing people in the NHS in Scotland, "Towards a New Way of Working", suggested the setting up of a Best Practice Steering Group and the Scottish Partnership Forum. This led to the creation of the Partnership Information Network (PIN) Board. "Our National Health" then stated, "We intend to raise the status of good people management in the NHS in Scotland, to emphasise its importance alongside corporate and clinical governance..... We propose to establish a new Staff Governance Standard for the NHS in Scotland." A further major shift is the decision to have the Scottish Partnership Forum working in the SEHD deciding on policy.

Under the Staff Governance Standard, staff will be entitled to be


These are simple but meaningful statements, and there is a lot behind them.

"Performance against the Staff Governance Standard will be assessed by the Scottish Partnership Forum and local partnership forums and form an integral part of the new performance and accountability framework." Our National Health

"Local staff partnership forums will be directly involved in assessing the performance of NHS Boards as employers, as part of the new accountability arrangements." Rebuilding our NHS

"NHS Boards will be expected to convene Staff Governance Committees to underpin the establishment of staff governance as an integral part of the performance management of NHS organisations. These committees will have an important role in ensuring consistency of policy and equity of treatment of staff across the local NHS system, including remuneration issues, where they are not already covere by existing arrangements at national level. This role will assume particular importance in light of the new system wide approach to performance management." Rebuilding our NHS

"Parallel work is currently under way with the Scottish Partnership Forum and the Scottish Personnel Group to take forward the development of a Staff Governance Standard. Particular consideration will be given to the role and membership of Staff Governance Committees and other mechanisms needed locally to support NHS organisations in discharging their responsibilities as good employers." Rebuilding our NHS

It is likely that the Staff Governance Committee will have a greater role once the White Paper is published. With the Staff Governance Standard, the NHS is trying to reach exemplar employer status.

The Performance Assessment Framework is designed to measure standards and indicators of performance under headings including staff governance. There are to be accountability reviews and local staff partnership forums will be directly involved in assessing the performance of the NHS Board as an employer, as part of the new accountability arrangements. The Staff Governance working group designed the standard to be meaningful, simple and to avoid duplication. Basically, they wanted to produce something that was readable and usable. The standard comprises six parts


The Performance Assessment Framework will require
The Staff Governance Committee remit is to "support the creation of a culture where the highest standard of staff management is understood to be the responsibility of everyone working within the system and is built upon partnership and collaboration. The Staff Governance Committee will require to introduce structures and processes which assure this is happening." It has been established as a standing committee of the NHS Board to complete the governance arrangements with audit and clinical governance. As a minimum, membership will comprise the Chair from each NHS organisation and the Employee Director. Any additional members are agreed locally.

Until the Health White Paper is produced, "Our National Health" is still the national planning document and the policy has not changed.

The Staff Governance Working Group has been disbanded, as their remit has been completed. It was noted that other countries wish to use the PIN guidelines for themselves. Several NHS Board members have queried whether the statement "The committee will be responsible for the timely submission of all the data required as part of the Performance and Accountability Framework." is an error. However, it is not an error and was very deliberate.

Debates about how to include and fund Staff Governance are taking place at the moment. The agenda needs to be broken down into manageable chunks and be a collective agreement between staff and managers. There was a deliberate decision not to include a date for implementation as it was recognised that different organisations will take different times to implement.

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Staff Governance Self Assessment Audit Tool (SAAT)
Rona Webster, HR Director, Fife Acute Hospitals Trust (FAHT)

A previous version of this tool, "Managing People", was produced by Audit Scotland five years before the creation of the SAAT. However, it comprised four documents and was very paper intensive. The decision was made that the SAAT had to be simple and straightforward. Rona gave an overview of how the SAAT pilot in FAHT had proceeded and one of the outcomes had been a realisation that it was not sensible to have action plans from both the SAAT and the staff survey. Instead, there should be only one plan. The pilot process is outlined below

Initial assessment using SAAT
Local partnership forum
draft action plan
partnership forum approves action plan
Trust Board approves action plan

It is not necessary for the Trust Board to approve the plan, but it was decided that getting them to sign up to it was important. The plan now goes to the Staff Governance Committee. If the NHS Boards don't do anything with the plan, they will have major problems when Trevor Jones questions them. As part of the PAF, it is rated as importantly as waiting times. When asked if a carrot and stick approach should be used, Jonathan Best responded that "a carrot is merely a genetically modified stick". It was noted that the situation in Argyll and Clyde was not actually about the money; it was about the relationships. The four Chief Executives could not work in partnership with the result that no decisions were being taken.

Then followed a discussion on what practical steps could be taken by reps in their organisations to support the Staff Governance agenda, what help was needed and from whom?

Communication is the big problem. The significance of neither the Staff Governance Standard nor the staff survey is registering with staff. Guidance literature, improved communications from local and area partnership forums, joint education and training for managers and staff on PDPs would all help but overcoming apathy remains the biggest hurdle.

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Agenda for change (ii)
Janis Millar, Pay Modernisation Implementation Co-ordinator

A short history of AFC was followed by a presentation intended to be used in the joint road-shows planned by SPRIG. The 500 jobs investigated have been compiled into 200 profiles. Around 90 are included in the first edition of the job evaluation handbook and another 80 have just been agreed and will be published within the next week. The Knowledge and Skills Framework should also be out soon. It has been agreed that Recruitment and Retention Premia will be decided on a Scotland-wide basis.

Implementation plans for Scotland
SPRIG are building up a detailed proposal to be issued as soon as possible for consultation. The intention is to create 3 pay modernisation implementation teams - one for AFC, one for the new consultants contract and one for the new GP contract. The first stage for each team will be to establish partnership reference groups. This will be a central team which will link to the local implementation teams that will be needed. Ringfenced funding of 3.5m over the next two years has been agreed to release a dedicated resource to the project, although extra funds might be available if necessary. Gains and losses documents will be available. Matching Panels - joint panels of no less than 5 people - will use the job profiles and match local jobs to them. This will probably be at Board level, although it would be preferable to have them at Scottish level. There is a 5-day training course for panel members. At that stage, the number of posts needing evaluation will be known. The intention is to get all jobs evaluated before the package is rolled out, but it is acknowledged that this might not be possible. Interestingly, it was noted that the profiling has been done for a few medical posts and apparently the system would work, with a bit of tweaking.

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Agenda for change (iii)
Michael Fuller, Regional Officer, Amicus-MSF

Process
There will be a postal ballot of all members. Posters advertising the ballot and detailing contact numbers for those who do not receive a ballot paper will be issued. Ballot papers will be sent out on 7th April 2003 and need to be returned by 28th April. There will be a briefing for ALL reps on 18th March in Glasgow. This will give reps an opportunity to quiz National Secretary Roger Spiller and possibly also Colin Adkins. In order to get a voting paper, new members must join by the end of March. Home addresses MUST be on the membership database as they are required for a postal ballot.

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Sharon Duncan
Agenda for change (iii)

What do we as a trade union need to do in Scotland around AFC?
pre-ballot

post-ballot (assuming a yes vote)
Maureen Jenkins reporting back

Actions from the course
A list of tasks for senior reps was formulated from group discussions.

Priorities

The meeting identified the priorities for the Scottish NHS Committee for 2003 as -


and the needs from Amicus are -

Colin Rodden
5.5.03

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